PMNCH Knowledge Summary #34 Operationalizing human rights in efforts to improve health

Overview

Introduction

Preventable maternal, child and adolescent mortality and morbidity remain high in many countries, and reflect deep inequities within and across population groups.^1,2 Systematic integration of international human rights standards and principles in laws, policies and programmes contributes to women’s, children’s and adolescents’ health and wellbeing. ³ Practical guidance is now available to assist countries in doing this.^{4,5,6,7,8,9,10} This knowledge summary introduces the importance and added value of human rights standards and principles, and provides practical examples of human rights integration for women’s, children’s and adolescents’ health along the life course, and across the policy cycle and in service delivery. For more in-depth information, readers are encouraged to consider carefully available guidance documents, and apply them in their own context and settings (see Box 1).

The challenge

Despite a widespread, multi-sectoral commitment to improve women’s, children’s and adolescents’ health, persistent challenges remain:

• Many deaths are the result of inequities and other social conditions including poverty, harmful gender, ethnic and age stereotypes, violence, lack of access to quality education, malnutrition and disadvantaged geographical location;^11,12,13
• Efforts to ensure and improve both access to, and quality of, care are hindered by the failure to eradicate discrimination and social exclusion in policy development and service provision;
• Too few women, children and adolescents are able to participate meaningfully - or even to have their interests represented - in the development, implementation and evaluation of laws, policies, programmes and services that affect their health and wellbeing;
• Significant gaps exist in accountability mechanisms for monitoring, review and remedy or action, including vital registration and health information systems.

Integrating human rights

Realising the human rights that underpin women, children and adolescents' health and wellbeing lies at the core of the updated Global Strategy on Women's, Children's and Adolescents' health.^14,15 In the transition from the Millennium Development Goals (MDGs) to the Sustainable Development Goals (SDGs), this is an important acknowledgement and emphasises that human rights principles and standards can serve as practical tools to guide governments in addressing these challenges, and to strengthen legal/policy environments and health systems, deliver health care for all and improve accountability for the health of women, children, and adolescents (see Box 1).^16,17

Human rights instruments, notably the Convention on the Rights of the Child, the Convention on the Eliminations of All Forms of Discrimination Against Women, and the Covenant on Economic, Social and Cultural Rights, provide a legal and normative framework for the respect, protection and fulfilment of the right to health and other related rights of women, children and adolescents. These instruments also ensure the integration of key human rights principles in all aspects of planning and programming: participation and inclusion; accountability and the rule of law; non-discrimination and equality. The guidance documents in Box 1 provide further details on how to do so.

Applying human rights principles and standards to improving the health of women, children and adolescents is an important step in formally recognising their health and development needs as essential and enforceable legal entitlements, which places corresponding obligations on governments and responsibilities on other stakeholders. Two reports from the UN Human Rights Council provide a detailed analysis on the relevance of human rights in the context of preventable maternal mortality and under-five mortality.^18,19

What works

Systematic integration of human rights in actions to improve health is needed across the policy cycle and in service delivery. Below are examples of the importance and added value of integrating human rights in various elements of the policy cycle (further examples can be found in Figure 1).

Analysis

1. Assess legal and policy frameworks and take action to remove barriers to health

A comprehensive situational analysis should assess national and sub-national legal and policy frameworks for compliance with human rights principles and standards, and identify barriers to the right to health and other related rights for women, children and adolescents. Participatory mechanisms such as public hearings, are a key part of these analyses to ensure the engagement not only of government actors, but of other stakeholders—including women, children and adolescents themselves. Laws, policies and guidelines should then be reformed or adopted to remove identified barriers. Following an assessment on the health rights of women on maternity leave in Kenya, a multi-stakeholder lobbying process lead to legislative change and improved maternity leave provisions for all women.²⁰

