Why are free clinics necessary and what role do they play in the provision of health care in the US. The answer is presented in the book’s foreward:
In 2011, 46.3 million people were uninsured in the United States, about 15% of the population) This figure was expected to rise by the end of 2012. For minorities, the figures are worse, with nearly 30% of Hispanics and nearly 20% of African Americans being uninsured) Free clinics receive nearly 4 million patient visits a year. Without these clinics, the nation’s emergency departments and public health clinics (including federally qualified community health centers) would have to absorb all these patients and the costs associated with their care.
Simply put, free clinics provide an enormous amount of care. Even after the full implementation of the Affordable Care Act it is estimated that 20 million plus people will be without health insurance in the US. Many millions more will be under-insured meaning that the cost of actually using their insurance will be prohibitive. Thus, “free clinics” stand as a reminder of the failure of our society to guarantee health care as a human right. They also demonstrate the enormous commitment of many health care professionals to caring for people even when not paid.
Since the chapters come from an academic journal there is focus on critical thinking and data-driven evaluation. This is not a coffee table book idealizing the people who provide free care. There is, for instance, discussion of the “stop-gap” and “band-aid” nature of free clinics. Half of the book is devoted to general experiences with free clinics and the other half is devoted to papers on student-run free clinics. The book will be particularly valuable for those involved with (or thinking of setting up) free clinics.
Free clinics should not really be needed. Yet for those of us working in primary care the problems of un-insurance or under-insurance (particularly in working-class immigrant communities) is a daily reality. We work at and we refer to free clinics because we must. But all the while we remember that in the great towers of Wall Street – the banks, the insurance companies, the brokers – there is the money to set this problem right.
Readers of the Portal who are interested in purchasing this book can take advantage of a special 25% discount. The book has been published by Johns Hopkins University Press.
Health/PAC (the Health Policy Advisory Center) has recently posted PDF versions of all their Bulletins at: http://www.healthpacbulletin.org/. The Bulletin was published from 1968 to 1994 and documented the work and analysis of progressive health activists from around the country. The introduction to the collection provides a history of the organization and the Bulletin. Health/PAC’s organizational archives are housed at the Temple University Library: http://library.temple.edu/collections/scrc/healthpac-policy-advising.
Health/PAC was also responsible for the publication of three books:
The American Health Empire (1971): Chapter 1 is available at this link.
Beyond Crisis: Confronting Health Care in the United States (1994)
Health/PAC developed the concepts of “medical empire” and “medical-industrial complex.” With time we have seen the increasing relevance of these terms for the analysis of a economic sector that makes up nearly 1/5 of our economy. This is an invaluable collection for the critical analysis of health and health activism.
April 29 – July 19, 2013 / Reception: May 17, 2013
Born in a Cambodian refugee camp where both parents worked in labor camps, Pin immigrated to the U.S. in 1983. Drawing from the experiences of his family as survivors of the Khmer Rouge regime (1975-1979), Pin photographs Cambodian communities throughout the United States. He documents the struggle and pain of the survivors and the direct descendants of the genocide that took millions of lives. The series is a testament to those who died, and an examination of where future generations are now. In an attempt to understand his heritage, Pin pays tribute to the lives of the survivors.
Pin states, “I have struggled for most of my life to understand the legacy of my people. They are among the most heavily traumatized people in modern memory, the human aftermath of a cultural, political, and economic revolution that killed an estimated two million, nearly a third of the entire population, within a span of four years. That tragedy casts a long shadow on the lives of Cambodians that bleeds generationally, manifesting itself across generations.”
Pin studied at the International Center of Photography and is currently finishing his Artist in the Marketplace residency at the Bronx Museum of the Arts. Pin is also a Season of Cambodia artist, an initiative that promotes Cambodian artists.
Location: En Foco at Montefiore Family Health Center360 E. 193 Street, Bronx, NY 10458 t: 718.921.9311Reception: Friday, May 17, 2013 from 4:30–6pmArtist Talk: Friday, May 17, 2013 from 6–7pmExhibit Dates: April 29 – July 19, 2013Hours: Monday – Thurs, 8:00am–8:00pm; Friday, 8:00am–4:00pm; Saturday 8:00am–noon
En Foco’s Touring Gallery exhibitions feature presentations by emerging photographers in community spaces throughout New York City, curated by staff or emerging guest curators. Photographers gain professional exhibition experience, an opportunity to interact with local audiences, and are awarded an honorarium. All Touring Gallery events are free and the public is encouraged to attend. Touring Gallery is funded in part by the NY State Council on the Arts, the NY City Department of Cultural Affairs, the Bronx Council on the Arts, the Andy Warhol Foundation for the Visual Arts, and En Foco friends. Special thanks to Montefiore Family Health Center and Montefiore Art for Health, for their collaboration and support.
