The human right to the highest attainable standard of health

A women’s self help group in India

What does it mean to talk about the right to the highest attainable standard of health? How have our perceptions and our actions changed in the past few years?

Paul Hunt, UN Special Rapporteur on the right to the highest attainable standard of health (2002-2008) shares his perspective.

The foundations for the fundamental human right to the highest attainable standard of health (also known as the right to health) are in the Universal Declaration of Human Rights. The right is in major legally binding international human rights treaties that countries have drafted and chosen to sign up to. It is part of what is known as the International Bill of Rights. Until 2000, however, it was not clear what the right to the highest attainable standard of health meant. In that year, a group of international experts agreed a document, called General Comment 14, which sets out in some detail what is understood by this human right. These experts were chosen by governments but, once appointed, were independent. They drew upon international human rights, as well as good health practices. They benefited from the expertise of the World Health Organization (WHO) and civil society organisations. The right to health provisions of most international treaties are only a few sentences, whereas General Comment 14 has 65 paragraphs. It transformed the right to the highest attainable standard of health from a slogan to something that can make a constructive, concise contribution to health-related policies, programmes and practices.

What does this human right consist of? Briefly, it encompasses medical care, as well as access to safe drinking water, adequate sanitation, a safe working environment, access to health-related information and education and other critical pre-conditions of good health. Moreover, it places an obligation on governments to address discrimination and inequality. The right to the highest attainable standard of health requires governments to enhance access for disadvantaged individuals, communities and populations. In other words, it has a social justice component. It also requires that governments put in place arrangements that facilitate the active and informed participation of those affected by health-related policies, programmes and practices.

Crucially, the right to the highest attainable standard of health is subject to progressive realisation, i.e. no government is expected to realise it overnight – or even in 10 years – but to progressively work towards its realisation. This means we need indicators and benchmarks to measure whether or not progress is being made. The right to health is also subject to resource availability. In other words, more is demanded of Canada, than of Chad. Independent monitoring and accountability are crucial elements of the right to the highest attainable standard of health. Too often today, the same body is responsible for delivering and regulating health-related services, as well as holding those responsible to account; from the right to health perspective, this is problematic. At the core of the right to health is an equitable, integrated, responsive, effective health system that is accessible to all and of good quality.

This human right is not just the preserve of international human rights systems. It is enshrined in the WHO constitution, Declaration of Alma-Ata, Ottawa Charter for Health Promotion and other important documents agreed by the health community. Over the last six years, the UN General Assembly and the UN Commission (now Council) of
Human Rights has routinely received reports on numerous aspects of the right to health, including water and sanitation, the Millennium Development Goals, maternal mortality, the skills drain, access to medicines, the right to health responsibilities of pharmaceutical companies and so on.

Numerous constitutions and other national laws include the right to the highest attainable standard of health. Of course, some of these provisions are little more than adornments. But some are not. Some are giving rise to important cases that are leading to improvements in health-related services. For example, the Colombian Constitutional Court recently ordered a phased re-structuring of the country’s health system by way of a participatory and transparent process based on current epidemiological information. The Court’s decision relies upon the right to health.

The right to the highest attainable standard of health, as well as other health related rights are now being taken seriously at the international, national and local levels. There can be no doubt that the right to the highest attainable standard of health encompasses social determinants, particularly poverty and discrimination. This fundamental human right places legal obligation on governments to tackle social determinants where they harm health.
As the UN and many others have devoted more attention to the right to health over the last ten years, new human rights tools and techniques have been developed, as articles in this issue of Health Exchange show. We no longer only think in terms of taking test cases in the courts, letter-writing campaigns and ‘naming and shaming’ – although these continue to have an important role to play. Additionally, we use indicators, benchmarks, impact assessments, budgetary analysis and so on. Accountability is now understood to be so much broader, and more subtle, than judicial accountability, which is accountability of the last resort. There are other forms of accountability such as national human rights institutions, public inquiries, local health councils, regional health conferences with grassroots participation, maternal health audits or reviews and so on. Human rights accountability is not just about blame, sanction and punishment. It is about finding out what works, so it can be repeated, and what does not, so it can be revised

Paul Hunt UN Special Rapporteur on the right to the highest attainable standard of health (2002-2008)
Professor of Law, Human Rights Centre, University of Essex

Korsang: Cambodian drug users’ right to health

Drug users in Phnom Penh were once without self esteem, felt ashamed and worthless and had no concept that they were entitled to, and deserve, the same quality of life and health care as other Khmer citizens. Previously, no services existed for the adult drug using community and until Korsang was founded in 2004, there was no needle exchange programme serving adult intravenous drug users (IDUs).