2. Expand legal awareness and literacy

Essential elements of good governance include legal awareness and literacy on rights and entitlements granted in health-related laws, regulations and policies. This includes providing women, children and adolescents with access to public information on their rights to health and health services, and to remedy and redress when needed. Similarly, improved knowledge of human rights helps policymakers, service providers and practitioners to understand and act upon their obligations and also eliminate discrimination. In Mexico, the public insurance scheme, Seguro Popular, has helped raise awareness of health care as a legal entitlement. More than 50 million people are covered by the scheme which has contributed to increased access to services and coverage of essential health interventions for women and children; the promotion of sexual and reproductive rights of adolescents and women; and overall decline in maternal and child mortality rates.^21,22

Planning

1. Develop processes and mechanisms for participation

Women, children and adolescents must have access to information and resources to enable their active participation in health planning, budgeting processes and service design. For example, participation through innovative technology and public dialogues, helps ensure national plans budgets, and service delivery address essential health needs of all population groups. Multisectoral participation in a UNICEF child-rights-centred budget analysis in Ecuador improved social and economic decision-making to benefit marginalized populations and led to an increase in social spending by 15.5%.²³

2. Promote access to information through the dissemination of user-friendly health plans and budgets

To promote the right to information, health plans, strategies and budgets must be disseminated in a format which takes account of factors such as literacy, educations levels and language, and ensures access for marginalized or geographically remote populations. This requires establishing and using appropriate and context-specific communication strategies and channels, with the support of civil society, to convey information and messages for women, children and adolescents. Methods include visual and written communication, the internet, radio and television and social media. Experiences in health promotion offer helpful insights for the dissemination of health plans and strategies. In Cambodia, demand for essential maternal and child health interventions increased in rural areas due to a coordinated, innovative and relevant national media campaign, including television and radio advertisements, soap operas and songs.^24,25

Implementation

1. Provide inclusive, high quality health care that respects and protects human rights

Health care provision must be inclusive and peoplecentered, and respectful of the dignity and rights of women, children and adolescents. This requires active participation of all women, children and adolescents in decision-making processes, including in treatment options. In addition, userfriendly access to age and gender appropriate information concerning health status and related interventions is required, as well as privacy and confidentiality. Informed consent is essential, and where needed, in accordance with the evolving capacity of the child. Moreover, proper and suitable sanitation facilities, as well designated child-friendly spaces for rest and recreation, and unrestricted visiting hours must be in place. To reduce discrimination and stigmatization in the health care setting, health care professionals must be equipped with the skills and tools necessary to meet their obligations.

Quality of care must be periodically monitored and evaluated to ensure that it is people-centered, and respectful of the dignity and rights of patients. Direct engagement of children, their caregivers, and hospital management and staff in a WHO rights-based assessment in Tajikistan and Kyrgyzstan was key to improving the design and provision of services for the quality of care of children in hospitals.²⁶

2. Establish and make available complaint mechanisms in facilities

Access to effective remedies via complaint mechanisms or other avenues for redress makes it possible for people to claim – not beg for – their rights to quality health goods and services. Accountability is about empowering responsible stakeholders including women, children and adolescents, to identify obstacles to and solutions for improving health services. These include improving providers’ listening skills, the use of complaints boxes, community consultations with health staff, and building on established women’s forums to monitor access to services. In India, several mechanisms allow women to record grievances, such as by registering complaints directly with the managers of health facilities or through Patient Welfare Committees.²⁷

Monitoring, evaluation and accountability

1. Improving processes and mechanisms for independent review to assess equal distribution of health gains and investments

Accountability mechanisms, including human rights institutions, children’s ombudspersons, and regional or international human rights bodies, are fundamental in assessing distributions of health gains and investments. Such mechanisms can be used to identify accountability gaps in situational analyses, advocate for appropriate monitoring mechanisms and remedies in national plans and service delivery, undertake independent quality of care reviews, and provide feedback from review processes. South Africa has institutionalized programmes to audit maternal and child mortality, and avoidable associated factors. These audits demonstrate the potential for accountability mechanisms to systematically identify and recommend action to address factors influencing maternal and child mortality within the health system and beyond.^28,29,30,31

2. Establish national and sub-national processes and mechanisms for remedy and redress

When rights violations occur, effective enforceable remedies and mechanisms for redress should be available at the national and sub-national level. This can be achieved through courts, national human rights institutions, ombudspersons and/or sub-national social accountability and complaints mechanisms. Following a complaint alleging the systematic violation of women’s reproductive health rights in health facilities, in 2011 Kenya’s National Human Rights Institution initiated a public inquiry into causes of high maternal mortality.³² The recommendations provided a mechanism to hold the Government accountable to their international and regional human rights commitments. For adolescents in particular, it was recommended that youth-friendly, non-discriminatory sexual and reproductive health services be made widely available.

