THE ASSESSMENT OF THE RIGHT TO HEALTH AND HEALTH CARE AT THE COUNTRY LEVEL:

A People’s Health Movement Guide

October 2006

1. Introduction
   The People’s Health Movement (PHM) Right to Health and Health Care Campaign (RTHHC)
   is designed to focus national and international attention on how the right to health and health
   care can be implemented worldwide with a relatively small shift of resources. Using this guide
   to evaluate the status of this right in your country can be the first step in the Campaign.
   [Note: Bolded words and phrases are defined in the Glossary in Annex IV].
   The RTHHC centers on the right to health care because PHM has been a leader in the
   promotion of the Primary Health Care Strategy as the best strategy to acheive health for all.
   However, each country participating in the campaign may also look at any other health issues
   using the framework of the guide. The RTHHC will denounce any documented violations of the
   right to health, including those related to the social determinants of health. Once your
   country assessment is finished, it can be used in different ways, depending on the situation in
   your country, in addition to following the RTHHC process as set out in the campaign proposal
   (See it at www.phmovement.org).
   The main focus of this assessment is on government responsibilities. By answering a series
   of five main questions you will be able to demonstrate how your government is fulfilling (or not
   fulfilling) its committments to promote the wellbeing of its people. You will then develop policy
   demands that will be presented at the national and international levels during the latter stages
   of the campaign. You can also choose to hold non-state actors (such as corporations, or nongovernmental
   organizations) accountable for their role in violations to the right to health. In that
   sense, this assessment guide and the RTHHC provide the opportunity for claim-holders and
   civil society actors to work together to challenge the private exploitation of the health sector.
   1.1. Who can use this guide?
   This assessment tool is designed for PHM national circles, NGOs, health organizations and
   human rights organizations that will be participating in the PHM Campaign. The assessment
   process should be used to attract as many people from diverse groups to the RTHHC. Its
   purpose is to get a country diagnosis of how the right to health and health care is being upheld
   for poor and marginalized populations. The results will be used to lobby governments for
   corrective actions. For PHM, the purpose is to get an overview of the status of the right to
   health and health care in about forty countries in five continents. This information will also
   serve to generate support at the international level, and at WHO, to more actively advocate for
   the health rights of the underserved.
2. Analysing the denial of the right to health and
   health care
   2.1. What is meant by denial of the Right to Health?
   There is an existing body of international covenants and consensus documents which
   mandates the Right to Health for all. Most country governments have committed themselves,
   to varying degrees, to implement the Right to Health, including the right to health and health
   care, by signing certain of these international covenants. Many national constitutions also
   recognise the Right to Health and mention the obligation of the state to provide health care and
   public health services.
   The non-fulfillment of these state obligations may be considered a denial of the Right to
   Health.To demonstrate this denial, essentially you have to do two things:
3. Examine the national level obligations of your government related to the Right to Health in
   detail.1
4. Examine whether all these obligations are being carried out and, if not, determine what
   characteristics this denial has in your country.
   On the basis of this analysis, you can make recommendations for improvements that will lead
   to a better implementation of people’s health rights.
   2.2. How can you assess the denial of the right to health?
   By following this assessment guide, you will be undertaking a five step process to document
   most aspects of the denial of the Right to Health in your country. Moreover, you will be
   proposing ways of improving the realization of this right for all.
   The five key questions this assessment asks are:
   I. What are your government’s commitments?
   II. Are your government’s policies appropriate to fulfill these obligations?
   III. Is the health system of your country adequately implementing interventions to realize the
   right to health and health care for all?
   IV. Does the health status of different social groups and the population as a whole reflect a
   progression in their right to health and health care?
   V. What does the denial or fulfillment of the Right to Health in your country mean in practice?
   These questions lead to the five steps we suggest you follow in applying this guide.
   2.3. What do the five steps assess?
   STEP I. What are your government’s commitments?
   1
   In case your government has not signed a major treaty or covenant, you can still judge the obligations against widely accepted international
   norms.
   Government commitments are the standards you can hold your government accountable for.
   Only if your government made a committment under national or international law can you hold
   the government legally responsible for the impact its policies have on the Right to Health.
   You will list the major commitments made by your government concerning the right to health
   and health care based on it having signed these international covenants. You will also examine
   provisions in your constitution, your national laws and policy agendas. In the case that your
   government has not signed a particular covenant, this too needs to be noted.
   The right to health and health care is closely related to and dependent upon the realization of
   other human rights. Other rights affected are the rights to life, to food, to housing, to privacy,
   to work, to access to information, to education, to freely associate and assemble, to human
   dignity, to equal treatment, to non-discrimination.2
   STEP II. Are your government’s policies appropriate to fulfill these obligations?
   You will examine major health-related policies and programmes to determine whether they are
   adequate to fulfill the right to health and health care committments your government has
   made. This will include looking at budgetary allocations at national and provincial levels.
   Special attention must be given to trends over time (the past 5 to 10 years) to assess whether
   health policies have been changed due to ‘reforms’ that may have increased health rights
   violations.3
   The influence of larger political and economic factors (e.g., structural adjustment) and the role
   of external agencies (such as the World Bank) should be analysed in relation to the evolution
   of health policies. Decisions by the WB can and do have an important impact on human
   rights. Fragmentation into national vertical programmes, often promoted by different donor
   agencies, should also be noted.
   STEP III. Is the health system of your country adequately implementing interventions to
   realize the right to health and health care for all?
   You will look at the actual structure and functioning of the health system in your country. to
   evaluate:

• Availability of health facilities and hospital beds per capita (urban and rural); availability of
  doctors, nurses and other health personnel especially in rural areas; availability of medicines
  and medical supplies, and other parameters you may add.
• Access to immunisation programmes and perinatal care, average health care expenditure
  per household and other good indicators of access.
• Acceptability, appropriateness and accountability of health services by assessing aspects
  like decentralisation, participation in decision-making, mechanisms for accountability to the
  community, provision of relevant information and other as relevant.
  In a separate section, you will look specifically at the private health sector — particularly the
  mechanisms for its regulation (if any)– and at the pharmaceutical industry, including price
  control mechanisms.
  2
  Based on: ICESCR General Comment 14, paragraphs 3 and 8
  3
  Violation is a concept that clarifies the ways in which the government and other actors fail to address people’s rights. Violations can occur
  through an action, or through failure to act. [Based on ICESCR General Comment 14, paragraphs 48-49, and Maastricht guidelines on
  violations of ESC Rights, paragraphs 14 and 15].
  Moving beyond averages, you will investigate health care inequities. By comparing health
  care availability and access for the more privileged versus the less privileged segments of
  society, you will assess to what extent the less privileged are being denied improved conditions
  that are attainable with existing national resources. You will also be looking at the provision of
  health care for vulnerable groups and groups with special needs — those whose health rights
  are most likely to be violated.
  STEP IV. Does the health status of different social groups and the population as a whole
  reflect a progression in their right to health and health care?
  Here, you will look at the ultimate impact the health system, and at how several of the social
  determinants of health are being addressed. More specifically, you will review major health
  indices and other indicators, which will tell you to what extent the right to health and health
  care of various social groups is being respected and fulfilled. Health inequities will be assessed
  by comparing health status indicators for the more privileged with those of the less privileged.
  The presentation of specific case studies can provide real-life examples of how individuals
  have suffered a denial of health care due to existing policies and/or their ineffective
  implementation (Optional).
  STEP V. What does the denial or fulfillment of the Right to Health in your country mean
  in practice?
  The final step is to systematically contrast the obligations outlined in Step I with the realities
  documented in Steps II, III and IV, and briefly highlight the main areas of denial of health rights
  in your country. Looking at recent trends will help assess whether the country is moving
  forward or backward in the realization of this right. You will be judging whether your
  government is doing all it is capable of to realize the Right to Health, and if its efforts are
  inadequate, in the light of its existing capacity.4
  Lack of capacity in itself is no justification for bad or non-existent health policies. The
  government can take many measures that do not require extensive resources. Even in times of
  severe resource constraints, the government has to protect vulnerable groups through targeted
  programmes.5 Governments can (and if necessary, should) expand their capacity by seeking
  international assistance.6 Lack of resources is sometimes the result of lack of priority, when
  governments spend large amounts on issues other than health, such as military expenditures,
  or when they fail to implement reasonable taxation policies.
  4
  Note there may be a difference between what the government wanted to achieve and the effect a policy has had in practice, i.e., a different
  effect than foreseen or no effect at all.
  5
  ICESCR General Comment 14, paragraph 18.
  6
  ICESCR article 2 and General Comment 14, paragraph 38.
  2.4. Before you start
  Please keep the following in mind while carrying out the assessment.
  Time: A full assessment may take one to two months and provides comprehensive human
  rights lobbying arguments. The data collection is the most time consuming part of the
  process. Sound lobbying arguments need to be based on facts and not all the required
  information will be readily available.
  Selectiveness: You need to answer only the questions you find relevant for your own
  assessment. Questions that have little or no relevance to your country’s situation should be
  skipped. You can also be selective in the level of detail. Only go into detail if you expect that
  the information will be necessary for your analysis or lobbying. At some points you may want to
  add questions that are specific to your situation.
  Preparation: First, read through all the annexes for necessary background information. Then
  go through the steps without answering the questions to get an idea of the information you will
  need to collect. Also, check if there are any existing reports on the human rights implications of
  the health system you can build upon. Make a work plan to help organize the process you will
  follow.
  You will need to involve people from within your organization and from other organizations to
  help with data collection and to discuss the findings. The more people from different sectors of
  the country are involved, the more credibility your report will have. More people involved also
  means more lobbying power.
  Finding the information: You may find relevant information to answer this assessment’s
  questions in: government policy documents/websites, websites of human rights
  organizations and health organizations (see annex iii on sources and resources), interviews
  with the people involved, and government and NGO reports to United Nations (UN) bodies.
  A final note: The government cannot be blamed for each individual health problem. After all,
  the Right to Health does not mean that people have the right to be healthy. However, you can
  hold your government accountable for what it does or does not do to prevent and reduce
  health problems.

1. The Assessment Guide
   Chapter 3 outlined the main purpose of each step. The following section provides suggestions
   for more specific questions to answer or issues to consider.
   STEP I. What are your government’s commitments?
   International treaties signed by a government and/or ratified by its legislature are as legally
   binding as any law. The commitments your government has made by ratifying human rights
   treaties often require changes at the national level. For instance, it must recognize the right to
   health and health care in its political and legal system.7 It has to abandon any laws or
   measures that have a discriminatory impact. Inclusion of the provisions of a treaty in national
   legislation makes it easier for people to claim their rights.
   Look in Annex III for references on treaties, consensus documents, and other agreements your
   governement may have signed.
   MAIN AREAS TO ASSESS RELEVANT ISSUES TO EXPLORE
   What international covenants,
   treaties, and consensus
   documents has your government
   ratified/signed-on to?