-The fact that we have so many poor people is sad. But that it always is the same people is definitely unfair.
-Being poor, you do not complain, you are relegated to a position of accepting. (F. Monckeberg)
1. From a human rights (HR) point of view, the real problem we face is not only a concern of unacceptable levels of poverty but, together with it, appalling and morally objectionable levels of excess affluence. We cannot thus end poverty without touching the structures of property and of wealth distribution, i.e., without modifying power relations. I am afraid that policies that are centered around ‘combating poverty’ only attempt to avoid the ultimate fear of the haves, namely entering into a to-them-damaging conflict with the have-nots of this world. (R. Zibeki)
2. This is why I urge readers to rather use the concept of disparity reduction (instead of speaking of poverty alleviation or poverty eradication). Doing so rightly contextualizes poverty in the process of exploitation, of domination and of power imbalances it really is. I also thus agree with those that speak of poverty being a state of ‘ill-being’ (as opposed to well-being).
3. What this implies is that we should not continue measuring poverty just in figures, but rather looking at it as the broader lack of basic capabilities to live in dignity. Poverty is about physical and economic insecurity, about lost opportunities, about fear of the future and about a constant sense, not of being vulnerable, but rather (intentionally) marginalized. It is about a sense of powerlessness.*
*: Persons experiencing extreme poverty live in a vicious cycle of powerlessness, stigmatization, discrimination, exclusion and material deprivation, which all mutually reinforce one another.
4. In that sense, as we know, there is not only a North-South rich/poor divide, but there are also huge inequalities within societies.** Inequality is actually omnipresent and that is where we need to focus our efforts-on and why that focus, in the spirit of HR, has to be on the reduction of disparities.
**: So, who then is poor and who is rich? For consumer society apologists rich is not he who has everything, but he who does not need anything and thus does not consume. For the more liberal-minded: Rich people are people who are so poor that they only have money. (L. Esquivel)
5. In the ‘poverty reduction’ interventions we so often see, the deplorable outcome has been (and is) what has been termed ‘elite capture’, i.e., the process by which the economically better off appropriate for themselves resources that are actually intended for poverty eradication… both at the national and at the international level. (Remember that conservatively estimated, more than 50 cents on the dollar of bilateral foreign aid reverts to the donor country!).
6. What all this boils-down-to is that the problem of poverty is not one of the poor, but rather one of the entire society; and it will persist until the heart of the economic system, i.e., the transfer of wealth from worker to employer, is eliminated. (M. Anderson)
7. From the HR point of view, a truly compelling rationale for disparity reduction is the recognition that, among other, it can make use of existing internationally sanctioned legal obligations. But disparity reduction strategies must further seek to foster an enabling environment for claim holders to get actively involved based on the initiatives and solutions they themselves sanction and endorse. We know that those that happen to be poor are seldom claiming their rights; so the challenge is to set up human rights learning opportunities that contribute to raise their political consciousness so they get organized and start interacting with duty bearers and actually start claiming and demanding.
Pauperization in the context of the current global crisis
-Margaret Thatcher is known to have said: “Class is a communist concept”, “morality is personal” and “poverty is not material, but behavioral.”
-What characterizes the unemployed is not that they have no work, but that they have no money; nobody tells a millionaire that he is an unemployed if he does not work.
8. Regrettably, the human rights toll of the painfully slow economic recovery from the crisis (if any) is underestimated. Take just one example: the high levels of unemployment with record levels in Europe.*** And beware: the mortality rate of laid-off workers is higher and persists 20 years after the job loss leading to 1-1.5 years lower life expectancy. (We are talking human right to life here!) Note: Totally under-utilized (or ignored) is the option of providing unemployment insurance tied to community service. (F+D, 47:4, Dec.2010)
***: Have you ever heard of the ‘Misery Index’?: It is the sum of the unemployment rate and the inflation rate. Would be interesting to use more often.
