Human Rights, Health and Poverty Reduction Strategies

Health and Human Rights Publications Series • Issue No 5 • December 2008

Poverty and ill health are deeply intertwined with disempowerment, marginalization and exclusion. Today’s major challenge to effectively address poverty is to weaken the web of powerlessness and Human Rights, to enhance the capabilities of women and men so that they can take more control of their lives. In this context, poverty is increasingly being addressed as the lack of power to enjoy a wide range of human rights – civil, cultural, economic, political and social. Health constitutes a fundamental Health and human right, particularly relevant to poverty reduction. A healthy body enables adults to work and children to learn, key ingredients for individuals and communities to lift themselves out of poverty. Poverty

The task of addressing poverty, health and human rights cannot be handled by any single global Reduction institution and requires rigorous interdisciplinary and coordinated action. This is why the WHO and the OHCHR have worked together with a range of stakeholders to develop this guide. It is intended Strategies as a tool for health policymakers to design, implement and monitor a poverty reduction strategy through a human rights-based approach. It contains practical guidance and suggestions as well as good practice examples from around the world.

HealtH & HumaN RIgHtS PublIcatIoN SeRIeS ISSue No.5 HR/Pub/08/05

For more information, please contact: office of the united Nations Health and Human Rights Adviser High commissioner for Human Rights Department of ethics, equity, trade and Human Rights Palais des Nations Information, evidence and Research (IeR/etH) 8-14 avenue de la Paix World Health organization cH 1211, geneva 10 20 avenue appia, cH 1211, geneva 27 Switzerland Switzerland Website: www.ohchr.org Ph: 41 (22) 791 2523/Fax 41 (22) 791 4726 Health & Human Rights website: www.who.int/hhr Acknowledgements

Human Rights, Health and Poverty Reduction Strategies is a joint product of the Office of the United Nations High Commissioner for Human Rights (OHCHR) and of the Department of Health Policy, Development and Services, and the Health & Human Rights Team of the Department of Ethics, Equity, Trade & Human Rights, of the World Health Organization (WHO).

The booklet was written by Penelope Andrea and Clare Fergusson, consultants to WHO working under the guidance of Rebecca Dodd and Helena Nygren-Krug (WHO) and Mac Darrow, Alfonso Barragues and Juana Sotomayor (OHCHR).

Important milestones in the process of developing the booklet were a web conference organized by InWent Capacity Building International on 9-11 January 2006, and a workshop sponsored by German Cooperation held in Nairobi, 27-29 June 2006. Both events brought together participants from ministries of health, WHO, national human rights commissions, civil society groups and OHCHR.

Other individuals who provided guidance and support include: Anjana Bhushan, Jane Cottingham, Judith Bueno de Mesquita, Paul Hunt, Urban Jonsson, Alana Officer, Eugenio Villar Montesinos. coveR PHoto cReDItS IN HoRIzoNtal oRDeR: 1 & 5. Pierre Virot (WHO-218843); 2. Julio Vizacarra (WHO-348086); 3 & 4. C. Gaggero (WHO-200780)

All rights reserved. Material contained in this publication may be freely quoted, as long as the source is appropriately acknowledged. Requests for permission to reproduce or translate this publication – whether for sale or for noncommercial distribution – should be addressed to either the Office of the United Nations High Commissioner for Human Rights, Palais des Nations, 8–14 avenue de la Paix, CH–1211 Geneva 10, Switzerland (e-mail: [email protected]) or to WHO Press, World Health Organization, 20 avenue Appia, CH–1211 Geneva 27, Switzerland. (fax: +41 22 791 4806; e-mail: [email protected]).

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the United Nations or the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.

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All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

HR/PUB/08/05 Human Rights, Health and Poverty Reduction Strategies

“We recognize that development, peace and security and human rights are interlinked and mutually reinforcing...”

“We resolve to integrate the promotion and protection of human rights into national policies and to support the further mainstreaming of human rights...”

2005 World Summit Outcome (General Assembly resolution 60/1)

GenevA, 2008

Foreword by navanethem Pillay

We are celebrating two The human rights principles of equality important anniversaries and freedom from discrimination are central this year: the adoption to any efforts to improve health. We should of the Universal strive to go beyond statistical averages Declaration of Human and identify vulnerable and marginalized Rights (UDHR) and groups. And beyond identifying the most the establishment vulnerable, we must engage them as active of the World Health participants and generators of change. This Organization (WHO). is not only to ensure that health policies The UDHR proclaimed 'freedom from fear' and programmes are inclusive. It is also a and 'freedom from want' as the highest question of empowering people. aspiration of all peoples and affirmed the We hope that this booklet Human Rights, inherent dignity and equality of every human Health and Poverty Reduction Strategies being. The WHO Constitution enshrined will inspire and guide health policymakers the enjoyment of the highest attainable to design, implement and monitor poverty standard of health as a fundamental human reduction strategies through a human right. The key messages of the UDHR and rights-based approach. the Constitution of the WHO – now both 60 years old – are more relevant than ever. Globalization has brought an increased flow of money, goods, services, people and ideas. Yet, gaps are widening, both within and between countries – in life expectancy, in wealth, and in access to life-saving technology. Those left behind, and experiencing poverty and ill health, feel Nava Nethem Pillay uNited NatioNs high commissioNer disempowered, marginalized and excluded. for humaN rights

Foreword by Heidemarie Wieczorek-Zeul

The right to the enjoyment of the highest to promote and protect human rights and attainable standard of physical and mental to integrate human rights principles more health is at the centre of our development systematically into development cooperation efforts for the achievement of the Millennium at all levels of intervention as part of a Development Goals (MDGs). Adopting a broader governance agenda. human rights-based approach to health in Poverty and ill health are strongly Poverty Reduction Strategy processes has interlinked: lack of education, lack of not only an instrumental value for poverty nutritious food or safe water and unhealthy reduction. More importantly, it also has an housing conditions often have a negative intrinsic value as most UN Member States impact on the health of populations – with have ratified the International Covenant the effect that poor people suffer the on Economic, Social and Cultural Rights, highest burden of disease. Vice versa, ill which enshrines the right to health at the health invariably increases vulnerability to universal level. A human rights-based poverty and increases the risk of poverty approach recognizes that every human being transmitted to the next generation. A being, by virtue of his or her inherent human human rights-based approach to health can dignity, is a holder of rights. And it is an bring about a stronger poverty focus in PRS obligation on the part of the Government to processes since it consistently focuses on respect, protect and fulfil these rights. issues of inclusion, availability, accessibility, Supporting Member States in acceptability and affordability for all. A progressively realizing the right to better targeting of health services towards health for all is thus a legal and moral the poor can contribute decisively to poverty obligation incumbent on all members of the reduction and pro-poor economic growth and, international community. The commitment ultimately, to achieving the MDGs. to stronger focus on human rights in I am pleased that the collaboration development cooperation has been underlined between WHO, OHCHR and my Ministry by the adoption of the first OECD DAC policy through its technical cooperation (GTZ) paper on “Human rights and development” made this publication possible and hope in February 2007. This policy paper it will provide constructive guidance demonstrates that an increasing number of for policymakers in both developed and bi- and multilateral donors – Germany being developing countries so as to make the one of them – are intensifying their efforts achievement of all MDGs a reality for all.

h eidemarie wieczorek-zeul german federal minister for economic cooperation and development

Table of Contents

Introduction ...... 01

SECTION 1 Principles of a human rights-based approach to poverty reduction strategies ...... 05 1.1 What are the characteristics of human rights? ...... 05 1.2 What are the links between human rights and poverty? ...... 06 1.3 How is health protected by the human rights legal framework? ...... 08 1.4 What are poverty reduction strategies? ...... 10 1.5 Putting human rights into practice through development policies and programmes ...... 11 1.6 In what ways do human rights and poverty reduction strategies complement each other? 12

SECTION 2 Formulating a pro-poor health strategy based on human rights principles ...... 14 2.1 Participation ...... 14 2.2 Human rights-based analysis of health and poverty ...... 20

SECTION 3 Developing the content and implementation plan ...... 33 3.1 Addressing inequality in the realization of the right to health ...... 34 3.2 Addressing institutional constraints and capacity gaps ...... 37 3.3 Financing the health strategy ...... 43 3.4 Drafting or implementing a long-term strategy ...... 49 3.5 Working with donors to promote human rights through the PRS ...... 50

SECTION 4 Implementation: transparency and accountability through monitoring and evaluation ...... 53 4.1 Community-based and civil society monitoring ...... 53 4.2 Budget initiatives ...... 54 4.3 National monitoring and statistics collection ...... 56 4.4 Indicators ...... 58 4.5 Targe t s ...... 61 4.6 Political, judicial and quasi-judicial accountability ...... 62

SECTION 5 Human rights instruments, international resolutions and declarations, useful documents, and organizations ...... 67 5.1 The evolution of the right to health and poverty in development ...... 67 5.2 Key references and organizations on the right to health and poverty ...... 69

List of Acronyms and Terms

AAAQ Availability, accessibility, acceptability and quality Common Understanding Central elements of the UN's understanding of a human rights-based approach to development DAC Development Assistance Committee General Comment 14 General Comment on the Right to Health (2000) ICCPR International Covenant on Civil and Political Rights ICESCR International Covenant on Economic, Social and Cultural Rights ICPD International Conference on Population and Development ICPD+5 Five-Year Review of ICPD (1999) IMF International Monetary Fund MDGs Millennium Development Goals NGOs Non-governmental organizations OECD Organisation for Economic Co-operation and Development OHCHR Office of the United Nations High Commissioner for Human Rights PAP Participatory action plan PPA Participatory poverty assessments PRS Poverty reduction strategy PRSP Poverty reduction strategy paper PSIA Poverty and social impact assessment TRIPS Agreement Agreement on Trade-Related Aspects of Intellectual Property Rights UDHR Universal Declaration of Human Rights UN United Nations UNDP United Nations Development Programme UNICEF United Nations Children’s Fund WHO World Health Organization

Human RigHts, HealtH and PoveRty Reduction stRategies

Introduction

Human rights are central to the achievement effectiveness and coherent donor action of the Millennium Development Goals to support poverty reduction. The benefits (MDGs), the eight overarching targets derived of these approaches are beginning to be from the Millennium Declaration that aim measured in terms of greater use of to reduce poverty, ill health and inequality services by excluded groups and improved as well as increase access to education and health outcomes. improve environmental sustainability. Human The present booklet draws on this more rights highlight the discrimination, inequality, recent body of experience and research. powerlessness and accountability failures It seeks to strengthen efforts to achieve that lie at the root of poverty and deprivation. the MDGs by helping policymakers Human rights have, in the past, been incorporate human rights into the design and associated with conditionality and a focus on implementation of the health component of civil and political rights. This emphasis, together national poverty reduction strategies (PRSs). with a lack of understanding of economic, social It sets out how human rights standards and and cultural rights, obscured the connections principles can provide a framework for: between human rights and poverty reduction and meant that human rights were seen as l analysing and addressing inequalities and too controversial for use in development. discrimination in access to health; Some Governments and organizations remain l supporting the demand side of reluctant to address human rights explicitly in poverty reduction through participation, their policies and programmes. accountability and redress; A growing number of donors, Governments l addressing the linkages between health and non-governmental organizations are now and other areas, including macroeconomic exploring the practical ways in which human policies and relevant sectors such as water rights can be integrated into development. and sanitation; Human rights standards and principles have l identifying and delivering concrete been used in villages and communities to entitlements to health service provision; strengthen the accountability of service l formulating and monitoring budget providers and to monitor budget allocations allocations on health; and expenditure. They have formed the l clarifying Governments' and health basis of national strategies to address HIV/ ministries' regulatory role and enhancing AIDS as well as reproductive and sexual health policy coherence; health. Human rights are increasingly seen l promoting mutual accountability and as a useful framework for ensuring aid coherence in donor-Government relations.

Human RigHts, HealtH and PoveRty Reduction stRategies • 01 Operationalizing and realizing human guidance on strengthening processes for rights in practice is rarely straightforward, participation, inclusion and accountability particularly in view of the financial and that empower excluded and marginalized political constraints faced by all countries. people to claim their right to health. This booklet provides examples of successful initiatives using human rights standards and Section 1 provides an introduction to human principles to address poverty; some reflect rights standards and principles, and explores national policies, others highlight initiatives how these apply to issues of poverty and health. by regional authorities or non-governmental It starts by examining the characteristics of actors. It aims to provide practical guidance on human rights. It then reviews the principles how to bring human rights, sound development underlying all human rights – including the practice and public health polices together in indivisibility of rights, equality and non- the health component of a PRS and addresses discrimination, participation and accountability some of the challenges that this process – and examines the importance of these may produce. The primary audience for the principles for poverty reduction. booklet is policymakers and planners working The section sets out how health is in ministries of health and other national protected by human rights standards. It ministries addressing health-related issues. discusses the meaning of the right to health It is hoped that it will also be a useful source as set out in the International Covenant reference for anyone working on health and on Economic, Social and Cultural Rights PRSs, including those working in multilateral, (ICESCR). It further discusses how the UN donor and non-governmental organizations. Committee on Economic, Social and Cultural The structure of the booklet mirrors Rights, which monitors compliance with the process of developing a PRS, from the ICESCR, has further clarified the scope initial analysis to design of its content to and content of the right to health when its implementation, and is consistent with adopting a General Comment on the Right the approach recommended by the World to Health in 20002. This General Comment Bank in its Poverty reduction strategy papers (hereinafter referred to as “General Comment 1 1 Klugman J, ed. A sourcebook for poverty (PRSP) sourcebook. The guidance would be 14”) on the right to health states that the reduction strategies. Washington, DC, equally relevant in designing any pro-poor right to health extends not only to timely World Bank, 2002. health policy. The booklet does not provide a and appropriate health care but also to the http://www.worldbank.org blueprint, but instead offers broad guidance underlying determinants of health, such

2 General Comment 14 (2000), on how to apply a human rights-based as access to safe and potable water and The right to the highest attainable standard of approach to health in the context of poverty adequate sanitation, an adequate supply health (article 12 of the International Covenant reduction. This guidance can be adapted to of safe food, nutrition and housing, healthy on economic, Social and Cultural Rights). Geneva, United nations, 2000 (e/C.12/2000/4). fit the particular circumstances of different occupational and environmental conditions www.ohchr.org countries. Each of the sections provides and access to health-related education,

02 • Human RigHts, HealtH and PoveRty Reduction stRategies i NtroductioN

including on sexual and reproductive health. The second step is to use international and Underlying determinants and facilities, goods national standards as a basis for identifying and services must be available, accessible, who is a duty-bearer in the context of the acceptable and of good quality. provision of health care and the underlying The section reviews human rights-based determinants of health. The primary approaches to development. Common responsibility lies with the State in light of its elements in these approaches include human rights obligations under international the use of human rights principles as human rights law. However, other duty- the basis for participatory, inclusive and bearers, which may have responsibilities, accountable analysis and interventions, and include the private sector and international the achievement of human rights standards donors. In the context of a PRS, rights-holders as objectives. The section concludes with are those people who are most excluded from a review of the value added of using a access to health. human rights-based approach in the task of The third step is assessment of the formulating a PRS. institutional frameworks and capacity gaps shaping relations between rights-holders Section 2 provides suggestions for the and duty-bearers. Institutional assessment process of designing the health segment includes analysis of mechanisms for ensuring of a PRS based on human rights standards participation and accountability, review of and principles. It highlights both the intrinsic health-related legislation and policies, and and instrumental value of participation assessment of financial constraints. Analysis of and suggests a methodology to enable capacity gaps focuses on the knowledge, skills the meaningful participation of the poor and information that rights-holders and duty- or excluded in all stages of the PRS. It bearers require to realize the right to health. emphasizes the importance of provision of information and of transparency for Section 3 addresses the challenge of meaningful participation. developing the content of a PRS in line with The second half of the section explores the rights-based analysis of health and how a rights-based approach can be poverty. Information from the rights-based used to analyse issues of health and analysis, PRS consultation process and poverty. It proposes three steps. The first clinical and geographical data are used to step is to use the criteria of availability, identify the essential health services and accessibility, acceptability and quality to underlying determinants of health. A key examine the barriers that prevent people element of a human rights-based approach is who are marginalized and excluded from the identification of concrete entitlements, or obtaining health services and the underlying minimum standards of service provision, that determinants of health. enable people to hold public policymakers

Human RigHts, HealtH and PoveRty Reduction stRategies • 03 to account for service delivery. The analysis sector, and looks at formulating the health of availability, accessibility, acceptability sector budget on the basis of agreed policy and quality of health services helps to define objectives, minimum standards of service these entitlements. The section then reviews provision and human rights principles. the challenges of targeting excluded and Indicating the importance of taking into marginalized populations, highlighting the account the additional costs of reaching importance of forming partnerships with underserved populations, it discusses some of a broad range of organizations, identified the challenges of allocating and redistributing through the review of rights-holders and resources against agreed priorities. duty-bearers, to address the underlying Finally, the section explores how human determinants of health. rights principles can provide the basis for The creation of a task force is proposed, to building Government–donor relations to address participation, accountability and the support the health sector strategy. information needs of rights-holders identified in the institutional analysis. Such a task force Section 4 is concerned with the should also ensure the effectiveness of linkages implementation stage of a PRS. It reviews between local, national and international civil society PRS-monitoring initiatives, processes of participation and accountability. including community-based service monitoring Skills, training and empowerment initiatives and budget analysis. After discussing the should be undertaken, to support the capacity challenges of establishing an effective national of both service providers and people claiming monitoring system and the production of those services. The amendment of existing disaggregated data, it suggests the type discriminatory legislation and policies is of indicators and targets that can be used recommended, as well as the initiation of new to measure changes in health inputs and legislation to ensure that people are protected outcomes. The section concludes by exploring from actions by private sector and other the role of political, judicial and quasi- organizations that may have a negative impact judicial institutions in ensuring Government on their health. accountability for human rights. Section 3 also addresses issues of funding for the health sector strategy, stressing Section 5 is a detailed reference section of the importance of human rights principles relevant human rights instruments. It points to of transparency, accountability, non- key documents and texts of specific relevance discrimination and participation in decisions to health, human rights and poverty reduction about macroeconomic policies. It reviews that the reader may wish to refer to for further the key areas of macroeconomic policy that reading. Also included is a list of organizations are likely to have an impact on the health active in this area.

04 • Human RigHts, HealtH and PoveRty Reduction stRategies Section 1 Principles of a human rights-based approach to poverty reduction strategies This section provides an introduction to human rights principles, the links between human rights and poverty, and how health is protected by the human rights legal framework. It outlines the elements of a human rights-based approach, and explores the value of using this approach to 3 Office of the united nations High formulate the health component of a PRS and to ensure that the overall Commissioner for Human rights. Frequently asked questions on a human rights-based PRS promotes and protects the right to health. approach to development cooperation. new York and geneva, united nations, 2006 (Hr/ PuB/06/08) http://ohchr.org 1.1 What are the characteristics of economic, political and social rights set human rights? out in the Universal Declaration of Human 4 international Convention on the elimination of all Forms of racial Human rights are internationally agreed Rights (UDHR 1948). The key international Discrimination www.ohchr.org standards which apply to all human beings. human rights treaties – the International They encompass the civil, cultural, Covenant on Economic, Social and Cultural 5 Convention on the elimination of all Forms of Discrimination against Women Rights (ICESCR 1966) and the International www.ohchr.org Covenant on Civil and Political Rights

6 Convention on the rights of the Child Human rigHts are: (ICCPR 1966) – further elaborate the content www.ohchr.org ● universal, the birthright of every human being; of the rights set out in the UDHR and contain legally binding obligations for the 7 international Convention on the Protection ● aimed at safeguarding the inherent dignity and of the rights of all migrant Workers and equal worth of everyone; Governments that become parties to them. members of their Families www.ohchr.org ● inalienable (they cannot be waived or taken away); Building upon these core documents, other international human rights treaties 8 Convention on the rights of Persons with ● interdependent and interrelated (every human Disabilities www.ohchr.org right is closely related to and often dependent have focused on groups and categories 4 9 upon the realization of other human rights); of populations, such as racial minorities, international Convention for the Protection 5 6 7 of all Persons from enforced Disappearance ● articulated as entitlements of individuals (and women, children, migrants, and persons 8 www.ohchr.org groups) generating obligations of action and with disabilities or on specific issues such as enforced disappearance9 or torture.10 10 Convention against torture and Other omission, particularly on states; Cruel, inhuman or Degrading treatment or ● internationally guaranteed and legally protected.3 All UN Member states have ratified at Punishment www.ohchr.org least one of the nine main human rights

Human RigHts, HealtH and PoveRty Reduction stRategies • 05 State obligations treaties, and 80 per cent have ratified four Economic, Social and Cultural Rights has All human rights impose or more. When Governments ratify a defined poverty as: three types of obligations on treaty, they become legally bound to States: respect, protect and fulfil the rights they “a human condition characterized by Respect: This simply means have acknowledged. sustained or chronic deprivation of the not to interfere with the Human rights law recognizes the severe enjoyment of human rights. constraints that poor countries face and resources, capabilities, choices, security Protect: This means ensuring allows for the fact that it may not be that third parties (non-State and power necessary for the enjoyment possible to realize all economic, social actors) do not infringe upon of an adequate standard of living and the enjoyment of human and cultural rights for everyone rights. immediately. However, Governments are other civil, cultural, economic, political and Fulfil: This means taking obliged to provide a long-term plan that social rights.” 11 positive steps to realize will lead to the progressive realization human rights. of human rights. They should also take Human rights standards set out the immediate concrete steps, including 11 different objectives of development that united nations economic and social financial measures and political Council, Committee on economic, social have to be achieved in order to eliminate and Cultural rights. substantive issues commitments in accordance with available poverty, including health, education, arising in the implementation of the resources, targeted deliberately towards freedom from violence, the ability to exert international covenant on economic, the full realization of all human rights. political influence and the ability to live social and cultural rights. Poverty and In situations where a significant number a life with respect and dignity. Human the international covenant on economic, of people are deprived of human rights, social and cultural rights. geneva, united rights principles underpin all civil, cultural, nations, 2001 (e/C.12/2001/10) the State has the duty to show that all its economic, political and social rights www.ohchr.org available resources – including through and provide the foundation for building requests for international assistance, as interventions to achieve the realization of 12 adapted from: Frequently asked questions needed – are being called upon to fulfil human rights and the elimination of poverty. on a human-rights based approach to these rights. development cooperation, op. cit. Some human rights principles, including participation and non-discrimination, are 1.2 What are the links between human also standards. This means that they should rights and poverty? be incorporated into both the processes Poverty has conventionally been and objectives of development. Human defined in economic terms, focusing rights principles include:12 on individual and household, relative or absolute financial capacity. It is Indivisibility: Indivisibility means that civil, now generally recognized that poverty cultural, economic, political and social is multidimensional and not only defined rights are all necessary for the dignity of by a lack of material goods and the human person and are interlinked. opportunities. The UN Committee on The principle of indivisibility implies that

