Introduction
The background
The concept of Human Rights in health and why it is used
Experiences from some NGOs already using the Equity/Human Rights approach
Practical ways for NGOs to adopt the Equity/Human Rights focus in their health work (See CARE, 2001 and 2002)
References
Acknowledgements
Introduction
1. Equity and Human Rights (HRs) are by no means new concepts to NGOs.
2. Moreover, Equity and HRs are inseparately linked since equity is key to the realization of HRs. (Oxfam International 2001) The question here is what NGOs are doing with/about these two concepts in the realm of their work in health and nutrition.
3. A paradigm shift is clearly in the making in development and in health/nutrition work. New models are more politically driven in a direction that hinders and hampers the resolution of the problems at hand. (SIM, 2000) Therefore, these days, more and more NGOs are discussing and trying to operationalize the ‘Equity and Human Rights-based Approach’ to apply it to their work. This paper is a contribution to that discussion.
The background
4. Underlying the analysis here made are several statements (with which the author agrees) found in a recent publication; they read as follows:
“Most NGOs today have become very specialized and contribute marginally to the relief of poverty/ill-health/malnutrition, but significantly to undermining the struggle of the people to emancipate themselves from oppression. Programs delivered by these NGOs do not really seek to redress the social circumstances that cause impoverishment/preventable ill-health and malnutrition. The development discourse is framed not in the language of emancipation or justice, but using the vocabulary of charity, technical expertise, neutrality and paternalism. NGO programs have often worked to undermine popular mobilization. NGOs accept or do not comment on the manner in which the State exercises its power. NGOs work is limited to project work, armed with manuals and technical tricks rather than seeking justice and standing up against violations of HRs. Many NGOs were co-opted by funders to take up such a role (a typical example is health and nutrition work done to set up ‘safety nets’ for the poor). NGOs have become an integral part of a system that sacrifices respect for justice and rights, instead taking a missionary position. If NGOs stand in favor of emancipation, then the focus of their work has invariably to be in the equity/HRs/political domain, supporting those social movements that seek to challenge a social system that benefits a few and impoverishes the many”. (Manji and O’Coill, 2002)
5. Most NGOs tend to work on the issues that are before them, and forget those that are hidden away; such hidden truths have to be brought to the forefront. For example, issues of voice, power, risk and neglect are essential in a HRs discourse – as difficult to surface as they may be.
6. The fallacy that actually needs to be uprooted is that health programs addressing the urgent needs of women and children implicitly address human rights. In the HRs approach, nothing is left implicit; without an explicit retooling to a HRs focus, such claims remain but hot air; they are hollow commitments to HRs that allow controlling hierarchies to persist.
7. NGOs have ample accumulated knowledge of what is going on….and have just begun to realize that, if they do not act on that knowledge, they are not really serving the people of the communities that they work with to the fullest.
8. There is a need, then, for a more determined commitment to pro-poor social policies and programs (including health)and an increase in the funding for such an approach. Activities are to concentrate on institutional capacity building to better promote education and consciousness-raising at the community level. A key question is to give advocacy tasks more prominence so as to hold governments more accountable. (Global Team, 2000)
The concept of Human Rights in health and why it is used
9. In contrast to a ‘deficit-filling approach’ to poverty and preventable ill-health alleviation, the Equity/Human Rights-based approach (E/HRs-based approach) defines poverty as social exclusion. Instead of focusing on creating an inventory of public goods or services that must be provided and then seeking to fill the deficit via foreign aid, the rights-based approach focuses on trying to identify the critical exclusionary mechanisms. This, because work in health and development is about assisting poor communities overcome obstacles, rather than about the endless pursuit of grant aid for social goods. The E/HRs-based approach enables NGOs to see much more clearly the kinds of power relations and systemic forces that drive and perpetuate poverty. But the transition to mainstreaming a rights-based approach into the organizational structure of NGOs is a complex enterprise; it cannot simply be decreed and implemented. (Oxfam America, 2001)
10. The E/HRs-based approach asserts that work in health should be seen as a process that unequivocally leads to people fully realizing all their human rights (and not only their right to health); the approach should thus be reflected both in the processes engaged and the outcomes pursued by NGOs.