9. On top of unemployment, 152 million young people were living on less than $1.25 a day in 2008 (28% of all young workers in the world). The rate is most probably higher today –certainly in some countries in Europe. (ILO) Most governments self-servingly care more about production than about distribution. Nothing new here. No wonder desperation and neuroses have been growing much faster than the economy! I have even read that poverty can more easily lead someone to delinquency (or suicide) than to spirituality. In any case, falling back on religion does not seem to help much. (Albino Gomez)
10. Bottom line,
poverty is the key determinant of social exclusion;
the HR framework focuses on human deprivation and on the mechanisms that produce and reproduce it;
the social protection the HR framework seeks **** refers to publicly-mandated policies and programs that address the needs, risks and vulnerabilities of poor and near-poor households.
****: Social protection includes social security, social assistance, labor rights, the right to public services and environmental rights (F. Mestrum)
universal social protection is supposed to bring about social inclusion by addressing the main drivers of exclusion;
looking at poverty as a social exclusion process gives us an understanding not only about its effects on people’s livelihoods, but is also an eye-opener that exposes the relationship between the income and non-income aspects of well-being;
social exclusion makes us focus on the role of income in the access to essential services and the social participation therein; it also highlights the role of social and institutional factors that result in human deprivation through ongoing economic marginalization. (B. Babajanian, J. Hagen-Zanker)
In part adapted from The Broker, Issue 23, Dec.2010/Jan2011; The Broker, Issue 24. Feb/March 2011; UNFPA, A HRBA to Programming: Practical implementation manual and training materials, 2010; and F+D, 47:4, Dec.2010.
Postscript: “Do not smoke, and if you cannot, smoke less; consume a balanced diet, eat a lot of fruit and vegetables, keep physically active; if you drink alcohol, do it in moderation; protect yourself from the sun; practice safe sex…” We all hear these recommendations day-in-day-out. A decade ago, David Gordon, a critical social epidemiologist, came up with a list of alternative recommendations to the aforementioned. A couple examples of his alternative list is the following: “Do not be poor, but if you are, stop being poor and, if you cannot do it, try to be poor for not too long; do not reside in a poor depressed neighborhood, but if you do, move and go live elsewhere; do not work in a stressful, poorly paid, labor intensive job; neither live in a house of poor quality nor be homeless…” Sarcasm at its best, no?
[Perhaps people who are poor better focus on lifting-themselves-out-of- poverty, not on spending time enjoying themselves, watching telenovelas, drinking or having sex…. (quoted by D. Eade)]
To a chronic problem we cannot apply crises methods.
1. The climate, the economic and financial, the food and the fuel prices crises we have been faced with underscore yet again the need to organize and mobilize for badly needed social changes — and also the need to actually grasp the unprecedented opportunities these crises offer for doing so.* It is challenges that make women and men prove themselves!
*: The collateral damage from these concomitant crises has extended, not least on human rights (HR) territory. But it has also increased people’s hostility towards the market economy model….and this is an opportunity.
2. To prevent a return to business as usual in a move that leads us nowhere, the roots of all these crises need to be understood by the majority of people so they understand the nature, the self-interest bias and the limitations of the elites’ responses to these crises. (The Cornerhouse) These responses merely contribute to the winners getting the accolades and the losers being pushed under and into despair.
3. Not really as a surprise, contemporary macroeconomics does not even deal with the subject of crises. To crises we respond with relief efforts. But the human rights-based framework has blurred the traditional distinction between relief agencies and those active in people’s development. Jumping-in with short term life-saving aid through quick interventions and then leaving has now become insincere and disingenuous.
4. As regards the financial crisis, the ‘great regression’ of the last few years has prompted an age of austerity. Among other, for Amartya Sen, the responses have been a ‘spiraling catastrophe’; it has exposed the dark side of austerity-driven cutbacks, i.e., a deepening economic-and-social-rights-deficit. Deep cuts in public expenditure for social services are indeed actually slimming the State…and this is considered the ‘obvious’ cure. Unbelievable!
5. The slashing of public expenditure in health care, education, social protection and job programs required by these policies is violating people’s rights and making ordinary people pay disproportionately for a budget crisis they had no hand in creating. The ‘cut-to-grow’ fever has caught fire, with many low- and middle-income countries joining the headline countries in Europe and the US to cut public expenditure –at times clearly excessively– on the false assumption that austerity will drive growth.**
**: Have you heard of governments borrowing to invest in programs with real returns in social and environmental terms, as well as in economic terms? I have not. They would be doing a service to their people.
6. It is no news to you that economic policy-making is a highly contested terrain heavily influenced by political considerations and relations of power. It is not a fallacy or a myth that HR law can have a fundamental role in exposing economic and social injustice and in checking for the misuse of power. In an era of crises and of austerity, HR considerations should, more than ever, influence policy and be the basis for follow-up to secure accountability for lasting outcomes.
