PHA-Exchange> PHM Right to health and health care campaign proposal

[Claudio]

As promised:


Proposal for a global 'Right to Health and Health Care Campaign' to be launched by the People's Health Movement.

 [Short Version, December 2005]

 

The context

1. There is an urgent need to replace the dominant discourse in health by a process aimed at universally achieving the 'right to health and to health care' as the main objective to achieve more equitable health care systems in both developing and developed countries. 

2. The People's Health Movement (PHM) is launching a global initiative to strengthen the 'Right to Health' (RTH) with a focus on defending and operationalising the 'Right to Health Care'. 

3. Since it is predictable socio-political forces at work that determine the risk of most forms of human rights violations, this Campaign looks at what additional measures have to be taken now. 8. It grounds our understanding of human rights violations in the broader analyses of power and social inequality. Knowing carries obligations --thus the proposed Campaign.

4. Poverty is the world's greatest killer. It is thus not enough to improve the situation of the poor within the existing social relationships. Structures and not just individuals must be changed if the RTH of the marginalized in the world is to be achieved. 

5. Rights are realised by changing the prevailing power relations. Rights cannot be advanced but through the organised efforts of the state and of civil society. 

6. Public health must be linked to a return to social justice and equity; this is the central challenge for the future of public health. The Campaign here proposed by PHM thus seeks the social transformations indispensable to resolve the inequities found in health.

 

The justification
7. There is now a need to launch a global process of mobilization to actually implement the provisions of General Comment 14* in all countries. The 'Right to Health' will be operationalized by changing global and national health sector reform initiatives.
*: Nearly 150 countries around the world are parties to the International Covenant on Economic, Social and Cultural Rights. General Comment 14 (GC 14) of the Committee on Economic, Social and Cultural Rights (CESCR) adopted in the year 2000 elaborates on and clarifies the Right to Health by defining the content, the methods of operationalization, the violations and the suggested means to monitor the implementation of this right. GC14 is the most authoritative interpretation of international law relating to the right to health. (http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En?OpenDocument)

 

8. But why do we need a global campaign on the Right to Health? Much is wrong with the neo-liberal model of global restructuring in the world. This process is unchecked either by national or global mechanisms. It is in this context that there is growing recognition of the need for a global initiative to address health systems issues in a rights-based framework.  What will this entail?:

  1.. Neo-liberal policies restrict the revenue of the state for use for welfare purposes so that governments find themselves unable to finance health security systems. To put in place mechanisms of effective redistribution of resources is only possible through a globally coordinated effort, thus the Global Campaign.
  2.. We need to establish universal norms regarding a basic standard of essential health care services that must be ensured. Further, health care workers distribution must be based on need rather than on the ability of richer countries to pay more for human resources from poorer countries. 
  3.. There is also a need to challenge the dominant global discourse of  'Health care as a commodity' and 'safety nets for those left outside the benefits' wherein health services are increasingly marketized and governments retreat from the provision of health care. We need to counter this with a 'Health care as a human right' discourse.
 

A Campaign focusing on the Right to Health Care

9. PHM struggles for and demands the respect of all aspects of health rights. 

10. This right includes both the Right to health determinants such as water, food security, housing, sanitation, education, a safe and healthy working and living environment, etc., and the Right to health care (the right to the entire spectrum of preventive, curative and rehabilitative services plus health education and selected promotive activities).

11. Naturally, the global health movement has an important role to play regarding both of the above components of the Right to Health. However, in practice, this suggests two types of tasks for the global health movement:

 

I. Tackling the right to health determinants

12.  Supporting campaigns on water, food security, housing, etc. There are existing initiatives already working for these rights. This recognition places the obligation on PHM activists to actively support such initiatives though not necessarily to take up the responsibility of primary leadership of such groups. 

13. A specific role that has to be played by PHM activists is to document violations of the Right to Health and its underlying determinants. Health-based arguments can indeed significantly strengthen the demands to tackle these determinants. 

 

II. Strengthening the right to health care

14. This is a task for which the global health movement has an unquestionable responsibility to take the lead on. 

We suggest the following overall strategy for PHM:

15. Regarding the strengthening the Right to health determinants, PHM country circles would continue to expand their involvement in these initiatives in their countries and regions. PHM may even co-initiate specific international campaigns on a particular health determinant (e.g., the Right to Water). However, it is not strategically possible for a global health movement like PHM to launch a single campaign encompassing all health determinants on a global scale.

