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Human Rights Reader 37

PUTTING EQUITY AND HUMAN RIGHTS IN HEALTH ON THE AGENDA: THE ROLE OF NGOS.

Introduction:

1.Equity and Human Rights (HRs) are by no means new concepts to NGOs.

2.Moreover, Equity and HRs are inseparately linked since equity is key to
the realization of HRs. The question here is what NGOs are doing with/about
these two concepts in the realm of their work in health and nutrition.

3.A paradigm shift is clearly in the making in development and in
health/nutrition work. New models are more politically driven in a direction
that hinders and hampers the resolution of the problems at hand. Therefore,
these days, more and more NGOs are discussing and trying to operationalize
the 'Equity and Human Rights-based Approach' to apply it to their work.

The background:

4.Underlying the analysis here made are several statements found in a recent
publication; they read as follows:

"Most NGOs today  have become very specialized and contribute marginally to
the relief of poverty/ill-health/ malnutrition, but significantly to
undermining the struggle of the people to emancipate themselves from
oppression. Programs delivered by these NGOs do not really seek to redress
the social circumstances that cause impoverishment/preventable ill-health
and malnutrition. The development discourse is framed not in the language of
emancipation or justice, but using the vocabulary of charity, technical
expertise, neutrality and paternalism. NGO programs have often worked to
undermine popular mobilization. NGOs accept or do not comment on the manner
in which the State exercises its power. NGOs work is limited to project
work, armed with manuals and technical tricks rather than seeking justice
and standing up against violations of HRs.  Many NGOs were co-opted by
funders to take up such a role (a typical example is health and nutrition
work done to set up 'safety nets' for the poor). NGOs have become an
integral part of a system that sacrifices respect for justice and rights,
instead taking a missionary position. If NGOs stand in favor of
emancipation, then the focus of their work has invariably to be in the
equity/HRs/political domain, supporting those social movements that seek to
challenge a social system that benefits a few and impoverishes the many".
(Manji and O'Coill, 2002)

5.Most NGOs tend to work on the issues that are before them, and forget
those that are hidden away; such hidden truths have to be brought to the
forefront. For example, issues of voice, power, risk and neglect are
essential in a HRs discourse --as difficult to surface as they may be.

6.The fallacy that actually needs to be uprooted is that health programs
addressing the urgent needs of women and children implicitly address human
rights. In the HRs approach, nothing is left implicit; without an explicit
retooling to a HRs focus, such claims remain but hot air; they are hollow
commitments to HRs that allow controlling hierarchies to persist.

7.NGOs have ample accumulated knowledge of what is going on....and have just
begun to realize that, if they do not act on that knowledge, they are not
really serving the people of the communities that they work with to the
fullest.

8.There is a need, then, for a more determined commitment to pro-poor social
policies and programs (including health)and an increase in the funding for
such an approach. Activities are to concentrate on institutional capacity
building to better promote education and consciousness-raising at the
community level. A key question is to give advocacy tasks more prominence so
as to hold governments more accountable.

The concept of Human Rights in health and why it is used:

9.In contrast to a 'deficit-filling approach' to poverty and preventable
ill-health alleviation, the Equity/Human Rights-based approach (E/HRs-based
approach) defines poverty as social exclusion. Instead of focusing on
creating an inventory of public goods or services that must be provided and
then seeking to fill the deficit via foreign aid, the rights-based approach
focuses on trying to identify the critical exclusionary mechanisms. This,
because work in health and development is about assisting poor communities
overcome obstacles, rather than about the endless pursuit of grant aid for
social goods.
The E/HRs-based approach enables NGOs to see much more clearly the kinds of
power relations and systemic forces that drive and perpetuate poverty.
But the transition to mainstreaming a rights-based approach into the
organizational structure of NGOs is a complex enterprise; it cannot simply
be decreed and implemented.

10.The E/HRs-based approach asserts that work in health should be seen as a
process that unequivocally leads to people fully realizing all their human
rights (and not only their right to health); the approach should thus be
reflected both in the processes engaged and the outcomes pursued by NGOs.

11.More importantly, the E/HRs-based approach sees ill-health, malnutrition
and poverty as a denial of human dignity, i.e. as an important part of the
denial of people's economic, social, cultural, civil and political rights.
And these rights are more than just moral principles and norms governing
human behavior ... they are international legal standards.
Poverty itself is seen as an abuse of HRs... The poor and marginalized are
not where they are by accident...

12.Because health is not the exclusive business of governments, this broad
approach definitely brings an added value to communities and to NGOs when
sitting down among themselves and with government representatives to jointly
evaluate and plan local or national health strategies. It brings something
different and potentially powerful to existing efforts by all actors in
their efforts to overcome ill-health, malnutrition and poverty in a more
sustainable manner.

13.The principles of equity in health (and prominently those related to
gender equality) are not currently codified in any way to allow monitoring
their implementation; more often than not, they are lost when implementing
health sector reform or macro-economic corrective measures.
Human rights, on the other hand, are enshrined in legal covenants that
protect human dignity and place obligations (or duties) on providers and
others, mainly but not exclusively the State. While NGOs do have the
responsibility to respect the rights of others, it is now widely accepted
that states have very specific obligations to respect, protect and fulfill
human rights in the realm of health and nutrition.

