Food for an urgent agenda's thoughts (2)
----------------------------------------
Human Rights Reader 38
PUTTING EQUITY AND HUMAN RIGHTS IN HEALTH ON THE AGENDA: THE ROLE OF
NGOs. (2)
Experiences from some NGOs already using the Equity/Human Rights ap-
proach:
17. As far as international NGOs are concerned, CARE has probably ad-
vanced the most in its efforts to operationalize the Equity/Human
Rights (E/HRs)-based approach. Since January 1999, they have had a
(CARE) Human Rights Initiative with a HQs coordinator and program ad-
visor and a field program assistant devoted full-time to the Initia-
tive. They have been raising awareness in most CARE country offices
around the world, building the capacity of their staff globally, en-
suring that CARE's principles and policies facilitate the HRs-based
approach being progressively adopted, and they have been forging
strategic alliances with like-minded programs and initiatives. They
carry out training, research and pilot activities in HRs, and they
publish a quarterly newsletter ('Promoting Rights and Responsibili-
ties') featuring cases from the field, staff reflections, conceptual
pieces, a section called Window to the Wider World and a section on
worldwide new resources. They are about to publish a Rights-based
Training Manual and a set of Case Studies on CARE's Implementation of
the Rights-based Approach. Very helpful has been the compilation of a
Frequently Asked Questions About the Adoption of a Rights-based Ap-
proach document which has been revised a few times. (More information
to be had from Michael Rewald at <rewald@care.org>)
18. Note: Equity and HRs do not feature explicitly in the charters of
international financial institutions (IFIs) and those of many donors
although most bilateral development agencies now give prominence (and
mostly lip service?) to both participation and the promotion of eq-
uity and human rights. Moreover, the commitments of national govern-
ments to respect, protect and fulfill health as a right has yet to be
properly reflected in their policies and practice. The E/HRs-based
approach demands that government policies address ill-health and mal-
nutrition 'to the maximum of available resources' (including re-
sources available through international development assistance). It
is this what some NGOs are starting to make governments accountable
for. Finally, also note that a new publication of WHO states that
poorly designed and implemented current health programs and policies
can (and do) already violate HRs.
Practical ways for NGOs to adopt the Equity/Human Rights focus in
their health work:
19. The equity/human rights approach does not offer a panacea or
magic bullet that will see resources, services and power instantly
transferred to the poor and vulnerable. In part, this is due to the
fact that the international community has no practicable ways of im-
posing punishments or fines on governments (or others) that violate
or ignore their commitments to human rights. On the other hand, NGOs
have not used their potential to more proactively seek government
compliance in this area. There are proven tactics that can be used --
and these need to be shared more widely.
20. The main question at hand here for NGOs is: If current health
programming is mostly time-bound, donor-driven, and supposedly apo-
litical, how can they pursue meaningful, long-term and rights-
holders-driven transformations in the sector based on challenging op-
pressive power relations?
21. Understanding how societies construct the system of inequities
that include inequities in health is the first step for NGOs to help
people claim their rights.
22. But understanding is not enough. The E/HRs-based approach insists
on behavioral changes of the NGOs professional staff themselves (to
be seen as a 'staff investment') rather than the latter simply start-
ing more 'HRs-compatible' new programming; it insists that the E/HRs-
based approach entails a different concept of development programming
that does not only focus on the methods of implementing new activi-
ties. Without behavioral changes, staff will simply repackage what
they are currently doing in an 'E/HRs-based approach language'.
23. When designing projects, a formal analysis of the rights being
addressed has to be done with the community; this includes under-
standing how aid can compound some of the problems to be solved, as
well as analyzing the unintended consequences of the work to be un-
dertaken. (Unintended impacts on people's rights happen for three
different reasons: a lack of knowledge about the context in which
NGOs work; a lack of thought about unintended impacts of their inter-
ventions, and a failure to take responsible actions).
24. For all the above reasons, from now on, a growing part of NGO ef-
forts should focus on making governments accountable to meet their
equity/human rights obligations; and there are concrete steps that
can be followed to do this (see below). More and more, the root
causes issue (i.e., taking a new look at issues of power, control,
ownership and sustainability) and the rights violations actually
found should become the main agenda for discussions with authorities.