06 • Human RigHts, HealtH and PoveRty Reduction stRategies section 1

13 World Bank. World development report responses to poverty should be cross- all peoples are entitled to active, free and 2006: equity and development. Washington sectoral and include economic, social and meaningful participation in, contribution DC, World Bank, 2005 political interventions. to, and enjoyment of civil, economic, social, http://econ.worldbank.org/wdr cultural and political development in which

14 elson D. Budgeting for women's rights: Equality and non-discrimination: Human human rights and fundamental freedoms monitoring government budgets for rights standards and principles define can be realized. It implies that people compliance with CeDaW. new York, united all individuals as equal and entitled to who are poor are entitled to participate in nations Development Fund for Women, 2006 their human rights without discrimination decisions about the design, implementation www.unifem.org/resources/item_detail. of any kind, such as race, colour, sex, and monitoring of poverty interventions. php?ProductiD=44, accessed 4 October 2007. ethnicity, age, language, religion, political This requires access to information, and

15 Hunt P. report of the special or other opinion, national or social origin, clarity and transparency about decision- rapporteur on the right of everyone to disability, property, birth, physical or making processes. It also means that all the highest standard of physical and mental disability, health status (including people are entitled to share the benefits of mental health. new York, united nations HIV/AIDS), sexual orientation or any other the resultant policies and programmes. general assembly. 17 January 2007 (a/ status as interpreted under international HrC/4/28) www.ohchr.org law. Inequality and discrimination can Accountability, transparency and the rule of 16 gauri V. social rights and economics slow down economic growth, create law: Processes of accountability determine claims to health care and education in inefficiencies in public institutions and what is working, so that it can be repeated, developing countries. Washington, DC, reduce capacity to address poverty.13 and what is not, so that it can be adjusted.15 World Bank, march 2003 (World Bank Policy Human rights law and jurisprudence Accountability plays a key role in research Working Paper 3006) www.worldbank.org recognize the importance of both formal and empowering poor people to challenge the substantive equality. Formal equality prohibits status quo, without which poverty reduction is the use of distinctions, or discrimination, in unlikely to succeed. It is generally recognized law and policy. Substantive equality considers that both the State and private sector are laws and policies discriminatory if they have insufficiently accountable to support effective a disproportionate negative impact on any and equitable service provision.16 group of people. Substantive equality requires Accountability has two elements: Governments to achieve equality of results.14 answerability and redress. Answerability This implies that the principle of equality and requires Governments and other decision non-discrimination requires poverty reduction makers to be transparent about processes strategies to address discrimination in laws, and actions and to justify their choices. policies and the distribution and delivery of Redress requires institutions to address resources and services. grievances when individuals or organizations fail to meet their obligations. There are many Participation and inclusion: The human forms of accountability. Judicial processes rights principle of participation and are one form of accountability used to inclusion means that every person and support the implementation of human

Human RigHts, HealtH and PoveRty Reduction stRategies • 07 17 Paul Hunt, 17 January 2007 op. cit. rights. Human rights law means that States and other duty-bearers are answerable for tHe rigHt tO HealtH 18 & 19 international Covenant on the observance of human rights. Where 1. the states Parties to the present Covenant economic, social and Cultural rights, 1966 (art.12). www.ohchr.org they fail to comply with the legal norms recognize the right of everyone to the and standards enshrined in human rights enjoyment of the highest attainable standard of instruments, rights-holders are entitled physical and mental health. to institute proceedings for appropriate 2. the steps to be taken by the states Parties to redress before a competent court or other the present Covenant to achieve the full realization adjudicator in accordance with the rules and of this right shall include those necessary for: procedures provided by law. Some processes of accountability are a. the provision for the reduction of… infant specific to human rights, for example mortality and for the healthy development of inquiries by national human rights the child; institutions and reporting to the UN human b. the improvement of all aspects of rights treaty-monitoring bodies. Others environmental and industrial hygiene; are general, including administrative c. the prevention, treatment and control of systems for monitoring service provision, epidemic, endemic, occupational and other fair elections, a free press, parliamentary diseases; commissions and civil society monitoring.17 d. the creation of conditions which would The principle of accountability assure to all medical service and medical requires that PRS processes of design, attention in the event of sickness.19 implementation and monitoring should be transparent and decision makers To clarify and operationalize the provisions of should answer for policy process and article 12, the UN Committee on Economic, choices. In order to achieve this, the PRS Social, and Cultural Rights adopted General should build on, and strengthen links to, Comment 14. This acknowledges the those institutions and processes that importance of the underlying determinants enable people who are excluded to hold of health by stating that the right to health policymakers to account. is dependent on, and contributes to, the realization of many other human rights, such 1.3 How is health protected by the as the rights to food, to an adequate standard human rights legal framework? of living, privacy and access to information. The most authoritative definition of the right According to General Comment 14, of everyone to the enjoyment of the highest moreover, the right to health contains both attainable standard of physical and mental freedoms and entitlements. Freedoms include health, often referred to as the right to health, the right to be free from non-consensual is set out in article 12 of the ICESCR.18 medical treatment, torture and other cruel,

08 • Human RigHts, HealtH and PoveRty Reduction stRategies section 1

20 http://www.who.int/reproductive-health/ inhuman or degrading treatment or punishment, access to health care and the underlying gender/index.html and the right to control one’s body, including determinants of health. States must sexual and reproductive freedom. Entitlements recognize and provide for the differences include the right to a system of health and specific needs of population groups, 21 World Health Organization/Office of the united nations High Commissioner for protection; the right to prevention, treatment such as women, children, or persons with Human rights 2008. Fact sheet no31 on and control of diseases; the right to healthy disabilities, which generally face the right to Health. natural and workplace environments; and the particular health challenges, such as higher www.ohchr.org right to health facilities, goods and services. mortality rates or vulnerability Participation of the population in health-related to specific diseases.21 decision-making at the national and community levels is another important entitlement. Non-discrimination and equality are critical i nternatiOnal Human rigHts components of the right to health. States treaties reCOgnizing tHe rigHt have an obligation to prohibit discrimination tO HealtH (see references below, section 5.2): and ensure equality to all in relation to l international Convention on the elimination of all Forms of racial Discrimination (1965): article 5(e)iv; l international Covenant on economic, social and rePrODuCtiVe rigHts Cultural rights (1966): article 12; l Convention on the elimination of all Forms of reproductive rights rest on the recognition of Discrimination against Women (1979): articles 11(1) the basic right of all couples and individuals f, 12 and 14(2)b; to decide freely and responsibly the number, l international Convention on the rights of the spacing and timing of their children and to have Child (1989): article 24; the information and means to do so, and the right l international Convention on the Protection of the to attain the highest standard of sexual and rights of all migrant Workers and members of their reproductive health. they also include the right Families (1990): articles 28, 43(e) and 45; of all to make decisions concerning reproduction l Convention on the rights of Persons with free of discrimination, coercion and violence.20 Disabilities (2006): article 25.

General Comment 14 sets out four criteria by which to evaluate the right to health:

Availability. Functioning public health and health facilities, goods and services, as well as programmes, have to be available in sufficient quantity.

Human RigHts, HealtH and PoveRty Reduction stRategies • 09 Accessibility. Health facilities, goods 1.4 What are poverty reduction and services have to be accessible to strategies? everyone without discrimination, within the A PRS is a national cross-sectoral jurisdiction of the State party. Accessibility development framework, designed and has four overlapping dimensions: implemented by the national Government, 1. non-discrimination; specifically to tackle the causes and impact 2. physical accessibility; of poverty in a country. Even in high-income 3. economic accessibility (affordability); States, groups or sectors of poor people 4. information accessibility. remain and a national PRS is as necessary in these countries as in poorer ones. In Acceptability. All health facilities, goods low- and middle-income States, PRSs and services must be respectful of medical were initially introduced as a requirement ethics and culturally appropriate, sensitive to for countries seeking concessional loans gender and life-cycle requirements, as well as from the World Bank or the International being designed to respect confidentiality and Monetary Fund (IMF). In these countries, improve the health status of those concerned. Governments produce a PRSP setting out their macroeconomic and social policies and Quality. Health facilities, goods and plans. Today, PRSs are increasingly seen services must be scientifically and as the principal mechanism around which medically appropriate and of good quality. many bilateral and multilateral donors build their development cooperation programmes. The Right to Health They are also considered to be the national operational framework for achieving the MDGs. By March 2005, 44 countries had completed full PRSPs, and several are now revising their original strategies. There is now broad agreement among all the leading development agencies, including the World Bank, on the key principles on Underlying determinants Health care which a PRSP should be based. Water, sanitation, food, nutrition, housing, healthy occupational and l It should be result-oriented, with targets environmental conditions, for poverty reduction that are tangible and education, information, etc. can be monitored. AAAQ l It should be comprehensive, integrating Availability, Accessibility, Acceptability, Quality macroeconomic, structural, sectoral and

(General Comment No. 14 of the Committee on Economic, Social and Cultural Rights) social elements.

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23 Paris declaration on aid effectiveness: l It should be ‘country-driven’, representing empowerment initiatives which encompass ownership, harmonisation, alignment, results the consensus on what steps should be taken. human rights education, mobilization, and mutual accountability. Paris, High level l It should be participatory; all advocacy and monitoring of Government Forum, February 28 - march 2, 2005 stakeholders should participate in its policies by and on behalf of people who are www.oecd.org formulation and implementation. poor and marginalized. 24 “legal opinion on human rights and the l It should be based on partnerships A number of donor and multilateral work of the World Bank”, dated January 27, between the Government and other actors. agencies have endorsed approaches that 2006 http://www.ifiwatchnet.org l It should be long-term, focusing on use human rights as a framework for reforming institutions and building capacity development planning and implementation. 25 Development assistance Committee, 23 action-oriented policy paper on human rights as well as long-term goals. The opportunities for the application of this and development. Paris, Organisation for work have been broadened by the World economic Co-operation and Development, 1.5 Putting human rights into practice Bank’s legal opinion,24 issued in 2006, 23 February 2006 [DCD/DaC(2007)15/Final] through development policies and which indicates that it has a significant www.oecd.org programmes role to play in supporting Governments to While the value of human rights as a 26 the human rights-based approach fulfil their human rights obligations relating to developement cooperation: towards set of guiding norms is well established, to development and poverty reduction. a common understanding among un development practitioners are now The Development Assistance Committee agencies. in: interagency workshop on exploring how human rights can be (DAC) of the Organisation for Economic a human rights-based approach in the used to strengthen poverty analysis and Co-operation and Development (OECD) context of un reform, stamford, Ct 3-5 development operations. may 2003. new York, united nations has also issued guidance on integrating www.undp.org For many civil society organizations, human rights into development. It includes human rights provide a focus for recommendations for the integration of human rights principles and analysis into tHe Human rigHts-BaseD aPPrOaCH tO DeVelOPment the roll-out of the Paris Declaration on Aid Effectiveness.25 The DAC guidelines COOPeratiOn: t owards a common understanding among un agencies highlight the potential of the human rights l gOal: all programmes of development other international human rights instruments framework to strengthen principles of cooperation, policies and technical should guide all development cooperation ownership, alignment, harmonization, assistance should further the realization of and programming in all sectors and in all managing for results and mutual human rights as laid down in the universal phases of the programming process. accountability in the delivery of aid. Declaration of Human rights and other While there is no universal recipe human rights instruments. l OutCOme: Programmes of development for incorporating human rights into cooperation should contribute to the development processes, rights-based l PrOCess: Human rights standards development of the capacities of duty- approaches generally have the fulfilment contained in, and principles derived from, the bearers to meet their obligations and of of human rights as their objective and universal Declaration of Human rights and rights-holders to claim their rights.26 apply underlying human rights principles to policies and programmes. In 2003 United

Human RigHts, HealtH and PoveRty Reduction stRategies • 11 Nations agencies agreed on a “Common both include emphasis on participation, 27ibid. Understanding” of the central elements monitoring and accountability, long- 28 of a human rights-based approach to term planning and incorporation of a PrsPs: their significance for health: second synthesis report. geneva, Workd development that would inform UN policies multidimensional understanding of poverty. Health Organization, 2004 (WHO/HDP/ 27 and practices. A human rights-based approach can help PrsP/0.4.1) www.who.int This booklet draws on the approach to strengthen these elements of a PRS. set out in the Common Understanding as Review of completed PRSPs suggests the basis for exploring how human rights that, in many cases, they have been weak standards and principles can strengthen on issues of inequality in health provision. the design and implementation of the A WHO review of completed PRSPs found health component of a PRS. It uses the a lack of in-depth analysis of the linkages definition of the right to health set out between poverty and health, insufficient in the ICESCR and General Comment 14 emphasis on non-discrimination and an as a basis for building a cross-sectoral absence of indicators of health inequalities. approach to health, with the criteria of In addition, the review identified a lack of availability, accessibility, acceptability participation by the relevant ministry of and quality providing the underlying health in the PRS process.28 framework for analysis, design and This booklet uses a human rights- implementation of the health strategy. based approach to address these gaps and It suggests processes and interventions strengthen the formulation of the health which are based on the human rights component of a PRS by identifying methods principles of indivisibility, equality and non- and interventions which support: discrimination, participation and inclusion, and accountability, transparency and l a coherent, cross-sectoral approach to the rule of law. Interventions address the health and an enhanced regulatory role for institutional constraints and capacity gaps the ministry of health; that prevent rights-holders from claiming l the participation of marginalized and their rights and duty-bearers from meeting excluded people in decisions that impact their obligations. upon their health; l the definition and communication of 1.6 In what ways do human rights entitlements and minimum standards of and poverty reduction strategies service provision that enable people to complement each other? hold public policymakers and providers to There are many similarities between a account for their actions; human rights approach to poverty reduction l the non-discriminatory delivery of and the key principles of a PRS. Strategies entitlements and identified minimum and approaches that are common to standards on a universal basis;

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l health sector budget allocations based on agreed service priorities and standards; l accountability procedures which enable people to monitor provision and obtain redress when standards are not met; l coherent and mutually accountable donor–Government relations.

The powerlessness, discrimination, inequality and accountability failures that lead to poverty are often politically driven, deeply rooted and not easily remedied. Nonetheless, these are the challenges that policymakers and planners have to face if health outcomes are to be improved. The following sections provide guidance and case studies that health planners can utilize to address these issues in their own countries. Summaries of experience and (WHO-212124) Virot Pierre lessons learned inevitably gloss over the and build relations with a wide range of problems and setbacks that all individuals different organizations from the and organizations face when they try to community, non-governmental and support difficult changes. Policymakers private sectors. Applying human rights and planners have to be determined, principles of participation, inclusion, persuasive and innovative to overcome accountability and transparency to all conflicts of interest within their own these partnerships and working relations, ministries as well as in the communities within and outside the ministry of health, with which they are working. Champions of provides the most effective foundation for change at different levels of the actions to support the realization of the ministry of health need to work together right to health for all.

Human RigHts, HealtH & PoveRty Reduction stRategies • 13

Section 2 Formulating a pro-poor health strategy based on human rights principles This section provides guidance on how human rights can support the process of developing and formulating the health segment of a PRS.

No two countries are faced with the same exclusion that lead to inequalities in health health problems and each country’s health outcomes. Potential entry points for action strategy differs accordingly. A human are identified through assessment of rights- rights-based analysis of health and poverty holders and duty-bearers and analysis of provides context-specific cross-sectoral the institutional frameworks and capacities assessment of the causes of ill health. It which shape their relations. addresses questions about who is denied the right to health, why they are deprived, 2.1 Participation and what can be done to improve their Participation is an essential principle of situation and prevent others from suffering. human rights and is intrinsic to inclusion Participation, enabling people to have a and democracy at local, national and voice in the decisions that affect their lives, international levels. Information sharing is a is a central element of this process. critical component of participatory processes whether at the planning, implementation or The first part of this section looks at monitoring stages of the PRS. participation as an essential principle An effective participatory process is of all phases of the PRS process, from a key factor in the success of any PRS. gathering information about poverty, It increases ownership and control over inequality, powerlessness and health to the development processes and helps to ensure participation process aimed at engaging a that interventions are responsive to the broad range of individuals and organizations situations of the people they are intended to in health-policy decisions. The second benefit. Building a health sector component part of the section explores approaches of a PRS on sound information and broad- for building a comprehensive information based participation places the ministry of base on processes of discrimination and health in a stronger position in resource

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negotiations with the ministry of finance and iii. determining the feasible level of other organizations that have a strong stake participation for the PRS in the PRS. iv. identifying the appropriate However, it is not without its inherent mechanisms for participation risks. Participation requires a willingness v. developing institutional mechanisms to share power and information on a non- for coordinating participation discriminatory basis. Participation is, vi. developing an action plan.29 consequently, politically and logistically challenging. Participatory processes may These stages are discussed briefly below. raise expectations unrealistically or expose -200778) o conflicting interests and power struggles. Identification of starting point . c Initiating participatory processes requires i Participation in the PRS will be

aggen aggen time, patience, resources and planning. different in each country, depending on a g (WH Whether it takes place at the local project number of factors, including governance level or at national policy level, the principal and political structures and the extent to mechanism for participation should, as which civil society and politicians regard far as possible, be existing democratic the PRS as an important instrument for structures. In some circumstances, addressing poverty. In order to find a establishing alternative frameworks for country’s starting point, and a rough idea participation can undermine fledgling of the feasible level of participation, it is democratic structures, create unwelcome useful to assess the following factors: parallel systems and, in the longer term, prove unsustainable. Nevertheless, in many l degree of ownership of previous national cases, innovative arrangements may well be poverty reduction processes needed to ensure that participation is both l civil society organization and capacity inclusive and deep. l previous experience with participation in Many countries design what is commonly policy processes known as a Participatory Action Plan (PAP). l Government capacity for organizing This provides a roadmap for participation participatory processes. in all stages of the PRS cycle from design and implementation to monitoring. The exact Stakeholder analysis content of a PAP varies from country to ii One of the key steps in the country. Key stages in designing a realistic participatory process is the identification PAP include: of the stakeholders — all those individuals, 29 Adapted from: Tikare S et al. Organizing groups and organizations that are affected participatory processes in the PRSP. Washington, DC, World Bank, April 2001 i. identification of starting point by, or involved in the delivery of, the PRS. (draft for comments). ii. stakeholder analysis From a human rights perspective, it is

Human RigHts, HealtH and PoveRty Reduction stRategies • 15 important that the most marginalized groups l Government policy planners, and communities are identified and engaged including civil servants in central in the PRS from the outset. ministries, line ministries and local The nature of exclusion and the identity government bodies; of the most marginalized vary from l representatives from other State country to country. By definition, people institutions, including elected bodies, who are marginalized live on the edges national human rights institutions and of society and may be invisible to the judiciary; Selected from Voices of the Poor, World Bank, 2000 policymakers and others in positions l civil society organizations, including “If you don’t have money of authority. In most countries, however, non-governmental organizations (NGOs), today, your disease will take there are particular social groups community-based organizations, you to your grave!” Ghana within the population that tend to be more faith-based organizations, indigenous excluded and more likely to suffer from organizations and traditional leaders, trade “Poverty is lack of freedom, poverty on a consistent basis than others. unions, academic institutions, consumer enslaved by crushing daily burden, by depression and The number of women living in poverty, groups, professional associations; fear of what the future will for example, is increasing disproportionately l private sector organizations, including bring.” Georgia to the number of men, particularly in health service providers, equipment developing countries. The feminization of suppliers and representatives of “If you don't know anyone, poverty is also a problem in countries pharmaceutical companies; you will be thrown to the corner of a hospital” India with economies in transition as a l donors and multilateral organizations. short-term consequence of the process “For a poor person of political, economic and social Level of participation everything is terrible - illness, transformation. Other groups which are iii Participatory processes aim for, or humiliation, shame. We are consistently excluded include children, result in, different levels of engagement. cripples; we are afraid of everything; we depend on adolescents, the elderly, people living with everyone. No one needs us. HIV/AIDS, ethnic, religious and linguistic l Information sharing. Authorities provide We are like garbage that minorities, people with mental or physical people and communities with information everyone wants to get rid of.” disabilities, migrants (including migrant about policies and policy processes — a Moldova workers), internally displaced people, basic requirement for participation and “When one is poor, she has refugees, slum-dwellers, homeless increased transparency. no say in public, she feels persons and indigenous peoples. It is an l Information gathering. Participatory inferior. She has no food, so important part of designing a PRS to methods are used to obtain information from there is famine in her house; determine which sections of the population different communities and social groups. no clothing, and no progress are marginalized and excluded and to l Consultation. Policymakers ask for in her family.” Uganda30 identify their location. participants’ views, but there is no 30 www1.worldbank.org/prem/poverty/ In addition to those people excluded, obligation to listen or incorporate voices/listen-findings.htm other key stakeholders are likely to include: opinions expressed.