   • Which treaties has your country ratified? First consider
   the major international treaties (ICESCR, CEDAW and
   CRC) and regional treaties.
   • Has your country expressed any reservations or
   limitations on those?
   (You can find information on treaties and
   ratification on the websites of the UNHCHR,
   www.ohchr.org/english/law/index.htm,
   and the Human Rights Library of the University of
   Minnesota, www.umn.edu/humanrts/treaties.htm.)
   • Which consensus documents has your country signed?
   Millennium Development Goals (MDGs), Beijing
   Platform for Action, International Conference on
   Population and Development (ICPD), others.
   • Also consider other bilateral or multilateral agreements
   that may influence policy. For example, free trade
   agreements allowing international companies to compete
   with local industry (e.g., the GATS), agreements with the
   World Trade Organization (WTO), the World Bank
   (PRSPs) or other funding institutions.
   7
   ICESCR General Comment 14, paragraphs 34-36 and 60.
   Step I continued
   National constitution, laws and
   policy goals.
   International Covenant on Economic, Social and
   Cultural Rights (ICESCR) Article 12: “The state
   parties to the present covenant recognize the right of
   everyone to the enjoyment of the highest attainable
   standard of physical and mental health”
   ICESCR General Comment 14 specifies the
   desirability of a national legislation on Right to health:
   “56. States should consider adopting a framework law
   to operationalise their Right to Health in their national
   strategy. The framework law should establish national
   mechanisms for monitoring the implementation of
   national health strategies and plans of action.”
   GC 14 also stipulates: “The obligation to fulfil requires
   State parties, inter alia, to give sufficient recognition to
   the Right to Health in the national political and legal
   systems, preferably by way of legislative
   implementation”. “…and to adopt a national health
   policy with a detailed plan for realizing the Right to
   Health”.
   “States must ensure provision of health care…
   including immunization programmes against the major
   infectious diseases, and ensure equal access for all to
   the underlying determinants of health, such as
   nutritiously safe food and potable drinking water, basic
   sanitation and adequate housing and living
   conditions.”
   “Public health infrastructures should provide for sexual
   and reproductive health services, including safe
   motherhood, particularly in rural areas.”
   • Does the constitution or any relevant law commit the
   government to provide health services for the
   population?
   • Are there any specific constitutional or legal provisions
   applicable against which one can assess the right to
   health and health care?
   • Do official documents recognize the basic concept of
   comprehensive and universal primary health care? Are
   they in any way committed to “Health for All”? Do they
   refer to the Alma Ata Declaration of 1978?
   • Are there specific commitments related to women’s health
   and nondiscrimination concerning women? Commitments
   related to children’s health? To other vulnerable groups
   such as disabled people, people living with AIDS,
   refugees, migrants, adolescents, ethnic minorities, male
   and female sex workers, incarcerated men and women,
   and mentally ill people?
   • Do official documents speak of the need for the
   availability of essential drugs and the need of price
   controls for drugs?
   • Do policies place targets regarding public health
   investment as percentage of the GDP? 8
   • Do policies mandate equitable distribution of resources to
   all segments of the population (e.g., urban-rural, different
   geographical areas, different ethnic groups)?
   Step 1 Conclusion
   Summarise your government’s current obligations regarding the Right to Health and Health
   Care.
   8
   For example:
   • Countries to raise the level of tax revenue to at least 20% of their GDP;
   • Public health expenditure (including government and donor financing) to be at least 5% of the GDP;
   • Government expenditures on health to be at least 15% of total government expenditures;
   • Direct out-of-pocket payments to be less than 20% of total health care expenditures;
   • Expenditures on district health services (up to and including level 1 hospital services) to be at least 50% of total public health
   expenditures –of which half (25% of total) is to be spent on primary level health care;
   • Expenditures on district health services (up to and including level 1 hospital services) to be at last 40% of total public and private
   health expenditures;
   • The ratio of total expenditures on district health services in the highest spending district over that of the lowest spending district to
   be no more than 1.5.
   These indicators would complement service output and outcome indicators such as immunization coverage, rates of skilled attendance of
   deliveries, completed TB treatment rates and maternal, peri-natal and child mortality rates. [Global Health Watch 2005-2006, p.85].
   STEP II. Are your government’s policies appropriate to fulfill
   these obligations?
   In addition to what is explained in Section 2 under this step, consider answering the following:
   MAIN AREAS TO
   ASSESS
   RELEVANT ISSUES TO EXPLORE
   Which are the main policies
   and programmes that guide
   the health system in your
   country?
   Checklist:
   • Five-year national health policy or plan,
   • Reproductive health policy and/or family planning policy,
   • Women’s health policy,
   • Policies targeting AIDS, tuberculosis, mental health or other
   conditions,
   • Drug policy including (or not) essential medicines price controls,
   • Programmes to provide health care to the poor,
   • Other.
   Pay specific attention to what policies and programmes say regarding:
   • Primary health care;
   • Services to remote areas;
   • Village health workers;
   • Decentralization;
   • Privatization.
   What external factors have influenced these policies (e.g., debt, war,
   the impact of HIV/AIDs, other)?
   Are there any programs that already prioritize vulnerable groups for
   services? What are these groups and in what way are they targeted?
   Step II continued
   Who participates or
   participated in the
   development and
   implementation of health
   policies and programmes?
   What are the perceptions of affected groups regarding their major
   health problems and how they relate to the main national health
   policies? Have they received adequate information?
   [Rather than just talking about people, it is a good idea to talk with
   them and find out their views].
   Checklist of participation:
   • village/community committees,
   • voting in elections and referenda (local, regional and national),
   • patients’ associations and volunteer organizations,
   • government-NGO partnerships,
   • any consultation in the development, monitoring and evaluation
   stages of policy,
   • representative committees that monitor the implementation of
   services,
   • oral and written reports to international organizations and to
   national and international conferences.
   • government advisory bodies
   Where can people go to make a complaint (mechanisms for redress)?
   Are these mechanisms being used? Do these mechanisms
   effectively redress problems?
   What are the main changes
   taking place in your health
   system that concern you as
   public health-oriented
   advocates?
   Checklist of areas of concern:
   • Health sector reform (Have ‘reforms’ involving reduced public
   subsidies or ‘cost-effective measures’ –based on policy
   prescriptions by international institutions – been implemented in
   some form in the country?).
   • Privatisation (Have any public health services been privatised? If
   so, these should be listed and the impact of this privatisation on
   access to health services should be documented).
   • Participation in decision-making (Understood as the involvement
   of the beneficiaries in all health-related decision-making, as well
   as in the development, implementation and monitoring of policies,
   plans and strategies).
   • User fees.
   • The dismantling of primary health care programmes.
   • National vertical programmes
   • Population control and Family Planning.
   • Women’s health and reproductive health policies.
   • Pharmaceutical and drug policies.
   • Other.
   Step II continued
   What is the budget allocated
   to health? How is health
   care financed?
   A change in the health budget
   caused by a shift in allocations within
   the total national budget indicates a
   change in priority. A decrease in the
   total budget makes it more difficult to
   improve health rights. However, it
   does not relieve the government of
   its responsibility to at least protect
   ‘vulnerable’ members of society.
   What is the government expenditure on health as percentage of GDP?
   What is the overall (public and private) per capita spending on health
   care? (See footnote 9)
   What is the percentage of government spending as a proportion of the
   total expenditure on health care? Has this percentage been falling? Does
   the health care system function to transfer money from taxpayers and
   patients to private enterprises?
   What is the government per capita spending in rural areas compared to
   urban areas? (In 2000, the World Health Organization estimated that $60
   per person per year was needed for reasonable health care.)
   How does the above compare with other countries with the same level of
   development?
   Is the budget for health decreasing or increasing, i.e., has government
   spending in the health sector diminished in relative or absolute terms? If
   so, can you quantify the cuts made in the budget?
   As a result, do fixed expenditures (especially salaries) now tend to take
   up a larger part of total expenditures? Can you quantify this in
   percentage?
   Which areas have been most affected by budget cutbacks or by increased
   investments, e.g. infrastructure, salaries, medical supplies, rural health
   services, secondary & tertiary health care?
   Are expenditure patterns on health care skewed in favour of urban areas?
   Have investments correspondingly fallen in rural health services?
   Are there significant public-private inequalities in health expenditure and
   coverage?
   What kind of health staff is
   available? Is it sufficient?
   ICESCR, GC 14:“States have to
   ensure the appropriate training of
   doctors and other medical
   personnel, the provision of a
   sufficient number of hospitals, clinics
   and other health-related facilities,
   and…the establishment of
   institutions providing counselling and
   mental health services, with due
   regard to equitable distribution
   throughout the country.”
   A functioning health system requires sufficient staff that is well trained,
   gender sensitive and motivated.
   Checklist of staffing issues:
   • Ratio of doctors to population in rural areas compared to urban,
   • Availability of staff in different regions (particularly minority areas),
   • Representation of different ethnic, religious and cultural groups
   among staff.
   • Balance between female and male staff, especially in decision-making
   positions,
   • Number and quality of staff available for special sectors of the health
   system, e.g., the private sector or foreign-funded programmes,
   • Emigration of health staff,
   • Is the training of health staff adequate for the needs of the country?
   Step II continued
   Have public health services
   been privatized?
   Have health programmes suffered due to reduced funding or
   privatization? If so, this change should be quantified to the extent
   possible.
   Are health services sub-contracted to profit making companies or to
   NGO’s? What are the largest for-profit health-related corporations in
   your country?
   Does the government provide incentives, tax holidays and subsidies
   to the private sector (including the private pharmaceutical and the
   medical equipment industry)?
   More about this is found in step III.
   To what extent do other
   international actors expand
   or limit the capacity of the
   government to implement
   health programmes?
   Look at the positive and negative influences of technical and financial
   assistance on the right to health and health care.
   What are the priorities of those other actors? (Donor countries are
   usually more willing to fund activities that correspond to their
   priorities).
   Checklist international actors:
   • other governments,
   • international donors
   • International agencies such as the World Bank, IMF, WTO, UNDP,
   EU, WHO, ILO, UNICEF, UNFPA,
   • transnational and multinational corporations.
   Step II Conclusion:
   Summarise the appropriateness or inappropriateness of the government’s health sector
   policies and programmes in relation to the right to health and health care.
   Step III. Is the health system of your country adequately
   implementing interventions to realize the right to health and
   health care for all?
   In addition to what is said in Section 2 under this step, consider answering the following:
   MAIN AREAS TO ASSESS RELEVANT ISSUES TO EXPLORE
   What is the situation regarding the
   availability of relevant health
   services, goods and facilities?
   What does the government do to
   insure availability?
   What are the trends in availability,
   especially for marginalized
   groups?
   ICESCR General Comment 14, paragraph
   12: “Functioning public health and healthcare
   facilities, goods and services, as well as
   programmes, must be available in sufficient
   quantity in the country”.
