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Collaborative Course on Infectious Diseases January 2009. LECTURE # 8 Human Rights and Health ( Direitos Humanos e Saúde ) Sofia Gruskin , JD, MIA

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Collaborative Course on Infectious Diseases

January 2009

  • LECTURE # 8

  • Human Rights and Health

  • (DireitosHumanos e Saúde)

  • Sofia Gruskin, JD, MIA

  • Program on International Health and Human RightsDepartment of Global Health and PopulationHarvard School of Public Healthhttp://www.hsph.harvard.edu/pihhr/

  • sgruskin@hsph.harvard.edu

  • http://www.hsph.harvard.edu/pihhr/

Harvard School of Public Health

Centro de Pesquisa Gonçalo Moniz, Fundação Oswaldo Cruz (Fiocruz)

Brazil Studies Program, DRCLAS, Harvard University


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What We Will Cover:

  • Linkages and Definitions

  • The Rights to Health and to Non-Discrimination

  • Governmental Obligations: Respect, Protect and Fulfill

  • Progressive Realization

  • Valid Limitations on Rights

  • Approaches to Doing Work in Human Rights and Health

  • Application to Public Health Practice: A Rights-Based Approach (concepts and specific examples)

  • Issues for Discussion


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Questions for Discussion

  • What is meant by a rights-based approach to HIV in Brazil?

  • How relevant is this approach to other health issues in Brazil?

  • Is this approach transferable to other middle and low income countries? Why or why not?

  • What about to the United States? Why or why not?

  • How and in what ways are human rights relevant to the design, implementation, monitoring and evaluation of your course project? (Consider both approach and specific rights)


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Human Rights, International Law HIV/AIDS and Health

  • History

  • Concepts

  • Impacts


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Conceptual Relationships Between Human Rights and Health

Health  Human Rights

Health  Human Rights

Health  Human Rights


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The Good News

  • No longer the question of why health and human rights but how?

  • Massive violations in health and human rights have been averted

  • Health and human rights education and training is on the rise

  • Research and publications are expanding

  • Human rights principles are increasingly applied to health policies and programs


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Now The Bad…..

  • Assertions against human rights by some well-known public health practitioners (public health approach vs human rights approach)

  • The overwhelming burden of global health concerns is not going away

  • Perceived limitations of the value of state and non-state compliance with human rights as they relate to public health

  • Inadequate accountability for human rights by pharmaceuticals and multinationals

  • Politics, politics, politics!!

  • Lack of understanding/consensus of what is meant by inclusion of human rights in public health programming efforts

  • Lack of evidence-base for the role that human rights play in achieving desired outcomes


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What Is Meant By Health

As an aspirational goal:“Health is a state of complete physical, mental and social well-being and not merely the absence of disease. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic and social condition”

Constitution of the World Health Organization, adopted by the International Health Conference, New York, 19 June-22 July 1946

As an instrumental goal:“Ensuring the conditions in which people can be healthy”

Institute of Medicine, Future of Public Health, Summary and Recommendations (Washington, DC: National Academy Press, 1988US Institute of Medicine)


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What Is Meant By Human Rights

  • International human rights law defines what governments can do to us, cannot do to us, and should do for us

  • Human rights law is meant to be equally applicable to everyone, everywhere in the world, across all borders and across all cultures and religions

  • Human rights are universal, interrelated and indivisible

  • Human rights are primarily about the relationship between the individual and the state

  • International human rights law consists of the obligations that governments have agreed they have in order to be effective in promoting and protecting our rights

  • Governmental obligations to respect, protect and fulfill human rights


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Relevant International Human Rights Law

1948: Universal Declaration of Human Rights (UDHR)*

Treaties: Legally binding on nations that have ratified

1965: International Convention on the Elimination of All Forms of Racial Discrimination

1966: International Covenant on Economic, Social, and Cultural

Rights

1966: International Covenant on Civil and Political Rights

1979: International Convention on the Elimination of All Forms of Discrimination Against Women