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Mongolia: Vulnerability l Joint decision-making. Where those of communities and individuals who are analysis consulted have some rights with regard to impoverished and marginalized. Ensuring A participatory approach decision-making. that participation in the formulation of the has helped to identify l Empowerment. Initiation and control of PRS is both deep and broad may require a the complex, interlocking 31 reasons for the increased decision-making by stakeholders. combination of mechanisms and methods. vulnerability of Mongolia’s poor pastoral communities. In a human rights-based approach, PARTIcIPATORy RESEARcH METHODS Economic vulnerability had participation is both an underlying Participatory research methods strengthen been exacerbated by a crisis principle and a standard. While the the analysis of poverty, powerlessness, in the banking sector, which in turn led to indebtedness, principle stresses that all development inequality and health by exploring the selling of assets and a decline processes should be participatory, the perspectives and priorities of the poor in livestock. Natural hazards standard defines the empowerment themselves. Planning a comprehensive compounded matters and of people who are marginalized and participatory research process takes conflict emerged between excluded as a development objective. In time. Depending on the point in the PRS communities over access to safe pasture. This led to a practice, this means that the process of cycle, it might be more appropriate to build breakdown in the traditional formulating the PRS should be based on participatory research into future cycles kinship and social support the highest possible standard of active, or to consider using participatory research structures, which in turn free and meaningful participation, as methods to support implementation or led to increased alcoholism, defined in the United Nations Declaration monitoring and evaluation. collaboration domestic violence and 32 crime. The analysis revealed on the Right to Development. Specific from the outset of the PRS process with how vulnerable poor resources, mechanisms and strategies other Government sectors is likely to communities can be to a to enable the participation of people be the most effective way of ensuring a series of unconnected yet who are marginalized and excluded, as cross-sectoral approach to health in policy cumulative shocks. set out below, should be considered. implementation. The achievement of participation as a The primary experience in using 31 Adapted from: McGee R, Norton A. Participation in poverty reduction development objective requires that, in participatory research methods in strategies: a synthesis of experience with addition, the institutional constraints and developing countries has been with participatory approaches to policy design, capacity gaps that act as barriers to poor Participatory Poverty Assessments (PPAs). implementation and monitoring. Brighton, people’s empowerment are addressed in the These are structured research processes Institute of Development Studies, 2000 content of the PRS. that include group discussions in villages (IDS Working Paper 109) www.ids.ac.uk and the use of peer group interviews, 32 Declaration on the Right to Identifying the appropriate ranking and mapping techniques to explore Development. General Assembly resolution iv mechanisms for participation people’s views and priorities. 41/128 of 4 December 1986. Different participatory mechanisms may The information produced by PPAs is result in varying depth and breadth of generally qualitative. PPAs often highlight participation, with some approaches being issues that are common knowledge but more effective at reaching a wide range may not be publicly admitted, such as

Human RigHts, HealtH and PoveRty Reduction stRategies • 17 Mozambique: extortion of bribes for health treatment. PARTIcIPATORy PROcESS SolidarMed HIV and AIDS Single-sex, age-specific or similarly focused The primary objective of the participatory prevention project SolidarMed facilitated groups are useful for exploring issues process is in-depth civil society a joint analysis of high- – such as reproductive and sexual health engagement in decisions about the different risk practices between and domestic violence – that may be too policy options for the health component of health-care providers and sensitive or complex to uncover through the PRS. Where possible, the participatory community members, conventional research techniques. process should build on existing decision- which identified possible sources of public health The World Bank and some bilateral making bodies and channels which may problems that may increase agencies have supported PPAs in a range later be engaged in implementation and risk for HIV infection. of countries. Many international NGOs and monitoring of the PRS. These are the multiple academic institutes have experience in It is important to aim for the greatest use of material without using participatory research techniques. depth of participation possible in this sterilization by informal (illegal) care providers for It is important to involve locally based process. In countries where there is not injections and by traditional organizations in the process to build much experience of policy engagement healers for circumcision domestic capacity as well as to extend with civil society, Government ministries and scarification. Local the reach of the research. Participatory have tended to consult NGOs and other explanatory models were research also offers administrators, or stakeholders about their views on possible shared and exchanged (for example, blood contact is not indeed politicians, the opportunity to policies to be included in the PRS. perceived as bearing any risk engage with local communities and reality- Over subsequent PRS cycles, with the of contamination). Common check their own perspectives accumulation of experience and trust, some risk behaviours (for example, and priorities.34 Governments have moved towards joint informal exchange of sexual services against material and financial benefits is not u SING PARTICIPATORy ReSeARCh MeThODS TO considered ‘prostitution’) and the social situations where INVeSTIGATe MATeRNAL heALTh-SeeKING BehAVIOuR IN NePAL they frequently take place Key Informant Monitoring is a research methodology emergency obstetric care. For example, key informant (for example, meetings at taxi that is based on local women and men collecting researchers have recorded instances of health and bus stations or women selling beer in local markets) information from peers or key informants on their workers discriminating against low-caste women, and were jointly identified and perceptions of how the social environment enables the functional exclusion of extremely poor women analysed. This stage of women to access care. The conversations are from community emergency fund schemes. Local NGOs analysis then leads to a structured around three themes: reduced barriers have facilitated meetings between key informant dialogue with the aim to obstetric care, improved quality of care, and researchers and Village Development Committees of finding adapted, culturally acceptable and improvements in women’s social status and mobility. on findings and recommendations of the research. locally owned solutions.33 The findings from use of the Key Informant Monitoring The dialogue generated through this process has tool in Nepal highlighted barriers to change and facilitated changes being made to improve the quality the reasons why families are delaying the use of of service delivery.35

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33 Communication of Ruedin L, published decision-making, particularly where civil The institutions and processes most likely in: Somma D, Bodiang C. The cultural society and Government working groups to achieve legitimacy and inclusion vary approach to hIV/AIDS prevention. or other permanent institutions have been between countries. Some have coordinated Geneva, Swiss Agency for Development set up. In all cases, it is important that the issue-specific working groups from a and Cooperation and Swiss Centre for International health, 2006 purpose and scope of the consultation are central point in the Government; others www.sdc-health.ch discussed and agreed with stakeholders have delegated the task to local at the outset. It is better to be clear government officials and community 34 Norton A et al. A rough guide to PPAs: about the limitations of the process than leaders. If the country context permits, participatory poverty assessment, an to raise false expectations and foster working alongside a reputable civil society introduction to theory and practice. London, Overseas Development Institute, disillusionment and cynicism. organization or NGO may generate 2001 www.hri.ca It is essential that no groups of additional trust in the process and a belief individuals that have been identified as in its worth. 35 hawkins K et al. Developing a human being discriminated against or marginalized rights-based approach to addressing are left out of the consultation. The maternal mortality: desk review. London, DFID health Resource Centre, challenge then is to find organizations or January 2005 www.dfid.gov.uk individuals that legitimately represent these C hILDReN’S PARTICIPATION groups. This may involve assessment of IN The PRS 36 O’Malley K. Children and young people groups’ capacity, representativeness and participating in PRSP processes. London, Civil society participation in PRSs can be highly their internal accountability mechanisms. Save the Children, 2004 contested. As relative newcomers, children, and www. inclusion-international.org It may be necessary to manage tensions the organizations that represent them, have to among NGOs themselves about who should negotiate with other civil society actors for space to participate and identify those organizations engage. They have to raise awareness of their right with less experience of policy engagement, to participate and the value of their contributions such as those representing children, to among their fellow citizens, as well as officials. As prevent them from being squeezed out of with other people’s engagement in the PRS process, the process. it is hard to gauge systematic impact. Nonetheless, there are examples of children’s participation v Build the institutions and mechanisms leading to small, but significant, policy changes. In to ensure meaningful participation Viet Nam, Save the Children organized three large- This is frequently the most challenging part scale consultations in ho Chi Minh City involving of any participatory process. It is useful to over 400 children and young people. Children at start with an assessment of the institutions, these meetings highlighted the problems migrant quality of information and tools that would families faced in accessing education, health care allow for an inclusive process for diverse and social welfare services. This information helped stakeholders, particularly those sectors of change procedures to allow unregistered migrants the population that have been marginalized access to services more quickly.36 or excluded.

Human RigHts, HealtH and PoveRty Reduction stRategies • 19 Ireland: traveller health Develop an action plan 2.2 Human rights-based analysis of strategy vi The cost of the participatory health and poverty Ireland’s recent economic process will depend on the starting point, Participatory research processes can success has exposed the increasing disadvantages coordination mechanisms, the extent of be used to build an information base facing its minority traveller use of participatory research methods, the on inequality, poverty and health. This community, which is now types of activities planned and the amount information base should also draw on recognized as a distinct of local civic engagement envisaged. Ways existing research on poverty, gender, minority group with its own to minimize costs include drawing on geographical and clinical data. The analysis culture and customs. The community suffers from far local capacity to organize participatory should aim to assess who is denied the lower-than-average levels of processes, working with existing networks right to health, why they are deprived and health and life expectancy, and organizations, use of low-key but what can be done to improve their position. having experienced exclusion, well planned focus groups, interviews The approach suggested here outlines three prejudice and poverty and town-hall meetings rather than large steps that can be used to answer these for generations. Previous strategies to address workshops, and looking for donors to questions and can be adapted and tailored traveller health needs have share costs. to different contexts: tended to focus on bringing the traveller population i. country analysis of the level of the to services designed for realization of the right to health; settled communities, with little success. However, in ii. identification of rights-holders and 1998, a Traveller Health duty-bearers in relation to the right to Advisory Committee health and related rights; with the participation iii. assessment of institutional of representatives of the

-200780) constraints and capacity gaps that traveller community was o .(WH established to look specifically c prevent individuals, groups and at the particular needs of organizations from claiming or fulfilling aggero aggero g travellers and to design the right to health. a strategy to meet these needs. The national strategy carrying out an effective participatory The analysis will inevitably uncover a was launched in 2002 to address a wide range of process requires sufficient time. In broad range of social, economic and issues from discrimination many countries, the constraints of the political causes of discrimination and ill and racism, to water and PRS process have meant that there is health, moving beyond the usual remit sanitation at traveller sites, usually a maximum of 12 to 18 months of the ministry of health. This broad and from increasing traveller available for participation. It is perspective enables the development of participation in priority setting to specific health risks important, however, to think beyond the a comprehensive health strategy. It also facing traveller mothers.37 production of the strategy and to plan allows the identification of effective entry 37 Department of health and Children, participation in both implementation points for action and strategic partnerships Ireland. www.dohc.ie and monitoring. with private and non-profit as well as

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and excluded populations will invariably Country Analysis reveal higher-than-average instances of disease, premature mortality, maternal GatherinG information mortality, or HIV/AIDS infection rates. about development problems from existing sources, Participatory research may further reveal esp. national treaty reports and observations population groups more likely to suffer and recommendations from treaty bodies from a range of health problems including environment-related and occupational conditions and injuries. Examination of the health-care services in the country may assessment confirm that those living in poverty do shortlist major development problems for deeper analysis not enjoy the same levels of health care, treatment and protection as other people. children within poor communities may not be systematically immunized against analysis preventable diseases. Other means of of root causes & prevention, such as condoms to protect their linkages against HIV/AIDS or insecticide-treated Source: Common Learning package on a Human Rights Based Approach (2007) bednets to prevent malaria, may not be available or affordable to poor communities. State institutions aimed at generating While the specific linkages between an enabling environment for the population groups and health will be realization of the right to health of people different in each country, it is likely living in poverty. that those groups already identified as being poor and excluded will suffer Country analysis of the level of the disproportionately from morbidity and realization of the right to health premature mortality. People who experience i Important sources of information multiple forms of disadvantage, such on the country concerned, and available as women refugees or children with at the international level, are reports disabilities, are likely to be particularly from UN human rights treaty bodies, the vulnerable to ill health. The identity of those Universal periodic review mechanism and most deprived of the right to health cannot UN special rapporteurs of the UN human be assumed, but needs to be investigated rights council. Others are the WHO and in each country. other international organizations working These differences in access to health on health and human rights in countries. and health outcomes are often the product At national level, clinical data from poor of different forms of discrimination and

Human RigHts, HealtH and PoveRty Reduction stRategies • 21 personnel receiving domestically Causal analysis: “why?” competitive salaries; l Rights not fulfilled essential drugs, as defined by the WHO; l nutritious food; l adequate housing and shelter. immediate causes “status” The Accessibility of the underlying determinants and of health care such as: underlyinG causes l whether access to health facilities, “services, access, Practices” goods and services is ensured on a non- discriminatory basis in law and in fact; Basic/structural causes l whether health facilities are in safe “society, Policies, resources” reach for all sections of the population including rural populations, persons with Source: Common Learning package on a Human Rights Based Approach (2007) disabilities, children, adolescents and older persons; inequalities in the distribution and delivery l whether health services are affordable of health services and other resources to all, including economically that impact upon health. Exploration of disadvantaged groups; these inequalities requires analysis of the l whether information about different underlying barriers to access to services health services, medicines, or preventive and resources. The availability, accessibility, measures are freely available to all acceptability and quality (AAAQ) framework groups, such as adolescents, within set out in General comment 14 on the Right the communit y. to Health (section 1.3) is useful for the systematic exploration of these barriers. The Acceptability of the underlying Although the precise nature of the health determinants and of health care: facilities, goods and services as well as l such as the extent to which health underlying determinants of health will vary facilities, goods and services are culturally depending on numerous factors, including appropriate, sensitive to gender and life- the State party’s developmental level, an cycle requirements. analysis will include questions as to: The Quality of the underlying determinants and of health care: The Availability of: l such as whether available drugs are l safe and potable drinking water and scientifically approved and unexpired; adequate sanitation facilities; l whether available water is safe l trained medical and professional and potable;

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of other human rights. Migrant workers, KeNyA: OLDeR PeOPLe’S ACCeSS TO heALTh SeRVICeS for example, are frequently employed in Since 2003, helpAge Kenya has been working l neglect if older people were admitted to mining, construction, heavy manufacturing with older people in Ngando, an urban slum hospital. 86 per cent of older people in Ngando and agricultural tasks that can expose area of Nairobi, and Misanyi, a rural area, to reported having shared beds in hospital. them to a range of occupational health monitor their access to health services. risks including unprotected exposure to Older people voiced concerns such as: In order to address these issues, older toxic agents, unsafe equipment and long l the distance they have to travel to the people organized themselves into groups and hours. Migrants often live in poor urban nearest hospital and the prohibitive cost of elected community leaders. They identified a areas in overcrowded, substandard housing transport. Many older people live on less number of indicators to use for monitoring. with inadequate sanitation. conditions than a dollar a day but the average fare to Community leaders met with health services creating vulnerability to ill health are often the hospital is uS$ 0.80; to highlight their concerns and to change compounded by limited entitlements to l discriminatory treatment, abusive the attitudes of health staff. As a result of health care as well as barriers of language, language and rough handling. 70 per cent of these actions, older people have reported culture, information and finance. older people in Ngando said that health staff an improvement in the attitude of staff at Human rights standards provide a basis had a negative attitude towards them; the hospital near to Misanyi. The doctor for the systematic identification of the civil, l long queues. 54 per cent of older people in charge has agreed to set up a separate political, economic, social and cultural surveyed in Misanyo waited for between 2 section in the ward for older people. The factors that impact on the health of people and 5 hours before seeing a doctor; Ministry of health has provided an annual who are marginalized and excluded. l health practitioners' ignorance about supply of uS$ 2,650 worth of drugs to Other standards defined in key human diseases in later life; Misanyi health Centre. The Ministry of rights instruments can be used as a l the prohibitive cost of health services. health's second National health Sector reference point for participatory research 12 per cent of older people in Ngando were strategic plan includes specific reference into underlying factors that directly or unable to afford the medication they were to entitlements for older people as a special indirectly affect the health of marginalized prescribed; group with special medical needs.38 and excluded people. common issues are:

l violence against women 38 helpAge International. Report on older l whether the health personnel is trained l violence and abuse at home and at work citizens’ monitoring project, Kenya. and skilled; l harmful traditional practices, including www.helpage.org l whether the quality of the hospital female genital mutilation equipment is adequate and safe; l lack of voice in household and l whether places of employment are safe community decision-making and healthy. l lack of access to education l inadequate or non-existent social UNDERlyING DETERMINANTS OF HEAlTH protection Inequalities in the realization of the right to l lack of birth registration or health are also a consequence of the denial identity papers.

Human RigHts, HealtH and PoveRty Reduction stRategies • 23 Women’s health and social A causal analysis reviews and reveals compromises in Mali the immediate, underlying and basic/ POVeRTy IN AN INDIGeNOuS By the age of 17, 38 per cent of women in Mali have already structural causes of the non-fulfillment CONTexT had one child or are pregnant. of the right to health. Rather than simply stating that indigenous peoples 94 per cent of women in are poor, it is important to look at impoverishment Mali of childbearing age have Identification of rights-holders and undergone female genital processes. Indigenous peoples do not necessarily ii duty-bearers mutilation. High fertility consider themselves to be poor; many in fact dislike and vulnerability to domestic The next step requires identification of the being labelled as such because of its negative and violence are common features wide range of stakeholders. These comprise discriminatory connotations. On the contrary, they of the life of many rural both those responsible for ensuring that the consider that they have resources, unique knowledge women. Traditional attitudes right to health is realized (duty-bearers) and and discrimination discourage and know-how, and that their cultures have special those with a claim or entitlement to the right women from working outside values and strength. however, they often feel the home. Early marriage to health (rights-holders). impoverished as a result of processes which are out prevents many girls from In the context of a PRS, the primary of their control and sometimes irreversible. These continuing their secondary concern is with those rights-holders who are processes have dispossessed them of their traditional education, leaving women most deprived of their enjoyment of the right economically dependent on lands, restricted or prohibited their access to to health. Rights-holders, in this context, their husbands. Women are natural resources, resulted in the breakdown of their expected to keep working can be understood as those individuals and communities and the degradation of their environment, throughout pregnancy and population groups that have been identified thereby threatening their health and social well-being, to resume work shortly after as facing discrimination and inequalities in as well as physical and cultural survival. childbirth. It is the social norm their access to health care and the underlying for women to eat last at meal- determinants of health. times, even during pregnancy. It is a woman’s husband or Duty-bearers are those individuals and non-governmental organizations, private- mother-in-law who decides organizations that have obligations and sector organizations and the international whether she seeks obstetric responsibilities in relation to the right to community all have human rights care and controls the household health and the underlying determinants. responsibilities, even if less clearly defined resources to pay for that care.39 Reference to human rights standards in law. The Government, in turn, has 39 hawkins K et al., op. cit. provides a basis for the systematic obligations to regulate and support civil identification of duty-bearers in relation society and private sector organizations in to different rights, and the nature of their fulfilling their responsibilities. obligations and responsibilities. Human rights Reference to national laws and procedures law defines the State as the primary duty- can help to identify the specific obligations bearer with respect to the human rights of the and rights assigned to different duty-bearers people living within its jurisdiction. The State and rights-holders. For example, national has obligations to respect, protect and fulfil health legislation can establish concrete all human rights (see section 1). However, standards that should be met by public and individuals, families, communities, private health service providers and specific

24 • Human RigHts, HealtH and PoveRty Reduction stRategies section 2

non-governmental and private sector Detailed Steps organizations as well as Government ministries, donor organizations and 1. causal analysis Getting to root causes multilateral development agencies. legal, institutional and policy frameworks Identification of the range of organizations with responsibilities for realizing the right to health and the underlying determinants of health is an important step in the 2. role/Pattern analysis development of a comprehensive and coherent Government approach to its duties to respect, protect and fulfil the 3. caPacity GaP right to health.

Source: Common Learning analysis package on a Human Rights Based Approach (2007) Assessment of institutional iii constraints and capacity gaps European Roma Rights mechanisms for users Analysis of rights-holders and duty-bearers Centre to complain if the service received does not will reveal a complex web of organizations “Poor Roma frequently become meet these minimum standards. that have an impact on the health of ill, because Roma live in slums, In order to identify all relevant duty- jammed together in unhygienic people who are poor and marginalized. It is conditions; they have inadequate bearers, it may be helpful to chart different the relations between rights-holders and diets, and cannot get decent health services, including mother and these duty-bearers which underpin the medical care. When they become child, and reproductive and sexual health barriers to access to health care and the sick, they stay sick longer than services, and the underlying determinants underlying determinants of health. Where others. Because they are sick of health. In each of these areas, the more often and longer than rights-holders can participate, directly or anyone else, they lose wages organizations and groups that operate indirectly, in the decision-making of and work, and find it difficult at different levels from the community, duty-bearers and hold them to account, to hold a steady job. Because of local and provincial authorities through services and resources are more likely to this, they cannot pay for good to national Government and international reach poor populations and be responsive housing, for a nutritious diet, organizations should be identified. At for doctors. At any given point to their needs. in the circle – particularly when the local level, there is likely to be a wide Examining the institutional frameworks there is major illness – they are range of health-care providers including and capacity issues that shape the threatened with sinking to an traditional healers, skilled birth attendants relations between duty-bearers and rights- even lower level, towards even and pharmacies in addition to government holders can help to highlight entry points more suffering.”40 and non-governmental health facilities. for Government interventions to improve At national and international levels, poor people’s access to health. The term 40 “Grassroots strategies to combat the duty-bearers are likely to include extreme poverty” eRRC talks with András “institutional frameworks” is used here to Bíró. http://www.errc.org parastatal, domestic and international refer to the rules and procedures that

Human RigHts, HealtH and PoveRty Reduction stRategies • 25 Mozambique - health and define entitlements and obligations, pover ty The Role of accountability, people’s voice in decision- The Special Rapporteur on the Capacity Development right of everyone to the enjoyment making processes and the availability of of the highest attainable standard financial resources to fund provisions. realization of human riGhts and human of physical and mental health, “capacity” refers to the knowledge, skills develoPment Goals Paul Hunt, has systematically and information that people require to emphasized in his reports claim and deliver entitlements and engage that health problems must be understood in the context in decision-making. of widespread poverty. In his Analysis of institutional frameworks and claiminG and Mozambique Mission report of capacity is likely to reveal how little power exercisinG fulfillinG riGhts oBliGations 2005, the Special Rapporteur people who are poor have to affect changes notes that some of the major ill- in the organizations that impact on their health conditions in this country health and lives. It may reveal the severe are both cause and consequence human riGhts-Based caPacity develoPment of extreme poverty. The country’s skills and financial constraints that face gross domestic product of US$ many Governments attempting to improve 230 per capita is well below even the health of excluded populations. But it the average for least developed caPacities for caPacities for can also show where actions can be taken to emPowerment accountaBility countries. Approximately 70 per ensure that existing resources and services cent of the population lives below Source: Common Learning package on a Human Rights Based Approach (2007) the poverty line and an estimated reach poor populations rather than being 13–16 per cent of Mozambique’s captured by elites. of decentralization, however, mean that there is population is living with HIV/ often some form of local government, district AIDS. Malaria accounts for 30–40 The analysis reviews institutional or village level health committee. The extent to per cent of under-five deaths, and is a particular problem in some frameworks and capacity issues that shape: which these enable people who are excluded rural areas. Water- and sanitation- to have a voice in decisions that impact on related diseases, such as diarrhoea, l participation their health depends on a number of factors. cholera, dysentery, malaria, l accountability Questions to address include: scabies and schistosomiasis, are l knowledge, information and skills widespread. Around 30–40 per l are the powers of local-level decision- l legislation and policies cent of children suffer from chronic making bodies clearly defined by law? malnutrition.41 l financial resources. l are there rules and processes for the inclusion of women and representatives of 41 hunt P. Report of the Special PARTIcIPATION excluded groups in local- and higher-level Rapporteur, Paul hunt, to the Commission The continued participation of people who decision-making bodies? on human Rights. Mission to Mozambique. are poor in decisions that affect their health New york, united Nations economic and l do local communities have access to requires the existence of effective inclusive and Social Council, 4 January 2005 relevant information about policies and democratic governance bodies. In some countries (e/CN.4/2005/51/Add.2). budgets? decision-making bodies only exist at the higher, l are local decision-making institutions 42 www.ohchr.org national levels of the health service. Programmes effectively linked to higher-level bodies?