Crisis or not, HR are not only legally compelling, but also morally right
7. Particularly during times of economic hardship, States must come-up with and implement policies according to their human rights obligations, as well as promote economic alternatives that are not only centered on HR principles and norms, but also on human dignity and on prioritizing the most vulnerable.***
***: “No global economic and financial crisis diminishes the responsibility of State authorities and the international community with regard to human rights,” (United Nations Human Rights Council, 2009).
8. In too many places, human rights are increasingly being sacrificed at the altar of financial stability. When individuals, households, communities, and whole nations must surrender their hard-won rights to education, to adequate health care, and to decent jobs in healthy conditions to balance budget sheets, the basic values of human dignity are turned on their head. Why shouldn’t, in these times, indicators of social and human well-being be monitored, prioritized and valued at least as much as financial balances and the production of tradable goods and services? Remember: Occasionally, small numbers tell a big story. (M. Soussan).
9. Crises are now multipolar; people both in the North and in the South must fight back for their human dignity**** in defiance of un-necessary, disproportionate and unjustified cutbacks –yes, beyond what they were doing before the onset of these crises.
****: I call your attention to the common etimological root of the words dignity and indignation!
Some quotes taken from D+C, 36:5, May 2009; Z. Acevedo Diaz, La Dama de Cristal, Fondo Editorial Casa de las Americas, La Habana, 1999; Albino Gomez, Despojos y Semillas, Editorial Belgrano, Buenos Aires, 1997; D+C Vol.37, No.9, Sept. 2010; and The Broker, Issue 24. Feb/March 2011.
Postscript:
Le succès est un voyage et non une destination! Is it to get the priorities not right, but left…?
The HR Readers argue cases; they show clearly the position I hold. They present not assertions, but reasoned arguments; they try to anticipate objections* and take the offensive against critical positions thus being clear about what my position is. Readers reflect my deepest concerns and attitudes towards life itself. (R.C. Solomon)
*: If you cannot imagine how anyone could possibly disagree with you, you probably have not thought through your position thoroughly and carefully enough.
Has the concept of good governance been overused and has it become a rather insincere cliché? It is certainly old. The World Bank Development Report of 1997 was on good governance.
1. If I stick to the title, governance assessments simply have to use a human rights perspective; they must identify the specific problems and needs of marginalized population groups in each country and the actions taken (or not) by government to address them. Among other, the assessment must also identify duty bearers and claim holders and advise on how to assess their respective capacities, the same being a) to fulfill their human rights obligations and b) to actively claim their human rights respectively.
2. Let’s take an example: Comparing the indicator ‘utilization of health care facilities’ of children who live in poverty in a country, with the same indicator for the general population (or of other groups in the population) gives us an indication of the level of equality of fulfilling the human right to health in the country in question; the aggregated indicator of utilization of health care facilities of the whole population thus hides the actual fulfillment of this right for the different social groups, notably the most vulnerable. Right? Well, how does this relate to governance? If we take the attributes of good governance: Is it an issue of mismanagement or corruption? No. An issue of transparency? No. An issue of effectiveness? No. But an issue of non-inclusiveness, of accountability, of discrimination, of missing responsiveness and of equality, YES….all these being principles of human rights (HR) to hold governance and governments to account.
3. I urge you to never forget that in governance terms, HR accountability entails: a) detection (determination if there is a HR violation), and most importantly b) correction. Why this reminder? Because better governance does not mean the government will automatically address HR violations and poverty with greater urgency!
4. HR issues in governance, in turn, point us in the direction not only of social and political, but also of legal exclusion giving us an accurate overview of the equal or unequal fulfillment of the concerned HR for different groups in the population.*
*: Beware that social class generates both economic inequality and a pathway to individual ill-health. (C. Muntaner)
5. Not to forget is the fact that, under regimes of both poor and good governance, legality is, more often than not, a privilege accessible only to those with economic and political power.** Law makers may pass laws, but what good are they if they are never implemented? Therefore, the poor classes have no other alternative than to acquire political power.(M.Vargas Llosa)
**: The king said it was night. The minister said it was night. The court said it was night. It was early morning! King and minister (and court?) find a way to negate what really exists as a clear vision. (C. Fuentes)
6. Using the HR framework to asses governance, we look at socio-economic issues through a specific human-rights-based lens. Conversely, in daily practice, issues of governance are mainly assessed with socio-economic, administrative and/or development indicators.
