PHA-Exch> The human rights-based framework: how is it related to the Social Determinants of Health?

[Claudio Schuftan]

As a corollary to the posting of yesterday, many of you may wonder how the
human right to health relates to the Social Determinants of Health. Here is
one vision:


*The human rights-based framework: how is it related to the SDH?*

1. *Human rights based planning: the new approach: What is it?*

To prepare long term plans of action, one has to go through detailed
situation analyses that identify the most important causes of the problems
to be solved.

Situation analyses are based on an Assessment and an Analysis of the
existing situation that will then lead to decisions being made for Action;
this has been called a  triple A (AAA) process.

But the assessment and the analysis cannot be done in a vacuum --without
previously having worked on a Conceptual Framework of the causes of the
problems that are to be solved. Considering the SDH thus requires such a
framework where these causes figure prominently as determinants.

This means that one has to have an in depth understanding of how those
problems come about --what their determinants are (biomedical, social and
economic) before one can decide what the best options are to take the most
effective actions to solve them. In short: "One finds what one looks for".

The essence of a good situation analysis, then, is to carry out a Causal
Analysis based on a pre-existing Conceptual Framework that includes the SDH
--and to base all decisions for action to be taken on this analysis.

Therefore, appropriate interventions for the main causes at *each* causal
level (immediate, underlying and basic or structural) have to be found.

Addressing each cause is necessary, but not sufficient to change the outcome
(i.e., preventable ill-health,  malnutrition and excess deaths).

One needs to act at all levels of determinants at the same time; this is why
so many "selective PHC interventions" failed in the past.

The above, basically summarizes what professionals in the field were
expected to be doing up to now when trying to solve health and nutrition
problems.

But the Human Rights Based Framework to Planning brings with it a new
perspective to our work.

The essence of the Human Rights based approach is that it tells us that,
additionally,  we now need to carry out what is called a Capacity Analysis
(or accountability analysis).

2. *What is a Capacity Analysis? *

To analyze any Human Rights situation it is essential to identify two main
groups of actors:  *Claim Holders and Duty Bearers*.

Claim Holders are the groups whose universally recognized entitlements are
or are not being catered for by the societies they live in, and whose rights
are thus being upheld or violated.

Duty Bearers are those individuals or institutions that are supposed to
uphold the specific right related to each entitlement.

For example,  in the case of a child as a claim holder, the first-line duty
bearer is the mother; next are the father and other family members.

But --forming a veritable pattern-- there also are duty bearers for
children's rights further up the ladder: community leaders, district and
provincial authorities, national and international leaders and institutions.
(Some call this analysis of claim-duty relationships 'Pattern Analysis').

To recap, the end result of a good causal/situation analysis is a list of
locally specific immediate*,* underlying and basic causes that determine the
problems being addressed (arrived at through a participatory AAA process
that identifies all those causes and comes up with the suggested solutions
for each cause identified).

It is here --when potential solutions have been collectively identified--
where Capacity Analysis comes in.

Capacity Analysis takes what is being proposed to be done for each
determinant at each causal level and looks at what is already being done or
not being done (and why) for that problem.

It then looks at *who* should be doing something about it [individual and/or
institution(s) who is (are) the corresponding duty bearer(s)] and attaches
the name of that (those) person(s) or institution(s) to each proposed
solution.

This results in a list of the most crucial persons/institutions that have to
be approached to push them to get the proposed solution(s) for each cause
implemented.

Note that, often --as a result of a pattern analysis-- a particular duty
bearer is found not to be able to meet her/his obligations, because some of
her/his rights are being violated by a duty bearer higher up (e.g., parents
without resources to pay health user fees cannot be blamed…).

In a very simplified way, the end result of a good Capacity Analysis is a
four or five columns table:

·          the first column lists the causes listed from immediate to basic;


·         the second column lists the respective right(s) being violated,
for which group of claim holders (for example, children) for each cause
(e.g., the human right to health care,  to food and adequate nutrition,
etc);

·         the third column identifies the gaps between what is being done
and what still needs to be done (i.e., the actions still needed).