25. That is why calling for an NGO (re)organizational meeting (or re-
treat) on these issues is now necessary. It is high time that people
in NGOs find out more about this equity/human rights-based approach
to health and particularly about how to operationalize it. This ex-
pertise is now badly needed.
26. The real tough challenge NGOs face in these organizational meet-
ings is in translating what some feel are still vague principles into
concrete plans and actions --even if they find it difficult to alter
power relations in the short-term.
What does it take, then, to understand and adopt an E/HRs-based ap-
proach?
27. To start from scratch and to familiarize NGO staff with this ap-
proach, a one-day general introduction to HRs and the E/HRs-based ap-
proach, defining its characteristics, is suggested; this is to be
followed by a series of meetings in which exercises are presented for
staff to learn how to carry out causal/ responsibility analyses and
to identify the responsible actors (duty bearers) at each level; this
is followed by exercises on how to develop advocacy strategies to in-
fluence pertinent decisions an actions. A final session should focus
on identifying the NGOs strengths and weaknesses to adopt the E/HRs-
based approach and should conclude with delineating the steps pro-
posed to progressively implement this approach. At the end of the
training, each staff member should be asking him/herself: 'Am I
really committed to this?'... and this should be discussed.
28. There is no shortcut or blueprint methodology to achieve a shared
understanding of these concepts. NGOs must acknowledge that this is a
time consuming and intense process. What is clear though is that NGOs
will identify a host of new priorities.
29. What the addition of these priorities will mean for each NG, and
what it will lead to in the future, is also to be explored in these
meetings. Towards the end, each NGO should have a long-term vision
for health --one that adds the equity/human rights perspective. This
should be ultimately reflected in increased funding for activities
that point to that vision (funding needed for this is considered to
be neither very substantial nor very difficult to raise); it should
also mean that NGOs will become more vocal advocates for both health
and human rights and better watchdogs of human rights violations and
of existing and emerging inequities in health.
30. Only after going through such a collective learning process will
the NGO 's internal organizational systems, its processes, policies
and organizational culture change as needed. It is more, only when a
critical mass of people in the organization changes to think in the
new way will the NGO as a whole change. Each staff has relationships
with people at many levels of the organization; each should gradually
work to influence them so that more and more staff join by under-
standing and supporting the changes called for.
31. After going through the training, the next challenge for NGOs be-
comes to use the international human rights agreements, they now will
be more familiar with, practically: -in the health policy making
process (their own and the government's), -to guarantee people's par-
ticipation (beyond mere dialogue), -to assess and analyze people's
health and nutritional needs together with them, -to set commonly ar-
rived at and agreed objectives, -to, together with and/or backing
claim-holders, place informed and effective demands in front of au-
thorities and demand for accountability, and -to call for and get in-
volved in networking and solidarity work.
32. Also after the training, NGOs will find themselves moving things
traditionally deemed unchangeable (e.g. the assumptions column in
their project logframes) into more explicit objectives of what they
want to achieve in their different projects. This will also mean
that, later, measuring the impact of their projects will also have to
be from a HRs perspective. (What is here meant is that NGOs have to
honestly question what they put in the assumptions and risks column
of their project logframes and ask themselves: Are these assumptions
really out of their domain of influence or control? Can something be
done to proactively address them?).
33. Further, NGOs have to decide whether they start applying the
E/HRs-based approach in their current projects or rather wait for new
projects to come to do so. Alternatively, they can begin implementing
the E/HRs-based approach in selected projects and experiment using
the new HRs work tools, at the same time building the capacity of a
core team of trainers/implementers and encouraging senior management
to take a lead role. They also need to make sure they have the capac-
ity and the resources to implement these principles.
34. Later, NGOs will need to periodically review whether their pro-
grams are reflecting the E/HRs principles, document how they do devi-
ate from them and articulate steps to progressively get back to and
realize them.
35. Ultimately, the aim is to cede power in NGO programming to the
people they serve, ensuring they are increasingly represented and
heard in program/project decisions.