7. Indeed, too often, indicators that merely describe the socio-economic situation of a country or region are wrongly taken for an equivalent of the fulfillment (or non-fulfillment) of economic and social rights (ESR) although they do not incorporate any governance or human rights dimension.
8. The pressure that looking at governance from a HR perspective potentially puts on countries that are seen as performing poorly on ESR can be a stimulator for concerned governments to conduct more thorough assessments of the fulfillment of ESR at the country level. (J. Nahem, UNDP)
9. So, should it worry us that neoclassical economists –considered the ‘new intellectuals’– are called upon to be key judges of governance performance? Consider that governance as an issue was neglected by economists for a long time!
10. What also worries me is that there is little evidence that ‘responsible capitalism’ makes capitalism more egalitarian. For welfare states, now so much under attack, to play down their HR-based governance responsibilities and retrogress is simply irresponsible. Little will be achieved in terms of economic inequality if governments do not regulate/nationalize the financial sector, respect public pensions, adopt single payer health care systems, secure living wages… Aren’t these issues of governance?
11. But there is not only worry; there is also hope: Governments are not monolithic! So, do work with sympathetic cadres and non-traditional partners within!
12. In the absence of good governance, poor people are deprived of their right to participation. We have said this repeatedly. As a matter of fact, there is a need to create governance mechanisms that formally or institutionally require that people’s voices and contributions be part and parcel of key decision-making processes, especially those that will have direct impact on the lives of those who are marginalized. In principle, it should no longer be optional nor should it be up to the good will of any policy/decision-maker. If we are really serious about empowering people to participate then we also need to address this challenge. (R. Zambrano)
13. Bottom line, as much as about climate change, bad governance is about market failures and greed on a global scale. (A. Bowen) So, ultimately, it will be civic and political struggles that will lead to good governance. Will the post-2015 agenda launch such an era?
Some quotes taken from D+C, 36:12, Dec.2009; Z. Acevedo Diaz, La Dama de Cristal, Fondo Editorial Casa de las Americas, La Habana, 1999; Albino Gomez, Ultimo Patio, Ed. Turmalina, Buenos Aires, 2009; The Broker, Issue 24. Feb/March 2011; UNFPA, A HRBA to Programming: Practical implementation manual and training materials, 2010; and F+D 47:4, Dec.2010.
Postscript:
I am not here preaching to the converts, but preaching to the preachers…and I have hope.
Hope is not about having the conviction that something will end well, but having the certainty that that something makes sense, regardless of how it turns out. (Vaclav Havel)
So, if you want people to understand and heed what you are saying, you have to say it again and again, a hundred times, a thousand times. (John Boyd Orr)
But, on the other hand, it is not my duty to resolve problems, but to bring them up; not to give the ultimate explanations, but to ask for them. So, I have no intention to here bring the preachers either ‘the light’ or ‘the truth’; I think both only become visible in concrete, on-the-ground processes. (Albino Gomez and Cristina Laurell)
I wanted to share with readers of the Portal a talk I gave on March 14th at the NY Metro PNHP (Physicians for a National Health Program) monthly meeting. There was a good deal of discussion during the talk and most of it is audible despite the lack of microphones in the auditorium.
1. While not universally embraced, the notion that health care systems are public goods protecting an inalienable right of all human beings is increasingly invoked in debates about health care financing, and about global health governance.
2. But herein also lies a paradox in health and in human rights. At no time in human history has the notion of health as a human right enjoyed such prominence in the international and national health discourse as it does now. Yet this newfound prominence of the human right to health clashes with the ongoing expansion of the politics of exclusion and the economics of inequality.
3. Perhaps the major challenge in translating the many local successes of health activism into concrete health systems change is to increase the awareness and active involvement of those who stand to benefit the most from such changes, i.e., the most marginalized people.
4. Effective delivery systems without explicit human rights protections (for example, legislative guarantees or easier access to working redress mechanisms) will fail to deliver to those most marginalized. The point to be made here is that it is not the task of the private sector –whether for-profit or not-for-profit– to guarantee access to health care for the marginalized. It is the task of the latter themselves.
We must learn to better accompany governments
5. Accompaniment, in a human rights-based approach to public sector services, has two elements: working with governments as duty bearers to build their capacity to deliver services while working with communities as claim holders to hold governments accountable for the quality and equality of those services.