   Checklist of indicators of availability:
   • Services are functioning,
   • They are available in sufficient quantity throughout the
   country,
   • The inputs needed for adequate functioning exist at
   health care delivery points (water, sanitation, buildings,
   personnel, drugs, workplace environment),
   • The availability of appropriate mental health and HIV
   and AIDS treatment and care,
   • The availability of emergency medical care for
   accidents and disasters,
   • Programmes that discourage the use of alcohol,
   tobacco, drugs and other harmful substances.
   Checklist of vulnerable or marginalized groups:
   • Girls, adolescent and older women;
   • Refugees, internally displaced people and migrants;
   • Ethnic minorities and indigenous populations;
   • Sex workers;
   • People with physical or mental disabilities;
   • People living with HIV/AIDS;
   • Incarcerated men and women.
   • Other, as relevant in your country.
   What does the government do to
   guarantee the quality of services?
   ICESCR General Comment 14, paragraph
   12d: “Health facilities, goods and services
   must be scientifically, as well as medically
   appropriate and of good quality. This
   requires, among other, skilled medical
   personnel, approved and unexpired drugs
   and hospital equipment, safe and potable
   water and adequate sanitation”.
   Checklist of indicators of quality:
   • Government licenture or certification of health
   personnel requires demonstration of minimum skills
   consistent with international standards,
   • The drugs, equipment, buildings and sanitation in health
   facilities are scientifically and medically appropriate,
   • The government promotes international standards of
   care for mental health and HIV/AIDS services,
   • Measures are taken to discourage irrational use of drugs
   and of inappropriate technologies.
   Step III continued
   What does the government do to
   guarantee access to health care
   services, goods and facilities? What
   have been the trends in this respect?
   ICESCR General Comment 14, paragraph
   12b: “Health facilities, goods and services
   must be accessible to everyone without
   discrimination, within the jurisdiction of the
   State party”
   .
   Vulnerable and marginalized groups are particularly
   important to consider.
   Access includes physical access, economic access
   (affordability) and information access.
   Checklist of indicators of physical access:
   • Existence of services at community level (distance or
   travel time to services),
   • Access to buildings for persons with disabilities,
   • A safe and supportive environment for youth,
   • Barriers which the poor face to access health facilities
   such as high fees for services, absence of convenient
   and affordable public transport,
   • Opening hours.
   Checklist of indicators of economic access:
   • Average percentage of household income spent on
   health,
   • Proportion of household income spent on health by the
   poorest 25% of the population (or any other indicator of
   equity of access),
   • Free services (where called-for) for safe pregnancy,
   childbirth and post-partum care,
   • Sufficient funds are available to run health care facilities,
   • Health insurance and health care for the poor,
   • Prices of drugs: Have there been substantial increases?
   Does the government subsidize them?
   Has privatization affected the
   availability and access of health
   services for the poor and
   marginalized groups?
   See the checklist on vulnerable and marginalised groups
   above. Consider mechanisms to regulate the actions of the
   private sector, the application of user fees, economic barriers
   to hospitalization.
   Legal precedents Have there been any court cases concerning the right to
   health and health care, i.e., where your government or other
   actors have been taken to court over health issues?
   Document these cases.
   Step III continued
   What does the government do to
   guarantee the acceptability of
   health care services, goods and
   facilities?
   CEDAW General Recommendation 24, paragraphs 12
   and 22: 12. States parties should report on their
   understanding of how policies and measures on health
   care address the health rights of women from the
   perspective of women’s needs and interests and how it
   addresses distinctive features and factors which differ
   for women in comparison to men, such as:
   (a) Biological factors which differ for women in
   comparison with men;
   (b) Socio-economic factors that vary for women in
   general and some groups of women in particular. For
   example, for women and men in the home and
   workplace, for different forms of violence for the girll
   child and adolescent girl Some cultural or traditional
   practices such as female genital mutilation also carry a
   high risk of death and disability;
   (c) Psychosocial factors which vary between women and
   men including depression, as well as conditions that
   lead to eating disorders;
   (d) Lack of confidentiality affects women detering them
   from seeking treatment. Women are less willing to seek
   medical care for diseases of the genital tract, for
   contraception, for incomplete abortion and in cases
   where they have suffered sexual or physical violence
2. States parties should also report on measures taken
   to making health care more acceptable to women, e.g.,
   seeking their informed consent, respecting their dignity
   and, guaranteeing confidentiality. States parties should
   not permit forms of coercion, such as non-consensual
   sterilization, mandatory testing for sexually transmitted
   diseases or mandatory pregnancy testing as a condition
   of employment.
   Do the services and goods correspond to users’ needs and
   expectations?
   Checklist of indicators of acceptability:
   • Respect for patients’ dignity,
   • Respect for confidentiality,
   • Sensitivity to women’s and minorities’ special needs and
   perspectives,
   • Respect for the culture of minorities and communities.
   Step III Conclusion
   Summarise the adequacy of the current health delivery system to achieve the right to health
   and health care.
   Step IV. Does the health status of different social groups and
   the population as a whole reflect a progression in their right to
   health and health care?
   In addition to what is said in Section 2 under this step, consider answering the following:
   MAIN AREAS TO ASSESS RELEVANT ISSUES TO EXPLORE
   General health indicators
   • Life expectancy by income quintile,
   • Main causes of death for adults, disaggregated for women
   and men, rural and urban areas
   What is the government doing to
   remove barriers to the enjoyment
   of health rights of the poor,
   minorities, and marginalized
   groups?
   • Measures taken to meet their specific health needs,
   • Participation of the groups concerned in decision
   making,
   • Measures taken to reduce the stigma of HIV/ AIDS,
   mental illness and and other medical conditions,
   • Measures taken to reduce marginalization of women
   heads of household, minority groups and the poor.
   • Examples of instances in which the right to health and
   health care was realized?
   Health status of women
   CRC Article 24, 2: (State Parties shall.take
   appropriate measures “(d) To ensure
   appropriate pre-natal and post-natal health
   care for mothers.” “(f) To
   develop preventive health care, guidance
   for parents and family planning education
   and services.”
   • Differences in under 5 mortality rates between girls and
   boys,
   • Maternal mortality rates,
   • Percentage of women that die in childbirth,
   • Percentage of births attended by medically trained
   personnel in rural areas,
   • Trends of these in the last 5-10 years,
   • Are family planning policies aiming at giving women
   informed choice or only at controlling population growth?
   Step IV continued
   Health status of children
   CRC Article 24: “1. States Parties recognize the right
   of the child to the enjoyment of the highest attainable
   standard of health and to facilities for the treatment of
   illness and rehabilitation of health. States Parties shall
   strive to ensure that no child is deprived of his or her
   right of access to such health care services.”
   “2. States Parties shall pursue full implementation of
   this right and, in particular, shall take appropriate
   measures:”
   “(a) To diminish infant and child mortality.”
   “(b) To ensure the provision of necessary medical
   assistance and health care to all children with
   emphasis on the development of primary health care.”
   “(c) To combat disease and malnutrition, including
   within the framework of primary health care, through,
   inter alia, the application of readily available technology
   and through the provision of adequate nutritious foods
   and clean drinking-water, taking into consideration the
   dangers and risks of environmental pollution.”
   “(e) To ensure that all segments of society, in particular
   parents and children, are informed, have access to
   education and are supported in the use of basic
   knowledge of child health and nutrition, the advantages
   of breastfeeding, hygiene and environmental sanitation
   and the prevention of accidents.”
   • Infant mortality rates, disaggregated by sex and
   rural/urban areas,
   • How many avoidable/preventable child deaths per day?
   • Which are the major killers?
   • Immunization coverage rates,
   • Trends of these in the last 5-10 years.
   Considering the above, is the
   current health system
   discriminatory?
   A policy violates the right to non-discrimination if it:
   • negatively affects some groups, but not others;
   • positively affects groups that were already
   advantaged (thereby widening the gap);
   • affects all groups equally, without taking into
   account significant differences between those
   groups;
   • reaffirms stereotypes, which maintain certain
   groups in an inferior position.
   A policy is considered not discriminatory if it has a
   positive effect on only disadvantaged groups, on the
   condition that it is a temporary special measure with the
   specific aim of reducing the gap between advantaged
   and disadvantaged groups.9
   If yes, on which basis are people discriminated against?
   Checklist of grounds for discrimination:
   • sex and gender,
   • age,
   • race and ethnicity,
   • health status/disability,
   • sexual orientation,
   • language,
   • religion,
   • political or other viewpoint,
   • income,
   • national or social origin.
   Step IV Conclusion
   Summarise the human rights impact (negative or positive) of the health care system in your
   country on different vulnerable groups.
   9
   HeRWAI, 2006, page 38
   Step V. What does the denial or fulfillment of the Right to
   Health in your country mean in practice?
   Here you will be looking at the fulfilment of relevant State obligations. The most relevant core
   obligations for the Right to Health are listed and defined below. A detailed explanation of the
   concepts of core obligations can be found in ANNEX II. You are asked to select the obligations
   which are most relevant to the present situation, and to explore the difference between what
   your government has promised to do (Step II) and what the government has actually achieved
   (Step IV). This difference provides strong arguments to improve the right to health and health
   care situation, and will help you to determine the violations for which you can hold your
   government accountable. Be aware that quantity is not a factor in determining if a violation has
   occurred. If discrimination takes place, it is a violation of human rights, regardless of the
   number of people who are discriminated against.
   MAIN AREAS TO ASSESS RELEVANT ISSUES TO EXPLORE
   Which of the core obligations are
   not being fulfilled?
   ICESCR General Comment 14 specifies certain Core
   obligations of States related to the Right to Health:
3. “States parties have a core obligation to ensure the
   satisfaction of, at the very least, minimum essential
   levels of each of the rights enunciated in the Covenant,
   including essential primary health care.”
   “(a) To ensure the right of access to health facilities,
   goods and services on a non-discriminatory basis,
   especially for vulnerable or marginalized groups;”
   “(d) To provide essential drugs, as from time to time
   defined under the WHO Action Programme on Essential
   Drugs;”
   “(e) To ensure equitable distribution of all health facilities,
   goods and services;”
   “(f) To adopt and implement a national public health
   strategy and plan of action, on the basis of
   epidemiological evidence, addressing the health
   concerns of the whole population; the strategy and plan
   of action shall be devised, and periodically reviewed, on
   the basis of a participatory and transparent process; they
   shall include methods, such as Right to Health indicators
   and benchmarks, by which progress can be closely
   monitored; the process by which the strategy and plan of
   action are devised, as well as their content, shall give
   particular attention to all vulnerable or marginalized
   groups.”
   Core obligations require your government to ensure, at the
   very least, minimum essential levels of:
   • Access to health facilities, goods, and services on a nondiscriminatory
   basis, especially for vulnerable or
   marginalized groups,
   • Access to food,
   • Access to shelter, housing, water and sanitation,
   • Access to essential drugs.