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Vienna Declaration and ensure the answerability of duty-bearers Programme of Action 1993 T he uN’S APPROACh TO CAPACITy and redress for rights-holders when they article 1 “Human rights and fundamental DeVeLOPMeNT have a grievance: freedoms are the birthright Capacity development has become a dominant of all human beings; their l Administrative – local, district or protection and promotion strategy in the development work of the united provincial and national health management Nations. It entails the sustainable creation, use is the first responsibility of committees, complaints and mediation Governments.”42 and retention of that capacity in order to reduce processes and mechanisms for monitoring poverty, increase self-reliance and improve and regulation of public and private Declaration on the Right to people’s lives. under the uN’s human rights-based Development article 4 provision of health services. approach to programming, various components are “Sustained action is required l Judicial – including the ministry integral to capacity development. to promote rapid development of justice, local and national courts, of developing countries. As a l Responsibility/motivation/commitment/ traditional and indigenous justice systems complement to the efforts of leadership. This refers to things that rights-holders developing countries, effective and duty-bearers should do about a specified and a vibrant civil society with litigation international cooperation is problem. capacit y. essential in providing these l Authority. This refers to the legitimacy of an l Political – formal political procedures, countries with appropriate means such as parliamentary commissions, and facilities to foster their action, when individuals or groups feel or know local and national elections or informal comprehensive development.”43 that they may take action. l Access to and control over resources. Knowledge advocacy and voicing concerns to political representatives. 43 that something should and may be done is often Declaration on the Right to Development, l Social – community-based monitoring op. cit. not enough. Capacity must therefore also include the human, economic and organizational resources and action, participation in policy 44 Jonsson u. human rights approach to influencing whether a rights-holder can take action.44 processes, NGO monitoring and media development programming. Nairobi, eastern reporting. and Southern Africa Regional Office. l Quasi-judicial – national human united Nations Children’s Fund, 2003. l is the voice of excluded groups and poor rights institutions, ombudspersons, Cited in: Office of the united Nations high communities properly represented in national national commissions and international Commissioner for human Rights. Frequently and international policy processes? asked questions on a human rights-based institutions including UN human rights l do local communities have a voice in approach to development cooperation. treaty-monitoring bodies and Special Op.cit. www.unicef.org the decision-making processes of private Rapporteurs.45 sector providers? 45 There are other Special Procedures that Transparency of information on service deal with health issues, in addition to the AccOUNTABIlITy AND REDRESS performance, policy implementation Special Rapporteur on the right of everyone Participation in decision-making by itself is and budget processes is critical for the to the enjoyment of the highest attainable effective functioning of all these forms of standard of physical and mental health. not sufficient to ensure that duty-bearers examples include the Special Rapporteurs respond to the claims and concerns of accountability. dealing with adequate housing, food and rights-holders. Institutions and processes The analysis should aim to identify toxic waste. See www.ohchr.org for accountability need to be in place to the most effective entry points for

Human RigHts, HealtH and PoveRty Reduction stRategies • 27 Peru: local health strengthening the direct and indirect l what quasi-judicial institutions exist and administration associations accountability of health and other related does their mandate include health? Local health administration services to people who are excluded. In l is information about public health associations, called CLAS, were established as a result of many countries, administrative and social policies and performance made freely reform of the national health- accountability mechanisms are more likely available to the press, parliamentarians and care system in Peru in the to be directly accessible at local level other accountability systems? mid-1990s aimed at ensuring than legal, political and human rights l what procedures exist to ensure basic health care for all. They institutions. However, administrative accountability of domestic and international are legally created non-profit organizations working at the accountability institutions and procedures private sector, non-governmental and donor community level to oversee for health and related services, such as organizations? health-care services. Each CLAS local health committees, are often seen comprises six elected community as ineffective and unfair. While Government KNOWlEDGE, INFORMATION members and one health-care and some non-governmental providers may AND SKIllS worker who work together on a voluntary basis for three-year be subject to some form of accountability, Even where institutions exist that enable terms to help set priority needs it is less likely that local informal health people to participate and hold duty-bearers to for the communities, approve the providers, private sector or NGOs and donor account, claiming and fulfilling rights requires budget and oversee expenditure, organizations are answerable to rights- knowledge, information and skills that lead to determine exoneration from holders. Among the issues to assess are: changes in attitudes and behaviour. capacity fees, and monitor the quality of health services and attitude of gaps in the information and skills of rights- health-care providers to patients. l is service provision monitored and, if holders and duty-bearers are likely to exist at The CLAS have proved to be a so, by whom? all levels from local through to international. powerful means of community l is information about service Issues to consider include: participation in control over performance freely available to delivery of health services.46 local communities? l in addition to information about l what mechanisms exist to ensure that policy and budget processes, people 46 Altobelli LC, Pancorvo J. Peru: shared local concerns lead to effective local require information about health issues administration program and local health administration associations (CLAS) in level action? and their rights. Information should be Peru. Barcelona and Washington, DC, IeSe l what procedures exist for people to provided in formats and through media Business School, university of Navarra and voice concerns about service provision? that are accessible to marginalized and World Bank, 2000 Do these procedures protect excluded people; whistle-blowers? l individuals who have been discriminated l are vertical and horizontal lines of against may not believe that they have administrative accountability clearly entitlements to health, may be unable defined and effectively enforced? to access information about their l do local legal aid centres or rights to services or may lack the self- paralegals exist and address health and confidence to act on information that related issues? is provided;

28 • Human RigHts, HealtH and PoveRty Reduction stRategies section 2

Ukraine: The People’s Voice l communities, or groups within the fulfilled. In many countries, legislation Project: scaling up public community, may lack the organizational, and policies fail to provide all people participation advocacy, policy and budget analysis, with a clear and equal set of health The People’s Voice Project began in 1999 as a means to political networking and legal skills to entitlements and, where these do exist, enable the public to engage participate in decision-making, they are not always translated into effectively and influence local act collectively, voice their health protocols and administrative rules for government. It was implemented concerns or seek redress for violations front-line staff. In the absence of at the municipal level and of their rights; consistent, clear, and concrete legal and focused on service delivery issues of immediate day-to- l members of local health committees policy frameworks, service providers’ day concern to local people, and people in positions of authority, actions tend to be shaped by local norms and in particular worries over such as councillors, chiefs or local and customs. corruption. Coalitions of civil magistrates, may lack understanding, The Government’s obligation to society organizations that utilized information, training and skills on non- respect the right to heath requires it a number of citizen engagement mechanisms, such as public discrimination and human rights, policy to refrain from interfering directly or hearings and report cards, were and budget analysis; indirectly with its enjoyment. In reviewing formed. By 2003, results showed l health staff may lack knowledge national legislation, policies and practices, significant improvements in about their human rights responsibilities, it would be important to consider whether accessibility to local officials, and training and information which these conflict with the obligation to local capacity to monitor delivery and conduct surveys and the requires them to treat all people with respect the right to health. For example, introduction of municipal dignity and respect; it would be important to ensure that initiatives to tackle directly the l health staff may lack the management legislation and policies refrain from: 47 deficiencies exposed. skills and support to ensure consistent provision of services; l limiting access to contraceptives 47 http://www.worldbank.org l ministry of health personnel may lack and other means of maintaining sexual the requisite information and skills to and reproductive health, and from develop a comprehensive, cross-sectoral censoring, withholding or intentionally health policy and budget; misrepresenting health-related l staff in donor organizations may not information, including sexual education understand or support human rights. and information; l imposing discriminatory practices REVIEWING lAWS, POlIcIES, relating to women's health status REGUlATIONS AND OTHER MEASURES and needs; Under human rights law, it is the State’s l denying or limiting access for responsibility to provide a coherent, all persons, including prisoners or inclusive legislative and policy environment, detainees, minorities, asylum-seekers and which ensures that all people’s rights undocumented migrants, to preventive, to health are respected, protected and curative and palliative health services;

Human RigHts, HealtH and PoveRty Reduction stRategies • 29 Norway: Sámi Parliament l unlawfully polluting air, water and soil, The Government's obligation to protect Although already a well- e.g. through industrial waste from State- the right to health requires it to take functioning and inclusive owned facilities; measures that prevent third parties democracy, in 1989 Norway l decided to establish an prohibiting or impeding traditional from interfering with the enjoyment independent institution elected preventive care, healing practices of the right to health. When reviewing by and for the Sámi, the and medicines; national policies and legislation, in this indigenous peoples of Norway. l marketing unsafe drugs. context, consider: It has not replaced the existing national democratic structure l but is a complement to it, to Review of legislation and policies is also the extent to which legislation protects address and advise specifically likely to reveal health-related regulations, health and safety standards at work; on matters directly affecting or the absence of regulation, which l measures taken to ensure equal access Sámi people and culture expose people to harmful practices to health care provided by third parties; and to represent the Sámi to and prevent them from accessing the l efforts made to ensure that the national Government. It also has the responsibility underlying determinants of health. privatization of the health sector does to administer funds and to regulate expenditure provided by the Government.48

Ethiopia: women’s access At the international level, Governments are engaged l To date, international trade laws have been unable to information in a variety of multilateral and bilateral agreements, to provide incentives to the major pharmaceutical In Ethiopia, women are more treaties and commitments relating to a wide range of companies to invest in research devoted to diseases likely to be infected with issues from trade to environmental concerns, and from which specifically affect the poor. HIV/AIDS and less likely development assistance to tourism. The following areas to have ever heard of the disease or know about and use of international activity have already been identified as l There have been numerous examples over many prevention mechanisms. One having a possible negative impact on the enjoyment of years of multinational companies failing to ensure of the primary reasons for this the right to health: safe working conditions for employees or harming is their lack of access to outside the environment to the detriment of the health of information through media l The Agreement on Trade-Related Aspects of local communities. While efforts are increasing at the outlets. Less than 14 per cent of women in Ethiopia have access Intellectual Property Rights (TRIPS Agreement), which international level to impose some form of control over to the media, and women protects the use of patents on pharmaceuticals as these entities, it is the responsibility of the national are much less likely than men well as medical suppliers’ trademarks and research Government to oversee and regulate the activity of any to have heard of HIV/AIDS data, has done much to assure minimum standards in international company in order to protect the human through media resources.49 medical research and the development of new drugs. rights of its population. however, it may adversely affect the ability of indigenous peoples to benefit from traditional medicines, including commercially, and can push prices for essential drugs beyond the reach of poor countries with no domestic pharmaceutical manufacturing capacity.

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constitution and national legislation and whether there is a national health policy or plan which details its realization; l whether there is a health insurance system (public, private or mixed) affordable to all, including the economically disadvantaged; l whether the State disseminates and fosters the dissemination of appropriate information relating to healthy lifestyles and nutrition, harmful traditional practices and availability -352038) o of services; l whether the State promotes medical research, ensures appropriate training rmando Waak (WH Waak rmando a of doctors and other medical personnel not constitute a threat to the availability, and the provision of a sufficient number accessibility, acceptability and quality of of hospitals, clinics and other health- health care; related facilities; l the extent to which legislation l whether the State has formulated and effectively prohibits and addresses early implemented national policies aimed at marriage, female genital mutilation and reducing and eliminating pollution of air, violence against women, including rape water and soil. within marriage. FINANcIAl RESOURcES Finally, the Government’s obligation to constraints in the level, distribution fulfil the right to heath requires states and supply of financial resources are to adopt appropriate legislative, often at the heart of discrimination administrative, budgetary, judicial, and inequalities in access to health promotional and other measures towards and health outcomes. The rights-based 48 Gáldu Resource Centre for the Rights the full realization of the right to health. analysis can be used to provide a broad of Indigenous Peoples. www.galdu.org Reviewing Government laws, policies and assessment of the factors leading practice in this context will reveal: to financial resource constraints. 49 Alsop R, Bertelsen M, holland J. Bottlenecks may occur at different levels, empowerment in practice: from analysis to implementation. Washington, DC, World l whether health has been recognized from local to international, due to Bank, 2006 http://www.worldbank.org as a human right in the national various causes:

Human RigHts, HealtH and PoveRty Reduction stRategies • 31 l insufficient level of resources leading, supplies of medicines and vaccines or for example, to overall shortage of trained having appropriate storage facilities; health personnel or shortages in particular l failure to disburse funds to district geographical areas and clinical skills, such and village health committees as midwifery; may prevent them from carrying out l national distribution of resources, or their mandate; corruption and diversion of resources, l irregular or unreliable funding from may prevent some health centres from international donors may impact on level being well equipped, carrying sufficient and quality of health service provision.

INTeRNATIONAL COOPeRATION – A huMAN RIGhTS ReSPONSIBILITy The notion of shared responsibility for poverty that advancements in technology and science can reduction and the need for a partnership between benefit all countries. Some donors – including Denmark, developed and developing countries have been cited Luxembourg, the Netherlands, Norway and Sweden repeatedly in many united Nations conferences and – are meeting their commitment to provide 0.7 per declarations, including the 1986 Declaration on the cent of their gross national income in aid. Others, Right to Development. At the Millennium Summit in 2000, including France, Ireland and the united Kingdom, have the Doha Ministerial Declaration issued at the 4th World pledged to meet the 0.7 per cent target over coming Trade Organization Ministerial Conference in 2001, the years. even so, there is growing concern that there International Conference on Financing for Development are insufficient resources being made available to in 2002 and the Johannesburg World Summit on meet the targets set out in the MDGs. The Monterrey Sustainable Development in 2002, Governments Consensus agreed by Governments in March 2002 pledged to commit resources and assistance to enable noted that not only were additional domestic resources developing countries tackle poverty. Goal 8 of the required, but also increases in international financial MDGs states clearly the need for a global partnership flows and international trade as well as financial and to address the current inequities in the global trading technical cooperation, sustainable debt financing and system, to address the problem of debt and to ensure debt relief.50

50 A/CONF.198/11. www.un.org

32 • Human RigHts, HealtH and PoveRty Reduction stRategies Section 3 Developing the content and implementation plan Once the human rights-based analysis has been completed, the next challenge is to identify appropriate interventions. These will form the content of the PRS.

Designing a pro-poor health sector plan ii. targeting excluded and marginalized in the context of limited resources is not populations; a simple task. The human rights-based iii. engaging with other ministries to analysis is likely to reveal a wide range of address the underlying determinants sometimes conflicting issues to address. of health. Even where policy priorities can be clearly identified and agreed upon, the process 3.2 Addressing institutional constraints and of securing additional funding and moving capacity gaps by: resources between different areas within the i. strengthening participation and health sector is complex and may provoke accountability in health services; resistance. Human rights principles can ii. providing information and skills for provide guidance for agreeing on policy rights-holders and duty-bearers; priorities and helping to identify and resolve iii. enacting legislation and policies to conflicts and trade-offs. respect and protect the right to health. This section examines how human rights principles can be used by the ministry of 3.3 Financing the health strategy through: health and other ministries whose work i. macro-economic policies; impacts on the enjoyment of the right ii. the health sector budget. to health, to design interventions which address the issues identified through the human rights-based analysis. 3.4 Drafting a long-term strategy aimed at realizing the right to health Actions outlined in the subsections below by ensuring that health services and are as follows: underlying determinants of health are 3.1 Addressing inequality and made available, accessible, acceptable discrimination in health and the underlying and of the highest quality. determinants of health by: i. setting universal minimum standards 3.5 Working with donors to promote human of service provision; rights through the PRS.

Human RigHts, HealtH and PoveRty Reduction stRategies • 33 3.1 Addressing inequality in the Minimum essentials are: realization of the right to health Setting universal minimum standards of l minimum essential food which is health service provision nutritionally adequate and safe; The first step in formulating l basic shelter, housing and sanitation and i the content of the health sector an adequate supply of safe and potable water; component of the PRS is often the l essential drugs as defined under the definition of the package of essential WHO Action Programme on Essential services that the Government will ensure Drugs; to everyone. Many developing countries l reproductive, maternal (prenatal as well have identified an essential health as post-natal) and child health care; package on the basis of methodologies l immunization against the major which prioritize cost-effectiveness infectious diseases; rather than equality. Consequently, l education and access to information existing definitions of essential health concerning the main health problems in

ILO/Marcel Crozet ILO/Marcel services often fail to address the the country, including how to prevent and priorities of people who are marginalized control them. or excluded.51 Public debate about the content of In order to ensure equality of access, it is the essential service package, through important not only to decide what services the consultation process, provides a are to be provided but also to define potentially powerful basis for engaging minimum standards of service provision people in the PRS and making it locally that the Government will guarantee are owned rather than globally driven. Debate delivered to all people. The identification should be informed by the human rights- and widespread communication of rights based analysis carried out by the ministry and standards enables people to hold public of health together with other relevant policy makers and providers to account stakeholders through a participatory for service delivery and is a central part approach, and include information on the of a human rights-based approach to priorities of people who are marginalized, development.52 The AAAQ criteria outlined 51 Pearson M. Allocating public resources and disaggregated statistical data in section 1 and used as a suggested for health: developing pro-poor approaches. as well as clinical and geographical basis for the human rights-based analysis London, DFID health systems resource data. (See section 4.3 for discussion of in section 2.2 can also provide a sound centre, 2002 www.healthsystemsrc.org disaggregated data.) basis for developing minimum service General Comment 14 sets out 52 World Bank. Rights, entitlements and standards or entitlements. Information from social policy: concept note. Washington, DC, what it calls core obligations of the the consultation, participatory research, November 2006 www.worldbank.org right to health. disaggregated statistics, clinical and

34 • Human RigHts, HealtH and PoveRty Reduction stRategies section 3

53 Murthy RK, Klugman B, Weller S. geographical data can be used to identify information on ailment and drugs; free Service accountability and community service provision standards that are clear, health care; the right to be attended within participation. In Ravindran TKS, de Pinho concrete and meaningful to people who one hour.54 H (eds). The Right reforms? Health sector are excluded and address the key issues reform and sexual and reproductive health. Johannesburg, Women’s Health Project, identified under each of the criteria. Whatever the content of the rights defined School of Public Health, University of For example: and the vehicle for communicating them, Witwatersrand, 2005 (study manual). it is important that the Government should l reproductive and sexual health services be committed to meeting the standards 54 Björkman M, Svensson J. “Power to for all within a given distance; identified. Ensuring that standards are the people: evidence from a randomized experiment of a community based l no user fees for primary health care, relevant, obtainable and are more than monitoring project in Uganda”, London, including maternal and reproductive and empty promises requires attention to the Centre for Economic Policy Research, June sexual health services; following issues: 2007 (CEPR Discussion Paper No. 6344) l primary health-care facilities physically www.cepr.org accessible to people with disabilities; l standards should be established through 55 Norton A, Elson D. What’s behind the l access to comprehensive health services a democratic, participatory process – such budget? Politics, rights and accountability for migrant workers; as the PRS consultation process and in the budget process. London, Overseas l health information in local languages; participatory research; Development Institute, 2002 l separate and private rooms for l standards should be enshrined in www.odi.org.uk consultations; national law, and be consistent with l skilled birth attendants at all primary international law health-care facilities. l standards should be widely communicated; Publicizing minimum standards of service l local-level accountability mechanisms provision in the form of a charter of patients’ should be accessible and effective rights can be an effective method of (section 3.2i); communicating entitlements to people. l attention to training, professional Charters of patients' rights in Bangladesh information and raising awareness of and Ghana include guarantees for informed human rights, such as the prohibition of consent, medical confidentiality, a second discrimination, for health-care staff and opinion and access to one's medical ancillary workers is essential (section 3.2ii); records.53 In 2000 the Ugandan Ministry of l standards should be set at a level that Health set out patients’ rights in its quality can be financially met on a sustainable of care strategy for Government and NGO basis (section 3.3ii); primary health-care facilities, including the l standards should be regarded as a right to confidential treatment, the right to minimum and not a ceiling.55 polite treatment according to a first-come, first-served basis; the right to receive Setting standards that meet these criteria

