Claudio Schuftan, Laura Turiano and Abhay Shukla, People’s Health Movement.
cschuftan@phmovement.org; phm@turiano.org; abhayshukla1@gmail.com
1. The progressive weakening of public health systems, the growing privatisation of health care and the erosion of universal access to health care are phenomena seen across the globe. The health sector globally is still dominated by vertical and technocentric approaches, often supported by ‘public-private partnerships’ active at several levels. There is thus an urgent need to replace this dominant discourse by a process aimed at universally achieving the ‘right to health and to health care’ as the main objective to achieve more equitable health care systems in both developing and developed countries. To counter and reverse the tide promoting ‘health care as a commodity’, there is a need to establish a global consensus on ‘health care as a right’.
2. Human rights violations are not accidents; they are not random in distribution or effect; they are linked to social conditions. It is the socio-political forces at work that determine the risk of most forms of human rights violations. Our understanding of human rights violations is thus based on the broader analyses of power and social inequality
and their social, economic and political determinants. The promotion of equity is the central ingredient for respecting human rights in health.
3. It is mostly the poor who are the victims and they have too little voice and no influence, let alone rights. It is inequities of power that prevent the poor from accessing the opportunities they need to move out of poverty. Structures and not just individuals must be changed if this state of affairs is to change.
4. Since laws designed to protect human rights and the right to health (RTH) are mostly not applied, what additional measures have to be taken? This is what the People’s Health Movement’s “Right to Health and Health Care Campaign” (called RTH Campaign for short in this document) sets out to explore.
5. It is not enough to improve the situation of the poor within the existing social relationships. Rights are claimed through social action and the latter depends on how power is distributed and used to address health issues.
6. Human rights legislation alone –without enforcement mechanisms — is not up to the task of relieving the suffering already at hand. Rights are not equal to laws –they are realised through social action and by changing the prevailing power relations. Rights cannot be advanced but through the organised efforts of the state and of organised civil society. To work on behalf of the victims of violations of the RTH invariably means becoming deeply involved in pressing for social and economic rights.
7. Public health must be linked to a return to social justice. Denial of care to those who do not pay is simply legitimised in the free-market system. The commodification of health care changes people from citizens with rights to consumers with (or without) purchasing power. This leaves those who are economically marginalised also marginalised from accessing comprehensive health care.
8. The global Campaign proposed by the People’s Health Movement (PHM) is a step in the direction above, i.e., it seeks the social transformations indispensable to resolve the inequities found in health.
The Right to Health: A holistic overview of its components and tasks for the global health movement.
9. The right to health has been defined as the ‘right to the enjoyment of a variety of facilities, goods, services and conditions necessary for the realisation of the highest attainable standard of health’ (General Comment 14, CESCR).
(http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En?OpenDocument)
10. This right includes both the right to all the underlying determinants of health besides health care (such as water, food security, housing, sanitation, education, a safe and healthy working and living environment, etc.), and the right to health care (i.e., the right to the entire spectrum of preventive, curative and rehabilitative services plus health education and promotive activities).
11. The diagram below shows the main components of the RTH and some of its interrelationships: AVAILABLE FROM THE AUTHOR
12. In practice, this suggests two types of tasks for the global health movement:
a) Tackling the right to all the underlying determinants of health:
13. Supporting and even co-initiating, campaigns or initiatives addressing key health determinants (e.g., campaigns for water, for food security, or for housing) is important and justified by itself.There are initiatives already working on behalf of these rights, not necessarily spearheaded by health activists. We contend that the focal points for each of these initiatives should be the organisations with the most experience and commitment to that particular issue (e.g., water, food security, housing, the environment). This recognition places an obligation on health activists to actively support and strengthen such initiatives though not necessarily to take up the responsibility of primary leadership of such groups. When liaising with these groups, PHM will bring-in the health perspective into their campaigns.
14. An additional important role that has to be played by health activists is to help document violations of the right to the underlying determinants of health, e.g., showing how denial of food security leads to worsening malnutrition, increased morbidity and mortality. Health-based arguments can indeed significantly strengthen the demands of claim holders to tackle these determinants from a RTH perspective.
b) Strengthening the Right to Health Care
15. The global health movement has a primary and unquestionable responsibility to take the lead on this.The urgent need for action within the health care sector has already been pointed out. We are all witnesses to the often catastrophic consequences of the lack of economic access to adequate health care and the poverty trap that leads to avoidable morbidity and mortality.