   The following core obligations are of comparable priority:
   • Reproductive, maternal (pre-natal, as well as post-natal)
   and child health care;
   • Immunisation against major infectious diseases;
   • Measures to prevent, treat and control epidemic and
   endemic diseases;
   • Education and access to information concerning health;
   • Training for health personnel, including education on health
   and human rights.
   • Equitable distribution of all health facilities, goods and
   services;
   • A national public health strategy and plan of action.
   Are these ensured?
   Step V continued
   Is the government moving forwards
   towards a universal right to health
   and health care?
   The Universal Declaration of Human
   Rights, Article 25: “Everyone has the right to
   a standard of living adequate for … health
   and well-being of himself and his family,
   including food, clothing, housing, medical
   care and the right to security in the event of
   … sickness, disability…. Motherhood and
   childhood are entitled to special care and
   assistance…”
   The obligation of progressive realization requires
   governments to do whatever they can to improve the health of
   their people. This means that if the government can achieve
   more, it has the obligation to do so.
   Can it? Is it?
   Or, is the government failing to
   maintain its achievements
   regarding health rights?
   The obligation of non-retrogression is applicable only if:
   • the deterioration is avoidable,
   • the government has not done all it can to prevent the
   deterioration,
   • the government has not asked for international assistance
   to address the problem, and/ or
   • the government has not protected vulnerable groups
   against the deterioration.
   Which of the violations you found
   are a result of the government’s
   failure to meet its obligations to
   respect, protect and fulfil health
   rights?
   ICESCR GC 14: “52. Violations of the
   obligation to fulfill occur through the failure of
   States parties to take all necessary steps to
   ensure the realization of the Right to Health.
   Examples include the failure to adopt or
   implement a national health policy designed t
   o ensure the Right to Health for everyone;
   insufficient expenditure or misallocation of
   public resources which results in the nonenjoyment
   of the Right to Health by
   individuals or groups, particularly the
   vulnerable or marginalized; the failure to
   monitor the realization of the Right to Health
   at the national level, for example by
   identifying Right to Health indicators and
   benchmarks; the failure to take measures to
   reduce the inequitable distribution of health
   facilities, goods and services; the failure to
   adopt a gender-sensitive approach to health;
   and the failure to reduce infant and maternal
   mortality rates.”
   The government fails to respect people’s health rights if its
   policies reduce people’s chances to enjoy good health.
   The government fails to protect people’s health rights if its
   policies permit others to endanger people’s health.
   The obligation to fulfil means that the government has to take
   positive measures that enable and assist people to enjoy their
   health rights.
   It is a good idea here to refer to the commitments you identified
   in Step II.
   Step V continued
   Which of its commitments is the
   government more specifically
   violating?
   Refer to all commitments identified in Step I to respond to this
   question.
   Who are the responsible dutybearers
   for each major violation?
   Which government agencies or departments are responsible
   for the denial or violations of people’s health rights? Which
   individuals in the government? Which other national actor(s)?
   Do foreign governments or international actors have an
   influence on the violations?
   Is lack of resources a major
   obstacle?
   If yes:
   • Has the government used the resources it does have to
   the maximum extent?
   • Has the government attempted to obtain international
   technical and financial assistance?
   • Have other (donor) governments or international institutions
   extended the necessary assistance?
   • Document any examples of efforts to take steps that did not
   require additional resources.
   Base your answer on your findings in Step III.
   Step V Conclusion
   Summarise the denials/violations for which you can hold your government accountable.
4. What needs to be done to challenge the key
   elements of the denial of the Right to Health in your
   country?
   In today’s world the technical means exist to provide basic health-related services for all
   people. Even some developing countries with comparatively low per capita incomes have
   achieved significant progress towards securing the right to health and health care for all their
   citizens.
   However, a range of political and economic factors, policy decisions, and gaps in
   implementation, lead to some denial of health rights in every country. In the final step of this
   guide you will compile the information you have gathered the form of recommendations to
   improve government health policy. You will then use these recommendations or demands to
   prepare your national action plan to realise the right to health and health care. Further on in the
   PHM campaign, all the countries which have gone through this process will meet to share their
   findings and plans, and decide on what international steps can and should be taken to support
   their common goals.
   We suggest that the policy recommendations and action plan be developed in a participatory
   process that includes people who are usually left out of policy discussions. You will present the
   cases of violations of the right to health and health care you documented with this assessment
   tool. Participants will decide what changes should be made to stop these violations, and what
   should be done to bring about those changes. It is expected that each country will have
   different policy ideas and activist strategies that come out of that particular country context.
   The final product of your work will include a summary of the findings of the assessment, the
   policy and action recommendations, and at least a draft action plan. As we share this work
   internationally, common problems and solutions will emerge. We will build a groundswell of
   understanding of and support for human rights as the basis for development. Backed by all
   those who have contributed to the RTHHC, PHM will then take those common demands to the
   pertinent international institutions.
   4.1.Developing your policy recommendations
   Having carried out this assessment, you have clearly identified human rights gaps in the area
   of health care in your country, and you have documented them with qualitative and quantitative
   data. Use the following questions to help you decide which violations you will prioritize in the
   recommendations or demands.
   • Can you confidently say there are repeated and continued violations of the right to health
   and health care?
   • Which of the violations you document are of major concern in your country at this time?
   • Can several of the specific violations you have documented be addressed by changes in
   one policy area?
   • Do beneficiaries and NGOs you have worked with on the assessment share your findings?
   Are they willing to start mobilising to challenge relevant duty bearers?
   For each of the violations you have identified in Step V, try to formulate a recommendation to
   bring the government into compliance with its health rights obligations. Consider the following
   in formulating the recommendations:
   • Policy stage: The stage the respective policy is in may determine the type of solution or
   recommendation to be made and whom you need to approach.
   • Objectivity: Try to be as realistic as possible. In many cases, no easy solution will be
   available. This does not release the government from its obligations. The recommendation
   you may choose might be to undertake further research into the causes of and possible
   solutions to a specific health problem identified.
   • Type and basis of your arguments: Depending on who needs to be convinced, it may be
   strategic to use more legal, more medical or more political arguments.
   • Groups affected: Try to find solutions that suit the groups most affected by the policy (or
   absence of it). It is best to involve the most affected groups in the development of your
   recommendations.
   • Ownership: Whenever possible, you should involve the responsible policy-makers/duty
   bearers in the search for alternatives. This will increase their ownership of the suggestions
   and their chances for acceptance.
   • Preparedness: In Step V, you identified the main obstacles to the government meeting its
   obligations. The government will probably refer to those obstacles when confronted with
   your findings. What will your counter-arguments be? Build your case in advance of such a
   dialogue.
   • Include benchmarks: Benchmarks make it easier to monitor achievements. For each of
   your recommendations try to set benchmarks that will measure the impact of the policy
   changes. Preferably, these benchmarks should be related to those already set by the
   government, or proposed by WHO or other respected organization. If you are not able to
   formulate them yourself, you can also insist the government achieves its own benchmarks,
   adjusts them or sets new ones as needed.
   If policy change is not the solution, what action should the government take? Be prepared to
   make such recommendations. Consider things such as: scrapping bad policies; setting up a
   compensation mechanism for affected groups; or the publication of regulations to control the
   actions of, for example, the private sector.
   4.2. Questions to answer in preparing your action plan
   To which government department or person should you direct your lobbying efforts?
   To increase the chances that your recommendations are implemented, it is important to
   consider whom you are presenting the information to. The governmental level, role and
   competencies of the department or person will determine if they are able to actually make the
   changes you are demanding. Do they need authorization from a higher level? Have certain
   government responsibilities been delegated to the municipal or regional level? Should you aim
   your lobbying at those developing the policy or at those implementing or evaluating the
   policy? Are there procedures you must follow to get the attention of a particular department?
   Some governments or policy-makers are not aware of their human rights obligations. You
   may need to explain to them what their obligations are in relation to the Right to Health.
   Which other governments, funding agencies or other actors should you approach to
   point out how their funding or actions should contribute to the the realization of the
   right to health and health care in your coutry?
   These other actors may be able to put external pressure on governments or on private actors
   and may have an influence on the situation itself. When aiming your lobbying at these other
   actors keep in mind what their exact role/ mandate is and what they are most sensitive to.
   What is the most strategic time to present your findings?
   The response to this question requires some knowledge of the government’s agenda or the
   agenda of other actors you may want to approach. What deadlines are involved in changing a
   given policy? A conference, a debate in parliament, a visit of a high-level official, etc. can all
   provide strategic entry points to present your findings. It may also help to coordinate your
   actions with the international level of the right to health and health care Campaign.
   What options are available to you to increase pressure on the government?
   It is a good idea to identify other things you can do, besides lobbying, to pressure the
   government, for example public interest litigation (i.e., suing the government for the violation
   of human rights), going public using the local press, or mobilizing the affected community(ies)
   for mass actions. Begin thinking about how the global PHM can support and endorse your
   demands.
   When and how will you check whether changes have really led to an improvement of the
   right to health and health care?
   This check is necessary, because even if the government accepts your recommendations, this
   does not mean that the desired results will be achieved. It is possible that the changes you
   suggested were not adequate to improve health rights, or that other factors hampered their
   successful implementation. Use the benchmarks you defined earlier to set up a monitoring
   plan in advance.
   What awareness-raising activities should you use to inform the public about your
   findings and recommendations?
   Lobbying the government should be accompanied by advocacy work, to make people aware
   of their health rights and how they are being violated. This can be done through the media,
   organizing a conference or workshop, producing and distributing a leaflet or video, etc.
   Disseminating your findings to other organizations with an interest in health rights is a good
   strategy to involve more people in the right to health and health care Campaign.
   How much time and which resources (financial and in terms of skills) does your
   organization need to implement your action plan? Can these resources be made
   available?
   Developing a time frame and a budget will help to make a realistic action plan and will be
   useful if you need to ask for outside assistance and funding. If you do not have experience with
   lobbying, share your findings with more experienced organizations and invite them to get
   involved in the Campaign.
5. Concluding remarks and contact information
   Always keep in mind that this exercise on which you are embarking is part of a global effort to
   reverse the violations of the right to health and health care both in rich and poor countries.
   We again recommend that you review the campaign proposal as posted at the PHM website
   (www.phmovement.org ) under ‘Right to Health’. This will help you understand the
   campaign in its entirety and to keep things in perspective,
   At any time, you can seek further advice from others in the People’s Health Movement.
