Health & Human Rights

in our backyard

Presentations from Kenya, Uganda, Rwanda, the United

States, and Burundi

Recap: critical links

KENYA The human rights dimensions of major

health challenges in Kenya can be understood using the model of AAAQ: Availability Accessibility Acceptability Quality

In Kenya: Availability Population of approximately 33 million ppl. 2 referral hospitals Few health centres are fully equipped Rural Urban migration has affected the

development of rural areas As a result, more money is allocated to urban

areas Following this, the availability of

services, particularly in rural areas, has been compromised.

In Kenya: Accessibility Accessibility encompasses physical,

geographical and financial aspects. Within rural areas, poor infrastructure can

lead to inaccessible health facilities For the rural poor, health care costs can

be prohibitively high In remote areas adequately staffed and

supplied health facilities are difficult to reach.

In Kenya: Acceptability Health services, goods and facilities must be

sensitive to cultural, gender and age differences Many patients in Kenya seek medical attention

from traditional healers Critically, the provision of accurate health-related

information is key to ensuring the acceptability of services (such as awareness of contraceptives)

Provision of information is also part of the underlying determinants of health, and must be addressed by the government in its programming and health workers in their practice.

In Kenya: Quality Quality can be affected by the type of

facilities available. Many health facilities do not embrace

current available technology in order to improve the quality of services.

A shortage of properly trained health care providers, inequitably distributed, also contributes to challenges in terms of ensuring quality services.

Final thoughts & questions…

UGANDA The health and human rights challenges in

Uganda can be categorized into three broad groups: Challenges facing health care workers Challenges facing patients and the community Challenges facing policy makers and the

government

In Uganda: Challenges facing health workers Low salary

Adequate and appropriate salary for health workers is critical for the provision of available, accessible, acceptable and quality health services.

Poor working conditions in public hospitals Health workers have a right to safe working

conditions Government has an obligation to avail supplies

and put protective measures in place, such as vaccination of all health workers against Hep B

Challenges facing health workers, cont’d Inadequate continuous medical training

and education (CME) Adequate opportunities are necessary to

further studies and knowledge regarding the latest innovations in the global medical arena

Leaves health workers with fewer skills to match the ever increasing burden of disease

Gov’t should work to avail these opportunities in order to ensure appropriate training and service provision

Challenges facing health workers, cont’d Heavy workload

Doctor to patient ratio is estimated at 1:120,000 in the outskirts of urban areas and 1:13,000 in urban areas

Strains healthcare workers and affects the quality of care (as well as accessibility and availability of services)

Comments: Health workers have a right to safe

working environments Government has an obligation to provide this

A strong and vibrant health workforce is critical to the provision of available, accessible, acceptable and quality health services

While the lack of supplies or infrastructure is often beyond anyone’s control, it can also be the result of corruption and mismanagement

In Uganda: Challenges faced by patients Inequitable access to health services and

information Traditionally believed that health information is or should

be accessed only at hospitals, clinics and other health facilities

Rural-urban divide Patients have the right to access health

information The government and health workers both have a role to

play in this Information must be accessible: promoting the right to

health requires that the government make progressive steps to improve these aspects of health services

Challenges facing patients, cont’d Promoting equitable access

People’s needs guide the distribution of resources

Governments must work towards eliminating disparities in health that are associated with social disadvantage (being poor, being of a particularly vulnerable group, etc.)

In Uganda, poverty and gender inequality can exacerbate inequities in health service provision

Challenges facing patients, cont’d Gender inequality

Women seek permission on certain health-related decisions (e.g. VCT, RH/FP)

Gender perceptions in the community may lead to the denial of women’s rights (such as right to education, right to health, etc.)

Health care providers respect for women’s health-related decisions

Poverty People lack access to the underlying

determinants of health (clean water, sanitation, etc.)

Challenges facing patients, cont’d Drug stock-outs

Recent stock outs of TB drugs, antimalarials (Coartem) and other basic essential medicines

Mulago National Referral Hospital More extensive stock-outs in rural health

facilities Links with the obligation to provide available,

accessible health goods Severe effects on drug-resistance

Challenges facing the government and policy makers Corruption and poor planning within the health

care system Recent Global Fund and GAVI resources

Inadequate health financing Question of the government’s priorities within the health

budget and how it affects realization of the right to health in Uganda

Poor surveillance network Communication gap between policy makers and service

providers Brain drain!

Affects health workers, consumers, communities and the government

In Uganda: Ethical and organizational issues Illegally charging patient fees “Moonlighting” and running private clinics

in conjunction with public sector work Diversion of drugs and supplies Study leave, which contributes to

workforce shortages, but not to vacancies In the end, these practices negatively

affect the right to health of people throughout Uganda

Final thoughts & questions…

RWANDA Rwanda is currently struggling to establish

improved health conditions for its citizens following the 1994 genocide.

