Rights and health, water and sanitation

The links between human rights, right-based approaches and a selection of sectors and themes are increasingly playing a guiding role in sector policy debates. Rights perspectives are used as both a diagnostic tool and a policy and programmatic response. The burgeoning literature on human rights and a number of health, water and sanitation issues include donor guidance and policy statements, academic research, and advocacy papers. Many of these documents aim to show how a rights-based approach helps to enhance existing sectoral work. The indivisibility or interdependence of rights also demonstrates that cross-sectoral working is essential for realising rights.

Rights help to move beyond predominantly technical approaches, to recognise the need to address the wider political and social environment within which programmes occur. Rights often necessitate the use of new language or ways of thinking about how to make decisions and prioritise, with implications for policy formation.

Page contents

Health: an overview

Human rights standards include the right to life and survival. Therefore, human rights can be viewed as intrinsically linked to equitable health outcomes, as well as increased opportunities for those living in poverty to access health services. The realisation of human rights, therefore, is understood as having a positive effect on health outcomes. This poses the question as to whether health problems are tantamount to human rights violations.

A key discussion in the health literature is how service delivery can be made more effective. It is argued that a rights-based approach in healthcare can facilitate greater responsiveness in healthcare systems. This also concerns issues relating to voice and accountability in service delivery.

OHCHR/WHO, 2008, ‘The Right to Health: Fact Sheet No. 31’, OHCHR/WHO, Geneva
What is the right to health, and what are countries’ obligations in realising it? This paper outlines the right to health in international human rights law, implications for states, risks facing specific groups, and accountability and monitoring mechanisms. All states must: 1) respect the right to health, refraining from interfering directly or indirectly with it; 2) protect this right by preventing third parties from interfering with it; and 3) fulfil it through legislative, administrative, budgetary, judicial, promotional and other measures. Priority obligations are non-discrimination and concrete, deliberate and targeted steps as part of a national strategy.
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Braveman, P., and Gruskin, S., 2003, ‘Poverty, Equity, Human Rights and Health’, Bulletin of the World Health Organisation, vol. 81, no. 7
How do poverty, equity and human rights relate to health? This study suggests that they are closely linked conceptually and operationally and that each provides valuable, unique guidance for health institutions’ work. Equity and human rights perspectives can contribute to health institutions’ efforts to tackle poverty and health. Focusing on poverty is essential to operationalising those commitments.
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Hunt, P., 2007, ‘Neglected Diseases: A Human Rights Analysis’, Social, Economic and Behavioural Research Special Topics, no. 6, World Health Organization, Geneva
How can a human rights approach contribute to the fight against neglected diseases? Neglected diseases are understood to be those primarily affecting people living in poverty in developing countries, particularly in rural areas. This report aims to equip practitioners with an understanding of how human rights abuses can both cause and result from neglected diseases.
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Gostin, L. et al., 2003, ‘The Domains of Health Responsiveness: A Human Rights Analysis’, Health and Human Rights Working Paper Series, No.2, World Health Organisation, Geneva
What do human rights have in common with the responsiveness of healthcare systems? This report argues that the improvement of health is the main goal of health systems. It outlines eight domains of healthcare responsiveness and sets out how they can be understood through human rights principles, and in the context of international human rights instruments.
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Worm, I. (2013). Practitioners’ Tool: Health and Human Rights. Bonn: Deutsche Gesellschaft für Internationale Zusammenarbeit.
This document offers guidance on applying a rights-based approach to three common fields of intervention or programme components in the health sector: quality management and human resources; social (health) protection and health financ¬ing; and sexual and reproductive health and rights, and HIV / AIDS.
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Grodin, M., Tarantola, D., Annas, G., & Gruskin, S. (Eds.). (2013). Health and Human Rights in a Changing World. Abingdon: Routledge.
Section I is a Health and Human Rights Overview that lays out the essential knowledge base. Section II brings in concepts, methods, and governance framing the application of health and human rights, in particular the Human Rights-based Approaches to Health. Section III sheds light on issues of heightened vulnerability and special protection, stressing that the health and human rights record of any community is determined by what is being done and not done about those who are most in need. Section IV focuses on addressing system failures where health and human rights issues have been documented and recognised and yet insufficiently attended to. Section V examines the relevance of the health and human rights paradigm to a changing world, underscoring contemporary global challenges and responses.
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Additional Information

Maternal health

As a key Millennium Development Goal, strategies for improving maternal health can be supported through a rights-based approach. This means adopting a wider strategy that moves beyond scaling-up service delivery and focuses upon the accessibility of services, accountability of service providers to rights holders, and the political, social and institutional factors which affect women’s maternal health. The guiding principles of a rights-based approach to maternal health include non-discrimination and equity. In 2012, the United Nations Human Rights Council adopted a resolution welcoming a Technical Guidance on rights-based approaches to maternal mortality and morbidity.