Human RigHts, HealtH and PoveRty Reduction stRategies • 35 Chile: explicit health is not a simple task. The process is likely on the basis of individual poverty is less guarantees to be iterative, as the availability of financial effective as it is difficult to devise easily Chile’s law setting out its resources will shape the ministry of health’s administered and fair criteria that are Regime on Health Guarantees came into effect on 1 July 2006. capacity to deliver. Furthermore, demand is immune to corruption. Targeting has hidden The law, and associated joint not static and, in some cases, guaranteeing costs such as: decree of the Ministry of Health entitlements to particular services or and the Treasury, specifies 40 standards of provision may lead to unforeseen l cost of mis-targeting: it is difficult to medical conditions and the bottlenecks in quality and quantity of supply. identify the poor, especially poor women; services guaranteed in relation l to them. The law and decree The key issue here is to ensure that the cost of administration: narrower define standards of health-care institutions and procedures exist that allow targeting requires more checks on access, quality, opportunity changes in demand to be translated into beneficiaries; (waiting time) and financial political voice and response in the form of l cost to beneficiaries of documenting protection. The law entitles adjustments to resource allocations. Periodic eligibility and claiming benefits; the lowest-income groups in l the country to 100 per cent review and revision of standards will also be cost of non-sustainability: if people who payment for services by the necessary. The PRS cycle provides a useful are not poor are beneficiaries of services, Fondo Nacional de Salud, the vehicle for the revision process. political commitment to maintain their national health insurance fund scope and quality fails.57 to which most of the population ii Targeting is affiliated. The law also sets out rights of redress via Human rights law allows positive In some contexts, the costs of targeting procedures for making claims to discrimination (or affirmative action) that outweigh the potential savings from the Superintendency on Health. specifically targets people who are excluded. concentrating scarce resources on a The Ministry of Health and Targeting by type of service, community narrowly defined group of people. This is the Treasury are responsible or clear social categories, such as older likely to be the case in conflict-affected for reviewing and updating the legally defined standards every persons and children, can be an effective areas or crisis situations, where any 3 years.56 means of redressing disadvantage and is form of targeting may be inappropriate likely to be necessary to ensure universal or administratively impractical. In these provision of minimum standards of health situations, it may be more effective to care. Examples include: allocating higher- provide a basic range of universal services 56 World Bank. Prepared in collaboration than-average expenditure to improve rather than aiming to deliver a higher level with FUNASUPO and with inputs from the IDB, ECLAC and OAS. “Realizing health services for communities with high of targeted provision which, in practice, rights through social policy”. Draft rates of poverty; targeting immunization ends up being rationed and utilized by the working paper for “Workshop on explicit programmes that prevent diseases known to more priviliged. guarantees in the implementation of the disproportionately affect excluded groups; or economic, social and cultural rights in investing heavily in improving services such iii Addressing the underlying Latin America and the Caribbean” April 2-4, 2007, Santiago, Chile www.eclac.cl as water and sanitation in areas identified as determinants of health being particularly lacking. As the rights-based analysis of health and 57 Elson D, op. cit. Targeting services, or fee-exemptions, poverty highlights, inequalities in health

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Brazil: Bolsa Familia outcomes are the product of access to a issues such as maternal mortality and HIV/ Brazil’s Government has broad range of services and resources. AIDS generally requires a clear institutional focused considerable effort While the ministry of health may not have focal point to lead and coordinate and resources on improving social safety nets for very direct responsibility for addressing these activities. This does not necessarily have poor families. The programme underlying determinants, it does have to be located in the ministry of health. transfers money directly to the a duty to work with others to promote It is important that horizontal linkages family on condition that all coherence across the PRS and ensure that between sectors and organizations do not family members are able to policies in other sectors do not reinforce obscure the need for vertical linkages of benefit from social assistance when needed.59 vulnerability to ill health. The assessment participation and accountability to rights- of rights-holders and duty-bearers can be holders in poor communities. used to identify those organizations which Other health-related issues that require have direct responsibilities for, or impact intersectoral coordination include the upon, the underlying determinants of provision of: health. Building partnerships with a range of private and non-governmental as well as l safe and potable water for households public organizations is a key strategy for and basic sanitation services; addressing these issues. l adequate and safe housing or shelter; In many cases, the primary duty-bearer l safe and hygienic working conditions; 58 Merlin. Fact sheet: “TB treatment in will be another Government ministry. l sufficient quantities of nutritious food Tomsk, Russia” www.merlin.org.uk Intersectoral policy initiatives are often supplies and food security early warning logistically and managerially difficult. systems and responses; 59 Lindert K. “Brazil: Bolsa Familia To fulfil its obligations, the Government l social security (or insurance schemes); Program - scaling up cash transfers for leadership will need to support the ministry l the poor” In: MfDR principles in action: health education in schools. sourcebook on emerging good practices. of health in convening and working closely www.mfdr.org with other ministries. Addressing complex Standard setting and targeting issues outlined above are equally relevant to addressing discrimination and inequalities RUSSIAN FEDERATION: TB TREATMENT PROgRAMME IN PRISONS in access to the underlying determinants In countries with high TB low priority and they are left and in Dzerzhinsk, the British of health. prevalence, prisoners, many vulnerable to the hazardous NgO, MERLIN, is providing of whom are young men from environment in which they essential care to former 3.2 Addressing institutional constraints very poor backgrounds, are are kept. In Tomsk, the prisoners, ensuring they are i and capacity gaps up to 100 times more likely to Russian government has been able to finish their course of Strengthening participation and contract TB than the general working with a consortium of treatment and reducing the accountability in health service delivery population. Frequently, NgOs to extend a DOTS-Plus risk of drug resistance in the The content of the health section of the however, prisoners’ health is a programme to treat prisoners community at large.58 PRS should address the institutions and processes for enabling excluded groups to

Human RigHts, HealtH and PoveRty Reduction stRategies • 37 participate in, and ensure accountability of, available, so that people can see how their Mexico: Progresa health and other related services. health facility is performing in relation to Introduced by the Government In many countries, the human rights- others, is a key factor in the success of of Mexico in 1997, Progresa is the largest national poverty based analysis is likely to show that existing community-based monitoring. alleviation programme, reaching administrative accountability processes Greater local engagement in 2.6 million poor households. It and local governance institutions serve management of local health services can provides cash transfers and food the interests of local elites and that have a positive impact on the effectiveness supplements to poor families monitoring of services is not effective. In of bodies charged with responsibility for on condition they enrol their children in school and attend these contexts, social mechanisms can ensuring administrative accountability, preventive medicine and basic strengthen accountability between people such as local and district health health-care services. Designed who are excluded and marginalized and committees. Systematic improvements in to address many related providers. These mechanisms include report local-level accountability may, in turn, lead determinants of health, eligible cards and community-based monitoring. to improvements in quality of provision, use households receive benefits in return for agreeing and Where national legislation has enshrined a of services and health outcomes.62 continuing to participate in the minimum set of entitlements under the right One means of strengthening these services provided.61 to health or a charter of patients’ rights has institutions through the PRS is the been adopted, these can provide a useful establishment of a task force within the ministry basis for local engagement in identifying of health to facilitate community participation indicators, monitoring and reporting on and health service accountability.63 The remit implementation. Making information easily of the task force could encompass issuing

SRI LANKA: ACCESSIBILITy IN WATER AND SANITATION

In Sri Lanka, after the tsunami in December 2004, located at the back of buildings, outside or in the 60 Spitschan S, Mesman A. Accessibility thousands of people were left homeless and basement, and the problems of ensuring that local in water and sanitation: The Handicap accommodated in temporary camps. Handicap International constructors understood the importance of accessibility International experience. Leicestershire, carried out camp assessments within the districts of features such as standardized steps and smooth finishing Water Engineering and Development Batticaloa and Ampara to collect data on accessibility of of wooden rails. Rectifying these problems was more Centre, Loughborough University, 2006 http://wedc.lboro.ac.uk water and sanitation facilities. For each camp, a plan was difficult and costly than it would have been if accessibility

drawn up of how to improve access to water and sanitation features had been addressed in planning and the original 61 Wodon Q et al. “Mexico’s PROgRESA: facilities. The plan was implemented through lobbying of construction. After the post-emergency phase, the focus Innovative targeting, gender focus and implementing organizations, and construction funded by shifted to permanent construction. As a result of this impact on social welfare”. In: The World Handicap International and implemented by a local partner work, the Deputy Provincial Director of Health Services Bank group, “en breve” no. 17, January 2003. www.worldbank.org or private construction companies. Issues highlighted in Ampara has decided to introduce basic guidelines

by Handicap International included water and sanitation on accessibility for all new toilets built as part of the 62 Björkman M et al., op. cit. facilities that were difficult to reach because they were reconstruction programme.60 63 Murthy RK et al., op. cit.

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Philippines: community reccommendations on: people who are poor is addressed in planning and decision- l the interface between national, the final part of this section. The use making district and local level lines of of community-based mechanisms for In January 2003, the Government of the management, participation and monitoring and evaluation of the PRS is Philippines launched a accountability; explored in more detail in section 3.3, as community-based poverty l the use of report cards and other is the role of judicial, quasi-judicial and alleviation initiative – the community-based monitoring political accountability processes KALAHI-CIDSS Project. The mechanisms as a means of increasing in protecting the rights of people who initiative is based on local decision-making through direct accountability between people and are poor. village assemblies that service providers; include the whole community. l the effectiveness of administrative ii Information and skills for rights- Communities identify their forms of monitoring and redress, holders and duty-bearers own priorities, select projects, including watchdog organizations, Capacity-building programmes for monitor the flow of funds and oversee implementation. to ensure that policies are implemented knowledge, skills and practices that The project has now been and local concerns are translated support human rights are a key element extended across 42 of the into action; of a comprehensive health sector poorest provinces in the l measures to ensure transparency of strategy. Institutional reform is unlikely country.64 budget and monitoring processes; to succeed where people do not have l quota measures for the participation the capacity to engage with revised 64 www.worldbank.org of women, people with disabilities and systems and procedures. In contexts other people who are excluded and such as post-conflict States, where State marginalized on local, district and institutions are non-existent or completely national committees; discredited, capacity-building of l the scope and limits of parcipitation – rights-holders and duty-bearers may for instance, managing logistics of be the most effective entry point for drugs supply is not necessarily amenable strengthening the provision of health to participation; care and related resources. l measures to increase the capacity of Review of, and recommendations people who are excluded and marginalized, on, information needs of rights-holders and the organizations that represent and duty-bearers can form part of the them, to participate in decision-making remit of the task force on participation processes; and accountability (section 3.2i). Health l provision of information to enable information strategies conventionally people to claim their rights focus on informing people about public (see section 3.2ii). health issues, such as HIV and AIDS and reproductive and sexual health. A human The issue of donor accountability to rights-based approach emphasizes the

Human RigHts, HealtH and PoveRty Reduction stRategies • 39 and private health-care providers. Even UgANDA: EvIDENCE OF EFFECTIvENESS OF COMMUNITy- where legislation exists to regulate the BASED MONITORINg activities of private sector and non- In response to perceived weak health-care average utilization was 16 per cent higher governmental organizations that provide delivery at the primary level, a pilot citizen in the treatment communities; provider health services or impact upon health, the report card project was initiated by the practices – including immunization of number and diversity of these organizations World Bank and Stockholm University in children, waiting time and examination make it difficult to ensure their cooperation with the Ugandan Ministry of procedures – had improved significantly; accountability. In order to negotiate this Health in 50 health facilities in rural areas the weights of infants were higher and environment, people need basic information of Uganda. The main objective of the project the number of deaths among children on, for example, how to determine if over- was to strengthen providers’ accountability under-five markedly lower. Treatment the-counter drugs are genuine and within to users by enhancing communities’ ability communities became more extensively their sell-by date, and simple protocols on 66 to monitor providers on an ongoing basis. In involved in monitoring providers following common disease treatments. each participating district, half the facilities the intervention, but there was no evidence Individuals and groups within were randomly assigned to the treatment of increased government funding. These communities require a range of skills in order group, i.e. report cards were introduced, results suggest that the improvements in to claim their rights. Individuals who have and half to the control group. The patients’ the quality and quantity of health service suffered discrimination or abuse require rights identified in the government’s delivery resulted from increased effort by support to build their self-confidence so quality-of-care strategy provided a basis for health unit staff to serve the community as that they can be assertive when they have monitoring. One year into the programme, a result of improved accountability.65 to deal with service providers and officials. Individuals and groups within the community need the organizational, advocacy and 65 Björkman M et al., op. cit. importance of ensuring that information political skills as well as legal awareness and on health issues is evidence-based, freely training to participate in decision-making 66 Standing H. Understanding the ‘demand available and accessible to all people, and to claim their rights. Community-based side’ in service delivery: definitions, including adolescents. and non-governmental organizations are frameworks and tools from the health sector. London, DFID Health Systems People need to be aware of their rights often best placed to build these skills. Resource Centre, March 2004 and entitlements in order to claim them. Such organizations may be funded by www.dfidhealthrc.org Information about these issues can be international NGOs and donors. Ministry of publicized using a variety of innovative health policymakers, planners and providers 67 Khoza S, ed. Socio-economic rights in methods including mass media and can recognize the legitimacy of this work South Africa, 2nd ed. Bellville, Community Law Centre, University of the Western culturally relevant forms of communication by cooperating with local organizations Cape, 2007. such as theatre, role play and storytelling. and, where possible, engaging with their Providing the information that rights- capacity-building programmes. 68 www.autonomia.hu holders need to claim their entitlements to Government officials and health-care health is more complex in highly pluralistic staff themselves also need information environments with a wide range of public and training to enable them to promote the

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South Africa: complaints rights of people who are poor. Human rights Governments have enacted new anti- procedures training needs to go beyond providing formal discrimination legislation to protect, for The South African National information about rights, and to focus on example, the rights of people who have Health Act of 2003 says that building the skills, attitudes and practices there must be guidelines on HIV and AIDS. legislative review and procedures to be followed which enable service providers to treat all reform can be a lengthy process but, in by users making complaints, people with respect and in ways that are the long term, may be necessary to ensure claims or suggestions on culturally acceptable. Other skills that are a coherent legal framework to underpin the provision of health-care likely to require strengthening within the the standards set for the health system services. Every health-care ministry of health include budget formulation establishment must display and ensure consistency with international the procedure for laying a and analysis skills, cross-sectoral expertise human rights standards. complaint at its entrance so and research skills, and increased capacity legislation, policies and practices that that it is visible to everyone. to engage in participatory processes. lead to discrimination in access to the Every complaint received Capacity and skills-building programmes underlying determinants of health should must be acknowledged. for ministry of health personnel should be Complaints can also be made also be addressed. Gender discrimination to the councils that license included in the health-sector strategy and in legislation that determines access to doctors, nurses and other costed in the budget. resources and services is common. In many health professionals about Training in gender awareness, analysis countries, gender discrimination is not just the way a particular health and planning is a critical element of the result of gender bias in statutory law; it professional has behaved.67 capacity-building programmes to support is also the consequence of discriminatory Hungary: Autonómia human rights. Some international NGOs, customary laws, traditions, social norms Alapítvány – Hungarian donors and development agencies, as well as and attitudes. Addressing this issue may Foundation for Self- national academic research institutes and require training programmes for personnel Reliance NGOs, have expertise on these issues. Many in informal and formal legal systems (see Established in 1990, the donor organizations have clear commitments foundation works directly section 4.6) as well as legislative reform. with Roma communities to promoting gender equality and may be a Aspects to be considered include: to develop new models of useful source of funding for gender training. development that reflect the l equality between women and men to unique cultural and economic iii Legislation and policies to respect, own and inherit property; circumstances of the Roma. l Based on horizontal dialogue protect and fulfil the right to health equality between women and men between the funder and the RESPECTING THE RIGHT TO HEAlTH in access to employment and working beneficiary, the Roma plan The State’s obligation to respect conditions; their own projects and define human rights requires action to rectify l equal right of girls and boys to free 68 loan repayment schedules. discriminatory legislation, such as primary education; restrictions on adolescents’ and women’s l equal access to justice and access to reproductive and sexual health administrative mechanisms of redress. services, identified in the human rights- based analysis. In some countries, The PRS should include legislative and

Human RigHts, HealtH and PoveRty Reduction stRategies • 41 Peru: culturally acceptable policy measures to control and regulate l international and national NGOs. safe motherhood other activities that the human rights- While many of these organizations may Maternal mortality among based analysis identifies as being be supporting positive health outcomes, it Andean communities is triple the national average in some harmful to people's health. Regulatory is the Government's obligation to ensure areas. Many factors contribute mechanisms should: oversight and regulation, for example, by: to this – one of which is the proportion of mothers who l forbid the marketing or distribution of l regulating the marketing or distribution prefer to give birth at home unsafe drugs; of substances that harm health such as rather than at maternity clinics. Consultations with l prevent coercive medical treatment; tobacco, alcohol or some food groups; Andean women revealed that l ensure that important health l regulating and monitoring to ensure that the services available were information is not withheld or industrial and household waste, including based upon modern medical misrepresented; agrochemicals, are handled and disposed practices and were not sensitive l ensure that the confidential of in a way that does not harm the health of to traditional Andean practices, presenting a significant barrier health information of each person is either workers or local communities. to their acceptability to Andean safeguarded; mothers. UNICEF has been l prohibit traditional practices or Governments should also ensure that working with local health treatments known to be harmful to health; neither their own policies and activities nor providers to adapt the care l ensure that the use of safe traditional the overseas operations of any non-State provided to Andean women, to include preferences such as care and medicines is not impeded; actors, such as companies headquartered herbal teas, traditional birth l redress international commitments in their country, in any way violate the attendants, birthing positions, which have a negative impact on people's right to health of individuals living in other privacy from male health ability to realize their right to health. countries. This applies, for example, to professionals and decisions to impose sanctions or embargoes more acceptable wall and fabric colours.69 PROTECTING THE RIGHT TO HEAlTH on another country, to the negotiation of The identification of rights-holders and trade agreements or customs treaties, duty-bearers provides an overview of and to regulating the global activities of non-State actors which impact upon national pharmaceutical manufacturers. people’s health. Non-State organizations concerned FUlFIllING THE RIGHT TO HEAlTH are groups such as: The obligation to fulfil the right to heath requires States to take positive measures 69 Mayhew S. “Acting for reproductive l multinational corporations, including that enable and assist individuals and health in reform contexts: challenges and pharmaceutical companies communities to enjoy the right to health. research priorities” (background paper l national private sector companies It means that the State must engage prepared for Technical consultation on health sector reform and reproductive l health insurance providers proactively in activities that would health: developing the evidence base), l providers of private health care strengthen people’s ability to meet their geneva, WHO 2004 www.who.int/ l medical research institutes own needs. It also goes one step further,

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involving direct provision of services if formulate and implement national policies Philippines: HIV/AIDS access to health-care services cannot aimed at reducing and eliminating pollution anti-discrimination legislation be realized otherwise, for example to of air, water and soil. The 1998 National AIDS compensate for market failure or to Prevention and Control help groups that are unable to provide 3.3 Financing the health strategy Act of the Philippines was for themselves. Macroeconomic policies a result of an extensive In this context, the definition of the i Some of the interventions outlined campaign by a coalition of Philippine NGOs and package of essential services that the above can be achieved with minimal human rights lawyers over Government ensures will be delivered additional resources. Overall, however, several years that held (see section 3.1) will provide an important meeting obligations to respect, protect and the State accountable for reference for the minimum entitlements fulfil the right to health is likely to require recognizing the rights of under the right to health at the national both increases in funding and redistribution vulnerable groups. Among other things, the Act requires level. This package of essential services of existing resources. Macroeconomic should be integral to and with consistent written informed consent for policies determine the overall size of the HIV testing and prohibits with any national health insurance system Government’s resource envelope and the compulsory HIV testing. It in place. share of resources that is allocated to the also guarantees the right health sector. While there is no simple to confidentiality, prohibits discrimination on the basis of formula for identifying the macroeconomic actual, perceived or suspected policies that are most likely to advance HIV status in employment, the right to health, principles of non- schools, travel, public service, discrimination, equality, participation and credit and insurance, health 70 accountability can help to identify conflicts care and burial services. and evaluate trade-offs between health spending needs, inflation, debt and growth. Economic orthodoxy supports low WHO/WPRO/Image WHO/WPRO/Image Bank/Seppo Suomela rates of inflation, low budget deficits and More broadly, the obligation to fulfil the limiting public debt to sustainable levels as the best policies for achieving growth right to health requires the State to: 70 and reducing poverty. Policies based on HIv/AIDS and human rights in a disseminate and foster the dissemination nutshell: a quick and useful guide of appropriate information relating to these principles have not always been for actions, as well as a framework healthy lifestyles and nutrition, harmful effective at addressing poverty. It has to carry HIv/AIDS and human traditional practices and availability of been argued that greater flexibility on rights actions forward. Program on services; promote medical research; ensure macroeconomic targets would provide International Health and Human Rights, Francois-Xavier Bagnoud Center for appropriate training of doctors and other more resources for health and support Health and Human Rights, Harvard medical personnel and the provision of stronger growth. School of Public Health and the a sufficient number of hospitals, clinics In some countries a poverty and social International Council of AIDS Service and other health-related facilities; and impact assessment (PSIA) of projected Organizations, 2004

Human RigHts, HealtH and PoveRty Reduction stRategies • 43 Karnataka, India: the economic policy measures has been civil society actors to engage in these impacts of lack of undertaken and can, if carried out by issues is also important. regulation on maternal health care independent organizations, help identify In aid-dependent countries there may Research on maternal health potential negative impacts of different be additional challenges in managing the care in Karnataka, India, policy options. Work has recently been engagement of donors in macro-policy found that one of the key undertaken to suggest how a human rights decision-making. The Paris Declaration factors in maternal deaths impact assessment could be integrated into on Aid Effectiveness, outlined in section 1 and morbidity was the irrational or inappropriate other forms of policy assessment, including and discussed at the end of this care provided to women the PSIA.72 A PSIA can be a useful tool section, provides a basis for building with obstetric emergencies. for generating public debate about difficult donor–Government relations that are Government doctors and policy choices. However, the costs of coherent as well as participatory, junior health assistants undertaking a PSIA need to be carefully inclusive and accountable. as well as untrained rural medical practitioners considered. A PSIA entails financial costs provided, for example, both to lending institutions and borrowing The health sector budget injections or intravenous countries. It also requires that lenders and ii The health sector budget is the drips to women in labour borrowers are prepared to accept what may primary vehicle for ensuring that resource whether necessary or be unwelcome recommendations. allocations support agreed policy not. In the absence of effective regulation by the Human rights standards and principles objectives, priorities and service standards. Government or professional require macro-policy decision-making Estimating the costs involved, preparing associations, health processes that are participatory, an appropriate expenditure framework and providers are guided by inclusive, accountable and transparent. then mobilizing the necessary resources competitive pressures to sell This means parliamentary oversight and are highly complex technical and political pharmaceutical commodities and use diagnostic technology the engagement of key stakeholders, processes. Human rights principles of non- rather than provide including the ministry of health and civil discrimination, equality, participation and preventive advice or even society. In practice, macroeconomic accountability are applicable at each stage 71 effective curative services. policy is often formulated on the basis of the budget process. of bilateral discussions between the IMF and the ministry of finance without the COSTING THE STRATEGy involvement of the ministry of health Conventional budget allocation practices or other stakeholders.73 Formulating often lead to resources being distributed the health sector component of the as they have been in the past, with each 71 george A, Iyer A, Sen g. gendered PRS on the basis of broad-based civil facility receiving a particular allocation health systems biased against maternal society consultation may help to provide which is increased or decreased in line survival: preliminary findings from the ministry of health with leverage in with overall changes in the health budget. Koppal, Karnataka, India. Brighton, Institute of Development Studies, macroeconomic policy discussions with This incremental approach may exaggerate September 2005 (IDS Working Paper the ministry of finance. Building the existing inequalities in inputs and access 253) www.ids.ac.uk capacity of ministry of health staff and and can exacerbate inequalities in health