11. More importantly, the E/HRs-based approach sees ill-health, malnutrition and poverty as a denial of human dignity, i.e. as an important part of the denial of people’s economic, social, cultural, civil and political rights. And these rights are more than just moral principles and norms governing human behavior… they are international legal standards. Poverty itself is seen as an abuse of HRs… The poor and marginalized are not where they are by accident…
12. Because health is not the exclusive business of governments, this broad approach definitely brings an added value to communities and to NGOs when sitting down among themselves and with government representatives to jointly evaluate and plan local or national health strategies. It brings something different and potentially powerful to existing efforts by all actors in their efforts to overcome ill-health, malnutrition and poverty in a more sustainable manner.
13. The principles of equity in health (and prominently those related to gender equality) are not currently codified in any way to allow monitoring their implementation; more often than not, they are lost when implementing health sector reform or macro-economic corrective measures. Human rights, on the other hand, are enshrined in legal covenants that protect human dignity and place obligations (or duties) on providers and others, mainly but not exclusively the State. While NGOs do have the responsibility to respect the rights of others, it is now widely accepted that states have very specific obligations to respect, protect and fulfill human rights in the realm of health and nutrition.
14. It is thus timely for NGOs to use the equity and human rights-based approach – to apply the internationally agreed human rights standards to health policy and practice – emphasizing active grassroots participation and the right of people to choose their own path.
15. When doing so, priority is to be given to the poor, the marginalized and the vulnerable – those currently most denied their rights due to their lack of choice, of control and of resources.
16. The conceptual basis that justifies (and prescribes) the use of an Equity and Human Rights-based Approach in the health and nutrition work of NGOs is the following:
· HRs are entitlements all people have, to develop their full potential; they are valid for everyone – they are universal (A right is a right only when it is universal; otherwise it is a privilege).
· There is a difference between just delivering services and making clear to beneficiaries that they are legally entitled to specific services and can go somewhere to complain if they do not receive what is due them.
· HRs objectives are not to stabilize the problems at hand, but to make them disappear by tackling them at their roots.
· HRs are pre-conditions that must be met for people to have the opportunity to live with full dignity, full health and self-worth.
· HRs lack cultural legitimacy in many parts of the world; communities are traditionally more concerned with needs than with rights; that is why NGOs have to start from people’s own initial understanding of their rights (and the issues of power) to then support a bottom-up dialogue that deepens the ownership of HRs by the beneficiaries they work with. (Without concerned citizen action to uphold HRs close to home, we shall look in vain for progress).
· Rights are different from needs; rights are relational: where someone has a right, someone else has a duty or responsibility to honor and satisfy that right. There are two critical distinctions between health rights and heath needs: first, health rights always trigger duties and responsibilities, whereas needs do not; second, health rights imply standards that can be measured whereas needs do not. Therefore, NGOs need to start thinking in terms of rights rather than needs, of rights-holders (or claim-holders) rather than beneficiaries and of enabling rather than giving.
· In the E/HRs-based approach to health beneficiaries hold claims against those who are responsible (through their actions and omissions) for their health and nutritional wellbeing. People can only realize their rights in health if they are first exposed to the root causes of the marginalization they suffer from, and if they are empowered to claim and fulfill the rights essential to their health/nutrition and livelihood security. Rights, then, have an enormous potential to attract and mobilize people. (SIM 2000) First and foremost, this means NGO interventions have to transfer ownership to the people served; key actions for this to happen are HRs education and capacity building for community members to claim and defend their rights. Empowerment here is to be understood as generating several forms of power: self-respect (power within), community cohesion (power with), and a clear agenda for action (power to).
