To put the People’s Health Movement campaign in perspective, we wanted to share with Pambazuka readers the principle in which it is based. The progressive weakening of public health systems, the growing privatisation of healthcare and the erosion of universal access to healthcare are worldwide phenomena. The health sector globally is still dominated by vertical and technocentric approaches, often supported by ‘public-private partnerships’ active at several levels.

There is therefore an urgent need to replace this dominant discourse with a process aimed at universally achieving the ‘right to health and to healthcare’ as the main objective. In this way, we can hope to achieve more equitable healthcare systems in both developing and developed countries. To counter and reverse the tide promoting ‘healthcare as a commodity’, there is a need to establish a global consensus on ‘healthcare as a right’. Human rights violations are not accidents, they are not random in distribution or effect and are acutely linked to social conditions. It is the socio-political forces at work that determine the risk of most forms of human rights violations. Our understanding of human rights violations is thus based on broader analyses of power and social inequality and their social, economic and political determinants. The promotion of equity is the central ingredient for respecting human rights in health. It is mostly the poor who are the victims and they have too little voice and no influence, let alone rights. It is inequities of power that prevent the poor from accessing the opportunities they need to move out of poverty. Structures and not just individuals must be changed if this state of affairs is to change.

Since laws designed to protect human rights and the right to health are mostly not applied, what additional measures have to be taken? This is what the People’s Health Movement’s ‘Right to Health and Health Care Campaign’ (RTHHC) sets out to explore. It is not enough to improve the situation of the poor within existing social relationships. Rights are claimed through social action and the latter depends on how power is distributed and used to address health issues. Human rights legislation alone – without enforcement mechanisms – is not up to the task of relieving suffering already at hand. Rights are not equal to laws, they are realised through social action and by changing prevailing power relations. Rights cannot be advanced but through the organised efforts of the state and of civil society. To work on behalf of the victims of violations of the right to health invariably means becoming deeply involved in pressing for social and economic rights.

Public health must be linked to a return to social justice. Denial of care to those who do not pay is simply legitimised in the free-market system. The commoditisation of healthcare changes people from citizens with rights to consumers with (or without) purchasing power. This leaves those who are economically marginalised also marginalised from accessing comprehensive healthcare. The global campaign proposed by the PHM is a step in the direction outlined above, seeking the social transformations indispensable to resolving the current inequities found in health.

THE RIGHT TO HEALTH: A HOLISTIC OVERVIEW

The right to health has been defined as the ‘right to the enjoyment of a variety of facilities, goods, services and conditions necessary for the realization of the highest attainable standard of health’. This right includes both the right to all the underlying determinants of health (such as water, food security, housing, sanitation, education, and safe and healthy working and living environments), and the right to healthcare itself and the entire range of preventive, curative and rehabilitative services including education and activities around promoting good health.

In practice, this suggests two types of tasks for the global health movement: tackling the right to all the underlying determinants of health, and strengthening the right to healthcare. Tackling the right to the underlying determinants of health includes supporting and even co-initiating campaigns or initiatives addressing key health determinants (for example, campaigns for water, for food security, and for housing). There are initiatives already underway on behalf of these rights, initiatives which are not necessarily spearheaded by health activists. We contend that the focal point for each of these initiatives should be the organisations with the most experience and commitment to a particular issue, be it water, food security, housing, or the environment.

This recognition places an obligation on health activists to actively support and strengthen such initiatives, though not necessarily to take up the responsibility of primary leadership of such groups. When liaising with these groups, PHM will bring the health perspective to their campaigns. An additional important role that has to be played by health activists is to help document violations of the right to the underlying determinants of health, for example, by showing how the denial of food security leads to worsening malnutrition, increased morbidity and mortality. Health-based arguments can significantly strengthen the demands of claim-holders to tackle these determinants from a right-to-health perspective.

STRENGTHENING THE RIGHT TO HEALTHCARE

The global health movement has a primary and unquestionable responsibility to take the lead on the right to healthcare. We are all witnesses to the often catastrophic consequences of the lack of economic access to adequate healthcare and the poverty trap that leads to avoidable mortality.