Conclusion

The added practical value of applying human rights in policies, programmes and services for women’s, children’s and adolescents’ health is not always immediately clear to stakeholders within and beyond the health sector. Quality technical guidance and human rights documents can help to clarify and inform the integration of human rights in planning and programming. Efforts to integrate human rights must be accompanied by appropriately designed research on and evaluation of their impact on women’s, children’s and adolescents’ health.

References

^1. WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. Trends in maternal mortality: 1990 to 2013. Geneva: WHO; 2014 (http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2013/en/, accessed May 2015).
^2. UN Inter-agency Group for Child Mortality Estimation. Levels and Trends in Child Mortality, Report 2014. New York: UNICEF; 2014 (http://www.data.unicef.org/fckimages/uploads/1410869227_Child_Mortality_Report_2014.pdf, accessed May 2015).
^3. Bustreo F, Hunt P, Gruskin S, Eide A, McGoey L, Rao S, et al. Women’s and Children’s Health: Evidence of Impact of Human Rights. Geneva: WHO; 2013 ( http://apps.who.int/iris/bitstream/10665/84203/1/9789241505420_eng.pdf, accessed May 2015).
^4. Report of the United Nations High Commissioner for Human Rights, Technical Guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce and eliminate preventable mortality and morbidity of children under 5 years of age. Human Rights Council 27th Session; 2014.
^5. Report of the United Nations High Commissioner for Human Rights, Technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce preventable maternal morbidity and mortality. Human Rights Council 20th Session; 2012
^6. OHCHR et al. Health Policy Makers. Summary Reflection Guide on a Human-Rights Based Approach to Health. 2015.
^7. Ensuring human rights in the provision of contraceptive information and services: Guidance and recommendations. Geneva: WHO; 2014 (http://www.who.int/reproductivehealth/publications/family_planning/human-rights-contraception/en/, accessed May 2015).
^8. General Comment no.15 : the child’s right to the highest attainable standard of health. Geneva : United Nations Committee on the Rights of the Child; 2013 (http://www.refworld.org/docid/51ef9e134.html, accessed May 2015).
^9. Core competencies in adolescent health and development for primary care providers including a tool to assess the adolescent health and development component in pre-service education of health-care providers. Geneva: WHO; 2015. (http://apps.who.int/iris/bitstream/10665/148354/1/9789241508315_eng.pdf, accessed August 2015).
^10. UNFPA and Harvard School of Public Health. A Human Rights-Based Approach to Programming : Practical Implementation Manual and Training Materials. UNFPA; 2010.
^11. Practices in adopting a human rights-based approach to eliminate preventable maternal mortality and human rights (A/HRC/18/27).. Geneva: Office of the United Nations High Commissioner for Human Rights; 2011(http://www2.ohchr.org/english/bodies/hrcouncil/docs/18session/A-HRC-18-27_en.pdf, accessed May 2015).
^12. WHO Fact Sheet No. 349: Maternal Mortality. Geneva: WHO; 2014 (http://www.who.int/mediacentre/factsheets/fs348/en/, accessed May 2015).
^13. WHO Fact Sheet No. 178, Children: reducing mortality. Geneva: WHO; 2014 (http://www.who.int/mediacentre/factsheets/fs178/en/, accessed May 2015).
^14. Every Woman, Every Child. Shaping the Future for Healthy Women, Children & Adolescents: Learn More About the Process to Update the Global Strategy. Zero Draft GS 2.0. (http://www.everywomaneverychild.org/global-strategy-2)
^15. Every Woman, Every Child. Working Papers. Realising Rights for Women, Children and Adolescents’ Health. 2015. (http://www.everywomaneverychild.org/global-strategy-2/working-papers)