6. The concept of justice-in-action, i.e., of actually delivering health, nutrition, housing, water, and other services as a human right remains as powerful and important today as it ever was. (Perhaps even more powerful since it is impossible, in the 21st century, to argue that any of these challenges are somehow technically insuperable; they can be overcome, and we all know it).
7. To work towards providing health care as a human right is a good thing, but is it sustainable? Can it ever be brought to scale? Responses to these two questions will be different whether they are asked to start the conversation or to end it. To sustain such efforts requires that a new generation of practitioners, policymakers, scholars, researchers, and advocates take up the cause of human rights and of equality in global health. To bring such efforts to scale requires that we engage the public sector since only governments can confer rights to those living within their borders.
8. We cannot stop repeating: Acknowledging injustice is not enough; linking knowledge of injustice to reparative action is what we are all called to do.*
*: There is a Sanskrit-based word: nyaya; it means “justice in action” and is, perhaps, a shorter and more elegant term for global health delivery in the spirit of human rights; in the context of the pervasive current politics of exclusion, we suffer from a lack thereof. Nyaya!
9. A veritable people’s war for the human right to health (RTH) emerges as a response to the prevailing exclusion of several groups from the economic, political, and social power base, be it due to caste, gender, sexual orientation, religion, ethnicity and/or geography.
10. So far, motivation to bring RTH work to scale is constrained by the lack of an active constituency that musters the power to demand the needed changes. Building a solid base of citizens engaged in political mobilization for health takes time (for claim holders to build up their hope so as to truly believe they can demand the investments and the human and physical health infrastructure the state has the obligation to provide for them).
11. This is where the human rights framework is central to build-up that power. It is in fact the best frame to apply in settings of extreme poverty, where the social, historical, and cultural roots of under-utilization and under-implementation are fundamentally tied to a long long standing chronic lack of access to economic resources.
12. Without the political and social backing and pushing from organized claim holders, even responsive and progressive policy makers (duty bearers) will not have the needed clout to see needed changes through. **
**: It is not enough to have ‘a sound science’ about how to best solve problems and deliver interventions; what is further required is a social-action-plan that translates what we know from science into human rights realizations.
13. Local interventions that are not developed and carried out with the larger policy perspective in mind –those with human rights implications– are unlikely to achieve a broad, sustainable impact. Similarly, scaled-up interventions that are not rooted in smaller, more local realities are likely to face logistical, as well as practical implementation challenges.
14. At global level, a bit of the same is true. Protocols in global health are to include a social action strategy, as well as include clear plans for achieving the social and political mobilization needed to achieve any sustainable impact.
15. Some components of such a social action strategic plan have been proposed by Maru and Farmer:
Key Component
Related Questions
Current political, policy, and economic barriers to implementation
What are the major constraints to implementation? What are the actual numbers for utilization, financing, staffing, and supplying for the services under consideration? What are the major institutions and actors (duty bearers) that may have a stake in the status quo? Private sector providers? Pharmaceutical companies?
Key constituents, actors, and partners involved in overcoming these barriers
Who are the individuals and groups who are capable and essential in overcoming these barriers? (At a local level, these may be government staff and local politicians. At a national level, these may include politicians, policy makers, non-governmental organizations, and aid agencies.)
Concrete plan for the dissemination of findings and actions to implement them
What will be the immediate next steps? Who will be lobbied with demands? Who will receive an in-person meeting? Where will community or public meetings be conducted, and who will be invited?
16. The direct corollary of the application of human rights to health systems development is that the government must be deeply involved in ensuring its poorest citizens have access to health care. But it cannot do so without resources. Accompaniment of the public sector means working with governments to build capacity to finance and deliver services, as well as working with communities to hold governments accountable for the quality and equality of those services. This complex vision is central to the task of translating human rights declarations into human rights realized.
I feel disheartened that after over 30 years of publicly exposing the progressive deterioration of the situation of the many in the World that is now so evident, I and so many others, have not made much of a dent. I do recognize that criticism within my area of work (public health and public health nutrition) has been prominent. But I have also always contended that, when such criticism has not been able to bring about the needed changes, keeping silent towards the sufferers, about all that is wrong makes me an accomplice of the dire situation they live in; hence my militancy for grassroots mobilization. Achieving successes in health and nutrition (as for instance in some MDGs) still makes the same unsustainable as long as poverty is lingering in the background (or actually in the foreground…). To dream is good and necessary, but for dreams to come true it is necessary to be constantly on our toes. (F. Monckeberg)
If I ask for too much, it is because too much is needed. If we do not agitate, it does not shake people; if it does not shake it does not rouse.