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72 Hunt P, MacNaughton g. Impact assessments, poverty and human rights: a KEy ISSUES FOR CONSIDERATION IN DISCUSSION OF THE IMPACTS OF case study using the right to the highest MACROECONOMIC POLICy ON THE RIgHT TO HEALTH INCLUDE: 74 attainable standard of health. Paris, United Nations Educational, Scientific and Liberalization of trade in services may have a direct ‘Dutch Disease’, or macroeconomic instability in the Cultural Organization, 2006 (Health and Human Rights Working Paper Series No 6) impact upon the quality and availability of health form of inflation and exchange-rate appreciation. A www.who.ist/hhr services for the poor. Although it may increase rise in the exchange rate could reduce international opportunities for Internet-based medicine, allow competitiveness and ability to export and, consequently, 73 Wood A. IMF Macroeconomic Policies greater international mobility of patients in seeking slow economic growth. On the other hand, it is argued and Health Sector Budgets. Amsterdam, specialized treatment, attract foreign direct investment Wemos Foundation, September 2006 that these problems can be mitigated if aid is properly www.wemos.nl in health services and allow health services to recruit ‘spent’ and ‘absorbed’. This means that increased internationally, there is concern that all these may government spending should be focused on public 74 Influencing poverty reduction prove to be of benefit only for the wealthy and may investment and increased imports should be focused strategies, op. cit.; Wood A, op. cit. have a directly detrimental effect on poor countries on capital goods. In many developing countries, and poor communities. At present, national governments 75 McKinley T. Why is ‘the Dutch disease’ underutilized productive capacities can readily respond always a disease? The macroeconomic can control to a certain extent the rate at which they to rising government demand for domestic goods and consequences of scaling up ODA. Brasilia, will commit to liberalizing their services, including in services without leading to inflation and ‘crowding out’ International Poverty Centre, United the health sector. A careful examination of how any of private investment.75 Nations Development Programme, such moves may affect the right to health of all people, November 2005 (UNDP working paper particularly the poor, is imperative. number 10) www.undp.org Wage ceilings. Even if a country’s economic policy does not impose health sector wage ceilings, it may Monetary policy. The IMF has recently revised its encourage overall constraints on wages so that guidance on targets for inflation to accommodate inflation resources can be freed up to invest in and maintain rates of 5–10 per cent, instead of advocating rates in low priority areas and to maintain future budget flexibility. single figures. High levels of inflation can harm the poor This may have an indirect impact on health sector by reducing growth and the value of cash held by the poor. wage bills and human resources. In the health sector But where targets are set too low, measures may restrict the volume of workers per population is a vital factor spending on social sectors, including health, and other pro- in delivering effective health services. In many poor government expenditures. developing countries, staffing levels are below what is considered to be the necessary minimum. Cutting back Aid flows. There are mixed views on the macroeconomic on administrative staff to fund front-line workers may, impacts of increasing aid flows. On the one hand, in the end, reduce governments’ capacity to disburse it has been argued that large aid flows may lead to funds quickly and effectively.

outcomes. Instead, the budget should and services in accordance with policy support the distribution of resources objectives, priorities and minimum standards between populations, geographical areas identified through the consultation process.

Human RigHts, HealtH and PoveRty Reduction stRategies • 45 Work on gender budgeting has demonstrated the difficulties of identifying simple, quantitative expenditure ratios that provide an indicator of the resources that should be allocated to redressing particular inequalities. Gender budget analysis shows that not all expenditures targeted to women promote gender equality, while many programmes that are not specifically targeted to women have an equality-enhancing impact. Some Governments require a minimum proportion of the expenditure of all public agencies to be devoted to the promotion of gender equality. The Government of the Philippines, for example, requires 5 per WHO/Eric Miller cent of public finance to be allocated in of the intervention itself but the systemic this way. However, public agencies do not constraints that have led to inconsistent automatically spend this money in ways service provision in the past. The costs of that promote gender equality. A more useful improving the availability and accessibility formula has been defined as: of quality health care to people who are excluded may be significantly higher than Equal weight to women's and men's to wealthier groups. Reaching the poor priorities, with an emphasis on priorities in remote rural areas that have suffered that are, in fact, equality-enhancing.76 decades of underinvestment will inevitably cost more in terms of transport, staff costs Where priorities and minimum standards of and health infrastructure than reaching well- health-care provision have been established serviced areas. Calculation of costs should on a participatory basis as outlined in also take into account the greater burden section 3.1, similar formulas can be that ill health places on people who are extended to other excluded groups. excluded and the greater proportional cost Costing agreed services and standards to poor people of seeking health treatment. requires skill, expertise and sound While the costs of redressing inequalities judgement. There are various models and may be high, the potential longer-term costs methodologies for costing. Whichever model of failure to do so include less effective is chosen, health planners should consider public services, slower economic growth and not just the costs involved in the delivery social unrest. 76 Elson D. op. cit.

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As it is unlikely that increased resources shifting resources from one area to another. Porto Alegre - participatory alone will be sufficient to offset existing The process of completing the budget budgeting Participatory budgeting has its inequalities, gradual redistribution of for the health component of a PRS will origins in Porto Alegre, Brazil, existing allocations will often be necessary. involve several different actors, each with in 1990 and has since been Redistribution between geographical areas competing interests and priorities. It is implemented in at least 200 or levels of care in any setting is a political likely that once the budget has been drafted other municipalities throughout action and can only be effected successfully by the ministry of health, it will need the the country. Participatory budgeting gives citizens a direct if it has broad support. The PRS consultation endorsement of the other related ministries voice in the process of municipal process provides an opportunity to engage and sectoral departments, particularly those budget formulation. The process stakeholders and build coalitions in favour of whose mandates are concerned with related begins with neighbourhood resource distribution. Experience from South issues such as education, housing or water. assemblies in which citizens Africa suggests that the following issues In some countries, final decisions on budget deliberate and set budgeting priorities. It concludes when also need to be taken into consideration: allocation rest with the ministry of finance or delegates directly elected by planning. In others, further approval may be the neighbourhood assemblies l transparency is critical so that all required from parliament. Keeping a human formulate a citywide budget stakeholders can understand the basis on rights focus when defining the rationale that incorporates the citizens’ which resource allocations have behind the budget, particularly if choices demands. The aim of the process is to ensure that budget been made; have been made through consultation priorities correspond to local l a strong central role is essential. with the beneficiaries themselves, may priorities and popular needs.78 Although not requiring centralized help to foster understanding and determination of health budgets, it is ownership of the decisions made and the critical that the centre always monitors final budget approved. progress towards policy objectives and revises policy guidelines as appropriate; RAISING THE RESOURCES l the pace of budget reallocation must be Resources to pay for the costs identified realistic in order to ensure health sector usually come from a variety of sources: sustainability and to reduce opposition to the process of redistribution.77 l nationally raised resources such as direct and indirect taxation, distributed by IMF guidelines recommend that annual the treasury through the central budget; budgets should relate to, if not be l bilateral or multilateral official completely subsumed within, a Medium development assistance, contributed Term Expenditure Framework that typically directly to the central treasury; extends over three or more years. By l bilateral or multilateral funding, in the looking at spending priorities over a multi- form of loans or grants earmarked for

year period, Medium Term Expenditure specific health sector interventions or 77 Pearson M, op. cit. 76 Elson D. op. cit. Frameworks can facilitate the process of particular district-level hospitals or clinics; 78 Alsop R et al., op. cit.

Human RigHts, HealtH and PoveRty Reduction stRategies • 47 Mexico: analysing the l private sector funding for services to be paid by those seeking treatment budget delivered by non-State actors such as from hospitals or health-care centres. The Mexican NGO Fundar’s private companies or NGOs; Human rights treaties do not state that analysis of the Government’s budget showed that systems l public/private partnerships that target user fees for health services are a violation designed to address inequality certain vulnerable groups or focus on a of human rights. However, they do oblige were, in fact, exacerbating specific disease or issue; Governments to ensure that health services the problem. In Mexico, the l national- or community-level insurance are accessible and this includes economic Government has initiated schemes, either of a formal or informal accessibility (i.e. affordability). Impact FASSAR, a mechanism which is supposed to decentralize nature; assessments of user fees have shown health funds to offer services l out-of-pocket expenditure such as user them to be a significant impediment to for the population with no fees, costs of purchasing drugs or vaccines poor people being able to access health social security. The population or other associated costs incurred in services. In Africa, fees have been shown covered by FASSAR is heavily accessing health care. to discourage poor women more than concentrated in the poorer States of south and southeast poor men in seeking health care, because Mexico. But the amount of Sources of domestic revenue need to women have less income and less voice money available per capita in be expanded if public spending is to be in household decision-making. Exemption those States is lower, despite increased. It is important to ensure, however, schemes or waivers are often difficult being the areas where need that taxation and user fees are consistent to implement and manage effectively.80 is highest. Fundar’s analysis suggests that this is because with human rights principles and do not Moreover, evidence now suggests that the formula for allocation impose additional burdens on people who user fees raise only very small levels of between States gives higher are poor. The most excluded are likely to be resources and are an unreliable form of consideration to existing outside the direct scope of personal income financing in the long term. In practice, then, infrastructure and personnel tax since there is generally a minimum user fees for health services rarely support rather than to unfulfilled needs.79 income below which there is no liability to non-discrimination, equality and the rights pay. Indirect taxes, such as value-added of people who are poor. tax, are generally regressive as poor people contribute a higher share of their income to ENSURING FINANCIAl TRANSPARENCy payment of such taxes than do rich people. AND ACCOUNTABIlITy Indirect taxes can also discriminate against There is little point in using budget women when taxes are imposed on basic processes to increase the resources consumer items that women are more likely available to meet the priorities of 79 Keith-Brown K. Investing for life: making to buy and use than men. Indirect taxes can people who are poor if that money the link between public spending and be made less regressive through exemptions cannot be tracked to ensure that funds reduction of maternal mortality. Tizapán, of items purchased primarily by poor people, are released and that they reach their Fundar, Centro de Análisis e Investigación, 2005 www.fundar.org.mx particularly women. agreed destination. Accountability and Many health systems in developing transparency in financial and expenditure 80 Elson D, op. cit. countries rely on some form of user fees management are not only key human rights

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budget allocations and track whether BURUNDI: THE IMPACT OF USER FEES funding reaches those sources. These The international NgO Human Rights Watch not receive enough income from patient and other approaches to monitoring and reports that, over the past few years, public fees, direct donations and funding from the evaluation of the PRS are explored in hospitals in Burundi have detained hundreds government to allow proper functioning, section 4. of patients who were unable to pay their with well-trained staff, equipment and bills. The detention of patients results from medicine. Inconsistent funding as well as 3.4 Drafting or implementing a long- and draws attention to broader problems corruption among typically underpaid staff term strategy of health care in Burundi. Although one of add to the problem of funding shortfall. Human rights instruments acknowledge the the poorest countries in the world, Burundi Patients detained are generally very poor, fact that it would be virtually impossible for implemented a cost-recovery system as part often belong to vulnerable groups, such as any Government to raise enough resources of its delivery for health-care services in widows, orphans, single mothers or those to meet all the health needs identified 2002. Patients must pay all medical costs, displaced by Burundi’s civil war, and lack through participatory processes or to including consultations, tests, medicines and family or larger networks of social support. comply immediately with all its obligations supplies, as well as the costs of their stay In order to address this problem, President under the right to health. It was therefore in hospital. There is a health insurance and a Pierre Nkurunziza announced on 1 May 2006 agreed that human rights obligations should waiver system, meant to assist the poorest that maternal health care and health care fall under one of two categories: in meeting medical expenses, but neither for children under the age of five would be l functions effectively. Public hospitals do free of charge.81 those requiring immediate attention; l those that can be worked towards progressively over a period of time, known principles; they are also basic principles as the principle of progressive realization. of good governance and are essential in countering corruption and waste. The Core obligations requiring immediate availability of accurate information about attention include: the budget process is a critical factor in ensuring accountability at national as well l non-discrimination and equality of all as local levels. All individuals have the right persons; to seek, receive and impart information, l participation of all stakeholders; including on: l cessation of any detrimental activity or l where public money is being spent policy; l whether the funds are being disbursed l prohibition of any steps that may be appropriately and promptly retrogressive in the short term; l whether funds are being used effectively. l drafting and implementation of a 81 A high price to pay: Detention of poor plan or strategy that maps out how to patients in Burundian hospitals. Bujumbura, An increasing number of civil society make progress towards the realization of Human Rights Watch, 2006 www.hrw.org budget initiatives analyse Government all obligations.

Human RigHts, HealtH and PoveRty Reduction stRategies • 49 Universal Declaration of The human rights principle of progressive means of participating, directly or indirectly, Human Rights realization recognizes that in the short in donors’ decision-making processes or Article 28 term, as set out above, policy choices, in holding them to account. Principles of “Everyone is entitled to a social and international order in prioritizations and trade-offs have to be participation, inclusion, transparency and which the rights and freedoms made. It does not, however, allow for a accountability are central to maximizing set forth in this Declaration can Government to postpone its obligations aid effectiveness and improving the way be fully realized.” indefinitely. Progressive realization imposes Government and donors conduct and a continuing duty to move as expeditiously implement their aid programmes. Guidance Denmark: international development cooperation and effectively as possible towards the full issued by the Development Assistance Danish development policy realization of rights for men and women.83 Committee of the Organisation for is based on the Act on This calls for a clear, demonstrable Economic Co-operation and Development International Development plan that includes time-bound targets, includes recommendations for integrating Cooperation of 1971, most recently amended by benchmarks and indicators to measure human rights into the roll-out of the Paris Consolidated Act No. 541 of achievement and maps out a long-term Declaration on Aid Effectiveness. 10 July 1998. The Act strategy, using the maximum available l Development partnerships need to lays down the goals for resources, to reach the full realization of be grounded in national leadership and governmental cooperation with the right to health. developing countries: ownership which are, in turn, underpinned A PRS, with its associated budgets “The goal of Denmark’s by democratic and participatory processes. governmental assistance to and costing frameworks, as well as a clear Donor Governments inevitably work developing countries shall be to programme for monitoring and evaluation, closely alongside national Governments support – through cooperation constitutes a practical and concrete in designing and implementing PRSs but with the Governments instrument to articulate the rationale and official bodies of these it is important that the notion of national behind the policy choices that prioritize countries – their endeavours ownership is respected and upheld both to attain economic growth, some needs over others while meeting the from a human rights perspective and for thereby strengthening their obligations inherent within the principle of the long-term sustainability of the social progress and political progressive realization. independence in accordance strategy itself. with the United Nations Charter, its objectives and 3.5 Working with donors to promote l Predictability of resource flows is a key bearing principles, and also human rights through the PRS issue; it allows Governments to plan the use through cultural cooperation to Analysis of rights-holders and duty-bearers of aid over the long term. Building long-term promote mutual understanding is likely to reveal the extent to which development partnerships based on human and solidarity.”82 donors’ actions impact on poor people’s rights principles ensures that development right to health. Many middle- and low- cooperation programmes are less income countries may well be dependent vulnerable to short-term political changes 82 www.um.dk upon the financial and technical support of within the donor Government. Incorporating 83 CESCR, general Comment 3, para 9. donor partners to implement their PRSs. development cooperation policies within www.ohchr.org Rights-holders, however, rarely have any domestic legislation of donor countries

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provides a way to protect the long-term Canada: act to export predictability of aid flows, and provides OECD -DAC PRINCIPLES FOR generic drugs In May 2004, Canada passed coherence in aid policy as Governments INTEgRATINg HUMAN RIgHTS INTO new legislation to allow change. DEvELOPMENT COOPERATION compulsory licences to be issued to Canadian manufacturers of l The right to participation is recognized 1. Build a shared understanding of the links patented drugs for export to throughout the PRS process and is between human rights obligations and some low-income countries. The reaffirmed in many donor policies. It is development priorities through dialogue. products listed in the Act are essential, however, that donor Governments 2. Identify areas of support to partner drawn from the WHO’s list of recognize that effective participation governments on human rights. essential medicines and include antiretrovirals, used to treat requires funding and support. Moreover, 3. Safeguard human rights in processes of HIV/AIDS.85 it takes time and patience, and cannot State-building. be rushed to meet external deadlines. 4. Support the demand side of human rights. Incorporating indicators for donor 5. Promote non-discrimination as a basis for recipients and donors themselves to report more inclusive and stable societies. on participation in all phases – the design, 6. Consider human rights in decisions on alignment implementation and monitoring – of PRSs and aid instruments. may be a way of ensuring that participation 7. Consider mutual reinforcement between human actually happens in practice. rights and aid effectiveness principles. 8. Do no harm. l Donors should respect the priorities 9. Take a harmonized and graduated approach to set by the national Government and be deteriorating human rights situations. prepared to finance much needed but less 10. Ensure that the scaling-up of aid is conducive “attractive” interventions, such as building to human rights.84 management capacity. l While much focus has traditionally been placed upon the need for accountability of for mutual review and accountability the recipient Government to the donor, little into the memorandum of understanding emphasis has been placed on reciprocal between donor and Government and using or mutual accountability. This extends participatory methods to enable local not just to the accountability of the donor communities to review donor programmes Government to its own taxpayers and to and policies. the recipient Government but also to the very people for whom the aid programme l Donors should ensure that they, too, is designed, people who are poor and are incorporating human rights-based 84 Action-oriented policy paper on human vulnerable. Innovative means of addressing principles in their development cooperation rights and development, op.cit. this issue include building mechanisms programmes, particularly in the context 85 www.parl.gc.ca

Human RigHts, HealtH and PoveRty Reduction stRategies • 51 ActionAid: Accountability, of conditionality and selectivity in place substantial reporting or evaluation Learning and Planning development practice. Just as human rights requirements on Government, consuming System can form a sound basis to enable difficult scarce human and financial resources In 2000, ActionAid, an international non-governmental choices at the domestic level surrounding and seriously undermining the principle organization, launched its prioritization and trade-offs, so too can the of national ownership. Donors are aware Accountability, Learning and imperative of human rights principles help of the problems in coordination and Planning System. One of its guide the inevitable process of selecting cohesion between different development aims was to allow people who which countries to support. are poor a greater voice in the programmes and some are trying to organization’s monitoring and l Considerable overlap and contradictions improve matters by harmonizing their decision-making processes. may arise when different donors provide policies and activities and aligning behind Innovations included the advice and support to a country. This may country strategies. introduction of annual participatory review and reflection programmes at local, country and global levels to vIET NAM: PROgRESS IN ENSURINg NATIONAL OWNERSHIP OF THE PRS involve stakeholders – particularly the poor, but also partners, donors The government of viet Nam is with development partners on many of whom have yet to join the and peers – in the analysis of working hard to try to harmonize a framework within which the like-minded group and of which programme expenditure, plans the many different stakeholders government and the donors over 90 per cent are providing and initiatives. Other changes involved in the national PRS, the can cooperate and coordinate support to the health sector, included the development of new organizational incentives 10-year Comprehensive Poverty activities, finances, monitoring greater efforts at harmonization to support the Accountability, Reduction and growth Strategy. and evaluation. European donors and coordination are needed. The Learning and Planning System The harmonization initiative now coordinate much of their government is increasingly able and development of ways of includes not only relevant dialogue with the government to hold donors to account for sharing key financial data with government ministries but extends through the “Like-Minded Donor unfulfilled pledges or for deviating partners who had little financial experience and were, in many to bilateral and multilateral group” and plan their support away from the Comprehensive cases, illiterate. Tensions continue donors providing support to the through government-led sector Poverty Reduction and growth to exist between the pulls for strategy. According to the principle workshops. However, more work Strategy, but more commitment upward accountability to donors that the government must on aligning donor policies and on the part of the donors is and managers and downward take the lead in harmonization, monitoring requirements is needed needed to ensure transparency accountability to people who are poor and excluded. Nonetheless, the Ministry of Planning and particularly to reduce the burden and to share information with the country teams remain strongly Investment has endeavoured to of reporting. In addition, with over government and with one another committed to the Accountability, reach a common understanding 50 donors active in the country, on indications of aid flows.87 Learning and Planning System and the participatory review 86 David R, Mancini A. going against the flow: the struggle to make organisational systems part of the solution and reflection programmes have rather than part of the problem. Brighton, Institute of Development Studies, 2004 (Lessons for change in acted as a catalyst for coherent policy and organizations, No. 8) www.livelihoods.org change processes across the 86 organization. 87 www.oecd.org

52 • Human RigHts, HealtH and PoveRty Reduction stRategies Section 4 Implementation: transparency and accountability through monitoring and evaluation The final stage in completing any sectoral component of a PRS is to lay out clearly how the strategy will be implemented and how progress will be monitored and evaluated.