Hawkins, K. et al., 2005, ‘Developing a Human Rights-Based Approach to Addressing Maternal Mortality. Desk Review’, DFID Health Resource Centre, London
Can a rights-based approach reduce maternal mortality? Can its focus on equity improve health outcomes for poor women? This review argues that rights-based approaches can add impetus to reducing maternal mortality. It argues that policy actors in government and civil society should find ways of addressing the economic, social, cultural and political forces that prevent poor women from asserting their right to maternal health.
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Department for International Development, 2005, ‘How to Reduce Maternal Deaths: Rights and Responsibilities’, How to Note, DFID, London
How can a rights-based approach enhance programmes to reduce maternal death? This note shows how a rights-based approach adds value to public health and health systems approaches. It argues that reducing maternal deaths is not a purely technical action but one that challenges the political and social status quo and requires actions within and beyond the health sector.
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OHCHR, 2010, ‘Report of the Office of the United Nations Commissioner for Human Rights on Preventable Maternal Mortality and Morbidity and Human Rights’, OHCHR Geneva
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Yamin, A. E. (2013). Applying human rights to maternal health: UN Technical Guidance on rights-based approaches. International Journal of Gynecology & Obstetrics, 121(2), 190-193.
In 2012, the United Nations Human Rights Council adopted a resolution welcoming a Technical Guidance resource on rights-based approaches to maternal mortality and morbidity, and calling for a report on its implementation in two years. This paper provides an overview of the contents and the significance of the Guidance. It reviews how the Guidance can assist policymakers in improving women’s health and their enjoyment of rights by setting out the implications of adopting a human rights-based approach at each step of the policy cycle, from planning and budgeting, to ensuring implementation, monitoring and evaluation, and fostering accountability mechanisms. The Guidance should also prove useful to clinicians in understanding rights frameworks as applied to maternal health.
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A rights-based approach in the area of HIV/AIDS can be used to mitigate the effects of the illness, by preventing stigma and discrimination, but also by preventing its spread and the long-term effects it has upon children affected by the illness. A rights perspective in HIV/AIDS programming therefore contributes to social inclusion, the inter-generational transmission of poverty, and upon the rate at which HIV/AIDS spreads. It is important to note that HIV/AIDS also has detrimental psychological impacts upon those it affects and that by investing those affected with rights, rights-based approaches offer a level of empowerment to individuals and groups. In 2011, the United Nations adopted a Political Declaration on HIV/AIDS, with a view to an increased global response to the epidemic. This declaration has an increased rights-based approach.

Stephens, D., & Urbano, M. (2010). HIV and legal empowerment. In S. Golub (Ed.), Legal empowerment: Practitioners’ perspectives . Rome: International Development Law Organization.
How can legal empowerment advance the human rights of people living with and vulnerable to HIV? This study explores how HIV legal empowerment strategies are evolving. It shows that the law has been the axis around which debates have revolved on the restriction or promotion of rights. For a person experiencing HIV-related stigma, a legal empowerment approach affirms and restores his or her humanity and citizenship and supports psychological wellbeing. These are essential dimensions of overall welfare and health.
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UNAIDS. (2005). HIV-related Stigma, Discrimination and Human Rights Violations: Case Studies of Successful Programmes (UNAIDS Best Practice Collection). Geneva: UNAIDS.
Stigma and discrimination have fuelled the transmission of HIV and increased the negative impact of the epidemic. How can HIV-related discrimination be addressed in order to achieve public health goals and overcome the epidemic? UNAIDS examines this question, drawing on a range of case studies from all over the world. Stigma, discrimination and human rights violations are intimately linked, reinforcing and legitimising each other. Multi-faceted action, sustained over time, is needed to prevent stigma, challenge discrimination and promote and protect HIV-related human rights.
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OHCHR. (2011). The protection of human rights in the context of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) (Report of the United Nations High Commissioner for Human Rights). New York: United Nations.
In 2011, the United Nations adopted a Political Declaration on HIV/AIDS, with a view to an increased global response to the epidemic. This review from OHCHR analyses the declaration from a human rights perspective. It reaffirms that the full realisation of all human rights and fundamental freedoms for all is an essential element in the global response to HIV. It recognises that addressing stigma and discrimination is a critical element in the global response to HIV and also recognises the need to strengthen national policies and legislation.
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Sexual & reproductive rights

Sexual and reproductive health is increasingly being viewed as both a human right and an integral part of achieving the Millennium Development Goals. However, universal access to sexual and reproductive health facilities and support is far from being realised. Rights-based approaches are presented as a solution to this problem, as well as a means. A rights perspective offers an analytical tool with which to identify root causes of prevention, access and treatment problems, as well as a concrete response tool in order to promote the rights and responsibilities of relevant actors. This also encompasses acute concern with violence against women and the extent to which women can access justice against the perpetrators of violent acts.