Maybe there’s a world
Without want without worry
But what about meanwhile? (J. Koenig)
Human Rights Reader 311
[Adapted from The OPERA Framework for Monitoring Economic, Social and Cultural (ESC) Rights, Center for Economic and Social Rights, 2012. (OPERA stands for Outcomes, Policy Efforts, Resources and Assessment). cesr.org/downloads/the.opera.framework.pdf ]
OPERA: A step by step framework for assessing compliance
30. Given the fact that exclusion and disempowerment often breed bias, claim holders are not recognized as key players in all steps of applying the HR framework; the views of the most vulnerable are, therefore, too often lost. The OPERA framework aims at bringing about the right types of relationships among different actors and different sets of data.
Step 1 – Outcomes: Assessing the level of enjoyment of human rights
31. Information reflecting claim holders’ own perceptions about their rights enjoyment is collected at this stage. The information gathered is then played against human rights principles and standards to draw conclusions. The affected communities are then invited to play a central role in the selection of indicators aiming at setting benchmarks assessing the adequacy and progress of the state’s performance. Benchmarks that reflect the respect of key human rights principles and standards are: a) nondiscrimination, (b) non-retrogression, (c) fulfillment of minimum core obligations, and (d) progressive realization.
32. In an effort to demonstrate the importance of the prioritization of resources for meeting minimum core obligations, and exposing outlier governments, the country’s performance is assessed vis-à-vis its neighbors, regional averages, or other countries with similar characteristics. Time series analyses are carried out among countries with comparable levels of GDP per capita and progress on the indicators over time, and between groups is traced.
33. Key questions to explore here are whether or not progress being made is equitable and whether disparities are being reduced.
34. Descriptive statistics are interpreted in light of relevant human rights standards so as to measure the extent of the realization of the right in the country.
35. Ultimately, this step sets the scenario to close the gaps found with the intention of eliminating historic discrimination.
Step 2 – Policy Efforts: Assessing the state’s commitment and efforts to fulfill ESC rights
36. A useful methodology here (that is too often omitted) is the use of Community Score Cards or any similar approach that looks at these efforts from the claim holders perspective.
More traditionally, what is done is:
a) Identifying the country’s legal and policy commitments
37. Here, one looks at the extent to which a state has ‘domesticated’ its international commitments. One considers whether the international commitments the state has adopted have been internalized in the domestic legal order. Campaign promises and speeches may have clues in this direction. Also important is to identify any laws that run contrary to solemn commitments made.
b) Examining policy content and implementation
38. Here, what is being assessed is how such commitments have moved from paper to reality. One assesses whether actual deeds show that the state is giving human rights commitments its best shot. Central is to seek the views and perceptions of what has been implemented from the individuals and groups they are designed to reach.
c) Analyzing policy processes
39. The assessment here focuses on whether the policy making cycle upholds the human rights principles of participation, accountability and transparency (not forgetting to asses whether civil and political rights such as access to information are being fulfilled).
40. When one looks at processes, one is actually looking at procedural human rights principles that include seeking the views and perceptions of satisfaction with these mechanisms by the affected communities. Processes of redress as a consequence of effective accountability need to be assessed as well. Important also is to assess whether people have the ability to engage in their country’s governance structures.
41. Ultimately, here one aims at explaining why there are discrepancies between the policies on paper and the delivery in practice. At the end, capacity gaps in the implementation have to be identified* and an explanation sought of why more resources have not been made available.
*: Capacity, defined broadly, means having sufficient knowledge, organizational abilities, motivation, authority and, importantly, resources, including human, technical and financial.
Step 3 – Resources: Assessing the use and generation of adequate resources
42. Here, one inquires about the percentage of the state’s budget allocated to social spending, about which population groups are benefiting from past and current spending, about contrasting spending disparities that lead to disparities in human rights outcomes. One also looks into how spending has evolved over time –taking into account economic growth over the period; if and how there is participation in fiscal policy setting; one also identifies the structure of the tax base. Again here, one compares with similar countries.
43. One needs to always be aware that, frequently, government authorities attribute under-funding to a lack of sufficient resources. However, this claim needs to be interrogated, as often under-funding is, instead, due to a failure to equitably generate and distribute resources.
44. Budget analysis techniques are used to determine whether maximum available resources are being mobilized and used to prioritize minimum core HR obligations and to reduce inequalities thus keeping the trend of a progressive realization of the various HR.
a) Evaluating planned and actual resources expenditures
45. How much is the state allocating to the social sectors relevant to the HR under review and who benefits?
46. What is helpful here are comparisons to spending being made on other ‘non-priority’ sectors within the budget; analyses of how resources are distributed across regions and population groups; are they benefiting already better-off groups?