16. We suggest launching a Global Right to Health and Health Care Campaign. PHM has a primary responsibility regarding this issue. However, during this campaign, the documenting of violations will not be restricted to those in the sphere of health care, but will encompass denouncing violations of health rights related to the various determinants of health. 

17. These two types of activities should be combined as part of a comprehensive approach to the Right to Health. This differentiated strategy does not reflect any judgement on the relative importance of health care vs. the underlying and basic determinants of people's health; it is rather a question of the strategic approach chosen. 

 

What is the added value of adopting this focus?  

18. A RTH Campaign has a big social mobilization potential; the HR approach is backed by international legislation; the RTH approach demands that decision-makers take responsibility; HR imply correlative duties that are universal and indivisible; and (Unlike the MDGs) the HR approach is focused on processes that lead to concrete outcomes.

 

What does the RTH imply?

19. In every development process there are two types of actors: claim holders and duty bearers. When the State does not respect human rights, claim holders have to demand their rights from the duty bearers in government. 

20. The marginalized are being denied their rights, in part because, as claim holders, they do not have the capacity to effectively demand (claim) their rights; rights are also violated because duty bearers do not have the capacity or the will to fulfil their obligations (called 'correlative duties').

21. Therefore, in the HR-based approach (HRBAP) one has to carry out two types of analyses: a)  situation analyses in which one determines the causes of the problems placing them in a hierarchical causality chain of immediate, underlying and basic determinants, and b) capacity analyses in which one determines who are the individuals/institutions that bear the duty to do something about the above causes calling on them to fulfil their duties as per their country's obligations as signatory of the United Nations HR covenants. 

22. These two types of analyses have to be carried out with the community and the beneficiaries of the health system so that the rights being violated can be identified jointly and those responsible can be confronted --for them to do something about the problems identified.

23.  As a PHM ultimate goal, we do NOT look for health policies that favour the poor. We seek significant poverty reduction policies that directly address the social determinants of the inequitable distribution of resources, as much as we seek to end the exiting violations to the RTH.  The Campaign gives us the possibility of advancing PHM's political agenda that strives for equity and for the structural changes that will do away with the social, economic and political determinants of health.  

24.  We are no longer going to go to beg for changes to be implemented; we are now going to demand them based on existing international law already in force in most of the countries where we work. Disseminating this concept is in itself empowering and is part and parcel of this Campaign. 

25. We have to overcome the culture of silence and apathy about the HR violations in health we all know are happening. This, because HR and the RTH will never be given to poor, marginalized, discriminated and indigenous persons. Repeat: rights are never given, they have to be fought for! And this is what the RTH Campaign will attempt to do. 

 

Suggested focus of the Campaign
26. It does not need to be emphasised that specific important aspects of this Right, such as women's and children's right to health care, mental health rights, HIV and AIDS-affected persons health care rights, workers' health rights, the right to essential drugs, etc. need to (and will) be woven into the Campaign, bringing diverse branches of the global health movement into a broad coalition working for public health systems that strengthen universal access to health care.

27. PHM will document violations, which can help push for changes in the key wider determinants of health; they will also denounce and act upon adverse existing and new policies that are having negative impacts on the Right to Health (such as the privatisation of services, the weakening of universal access systems, vertical programmes that fragment health systems, the current 90/10 gap in research funding, the unjust international trade regimes --to name just but a few). 

 

Possible organizational collaboration
28. The United Nations Special Rapporteur on the Right to Health has already shown interest in the idea of this global Campaign. WHO will need to be strongly influenced, and could be a potential collaborator. PHM has been a key actor in the launching of the Commission on the Social Determints of Health (CSDH) of WHO which we see having a real potential in the fight for the RTH care. Most countries have National Human Rights Commissions or official bodies that can be involved in monitoring the Right to Health. Present PHM-member organizations will also involve a broader range of civil society organizations in our network including women's organizations, coalitions of HIV and AIDS-affected persons, trade unions of health sector personnel, people's movements, etc.; in this sense the campaign would be led by PHM-and-partners.

 

Suggested process to launch the Campaign
29. To move towards implementing the Campaign process, we here propose a sequence of activities.