During that period, many health facilities were destroyed and many human rights violations, including the right to health, occurred.

Currently, there are several major health challenges facing Rwanda, all of which have key human rights dimensions.

In Rwanda: Cost of health care Most medication in Rwanda comes from

abroad or as a result of support from NGOs, which increases its cost once it arrives in the country

Recognizing the human right to health, the government has created “mutuelles de sante” in an effort to ensure equal access to health services

Pay up to 1,000 frw per year and receive a 90% cost reduction in services

Cost of health care, cont’d This initiative has had a very positive

impact on the number of people visiting health facilities

Rate of enrollment was 42% in 2006 75% in 2007 85% in 2008

Challenges still remain in terms of access in rural areas

In Rwanda: Health workforce shortage For health services to be available and

reach all in need, there must be enough health workers

In Rwanda, challenges in achieving this include: High density population (total population is 9.3

million) 1 doctor for every 18,000 inhabitants; 1 nurse

for ever 1,690 inhabitants The gov’t and MOH are making great

efforts to orient and deploy health workers where they are needed most

In Rwanda: Maternal and infant mortality Infant mortality stands at 62/1,000 Maternal mortality stands at 750/100,000 Under 5 mortality stands at 103/1,000 52% of deliveries by skilled birth attendants

These are key indicators of the strength of the health system

Convention on the Rights of the Child, Chapter 2 (1) “Measures should be taken to diminish infant and child mortality”

In Rwanda: HIV, TB and Malaria These three diseases remain major

challenges due to Lack of behavior change Lack of access to information Lack of systemic control (for TB)

Human rights aspects of these challenges Must work to improve the availability and

acceptability of information and services to promote behavior change

Improve the provision of medication and counseling for people living with HIV/AIDS and TB

In Rwanda: Health and human rights at the University Every student in the medicine faculty is a

member of MEDSAR, which protects their needs and acts as a welfare body

Members of Mutuelles de Santes at 650 frw per month

Through MEDSAR health students receive funds to undertake community and campus-based projects relating to the right to health

In Rwanda: Health and human rights education Human rights health professionals come to

lead human rights seminars Sharing of knowledge through events and

activities organized through MEDSAR However, human rights are not formally

addressed within the curriculum Students, through MEDSAR, are undertaking

advocacy and lobbying to address this situation

Final thoughts & questions…

UNITED STATES Health Challenges

Human Rights Dimensions

Next steps

In the US: Lack of Universal Access

Challenge: U.S. – only industrialized nation without a universal health care coverage scheme for its citizens

HR dimension: Health care is a basic RIGHT, not a privilege, right to life

Next steps: Many activists/advocacy groups are advocating for universal coverage through a variety of mechanisms, public and private. Aspects of American cultural attitudes and industry voices impede progress.

In the US: Health care disparities Challenge: Different minority groups in the U.S.

have poorer health outcomes (e.g., Latino, Black American, First Nation, immigrant populations)

HR dimensions: Access to healthcare, health care professional assumptions affecting treatment decision-making, health literacy

Next steps: Increase access to health care; standardizing care and addressing stereotyping; improved health literacy outreach; increased funding to research and minimize health disparities vs. genetic differences (e.g., hypertension, diabetes, cancer); narrow SES gap.

In the US: Maternal and women’s health

Challenge: In the US, 2-3 women die of pregnancy-related complications every day, and African American women are 3 times more likely to die than white women.

HR dimension: Preventable deaths, right to life, freedom from any health discrimination

Next steps: Half of these deaths could have been prevented if women had better access to adequate quality healthcare.

http://www.amnestyusa.org/poverty-and-human-rights/health-and-human-rights/maternal-health-in-the-united-states-an-aiusa-research-report/page.do?id=1041211

In the US: AIDS in our capitol

Challenge: Highest HIV infection rate in the U.S. in Washington, DC (2%); 81% new infections in Black Americans and they carry 86% of the HIV/AIDS disease burden overall

HR dimension: Extreme health and wealth disparities in the U.S. and problems with access to care

Next steps: Appropriate targeting of at-risk groups in DC; increased funding for outreach and treatment activities; free-condom distribution and expanded availability of testing.

