Food for an Urgent Agenda's Thoughts
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Human Rights Reader 37 (Part one)
Putting Equity and Human Rights in Health on the Agenda: The Role of
NGOs.
Introduction:
1. Equity and Human Rights (HRs) are by no means new concepts to
NGOs.
2. Moreover, Equity and HRs are inseparately linked since equity is
key to the realization of HRs. The question here is what NGOs are do-
ing with/about these two concepts in the realm of their work in
health and nutrition.
3. A paradigm shift is clearly in the making in development and in
health/nutrition work. New models are more politically driven in a
direction that hinders and hampers the resolution of the problems at
hand. Therefore, these days, more and more NGOs are discussing and
trying to operationalize the 'Equity and Human Rights-based Approach'
to apply it to their work.
The background:
4. Underlying the analysis here made are several statements found in
a recent publication; they read as follows:
"Most NGOs today have become very specialized and contribute margin-
ally to the relief of poverty/ill-health/ malnutrition, but signifi-
cantly to undermining the struggle of the people to emancipate them-
selves from oppression. Programs delivered by these NGOs do not
really seek to redress the social circumstances that cause impover-
ishment/preventable ill-health and malnutrition. The development dis-
course is framed not in the language of emancipation or justice, but
using the vocabulary of charity, technical expertise, neutrality and
paternalism. NGO programs have often worked to undermine popular mo-
bilization. NGOs accept or do not comment on the manner in which the
State exercises its power. NGOs work is limited to project work,
armed with manuals and technical tricks rather than seeking justice
and standing up against violations of HRs. Many NGOs were co-opted by
funders to take up such a role (a typical example is health and nu-
trition work done to set up 'safety nets' for the poor). NGOs have
become an integral part of a system that sacrifices respect for jus-
tice and rights, instead taking a missionary position. If NGOs stand
in favor of emancipation, then the focus of their work has invariably
to be in the equity/HRs/political domain, supporting those social
movements that seek to challenge a social system that benefits a few
and impoverishes the many". (Manji and O'Coill, 2002)
5. Most NGOs tend to work on the issues that are before them, and
forget those that are hidden away; such hidden truths have to be
brought to the forefront. For example, issues of voice, power, risk
and neglect are essential in a HRs discourse -- as difficult to sur-
face as they may be.
6. The fallacy that actually needs to be uprooted is that health pro-
grams addressing the urgent needs of women and children implicitly
address human rights. In the HRs approach, nothing is left implicit;
without an explicit retooling to a HRs focus, such claims remain but
hot air; they are hollow commitments to HRs that allow controlling
hierarchies to persist.
7. NGOs have ample accumulated knowledge of what is going on....and
have just begun to realize that, if they do not act on that knowl-
edge, they are not really serving the people of the communities that
they work with to the fullest.
8. There is a need, then, for a more determined commitment to pro-
poor social policies and programs (including health)and an increase
in the funding for such an approach. Activities are to concentrate on
institutional capacity building to better promote education and con-
sciousness-raising at the community level. A key question is to give
advocacy tasks more prominence so as to hold governments more ac-
countable.
The concept of Human Rights in health and why it is used:
9. In contrast to a 'deficit-filling approach' to poverty and pre-
ventable ill-health alleviation, the Equity/Human Rights-based ap-
proach (E/HRs-based approach) defines poverty as social exclusion.
Instead of focusing on creating an inventory of public goods or ser-
vices that must be provided and then seeking to fill the deficit via
foreign aid, the rights-based approach focuses on trying to identify
the critical exclusionary mechanisms. This, because work in health
and development is about assisting poor communities overcome obsta-
cles, rather than about the endless pursuit of grant aid for social
goods. The E/HRs-based approach enables NGOs to see much more clearly
the kinds of power relations and systemic forces that drive and per-
petuate poverty. But the transition to mainstreaming a rights-based
approach into the organizational structure of NGOs is a complex en-
terprise; it cannot simply be decreed and implemented.
10. The E/HRs-based approach asserts that work in health should be
seen as a process that unequivocally leads to people fully realizing
all their human rights (and not only their right to health); the ap-
proach should thus be reflected both in the processes engaged and the
outcomes pursued by NGOs.
11. More importantly, the E/HRs-based approach sees ill-health, mal-
nutrition and poverty as a denial of human dignity, i.e. as an impor-
tant part of the denial of people's economic, social, cultural, civil
and political rights. And these rights are more than just moral prin-
ciples and norms governing human behavior... they are international
legal standards. Poverty itself is seen as an abuse of HRs... The
poor and marginalized are not where they are by accident...
12. Because health is not the exclusive business of governments, this
broad approach definitely brings an added value to communities and to
NGOs when sitting down among themselves and with government represen-
tatives to jointly evaluate and plan local or national health strate-
gies. It brings something different and potentially powerful to ex-
isting efforts by all actors in their efforts to overcome ill-health,
malnutrition and poverty in a more sustainable manner.
13. The principles of equity in health (and prominently those related
to gender equality) are not currently codified in any way to allow
monitoring their implementation; more often than not, they are lost
when implementing health sector reform or macro-economic corrective
measures. Human rights, on the other hand, are enshrined in legal
covenants that protect human dignity and place obligations (or du-
ties) on providers and others, mainly but not exclusively the State.
While NGOs do have the responsibility to respect the rights of oth-
ers, it is now widely accepted that states have very specific obliga-
tions to respect, protect and fulfill human rights in the realm of
health and nutrition.