Department for International Development, 2004, ‘Sexual and Reproductive Health and Rights: A Position Paper’, London
Sexual and reproductive health is a human right, essential to human development and the achievement of the Millennium Development Goals. This paper reviews achievements since the 1994 International Conference on Population and Development (ICPD), sets out DFIDs position on sexual and reproductive health and rights, and its view of the future. Important progress has been made, but there remains much to be done to achieve universal access to reproductive health services by 2015.
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Crichton, J., Nyamu Musembi, C. and Ngugi, A., 2008, ‘Painful Tradeoffs: Intimate-partner Violence and Sexual and Reproductive Health Rights in Kenya’, IDS Working Paper no 312, Institute of Development Studies, Brighton.
How does intimate-partner violence affect Kenyan women’s rights? How can the government, NGOs, and the legal and healthcare systems support abused women? This paper explores links between intimate-partner violence and sexual and reproductive health (SRH) rights in Nairobi. Significant gaps exist between formal legal rights and the realities experienced by individuals. Legal reform, improved services for affected women and better coordination among service providers are required.
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UNFPA & Harvard School of Public Health. (2010). A human rights-based approach to programming: Practical information and training materials. New York: UNFPA.
This Manual provides step-by-step guidance on how to apply a culturally sensitive, gender-responsive, human rights-based approach to programming in three areas of work: population and development, reproductive health, and gender. It also covers how to apply such an approach in the context of a humanitarian emergency.
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Shaw, D., & Cook, R. J. (2012). Applying human rights to improve access to reproductive health services. International Journal of Gynecology & Obstetrics, 119, S55-S59.
This article explores how constitutional and human rights are being used, and could be used more effectively, to improve maternity services and to ensure access to drugs essential for reproductive health. Human rights provide tools to hold governments legally accountable for their failure to address the preventable causes and to distribute medicines essential for reproductive health.
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Water and Sanitation

The international campaign for a human right to water and sanitation has gathered huge momentum in the last decade, particularly in response to the privatisation of water provision in many instances. The right to water and sanitation was acknowledged in July 2010 by the UN General Assembly. Whilst rights-based perspectives on water and sanitation play an increasing role in government policy discussions, embedding water and sanitation in the human rights discourse still requires fundamental changes in the following three areas: policy and legislation; service delivery and accountability; and attitudinal and behavioural change at all levels.

As in the health sector, enshrining the human right to water and sanitation in official laws and treaties is not sufficient: a service-delivery approach is necessary in order to implement and maintain adequate systems which function to identify the greatest need, introduce participation, recognise the roles and responsibilities of a variety of actors, and provide clear accountability mechanisms.

Sultana, F. and Loftus, A. (eds.), 2011, ‘The Right to Water: Politics, Governance and Social Struggles’, Earthscan
This book analyses how struggles for the right to water have attempted to translate moral arguments over access to safe water into workable claims. It engages with approaches that focus on philosophical, legal and governance perspectives, and applies these to case studies from around the world.
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DFID, 2011, ‘Assessing the Impact of a Right to Sanitation on Improving Levels of Access and Quality of Services: Executive Summary’, DFID in association with Coffey International Development, London
Does formal recognition of a right to sanitation (RTS) increase levels of availability and access to quality, affordable and adaptable sanitation services? This study finds that progress towards these goals seems to be faster in countries that have recognised an RTS. It is highly probable that sanitation services in countries seeking to fulfil an RTS will be more equitable and inclusive than elsewhere. However, attributing successes to a rights approach will require better monitoring and evaluation that includes rights-sensitive indicators. A further finding is that what makes formal recognition meaningful is a participatory approach to working to fulfil rights: citizen-state engagement is crucial.
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COHRE, UN-HABITAT, WaterAid, SDC, 2008, ‘Sanitation: A Human Rights Imperative’, Centre on Housing Rights and Evictions, Geneva
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COHRE, AAAS, SDC and UN-HABITAT, 2007, ‘Manual on the Right to Water and Sanitation’, Centre on Housing Rights and Evictions, Geneva.
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WASH United, Freshwater Action Network (FAN Global), & WaterLex. (2012). The human right to safe drinking water and sanitation in law and policy. WASH United, Freshwater Action Network (FAN Global), WaterLex.
This sourcebook provides a broad overview of the right to safe drinking water and sanitation in international and national law and policy. It considers how the right has been recognised and elaborated at the different levels.
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De Albuquerque, C., & Roaf, V. (2012). On the right track: good practices in realising the rights to water and sanitation. UN Special Rapporteur.
This book collects good practices on the implementation of the rights to water and sanitation. Practices encompass legal and policy frameworks as well as implementation and accountability mechanisms.
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Boelens, R., Duarte, B., Manosalvas, R., Mena, P., Roa Avendaño, T. & Vera, J. (2012). Contested territories: Water rights and the struggles over indigenous livelihoods. The International Indigenous Policy Journal, 3(3)
This paper examines the threats to Indigenous water rights and territories in the Andean countries. It analyses how water and water rights are embedded in Indigenous territories, and how powerful actors and intervention projects tend to undermine local societies and indigenous livelihoods by developing large-scale water infrastructure. Three cases illustrate the encroachment process: Colombia, Ecuador and Peru. Indigenous peoples and communities actively contest the undermining and subordination of their water and territorial rights through multiple livelihood defence strategies.
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