1985: Convention Against Torture

1990: Convention on the Rights of the Child (B

2000: Convention on the Protection of Migrant Workers and their Families

2006: Convention on the Rights of Persons with Disabilities

* The UDHR is not a legally binding document, but has served as inspiration for, and been incorporated into, all the human rights treaties that have followed


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Political Consensus Documents

Relevant to Human Rights and Health

not legally binding but set important political commitments

1990: World Summit on Children

1993: World Conference on Human Rights (and its 5 year review)

1994: International Conference on Population and Development (and its 5 year review)

1995: Fourth World Conference on Women (and its 5 year review)

1995: World Summit for Social Development (and its 5 year review)

2000: United Nations Millennium Declaration Resolution (the MDGs)

2001: United Nations General Assembly Special Session on HIV/AIDS

2002: United Nations General Assembly Special Session on Children 


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The right to equality and non-discrimination

The right to life, survival, and development

The right to travel

The right to bodily integrity and security of the person

The right to an identity

The right to privacy

The right to health

The right to food

The right to housing

The right to social security

The right to be free from torture

The right to association

The right to the benefits of scientific progress

The right to education

The right to seek, receive and impart information

Human Rights Relevant to Health


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The Right to Health International Covenant on Economic, Social and Cultural Rights: The Right to the Highest Attainable Standard of Health, Art. 12

  • Article 12 recognizes “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.”

  • The steps to be taken by the States parties…to achieve the full realization of this right shall include those necessary for:

    • The provision for the reduction of still-birth rate and of infant mortality and for the healthy development of the child;

    • The improvement of all aspects of environmental and industrial hygiene;

    • The prevention, treatment and control of epidemic, endemic, occupational and other diseases;

    • The creation of conditions which would assure to all medical service and medical attention in the event of sickness.


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Further Defining The Right to Health:

General Comment 14

  • The right to health is closely related to and dependent upon the realization of other human rights

  • The right to health contains both freedoms and entitlements. The freedoms include the right to control one's health and body, including sexual and reproductive freedom, and the right to be free from interference, such as the right to be free from torture, non-consensual medical treatment and experimentation. The entitlements include the right to a system of health protection which provides equality of opportunity for people to enjoy the highest attainable level of health.

  • The right to health is inclusive extending not only to timely and appropriate health care but also to the underlying determinants of health, such as access to safe and potable water and adequate sanitation, an adequate supply of safe food, nutrition and housing, healthy occupational and environmental conditions, and access to health-related education and information, including on sexual and reproductive health. A further important aspect is the participation of the population in all health-related decision-making at the community, national and international levels.

  • The right to health ensure attention to the availability, accessibility, acceptability and quality ofhealth facilities, goods and services.

  • The right to health proscribes any discrimination in access to health care and underlying determinants of health, as well as to means and entitlements for their procurement, on the grounds of race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth, physical or mental disability, health status (including HIV/AIDS), sexual orientation and civil, political, social or other status.


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Non-Discrimination

.

  • Key concept in human rights

  • Every person should be treated with equal dignity and respect

  • Discrimination on the basis of difference is strictly prohibited

  • Can exist in law or practice

  • Not every differentiation is discrimination


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Progressive Realization

States must “take steps, individually and through international assistance and cooperation, especially economic and technical, to the maximum of its available resources, with a view to achieving progressively the full realization of the rights recognized in the [Economic, Social, and Cultural Rights] covenant by all appropriate means, including particularly the adoption of legislative measures.”

-ICESCR, Art 2 (1)


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Defining Governmental Obligations

  • Respecting the Right

  • Protecting the Right

  • Fulfilling the Right


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The Siracusa Principles

The restriction must be provided for and carried out:

  • In accordance with the law;

  • In the interest of a legitimate objective of general interest;

  • Strictly necessary to achieve that objective;

  • No less intrusive and restrictive means available to reach the same objective, and;

  • The restriction cannot be unreasonable or otherwise discriminatory in the way that it is written as a law or policy, or in the way that it is applied.