What does the RTH imply and what is the added value of adopting the human rights-based approach (HRBAP) to tackle it?
16. In every development process, there are three types of actors: claim holders, duty bearers and agents of accountability. When the State does not respect human rights, claim holders have to demand their rights directly from the duty bearers in government plus interact with agents of accountability (e.g., HR commissions, ombudsmen, HR-oriented NGOs) who overlook the procedures being put in place by government and make sure duty bearers fulfill their obligations (including remedies and restitutions). If claim holders do not do it, it is in part their fault. One can thus say that it is also the duty of those of us who are aware of human rights to generate awareness about the bases of these rights, in partnership with the marginalised and underserved groups we work with.
17. The RTH is thus violated, when the poor, the marginalised and the discriminated, as claim holders, do not have the capacity to effectively demand (claim) their rights; rights are also violated because duty bearers do not have the capacity or the will to fulfil their obligations (technically called ‘correlative duties’).
18. Therefore, in the HRBAP one has to carry out three types of analyses: a) situation analyses in which one determines the causes of the problems placing them in a hierarchical causality chain of immediate, underlying and basic causes or determinants, b) capacity analyses in which one determines who are the individuals/institutions that bear the duty to do something about the above causes calling them then to fulfil their duties as per their country’s obligations as signatory of the UN HR covenants, and a c) analysis of and liaison with accountability agents. Herein lies the call for HR activists to carry out rights awareness work, i.e., to educate and inform the broader society about what these rights mean and what accountability mechanisms should be put in place and make to work.
19. These three types of analyses have to be carried out with the representatives of the local community and the beneficiaries of the health system so that the rights being violated can be identified jointly and those responsible also be jointly confronted –for them to do something about the problems identified.
20. Note that, the rights activists’ ultimate goal is NOT to look for health policies that favour the poor… What is sought is significant poverty reduction policies that directly address the social determinants of health!
21. As rights activists, we are no longer going to go to beg for changes to be implemented; we are now going to demand them based on existing international law already in force in most of the countries where we work. Disseminating this concept is in itself empowering. Note that people in countries that have not ratified these covenants do have the same rights. Their problem is that their governments have not made a commitment to honour them.
22. PHM seeks to overcome the culture of silence and apathy about the HR violations in health we all know are happening. This, because HR and the RTH will never be given to poor, marginalised, discriminated and indigenous persons. Repeat: rights are never given, they have to be fought for! And this is what PHM’s Global RTH Campaign is attempting to do.
23. As regards the added value of adopting a HR-based framework, several advantages come to mind:
a) A RTH Campaign has a big social mobilisation potential –and this is an indispensable part of any campaign, b) as said, the HR approach is backed by international law, c) the RTH approach demands –from a position of strength– that decision-makers take responsibility, d) HR imply correlative duties that are universal and indivisible (there is no such a thing as ‘basic rights’), and e) the HR approach is focused on processes that lead to outcomes (just setting goals, like the MDGs, is thus not sufficient in the HR-based framework).
What may be realistically achieved through the proposed process?
24. PHM has no illusion that systematically raising the issue of the ‘Right to Health’ will by itself lead to an actual complete implementation of this right in countries across the globe. The universal provision of even basic health care services involves major budgetary, operational and systemic changes; in addition to shifting to a rights-based framework, major political and legal reorientations are thus needed –and such major changes cannot be expected to happen in full in the near future, given the political economy of health care in most countries of the world today.
25. However, PHM expects to and can work on a number of more achievable objectives that can take us towards the larger Human Rights goal. Some of these ‘achievables’ to be considered are: a) the explicit recognition of the Right to Health Care at country level, b) the formation, in some countries, of health rights monitoring bodies (accountability agents) with PHM and civil society participation, c) a clearer delineation of health rights at both global and country level, d) the shifting of the focus of WHO towards health rights/universal access systems and the strengthening of groups within WHO that will work along these lines, e) the bringing of the Right to Health Care more into the global agenda thus making it a central reference point in the global health discourse, and f), the strengthening of the HR activists’ network in as many countries as possible so that all its members work around a common and broad rallying point, along with building partnerships with other networks.
Why the global RTH Campaign?