 

I.        Preparatory phase (early to mid 2006) 

1.      Creation of a broad consensus on the Campaign idea. Formation of a 'Core Campaign Steering Group' of about 6-8 organizations who are willing to help coordinate the Campaign globally. This team will actively support a host of regional organizers and will lead the international networking work, plus the fund-raising and advocacy work for the Campaign. To support this team, a global campaign secretariat (of about three to four .persons) will need to be formed to coordinate the campaign.

2.      Identification of specific (existing PHM or newly associated) groups that will take regional responsibilities. If possible, at least one consultation within each region to discuss the campaign will have to be held. 

3.      Identification of short and long-term sources of funding.

4.      Ensure local campaign ownership and active involvement throughout the process. A mechanism for regular consultation with allies will be set up.

5.      Completion of guidelines for the preparation of status papers on 'The State of the Right to Health' in each country (early 2006). 

6.      Contribution to the next (2007) edition of the Global Health Watch.



30.This phase will culminate in a restricted consultation of the Steering Group in the first quarter of 2006 in which the developments so far will be reviewed and plans made for the next phase of the Campaign. 

 

II.     Documentation and analysis phase (the last three quarters of 2006).

31. During this period, country, regional and global reports will be prepared as follows:

1.      Country papers or reports on the Status of the Right to Health Care will be completed in the countries of at least two regions; in the other regions, the process will be started and brought to as an advanced stage as possible. Options are as follows:

    a.. Full blown Country Reports: These will be the most extensive and will analyse all or most aspects of the health care system in the country and report on their current status with facts and figures, documenting why and how General Comment 14 has (not) been fulfilled five years after its adoption (within the framework of a 'progressive realization of the right to health').
    b.. Country Status Papers: These will be less detailed and may not cover all components of the health sector, but will be based on country level information and statistics that bring out major health care system gaps.
    c.. Country Overviews: These will only contain a listing of major issues of concern from the Right to Health perspective (e.g., declining health budgets, unregulated privatization, imposition of user fees, dismantling of the social security system). 
32. The aim is that about 40-50 countries will prepare these country reports or status papers -aiming at a minimum of 5 in each region.

2.      A Global Health Watch Report chapter on the Right to Health could be drafted focused on how the various global agencies and actors are infringing the Right to Health in different ways. It will also focus on the minimum obligations developed countries have to contribute to health care development in poorer countries and to stop the northward migration of health professionals.

33. This phase will culminate with the concrete planning of Regional Assemblies on the Right to Health in the seven or eight regions (to be determined) of the world: Dates, venues, financial arrangements, major agenda contents and organising agencies will be identified and given concrete mandates. For this, a pre-planning meeting to finalise the program of these regional assemblies may be held at the end of 2006.

 

III.   Regional Assemblies and subsequent action phase  (after the World Health Assembly of May 2007)

34: Plans are as follows:

1.                  Sequential Regional assemblies on the Right to Health will be held in all regions of the world: one assembly in each of the seven or eight regions, spaced about 2 months apart. These would be called by PHM, with involvement of the UN Special Rapporteur on the Right to Health and WHO, and will be attended by national health officials, national human rights committees and PHM, as well as other health and human rights activists. Available country reports/country performance report cards on the Right to Health will be presented and discussed. These assemblies will attract wide media coverage. Action plans to implement the Right to Health will be drawn, discussed and presented in the second half of the assemblies. 

2.                  This series of regional assemblies may culminate in some kind of a resolution being proposed for adoption at, say, the World Health Assembly in Geneva in 2008. Such a resolution will call for the time-bound implementation of the Right to Health. This will include demanding governments progressively incorporate RTH principles and standards into their national laws. Further, the resolution will put in place mechanisms for monitoring and redressal of this right in all countries of the world. PHM partner organizations will also use this as a concrete opportunity to draw-in many more organizations into the network, to dialogue with their country governments, and to engage with national NGOs and human rights bodies. 

3.                  Finalisation of the Global Health Watch report on the Right to Health is envisioned for April 2007. The same could include summaries of all the regional analysis papers and a one-page standardized abstract of the available country Right to Health reports. 

4.                  Preparation of a 'Global Action Plan on the Right to Health Care'. Such a document will convincingly show how quality essential health care services could be made available NOW to every human being on earth, provided certain key reallocation of priorities and resources are enacted. This Global assessment will be accompanied by practical recommendations for the countries in each region; the latter will form the basis of a Concrete Agenda to achieve the goals set out in the People's Charter for Health.

