Human rights are at the center of the UN Secretary-General’s Global Strategy for Women’s, Children’s and Adolescents’ Health and figure prominently in the new SDG framework. But what does it mean to apply a human rights approach to the implementation of policies and programs aimed at preventing maternal mortality and morbidity? In 2012, the Office of the United Nations High Commissioner for Human Rights (OHCHR) published a report providing technical guidance on this topic.
Applying a human rights-based approach to policy and program implementation requires a fundamental shift in mindset about the relationship between women and the healthcare system. Women seeking health and healthcare services have been characterized as patients, clients, consumers, users, beneficiaries, and sometimes as victims of poor or unavailable care. A human rights-based approach asks us to see them fundamentally and principally as rights-holders, and those in the healthcare system as duty-bearers, who are obligated to protect, uphold and fulfill women’s rights in the context of their health care. While states bear the ultimate obligation for protecting and enforcing the rights of citizens and ensuring redress and remedy for their violation, applying a human rights based approach to the implementation of MNH policies and programs requires an extension of this obligation all the way to the frontline provision of care.
Here at GMNHC, a panel of civil society advocates shared their experiences on the ground in four countries. Some were advocating specifically for uptake of the OHCHR technical guidance in their countries, while others sought to apply aspects of the guidance directly through their own work. They shared their challenges and lessons learned.
Alicia Ely Yamin of the FXB Center for Health and Human Rights, Harvard University moderated the panel. She pointed out a major challenge of effectively applying a human rights based approach to maternal health and survival is that it requires not only bridging efforts at all levels of the system, from global to grass roots, but also building crosswalks between legal and health sectors. It further requires various actors to close gaps in their understanding of the different realities experienced by others, for example, members of Parliament who do not know the realities on the ground in the area of service delivery and therefore do not hold decision makers in the health system to account, or women who do not understand the national or district-level budgeting processes and therefore cannot demand the allocation of sufficient resources to fulfill their rights.
Manuela Garza, from IMMHR in Mexico, described her work in the area of budget accountability, and how the way that resources are allocated and what influences those decisions reflects and impacts how women are treated in the healthcare system. Her main lesson was that while there is a need to sensitize key officials about applying a human rights based approach, advocates need to be prepared when they ask “HOW do we do this?” There is a need to operationalize, and instrumentalize a human rights-based approach within the financial, judicial, and legislative systems in countries, so that the obligation of the state is fulfilled by the state as a whole, not and relegated to any one entity.
Busisiwe Kunene, from the Society of Midwives South Africa, reported on her work training midwives to empower women to claim their rights. She challenges their concept that a woman who is pregnant or in labor is sick and disabled and teaches midwives about AAAQ and accountability, also working with within clinical structures and with policy makers on using a human rights approach to MNH. Her lessons learned were exhortations to be strategic, to know what you want and make clear asks, and if your first strategy doesn’t work, to find another one.
Ariel Frisancho, from the Catholic Medical Mission Board and ForoSalud, shared his reflections from implementing a program for citizen monitoring by indigenous women in Peru, suggesting that accountability should really be the fourth “A” in the AAAQ framework. Dignity is an important—and often missing—dimension of quality. Without indicators for dignity, we cannot track quality of care as it is defined by and matters to women. When up to one fifth of women are not going to facilities due to fear of mistreatment, we must look skeptically at claims that “we know what we have to do” to end preventable mortality. Non-discrimination, participation and accountability are missing pieces if we truly want people-centered health systems. His lessons learned were:
- Create spaces for dialogue and learn to listen to people for a people-centered approach
- Understand concepts of quality as defined by communities
- Work with health personnel and bring their voices to the table: they are not the enemies
- Overcome resistance by speaking in the language of each stakeholder group
- Things can change; we need to overcome our own mental barriers and assumptions
- Be visionary and courageous
Jashodhara Dasgupta, of SAHAYOG India, described her group’s efforts to advocate for adoption of the OHCHR Technical Guidance into maternal health policies in India through Parliamentary advocacy to oversight bodies. She argued a human rights approach is needed to achieve equity, promote respectful maternity care, and protect women’s sexual and reproductive health and rights. She shared a heartrending story of three marginalized women in Uttar Pradesh who were forced to give birth on the floor though beds were available and whose babies died as a result of egregious neglect and mistreatment. She pointed out that “By focusing on the wrongs, you can build awareness about rights,” as stories with strong emotional power can galvanize people to action and activism. She pointed to decentralization as a challenge: when policies are made at central level, but responsibility for implementation is at the local level, oversight is lost and accountability falls through the cracks.
Valentina Zendejas, from the Instituto de Liderazgo Siimone de Beauvoir in Mexico, shared challenges with attempts to sensitize frontline providers about human rights in the context of women’s health through human rights workshops. Her take-home message was that a change of mindset cannot be “trained” in one encounter, and that encouraging providers to think differently about their role and about the women they serve and their lived experiences takes time.
The ultimate message from this panel was that applying a human rights-based approach to the implementation of policies and programs for preventing maternal mortality and morbidity requires people at all levels who hold positions of power to recognize that they are duty-bearers and that as such they have an obligation to justify their decisions to rights-holders, through application of the human rights principles of participation, transparency, accountability, and with special attention to non-discrimination. Ali Yamin wrapped up the session with a powerful message that doing so is not largesse on the part of duty-bearers, but an entitlement of rights-holders, in all countries and all health systems.
Photo: “Universal Declaration of Human Rights” © 2008 Jordan Lewin, used under a Creative Commons Attribution-NonCommercial license.