26. Nearly 150 countries around the world are parties to the International Covenant on Economic, Social and Cultural Rights. General Comment 14 (GC 14) of the Committee on Economic, Social and Cultural Rights (CESCR) adopted in the year 2000 elaborates on and clarifies the Right to Health by defining the content, the methods of operationalisation, the violations and the suggested means to monitor the implementation of this right. There is now a need to launch a global process of mobilisation to actually implement the provisions of GC 14 in all ratifying countries. This clearly calls for measures to operationalise the RTH and to review and recast all global and national health sector reform initiatives in the light of the framework of health as a right (such as, for instance, recasting the reforms that are now being pursued to achieve the Millennium Development Goals!).
27. There are a host of reasons to adopt the Right to Health approach. Among them is the fact that the Basic Human Needs Approach (has) never delivered. Other, as valid, justifications are: a) the Human Rights-based Framework is the new UN policy, and b) PHM is founded on the principles of the right to health and to equitable access to health care services at all levels with no discrimination.
28. While PHM continues to struggle for the RTH as a basic human right at various levels, at this moment in time there is growing recognition of the need for a global initiative to address health system issues in a rights-based framework.
29. There is also a growing worldwide need for solidarity in and mutual learning from our struggles, so as to strengthen our efforts in the various countries and regions. There is a related need to challenge the dominant global discourse of ‘safety nets for those left outside the existing packages of benefits’ that results from health services being increasingly commodified and from governments retreating from funding the provision of universal health care, limiting their role to supporting said ‘safety nets’ or other kinds of reduced public health services ‘for the poor’. We need to counter this with a strong ‘Health care as a human right’ strategy that unequivocally asserts the central role of the state and public health systems –and their responsibility to provide health services for all.
Given the above, the following overall strategy has been adopted by PHM:
30. PHM country circles will continue to strengthen and expand their involvement in various concerned initiatives within their countries and regions. They will, at the same time, analyse the interrelatedness between various health determinants so as to enable PHM and its circles to develop integrated and holistic strategies.
31. PHM is focusing on its Global Right to Health and Health Care campaign. The Campaign will concentrate on strengthening the Right to Health Care since we argue that PHM has a primary responsibility regarding this issue. The Campaign will focus on tasks in which PHM (along with partners in the global health movement) can take the lead and primary responsibility.
32. The overall perspective about how the global health movement should approach the Right to Health is depicted in the following diagram: AVAILABLE FROM THE AUTHOR
Focus of the Campaign
33. The Campaign is, in its first phase, focusing on the issue of access to quality health care which can be importantly acted-upon from within the health sector. This is being broadened by PHM’s vision of health care that, as in Alma Ata, includes preventive, curative and rehabilitative health services, as well as health promotion services, e.g., nutrition, quality drinking water and sanitation, health education, health information systems. Specific important aspects of this Right such as women’s and children’s right to health care, mental health rights, HIV and AIDS-affected persons health care rights, workers’ health rights, the right to essential drugs, etc. are being woven-in into the Campaign, bringing diverse branches of the global health movement into a broad coalition that strengthens universal access to health care.
34. At the same time, PHM is denouncing and acting upon adverse existing and new policies that are having negative impacts on the Right to Health (such as the privatisation of services, the weakening of universal access systems, vertical programmes that fragment health systems, the current 90/10 gap in research funding, the unjust international trade regimes –to name just but a few). These policies, and violations of key health determinants, are being identified at the country level and are taken up as part of the proposed Campaign.
The three phases of the Campaign
35. In moving towards the full implementation of the Campaign, the following sequence of activities will ensue:
Preparatory phase (3rd quarter of 2006 to fourth quarter 2007)
a) Creation of a broad consensus on the Campaign concept. In each country, identified groups are invited to become part of the Campaign. At global level, a ‘Core Campaign Steering Group’ has been formed. This team actively supports a host of regional and local organisers and leads the international network, plus the upfront fund-raising and advocacy work for the Campaign.
b) Identification of existing PHM or newly associated groups that will take regional and local responsibilities.
c) Identification of short and long-term sources of funding for the various aspects of the Campaign, at regional and global level plus the development of a budget.
d) Completion of a multilingual Assessment Guide for the preparation of papers depicting ‘The State of the Right to Health’ in each country. (finalised in November 2006 and now available in four languages; see www.phmovement.org and follow the leads to the right to health campaign).
e) Contribution to the discussion and planning of the next (2008) edition of the “Global Health Watch” (the alternative world health report).