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Current Work in Human Rights and Health

  • Identifying, naming and remedying violations of human rights related to health

  • Advocating around health issues using human rights language

  • Assessing government performance in health through application of human rights standards

  • Promoting legal and political accountability at national and international levels

  • Integrating human rights in developing effective health policies and programs

  • Demonstrating the value of rights based approaches to health


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Categorizing Current Work in Human Rights and Health

  • Advocacy

  • The use of the law, including both international and national legal norms and standards

  • The use of key human rights principles for designing, implementing, monitoring and evaluating HIV policies and programs (a “rights-based approach”)


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Defining a rights-based approach to health

  • Attention to the legal and policy context

  • Participation

  • Non-discrimination

  • The right to health (availability, accessibility, acceptability, and quality of services)

  • Transparency and accountability


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Applying a Rights-Based Approach to Health

Legal and Policy Context

Participation

Nondiscrimination

Accountability

AvailabilityAccessibility Acceptability

Quality

Other rights

Situational Analysis

Design

Implementation

Monitoring and Evaluation


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Creating the Evidence Base: some evidentiary efforts

  • Human rights principles commonly noted as relevant to addressing public health concerns:

    • Participation

    • Non-discrimination

    • Availability, acceptability, accessibility and quality (3AQ) of good and services

    • Accountability

    • Other recognized rights as they may be specific to the intervention


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Some Examples

  • Global level

  • National level

  • Organizational level


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Determining how (or if) human rights are integrated into the HIV response

  • Assess the extent to which human rights are integrated into HIV and AIDS policy documents

  • Assess the extent to which human rights are integrated into existing HIV and AIDS programmatic efforts

  • Assess the extent to which indicators currently in use are sensitive to human rights concerns

  • Assess the extent to which international and national legal and policy environments are harmful or helpful for protecting human rights and for effective AIDS programs

    Ultimately the goal is to provide evidence that the extent to which AIDS programs pay attention to rights has a positive impact on reported behavior, HIV prevalence and treatment outcomes


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Why pay attention to human rights in the AIDS response?

Overall, UNAIDS and its partners operate from the position that human rights should be protected because:

  • there is a moral and legal obligation to respect, protect and fulfill rights

    AND

    (b) their protection results in more effective HIV programs and more positive outcomes


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Human rights in international and national responses to HIV and AIDS

  • Call for non-discrimination included in the first Global Response to AIDS (1987)

  • All global and many national strategy documents since have asserted the role of human rights for an effective HIV response

  • WHO’s 3X5 strategy referred to HIV treatment as ahuman right

  • Universal Access Framework recognizes the role of human rights for successful strategic efforts, and in relation to national level targets


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Setting national targets for Universal Access

  • Services have to be equitable, affordable, comprehensive and sustainable

  • National target setting and tracking have to be standardized based on a small set of core indicators

  • Countries should focus on overcoming identified and previously reported obstacles

    Source: Moving Towards Universal Access, (UNAIDS) October 2006


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Principles for setting national targets include:

  • Country ownership and participation

  • Building on past efforts

  • Review of existing data and data collection systems

  • Reviewing existing indicators

  • Setting targets as part of national strategic plans

  • Identifying and overcoming obstacles to scale-up

  • Human rights, gender and the greater involvement of People Living with HIV and AIDS (GIPA)

  • Quality of and equity in access to services

  • Setting priorities and overcoming obstacles

  • Limiting the number of targets

  • Using targets to mobilize resources

    Source: Moving Towards Universal Access, (UNAIDS) October 2006


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People living with HIV, women, young people and other most-at-risk populations, such as sex workers, men who have sex with men, drug users and prisoners should play a major role in setting national targets

Targets should be considered with regard to participation, availability, affordability, accessibility and quality

Coverage should be measured across different populations, with the aim of ensuring equitable access

Data should be disaggregated by age and sex at a minimum, but also, where possible, marital status, location (rural/urban) and ethnic background

Source: Moving Towards Universal Access, (UNAIDS) October 2006

Human rights, gender and the Greater Involvement of People Living with HIV and AIDS (GIPA)


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Determining how (or if) human rights are integrated into the HIV response

  • Assess the extent to which human rights are integrated into HIV and AIDS policy documents