47. It is thus indeed possible to infer who is benefiting from budgetary allocations, e.g., building of universities vs primary schools in poor
rural areas could be considered discriminatory spending.**
**: Benefit incidence analysis is a quantitative technique that can be adapted for human rights analysis; it can be used to identify which groups have benefited most from public spending.
48. How allocations have evolved over time gives an indication whether HR are progressively being realized. (Beware that here one has to make inflation-adjusted comparisons).
49. In the age of budget cuts, as the ones we are seeing in Europe, ascertaining whether fiscal austerity measures are duly justifiable and how they affect HR is crucial; are they allowing a retrogression of HR?
Moreover, what one has to be aware here is to make a distinction between planned (budget) and actual (end of fiscal year) expenditures.
b) Evaluating resources generation
50. Here one looks at the thorny issues of tax breaks, tax avoidance and tax evasion. Add to this tax revenue that is foregone in tax concessions often given to TNCs as an enticement for them to come and invest.
51. It is key to determine whether the tax system is progressive, flat or regressive, i.e., whether those who make more are paying more.
The VAT is a very popular tax in many countries. It is a regressive tax since it typically comprises a larger share of the income of poorer households compared to that of wealthier households.
52. One also looks at development assistance: Are conditionalities such as trade liberalization being imposed? Is there a demand to increase the role for the private sector in service provisions, e.g., in health –as many free trade agreements call for? These have clear HR implications.
c) Analyzing relevant policy processes
53. In some countries, governments still draw up budgets in secrecy.
In many, closing financial loopholes or prosecuting tax evaders is close to impossible.
54. This goes together with the difficulty to persuasively countering a state’s claim that lack of means prevents it from taking more action to fulfill ESC rights. This remains one of the biggest challenges for human rights advocates.
55. The under-funding of all social sectors is instead due to a failure to equitably generate and distribute available resources.
56. ‘Elite capture’, endemic corruption, and/or external pressures, such as aid conditionalities or competition to attract foreign investment are all elements to ascertain due to their HR implications.
d) Understanding the context
57. One has to understand the real constraints before assessing state compliance.
58. Recommendations to flow from this lengthy assessment are thus to be constructive and well-targeted. One has to distinguish HR deprivations that may be the result of factors genuinely beyond the control of the state from those for which the state should be held accountable for. Our role is to help pinpoint the responses to be reasonably expected from the state.
59. One right serves as a prerequisite for the enjoyment of another and thus denials of one can foster multiple levels of deprivation. Poor and socially excluded groups are less likely to be able to access information organize , participate in policy debates and to obtain redress.
60. All this boils down to carrying out political-economic analyses that seek to reveal the underlying interests, incentives and institution that enable of frustrate change towards improving the HR situation.
61. So the steps recommended by OPERA do not necessarily need to be followed in strict sequence. In some contexts, such constraints may be so central that they merit a more central focus in the analysis.
e) Determining state compliance
62. Central to any assessment is to identify the commitments made by the government on paper (or campaign promises) not translating into practical actions. This is the essence of accountability.
63. The final judgment will very often be a qualitative one and it will call for remedies to the current violations and for advancing reforms to prevent them in the future. Easier said than done, no? Therefore, what we cannot absolutely escape from addressing is the capture of the state by economic elites as a key structural constraint. We are talking about the privileges of the country´s oligarchic families and business leaders….
64. The challenge –through claim holders empowerment and mobilization– is to prompt decision-makers to cease being dismissive of human rights arguments which they see as irrelevant.
Lessons learned and questions looking ahead
65. Violations have long been difficult to ‘prove’ quantitatively in the restricted way social sciences have worked. OPERA calls for a balance of both quantitative and qualitative evidence as needed to support the argument about compliance with the obligation to fulfill ESC rights. In doing so, it
links obligations of result with obligations of conduct.
66. Ultimately, the question of ‘why’ HR must be upheld needs to be answered through more qualitative, contextual analyses, importantly through the lived knowledge of claim-holders themselves.
Our colleague Dr. Virginia M. Brennan, an associate professor in the Graduate School at Meharry Medical College has just published a new book entitled: Free Clinics, Local Responses to Health Care Needs. The book brings together 25 papers on free clinics that have been published in the Journal of Health Care for the Poor and Underserved.
