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

Access to healthmeaningful community input to decision making, 18,19 . Notsurprisingly, a recent World Health Organization Bulletin hascalled for papers on exactly this theme, seeking evidence forthe application of ethical frameworks for public healthdecision-making 32 .A third dimension to engagement with this area is howpolicy-makers, governments and national and internationalagencies respond to popular movements advancing explicitequity-related agendas. For example, the People’s HealthMovement, a global network of health civil society groups,has launched a campaign for the right to health 33 . In puttingequity and human rights explicitly on to a public agenda,policy-makers will be expected to weigh up competingdemands for attention. Of course, finding the path thateffectively balances rights and responsibilities is complex,particularly in the context of globalization, where devolvingresponsibilities to communities risks absolving duty-bearinggovernments of their obligations 5,15 .Then, there are difficult questions about assessing healthpolicy through a rights lens. For example, in terms ofdeveloping basic policies on health worker migration, whichpresent a challenge in balancing health workers’ rights towork freely where they wish against the needs of vulnerablegroups to health care 30 , it appears impossible to begin toengage on the issues without a clear understanding of thenature of a rights framework, the process by which differingand competing rights may be balanced and the proceduralstandards that must be met when restricting individual rightsin the interests of the public good 34 . Models have beendeveloped to assist policy-makers to assess the human rightsimpacts of health policies, adjudicate between policies andplan appropriately 16,35,36 . Experience in using these modelswill help to contribute to best practice with regard to publichealth planning for equity.Further, individual health workers and managers arefrequently set up as gatekeepers or intermediates incontestation over rights of access to health care. This kind ofadversarial relationship is not helpful to either users or thehealth professionals, and unlikely to enable any meaningfulprogress towards health equity. Patients’ rights charters,rather than serving as simply normative standards imposedon dysfunctional health systems, need to be set up so as toenable mutual identification of shared objectives betweenusers and providers, through processes that realizeprocedural rights as part of a health equity strategy. Of course,health workers need to be mindful of not becoming complicitas instruments of the violations of users’ rights, and so needsupport in situations where they may experience Dual Loyaltyconflicts 37 , but the strength of a rights approach is that itfocuses analysis on identifying system failures rather thanbranding individuals as the problem. For example, the SouthAfrican Human Rights Commission recently undertook aninvestigation into obstacles to access to health care in SouthAfrica as part of its mandate to assess the government’sperformance with regard to its core obligations on the right tohealth 38 .Lastly, how can we operationalize a rights system that isnot automatically adversarial, and that is able to realise a winwinscenario? For example, Rifkin 24 points out the problemsof framing community empowerment as an interventionrather than a political process because it avoids very realconflicts that may arise between communities and those whohold power. Understanding what a human rights frameworkimplies, provides us with a vehicle for explicitly recognizingthese differences and provides an accepted framework formanaging these conflicts 39 .If national and global policy-makers are to effect acommitment to going “beyond a ‘business as usual’approach” in promoting health equity and access to healthcare 3 , we need to think seriously about making human rightswork for the public’s health. ❏Leslie London is a senior specialist in public health at the Schoolof Public Health and Family Medicine in the University of CapeTown, South Africa. He is Head of the Health and Human RightsProgramme in the School of Public Health and Family Medicineand Portfolio Manager for Transformation and Equity for theFaculty. Professor London serves on the National Health ResearchEthics Council and the Advisory Committee to the HealthProfessions Council on Human Rights, Ethics and ProfessionalPractice. His research includes work on the right to health, dualloyalties and human rights, and environmental justice. He teachesunder- and postgraduates in human rights and public health atUCT and other higher education institutions in the country.Global Forum Update on Research for Health Volume 4 ✜ 057