Documentation and analysis phase (late 2007 to late 2008).
11. During this period, country and regional reports will be prepared. Over 25 countries are now engaged, are studying and implementing the ad-hoc Assessment Guide and are at different stages of organisation.
36. It is here noted that PHM does not see these (or any) reports as an end; rather, the processes launched to mobilise civil society to produce these reports is the real end.
37. This phase will culminate with a) the holding of national workshops to discuss the results of the assessment of the RTH and to prepare a commensurate action plan for the PHM circle and associates, and b) the concrete planning of Regional Assemblies on the Right to Health in all five or six regions of the world.
Regional Assemblies and subsequent action phase (after the World Health Assembly of May 2008)
38. The following is proposed:
a) One assembly in each region where the campaign is ongoing will be held sequentially thereafter. These assemblies will be called by PHM, with involvement of the UN Special Rapporteur on the Right to Health and WHO, and will be attended by national health officials, national human rights committees and PHM, as well as other health and human rights activists. Plans will be made to have health workers and beneficiaries represented in these meetings as well. Available country reports on the Right to Health will be presented and discussed. This will be complemented by a regional analysis paper in each region, dealing with how international macro and structural factors and global agencies are affecting the Right to Health in the region. Action plans to implement the Right to Health will be drawn, discussed and presented in the second half of the assemblies.
b) This series of regional assemblies may culminate in some kind of a resolution being proposed for adoption at, say, the World Health Assembly in Geneva in 2009 or 2010. Such a resolution will call for time-bound, progressive implementation of the Right to Health.
c) Preparation of a ‘Global Action Plan on the Right to Health Care’. Such a document will, with facts and figures, convincingly show how quality essential health care services could be made available NOW to every human being on earth, provided certain key reallocation of priorities and resources are enacted. These global recommendations will be accompanied by practical recommendations for the countries in each region.
d) Governments will be lobbied to accept the major points suggested during the regional assemblies and the 2009 or 2010 World Health Assembly will be asked to adopt a ‘Declaration on the Right to Health for All’ for implementation by member countries. The same will have time-bound, specific and monitorable benchmarks. The aim will be to foster more effective community involvement and monitoring in health to operationalise the Right to Health. Universal Access to Comprehensive Health Care will be endorsed as an overarching principle, together with a related call for definitive changes in the global trade and patents regime as it affects health.
Expected outcomes of the Campaign
39. In its work, the Campaign will use four broad approaches:
a) Documenting violations and facilitating redress of those violations.
b) Policy advocacy (denouncing and formulation of new policies) at national and international level.
c) Raising awareness and education.
d) Establishing alliances and embarking in civil society mobilisation.
40. Some shift in the focus of WHO towards the Human Rights-based framework to Health will definitively be needed: a shift that puts universal access to public services at the centre and that strengthens a group inside WHO that will continue to work and provide leadership on this work.
41. The strengthening and broadening of the PHM network in various countries across the globe will be both an outcome, and also an imperative to take PHM forward around the common, broad rallying point of the Campaign.
A clarification on the implementation of the right to health and health care (RTHC) Campaign.
42. The RTHC campaign uses a participatory process to inform people about their right to health and actually involves them in preparing the assessment of the right to health care in their country — at the same time that it builds and mobilises a sustainable PHM network.
43. Collecting the data that brings out the evidence of the violations of the RTHC does not, by itself, mobilise the sufferers of such violations into action. They must be present when doing the assessment itself and when the data are analysed. By going through this process, they themselves will learn about what the right to health and health care is all about and will thus meaningfully contribute to its operationalisation.
44. Country-level activities are the heart of the campaign. How the RTHC campaign is organised in Country X is up to the campaign committee in that country. PHM’s overall concerns are that the process involves as many people from different sectors and tendencies as possible, and that the final assessment report, as closely as possible, covers the different parameters described in the campaign’s RTHC Assessment Guide. As written, the Guide provides a step-by-step, user-friendly explanation of the reasoning process to be followed to identify violations of the right to health. Therefore, regardless of how country circles end up using this tool, it is recommended they consider its five main steps in reporting their findings so as to make country reports comparable.
45. The most important goal of this campaign is to empower and involve ordinary people to represent their own interests in a political process/movement that has the power to influence both the national and the international level of decision making. PHM wants to bring people’s claims for their health rights to a level that cannot be ignored.