   • The PHM website: www.phmovement.org
   • The PHM Global Secretariat: secretariat@phmovement.org
   • The PHA Exchange listserve: pha-exchange@lists.kabissa.org
   • The Right to Health and Health Care Campaign core group members are available to
   support you. We also welcome your feedback:
   Saskia Bakker (Netherlands), s.baskker@hom.nl
   Ariel Frisancho (Peru), afrisanchoarroyo@yahoo.es
   Abhay Shukla (India,) abhayseema@vsnl.com
   Cristianne Rocha (Brazil), cristianne.rocha@terra.com.br
   Claudio Schuftan (Vietnam), claudio@hcmc.netnam.vn
   Laura Turiano (USA), phm@turiano.org
   [The names and email addresses of regional coordinators will be added at a later stage].
   When you complete your assessment, we ask you to send a copy of your summary results and
   tentative action plans to the campaign core group at PHM: phm@turiano.org
   Congratulations on your work with the right to health and health care Campaign. You
   will hear from the core group when we are ready to launch phase II of the campaign.
   Annex I. CONCEPTS AND DEFINITIONS
   What is the right to health and health care?
   The right to health includes the availability, access, acceptability and quality of health care. Health is a
   fundamental right that influences all aspects of life, so it is important to look at health in a broad way. It
   is closely related to other human rights. Although we focus our analysis on the right to health, this does
   not mean it is considered more important than others are.
   What is the principle of non-discrimination?
   The principle of non-discrimination is a cornerstone of human rights. It means that all people have the
   same human rights even if they are different in some way from others. For example, discrimination
   based on sex is one common type of discrimination.10. Women and men should have equal access to
   health care. However, non-discrimination does not mean treating everyone the same. Such an
   approach disadvantages women as a result of past discrimination. Women require different treatment
   from men due to biological factors, socio-economic factors, and psychosocial factors.11
   States have important obligations with regard to discrimination:
    to eliminate not only their own discriminatory practices, but also those of individuals.
    to address direct as well as indirect discrimination. An example of an indirect discriminatory law is
   one that requires everyone to pay the same amount for health care, even though the cost is
   unaffordable for people without paid work, such as elderly widows.
    to implement temporary special measures (where necessary) to reverse the effects of past
   discrimination on particular groups.
    to take measures to ensure that women and men can, and do, participate in society on
   an equal basis, such as removing barriers which women face access their rights.
   What is the principle of participation?
   The participation of the general population in all health-related decision-making at the community,
   national and international levels is an important aspect of the right to health. Individuals and groups
   should be involved in making decisions about health policies.12 They should also have an opportunity to
   make complaints about the negative effects of laws and policies. Because of traditional gender roles,
   women tend to participate less than men in political and public life.13 Involving women in decisionmaking
   therefore requires specific attention by the government.
   10
   Universal Declaration of Human Rights, article 2; CEDAW article 1 and 2; ICESCR Articles 2 and 3, General Comment 16
   11
   CEDAW article 1, ICESCR general comment 24, paragraph 12
   12
   ICESCR general comment 14, paragraph 54, see also paragraph 11 and 17
   13
   CEDAW general recommendation 19, paragraph 11
   What is policy?
   A policy is a plan of action. A policy can refer to a nationwide five-year health strategy or to decisions
   about a particular disease or region. The process by which policies are developed can involve local or
   national government, NGOs, or individuals. This assessment mostly concentrates on government
   policy. The government policy process follows a number of stages (at least in theory):
    Agenda-setting: the process by which problems come to the attention of government;
    Policy formulation: the process by which policy options are identified by government;
    Decision-making: the process by which the government adopts a certain course of action (or nonaction);
    Policy implementation: the process by which the government puts the policy into effect;
    Policy evaluation: the process by which the results of policies are monitored both by the
   government and by civil society and which may lead to a new set of stages.
   During the stages of agenda setting, policy formulation and evaluation, people’s
   organizations may have a particularly strong role. In other stages participation may be
   more difficult.
   What are health reforms, PRSPs, MDGs and how do they influence health
   policies?
   Many countries throughout the world have introduced health sector reforms to control the costs of
   health services. These reforms have serious implications for the right to health.
   A much-debated trend is the privatization of health related services, whereby the government allows
   and often stimulates the private sector to take over the provision of certain services (e.g., in health
   clinics) or goods (e.g., the distribution of contraceptives). In some countries, health sector reforms are
   the result of Poverty Reduction Strategy Plans (PRSP), which governments write to be eligible for
   loans from the IMF, the World Bank and other donors. PRSPs determine the direction of health policies
   and their budgets.
   The Millennium Development Goals (MDGs) also have a considerable influence on health rights. This
   influence may be positive because the MDGs prompt governments to take action on many health
   related issues. But the MDGs may also have a negative effect if attention and resources are drawn
   away from important areas. For example, sexual and reproductive rights do not have a prominent place
   in the MDGs and may not receive necessary funding.
   Similar discussions are taking place concerning the effects of the General Agreement on Trade in
   Services (GATS) and the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS)
   on the price of health services and drugs.
   This right to health and health care assessment can show how these agreements impact the health
   rights of certain groups. In addition, the progress reports that countries make for the PRSPs, the MDGs,
   etc. may provide useful information for our analysis.
   How does globalization effect a government’s responsibility for the right
   to health and health care?
   Governments’ first responsibility regarding the right to health is at the national level. But in a globalized
   world, governments have a growing responsibility at the international level. First of all, a country’s
   actions often have impacts beyond its national borders. Air and water pollution are clear examples of
   such influence. Secondly, governments help each other on a bilateral basis, such as through
   development cooperation. According to human rights treaties, governments have the obligation to
   support each other in implementing health rights. A third way in which governments have international
   influence is through multilateral institutions. Influential international institutions such as the World Bank
   are owned by the governments of member nations, which have ultimate decision-making power within
   the organization. Last but not least, governments monitor each other through international agreements.
   These may be bilateral or multilateral; legally binding, such as UN human rights treaties, or morally
   binding, such as the Millennium Development Goals. It is clear that in a globalized world, decisions at
   the local, national and international levels influence each other.
   Annex II WHAT ARE HUMAN RIGHTS?
   Human rights are the rights possessed by all persons, by virtue of their common humanity. The first
   and most influential document describing human rights is the Universal Declaration of Human Rights
   of 1948. It is the predecessor of the major human rights treaties. The declaration recognizes the
   inherent dignity and equality of all human beings, the notion that lies at the heart of all human rights.
   Some other features of human rights are listed below:
   • Human rights are fundamental, because individuals need them to survive, to develop and to
   contribute to society. They are the primary means for every person to develop their full potential.
   • Human rights are not granted by governments or by international law. Every individual has human
   rights and is entitled to all of his or her human rights by virtue of being human.
   • Human rights are inalienable. They cannot be taken away from a person or denied to a person by
   the State.
   • Human rights are universal. This means that every human being is entitled to human rights,
   regardless of gender, race, age, ethnicity, citizenship, religion, disability or other status.
   • Human rights are indivisible; they are closely connected. The realization of the right to health, for
   example, is closely connected to the realization of other human rights, such as the right to
   education, food and an adequate standard of living.
   Women’s rights are human rights
   Even though all general human rights treaties include a provision on the equality of men and women,
   this has not proven sufficient to eliminate discrimination against women. The Convention on the
   Elimination of all forms of Discrimination Against Women (CEDAW) was developed to focus on the
   elimination of discrimination of women in a broad sense. By adopting this treaty in 1979, States
   recognized that special attention was needed to women’s human rights. CEDAW clearly defines what
   discrimination against women means and what States should do to prevent it. 25 years after its
   adoption there is still a gap between respect for women’s rights on paper and in practice: CEDAW
   provides a good basis to claim justice and equality for women throughout the world.
   Why a human-rights approach?
   Human rights treaties are the foundation of a human-rights based approach. States have the
   obligation to respect, protect and fulfill the human rights laid down in the treaties they have signed
   and ratified. Using the example of poor people’s right to health and health care, this means that
   governments are not allowed to violate their health rights (the obligation to respect) and that they
   should restrain others – companies for example – from violating them (obligation to protect). Moreover,
   the government should do all it can to make sure that poor people achieve the highest attainable
   standard of health (obligation to fulfill). In other words, when speaking of human rights we do not speak
   of mere aspirations by States, or of the needs of those claiming their rights, but of obligations for
   governments. Keeping this in mind, it can be said that:
   • A human rights based approach is based on the idea that every human being has rights. States are
   responsible for the realization of these. Citizens can hold the State accountable for its obligations to
   respect, protect and fulfill human rights.
   • The basis of a human-rights approach is that a human rights violation needs to be addressed, even
   when the number of people involved is small or not precisely known. In other words, each human
   rights violation stands on alone and should be taken seriously. A decrease in numbers of a certain
   type of human rights violation is a positive development, but does not excuse other violations still
   taking place.
   • A rights approach to poor people’s health care means monitoring the way they enjoy, exercise and
   claim their health rights.
   Why use international human rights treaties?
   A human rights treaty (or covenant or convention) is a written document binding States under
   international law. All countries that have agreed to be bound by international human rights treaties
   through ratification or accession have a legal obligation to implement these rights and principles at
   the national level14.
   Human rights treaties lay down important principles. CEDAW, for example, states that women and men
   must have equal rights with regard to health care and — at the same time — that governments must
   examine the specific health needs of women. Committees of independent experts (treaty-monitoring
   bodies) monitor the implementation of a certain treaty. They study reports on the implementation of the
   treaty that States have to submit regularly. NGOs and PHM circles can provide important input to this
   process via so-called shadow reports. Some treaties offer the possibility for individuals to submit
   complaints to a treaty-monitoring body. Annex III on Sources and Resources provides links to the most
   relevant international and regional treaties.
   14
   This is the main difference with consensus documents, such as the MDG’s, the outcome documents of world conferences and the UN
   General Assembly resolutions, which entail a moral, but not legal, duty to implementation.