5.                  The 2008 World Health Assembly will be asked to adopt a 'Declaration on the Right to Health for All' for implementation by member countries, The same will have time-bound, specific and monitorable goals and contain the basic principles of a bottom-up health sector reform. The aim will be to sponsor effective community involvement and monitoring in health thus operationalizing the Right to Health. A shift in policies of all the international agencies working in the health sector will be demanded so that they progressively move towards a human rights-based approach to health planning.

35. Some shift in the focus of WHO towards the Human Rights-based Approach to Health will be needed: a shift that puts universal access systems at the center and that strengthens a group inside WHO that will continue to work and provide leadership on this work. 

36. The strengthening and broadening of the PHM network in various countries across the globe will be both an outcome, and also an imperative to take the Movement forward around this rallying point.

 

A few conceptual and strategic points

37. i- The Campaign will challenge the commoditization of health, asserting the inalienable role of the state in public health systems with the public at the center.

ii- The Campaign makes health rights operational, and thus requires demanding specific commitments and norms that provide measurable parameters for monitoring and for the enforcement of redressal mechanisms. 

iii- The Campaign builds a broad strategic alliance involving various special health rights movements that already (or not yet) claim the Right to Health as a key human right.

iv- The Campaign is deeply rooted in national initiatives, yet also addresses key global processes and counters powerful strategic opponents.

v- The Campaign vies for putting the RTH more at the center of attention in the health discourse, and engages major actors making them take an explicit stand on the Right to Health.

vi- For today, the Campaign represents a strategy of resistance (i.e., preventing a further weakening of public health systems) and, for tomorrow, it offers a whole new alternative vision (i,e., universal access to comprehensive health care plus the tackling of the key negative  determinants of health). 

vii- The Campaign will be used to shift the discourse from the preoccupation with vertical programmes and privatisation-oriented measures to focusing more on widespread denial and violations of the Right to Health, on demanding a global consensus on the implementation of this right, and on asking that all programmes and measures now be critically evaluated according to the tenets of health as a right.

 

What may be realistically achieved through the proposed process?
38. We have no illusion that systematically raising the issue of the 'Right to Health' will by itself lead to an actual complete implementation of this right in countries across the globe. The universal provision of even basic health care services involves major budgetary, operational and systemic changes; in addition to shifting to a rights-based framework, major political and legal reorientations are thus needed --and such major changes cannot be expected to happen in full in the near future.

39. However, we can expect and can work on a number of more achievable objectives that can take us towards the larger Human Rights goal. Some of these 'achievables' to be considered in our Campaign are: the explicit recognition of the Right to Health Care at country level; the formation, in some countries, of health rights monitoring bodies with PHM and civil society participation; a clearer delineation of health rights at both global and country level; the shifting of the focus of WHO towards health rights/universal access systems and the strengthening of groups within WHO that will work along these lines; and, finally, the strengthening of the PHM network in as many countries as possible so all its members work around a common and broad rallying point.

 

Organization of PHM and of partners and the Campaign
40. Recognizing that PHM country circles --which were formed during or after the first People's Health Assembly (PHA1) need to move beyond discussions to develop forceful, shared advocacy activities; this is crucial if they are to develop further and to draw-in more groups into our movement. There is now a need to develop and carry out shared and more effective advocacy actions at country level. These are to be directed at engaging both claim-holder groups and decision-makers (duty-bearers) in an effort to bring about needed changes in the existing (and often deteriorating) situation. A 'Right to Health and Health Care' Campaign can be such a catalyst and unifying process bringing together existing and new PHM circles, as well as involving new partner groups and networks. The campaign has the potential to give space to new organizations and networks, which have so far not been active in PHM. Assessing the campaign's viability will start by ascertaining the existence of a minimum critical mass of PHM-and-partners strength and power in a substantial number of countries. Our appeal is for such a process to start as early as possible. As a first step, we plan to explore the potential of this global Right to Health and Health Care Campaign. We have to make use of the momentum achieved at PHA2 to crystallise and plan the future courses of action of the Campaign --understanding that each country will move at its best (individual) pace.

-Abhay Shukla and Claudio Schuftan, People's Health Movement India and Vietnam.

abhayseema at vsnl.com; claudio at hcmc.netnam.vn 
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