· The E/HRs-based approach addresses abuses and/or neglect of HRs in health mostly found in the form of discrimination or exclusion. It brings to the light underlying power relationships between rights-holders and authority structures; it emphasizes dignity, equality, and participation of the former and accountability of the latter.
· Moreover, let it be very clear that advancing gender equity issues is part and parcel of work on girls’ and women’s rights in relation to health.
· Such an approach means NGOs must stand in solidarity with the poor (women, children and men) whose rights are being denied – holding themselves accountable to them (and in addition ensuring they do not violate people’s rights themselves). NGOs must support people’s efforts to take control of their own health and lives. This also includes NGOs holding others accountable for fulfilling their responsibilities, as well as opposing discrimination of any sort, addressing the root causes of poverty/ill-health and malnutrition and the corresponding rights denials in their work with rights-holders. Finally, they must work in concert with others embarked in the same endeavor (forming a supportive coalition of NGOs on these issues).
· In short, the E/HRs-based approach calls for a purposeful and transparent de-facto engagement of NGOs in the more structural aspects of the determinants of ill-health while remaining steadfast allies of local communities throughout.
· NGOs will not be alone in this E/HRs-based approach since the paradigmatic (and mindset) shift towards it is growing globally with the force of international law behind it.
· Therefore, NGOs definitely need to take steps now to improve the HRs impact of their current actions in health. This means identifying previously unforeseen gaps and opportunities. But although focusing on health, NGOs have to take into account the whole range of HRs since HRs are indivisible.
· Weighing-in on rights can risk harsh reactions from the authorities. Standing up for communities whose rights are not respected, protected or fulfilled is inevitably being political in the sense of challenging those actors responsible for abuses. So NGOs have no choice but to take a stand against authorities, policies or practices when the communities they serve are abused, neglected or excluded. The name of the game is: Remain non-partisan, but at the same time take issue.
· Even if the E/HRs-based approach is inherently about confrontation – confronting the injustices of real world situations – two approaches are possible:
a) denouncing violations (which is often confrontational), and
b) engaging actors in the pursuit of rights, helping them to more fully live up to their responsibilities (which is more related to promotional work).
· Monitoring HRs conditions is also very important for NGOs, and there is a need to share and disseminate information about such violations (making documented grievances public); this information will ultimately strengthen advocacy. HRs-sensitive (and gender and socioeconomically disaggregated) data and indicators are critical to keeping aware of gender, equity, HRs and other issues.
· Despite growing clarity about all the issues above, there is no one blueprint for an equity and human rights-based approach to programming in health; each NGO will have to go through its own retreat(s) to revision and remission their mandates to adjust their very own approach and programs to it. (Adapted from CARE, 2002)
Experiences from some NGOs already using the Equity/Human Rights approach
17. As far as international NGOs are concerned, CARE has probably advanced the most in its efforts to operationalize the E/HRs-based approach. Since January 1999, they have had a (CARE) Human Rights Initiative with a HQs coordinator and program advisor and a field program assistant devoted full-time to the Initiative. They have been raising awareness in most CARE country offices around the world, building the capacity of their staff globally, ensuring that CARE’s principles and policies facilitate the HRs-based approach being progressively adopted, and they have been forging strategic alliances with like-minded programs and initiatives. They carry out training, research and pilot activities in HRs, and they publish a quarterly newsletter (‘Promoting Rights and Responsibilities’) featuring cases from the field, staff reflections, conceptual pieces, a section called Window to the Wider World and a section on worldwide new resources. They are about to publish a Rights-based Training Manual and a set of Case Studies on CARE’s Implementation of the Rights-based Approach. Very helpful has been the compilation of a Frequently Asked Questions About the Adoption of a Rights-based Approach document which has been revised a few times. (More information to be had from Michael Rewald at rewald@care.org)