  • Assess the extent to which human rights are integrated into existing HIV and AIDS programmatic efforts

  • Assess the extent to which indicators currently in use are sensitive to human rights concerns

  • Assess the extent to which international and national legal and policy environments are harmful or helpful for protecting human rights and for effective AIDS programs

    Ultimately the goal is to provide evidence that the extent to which AIDS programs pay attention to rights has a positive impact on reported behavior, HIV prevalence and treatment outcomes


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Determining how (or if) human rights are integrated into the HIV response

  • Assess the extent to which human rights are integrated into HIV and AIDS policy documents

  • Assess the extent to which human rights are integrated into existing HIV and AIDS programmatic efforts

  • Assess the extent to which indicators currently in use are sensitive to human rights concerns

  • Assess the extent to which international and national legal and policy environments are harmful or helpful for protecting human rights and for effective AIDS programs

    Ultimately the goal is to provide evidence that the extent to which AIDS programs pay attention to rights has a positive impact on reported behavior, HIV prevalence and treatment outcomes


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A review of HIV and AIDS programmatic efforts

  • Differences exist between policy level rhetoric and programmatic realities, a false dichotomy is often stated about there being a difference between a “public health approach” and a “rights-based approach”

  • Insufficient documentation exists of what successfully integrating human rights into programming means when it does happen

  • Where rights have been integrated, there has been insufficient monitoring of their impact

  • Donors are requiring indicators with short time frames that focus, for example, on the numbers of people receiving treatment. Thus, human rights which emphasize not only on numbers but who is gaining access, how they are gaining access, and over what period of time, not just howmany raise uncomfortable questions.

Source: Beyond the Numbers: Using Rights-Based Perspectives to Enhance Antiretroviral Treatment Scale-up,

Sofia Gruskin, Laura Ferguson and Dina Bogecho AIDS 2007, 21 (suppl 5): S13:S19


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Determining how (or if) human rights are integrated into the HIV response

  • Assess the extent to which human rights are integrated into HIV and AIDS policy documents

  • Assess the extent to which human rights are integrated into existing HIV and AIDS programmatic efforts

  • Assess the extent to which indicators currently in use are sensitive to human rights concerns

  • Assess the extent to which international and national legal and policy environments are harmful or helpful for protecting human rights and for effective AIDS programs

    Ultimately the goal is to provide evidence that the extent to which AIDS programs pay attention to rights has a positive impact on reported behavior, HIV prevalence and treatment outcomes


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Matrix for review of indicators cont. Example: Does your country have a policy to ensure equal access of men and women to prevention and care?


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Determining how (or if) human rights are integrated into the HIV response

  • Assess the extent to which human rights are integrated into HIV and AIDS policy documents

  • Assess the extent to which human rights are integrated into existing HIV and AIDS programmatic efforts

  • Assess the extent to which indicators currently in use are sensitive to human rights concerns

  • Assess the extent to which international and national legal and policy environments are harmful or helpful for protecting human rights and for effective AIDS programs

    Ultimately the goal is to provide evidence that the extent to which AIDS programs pay attention to rights has a positive impact on reported behavior, HIV prevalence and treatment outcomes


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Source: Gruskin S, Ferguson L, “Ensuring an effective HIV response for vulnerable populations-assessing national legal and policy environments.” The XVII International AIDS Conference, Mexico City, Mexico, 2-8 August 2008.


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2001 United Nations General Assembly Special Session (UNGASS) Declaration of Commitment (DOC) on HIV/AIDS

  • Research and development

  • HIV/AIDS in conflict and disaster-affected regions

  • Resources

  • Follow up:

    - National level

    - Regional level

    - Global level

  • Prevention

  • Care, support and treatment

  • HIV/AIDS and human rights

  • Reducing vulnerability

  • Children orphaned and made vulnerable by HIV/AIDS

  • Alleviating social and economic impact


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2001 United Nations General Assembly Special Session (UNGASS) Declaration of Commitment (DOC) on HIV/AIDS