   Annex III. SOURCES AND RESOURCES
   Resources on lobbying and advocacy
   Short guide on lobbying. Website of the Education and Training Unit, South Africa.
   http://www.etu.org.za/toolbox/docs/organise/weblobby.htm
   Short overview of the basics of lobbying. Website of the Democracy Center.
   http://www.democracyctr.org/resources/lobbying.html
   Online lobbying guide that can be downloaded. Website of the Independent Sector.
   http://www.independentsector.org/programs/gr/lobbyguide.html
   Good list of resources for advocacy, focus on ICDP Agenda. Website of the Asia-Pacific
   Alliance. http://www.asiapacificalliance.org/SITE_Default/Resources_for_
   Advocacy_Default.asp
   Good list of general resources on advocacy. Organization focuses on HIV/AIDS.
   http://www.aidsmap.com/en/docs/32364953-087A-45D3-AEED-E773BE45593D.asp
   General tips on advocacy. Website of the Ugandan AIDS Advocacy network.
   http://www.phrusa.org/campaigns/aids/uganda/toolkit/eightsteps_advocacy.php
   Health indicators, data sources
   PAHO gender differences in health and development in 48 countries in the Americas, focusing on
   women’s reproductive health, access to key health services and major causes of death.
   http://www.paho.org/english/DPM/GPP/GH/GenderBrochure.pdf PAHO Country
   Health Profiles.
   http://www.paho.org/english/sha/profiles.htm UNDP Human Development Reports 1990-2005.
   http://hdr.undp.org/reports/global/2005/ UNFPA Population and Reproductive Health
   Country Profiles.
   http://www.unfpa.org/profile UNFPA State of the World Report 2005.
   http://www.unfpa.org/swp/2005/english/ch1/index.htm UN Statistics Division.
   http://unstats.un.org/unsd/default.htm WHO Health indicators per country.
   http://www.who.int/countries/en/ (also available in Spanish and French)
   WHO World Statistical Information System.
   http://www3.who.int/whosis/menu.cfm WORLD BANK
   GenderStats; gender statistics and indicators.
   http://devdata.worldbank.org/genderstats/home.asp
   International treaties
   CEDAW Convention on the Elimination of All Forms of Discrimination against Women.
   http://www.un.org/womenwatch/daw/cedaw/index CEDAW the Optional Protocol.
   http://www.un.org/womenwatch/daw/cedaw/protocol/text.htm
   CEDAW General Recommendations. (see especially Recommendation 25 on health and 19 on
   violence against women)
   http://www.un.org/womenwatch/daw/cedaw/recomm.htm
   ICESCR International Covenant on Economic, Social and Cultural Rights.
   http://www.ohchr.org/english/law/cescr.htm http://66.36.242.93/treaties/cescr.php
   ICESCR General Comments. (see especially Comment 14 on health and 16 on equal rights for women
   and men)
   http://www.ohchr.org/english/bodies/cescr/comments.htm
   CERD International Convention on the Elimination of All Forms of Racial Discrimination.
   http://www.unhchr.ch/html/menu3/b/d_icerd.htm
   CRC Convention on the Rights of the Child.
   http://www.unhchr.ch/html/menu3/b/k2crc.htm
   CMC. Convention on the Protection of the Rights of All Migrant Workers
   http://www.unhchr.ch/html/menu3/b/m_mwctoc.htm
   UDHR Universal Declaration of Human Rights.
   http://www.unhchr.ch/udhr/
   Regional treaties and organizations
   Africa
   African Charter on Human and Peoples’ Rights (1981).
   http://www1.umn.edu/humanrts/instree/z1afchar.htm
   Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa.
   http://www.achpr.org/english/info/women_en.html African Union. http://www.africaunion. org/home/Welcome.htm African Commission on Human Rights. http://www.achpr.org/english/_info/index_women_en.html Europe European Convention on Human Rights (1950). http://www.hri.org/docs/ECHR50.html European Social Charter (1961). http://www1.umn.edu/humanrts/euro/z31escch.html Council of Europe. http://www.coe.int/t/e/Human_Rights/ European Court of Human Rights. http://www.echr.coe.int/echr EU and Gender Equality. http://europa.eu.int/comm/employment_social/gender_equality/index_en.html EU and Health. http://europa.eu.int/comm/health/ph_overview/overview_en.htm OSCE. http://www.osce.org/odihr/13371.html The Americas American Convention on Human Rights (1969). http://www.oas.org/juridico/english/Treaties/b-32.htm Additional Protocol to the American Convention on Human Rights in the Area of Economic, Social and Cultural Rights (1988). http://www.oas.org/juridico/english/Treaties/a-53.htm Inter-American Convention on the Prevention, Punishment and Eradication of Violence Against Women, ‘Convention of Belem do Para’ (1994). http://www.oas.org/cim/English/Convention%20Violence%20Against%20Women.htm Organization of American States. http://www.oas.org/main/main.asp?sLang=E&sLink= http://www.oas.org/key_issues/eng Inter- American Commission. http://www.cidh.org/basic.eng.htm Inter-American Court. http://www.corteidh.or.cr/index_ing.html Consensus documents Beijing plus 5 and Beijing Platform for Action. http://www.un.org/womenwatch/daw/followup/beijing+5.htm Declaration of Alma Ata (1978). http://www.phmovement.org/charter/almaata.html Declaration of Commitment on HIV/AIDS, ‘Global Crisis-Global Action’ (2001). http://www.un.org/ga/aids/coverage/FinalDeclarationHIVAIDS.html Declaration on the Elimination of Violence against Women (1993). http://www.unhchr.ch/huridocda/huridoca.nsf/(Symbol)/A.RES.48.104.En?Opendocument Declaration on the Right to Development (Vienna Declaration and Programme of Action) (1993). http://www.hri.ca/vien-na+5/vdpa.shtml Declaration on the Rights of Disabled Persons (1975). http://www.unhchr.ch/html/menu3/b/72.htm ICPD Programme of Action (Cairo Programme of Action) Report of the International Conference on Population and Development (1994). http://www.iisd.ca/linkages/Cairo/program/p00000.html Maastricht Guidelines on Violations of Economic, Social and Cultural Rights, Maastricht, January 1997. http://www1.umn.edu/humanrts/instree/Maastrichtguidelines.html
   Millennium Declaration (MDGs) (2000).
   http://www.developmentgoals.org
   People’s Charter for Health.
   http://www.phmovement.org/pdf/charter/phm-pch-english.pdf
   Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care
   (1991).
   http://www.unhchr.ch/html/menu3/b/68.htm
   Resources on treaties
   ABA-CEELI. The CEDAW Assessment Tool: An Assessment Tool Based on the Convention to Eliminate
   All Forms of Discrimination against Women.
   http://www.rightsconsortium.org/resources/assessment/CEDAWtool.pdf
   Office of the United Nations High Commissioner for Human Rights.
   www.ohchr.org/english/law/index.htm
   Human Rights Library of the University of Minnesota.
   www1.umn.edu/humanrts/treaties.htm
   Treaty Body Database on the Implementation of CEDAW and Other UN Human Rights Conventions.
   www.unhchr.ch/tbs/doc.nsf
   Women’s Human Rights Net provides information about women’s human rights throughout the world.
   Also available in French and Spanish.
   www.whrnet.org
   Other documents of interest
   OHCHR, Draft Guidelines: a Human Rights Approach to Poverty Reduction Strategies,
   2002, CESCR. http://www.unhchr.ch/development/povertyfinal.html
   WHO: 25 Questions and Answers on Health and Human Rights, WHO Health and Human Rights
   Publication Series, Issue No.1, 2002. http://www.who.int/hhr/activities/publications/en
   Special Rapporteur on Violence against Women: Cultural Practices in the Family That Are Violent
   towards Women, Report of the Special Rapporteur, January 2002.
   www.unhchr.ch/Huridocda/Huridoca.nsf/0/42e7191fae543562c1256ba7004e963c/$FILE/G0210428.pdf
   Annex IV. GLOSSARY
   Accession: When a State becomes party to a treaty after it has already been negotiated and signed by
   other States (generally when the treaty has already entered into force). It has the same legal effect as
   ratification. The conditions under which accession may occur and the procedure involved depend on
   the provisions of the treaty.15Also see Ratification.
   Advocacy: A process aimed at influencing policy decisions and lawmaking at national and international
   levels. Actions designed to draw a community’s attention to an issue and to direct policymakers to a
   solution.16Advocacy requires the existence of explicit mechanisms for the participation of organizations
   of civil society.
   Availability requirement: Functioning public health and healthcare facilities, goods and services, and
   programs must be available in sufficient quantity within the State party.17
   Access requirement: Health facilities, goods and services must be accessible to everyone without
   discrimination, within the jurisdiction of the State party.18It is of particular importance to consider the
   removal of barriers faced by vulnerable and marginalized groups. Access includes:
   • Physical access: facilities within safe physical reach for all sections of the population, especially
   vulnerable or marginalized groups.
   • Economic access (affordability): affordable for all, including socially disadvantaged groups. For
   example, poorer households should not be disproportionately burdened with health expenses as
   compared to richer households.
   • Information access: the right to seek, receive, and impart information and ideas concerning health
   issues. Access of information should not impair the right to have personal health data treated with
   confidentiality.
   Acceptability requirement: All health facilities, goods and services must maintain the standards of
   medical ethics, such as insuring the confidentiality of individual medical information, and actually
   improving the health status of those concerned. These services must also be culturally appropriate for
   the people being served. People’s traditional healing practices and medicines must be treated
   respectfully.19
   Important note: Acceptability may not be used as an excuse for practices that exclude (e.g. when
   reproductive health services and information are denied to adolescent girls ‘to protect their honor’).
   Another limitation of the term acceptability is where traditional practices harm women’s health rights
   (e.g. in the case of female genital mutilation). Such practices are considered discriminatory.
   Quality requirement: Health facilities, goods and services must be scientifically as well as medically
   valid and of good quality. This requires, among other things, skilled medical personnel, scientifically
   approved and unexpired drugs and hospital equipment, safe and potable water, and adequate
   sanitation.20
   15
   http://untreaty.un.org/English/guide.asp#accession
   16
   Women, Law and Development International, 1997, page 163.
   17
   ICESCR general comment 14, paragraph 12.
   18
   ICESCR general comment 14, paragraph 12.
   19
   ICESCR general comment 14, paragraph 12.
   20
   ICESCR general comment 14, paragraph 12.
   Beijing Platform for Action: Consensus document adopted by the 1995 Fourth World Conference on
   Women in Beijing, which reviews and reaffirms women’s human rights in all aspects of life; signed by
   representatives at the Conference and morally but not legally binding. The Beijing Plus 5 document
   followed it, and its progress was reviewed after 10 years, during the 49Th. session of the Commission
   on the Status of Women (2005).21
   Benchmark: Self-set goals or targets to be reached at some future date. National and international
   benchmarks are the framework for measuring progress in implementing the right to health and are
   normally used for assessing the effectiveness of policies and if progress has been made in all
   sections of the population.22
   Bilateral: between two countries.
   Cairo Program of Action: Outcome document of the International Conference on Population and
   Development, adopted by the United Nations in September 1994, in Cairo, Egypt.
   Civil and Political Rights: The classical rights of citizens to liberty and equality. In principle, citizens
   should be able to exercise these rights without interference from the government. Civil and political
   rights include the right to life, to a fair trial, to free practice of religion, to think and express oneself, to
   vote, to take part in political life and to have access to information.23
   Civil society: the voluntary civic and social organizations and institutions that form the basis of a
   functioning society as opposed to the force-backed structures of a state. The term civil society is
   currently often used by critics and activists as a reference to sources of resistance to globalization24.
   Claim-holder: a person who is entitled to a right that a duty bearer must provide. One individual may
   have both claim-holder and duty-bearer roles. The relationships between claim-holders and dutybearers
   form a pattern that links individuals and communities to each other and to higher levels of
   society (see duty-bearer).
