Health and human rights: Bridging theory and practice Abstract

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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 Program
on International Health and Human
RightsDepartment of Global Health and
PopulationHarvard School of Public
Healthhttp//www.hsph.harvard.edu/pihhr/ sgruskin
_at_hsph.harvard.edu http//www.hsph.harvard.edu/pih
hr/
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, 1988 US 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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Human Rights Relevant 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

• 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

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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 partiesto
  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 of health 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 Ava
ilability Accessibility Acceptability Quality Othe
r 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
• WHOs 3X5 strategy referred to HIV treatment as a
  human 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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Human rights, gender and the Greater Involvement
of People Living with HIV and AIDS (GIPA)

• 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

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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 how many 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) S13S19
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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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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 womens
  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 others 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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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?