  • Emphasizes the centrality of human rights to an effective HIV response

  • Countries submit reports to UNAIDS every two years on their progress towards fulfilling the DOC


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UNGASS National Composite Policy Index (NCPI)

  • Part A is completed by government officials:

    • I Strategic plan

    • II Political support

    • III Prevention

    • IV Treatment, care and support

  • Part B is completed by UN organizations, bilateral agencies and nongovernmental organizations:

    • I Human rights

    • II Civil society involvement

    • III Prevention

    • IV Treatment, care and support

      The NCPI is vetted and submitted by governments


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The existence of laws and policies is not enough: implementation is key

  • 82% of governments reported the existence of policies to ensure equal access between women and men to prevention and care but note that in reality access for women is harder

  • Yet how to determine implementation is still not clear


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What We Found

  • Both with respect to human rights and more broadly, the value of the NCPI and the UNGASS reporting process for efforts at country level is beyond doubt. However, there are very different benefits to be reaped from this process beyond the value of global level reporting.

  • In Brazil, and in some other countries, an over-riding benefit of the NCPI appears to be the way in which it brings together, in one place, a wide range of information. By painting this picture of the legal and policy components of the national response, the report assures that stakeholders become aware of parts of the response beyond their areas of concern, and thereby lends itself to use for multi-sectoral discussions about the response going forward.

  • In other countries its primary value appears to be derived from the process of completing the NCPI, which in bringing together actors from government, NGOs, groups of PLHIV, etc. in ways which can be unprecedented can lead to further collaboration.

  • In all countries, the NCPI has an important role in strengthening civil society engagement with HIV-related data.


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Proposed next steps to improve the NCPI

  • Add components to assess quality, content and implementation not only existence

  • Add component to highlight disparities within countries

  • “Officially” bring together NCPI and relevant portions of narrative and civil society reports

  • Strengthen national level processes for data collection and dissemination


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Determining how (or if) human rights are integrated into the HIV response

  • Assess the extent to which human rights are integrated into HIV and AIDS policy documents

  • Assess the extent to which human rights are integrated into existing HIV and AIDS programmatic efforts

  • Assess the extent to which indicators currently in use are sensitive to human rights concerns

  • Assess the extent to which international and national legal and policy environments are harmful or helpful for protecting human rights and for effective AIDS programs

    Ultimately the goal is to provide evidence that the extent to which AIDS programs pay attention to rights has a positive impact on reported behavior, HIV prevalence and treatment outcomes


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Using Human Rights to AdvanceSexual and Reproductive Health: a Tool for Examining Laws, Regulations and Policies

* a joint project of the Program on International Health and Human Rights, Harvard School of Public Health and the Department of Reproductive Health and Research, World Health Organization

Initial details can be found in: Sofia Gruskin, Jane Cottingham, Adriane Martin Hilber, Eszter Kismodi, Ornella Lincetto, Mindy Jane Roseman, Using Human Rights to Improve Maternal and Neonatal Health: History, Connections and a Proposed Practical Approach Bulletin of the World Health Organization, Vol 86, No.8, August 2008, 589-593


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The Tool is intended to assist countries to use a human rights perspective to:

  • Review and address legal and policy barriers to sexual and reproductive health;

  • Engage health sector and non-health sector actors to eliminate barriers to sexual and reproductive health; and

  • Review, document and improve government efforts to respect, protect and fulfill human rights related to sexual and reproductive health.

  • To bring attention to vulnerable populations in government efforts to meet the Millennium Development Goals.

  • To provide evidence of the effectiveness of a rights-based approach to health.

  • [To draw attention to the linkage between maternal and newborn health and reproductive and sexual health and rights issues more broadly]


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The Tool

  • The Tool is both a process and a research instrument.

  • The research component (The Instrument) aims to assess legal, regulatory and standard public health data from a human rights perspective.

  • It consists of: (1) questions regarding the international and national legal context of a country, including its human rights commitments, and such issues as health financing; (2) questions concerning broad, cross-cutting issues relating to sexual and reproductive health; (3) questions about laws, regulations and policies; and (4) questions about health systems and outcomes.