14. It is thus timely for NGOs to use the equity and human rights-
based approach -- to apply the internationally agreed human rights
standards to health policy and practice -- emphasizing active grass-
roots participation and the right of people to choose their own path.
15. When doing so, priority is to be given to the poor, the marginal-
ized and the vulnerable -- those currently most denied their rights
due to their lack of choice, of control and of resources.
16. The conceptual basis that justifies (and prescribes) the use of
an Equity and Human Rights-based Approach in the health and nutrition
work of NGOs is the following:
* HRs are entitlements all people have, to develop their full poten-
tial; they are valid for everyone -- they are universal (A right is a
right only when it is universal; otherwise it is a privilege).
* There is a difference between just delivering services and making
clear to beneficiaries that they are legally entitled to specific
services and can go somewhere to complain if they do not receive what
is due them.
* HRs objectives are not to stabilize the problems at hand, but to
make them disappear by tackling them at their roots.
* HRs are pre-conditions that must be met for people to have the op-
portunity to live with full dignity, full health and self-worth.
* HRs lack cultural legitimacy in many parts of the world; communi-
ties are traditionally more concerned with needs than with rights;
that is why NGOs have to start from people's own initial understand-
ing of their rights (and the issues of power) to then support a bot-
tom-up dialogue that deepens the ownership of HRs by the beneficiar-
ies they work with. (Without concerned citizen action to uphold HRs
close to home, we shall look in vain for progress).
* Rights are different from needs; rights are relational: where some-
one has a right, someone else has a duty or responsibility to honor
and satisfy that right. There are two critical distinctions between
health rights and heath needs: first, health rights always trigger
duties and responsibilities, whereas needs do not; second, health
rights imply standards that can be measured whereas needs do not.
Therefore, NGOs need to start thinking in terms of rights rather than
needs, of rights-holders (or claim-holders) rather than beneficiaries
and of enabling rather than giving.
* In the E/HRs-based approach to health beneficiaries hold claims
against those who are responsible (through their actions and omis-
sions) for their health and nutritional wellbeing. People can only
realize their rights in health if they are first exposed to the root
causes of the marginalization they suffer from, and if they are em-
powered to claim and fulfill the rights essential to their health/
nutrition and livelihood security. Rights, then, have an enormous po-
tential to attract and mobilize people. First and foremost, this
means NGO interventions have to transfer ownership to the people
served; key actions for this to happen are HRs education and capacity
building for community members to claim and defend their rights. Em-
powerment here is to be understood as generating several forms of
power: self-respect (power within), community cohesion (power with),
and a clear agenda for action (power to).
* The E/HRs-based approach addresses abuses and/or neglect of HRs in
health mostly found in the form of discrimination or exclusion. It
brings to the light underlying power relationships between rights-
holders and authority structures; it emphasizes dignity, equality,
and participation of the former and accountability of the latter. *
Moreover, let it be very clear that advancing gender equity issues is
part and parcel of work on girls' and women's rights in relation to
health.
* Such an approach means NGOs must stand in solidarity with the poor
(women, children and men) whose rights are being denied --holding
themselves accountable to them (and in addition ensuring they do not
violate people's rights themselves). NGOs must support people's ef-
forts to take control of their own health and lives. This also in-
cludes NGOs holding others accountable for fulfilling their responsi-
bilities, as well as opposing discrimination of any sort, addressing
the root causes of poverty/ill-health and malnutrition and the corre-
sponding rights denials in their work with rights-holders. Finally,
they must work in concert with others embarked in the same endeavor
(forming a supportive coalition of NGOs on these issues).
* In short, the E/HRs-based approach calls for a purposeful and
transparent de-facto engagement of NGOs in the more structural as-
pects of the determinants of ill-health while remaining steadfast al-
lies of local communities throughout.
* NGOs will not be alone in this E/HRs-based approach since the para-
digmatic (and mindset) shift towards it is growing globally with the
force of international law behind it.
* Therefore, NGOs definitely need to take steps now to improve the
HRs impact of their current actions in health. This means identifying
previously unforeseen gaps and opportunities. But although focusing
on health, NGOs have to take into account the whole range of HRs
since HRs are indivisible.
* Weighing-in on rights can risk harsh reactions from the authori-
ties. Standing up for communities whose rights are not respected,
protected or fulfilled is inevitably being political in the sense of
challenging those actors responsible for abuses. So NGOs have no
choice but to take a stand against authorities, policies or practices
when the communities they serve are abused, neglected or excluded.
The name of the game is: Remain non-partisan, but at the same time
take issue.
* Even if the E/HRs-based approach is inherently about confrontation
-- confronting the injustices of real world situations -- two ap-
proaches are possible: a) denouncing violations (which is often con-
frontational), and b) engaging actors in the pursuit of rights, help-
ing them to more fully live up to their responsibilities (which is
more related to promotional work).
* Monitoring HRs conditions is also very important for NGOs, and
there is a need to share and disseminate information about such vio-
lations (making documented grievances public); this information will
ultimately strengthen advocacy. HRs-sensitive (and gender and socio-
economically disaggregated) data and indicators are critical to keep-
ing aware of gender, equity, HRs and other issues.
* Despite growing clarity about all the issues above, there is no one
blueprint for an equity and human rights-based approach to program-
ming in health; each NGO will have to go through its own retreat(s)
to revision and remission their mandates to adjust their very own ap-
proach and programs to it. (Adapted from CARE, 2002)
--
Claudio Schuftan
Ho Chi Minh City, Vietnam
mailto:aviva@netnam.vn
(Part 2 to follow)
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