Monitoring and evaluation are key The first part of this section looks at elements of accountability. The collection community-based and civil society-led and dissemination of data about policy monitoring initiatives. The second part implementation increases the answerability reviews budget initiatives. The requirements of Governments and enables evaluation for the production of national statistical of whether obligations to respect, protect information on the right to health are and fulfil human rights are being met. then examined. Subsequent parts review Monitoring improves the effectiveness of indicators, goals and targets against Government spending and policymaking, which progress can be measured. Finally, particularly in the delivery of public different mechanisms of redress are services. It enables adjustments to be made discussed, including the judicial system and where necessary in budget allocations or international human rights reporting. in administrative policies and practices. It can help to build political will for change 4.1 Community-based and civil society by demonstrating the Government’s monitoring commitment to implementing pro-poor Community-based monitoring exercises policies, publicizing where reform has are usually initiated by civil society worked and highlighting the consequences organizations and often aim to empower of inequities in existing policy frameworks. people who are excluded and marginalized Monitoring should take place throughout as well as provide data on policy the entire application of the strategy. It implementation. They use participatory requires careful planning at the outset methods (see section 2.1) to enable local of the PRS process in order to fulfil its communities to assess service performance purpose effectively. against policy commitments. Civil society

Human RigHts, HealtH and PoveRty Reduction stRategies • 53 engagement in monitoring strengthens to monitor the impact of the Bolivian Poverty United Republic of social accountability, increases the depth Reduction Strategy and the use of financial Tanzania: A Plain Language Guide to and range of reporting and helps to build resources, including those resulting from the PRS responsiveness to ineffective or inefficient the cancellation of part of Bolivia’s external The Tanzanian civil society delivery of goods and services. debt under the Highly Indebted Poor organization, Hakikazi Community-based and civil society Countries Initiative. Catalyst, has produced a monitoring can provide an invaluable One simple way of facilitating community people's version of the national PRSP in both English and complement to national monitoring systems, and civil society engagement in the monitoring Swahili. Using accessible particularly given the difficulties in many process is to ensure adequate communication language and illustrative developing countries of building effective of the content of the PRS. Publicizing what cartoons, the guide answers comprehensive mechanisms for gathering the Government is proposing to do and key questions such as how statistical data. In some countries, including hoping to achieve is a step that is often poverty has been defined across the country and what South Africa and Uganda, civil society overlooked. Information about the PRS needs the elements of the overall monitoring processes are integrated to be disseminated in an understandable and plan are. It outlines the targets, with Government-initiated monitoring. informative format for the general public, activities and indicators, and As suggested in section 3, this can be a and most importantly the poorest sections of explains how it will all be constructive approach where there is mutual society for whom it is designed. paid for. It also describes how the process of developing the trust and sufficient separation of the political Where a charter of patient’s rights has strategy evolved and what and financial interests of Government and civil been developed or national legislation might change the next time. society organizations. While some degree of adopted (see section 3), this should be broadly The guide is available online cooperation is generally mutually beneficial, in communicated. In Uganda, for example, at www.hakikazi.org/eng some contexts civil society organizations may patients’ rights are publicized through posters wish to set up parallel monitoring systems in in local health facilities.88 The definition and order to maintain their independence. communication of standards also facilitates Whether or not Government and civil monitoring by providing an agreed baseline society monitoring initiatives are integrated, against which service delivery can be Governments have an obligation to promote assessed. Participatory methods can help to 88 an environment in which civil society can identify locally relevant indicators which can Björkman M et al., op. cit. operate. This requires promotion of rights then be used to measure progress in relation 89 Baez C, Barron P. Community voice to information as well as participation and to nationally agreed standards. and role in district health systems in association. In Bolivia, for example, the east and southern Africa: a literature Government passed the National Dialogue 4.2 Budget initiatives review. Regional Network for Equity 2000 Law that resulted in the setting-up of An increasing number of civil society in Health in east and southern Africa (EQUINET). June 2006 (EQUINET Bolivia’s National Social Oversight Mechanism. initiatives to monitor the implementation Discussion Paper 39). This law legitimizes civil society participation of the PRS focus on the budget. Analysis http://equ inetafrica.org/ in policy processes. One of the main objectives of resource flows and expenditures of the National Social Oversight Mechanism is provides concrete evidence of the extent 90 Norton A et al., op. cit.

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to which the Government acts upon its social movements, NGOs or research India: Bangalore citizen policy commitments. Moreover, budget organizations.90 report cards analysis generally includes a review of In 1994, a group of Bangalore citizens launched an initiative policies and their implementation, making Budget initiatives have been particularly to produce citizen report the approach a useful one for structuring successful as a method for assessing cards to assess the quality of a comprehensive evaluation of the PRS. the extent to which Governments’ use of public services in the city from Budget initiatives vary along a number of resources is promoting equality. In South the perspective of the users. axes including: Africa, the Women’s Budget Initiative is the Surveys were undertaken among users of different result of collaboration between civil society services including health-care l level of the exercise - central, sector or and Government that aims to use budget facilities and their views local government; and policy analysis to review resource were analysed on the quality, l scope of coverage - macroeconomic allocation from a gender perspective, adequacy and efficiency of the issues, expenditure or revenue; and the impact of policies on gender services provided, as well as the attitude of the staff. l role that Government plays in the equality and women’s rights. Some budget The media followed the initiative; initiatives, such as Fundar’s analysis of results carefully and public l involvement of different kinds of health expenditure in Mexico, have explicitly discussions and calls for change organizations - membership organizations, used the human rights framework as a followed. Later surveys and basis for assessing budget allocations. report cards have shown dramatic improvements in The methodology involved evaluating MAlAwI: the city's services and an CoMMUNITy sCoRE CARDs health budget allocations and changes in overall reduction in problems expenditure over time against international, and corruption as providers In Malawi, Community score Cards were regional and domestic commitments have responded to the wave introduced in some areas of the country on a trial to realize the right to health.91 Similar of publicity and calls for improvement. 93 basis. services are scored by users and the results methods have been developed to are compiled and presented to health centre staff analyse public expenditure, revenue, by a village health committee. The committee is macroeconomic policies and budget elected at consultative village meetings and is the decision-making processes in terms of bridge between health staff and the community. Governments’ obligations to ensure gender All aspects of health care are analysed from equality under the Convention on the 91 Dignity counts: a guide to using how staff listen to patients to how they care for Elimination of All Forms of Discrimination budget analysis to advance human undernourished children. staff also score their against Women.92 rights. Fundar, International Human own performance. All feedback is used to improve Transparency of information is central to Rights Internship Program and the way things work, ensuring that local needs budget initiatives. Some Governments are International Budget Project, 2004 www.iie.org/ are met. Reports suggest that where score cards reluctant to open up their budget processes

have been introduced, services have improved and to public scrutiny. Greater transparency, 92 Elson D, op. cit. community confidence has risen.89 however, can confer legitimacy on the budget process by allowing access to the 93 http://paf.mahiti.info

Human RigHts, HealtH and PoveRty Reduction stRategies • 55 Kenya: Mtaa dispensary information on which decisions were based include officials and elected representatives health information system and clarifying the rationale for resource as well as researchers and poor and excluded The key figure in developing the allocations. It can help to reduce the scope people themselves. Many people working in health management information system at Mtaa was a volunteer for corruption through the misallocation of Government ministries are unfamiliar with and a member of the Dispensary expenditure or the diversion of resources for the technical aspects of the budget and these Health Committee. Zabibu Chizi private ends. The IMF produces cross-country initiatives provide a good opportunity for Mwero started collecting data comparisons of budgetary transparency and them to build their own capacity to engage on for the Mtaa Dispensary and these can also provide a basis for building budget issues. writing it up on a blackboard and on charts. Information is taken support for increasing access to information from registers completed by the about budget flows and expenditures.95 4.3 National monitoring and statistics nurse-in-charge. Zabibu notes A number of countries, including Uganda collection how many patients have been and India, have passed legislation setting Governments developing a PRS generally treated for malaria, respiratory out citizens’ rights to access Government set up a national mechanism to monitor problems and bilharzia, as well as figures for growth monitoring information. Even where such legislation implementation, such as Uganda’s National and immunization. For all exists, however, it is important to ensure that Integrated Monitoring and Evaluation the main activities, the Mtaa local officials are given training and practical System. In some cases, as indicated Dispensary Health Committee guidance on transparency and information above, the national monitoring system is sets targets and the board shows dissemination. It is often at the local level integrated with civil society monitoring whether the dispensary achieves each target every month. that civil society access to information is initiatives. Numerous organizations may Information is used by the blocked.96 Suggestions for incorporating a produce data, narrative or survey-based Dispensary Health Committee review of information needs for rights-holders reports relevant to PRS monitoring: and people using the clinic can and duty-bearers are outlined in section 3.2. see what the Dispensary Health A key factor in the success of budget l local and district health committees; Committee is doing about health problems.94 initiatives is an often lengthy process of l parliamentary committees; capacity-building of those involved. This may l quasi-independent government departments; IANNDIA: J sUNvAIs, PUBlIC HEARINgs l ombudspersons, national human rights commissions or special rapporteurs; originally initiated by a local any misappropriation of the right to health care. l civil society organizations; organization of poor workers public funds or negligence Evidence gathered is used l international NGOs; and farmers in Rajasthan, in programme management. in court cases against l international organizations; jan sunvais, or public The hearings are now corrupt officials, and laws l United Nations human rights treaty hearings, have now become supported by the national have been changed to bodies, regional human rights bodies and an established means for government and have spread allow all citizens access to United Nations special rapporteurs. citizens to scrutinize public to urban areas, including documentation concerning records and hold government the capital, New Delhi. any government-run anti- One of the primary sources of data for officials to account for some focus specifically on poverty programme.97 national monitoring is official quantitative

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managing a national statistical system Philippines: community soUTH AFRICA: the Children’s takes time and resources and presents auditing The Philippine Commission Budget Unit a significant challenge to any country. In of Audit introduced a scheme After the end of apartheid, the new south African large, sparsely populated countries that to involve civil society in the government committed itself to addressing the are predominantly rural and have little auditing process. The “Value for desperate needs of the nation's children, over 10 nationwide infrastructure or internal Money” audit system focuses not only upon transparency million of whom were living in poverty. It began by communication, it can pose huge problems. and accountability of public Where such technical problems exist, ratifying the Convention on the Rights of the Child funds and expenditure but also and entrenched human rights in the new Constitution. donors and Governments need to recognize provides a judgement by the IDAsA, a national Ngo, established the Children's the importance of a functioning statistical community as to whether it Budget Unit in 1995 to monitor the extent to which system and invest in building national has been money well spent, particularly for the benefit the government's human rights commitments statistical skills and capacity. of excluded groups in the were being reflected in its budgets. The Children's community, including women. Budget Unit focuses on the principle of progressive The main functions of a statistical system Links with the media are being realization of rights and whether this is being done are to: established to keep the public for the poorest of the poor using the maximum informed of the results of the scheme, which is being scaled available resources. It disseminates its analysis l collect data from a variety of sources up to include many more l process and analyse the information to widely to the public and to Parliament and has done communities and regions.99 much to advocate the special needs of children highlight differences and trends orphaned through AIDs, who lack parental, legal or l coordinate data from different sectors 94 Baez C et al., op. cit. financial support. 98 and cross-reference it 95 Robinson M. Budget analysis and policy l disseminate the results to users in advocacy: the role of non-governmental public action. Brighton, Institute of socio-economic statistics. Quantitative data suitable formats l produce measurable results of reliable Development studies, september 2006 (IDs are important as they enable Governments working Paper 279). www.ntd.co.uk to report systematically on their actions to quality over time. 96 wood A. Beyond data. A panorama of Cso address poverty and realize human rights. The kind of information required for experiences with PRsP and HIPC monitoring. It is also useful for civil society initiatives, The Hague, Cordaid, october 2005 health and poverty analysis will range which aim to hold Governments to account www.cordaid.nl from broad nationwide statistics down to for their commitments. 97 www.sasanet.org focused quality detail from the household 98 Official statistics are compiled by national or community level. Statistical information www.idasa.org.za institutes and international organizations and data can be obtained from a variety of 99 (case study) The Philippines: enhancing mandated by the State. Organizations sources which may already exist, and others public transparency and accountability compiling official statistics are expected that may need to be generated. The choice through civil society participation in monitoring government services, in to be impartial, neutral and objective. In of source to use will be determined largely Responsiveness and accountability for many developing countries, their capacity by the type of information and the level of poverty reduction, Bergen seminar series is severely limited. Establishing and specificity required. 2002/2003 www.undp.org/oslocentre/

Human RigHts, HealtH and PoveRty Reduction stRategies • 57 From a human rights perspective, it is critical that data are disaggregated as far as possible. Data should, ideally, be disaggregated by prohibited grounds of discrimination, such as sex, age, disability, ethnicity, religion, language, social, economic, regional or political status of people. It is not always feasible, however, to disaggregate data to the desired level. Disaggregation by sex, age, regions or administrative units, for instance, may be less difficult than by ethnicity. Identification on the basis of ethnicity may require both subjective criteria, such as self-identification, as well as objective criteria, including language. Attempts to produce disaggregated data sometimes invoke social and political Kelly T (WHO-200387) Kelly sensitivities where, for example, minority 100 l The national census is the most complete Diaz D, Hofbauer H. The public budget and groups fear victimization as a result of maternal mortality in Mexico: an overview of statistical profile of a country, but it is identification. Data gathering should respect the experience. washington, DC, International expensive and time-consuming and therefore Budget Project, Center on International Budget these sensitivities as well as issues of privacy usually only undertaken every decade. and Policy Priorities, November 2004 and confidentiality. l Sample surveys can be conducted at much www.internationalbudget.org In some countries legal restrictions more frequent intervals and can provide an prevent the collection of data along ethnic approximate picture of the national situation. lines in order to promote social cohesion. l Focused surveys that look at a particular While such restrictions may be grounded in vulnerable group, such as indigenous genuine concerns, arguments about potential communities or internally displaced tensions have also been used as an excuse persons, can help determine the particular by Governments to prevent the publication of problems faced by that group, especially data that could be politically embarrassing. In when compared with national averages. these cases, civil society organizations, donors l Regular administrative systems such and other interested stakeholders may need to as health centre or school records or local develop strategies to demonstrate the value of authority information can provide a plethora statistical information, influence Government of detailed data but, crucially, will not behaviour and remove restrictions. include those who do not use these services, such as the very poor or some specific 4.4 Indicators groups. Data gathered through the national

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statistical system are used to produce to, policy objectives and commitments. Mexico: the public budget indicators of different socio-economic Where a charter of patients’ rights has and maternal mortality trends. Indicators are tools with which to been developed, or national legislation During 2002, Fundar, a research organization working measure a wide range of factors at any adopted, indicators should relate to the on budget issues in Mexico, given moment. They provide a picture at the implementation of agreed standards of evaluated the extent to which start of implementation of a strategy and, service provision, thus reflecting legal and public resources were being when compared with later results, can show policy commitments and the implementation allocated to the reduction of trends and changes, and highlight emerging of policy as well as health outcomes. maternal mortality. Initial analysis found that the basic differences or setbacks. In the health health services were insufficient sector, they frequently include mortality and Suggested indicators include: to meet the challenge of morbidity rates, numbers of doctors available reducing maternal mortality in the country and vaccination coverage l the period of application and coverage among the poor. The services rates. The availability of reliable data is a key of domestic laws relevant to the provided to marginalized communities relied on mobile issue in selecting indicators. implementation of the right to health; attention and could not offer OHCHR defines human rights indicators l the net official development assistance the coverage and quality needed as specific information on the state of for health sector received/provided as a to guarantee continual medical an event, activity or an outcome that proportion of public expenditure or gross care, effective and timely can be related to human rights norms, national income; transfer of women to the second level of medical attention, standards and principles. In many cases, l the proportion of the population covered real access to emergency MDG indicators or other existing national under awareness-raising programmes on the services and availability of indicators can be related to human transmission of diseases, e.g. HIV/AIDS; blood transfusions. These rights norms and standards. Maternal l the incidence of deaths/diseases structural shortcomings were and infant mortality rates, for example, caused by unsafe natural and occupational the product of decreasing funds. Under the Coverage can be understood as outcomes that are environments. Extension Programme, one central to the realization of the right to of the explicit goals was to health. Indicators chosen to measure Indicators to measure adherence to provide ‘universal coverage’ of implementation of the health strategy human rights standards and principles, basic health services. Priority should cover the different dimensions of including non-discrimination, participation, was consequently given to the number of people reached the right to health identified in General accountability and transparency, should instead of putting emphasis on Comment 14, including reproductive health; also be identified. For example: real access to health services. child mortality and health care; sanitation This meant that every year, and potable water; natural and occupational Non-discrimination: the per capita allocation was environment; prevention, treatment and l the existence of laws prohibiting violence reduced, decreasing from US$ 4.6 to US$ 3.8 per person control of diseases; and accessibility to against women and harmful traditional between 1998 and 2001. The health facilities and essential medicines. practices; States with the highest number The specific indicators chosen in any l the existence of laws allowing migrants of poor people had the lowest country should reflect, and be adapted access to comprehensive health services; per capita allocations.100

Human RigHts, HealtH and PoveRty Reduction stRategies • 59 Bangladesh: older citizens’ sTRUCTURAl, PRoCEss AND oUTCoME INDICAToRs: oHCHR's approach to monitoring project HelpAge International and the indicators for promoting and monitoring the implementation of human rights Resource Integration Centre in Bangladesh have set up a monitoring project that aims to oHCHR has developed a standards (structural indicators) victims, witnesses or Ngos. increase older people’s access conceptual and methodological to efforts being undertaken by the Based on the framework and to the Government’s old-age framework for using qualitative primary duty-bearer, the in consultation with experts, allowance and other services. and quantitative indicators state, to meet the obligations illustrative lists of indicators The project covers 3,325 older to promote and monitor the that flow from the standards have been drawn for a number of people in 54 villages in Pubail and 2,401 older people in 26 implementation of human rights. (process indicators), on to the rights that are being validated villages in Sriramkathi. At The framework outlines an outcomes of those efforts from through expert consultations an early stage of the project, approach to systematically the perspective of and workshops at country level. the older people conducted translate universal human rights rights-holders (outcome For the ‘right of everyone to their own census and found standards into operational and indicators). An assessment of the enjoyment of the highest significantly higher percentages of older people than the last contextually relevant indicators a state’s commitments, efforts attainable standard of physical Government census had at country level. and the results of those efforts and mental health’, the framework recorded. In Sriramkathi, for in meeting its human rights identifies five attributes namely example, 9 per cent of the More specifically, the framework, obligations is the cornerstone of ‘reproductive health’; ‘child total population was over which adopts a common approach this approach. mortality and health care’; 60, compared to 6 per cent recorded by the official census. for civil and political rights and ‘natural and occupational As a result of this project, more economic, social and cultural The framework focuses on environment’; ‘prevention, people who are eligible for the rights, transforms the narrative two categories of indicators treatment and control of old-age allowance are now on the normative content of and data-generating diseases’; ‘accessibility to receiving it. At national level, a human right, as articulated mechanisms: (a) indicators health facilities and essential in 2005 there was an increase in the allowance from US$2.5 in core international human that are or can be compiled medicines’ and the corresponding to 2.6 per month and the rights instruments, into a few by official statistical systems configuration of structural, number of people receiving it characteristic attributes and using statistical surveys and process, outcome indicators. was extended from 1 million to a configuration of structural, administrative records, 1.32 million.101 process and outcome indicators. which in most instances are The framework developed by For a human right, the identified available; and (b) indicators or oHCHR was outlined in the Report indicators bring to the fore standardized information more on Indicators for Monitoring an assessment of steps taken generally compiled by non- Compliance with International by a state in addressing its governmental sources and human Human Rights Instruments (HRI/ obligations – from acceptance rights organizations focusing on MC/2006/7) available at http:// 101 HelpAge International Asia/Pacific. of international human rights alleged violations reported by www.ohchr.org older citizens’ monitoring: the experience of Bangladesh. Chaing Mai, Thailand, 2007 www.helpage.org

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l the proportion of the health budget momentum can easily be lost over time, 102 vandemoortele J, Roy R. Making sense allocated to maternal health care; and efforts and resources distracted by of MDg costing. New york, Poverty group, l the proportion of births attended by other concerns that may emerge. Targets United Nations Development Programme, August 2004 www.undp.org skilled health personnel; should not be set unrealistically high, but l the proportion of children covered under neither should they be set too low, allowing nutrition supplement programmes; complacency to set in. They should present l the adolescent fertility rates. a challenge that with sufficient levels of commitment and resources could be Participation, information and accountability: achievable. They should be set for the end l coverage of domestic laws on rights to of the duration of the PRS, as well as at information, decentralization, civil society regular intervals along the way. Interim participation and association; targets are equally important, as it is only l number of registered civil society when indicators are measured against them organizations involved in the promotion and that it is possible to ascertain whether protection of the right to health; progress is being made in all areas or l representation of women and people from other excluded and marginalized whether there are some areas that are groups on national, district and village level slipping, and require urgent attention. health committees; This is vital, not only for the successful l proportion of sector budget earmarked to outcome of a PRS, but also as a way of support participation; demonstrating that the Government is l information available on budget flows meeting its obligation of the progressive and expenditures at national and district realization of human rights. level; The many international targets that have l information available on entitlements been set in the health sector, as well as the and minimum standards of service more technical goals that relate to certain provisions; health interventions or particular health l the existence of a human rights challenges, provide a broad framework institution or ombudsperson working on for national target setting. These targets, health issues; including the MDGs, represent indicators l number of health-related reports of international progress and cooperation. submitted on time to UN human rights These targets should be adapted to reflect treaty-monitoring bodies. national circumstances and priorities. 4.5 Targets Governments should aim to make the Targets are an important partner to greatest and fastest progress given indicators. They represent the progress the country-specific constraints and level of country would ideally like to make in the external support, rather than aiming to medium and long term. Without targets, keep on track with international targets.102

Human RigHts, HealtH and PoveRty Reduction stRategies • 61 Brazil National targets provide a framework within so forth is essential, so that the aggregate With help from the United which subnational and local targets can picture does not obscure critical disparities in Nations Children’s Fund be identified. Target setting that is based social and economic progress. (UNICEF), Brazil developed l an equity ratio to apply to the on civil society input and participatory The ICPD held in Cairo in 1994 and the MDGs to cover all regions, processes increases local ownership 1999 Five-year Review (ICPD+5) by the States and municipalities, and relevance. It is also important that UN General Assembly104 set out many disaggregated by gender, strategies geared towards achieving targets detailed targets of specific relevance to income, race/ethnicity, for whole populations do not subsume reproductive rights. disability, level of education l and location.103 efforts to improve equality and address Resolutions made at World Health the rights-holders who are extremely poor, Assemblies may also include targets and excluded and difficult to reach. goals related to specific aspects of health, and may also be useful in defining health GOALS AND TARGETS ENDORSED targets to include in the PRS. By GOVERNMENTS Referring to internationally recognized TARGETS AND OBjECTIVES OF targets such as the MDGs and others HEALTH INITIATIVES resulting from international conferences In addition to the general international not only brings legitimacy to the targets health targets, there are many specific and ensures consistency, but can also goals that may relate to eradication of a prove powerful advocacy tools to mobilize specific disease or achievement of a certain the support of development partners and level of vaccine coverage. These targets Government ministries concerned: relate to the goal of a specific technical programme or initiative, and may prove l MDGs: These eight goals aim to useful and relevant in particular national encapsulate the many and wide-ranging contexts and may attract the support of commitments made by Governments at a various parties. Some of the many “disease- series of United Nations conferences held specific health targets” are: in the 1990s. Health outcomes and the underlying determinants of health for the poor l universal access to comprehensive feature prominently in the MDGs. At national prevention programmes, treatment, care level, MDG targets should be complemented and support for people living with HIV/AIDS with locally relevant targets such as those by 2010; related to health threats from injuries, non- l halve the burden of malaria by 2010. communicable diseases or environmental factors, or targets related to strengthening 4.6 Political, judicial and quasi-judicial 103 http://hdr.undp.org health systems in general. Disaggregation accountability 104 www.unfpa.org according to ethnicity, region, gender and Throughout this booklet the importance of