18. Note: Equity and HRs do not feature explicitly in the charters of international financial institutions (IFIs) and those of many donors although most bilateral development agencies now give prominence (and mostly lip service?) to both participation and the promotion of equity and human rights. Moreover, the commitments of national governments to respect, protect and fulfill health as a right has yet to be properly reflected in their policies and practice. The E/HRs-based approach demands that government policies address ill-health and malnutrition ‘to the maximum of available resources’ (including resources available through international development assistance). It is this what some NGOs are starting to make governments accountable for. Finally, also note that a new publication of WHO states that poorly designed and implemented current health programs and policies can (and do) already violate HRs. (WHO, 2002)
Practical ways for NGOs to adopt the Equity/Human Rights focus in their health work (See CARE, 2001 and 2002)
19.The equity/human rights approach does not offer a panacea or magic bullet that will see resources, services and power instantly transferred to the poor and vulnerable. In part, this is due to the fact that the international community has no practicable ways of imposing punishments or fines on governments (or others) that violate or ignore their commitments to human rights. On the other hand, NGOs have not used their potential to more proactively seek government compliance in this area. There are proven tactics that can be used – and these need to be shared more widely. (Benoit, et al, 2000)
20. The main question at hand here for NGOs is: If current health programming is mostly time-bound, donor-driven, and supposedly apolitical, how can they pursue meaningful, long-term and rights-holders-driven transformations in the sector based on challenging oppressive power relations?
21. Understanding how societies construct the system of inequities that include inequities in health is the first step for NGOs to help people claim their rights.
22. But understanding is not enough. The E/HRs-based approach insists on behavioral changes of the NGOs professional staff themselves (to be seen as a ‘staff investment’) rather than the latter simply starting more ‘HRs-compatible’ new programming; it insists that the E/HRs-based approach entails a different concept of development programming that does not only focus on the methods of implementing new activities. Without behavioral changes, staff will simply repackage what they are currently doing in an ‘E/HRs-based approach language’.
23. When designing projects, a formal analysis of the rights being addressed has to be done with the community; this includes understanding how aid can compound some of the problems to be solved, as well as analyzing the unintended consequences of the work to be undertaken. (Unintended impacts on people’s rights happen for three different reasons: a lack of knowledge about the context in which NGOs work; a lack of thought about unintended impacts of their interventions, and a failure to take responsible actions).
24. For all the above reasons, from now on, a growing part of NGO efforts should focus on making governments accountable to meet their equity/human rights obligations; and there are concrete steps that can be followed to do this (see below). More and more, the root causes issue (i.e., taking a new look at issues of power, control, ownership and sustainability) and the rights violations actually found should become the main agenda for discussions with authorities.
25. That is why calling for an NGO (re)organizational meeting (or retreat) on these issues is now necessary. It is high time that people in NGOs find out more about this equity/human rights-based approach to health and particularly about how to operationalize it. This expertise is now badly needed.
26. The real tough challenge NGOs face in these organizational meetings is in translating what some feel are still vague principles into concrete plans and actions – even if they find it difficult to alter power relations in the short-term.
What does it take, then, to understand and adopt an E/HRs-based approach?:
27. To start from scratch and to familiarize NGO staff with this approach, a one-day general introduction to HRs and the E/HRs-based approach, defining its characteristics, is suggested; this is to be followed by a series of meetings in which exercises are presented for staff to learn how to carry out causal/responsibility analyses and to identify the responsible actors (duty bearers) at each level; this is followed by exercises on how to develop advocacy strategies to influence pertinent decisions an actions. A final session should focus on identifying the NGOs strengths and weaknesses to adopt the E/HRs-based approach and should conclude with delineating the steps proposed to progressively implement this approach. At the end of the training, each staff member should be asking him/herself: ‘Am I really committed to this?’…and this should be discussed.
28. There is no shortcut or blueprint methodology to achieve a shared understanding of these concepts. NGOs must acknowledge that this is a time consuming and intense process. What is clear though is that NGOs will identify a host of new priorities.