^16. Yamin AE. From Ideals to Tools: Applying Human Rights to Maternal Health. PLoS Med. 2013;10(11): e1001546.
^17. Commission on Information and Accountability for Women’s and Children’s Health. Keeping Promises, Measuring Results. Geneva : WHO; 2011 (http://www.who.int/topics/millennium_development_goals/accountability_commission/ Commission_Report_advance_copy.pdf, accessed May 2015).
^18. Study by the World Health Organization on mortality among children under five years of age as a human rights concern. A/HRC/24/60. United Nations; 2013.
^19. Report of the Office of the United Nations High Commissioner for Human Rights on preventable maternal mortality and morbidity and human rights. A/HRC/14/39. United Nations; 2010.
^20. Changing the labour law for maternity leave in Kenya with HeRWAI. (http://www.rights4change.org/index.php?id=63; accessed May 2015).
^21. Frenk J, Gómez-Dantés O, Langer A. A comprehensive approach to women’s health: lessons from the Mexican health reform. BMC Women's Health. 2012; 12:42.
^22. Knaul F, Gonzalez-Pier E, Gomez-Dantes O, Garcia-Junco D, Arreola-Ornelas HBarraza-Llorens M, et al. The quest for universal health coverage: achieving social protection for all in Mexico. Lancet.2012;380.
^23. Gore R, Minujin A. Background Note: Budget Initiatives for Children. UNICEF: New York; 2003.
^24. “CAMBODIA: Communication for Behavioural Impact to promote early antenatal care” in Innovative Approaches to Maternal and Newborn Health Compendium of Case Studies. UNICEF: New York; 2013.
^25. Success Factors for Women’s and Children’s Health: Policy and Programme Highlights from 10 fast-track countries. Geneva: WHO; 2014 (http://www.who.int/pmnch/knowledge/publications/success_factors_highlights.pdf?ua=1, accessed May 2015).
^26. Assessing the respect of children’s rights in hospitals in Kyrgyzstan and Tajikistan. WHO project: Improving the quality of paediatric care in the first level referral hospitals in selected countries of central Asia. WHO; 2014.
^27. Bowser D, Hill K. Exploring Evidence for Disrespect and Abuse in Facility-Based Childbirth: Report of a Landscape Analysis. Washington DC: USAID; 2010.
^28. South Africa Every Death Counts Writing Group, Bradshaw D, Chopra M, Kerber K, Lawn JE, Bamford L, et al. Every death counts: use of mortality audit data for decision making to save the lives of mothers, babies, and children in South Africa. Lancet. 2008; 371(9620):1294-304.
^29. Belizan M, Bergh AM, Cilliers C, Pattinson RC, Voce, Synergy Group. Stages of change: A qualitative study on the implementation of a perinatal audit programme in South Africa. BMC health services research. 2011; 11: 243.
^30. Child PIP: Saving lives through death auditing. Available at: http://www.childpip.org.za/
^31. PMNCH Knowledge Summary #27 Death reviews: maternal, perinatal and child. Geneva: WHO, 2013 (http://www.who.int/pmnch/knowledge/publications/summaries/ks27/en/, November 2014).
^32. Kenya National Human Rights Commission. Realising Sexual and Reproductive Health Rights in Kenya: A myth or reality? A Report of the Public Inquiry into Violations ofSexual and Reproductive Health Rights in Kenya. April 2012.

Acknowledgements

Anhsu Banerjee, Chantal Baumgarten, Laura Ferguson, Jennifer Franz-Vasdeki, Sarah Galbraith-Emami, Elizabeth Gibbons, Kate Gilmore, Robin Gorna, Sofia Gruskin, Imma Guerras-Delgado, Ana Isabel Guerreiro, Vaibhav Gupta, Rachael Hinton, Paul Hunt, Frank Oberklaid, Lucinda O’Hanlon, Rajat Khosla, Shyama Kuruvilla, Thiago Luchesi, Tarek Meguid, Raul Mercer, Marcus Stahlhofer, Rebekah Thomas-Bosco, Mary-Nell Wagner, Alicia Ely Yamin, Farouk Shamas Jiwa. Design by Roberta Annovi.