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accountability has been emphasized. A highlighted the importance of accountable range of institutions and processes have and transparent budget processes. The first been outlined that can support different part of this section discussed methods for forms of accountability at various levels promoting social accountability, including from local through to international. Section community-based monitoring and budget 2 looked at analysis of the different systems initiatives. The role of national statistical of accountability that are accessible to systems, targets and indicators was then people who are poor and excluded. Section reviewed. The final part of this section 3 explored the development of minimum looks at judicial, quasi-judicial and political standards that people could use to hold institutions that support accountability for (WHO-212117) Pierre Virot policymakers and providers to account, human rights standards and principles. and examined ways of building health Enabling the work of these institutions service institutions to ensure administrative through, for example, full and timely accountability and redress. It also provision of information on health policies and issues, is an important strategy for MIllENNIUM ensuring the implementation of the health DEvEloPMENT goAls sector strategy of the PRS. The health targets: ● Halve, between 1990 and 2015, the proportion PARLIAMENTARy OR OTHER POLITICAL of people who suffer from hunger. PROCESS ● Reduce by two thirds, between 1990 and 2015, Depending upon the complexity or the under-five mortality rate. nature of the domestic parliamentary ● Reduce by three quarters, between 1990 and system, opportunities for oversight and 2015, the maternal mortality rate. accountability may exist within the national ● Have halted by 2015 and begun to reverse the governance system. In a multiparty spread of HIv/AIDs. democratic system, many parliaments ● Have halted by 2015 and begun to reverse the will have mechanisms such as cross-party incidence of malaria and other major diseases. committees that can be empowered to ● Halve by 2015 the proportion of people without undertake impartial reviews of Government sustainable access to safe drinking water. activities and ensure they are implemented ● By 2020 to have achieved a significant in line with their commitments. Where 105 improvement in the lives of at least 100 million excluded groups are given a voice in the Programming for justice: access for all. A practitioner’s guide to a human slum-dwellers. hearings of parliamentary committees and rights-based approach to access to other oversight mechanisms, they can play ● In cooperation with pharmaceutical companies, justice. Bangkok, Asia-Pacific Rights provide access to affordable, essential drugs in a significant role in ensuring the delivery and Justice Initiative, United Nations developing countries. of constitutionally guaranteed Development Programme, 2005 socio-economic rights.105 www.undp.org

Human RigHts, HealtH and PoveRty Reduction stRategies • 63 National courts have for many years been South Africa: legal action to mechanisms through which human rights secure Nevirapine In December 2001, the Pretoria violations are addressed. It is only recently High Court passed judgement that litigation has been used specifically in the case of the South African for economic and social rights. The Ministry of Health versus the collective nature of these rights as well Treatment Action Campaign, as the budgetary implications associated a civil society organization that campaigns for the rights of with economic and social policy has made people with HIV and AIDS. The litigating these violations more difficult case involved the enforcement than action to defend civil and political of the right of access to health rights. In general, litigation is difficult, care and the obligation of the costly and not a route that is easy for State to make Nevirapine

Pierre Virot (WHO-218261) Virot Pierre available to pregnant women individuals living in poverty. Paralegals living with HIV so as to prevent There are other means by which and legal advice centres can facilitate mother-to-child transmission of parliamentary oversight of the access to court systems. But courts are HIV. At the time, Government- implementation of health and related often inefficient, corrupt, out of touch with provided Nevirapine was limited policies can be strengthened, such as: the realities of people living in poverty, to 18 pilot-study sites. The Court’s judgement required and biased against marginalized groups, l engaging research institutes and the State to make Nevirapine including women. immediately available to universities to carry out research and However, where civil society pregnant women with HIV who audits; organizations can pursue cases on behalf give birth in facilities in the l ensuring that NGOs can have access to of people who are excluded, litigation can public sector, and to their babies, where medically indicated. all relevant public policy documents; provide a springboard for broader social l stimulating the existence and The Court also ordered the and political action. As the landmark South Government to devise and functioning of NGOs by lowering the African Grootboom107 and Treatment implement in a reasonable bureaucratic barriers for legal recognition Action Campaign cases (below) have manner an effective national of NGOs or giving financial support; demonstrated, social and economic rights programme to reduce mother- to-child transmission, including l allowing the media to cover issues of are justiciable and judges can make policy- Government performance and encouraging Nevirapine or other appropriate literate rulings. In the latter case and many medicine, the provision of media awareness on issues relevant to the others, litigation has helped to ensure that voluntary counselling and health sector; Governments fulfil their constitutional and testing, and formula milk. The l requesting that independent institutions international treaty obligations, and has judgement was upheld by the Constitutional Court in 2002. conduct research on the executive's budget vindicated the entitlements of people who and activities.106 As a result of the judgement, are excluded. the South African Government jUDICIAL In many countries, including those that adopted a comprehensive Full accountability requires the availability have just emerged from conflict, local-level mother-to-child transmission programme.109 of redress for human rights violations. disputes are settled through traditional or

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informal courts using customary law. While human rights institutions now established India: Legal action against these bodies are generally more accessible in all parts of the world can be grouped discrimination The Lawyers Collective, HIV/ to people who are poor than the formal together in two broad categories, “human AIDS Unit, responds specifically judicial system, it cannot be assumed that rights commissions” and “ombudspersons”. to the legal needs of people living such processes support the entitlements Some “specialized” national institutions with HIV/AIDS. For example, of all and are non-discriminatory. Women function to protect the rights of a it filed a writ petition with the and children may be at a particular particular population group such as ethnic Bombay High Court on behalf of a person who was removed from disadvantage in traditional or customary and linguistic minorities, indigenous employment from a public sector law systems in relation to issues including populations, children, refugees or women. corporation because of his HIV inheritance, property, early marriage and status. The High Court agreed violence against women.108 Access-to-justice “The Paris Principles”, adopted by the with the petitioner and directed programmes work with these processes to General Assembly in its resolution 48/134 that individual be reinstated and be paid compensation for the increase awareness of, and adherence to, of 20 December 1993,110 give guidance on period of his non-employment human rights standards and principles. the role, composition, status and functions with the corporation.112 of national human rights institutions National human rights institutions (see also section 3). The effectiveness National human rights institutions are of national human rights institutions 106 Ibid. quasi-judicial or statutory bodies whose depends on their mandate, resources and 107 government of the Republic of south general mandate includes investigation links to civil society and Government. Africa and others v grootboom and others of complaints in cases of human rights For example, the South African Human 2000 (11) BClR 1169 (CC) violations, promotion of human rights Rights Commission helps to monitor the www.communitylawcentre.org.za/ education and review of potential implementation of socio-economic rights 108 Ncube w, ed. law, culture, tradition and legislation. Most of the nearly 100 national nationally through an ‘Economic and Social children’s rights in Eastern and southern Africa. Brookfield, vT, Aldershot, 1998.

109 Minister of Health v Treatment Action ARgENTINE HAEMoRRHAgIC FEvER vACCINE Campaign. Bellville, south Africa, Community law Centre, University of western Cape, 2002 Argentine haemorrhagic fever obtain. The Centre on social and care for a population, the state www.communitylawcentre.org.za. has become endemic in the legal studies mounted a court must find the necessary resources 110 pampa zone of Argentina. The challenge based on the right to do it. The court further UN general Assembly Res.48/134, 1993. www.un.org/ best way to combat this disease to health, and eventually won. established a schedule according 111 is through a highly effective The court, citing Argentina’s to which the state had to proceed viceconte, Mariela c. Estado Nacional (Ministerio de salud y Ministerio de vaccine. The production of constitutional and international and followed up to monitor Economía de la Nación) s/ Acción de Amparo, this vaccine, however, had human rights law obligations, compliance with the schedule. The Federal Administrative Court of Appeals, June proven unprofitable for private stated that when, for economic Centre on social and legal studies 2, 1998 www. http://www.escr-net.org laboratories and, as a result, the or commercial reasons, private is continuing to pressure the 112 vaccine had become difficult to institutions do not provide health government for progress.111 HIv/AIDs and human rights in a nutshell, op. cit.

Human RigHts, HealtH and PoveRty Reduction stRategies • 65 Brazil: national rapporteur Rights Protocol’ system, involving periodic these monitoring bodies consider the on the right to health surveys issued to Government authorities reports that States are periodically required In October 2002, Brazil appointed six national assessing compliance with constitutional to submit outlining progress. They can also rapporteurs to monitor and international human rights obligations. receive reports from other sources, such economic, social and cultural as NGOs or United Nations agencies, and rights, including one for the International human rights reporting some are able to receive complaints from right to health. Chosen by a There are seven human rights treaty bodies individuals who have reason to believe their council comprising NGOs and United Nations agencies as monitoring the implementation of core rights have been violated. The reports of the well as Government officials, international human rights treaties that treaty bodies can serve to raise awareness the rapporteurs have the contain provisions relating to the right to of the state of human rights in a country mandate to receive complaints, health and other health-related human and can bring pressure to bear to change investigate violations and make rights. Comprising independent experts, policies or practices where needed. annual reports. They can also recommend needed changes in policies or laws. Candidates are chosen for their professional expertise as well as their proven commitment to human rights principles such as equality and non-discrimination.113

113 http://www.gajop.org.br

66 • Human RigHts, HealtH and PoveRty Reduction stRategies Section 5 Human rights instruments, international resolutions and declarations, useful documents, and organizations The first part of this section provides an outline of the evolution of work on the right to health and poverty in development. The second part lists key resources on the right to health and documents for further reading on health, poverty and human rights. All the documents mentioned in the overview are referenced in the resource lists.

5.1 The evolution of the right to health Civil society campaigns, including on issues and poverty in development of reproductive and sexual health and HIV/ The right to the highest attainable standard AIDS, helped open up debates about the of health has been recognized as a interpretation and application of the right fundamental human right for many years. to health. This, along with growing interest It was enshrined in the Preamble to the in developed and developing countries in WHO Constitution in 1948 and reaffirmed using a rights framework, and research in the Alma-Ata Declaration on primary and advocacy from academia and UN health care in 1978. The most authoritative institutions, placed human rights firmly on 114 Programme of action of the definition of the right to health was set out international development agendas. This is international conference on population in article 12 of the ICESCR. reflected in the emphasis on reproductive and development, Cairo, Egypt, op. cit. rights and women’s human rights in the 115 Beijing declaration and platform Constitution of the reports of the 1994 Cairo ICPD,114 the for action. Fourth World Conference on World Health Organization 1995 Beijing Fourth World Conference on Women, A/CONF.177/20 and Add.1 Preamble: Women115 and in the publication of the 116 International guidelines on HIV/AIDS “The enjoyment of the highest attainable International Guidelines on HIV/AIDS and and human rights. 2006 consolidated standard of health is one of the fundamental Human Rights.116 version. Geneva, Office of the United Nations High Commissioner for Human rights of every human being without In 2000 the Committee on Economic, Rights/the Joint United Nations Programme distinction of race, religion, political belief, Social and Cultural Rights adopted General on HIV/AIDS, 2006 www.ohchr.org economic or social condition.” Comment 14 which outlined in detail the

Human RigHts, HealtH and PoveRty Reduction stRategies • 67 normative substance of the right to health, which presented a thorough assessment of 117 General Comment 14 the obligations associated with it and the the potential of health in global economic 118 25 questions & answers on health & human measures required for its implementation.117 development. rights, op.cit. Two years later, the Commission on Human Development practitioners, most 119 Poverty and health. Geneva, World Health Rights appointed a Special Rapporteur notably those in UNDP and UNICEF, as Organization/Paris, Organisation for Economic to focus on the right of everyone to the well as many civil society organizations, Co-operation and Development, 2003 (DAC enjoyment of the highest attainable standard have been working with their colleagues Guidelines and Reference Series). www.who.int of physical and mental health. The ongoing in the human rights community to explore 120 Commission on Macroeconomics and Health. Macroeconomics and health: investing in health work of the Special Rapporteur continues the links between poverty and human for economic development. Geneva, World Health to explore and raise awareness of this rights. A growing number of civil society Organization, 2001 www.who.int fundamental human right. In parallel, organizations, such as the People’s Health 121 www.phmovement.org health professionals have been cooperating Movement Right to Health campaign,121 122 Human rights and poverty reduction: a with their human rights counterparts to now articulate their concerns about health conceptual framework. Geneva, Office of the consider the operational significance of and poverty in terms of human rights. Their United Nations High Commissioner for Human the relationship between health and work demonstrates how human rights can Rights, 2004 www.ohchr.org human rights, and have acknowledged the be used to empower marginalized people 123 Principles and Guidelines: a human rights approach to poverty reduction strategies. Geneva, powerful contribution that human rights and communities and contribute to pro-poor Office of the United Nations High Commissioner can make in improving health outcomes. policy change. for Human Rights, 2006 www.ohchr.org

The WHO publication 25 questions & In 2001, the United Nations Committee 124 Claiming the MDGs: a human rights approach. answers on health & human rights of 2002 on Economic, Social and Cultural Rights Geneva, Office of the United Nations High provides an accessible introduction to expressed an interest in understanding how Commissioner for Human Rights, 2008 this issue.118 human rights principles could be brought The link between poverty and ill health to bear in designing development policies has been recognized for some time and is and, in particular, PRSs. OHCHR responded reflected clearly in the prominence given by articulating this approach in three key to health within the MDGs. However, it has documents, Human rights and poverty only been relatively recently that headway reduction: a conceptual framework,122 has been made in exploring the central role Principles and guidelines: a human rights good health can play in macroeconomic approach to poverty reduction strategies,123 development and growth. The publication and Claiming the MDGs: a human rights Poverty and health, published jointly by approach,124 which together provide OECD and WHO,119 is a clear reference practitioners with concrete guidance on the document on this matter and includes a overall approach to utilizing human rights useful set of policy recommendations. In norms and standards in PRSs. WHO has 2001, the Commission on Macroeconomics now attempted to take forward this work and Health published its report Investing and explore what it means when applied, in a in health for economic development,120 practical way, to health.

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5.2 Key references and organizations on l Convention on the Rights of Persons the right to health and poverty with Disabilities, 2006 www.ohchr.org Relevant international human rights instruments l Convention on the Rights of the Child, 1989 Below is a selection of key international www.ohchr.org human rights instruments that relate to the right to health and/or other health-related l International Convention on the human rights: Protection of the Rights of All Migrant Workers and Members of l Universal Declaration of Human Their Families, 1990 Rights, 1948 www.ohchr.org www.ohchr.org

H For a more comprehensive list of l International Convention on the international human rights instruments, Elimination of All Forms of Racial please refer to www.ohchr.org/ or www.who. Discrimination, 1965 int/hhr/readings/en www.ohchr.org l International Covenant on Economic, Relevant basic texts and resolutions of WHO Social and Cultural Rights, 1966 l Constitution of the World Health www.ohchr.org Organization, 1948 www.who.int/governance/eb/who_ l International Covenant on Civil and constitution_en.pdf Political Rights, 1966 l Declaration of Alma-Ata, International www.ohchr.org Conference on Primary Health Care, 1978 l Convention on the Elimination of www.who.int/hpr/NPH/docs/ All Forms of Discrimination against declaration_almaata.pdf Women, 1979 www.ohchr.org Examples of relevant United Nations conference documents l Declaration on the Right to l Vienna Declaration and Programme Development, 1986 of Action, 1993 www.ohchr.org www.ohchr.org

Human RigHts, HealtH and PoveRty Reduction stRategies • 69 l Copenhagen Declaration on Social Relevant WTO documents Development and Programme of l Ministerial Declaration adopted Action ofthe World Summit for Social at the Fourth Session of the Ministerial Development,1995 and 2000 Conference, Doha, 9-14 November 2001. www.un.org (WT/MIN(01)/DEC/1), 20 November 2001 www.wto.org l Declaration of Commitment on HIV/AIDS. Special Session of the UN General l Agreement on Trade-Related Aspects Assembly on AIDS, 2001. Resolution of Intellectual Property Rights (TRIPS) S-26/2 of 27 June 2001 signed in Marrakesh, Morocco, 15 www.un.org April 1994 www.wto.org l Monterrey Consensus of the International Conference on Regional human rights instruments Financing for Development, l American Convention on Human Monterrey, Mexico, 18-22 March 2002 Rights, 1969 (A/CONF.198/11) www.corteidh.or.cr www.un.org l African Charter on Human and Peoples’ Rights, 1981 l United Nations Millennium Declaration. www.achpr.org General Assembly resolution 55/2 of 8 September 2000 l European Convention on Human Rights, 1950 www.un.org www.coe.int l Health in the Millennium Useful source documents and suggestions Development Goals chart for further reading www.who.int/mdg/goals/en/ l Asher, Judith. The right to health: a l Johannesburg Declaration on resource manual for NGOs, 2004 Sustainable Development and Plan of http://shr.aaas.org/Right_to_Health_ Implementation of the World Summit Manual/index.shtml for Sustainable Development, 2002 www.un.org l Committee on Economic, Social and Cultural Rights. General Comment 14. The right to the highest attainable standard of health (article 12). (E/C.12/2000/4), 11 August 2000 www.ohchr.org

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l Jonsson, Urban. Human rights approach l Elson, Diane and Norton, Andy. What’s to development programming. Eastern behind the budget? Politics, rights and and Southern Africa Regional Office. accountability in the budget process. United Nations Children’s Fund, 2003 Overseas Development Institute, 2002 www.unicef.org/rightsresults/files/ www.odi.org.uk/pppg/publications/books/ HRBDP_Urban_Jonsson_April_2003.pdf budget.html l International Guidelines on HIV/AIDS and l Poverty reduction and human rights: a Human Rights, 2006. Consolidated practice note. United Nations version. Geneva, Office of the United Development Programme, June 2003 Nations High Commissioner for Human www.undp.org/governance/docs/HRPN_ Rights and Joint United Nations (poverty)En.pdf Programme on HIV/AIDS www.ohchr.org l Principles and Guidelines: a human rights approach to poverty reduction strategies. l Commission on Macroeconomics and Office of the United Nations High Health. Macroeconomics and health: Commissioner for Human Rights, 2006 investing in health for economic www.ohchr.org development. Geneva, World Health Organization, 2001 l Claiming the MDGs: a human rights www.who.int approach. Office of the United Nations High Commissioner for Human l Poverty and health. DAC Guidelines and Rights, 2008 Reference Series. Geneva, World Health www.ohchr.org Organization/Paris, Organisation for Economic Co-operation and Development, l United Nations Commission on Human 2003 http://whqlibdoc.who.int/ Rights. The highly indebted poor countries publications/2003/9241562366.pdf (HIPC) initiative: a human rights assessment of the poverty reduction l Human rights and poverty reduction: a strategy papers (PRSP). United Nations conceptual framework. Office of the Economic and Social Council. 18 January United Nations High Commissioner for 2001 (E/CN.4/2001/56) Human Rights, 2004 (HR/PUB/04/1) www.ohchr.org http://www.ohchr.org

Human RigHts, HealtH and PoveRty Reduction stRategies • 71 l Human development report 2000. Human l Health & Human Rights Fact Sheet Series, rights and human development. New York, Geneva, World Health Organization, 2007 United Nations Development Programme, 2000 http://www.who.int/hhr/activities/ http://hdr.undp.org/reports/global/2000/en/ factsheets/en/index.html l Klugman J, ed. A sourcebook for poverty Selection of organizations addressing reduction strategies. Washington, DC, human rights, health and poverty reduction World Bank, 2002 www.worldbank.org l CARE www.careinternational.org l PRSPs: their significance for health: second synthesis report. Geneva, l Center for Economic and Social Rights WorldHealth Organization, 2004 (WHO/ www.cesr.org HDP/PRSP/04.1) www.who.int/hdp/en/prspsig.pdf l Commonwealth Medical Trust www.commat.org l Health & Human Rights Publication Series. Geneva, World Health l Fundar Organization www.fundar.org.mx http://www.who.int/hhr/activities/ publications/en/ l International Council on Human Rights Issue No. 1 25 questions & answers on Policy www.ichrp.org health & human rights, July 2002 www.who.int/hhr/en/NEW37871OMSOK.pdf l International Network for Economic, Issue No. 2 Health and freedom from Social & Cultural Rights discrimination, August 2001 www.escr-net.org www.who.int/hhr/activities/q_and_a/en/ Health_and_Freedom_from_ l Office of the United Nations High Discrimination_English_699KB.pdf Commissioner for Human Rights Issue No. 3 The right to water, 2003 www.ohchr.org www.who.int/docstore/water_sanitation _health/Documents/righttowater/ l Oxfam International righttowater.pdf www.oxfam.org Issue No. 4 International Migration, Health & Human Rights, December 2003 l Save the Children www.who.int/hhr/activities/en/FINAL- www.savethechildren.org.uk Migr-HHR-01%203-Qd-Uk_90.pdf

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l UNDP www.undp.org l UNICEF www.unicef.org l Wemos Foundation www.wemos.nl l World Bank www.worldbank.org l World Health Organization www.who.int

Human RigHts, HealtH and PoveRty Reduction stRategies • 73 Acknowledgements

HR/PUB/08/05 Health and Human Rights Publications Series • Issue No 5 • December 2008

HealtH & HumaN RIgHtS PublIcatIoN SeRIeS ISSue No.5 HR/Pub/08/05