In the US: Lifestyle disease epidemics

Challenge: Increasing prevalence of obesity, metabolic syndrome

HR dimension: Food deserts, inadequate prioritization of prevention, food industry clout for additives/national diet structure

Next steps: Increased funding and campaigning for preventive health measures, emphasis on lifestyle and behavior modifications, change school cafeteria food options, making fruits/vegetables more accessible and affordable

In the US: Environmental protections Challenge: Environmental pollution and negative

health effects, particularly among minorities and people with low SES

HR dimension: G.W. Bush administration’s weakening of environmental health standards, people at risk of lung and other diseases

Next steps: improving environmental standards (e.g., pollutants) with legislation, “greening” technology, stricter FDA standards of cosmetic chemicals and technologies, improved HCP recognition of occupational and environmental etiologies of disease. Succeeding story: smoking bans in major U.S. cities and many smaller ones.

In the US: Torture of detainees Challenge: Detainee rendition in order to

torture, human rights and legal abuses of detainees

HR dimension: Violation or manipulation of international agreements and declarations, violation of human dignity

Next steps: Instate due of process of law, cease extraordinary rendition practices used for torture, stricter anti-torture practice/legislation.

In the US: Shortage of health workers Challenge: Lack of adequate domestic health

workforce, especially in rural areas and primary care areas of medicine

HR dimensions: Skewed levels of access to care across the U.S., contribution to health care worker “brain-drain” internationally

Next steps: Increase funding and compensation for primary care & geriatric medicine; increase medical school class sizes and/or number of schools; improve access in rural and economically depressed areas of inner cities.

Concluding thoughts:

These are only a few of many more issues health professionals confront and need to confront

Lack of health & human rights educational components in most medical schools needs to be addressed

Of all the forms of inequality, injustice in health care is the most shocking and inhumane.

-Martin Luther King, Jr.-

BURUNDI Burundi is an East African Country

bordered by Rwanda in the North, Democratic Republic of the Congo in the West, and Tanzania in the East and South.

8.5 million people, density of 189 Hab./km square

Rural population is 90% 7,000 health workers, half of which work in

urban areas

In Burundi: HIV prevalence

3% of adults (150,000) HIV positive pregnant women

12.6% in 2004 18% in 2005

HIV among women, 15-24 years old 8.6% in 2004 15.5% in 2005

In Burundi: Health rights background Emerging from civil war, lasting from 1993

– 2003 70% of the population lives in poverty Widespread refugee camps

Poor hygiene Malnutrition HIV prevalence

Violence during the period of civil war Lack of human rights awareness and

education

In Burundi: Health care costs Medical consultation costs an average of 1

USD Majority cannot afford this, and resort to

traditional healers Economic accessibility (affordability) is a

key component of the right to health Even in emergency situations, people must pay

before they can access services Patients who fail to pay for their services are

detained in the health facility No insurance schemes for the majority of the

population

In Burundi: Health workforce shortages While the rate of medical students

graduating increases every year, there is still a shortage of doctors and nurses throughout the country Insufficient salary Poor working conditions Lack of materials and sufficient infrastructure

Without an adequate health workforce, it is very difficult to provide services that are available, accessible, affordable and of good quality

In Burundi: Acceptability of services Health workers currently in post are not

adequately trained about effective communication

Many patients have negative experiences in public health facilities

Health workers must appropriately trained to provide culturally sensitive, gender sensitive and ethical services.

In Burundi: Access to health-related information Government has an obligation to “protect”

the right to health from infringement by other parties Nutrition and food products Medicine quality Adequate housing and shelter – pre-fabricated

homes Access to information is an “underlying

determinant of health” – without it, you can’t fully enjoy the highest attainable standard of physical and mental health

In Burundi: Women’s vulnerability

High HIV/AIDS infection rate among women Due to sexual and gender-based violence Social aspects that affect access to health services must

be addressed in rights-based health programming Male condoms are freely distributed, but female

condoms are rarely available Rights-based approach requires special attention be

given to vulnerable and marginalized groups Government must take proactive steps to address

women’s increased vulnerability (and that of other groups)

Women’s vulnerability, cont’d In order to ensure equal access to non-

discriminatory health care, we must address Low levels of access to adequate health care

services Access to information on antenatal and

postnatal care and family planning Economic disempowerment

In Burundi: What is being done? Civil society is widely involved in health rights

advocacy Religious organizations and the media are

contributing to raising awareness of health and human rights

Government has adopted some key policies: Free healthcare for children under 5 Free access to health care for PLWHA Organized vaccination campaigns Reviewing salaries of health professionals and hospital

equipment

Conclusion: Everyone must be engaged and play their

own role Government must plan and link their

policies in the health field to national and international policy

Government must improve the underlying determinants of health and the population’s lifestyle Promote education Fight poverty, malnutrition and endemic

diseases

Conclusion: Civil society must continue to lobby the

government, in collaboration with other NGOs and stakeholders

Health professionals are called upon to provide culturally sensitive, gender sensitive and ethical services to ensure the quality of health services

Health professional students have to advance an understanding of health and human rights in health-related institutions Promote student skill development and activism on key

health and human rights issues