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

Access to health✜ Rights alone are not enough, but need to be coupled with communityengagement.✜ Rights, appropriately applied, can strengthen community engagement.✜ Rights, conceived in terms of agency, are the strongest guarantors ofeffective equity-promoting impacts.✜ Rights should strengthen the collective agency of the most vulnerablegroups.✜ Rights approaches should aim to address the public-private and globaldivides in relation to human hights.✜ Information and transparency are key to human rights approaches thatbuild equity.✜ Human rights approaches provide additional opportunities formobilizing resources outside the health sector.Table 1: Human rights and health equity – critical success factorslevels, the erosion of civil society structures post apartheidthat accompanied the formalization of local governmentstructures led to a decline in political accountability andalienation of communities from decision-making processeswith regard to housing and sanitation 15 .Secondly, rights frameworks provide opportunity toreinforce community engagement by affording a mechanismfor input to, and negotiation around health policy. Concern forprocedural rights is becoming increasingly important inhealth 17-19 and development discourse 15,20 and has beenrecently applied in the Equity Gauge model, which usespolicy and monitoring information, channelled tocommunities and civil society, for political action to influencepolicy-makers to support a health equity agenda 1 . Proceduralrights are therefore key to enabling the realization of otherrights, 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 inrecognizing agency of those affected by health policy, are thestrongest guarantors of effective equity-promoting impacts.Considerable evidence already exists that the root causes ofhealth inequalities relate to powerlessness of both individualsand groups. Such power differentials give rise to a sequenceof processes: social stratification, differential exposure basedon social stratification, differential vulnerability given anexposure and differential consequences, which combine togive rise to health inequities 22 . Attempts to redress inequities,which are inherently about social change, therefore have tograpple with questions of power 23 , and must consequentlyseek interactions with communities that focus onempowerment rather than mere participation 24 . Hard as itmay be to manage, an active civil society is a better guaranteeof health equity than models which frame target groups byneed and deliver services and resources to passivebeneficiaries. Indeed, in public health debates, there hasbeen an increasing support for a return to the spirit of AlmaAta, to revive the notion of community agency in publichealth practice, and to take seriously our commitment tocommunity empowerment 25-28 . We hear endless appeals to,and laments about the lack of political will to address keyhealth problems. An active engagement by civil societymeans we no longer have need to resort to a concept ofpolitical will, given we commit to a model where “those whoare beneficiaries of programmes… negotiate their inclusion inthe health system” constituting “organized and activeConsiderable evidence already exists that theroot causes of health inequalities relate topowerlessness of both individuals and groupscommunities at the centre as initiators and managers oftheir own health” 28 .Fourthly, most evident in the EQUINET case studies wasthe role of rights approaches as critical to strengthening thecollective agency of the most vulnerable groups. Advocacywork in areas such as HIV treatment access and in bringingcommunity preferences to bear on national health policiesplays a key role in reversing the “thinness of reserves” 22characteristic of groups suffering health inequities. In thissense, the public health approach of targeting populationsaccording to need, and the priorization of the most vulnerableand marginal groups as a human rights concern represent asynchrony in approaches. What a rights analysis does is toadd the recognition that an inability to exercise power meansthat the poor and vulnerable cannot change the conditions oftheir vulnerability, and must remain dependent on others todo so 24 . Institutional frameworks for human rights thatpreferentially favour access for vulnerable groups, such as, forexample, in the identification of evidence in Health ImpactAssessments 29 are therefore key to realizing the liberatorypotential of rights approaches in health 5 .This leads naturally to the fifth implication – thatinformation and transparency are key elements for theachievement of health equity. Lack of information andtransparency undermines community agency, and drivesconflict and distrust that prevents redress of inequity. Forexample, the closure of channels of access to informationregarding Poverty Reduction Strategy Papers in Malawi hasbeen interpreted as reversing gains made through interactionwith policy-makers over other policies such as the nationalPatients Rights Charter 5 . It is both at an individual andcollective level that information serves to reverse thepowerlessness underlying health inequalities. Central to themodel of the Equity Gauge 1 is the role of information inempowering community partners to advocate for action.Similarly, in the case studies for EQUINET, civil society wasboth a user and generator of information, through strategicpartnerships with research and academic experts thatenabled organizations to lobby for policy change to advancethe interests of vulnerable communities 5 . Access toinformation is thus both a right in itself and an enablingmechanism to realize other rights. Policy-makers cantherefore play a critical role in ensuring that informationaccessibility and transparency are not only part of public life,but are geared towards reaching marginalized, isolated andvulnerable groups as a priority.A further consequence of rights-based approaches to healthequity is the capacity to address the public-private and globaldivides that may not be initially obvious to law-makers.Illustrated most clearly in the HIV treatment accessGlobal Forum Update on Research for Health Volume 4 ✜ 055