14.It is thus timely for NGOs to use the equity and human rights-based
approach --to apply the internationally agreed human rights standards to
health policy and practice-- emphasizing active grassroots participation and
the right of people to choose their own path.

15.When doing so, priority is to be given to the poor, the marginalized and
the vulnerable --those currently most denied their rights due to their lack
of choice, of control and of resources.

16.The conceptual basis that justifies (and prescribes) the use of an Equity
and Human Rights-based Approach in the health and nutrition work of NGOs is
the following:

? HRs are entitlements all people have, to develop their full potential;
they are valid for everyone --they are universal (A right is a right only
when it is universal; otherwise  it is a privilege).
? There is a difference between just delivering services and making clear to
beneficiaries that they are legally entitled to specific services and can go
somewhere to complain if they do not receive what is due them.
? HRs objectives are not to stabilize the problems at hand, but to make them
disappear by tackling them at their roots.
? HRs are pre-conditions that must be met for people to have the opportunity
to live with full dignity, full health and self-worth.
? HRs lack cultural legitimacy in many parts of the world; communities are
traditionally  more concerned with needs than with rights; that is why NGOs
have to start from people's own initial understanding of their rights (and
the issues of power) to then support a bottom-up dialogue that deepens the
ownership of HRs by the beneficiaries they work with. (Without concerned
citizen action to uphold HRs close to home, we shall look in vain for
progress).
? Rights are different from needs; rights are relational: where someone has
a right, someone else has a duty or responsibility to honor and satisfy that
right. There are two critical distinctions between health rights and heath
needs: first, health rights always trigger duties and responsibilities,
whereas needs do not; second, health rights imply standards that can be
measured whereas needs do not. Therefore, NGOs need to start thinking in
terms of rights rather than needs, of rights-holders (or claim-holders)
rather than beneficiaries and of enabling rather than giving.
? In the E/HRs-based approach to health beneficiaries hold claims against
those who are responsible (through their actions and omissions) for their
health and nutritional wellbeing. People can only realize their rights in
health if they are first exposed to the root causes of the marginalization
they suffer from, and if they are empowered to claim and fulfill the rights
essential to their health/nutrition and livelihood security. Rights, then,
have an enormous potential to attract and mobilize people. First and
foremost, this means NGO interventions have to transfer ownership to the
people served; key actions for this to happen are HRs education and capacity
building for community members to claim and defend their rights. Empowerment
here is to be understood as generating several forms of power: self-respect
(power within), community cohesion (power with), and a clear agenda for
action (power to).
? The E/HRs-based approach addresses abuses and/or neglect of HRs in health
mostly found in the form of discrimination or exclusion. It brings to the
light underlying power relationships between rights-holders and authority
structures; it emphasizes dignity, equality, and participation of the former
and accountability of the latter.
? Moreover, let it be very clear that advancing gender equity issues is part
and parcel of work on girls' and women's rights in relation to health.
? Such an approach means NGOs must stand in solidarity with the poor (women,
children  and men) whose rights are being denied --holding themselves
accountable to them (and in addition ensuring they do not violate people's
rights themselves). NGOs must support people's efforts to take control of
their own health and lives. This also includes NGOs holding others
accountable for fulfilling their responsibilities, as well as opposing
discrimination of any sort, addressing the root causes of poverty/ill-health
and malnutrition and the corresponding rights denials in their work with
rights-holders. Finally, they must work in concert with others embarked in
the same endeavor (forming a supportive coalition of NGOs on these issues).
? In short, the E/HRs-based approach calls for a purposeful and transparent
de-facto engagement of NGOs in the more structural aspects of the
determinants of ill-health while remaining steadfast allies of local
communities throughout.
? NGOs will not be alone in this E/HRs-based approach since the paradigmatic
(and mindset) shift towards it is growing globally with the force of
international law behind it.
? Therefore, NGOs definitely need to take steps now to improve the HRs
impact of their current actions in health. This means identifying previously
unforeseen gaps and opportunities. But although focusing on health, NGOs
have to take into account the whole range of HRs since HRs are indivisible.
? Weighing-in on rights can risk harsh reactions from the authorities.
Standing up for communities whose rights are not respected, protected or
fulfilled is inevitably being political in the sense of challenging those
actors responsible for abuses. So NGOs have no choice but to take a stand
against authorities, policies or practices when the communities they serve
are abused, neglected or excluded. The name of the game is:  Remain
non-partisan, but at the same time take issue.
? Even if the E/HRs-based approach is inherently about
confrontation --confronting the injustices of real world situations-- two
approaches are possible:
       a) denouncing violations (which is often confrontational), and
       b) engaging actors in the pursuit of rights, helping them to more
fully live up to their responsibilities (which is more related to
promotional work).
? Monitoring HRs conditions is also very important for NGOs, and there is a
need to share and disseminate information about such violations (making
documented grievances public); this information will ultimately strengthen
advocacy. HRs-sensitive (and gender and socio-economically disaggregated)
data and indicators are critical to keeping aware of gender, equity, HRs and
other issues.
? Despite growing clarity about all the issues above, there is no one
blueprint for an equity and human rights-based approach to programming in
health; each NGO will have to go through its own retreat(s) to revision and
remission their mandates to adjust their very own approach and programs to
it. (Adapted from CARE, 2002)

Claudio Schuftan, Ho Chi Minh City
aviva at netnam.vn
(Part 2 to follow)