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

Access to health
meaningful community input to decision making, 18,19 . Not
surprisingly, a recent World Health Organization Bulletin has
called for papers on exactly this theme, seeking evidence for
the application of ethical frameworks for public health
decision-making 32 .
A third dimension to engagement with this area is how
policy-makers, governments and national and international
agencies respond to popular movements advancing explicit
equity-related agendas. For example, the People’s Health
Movement, a global network of health civil society groups,
has launched a campaign for the right to health 33 . In putting
equity and human rights explicitly on to a public agenda,
policy-makers will be expected to weigh up competing
demands for attention. Of course, finding the path that
effectively balances rights and responsibilities is complex,
particularly in the context of globalization, where devolving
responsibilities to communities risks absolving duty-bearing
governments of their obligations 5,15 .
Then, there are difficult questions about assessing health
policy through a rights lens. For example, in terms of
developing basic policies on health worker migration, which
present a challenge in balancing health workers’ rights to
work freely where they wish against the needs of vulnerable
groups to health care 30 , it appears impossible to begin to
engage on the issues without a clear understanding of the
nature of a rights framework, the process by which differing
and competing rights may be balanced and the procedural
standards that must be met when restricting individual rights
in the interests of the public good 34 . Models have been
developed to assist policy-makers to assess the human rights
impacts of health policies, adjudicate between policies and
plan appropriately 16,35,36 . Experience in using these models
will help to contribute to best practice with regard to public
health planning for equity.
Further, individual health workers and managers are
frequently set up as gatekeepers or intermediates in
contestation over rights of access to health care. This kind of
adversarial relationship is not helpful to either users or the
health professionals, and unlikely to enable any meaningful
progress towards health equity. Patients’ rights charters,
rather than serving as simply normative standards imposed
on dysfunctional health systems, need to be set up so as to
enable mutual identification of shared objectives between
users and providers, through processes that realize
procedural rights as part of a health equity strategy. Of course,
health workers need to be mindful of not becoming complicit
as instruments of the violations of users’ rights, and so need
support in situations where they may experience Dual Loyalty
conflicts 37 , but the strength of a rights approach is that it
focuses analysis on identifying system failures rather than
branding individuals as the problem. For example, the South
African Human Rights Commission recently undertook an
investigation into obstacles to access to health care in South
Africa as part of its mandate to assess the government’s
performance with regard to its core obligations on the right to
health 38 .
Lastly, how can we operationalize a rights system that is
not automatically adversarial, and that is able to realise a winwin
scenario? For example, Rifkin 24 points out the problems
of framing community empowerment as an intervention
rather than a political process because it avoids very real
conflicts that may arise between communities and those who
hold power. Understanding what a human rights framework
implies, provides us with a vehicle for explicitly recognizing
these differences and provides an accepted framework for
managing these conflicts 39 .
If national and global policy-makers are to effect a
commitment to going “beyond a ‘business as usual’
approach” in promoting health equity and access to health
care 3 , we need to think seriously about making human rights
work for the public’s health. ❏
Leslie London is a senior specialist in public health at the School
of Public Health and Family Medicine in the University of Cape
Town, South Africa. He is Head of the Health and Human Rights
Programme in the School of Public Health and Family Medicine
and Portfolio Manager for Transformation and Equity for the
Faculty. Professor London serves on the National Health Research
Ethics Council and the Advisory Committee to the Health
Professions Council on Human Rights, Ethics and Professional
Practice. His research includes work on the right to health, dual
loyalties and human rights, and environmental justice. He teaches
under- and postgraduates in human rights and public health at
UCT and other higher education institutions in the country.
Global Forum Update on Research for Health Volume 4 ✜ 057