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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,
Health and
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
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
as a tool for health policymakers to design, implement and monitor a poverty reduction strategy
Strategies
through a human rights-based approach. It contains practical guidance and suggestions as well as
good practice examples from around the world.
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.
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.
The mention of specific companies or of certain manufacturers’ products does not imply that they are
endorsed or recommended by the World Health Organization in preference to others of a similar nature that
are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by
initial capital letters.
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...”
GenevA, 2008
Foreword by navanethem Pillay
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.
heidemarie 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 Targets............................................................................................................................... 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
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
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
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
21 World Health Organization/Office of include the right to a system of health and specific needs of population groups,
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 internatiOnal 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.
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
25 Development assistance Committee, reforming institutions and building capacity development planning and implementation.
action-oriented policy paper on human rights as well as long-term goals.23 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
26 the human rights-based approach While the value of human rights as a 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
may 2003. new York, united nations
development operations. 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 roll-out of the Paris Declaration on
tHe Human rigHts-BaseD aPPrOaCH tO DeVelOPment Aid Effectiveness.25 The DAC guidelines
COOPeratiOn: towards 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
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
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
gaggen c. (WHo-200778)
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
reasons for the increased decision-making by stakeholders.31 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
crime. The analysis revealed on the Right to Development.32 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.
31 Adapted from: McGee R, Norton The achievement of participation as a The primary experience in using
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
(IDS Working Paper 109) www.ids.ac.uk
content of the PRS. that include group discussions in villages
and the use of peer group interviews,
32 Declaration on the Right to ranking and mapping techniques to explore
Development. General Assembly resolution iv Identifying the appropriate
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
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 ChILDReN’S PARTICIPATION
36 O’Malley K. Children and young people
groups. This may involve assessment of IN The PRS
groups’ capacity, representativeness and Civil society participation in PRSs can be highly
participating in PRSP processes. London,
their internal accountability mechanisms. contested. As relative newcomers, children, and
Save the Children, 2004
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
Build the institutions and mechanisms
v to ensure meaningful participation
leading to small, but significant, policy changes. In
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.
of representatives of the
traveller community was
constraints and capacity gaps that
established to look specifically prevent individuals, groups and
at the particular needs of organizations from claiming or fulfilling
travellers and to design the right to health.
a strategy to meet these
needs. The national strategy
was launched in 2002 to
carrying out an effective participatory The analysis will inevitably uncover a
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
participation in priority
available for participation. It is perspective enables the development of
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
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-
cent of children suffer from chronic l legislation and policies
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
on human Rights. Mission to Mozambique. decision-making bodies?
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?
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:
deficiencies exposed.47 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;
of services;
l whether the State promotes medical
research, ensures appropriate training
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
49 Alsop R, Bertelsen M, holland J. practice in this context will reveal: to financial resource constraints.
empowerment in practice: from analysis
Bottlenecks may occur at different levels,
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:
50 A/CONF.198/11.
www.un.org
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
reform and sexual and reproductive health.
are excluded and address the key issues
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
54 Björkman M, Svensson J.“Power to
l reproductive and sexual health services be committed to meeting the standards
the people: evidence from a randomized
for all within a given distance; identified. Ensuring that standards are
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
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
the poor” In: MfDR principles in action:
leadership will need to support the ministry l 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
and capacity gaps
very poor backgrounds, are
up to 100 times more likely to
are kept. In Tomsk, the prisoners, ensuring they are i Strengthening participation and
Russian government has been able to finish their course of
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
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
there must be guidelines on
building the skills, attitudes and practices 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
establishment must display
ministry of health include budget formulation 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.
Complaints can also be made
for ministry of health personnel should be 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
foundation works directly
donor organizations have clear commitments 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.
Based on horizontal dialogue
protect and fulfil the right to health l 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
loan repayment schedules.68 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
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
level. This package of essential services other things, the Act requires
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,
WHO/WPRO/Image Bank/Seppo Suomela
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.
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.
Frameworks can facilitate the process of particular district-level hospitals or clinics; 78 Alsop R et al., op. cit.
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
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
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: health budget allocations and changes in
the city's services and an
CoMMUNITy sCoRE CARDs expenditure over time against international,
overall reduction in problems
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
93 http://paf.mahiti.info
budget process by allowing access to the
socio-economic statistics. Quantitative data suitable formats public action. Brighton, Institute of
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.
experiences with PRsP and HIPC monitoring.
It is also useful for civil society initiatives, The kind of information required for
The Hague, Cordaid, october 2005
which aim to hold Governments to account health and poverty analysis will range www.cordaid.nl
for their commitments. from broad nationwide statistics down to
97 www.sasanet.org
focused quality detail from the household
98 www.idasa.org.za
Official statistics are compiled by national or community level. Statistical information
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
that may need to be generated. The choice through civil society participation in
compiling official statistics are expected
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/
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
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 United Nations Development Programme,
other concerns that may emerge. Targets
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
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
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,
the State to make Nevirapine
l engaging research institutes and 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,
all relevant public policy documents; where medically indicated.
provide a springboard for broader social
The Court also ordered the
l stimulating the existence and 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-
l allowing the media to cover issues of to-child transmission, including
are justiciable and judges can make policy-
Nevirapine or other appropriate
Government performance and encouraging 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
conduct research on the executive's budget Constitutional Court in 2002.
vindicated the entitlements of people who
As a result of the judgement,
and activities.106 are excluded. the South African Government
jUDICIAL In many countries, including those that adopted a comprehensive
have just emerged from conflict, local-level mother-to-child transmission
Full accountability requires the availability
disputes are settled through traditional or programme.109
of redress for human rights violations.
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 UN general Assembly Res.48/134, 1993.
pampa zone of Argentina. The challenge based on the right to do it. The court further
www.un.org/
best way to combat this disease to health, and eventually won. established a schedule according
111 viceconte, Mariela c. Estado Nacional
is through a highly effective The court, citing Argentina’s to which the state had to proceed
(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 HIv/AIDs and human rights in a nutshell,
vaccine had become difficult to institutions do not provide health government for progress.111
op. cit.
113 http://www.gajop.org.br
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
reports of the 1994 Cairo ICPD,114 the
115 Beijing declaration and platform
Constitution of 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
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
Guidelines and Reference Series). www.who.int
enjoyment of the highest attainable standard have been working with their colleagues
120 Commission on Macroeconomics and Health.
of physical and mental health. The ongoing in the human rights community to explore
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
Rights, 2004 www.ohchr.org
the relationship between health and work demonstrates how human rights can
123 Principles and Guidelines: a human rights
human rights, and have acknowledged the be used to empower marginalized people
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
Commissioner for Human Rights, 2008
provides an accessible introduction to expressed an interest in understanding how
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.
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 UNDP
www.undp.org
l UNICEF
www.unicef.org
l Wemos Foundation
www.wemos.nl
l World Bank
www.worldbank.org
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.
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.
The mention of specific companies or of certain manufacturers’ products does not imply that they are
endorsed or recommended by the World Health Organization in preference to others of a similar nature that
are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by
initial capital letters.
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
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,
Health and
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
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
as a tool for health policymakers to design, implement and monitor a poverty reduction strategy
Strategies
through a human rights-based approach. It contains practical guidance and suggestions as well as
good practice examples from around the world.