46. As said, the point of this campaign is not to produce RTHC reports. The reporting process is a process to find evidence, to educate people about their rights and about key principles of public health, as well as to bring them together behind shared, common goals. This is what is needed to make effective demands on governments.
47. For the above reasons, before engaging in the actual assessment, it is crucial to set up a credible network of strategic allies. Country focal points for the campaign are thus to contact such allies (individuals and institutions).
48. Establishing such a critical-size network to get started is key. To arrive at a point when the time is right to launch the assessment, PHM circles ought to take as many weeks or months as needed to assure success. Consequently, the criteria for proof of social mobilisation preceding the launching of the actual phase I of the campaign have been tightened and now are:
– Organising at least two national level (or regional in bigger countries) meetings to discuss the campaign, involving participants from various organisational backgrounds, preferably including some from different regions of the country.
– Formation of a first campaign coordination group which will take collective responsibility for expanding and developing the campaign.
– A formal agreement on the provisional decision-making mechanisms for the development of the campaign in the country.
– Existence of a functional e-group/listserver or other means of communication among the participating organisations/individuals to facilitate campaign communications.
49. Each country will decide for itself how to use the assessment process as a tool for additional mobilisation.
50. Countries do not have to do their assessments at the same time or finish at the same time. But there does have to be a certain critical mass of countries in a region that have gone through the assessment process and the national strategic action planning before it makes sense to have a regional meeting (phase II). Each of the regional meetings should nevertheless happen within a reasonable period of time so that an international momentum can be generated.
51. To summarise, each new or strengthened national PHM circle needs to create the critical mass of popular support/power so as to be able to follow-through with the action plan called-for at the time the assessment is completed (starting at the end of phase I).
52. If the campaign does not succeed in mobilising claim holders and their organisations to be ready for and to actively participate in the assessment, there is the risk that the campaign may backfire. We have to be careful not to build expectations only to then let down the people whose RTHC is being violated (plus those persons who gave of themselves to get the assessment going).
53. The local political scene has to be analysed by the PHM circle so that committed strategic allies can be aligned and given concrete responsibilities, as part of an ad-hoc plan for the whole campaign as duly agreed with them. The question also has to be asked, then, whether the timing for launching the campaign is right given the concrete local political realities.
54. Putting pressure on duty bearers by using the results of the assessment, therefore, has to go hand-in-hand with mobilising the participating claim holders for actions at different levels: The process is as important as the outcome!
55. The assessment process is not to be just a technical ‘desk exercise’ that analyses data, but should preferably include documentation of testimonies of denial of health care, and participatory case studies of health care facilities or health- related services being successfully carried out by participating organisations. Such activities simultaneously build evidence and generate involvement. Holding of dialogues between groups of health activists and health authorities, public hearings, workshops on the Right to Health, and/or carrying out symbolic protest actions of various types will be important features of the campaign, to be planned.
56. Starting the mobilisation drive after the assessment, when the evidence is in, is considered to be too late –although the mobilisation will gain momentum after the assessment results are presented and constitute an incontrovertible ‘evidence base’ of violations to this right.
57. As part of the mobilisation effort, country PHM circles can choose to hold public hearings on the RTHC (as PHM India and PHM South Africa successfully did) or any other community-based action, right from the beginning.
58. The campaign will greatly depend on proactive country-level organisers that are willing to commit quality time, not only to do a desk job or carry out a mere assessment project: this is not the essence of the campaign. An assessment report so produced will be of limited use; it will gather dust in duty bearers’ in-boxes –and has never been the intention of the campaign.
59. Some countries may centre their mobilisation around already strongly felt needs in the population and, as an entry point to the campaign, address these strong felt issues as they relate to the RTHC. Connecting the campaign to ongoing national popular struggles is a good idea.
60. The campaign will not attempt to be confrontational, unless needed. The lobbying strategies outlined in the Assessment Guide discuss ways to work with duty bearers in a constructive manner.
61. The campaign highly encourages, the early involvement of health workers and their unions. They are, at the same time, claim holders and duty bearers (i.e., claim holders of decisions made at higher-up levels), and their involvement will give the campaign access to valuable information, as well as greater depth and additional credibility. The endorsement of the campaign by well known personalities and prestigious institutions is also invaluable.
Claudio Shuftan, Ho Chi Minh City.