36. When Northern NGOs become actors in a rights-based framework,
they also need to recognize the existing tensions in their relation-
ship with Southern partners; these often relate to economic and other
inequalities in their relationship at a time when Northern NGOs are
seeking equity. (Beware that, in HRs work, Southern NGOs are indis-
pensable allies, because they are better placed to exploit the oppor-
tunities and avoid the dangers of HRs advocacy in their own coun-
tries).
37. An additional point for NGOs to ponder is that, in an era of
Globalization, it is not sufficient for them to work exclusively at
the community level. The drivers of poverty and inequity are much
more global than local. Northern NGOs are in a better position to act
at the global level and should do so. Agreement on the agendas for
such advocacy work should be sought with Southern partners.
What will refocusing on E/HRs mean to NGOs working in the health sec-
tor? What is the added value of and the new visibility gained from
adopting an E/HRs-based approach?:
38. Working with an Equity/HRs focus will mean finding gaps in HRs in
the current health work they do; it will mean revising their plans;
it will mean increasing their staff's skills to analyze health from a
HRs perspective; it will mean adopting a 'HRs language' in most of
their work; it will mean focusing more on activities they are not fa-
miliar with yet; it will mean selecting a new set of health priori-
ties (or priorities in health) and determining whether they do con-
flict with or complement their existing priorities and whether they
will mean extra work; it will mean re-examining who their strategic
allies are (and which they should take on), as well as look at their
allies' respective roles to find synergies/conflicts/gaps; it will
mean NGOs will also have to increase their resolve to say no to cer-
tain donors; it will mean changing their focus on monitoring and
evaluation. And, last, but not least, it will mean a major reposi-
tioning of the NGO's identity with its various publics and stake-
holders.
39. NGOs' HRs advocacy should, from now on, also be international-
ized. A successful example is NOVIB's Social Watch Initiative that
watches over the implementation of governments' commitments taken up
and signed on in global UN meetings; initiatives like this should now
be expanded to cover monitoring E/HRs violations in health and other
domains.
40. Operationalizing the E/HRs-based approach therefore requires NGOs
to work at the target group level, work on civil society building,
work in monitoring and influencing government policies, as well as
work internationally. What this challenging agenda means is that
without a political commitment to social equity and HRs, PHC strate-
gies will fail. This, because poverty eradication strategies cannot
ignore the health status of rights-holders --and that requires ad-
dressing unequal power relations (i.e. analyzing who wants and needs
changes in health and who wants to maintain the status quo).
41. NGOs are, therefore to remain active in structural poverty/ill-
health/ malnutrition eradication. Demanding for rights is a battle
that has to be fought in the social and legal arenas, at national,
regional and international level. NGOs cannot do this by just imple-
menting government commitments and absolving the state of their re-
sponsibilities. The difficult struggle against the impunity of state-
related perpetrators of violations of HRs has to be undertaken now.
NGOs must combine political action (with a small p) with capacity
building and service delivery to achieve the needed change. Strate-
gies used should not be confined to the use of legal resources that
ignore the political nature of the struggle. (But, at the same time,
beware: NGOs cannot risk creating expectations which, in the end,
they may not be able to fulfill). Governments have simply to be
pushed (using a combination of means) to redefine their responsibili-
ties towards health.
42. In short, NGOs need to shift from working from a welfare perspec-
tive to an economic justice perspective. The E/HRs-based approach is
rather a matter of commitment than of just another way of approaching
the problems of ill-health and poverty. (SIM 2000) To undergo the
shift, NGOs have to take stock of their social investments so far in
social development, as well as in health and nutrition so as to cre-
ate themselves a new niche in HRs work and lobby governments and mul-
tilateral agencies alike.
43. To sum up, adopting the Equity/HRs-based approach to health is
not a matter of choice anymore; NGOs have to decide what?, how? and
when? This, since the E/HRs-based approach will become the overall
'best practice' of the decade...and this is irreversible.
Claudio Schuftan
Ho Chi Minh City, Vietnam
mailto:aviva@netnam.vn
[Note of interest: There are one million NGOs in India; 210,000 in
Brazil; 35,000 NGOs are operating internationally. All NGOs put to-
gether dispense an estimated 12-15 billion USD per year].
References available upon request.
Acknowledgements: The preparation of this paper was financially sup-
ported by NOVIB (Oxfam Netherlands).
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