What then does the right to health imply and what is the added value of the human rights-based approach? In every development process, there are three types of actors: Claim-holders, duty bearers, and agents of accountability. When the state does not respect human rights, claim-holders have to demand their rights directly from the duty bearers in government, all the while interacting with agents of accountability in the form of human rights commissions, ombudsmen, and human-rights-oriented NGOs who oversee the procedures being put in place by government and make sure duty bearers fulfil their obligations, including remedies and restitutions.

If claim-holders do not do this, they are partly responsible for their situation. One can thus say that it is also the duty of those of us who are aware of human rights to generate awareness about the bases of these rights, in partnership with the marginalised and underserved groups we work with. When the right to health is violated and when the poor, the marginalised and the discriminated, as claim-holders, do not have the capacity to effectively demand their rights, these rights themselves are also violated because duty bearers do not have the capacity or the will to fulfil their obligations (technically called ‘correlative duties’). Therefore, in a human rights-based approach one has to carry out three types of analyses: 1) Situation analyses in which one determines the causes of the problems by placing them in a hierarchical causality-chain of immediate, underlying and basic causes or determinants; 2) Capacity analyses in which one determines who are the individuals and institutions that bear the duty to do something about the causes identified by calling on them to fulfil their duties (as per their country’s obligations as signatories of the UN human rights convention); and 3) Analysis of and liaison with accountability agents.

Herein lies the call for human rights activists to carry out rights awareness work, for instance to educate and inform broader society about what these rights mean and what accountability mechanisms should be put in place and made to work. These three types of analyses have to be carried out in conjunction with representatives from local communities and the beneficiaries of the health system so that the rights being violated can be jointly identified and those responsible also be jointly confronted in order that problems be effectively tackled. Note that the rights activist’s ultimate goal is not to look for health policies that favour the poor as such; what is sought is significant poverty reduction policies that directly address the social determinants of health. As rights activists, we are no longer going to go and beg for changes to be implemented; we are now going to demand them based on existing international law already in force in most of the countries where we work.

Disseminating this concept is in itself empowering. We should note that people in countries that have not ratified these conventions have the same rights; their problem is simply that their governments have not made a commitment to honour them. PHM seeks to overcome the culture of silence and apathy about the human rights violations in health that we all know are happening, because human rights and the right to health will never be given to poor, marginalised, discriminated and indigenous persons. Rights are never given, they have to be fought for!

Fighting for these rights is precisely what PHM’s global RTHHC campaign is attempting to do. As regards the added value of adopting a human-rights-based framework, several advantages come to mind: 1) A RTHHC campaign possesses big potential for social mobilisation, and this is an indispensable part of any campaign; 2) The human rights approach is backed by international law; 3) The right-to-health approach demands – from a position of strength – that decision-makers take responsibility; 4) Human rights imply correlative duties that are universal and indivisible; and 5) The human rights approach is focused on processes that lead to specific outcomes, and not simply setting goals like those underpinning the Millennium Development Goals (MDGs).

WHAT MAY BE REALISTICALLY ACHIEVED?

PHM has no illusion that systematically raising the issue of the ‘right to health’ will, by itself, lead to the complete implementation of this right in countries across the globe. The universal provision of even basic healthcare services involves major budgetary, operational and systematic changes. In addition to shifting to a rights-based framework, major political and legal reorientations are needed, and such major changes cannot be expected to happen in full in the near future, given the political economy of healthcare in most countries of the world today. PHM expects, however, to be able work on a number of more achievable objectives, objectives which can take us towards a broader human rights goal. Some of these achievable objectives to be considered are: 1) The explicit recognition of the right to healthcare at country level; 2) The formation, in some countries, of health rights monitoring bodies (accountability agents) with PHM and civil society participation; 3) A clearer delineation of health rights at both global and country levels; 4) The shifting of the focus of the World Health Organization (WHO) towards health rights and universal access systems and the strengthening of groups within the WHO that will work along these lines; 5) Putting the right to healthcare firmly on the global agenda by making it a central reference point in global health discourse; and (6) Strengthening human rights activists’ networks in as many countries as possible so that all their members work around a common and broad rallying point while continuing to build partnerships.

* The People’s Health Movement (PHM) is firmly committed to expanding the Right to Health and Health Care Campaign (RTHHC) in Africa. Any country not mentioned within this article is welcome to inquire with us how they can get a PHM circle going. Please contact us at [email][email protected].
* Please send comments to [email protected] or comment online at http://www.pambazuka.org/