29. What the addition of these priorities will mean for each NG, and what it will lead to in the future, is also to be explored in these meetings. Towards the end, each NGO should have a long-term vision for health – one that adds the equity/human rights perspective. This should be ultimately reflected in increased funding for activities that point to that vision (funding needed for this is considered to be neither very substantial nor very difficult to raise); it should also mean that NGOs will become more vocal advocates for both health and human rights and better watchdogs of human rights violations and of existing and emerging inequities in health.
30. Only after going through such a collective learning process will the NGO’s internal organizational systems, its processes, policies and organizational culture change as needed. It is more, only when a critical mass of people in the organization changes to think in the new way will the NGO as a whole change. Each staff has relationships with people at many levels of the organization; each should gradually work to influence them so that more and more staff join by understanding and supporting the changes called for.
31. After going through the training, the next challenge for NGOs becomes to use the international human rights agreements, they now will be more familiar with, practically:
– in the health policy making process (their own and the government’s),
– to guarantee people’s participation (beyond mere dialogue),
– to assess and analyze people’s health and nutritional needs together with them,
– to set commonly arrived at and agreed objectives,
– to, together with and/or backing claim-holders, place informed and effective demands in front of authorities and demand for accountability, and
– to call for and get involved in networking and solidarity work.
32. Also after the training, NGOs will find themselves moving things traditionally deemed unchangeable (e.g. the assumptions column in their project logframes) into more explicit objectives of what they want to achieve in their different projects. This will also mean that, later, measuring the impact of their projects will also have to be from a HRs perspective. (What is here meant is that NGOs have to honestly question what they put in the assumptions and risks column of their project logframes and ask themselves: Are these assumptions really out of their domain of influence or control? Can something be done to proactively address them?).
33. Further, NGOs have to decide whether they start applying the E/HRs-based approach in their current projects or rather wait for new projects to come to do so. Alternatively, they can begin implementing the E/HRs-based approach in selected projects and experiment using the new HRs work tools, at the same time building the capacity of a core team of trainers/implementers and encouraging senior management to take a lead role. They also need to make sure they have the capacity and the resources to implement these principles. (There exist already sets of questions to be asked to determine whether and how an NGO is putting an E/HRs-based approach into practice). (Benoit et al, 2000)
34. Later, NGOs will need to periodically review whether their programs are reflecting the E/HRs principles, document how they do deviate from them and articulate steps to progressively get back to and realize them.
35. Ultimately, the aim is to cede power in NGO programming to the people they serve, ensuring they are increasingly represented and heard in program/project decisions.
36. When Northern NGOs become actors in a rights-based framework, they also need to recognize the existing tensions in their relationship with Southern partners; these often relate to economic and other inequalities in their relationship at a time when Northern NGOs are seeking equity. (Beware that, in HRs work, Southern NGOs are indispensable allies, because they are better placed to exploit the opportunities and avoid the dangers of HRs advocacy in their own countries).
37. An additional point for NGOs to ponder is that, in an era of Globalization, it is not sufficient for them to work exclusively at the community level. The drivers of poverty and inequity are much more global than local. Northern NGOs are in a better position to act at the global level and should do so. Agreement on the agendas for such advocacy work should be sought with Southern partners.
What will refocusing on E/HRs mean to NGOs working in the health sector? What is the added value of and the new visibility gained from adopting an E/HRs-based approach?:
38. Working with an Equity/HRs focus will mean finding gaps in HRs in the current health work they do; it will mean revising their plans; it will mean increasing their staff’s skills to analyze health from a HRs perspective; it will mean adopting a ‘HRs language’ in most of their work; it will mean focusing more on activities they are not familiar with yet; it will mean selecting a new set of health priorities (or priorities in health) and determining whether they do conflict with or complement their existing priorities and whether they will mean extra work; it will mean reexamining who their strategic allies are (and which they should take on), as well as look at their allies’ respective roles to find synergies/conflicts/gaps; it will mean NGOs will also have to increase their resolve to say no to certain donors; it will mean changing their focus on monitoring and evaluation. And, last, but not least, it will mean a major repositioning of the NGO’s identity with its various publics and stakeholders.