Holly Bradford, Korsang founder and technical advisor shares the story.

Many hospitals and clinics in Phnom Penh discriminate harshly against intravenous drug users (IDUs), including IDUs living with HIV. Commonly, doctors refuse to admit or treat them, regardless of how critical their health situation is. Patients who are admitted are frequently ignored and go untreated for days. In hospital, neglect and withdrawal without medical assistance, means nearly 100 per cent of IDUs living with HIV leave before finishing treatment. Those unfortunate enough to become involved in the Cambodian drug user detention system befall the same fate.

Korsang is a grassroots harm reduction programme in Phnom Penh working with the Khmer population to prevent HIV and other drug related harm. HIV transmission among IDUs in Phnom Penh is a growing problem, with an estimated infection rate of 34 per cent. The two main reasons are lack of proper education about the risks of drug use and poor access to good health care services.

For IDUs living with HIV, there is a serious lack of public services. Unsanitary living conditions and lack of access to antiretrovirals (ARVs) and other HIV medicines, means many people are prematurely and unnecessarily overcome by opportunistic infections. Many infections develop as a result of abscessed injection sites and in some cases are fatal.

The focus of the Korsang team is to engage in intensive, harm reduction street-based services. We do not discriminate against clientele based on age, and serve a population of over 3,300 users between 12 and 55 years of age. Korsang targets Cambodians who are engaged in injection drug use and yama use, who are at serious risk of HIV and other health-related hazards that accompany drug use and high-risk sexual behaviour. Korsang staff visit 20 areas where street-based injection drug use is a serious issue and sex worker areas where yama and unprotected sex go hand in hand. We have created multiple educational programmes to reduce the risk of HIV infection among IDUs and offers a menu of services and options for the drug users of Phnom Penh including a drop-in centre, citywide street-based outreach, needle and syringe distribution, peer education, methadone transportation, methadone case management, referral and advocacy, a transitional living programme and HIV testing.

Since Korsang began serving drug users, many opportunities to reduce the risk of drug-related HIV transmission and other drug related harm have increased. Our on-site medical services have been invaluable in this sense. Since drug users in Cambodia have no immediate access to medical care, Korsang has an on-site medical infirmary with a full time doctor and a medical crisis team of three full time staff and three part time staff. The medical team treats an average of 1,000 drug users each year, and case manages and advocates for another 250 drug users who require in-patient care at a local hospital. The majority of our participants have never been to see a doctor and are therefore unvaccinated, undiagnosed and untreated for other chronic illness such as diabetes, thyroid dysfunction and asthma.

The Korsang medical team is not only responsible for administering basic first aid in the field, but also for the transportation of sick and injured participants to our infirmary and the hospital. If a participant is hospitalised, the team is responsible for making sure food is provided, along with a mat, mosquito net and water. Hospitals in Cambodia provide no personal provisions, so the medical team provides 24-hour supervision and advocacy to inpatient participants. The team also provides Direct Observation Treatment (DOT) for participants on ARVs and tuberculosis medication throughout Phnom Penh. Outsourced services to local hospitals are paid for by Korsang and include pre- and post-natal care, midwife consultations, deliveries, minor and major surgery, X-ray and electrocardiography, severe emergency trauma services and all in-patient care. Finally, the medical team also tends to participants who die, ensuring each has a proper cremation and burial.

Some of the medical issues that participants are treated for include: HIV and AIDS and related opportunistic infections, injection-related infections, for example: cellulites, abscesses, endo-cardnitis, skin ulcers, septicemia, gangrene, hepatitis B and C, as well as acute tetanus. We see a fair amount of needles that have broken off and are lodged under the skin. This situation requires minor out-patient surgery, which our clinic provides. Other medical conditions are less associated directly to injection related behaviour, but are linked with the harsh and chaotic lifestyle drug users who live in Cambodia endure. These conditions include, but are not limited to: gun shots, stabbings, machete wounds, stoning contusions, broken bones, amputations, tuberculosis, eye infections, pregnancies and subsequent births, sexually transmitted diseases, chest infections, parasites and food- and waterborne disease, malnourishment and vitamin deficiency, as well as an array of other medical problems.

The medical clinic is dedicated to providing the best possible health and medical care for all IDUs, providing care which is focused on the patient, their needs and desires. The staff focus is on the whole patient, not just the illness or condition, and every patient is treated with dignity, compassion, confidentiality, respect, and as a person who is involved in decisions regarding their own treatment and care.