·         the fourth column --to be realistic-- identifies the most critical
respective duty bearer(s) *by name* (individuals and/or institutions
responsible, often at more than one level);

·         a fifth column may be added to specify who is going to approach
those duty bearers and by when.

This table thus becomes an action plan to get the various Human Rights
deemed to be violated redressed for each specific group of claim holders.

What this new Human Rights Framework to Planning does, then, is to couple
the causal and the capacity analyses.

At first glance, this may not mean much to readers being introduced to this
new concept; but it is a powerful combination.

The coupling not only identifies what needs to be done, and at what level,
but it also targets the person or institution that has to be
lobbied/pressured, because they are legally responsible to do something
about it under the Covenants of International Human Rights officially signed
and ratified by most countries in the world.

The Human Rights-based framework (HRBF), therefore, gives advocates of
children's welfare or of any other human right new powers: As advocates, we
can now approach duty bearers as 'guilty of not doing what they are legally
(and not only ethically) supposed to do'.

The Human Rights covenants currently in force are very explicit about this;
we just have not sufficiently used this added power in our work so far.

Duty bearers have to be approached using the Human Rights violation
justification, and have to be made accountable to comply!

Alleging a "lack of resources" is not a good enough justification by duty
bearers not to uphold the rights being violated.

They have to convincingly demonstrate that resources available (even if
meager) are not being used for other less essential functions. A progressive
realization of the violated rights has to be in place even in the poorest
countries --including intermediate benchmarks for its realization.

If we all do follow this new approach, we may set a growing precedent that
will further the cause of those claim holders whose basic human rights are
being violated worldwide.

Issues are a bit more intricate than here reflected, but this is a good
introduction.

Much of the HRBF is still in the making and not yet applied.  UNICEF, before
Ann Veneman, had been at the forefront of working on how to apply the HRBF
to the planning, implementation and execution of health and nutrition
programs. NGOs have also started to apply the HRBF.  But many NGOs have not
yet revisioned and remissioned themselves to apply the HRBF.

3. *So, how does the HRBF relate to the SDH*?

The HRBF gives us the possibility to advance a political agenda towards
equity and towards the indispensable structural changes that need to be made
for health and other social services to receive the resources they need to
reverse the corresponding human rights currently being violated.

The HRBF is about a more equitable distribution of resources in society, and
health is one of many entry points to achieve this goal. Human beings are
born with a right to health and society has to proactively make the
investments to prevent totally preventable ill-health and malnutrition and
to treat those affected by the diseases of poverty. Being the UN mandate,  the
HRBF is thus the a prime approach to tackle the SDH. Focusing our efforts in
anything short of this is a job half done, more so if we do not arrive at
such a situation through the empowerment of claim holders themselves to
relentlessly demand that the needed changes are implemented. This is not a
task for an avant-garde only: it is a mass mobilization task.

4. *How does the HRBF address global governance (GG) in general?…how has it
addressed it so far*?

GG leaders belong to the highest level of duty bearers the HRBF needs to
approach and to hold accountable. But to address them directly, one has to
know who they are and which are the key global health institutions they work
for. A better capacity analysis is called for here. Right to health
advocates have to address duty bearers at many levels, and should not miss
addressing those in GG bodies. This requires high levels of claim holder
mobilization and organization so they can be approached from a position of
power. The People's Health Movement has successfully lobbied WHO at the
highest levels and is now embarked in a global right to health care
campaign  which will include such global-level advocacy.  GG institutions
now need to be addressed more proactively since it is in them where more
power lies on decisions being made on global health policy issues.

___________

References:

1) Jonsson, U., Human Rights Approach to Development Programming, UNICEF
ESARO, Nairobi, 2003.

2) Schuftan, C., www.humaninfo.org/aviva No
69<http://www.humaninfo.org/aviva%20No%2069>

Claudio Schuftan, Ho Chi Minh City

cschuftan at phmovement.org

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