   Committee(s): Treaty-monitoring bodies created under various conventions to monitor the
   implementation of the treaty. Committees consist of independent experts. They examine State reports
   about the application of the treaty and deal with cases involving violations of rights. See also CEDAW,
   Human Rights Committee and ICESCR. The term ‘Human rights committee’ is meant to refer
   specifically to the treaty-monitoring body of the International Covenant on Civil and Political Rights
   (ICCPR).
   Convention: See Treaty
   Consensus documents: Statements of political agreement that have been adopted by declaration.
   Though they are not legally binding, they are important because governments feel a moral obligation
   to abide by them. They are also called political documents. One of the oldest and most influential
   consensus documents is the Universal Declaration for Human Rights. Other famous examples are
   the Beijing Platform for Action and the Millennium Development Goals.
   21
   http://www.un.org/womenwatch/daw/csw/index.html
   22
   Asher, 2004, page 89.
   23
   Kooijmans, 2000, page 255.
   24
   http://en.wikipedia.org/wiki/Civil_society
   Convention on the Elimination of All Forms of Discrimination against Women: CEDAW was
   adopted in 1979 and entered into force in 1981. It is the first legally binding international document
   prohibiting discrimination against women and obligating governments to take affirmative steps to
   advance the equality of women.25Currently, 180 countries are party to CEDAW. In 1999, an optional
   protocol (see Optional Protocol) to CEDAW was adopted, which entered into force in 2000. It
   established two new procedures: a procedure for individual complaints to the Committee, and an
   inquiry procedure on the basis of which the Committee can start an investigation about an alarming
   situation in a specific country.
   CEDAW (the Committee): Treaty body of the Convention on the Elimination of All Forms of
   Discrimination against Women. The Committee consists of a group of 23 independent experts who
   monitor the implementation of the Convention by State parties. The experts have been elected on the
   basis of their knowledge of relevant topics. They are nominated by governments of State parties, but
   operate independently from the governments.
   Core obligations: What must be done to ensure the minimum content of each right.
   Covenant: See Convention. See also International Covenant on Economic, Social and Cultural Rights
   (ICESCR) and International Covenant on Civil and Political Rights (ICCPR).
   De facto: ‘In reality’ or ‘in fact’. A situation that actually exists, whether lawful or not.26 See also: de jure.
   De jure: ‘By law’ or ‘by right’.27 How a situation should be, according to the law. In reality, the actual
   situation does not always conform with the law. For example, according to the law of a certain State
   (de jure), everyone may have equal access to health care, but, in practice (de facto), due to local
   customs women need their husband’s or father’s permission to see a doctor. See also: de facto.
   Declaration (document): Document that contains agreed-upon standards but is not legally binding.
   UN conferences, such as the 1993 UN Conference on Human Rights in Vienna and the 1995 World
   Conference for Women in Beijing, usually produce two sets of declarations: one written by
   government representatives and one by NGOs. The UN General Assembly often issues influential but
   legally non-binding declarations.28
   Declaration (statement): Sometimes a State wants to make a general statement about a treaty, for
   example, the way it interprets a definition/word included in the treaty. This is done by way of a
   declaration. In cases where the treaty prohibits reservations, States sometimes (abusively) make use
   of declarations in order to limit the content of certain provisions or scope of application.29
   Determinants of health: Conditions that make it possible to live in health, such as access to safe
   water, adequate food and housing, and safe and healthy working conditions. Resource distribution,
   gender differences and access to health-related education and information (including information on
   sexual and reproductive health) are also health determinants. Determinants are not necessarily
   directly related to health care. However, their analysis helps to make clear where barriers lie to
   claiming health rights.
   25
   http://www.un.org/womenwatch/daw/cedaw/index
   26
   http://www.hyperdictionary.com/search.aspx?define=de+facto
   27
   http://www.hyperdictionary.com/search.aspx?define=de+jure
   28
   http://www1.umn.edu/humanrts/edumat/hreduseries/tb1b/Section3/hrglossary.html
   29
   Information ON ratifications, reservations and declarations to specific treaties can be found on the UNHCHR website:
   http://www.ohchr.org/english/bodies/index.htm
   Discrimination: “Any distinction, exclusion or restriction…which has the effect or purpose of impairing
   or nullifying the recognition, enjoyment or exercise by” a group “of human rights and fundamental
   freedoms in the political, economic, social, cultural, civil or any other field.”30 Groups that often face
   discrimination include women, ethnic and religious minorities, homosexuals, and people with
   disabilities.
   Duty-bearer: a person who is obligated to provide the rights a claim-holder is entitled to. One individual
   may have both claim-holder and duty-bearer roles. The relationships between claim-holders and dutybearers
   form a pattern that links individuals and communities to each other and to higher levels of
   society (see claim holder).
   Economic, Social and Cultural Rights: Rights that give people social and economic security. These
   rights demand an active government policy. Examples are the right to food, education, shelter and
   health care and the right to preserve and develop one’s cultural identity.31
   GATS: General Agreement on Trade in Services, developed with the aim of creating a credible and
   reliable system of international trade rules; ensuring fair and equitable treatment of all participants;
   stimulating economic activity through guaranteed policy bindings; and promoting trade and
   development through progressive liberalization. Controversial for its limitations to the freedom of
   people and their governments to make democratic choices about the way their services are run and
   the effect it may have on the quality and availability of essential services across the world.32
   Gender: While ‘sex’ refers to the biological differences between males and females, gender describes
   the socially-constructed roles, rights and responsibilities that communities and societies consider
   appropriate for men and women. We are born as males and females, but becoming girls, boys,
   women or men is something that we learn from our families and societies. It is this learned behavior
   that forms gender identity and determines gender roles. These are not necessarily the same all over
   the world, or even within a country or region.33
   General Recommendations/ General Comments: Documents written by the Committees that monitor
   the implementation of human rights treaties explaining how a particular treaty should be interpreted
   and applied. Very relevant general recommendations in the context of this assessment instrument are
   CEDAW General Recommendation 24 concerning women and health and ICESCR General
   Comments 14 on the right to the highest attainable standard of health.
   Government: The word government is used in this assessment tool in a broad sense. It covers the law
   and policy-making forces, as well as the government institutions that are responsible for the
   implementation of policies. It also includes the local, regional and national government levels. While
   local and regional authorities may have considerable responsibilities in developing and implementing
   policies, the national (central) government has the final responsibility to ensure that human rights are
   respected.
   Grassroots organizations: Organizations set up by the local community and/or involving the
   community.
   30
   CEDAW article 1
   31
   Kooijmans, 2000, page 255.
   32 http://www.wto.org/english/tratop_e/serv_e/gatsqa_e.htm and http://www.peopleandplanet.org/tradejustice/gats/
   33
   http://www.unicef.org/gender/index_bigpicture.html
   Health: Health is a state of complete physical, mental and social well being and not merely the
   absence of disease or infirmity. It is not confined to health care, but includes socio-economic factors
   and extends to the underlying determinants of health, such as resource distribution, gender, food and
   nutrition, housing, access to safe and potable water and adequate sanitation, safe and healthy
   working conditions and a healthy environment.34 See also right to health and primary, secondary
   and tertiary health care.
   Human rights: The rights possessed by all persons, by virtue of their common humanity, to live a life of
   freedom and dignity. These rights and freedoms are irrespective of citizenship, nationality, race,
   ethnicity, language, gender, sexuality or abilities. They are universal and indivisible. Human rights
   become enforceable when they are codified as Conventions, Covenants or Treaties, or when they
   become recognized as Customary International Law.35
   Human rights approach: See rights-based approach.
   Indicator: An indicator is a variable or measurement conveying information that may be qualitative or
   quantitative, but which is consistently measurable. Indicators related to women’s health rights are, for
   example, maternal mortality rate, women suffering from epidemic diseases (both transmittable and
   non-transmittable), life expectancy of women, male-female ratio, nutritional level of women of all age
   groups, incidence of violence against women, female literacy rate, etc. Data regarding these
   indicators should be present in disaggregated form for all age groups and other socio-cultural and
   economic sub-groups.36
   Indivisibility of rights: The indivisibility of human rights is the basic assumption of the human rights
   system, first formulated in 1948 in the Universal Declaration of Human Rights. It states that all human
   rights (civil and political as well as economic, social and cultural rights) are interrelated and cannot be
   separated. In order to ensure the realization of human rights, their implementation must therefore be
   comprehensive. It is impossible to fully realize civil and political rights if economic, social and cultural
   rights are being ignored.
   International Covenant on Civil and Political Rights (ICCPR or CCPR): Adopted in 1966 and
   entered into force in 1976, the ICCPR declares that all people have a broad range of civil and political
   rights. It has been ratified by 154 countries as of October 2005. See also Civil and Political Rights.37
   International Covenant on Economic, Social and Cultural Rights (ICESCR): Adopted in 1966, and
   entered into force in 1976, the ICESCR declares that all people have a broad range of economic,
   social and cultural rights. By October 2005 the treaty had been signed and ratified by 151 countries. A
   group of 18 independent experts monitors its implementation. See also Economic, Social, Cultural
   Rights.38
   Life-cycle approach: Health is a lifetime concern. Health policies need to be tailored to the differing
   challenges people face at different times in life. Discrimination or other human rights violations that
   occur in infancy can determine the course of peoples’ lives.39
   34
   Adapted from ICESCR general recommendation 14, paragraphs 4 and 20.
   35
   Human Development Report 2000 Glossary: http://www.undp.org/hdr2000/english/presskit/glossary.pdf
   36
   WHO, 25 questions on Health and Human Rights,
   http://www.who.int/hhr/activities/publications/en/index.html
   37
   http://www.unhchr.ch/tbs/doc.nsf
   38
   http://www.un.org/Depts/Treaty/final/ts2/newfiles/part_boo/iv_boo/iv_3.html
   39
   24 http://www.unfpa.org/rh/lifecycle.htm
   Limitation: A State may have reasons to limit certain rights included in the ICESCR. For example,
   public health measures to control a contagious disease might infringe upon some rights. This is
   permitted only if the limitation is primarily intended to protect the rights of individuals, determined by
   national law, compatible with the nature of the rights protected by the ICESCR and pursues legitimate
   aims (e.g. not using the limitation to increase the military budget). Moreover, the limitation must be
   aimed at the general welfare of society (e.g. not just the elite) and it must be proportional. The least
   restrictive alternative must be chosen.40
   Lobbying: The practice of seeking to influence the legislature or policy development to reflect a certain
   point of view. Lobbying can be conducted by an individual, a group, an organization or an association.
   Millennium Development Goals: The eight Millennium Development Goals (MDGs) form a blueprint
   agreed to by all the world’s countries and all the world’s leading development institutions. They range
   from halving extreme poverty to halting the spread of HIV/AIDS and providing universal primary
   education, all by the target date of 2015. In the UN Millennium Declaration, UN member states also
   stress values such as freedom, equality and solidarity.41
   Monitoring and reporting procedure: Treaties have a monitoring and reporting procedure to check
   the implementation of the treaty in each country. In some cases the report resembles a ‘selfinspection’
   — governments report on their own compliance with human rights obligations. In others, a
   monitoring body (e.g. NGOs) initiates the report on government behavior.