  • The process brings government officials, policy makers and other stakeholders together to address barriers and challenges related to sexual and reproductive health and rights.


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Some More Information About The Instrument

  • Based upon a framework promulgated by Rebecca Cook and WHO -- "Advancing Safe Motherhood through Human Rights"

  • Designed and then revised collaboratively between PIHHR/HSPH and WHO

  • Field tested in Switzerland, Mozambique, Brazil and Indonesia with a focus on maternal and neo-natal health

  • Initially took human rights as an entry point and this was found not to be effective for countries or health practitioners. Has now been turned around to take health as an entry point

  • Turned around and adapted to reproductive and sexual health. Current testing going on in Sri Lanka and Tajikistan


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International Human Rights Treaties

International Development Goals and Targets

Government Effort

National Laws, Policies & Health Systems

Law/policy to reduce maternal mortality

Maternal mortality ratio

Number of births attended by skilled attendants

HIV prevalence rate in pregnant women

Law/policy on compulsory, free primary education

Female, primary/secondary school enrolment as a percentage of male enrolment

Incidence of FGM and/or other harmful traditional practices

Law/policy on elimination of practices harmful to maternal or neonatal health

Health Indicators

Rights Relating to Health and Maternity

Rights Relating to Life, Survival & Security

Rights Relating to Information & Education

Rights Relating to Non-discrimination

Multi Sectoral Action Planning


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Turning the Instrument Around

  • Designed in accordance with the WHO Global Strategy on Reproductive Health, adopted by the World Health Assembly in May 2004.

  • These are grouped under the five core aspects of sexual and reproductive health as defined in the WHO Global Strategy on Reproductive Health: improving antenatal, perinatal, postpartum and newborn care; provide high quality services for family planning, including infertility services; eliminating unsafe abortion; combating sexually transmitted infections, including HIV, reproductive tract infections, cervical cancer and other gynecological morbidities; and promoting sexual health.


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What The Information Gathered and Analyzed From The Tool Can Show

  • Compliance with international human rights standards

  • Discrepancies in laws, regulations, policies and/or health system standards which impact on reproductive and sexual health

  • Health and rights related considerations for vulnerable groups

  • Government efforts or lack of effort to address the areas of concern

  • Recommendations for action

  • Identification of priority health-related issues

  • Identification of key actors for action and implementation


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Preliminary Results from Indonesia

The Need to Focus on Unmarried People

  • Inaccessibility of contraceptive services for unmarried people

  • Husbands authorization needed to seek services

  • Lack of comprehensive knowledge about contraception and contraceptive methods by adolescents and unmarried people


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Next Steps for the Tool

  • Publish the Tool (both the Instrument and the process) so others can use it

  • Publish results and lessons learned in academic journals

  • Adapt the Tool to other health issues (adolescent health, HIV etc..)

  • Determine how to assess the quality and level of implementation of laws and policies rather than simply their existence

  • Link the Tool to other processes that are used to do situational analyses and priority setting exercises


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Implementation of an intervention:Linking efforts to prevent gender-based violence and HIV

Using health, human rights and sexuality as common entry points, the focus of this work is to enable organizations working in the area of HIV and in the area of gender-based violence to work together and create joint research and work agendas.

* a project of the Program on International Health and Human Rights, Harvard School of Public Health with funding from the Ford Foundation


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Organizational -level project

  • Training between partner organizations

  • Joint review and assessment of existing efforts including country-level data on HIV/AIDS and GBV, laws and policies from a health and human rights perspective

  • Joint design of an intervention to fill gaps with a focus on participation, non-discrimination, transparency and accountability that can be done together


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Results

  • China: analysis of call records from GBV hotline

    • lesbian, gay, bisexual and transgender clients are often not given information appropriate to their sexual activities

  • India: designed conceptual framework to address work of both organizations

    • Extensive orientation of staff; review of international commitments in relation to local context; interviews with experts to outline India context but limited ability to apply

  • Thailand: analyzed data from both organizations

    • common issues include culturally ascribed gender roles and attitudes circumscribing women’s sexuality lead to funding and programming changes