39. NGOs’ HRs advocacy should, from now on, also be internationalized. A successful example is NOVIB’s Social Watch Initiative that watches over the implementation of governments’ commitments taken up and signed on in global UN meetings; initiatives like this should now be expanded to cover monitoring E/HRs violations in health and other domains.
40. Operationalizing the E/HRs-based approach therefore requires NGOs to work at the target group level, work on civil society building, work in monitoring and influencing government policies, as well as work internationally. What this challenging agenda means is that without a political commitment to social equity and HRs, PHC strategies will fail. This, because poverty eradication strategies cannot ignore the health status of rights-holders – and that requires addressing unequal power relations (i.e. analyzing who wants and needs changes in health and who wants to maintain the status quo).
41. NGOs are, therefore to remain active in structural poverty/ill-health/malnutrition eradication. Demanding for rights is a battle that has to be fought in the social and legal arenas, at national, regional and international level. NGOs cannot do this by just implementing government commitments and absolving the state of their responsibilities. The difficult struggle against the impunity of state-related perpetrators of violations of HRs has to be undertaken now. NGOs must combine political action (with a small p) with capacity building and service delivery to achieve the needed change. Strategies used should not be confined to the use of legal resources that ignore the political nature of the struggle. (But, at the same time, beware: NGOs cannot risk creating expectations which, in the end, they may not be able to fulfill). Governments have simply to be pushed (using a combination of means) to redefine their responsibilities towards health. (SIM, 2000)
42. In short, NGOs need to shift from working from a welfare perspective to an economic justice perspective. The E/HRs-based approach is rather a matter of commitment than of just another way of approaching the problems of ill-health and poverty. (SIM 2000) To undergo the shift, NGOs have to take stock of their social investments so far in social development, as well as in health and nutrition so as to create themselves a new niche in HRs work and lobby governments and multilateral agencies alike. (NOVIB, undated)
43. To sum up, adopting the Equity/HRs-based approach to health is not a matter of choice anymore; NGOs have to decide what?, how? and when? This, since the E/HRs-based approach will become the overall ‘best practice’ of the decade…and this is irreversible.
Claudio Schuftan, Ho Chi Minh City
schuftan@gmail.com
[Note of interest: There are one million NGOs in India; 210,000 in Brasil; 35,000NGOs are operating internationally. All NGOs put together dispense an estimated 12-15 billion USD per year].
References
– Benoit, S. et al, 2000, Filling the Gap, www.11.be/index.htm?rights/index.htm&2, May.
– CARE, 2001 and 2002, Promoting Rights and Responsibilities Newsletter, four issues, June+Dec.2001 and Feb.+June, 2002.
– CARE, 2002, Frequently Asked Questions About the Adoption of a Rights-based Approach, draft, April.
– Global Team, 2000, Summary Report for Global Meeting, SCO2: Right to Health and Education, 17-21 Jan.
– Oxfam America, 2001,Challenges and Opportunities of Implementing a Rights-based Approach to Development, R.C. Offenheiser, and S. Holcombe, July.
– Oxfam International, 2001, Oxfam International’s Strategic Plan 2001-2004, Towards Global Equity, Nov.
– Manji, F. and O’Coill, C., 2002, The Missionary Position: NGOs and Development in Africa, International Affairs, 78:3, pp.567-83.
– NOVIB, undated, NOVIB and the Right to Basic Social Services: Position Paper.
– SIM (Netherlands Institute of Human Rights), 2000, Linking and Learning in the Field of Economic, Social and Cultural Rights, Special No.27, Oct.
– WHO, 2002, www.who.int/hhr/news/en.
Acknowledgements:
The preparation of this paper was financially supported by NOVIB (Oxfam Netherlands).