It is clear to Korsang that drug users need, and are entitled to, medical facilities that are 100 per cent dedicated to their special needs, services that do not discriminate, stigmatise or criminalise them. We hope our model will spread to other locations, both regionally as well as globally.

Holly Bradford, Korsang, Cambodia

The Right to Health in Uruguay

In 2007, the People’s Health Movement in Uruguay took a critical stance on the right to health and has been campaigning vigorously as part of the Global Campaign for the Right to Health.

Fernando Borgia shares the experience.

Uruguay is a small country, both geographically and in terms of population. Ninety per cent of people live in the capital and in the departmental capitals. There are however, small numbers in the countryside and people crowd around the horse changing posts and railroad stops. These populations, and also those that live on farms, comprise what we call “the deep inside” or “the real country”. There are few opportunities to receive information, exchange and discuss views on human rights topics, and to be heard. We decided to prioritise these populations in the ‘Right to Health Campaign’ in 2007 and linked up with the People’s Health Movement (PHM) globally.

A handful of volunteers from Montevideo held more than 80 briefings in over 60 locations in 19 departments to promote active participation in regional and national social health forums. We held preparatory meetings and regional forums, and shared these discussions at the 3rd Uruguayan Social Health Forum in 2007.

In Uruguay, we can say that we had a genuine dialogue about the right to health with more than 2,500 people. Lessons from Uruguay, from its people, and the problems and challenges they face, became a huge experience for us.

How useful was this mobilisation? Did it help us get closer to achieving the right to health? To answer these questions I should point out the context. Since March 2005, Uruguay has had a progressive government which recognizes health as a human right, and as a responsibility to be ensured by the State. This was a significant change from the previous government. When we held the forum in 2007, the law creating the National Integrated Health System (Sistema Nacional Integrado de Salud – SNIS) was still in debate; it was approved in December 2007. So, the forum was an area of discussion focusing on the health needs of people and their relationship with the health system. It showed the importance of social organisation in demanding rights, and the inter-relatedness of citizens and the health system.

Since the establishment of the SNIS we have continued to advocate for the right to health through our research project “The role of primary health care, community and rural clinics in the new SNIS”. The SNIS places special emphasis on primary health care, but as in many countries, the term “primary health care” has been used to describe multiple ways of operating the primary care level without a real development of primary health care in the original sense of the Alma Ata Declaration.

The creation of the ‘Movement of Users of Private and Public Health’ as a formal organisation in November 2007 was an important step. There are some particularly remarkable facts about this movement. It has members in all 19 departments of Uruguay. It has been recognised as an official task force by the national health authority. It has appointed one of its leaders to the National Board of Health, which is the highest health policy authority with citizen participation such as workers.

At the 4th Uruguayan Social Health Forum in Rio Negro (November-December 2008), we emphasised the importance and validity of the collaboration between different movements. Colleagues from the PHM in other parts of Latin America, such as Brazil also participated. PHM can be thought of as a common platform that unites various groups that make up the forum. In most of the groups, many people have endorsed on-line the People’s Charter for Health, the founding document of PHM.

The Social Health Forum is a space to connect national problems and experiences with the Latin American and global agenda for people’s health. It also acts as a chapter of the People’s Health Movement in Uruguay, and serves as a joint space of the Movement of Users of the Private and Public Health, ALAMES (the Latin American Association of Social Medicine), and the Uruguay Medical Union and, to a lesser extent, the Uruguayan Federation of Health (non-medical workers).

We have developed a training agenda for health activism. The most relevant result of the training activities has been to promote an alternative way of thinking in health. The representatives of the movement have modified their discourse, from demanding better health care services to demanding the right to health as a comprehensive vision including the social determinants of health. It is also important to note the growing relationship with trade unions, beyond the health sector, and various community organisations and NGOs interested in the right to health. Building a relationship with provincial governments has also been useful to ask for and to create opportunities for interaction with the Ministries of Health, Labor and Social Security, and Social Development.

Since 2004, we have been collaborating with other organisations in the preparation and presentation of the Annual Reports on Human Rights in Uruguay, especially in chapters concerning right to health, advances and setbacks in the country. This is the only independent systematic and collaborative report we have. In 2008 we edited jointly with Ideas-Action and Change (Ideas Acción y Cambio – IDAC, a social group from small town) a newspaper called ’People’s Graffiti’. We also have a blog, although it is not updated systematically.

When we linked up our national campaign with the People’s Health Movement, we found that many groups around the world are taking up the concept of the right to health, and using it as the standard for health systems and as a framework for making demands on their government and other duty bearers. We hope that by linking these local and national level groups together, we can help support them and build global awareness of the Right to Health.
Fernando Borgia