  • Viet Nam: analyzing data from GBV hotline and review of laws and policies

    • Issues were being raised by callers but the counsellors were not making the connection between the issues. This led to better trainings for the counsellors and staff, and information brought to policymakers in considering laws and policies


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    Lessons Learned: Implementation

    • Need to ensure a clear and common understanding of human rights and the intersection of these issues

    • Need to determine the type of partner organization, the amount of experience each organization has, and its method of operating to determine best way to implement

    • Ensure commitment to project from senior staff at the organization, and that there are clear channels of accountability

    • Need to contextualize issues to the local context and ensure that non-discrimination against most vulnerable groups is addressed in project activities

    • Need to provide platforms for partnering organizations to address common challenges, drawing on each other’s experiences

    • Need to ensure meaningful participation at all stages to promote ownership and commitment to the project

    • Need to support monitoring and evaluation mechanisms that bring attention to human rights concerns


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    Legal and Policy Context

    Situational Analysis

    Participation

    Nondiscrimination

    Accountability

    3AQ

    Other rights

    Design

    Implementation

    Monitoring and Evaluation

    Applying a Rights-Based Approach to Health


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    Issues to Consider in Designing and Implementing Your Project

    • 1) What laws or policies could help or hinder what you would like to accomplish?

    • 2) How would you ensure that discrimination is avoided at each stage of the process?

    • 3) What would it take to ensure the participation of affected communities throughout?

    • 4) How would you ensure the availability, acceptability, accessibility and quality of the service you want to provide?

    • 5) How would you ensure transparency in your decision-making and some level of accountability for the strategy chosen?


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    Some Issues to Consider: Non-discrimination

    • How are vulnerable groups being identified?

    • How will the rights of vulnerable groups be impacted?

    • What differences exist in relation to access and use of services between different population groups in the area?

    • What legal, policy or current programmatic barriers could constrain the access to services of [certain] vulnerable populations even if services are put in place?


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    Some Issues to Consider: Participation

    • In what ways are the opinions of affected communities and vulnerable groups being solicited? consulted?

    • Who speaks for the community?

    • What mechanisms, laws, policies, plans or strategies are in place to ensure the [meaningful] participation of affected communities and vulnerable groups throughout the life of the project?

    • Are participatory planning approaches being used to ensure necessary input from users?

    • What feedback loop is in place to ensure the community is involved at each stage of the process?

    • What is meaningful involvement?


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    Some Issues to Consider: The 3AQ

    • Availability

      • What relevant information and/or services are already readily available?

      • Are multiple actors involved in delivery of relevant services? If so, is this resulting in a co-ordinated effort between government and non-governmental actors which ensures availability or is this resulting in difficulties in availability for users?

    • Accessibility

      • What accessibility issues could potentially constrain the success of your project?

    • Acceptability

      • How can you ensure the information/services are culturally appropriate?

      • How can you ensure they are informed by international and nationally accepted good practice?

    • Quality

      • Are the information and services you plan to provide scientifically and medically appropriate?

      • How can you ensure the project is considered to be of quality by the users?


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    Some Issues to Consider: Transparency and Accountability

    • Is there a functioning court system that people know about and can access?

    • Is there transparency in how the program is designed and about what it intends to do?

    • Is there transparency in who made these determinations and what criteria were used in deciding the area of focus and approach?

    • Will progress towards chosen targets be easily measurable?

    • How will the results be shared with affected communities?

    • Is there involvement of affected communities in monitoring impact?

    • What targets will be chosen to show effectiveness of the strategy within one year, and over a 5 year period?

    • What criteria will be used to determine what level and type of data disaggregation will be most useful?

    • What system of monitoring and evaluation will be used?


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    Questions for Discussion

    • How and in what ways are human rights relevant to the design, implementation, monitoring and evaluation of your course project? (Consider both approach and specific rights)

    • What is meant by a rights-based approach to HIV in Brazil?

    • How relevant is this approach to other health issues in Brazil?

    • Is this approach transferable to other middle and low income countries? Why or why not?

    • What about to the United States? Why or why not?


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