   Non-governmental organizations (NGOs): Organizations formed by people outside the government.
   They can operate on an international, national, regional or local scale on the basis of different
   mandates, agendas and priorities. NGOs play a substantial role in influencing UN policy by writing
   shadow reports.
   Non-retrogression: The principle that governments are not allowed to remain passive in a situation
   where human rights deteriorate, nor can they take measures that reduce the enjoyment of rights. If a
   government takes retrogressive measures, it must prove that it had no other option, for example, due
   to a severe crisis. In such a situation the government also has to demonstrate that it has protected
   the rights of the most vulnerable groups.42
   Optional protocol: A separate treaty associated with a parent treaty, under which state parties to the
   parent treaty may choose to undertake additional obligations.43 The optional protocol to ICESCR
   grants individuals the right to send a complaint to the ICESCR Committee. The optional protocol to
   CEDAW also creates the possibility for the CEDAW Committee to review individual complaints
   (‘communications’) and, above that, enables the Committee to start an inquiry procedure.
   Participation: The process through which stakeholders (individuals and organizations) influence and
   share control over priority setting, policy-making, resource allocation and access to public good and
   services.44
   40
   See ICESCR article 4 and paragraphs 28 and 29 of general comment 14.
   41
   http://www.ohchr.org/english/issues/millenium-development/resources.htm
   42 ICESCR General Comment 14, paragraph 32.
   43
   http://www.un.org/womenwatch/daw/cedaw/protocol/whatis.htm
   44
   World Bank at http://lnweb18.worldbank.org/ESSD/sdvext.nsf/66ByDocName/ ParticipationatProjectProgramPolicyLevel
   Policy: A purposive course of action followed by an actor or set of actors in dealing with a problem or a
   matter of concern. Policies can vary considerably in scope. The term policy can refer to a nationwide
   5-year health strategy as well as to decisions of a more limited scope, such as a reduction of the
   funding to the maternity wards in a certain district. The actors can be local or national governments,
   organizations, enterprises or individuals.45
   Poverty Reduction Strategy Papers (PRSP): One of the conditions a country may have to fulfill in
   order to receive help and debt relief is to make a PRSP. A PRSP describes the macroeconomic,
   structural and social policies and programs that a country will pursue over several years to promote
   broad-based growth and reduce poverty.46
   Primary health care strategy: An integrated approach to improving health and socioeconomic
   development defined in the Alma Ata Declaration (1978). It emphasizes community education and
   participation, addressing social determinants of health, immunization; prevention and treatment of
   common and endemic disease, maternal/child and reproductive health, and access to essential
   drugs.
   Primary, secondary and tertiary health care: Primary health care is provided at relatively low cost by
   health professionals and/or generally trained doctors working within the community and dealing with
   common and relatively minor illnesses. Secondary health care is provided at relatively higher cost by
   specialty-trained health professionals in centers, usually hospitals, and typically deals with relatively
   common minor or serious illnesses that cannot be managed at community level. Tertiary health care
   is provided in relatively few centers, typically deals with small numbers of minor or serious illnesses
   requiring specialty-trained health professionals, doctors and special equipment, and is often relatively
   expensive. Forms of primary, secondary and tertiary health care frequently overlap and often
   interact.47
   Progressive realization: The principle that governments must do all they can to improve the situation
   regarding human rights, including the right to health. They must take deliberate, concrete and
   targeted steps towards the full realization of the right to health and eliminate discrimination in health
   care. The speed of progress depends on the specific situation of the state and may differ from country
   to country.48
   Ratification/ ratified: The official promise of a state to uphold a treaty or convention and adhere to the
   legal norms that it specifies.49
   Reproductive rights: The rights that enable all women, without discrimination on the basis of
   nationality, class, ethnicity, race, age, religion, disability, sexuality or marital status, to decide whether
   or not to have children. This includes the right to safe, legal abortion. These rights are basic human
   rights.50
   Reservation: In cases where States object to one or several articles of a human rights treaty it is
   common to make use of a reservation. The reservation is a written statement that narrows the content
   of the article, limits where it can be applied, or rejects the whole provision. The reservation is only
   valid if it is compatible with the object and purpose of the treaty, if the treaty does not prohibit
   reservations, and if other States Parties do not object to the reservation.
   45
   James Anderson in Howlet and Ramesh, 1995, page 6.
   46
   http://www.imf.org/external/np/exr/facts/prsp.htm
   47
   ICESCR general comment 14, paragraph 19.
   48
   ICESCR article 2 and article 12; ICESCR General Comment 14 paragraphs 30 and 31.
   49
   http://www.undp.org/hdr2000/english/presskit/glossary.pdf
   50
   http://www.wgnrr.org/home.php?page=1&type=menu
   Respect/ protect/ fulfill: States parties have the obligations to respect, protect and fulfil human rights.
   The obligation to respect requires States parties to refrain from interfering with the enjoyment of
   rights. The obligation to protect requires States parties to prevent rights abuses by third parties. The
   obligation to fulfill requires States parties to pro-actively engage in activities that ensure the
   realization of rights. Fulfill also requires States to take measures necessary to ensure that each
   person may obtain basic rights whenever they, for reasons beyond their control, are unable to realize
   these rights through the means at their disposal.51
   Rights-based approach: Because States are responsible for the realization of human rights, citizens
   can hold the State accountable for its obligations to respect, protect and fulfill them. The basis of a
   human rights approach is that a human rights violation needs to be addressed, even when the
   number of people involved is small or not known exactly. In other words, each human rights violation
   stands alone and should be taken seriously. A decrease in a certain type of human rights violation is a
   positive development, but does not justify other violations still taking place.
   Right to health: Health is a fundamental right that influences all aspects of life and is closely related to
   other human rights. It is important to look at health as a whole. People who are ill cannot fully enjoy
   their right to education or participation. Lack of food and housing, make it difficult to live in good
   health. The right to health includes the availability, accessibility, acceptability and quality of health
   care. See also health and primary, secondary and tertiary health care, and health determinants.
   Shadow report: Reports created by one or more NGOs that analyze the status of implementation of
   human rights obligations/commitments at the national level. In these reports, NGOs provide
   information that supplements government reports and thus assist the committees that monitor the
   treaties to address concerns that are omitted, neglected or misreported by the government.52 Shadow
   reports are also referred to as alternative reports.
   Social determinants of health: the social factors affecting health, including education, access to safe
   and healthy food, employment, and opportunity and control over one’s life.53
   Special Rapporteur: An official appointed to compile information on a subject, usually for a limited
   period.
   Special Rapporteur on Health: In April 2002, the commission on Human Rights appointed Paul Hunt
   as the Special Rapporteur. The Special Rapporteur’s duties are to gather and exchange information
   on the right to health; discuss possible areas of cooperation with all relevant actors, including
   governments, relevant United Nations bodies, specialized agencies, NGOs and international financial
   institutions; report on the status of the right to health and make recommendations on measures that
   promote and protect the right to health.54
   State obligations: State party obligations describe what a state must do, and must not do, in order to
   ensure that the population of the country is able to enjoy the rights set out in a Convention. See
   Respect, protect, fulfill.
   51
   http://shr.aaas.org/pubs/rt_health/rt_health_manual.pdf
   52
   http://swf.u2u.org/women2000.txt
   53
   http://www.unhchr.ch/Huridocda/Huridoca.nsf/0/9854302995c2c86fc1256cec005a18d7?Opendocument
   54
   http://www.unhchr.ch/Huridocda/Huridoca.nsf/0/9854302995c2c86fc1256cec005a18d7?Opendocument
   State(s) Party(ies): Those countries that have ratified a covenant, convention or treaty and are thereby
   legally bound to conform to its provisions.55 See also State obligations.
   Treaty: A contract or other written instrument binding two or more states under international law; used
   synonymously with Convention and Covenant. All countries that have agreed to be bound by a treaty
   through ratification or accession have a legal obligation to implement these rights and principles at
   the national level.56 See also Ratification and accession.
   TRIPS: WTO Agreement on Trade-Related Aspects of Intellectual Property Rights, obliging the 44
   member countries of the WTO to protect the intellectual property rights on marketed products and
   production processes. Intellectual property rights such as copyrights and patents are intended to
   compensate the costs that manufacturers have invested in research and development.57
   Universal Declaration of Human Rights (UDHR): Adopted by the General Assembly on 10 December
6. Primary UN document establishing human rights standards and norms. All member states have
   agreed to uphold the UDHR. Although the declaration was intended to be non-binding, over time its
   various provisions have become so respected by States that it can now be said to be Customary
   International Law.58
   Violation of human rights: Breach of the commitments in a treaty (convention / covenant) or an
   action/omission which is incompatible with the treaty.
   Vertical program: An intervention to decrease morbidity or mortality that focuses on a specific disease
   or technological solution, such as a campaign to promote oral rehydration therapy to treat diarrhea.
   This is in contrast to changing more fundamental causes of illness such as malnutrition or improving
   heath systems in general.
   55
   Human Development Report 2000 Glossary on Human Rights and Development.
   56
   http://untreaty.un.org/English/guide.asp#treaties
   57
   http://www.wemos.nl/en-GB/Content.aspx?type=Themas&id=1548
   58
   http://www.un.org/Overview/rights.html
   Annex V. LIST OF ABBREVIATIONS
   AIDS Acquired Immune Deficiency Syndrome
   CAT Convention against Torture
   CEDAW Convention on the Elimination of All Forms of Discrimination
   against Women
   CEDAW/the
   Committee
   Committee on the Elimination of Discrimination against Women
   CERD Convention on the Elimination of Racial Discrimination
   CESCR Committee on Economic, Social and Cultural Rights
   CRC Convention on the Rights of the Child
   DOTS Directly Observed Treatment (for tuberculosis)
   HERWAI Health Rights of Women Assessment Instrument
   HIV human immunodeficiency virus
   HOM Humanistisch Overleg Mensenrechten
   (Dutch abbreviation for Humanist Committee on Human Rights)
   GATS General Agreement on Trade in Services
   ICPD International Conference on Population and Development
   ICCPR International Covenant on Civil and Political Rights
   ICESCR International Covenant on Economic, Social and Cultural Rights
   ILO International Labor Organization
   IMF International Monetary Fund
   MDGs Millennium Development Goals
   NGO Non-governmental organization
   PHC Primary Health Care
   PHM People’s Health Movement
   PRSP Poverty Reduction Strategy Paper
   UN United Nations
   UNDP United Nations Development Program
   UNFPA United Nations Population Fund
   UNHCHR United Nations High Commissioner for Human Rights
   UNICEF United Nations Children’s Fund
   WHO World Health Organization
   WPF World Population Foundation
   WTO World Trade Organization