Combining health and social protection measures to reach the ultra ...

Access to health
✜ Rights alone are not enough, but need to be coupled with community
engagement.
✜ Rights, appropriately applied, can strengthen community engagement.
✜ Rights, conceived in terms of agency, are the strongest guarantors of
effective equity-promoting impacts.
✜ Rights should strengthen the collective agency of the most vulnerable
groups.
✜ Rights approaches should aim to address the public-private and global
divides in relation to human hights.
✜ Information and transparency are key to human rights approaches that
build equity.
✜ Human rights approaches provide additional opportunities for
mobilizing resources outside the health sector.
Table 1: Human rights and health equity – critical success factors
levels, the erosion of civil society structures post apartheid
that accompanied the formalization of local government
structures led to a decline in political accountability and
alienation of communities from decision-making processes
with regard to housing and sanitation 15 .
Secondly, rights frameworks provide opportunity to
reinforce community engagement by affording a mechanism
for input to, and negotiation around health policy. Concern for
procedural rights is becoming increasingly important in
health 17-19 and development discourse 15,20 and has been
recently applied in the Equity Gauge model, which uses
policy and monitoring information, channelled to
communities and civil society, for political action to influence
policy-makers to support a health equity agenda 1 . Procedural
rights are therefore key to enabling the realization of other
rights, as has been shown in many areas related to health,
such as in reproductive health 21 and in housing/sanitation 15 .
Thirdly, rights frameworks that address issues of power in
recognizing agency of those affected by health policy, are the
strongest guarantors of effective equity-promoting impacts.
Considerable evidence already exists that the root causes of
health inequalities relate to powerlessness of both individuals
and groups. Such power differentials give rise to a sequence
of processes: social stratification, differential exposure based
on social stratification, differential vulnerability given an
exposure and differential consequences, which combine to
give rise to health inequities 22 . Attempts to redress inequities,
which are inherently about social change, therefore have to
grapple with questions of power 23 , and must consequently
seek interactions with communities that focus on
empowerment rather than mere participation 24 . Hard as it
may be to manage, an active civil society is a better guarantee
of health equity than models which frame target groups by
need and deliver services and resources to passive
beneficiaries. Indeed, in public health debates, there has
been an increasing support for a return to the spirit of Alma
Ata, to revive the notion of community agency in public
health practice, and to take seriously our commitment to
community empowerment 25-28 . We hear endless appeals to,
and laments about the lack of political will to address key
health problems. An active engagement by civil society
means we no longer have need to resort to a concept of
political will, given we commit to a model where “those who
are beneficiaries of programmes… negotiate their inclusion in
the health system” constituting “organized and active
Considerable evidence already exists that the
root causes of health inequalities relate to
powerlessness of both individuals and groups
communities at the centre as initiators and managers of
their own health” 28 .
Fourthly, most evident in the EQUINET case studies was
the role of rights approaches as critical to strengthening the
collective agency of the most vulnerable groups. Advocacy
work in areas such as HIV treatment access and in bringing
community preferences to bear on national health policies
plays a key role in reversing the “thinness of reserves” 22
characteristic of groups suffering health inequities. In this
sense, the public health approach of targeting populations
according to need, and the priorization of the most vulnerable
and marginal groups as a human rights concern represent a
synchrony in approaches. What a rights analysis does is to
add the recognition that an inability to exercise power means
that the poor and vulnerable cannot change the conditions of
their vulnerability, and must remain dependent on others to
do so 24 . Institutional frameworks for human rights that
preferentially favour access for vulnerable groups, such as, for
example, in the identification of evidence in Health Impact
Assessments 29 are therefore key to realizing the liberatory
potential of rights approaches in health 5 .
This leads naturally to the fifth implication – that
information and transparency are key elements for the
achievement of health equity. Lack of information and
transparency undermines community agency, and drives
conflict and distrust that prevents redress of inequity. For
example, the closure of channels of access to information
regarding Poverty Reduction Strategy Papers in Malawi has
been interpreted as reversing gains made through interaction
with policy-makers over other policies such as the national
Patients Rights Charter 5 . It is both at an individual and
collective level that information serves to reverse the
powerlessness underlying health inequalities. Central to the
model of the Equity Gauge 1 is the role of information in
empowering community partners to advocate for action.
Similarly, in the case studies for EQUINET, civil society was
both a user and generator of information, through strategic
partnerships with research and academic experts that
enabled organizations to lobby for policy change to advance
the interests of vulnerable communities 5 . Access to
information is thus both a right in itself and an enabling
mechanism to realize other rights. Policy-makers can
therefore play a critical role in ensuring that information
accessibility and transparency are not only part of public life,
but are geared towards reaching marginalized, isolated and
vulnerable groups as a priority.
A further consequence of rights-based approaches to health
equity is the capacity to address the public-private and global
divides that may not be initially obvious to law-makers.
Illustrated most clearly in the HIV treatment access
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