UNDP Oslo Governance Centre

Civil Society Voices on Applying a Human Rights Based Approach

This network initiative aims to inspire and encourage network members in applying a HRBA in their work and to promote an understanding of what this approach entails in practice. NGOs and the broader CSO community have come a long way in institutionalizing a HRBA and there is much that can be learned from their experiences and strategies in this area.

Contributions/Suggestions
Network members are invited to recommend to Emilie Filmer Wilson any international and national NGOs and the broader CSO community that they would like to hear more about.

HURITALK Network Issue 4, January 2008

The Experience of Care Perú
“Expanding Participation in Policy Processes” 

Interview: Ariel Frisancho Arroyo, Program Coordinator:
“Improving the Health of the Poor: a Human Rights Approach”
December 2007

CARE is an international humanitarian organization committed to fighting poverty.  The organization applies a rights based approach to development through 6 programming principles : Promote empowerment,  Work in partnership with others, Ensure accountability and promote responsibility, Oppose discrimination, Oppose violence, Seek sustainable results.  For more see “Principles into practice: Learning from innovative rights-based programmes,” Care International UK (2005).

CARE Perú’s Health Rights Program promotes the right to health through partnership with civil society networks and government officials, and aims to improve the relationship between Peruvian society and the state by establishing policy spaces in which rural communities and civil society networks can engage with local, regional and national authorities on health policy.

1- What is the specific value of a human rights-based approach to development work in the health sector?

Bringing human rights into development programming can help address the capacities and inequity in power relations that are often the root causes of problems in the health sector.  Bringing marginalized people into policy processes helps to fight against institutional discrimination and the human rights focus on duty bearers forces programming to address the capacities of government officials, health service providers and local and regional authorities. Additionally, bringing duty bearers and rights holders together in policy dialogue contributes to more inclusive and generally better policy-making and implementation. 

2- What practical strategies have been most effective for strengthening the participation of the poor and excluded in Perú’s  health policy processes?

To bring “the voice of the poor” into policy design and public debate, our program works to strengthen the role of civil society networks. Together with other agencies, CARE has supported the Peruvian civil society network, ForoSalud as a “network of networks” for civil society working with health issues.  As a result, ForoSalud has been elected as the civil society representative of social organizations in the National Health Council, as well as in many Regional Health Councils.  At such “invited spaces”, they have succeeded in getting a number of their policy proposals included in Regional Health Policies. 
ForoSalud’s status has also enabled it to carry out capacity building initiatives with the members of its network. Each regional civil society network begins by providing  3 weeks of capacity development for network members in the regional capital.  This capacity development uses a mixed methodology in multiple languages and includes standard training situations, interactive activities and even faux social theater.  The main focus of all sessions is on health rights, health policy and the importance of social inclusion. The aim is to train ForoSalud members to conduct expanded participatory diagnostics in the provinces.
These expanded diagnostics are conducted over a period of 1 ½ months, beginning with public awareness raising on health issues through the use of focus groups and other mechanisms. In addition to health needs, the diagnostics aim to determine how people experience the Peruvian health system and to identify institutional weaknesses and “other factors influencing health.”  This broad and open approach allows us to better identify local priorities, without confining ‘the voice of the poor’ to existing policy debates. 
Finally, the process propelled by the regional and local networks brings public authorities into dialogue with community representatives and network members. Initially, public officials were very reluctant to participate in this stage, but persistence on the part of the CSO network and their increasing public presence encouraged them to participate.  Furthermore, as more participatory dialogues are conducted, officials’ participation is legitimized and seen to be more of a political advantage than a political liability. 

3- What have you learned about matching people’s participation with the meaningful participation of government officials?

There are many significant challenges to meaningfully engaging public authorities, largely left over from what has historically been a hierarchical and inequitable power relation between the government and the people of Perú. Many officials still do not understand the right to health, and this shortcoming is strengthened by traditional reluctance amongst some health authorities, unions and professional bodies (mainly physicians) to allow people to participate in the design, implementation and evaluation of public health policy. When beginning the Program implementation, we often encountered a hierarchical attitude when dealing with public officials that was most pronounced when citizens are poor, rural, women, illiterate and indigenous.
Additionally, we have learned to recognize that our work is constantly in risk of misperception by authorities, public officers and local providers.  These actors are used to cooperating with CARE but are not familiar with CARE’s work as a social advocate, and may take CARE’s criticism of health structures and institutions personally, perhaps even assuming a “you are with me or against me” attitude.
In light of these challenges we have learned to approach public authorities on the basis of common interests and views. In 2004, the upcoming visit by the UN Special Rapporteur on the Right to Health helped us to establish a common interest with the Ministry of Health in developing an institutional health rights approach. This genuine political interest, associated with the recent appointment of a new Health Minister, allowed us to meaningfully address institutional shortcomings in cooperation with the Ministry. It also helped us promote a human rights based approach to health that was endorsed by the Minister of Health.Though there was no immediate nation-wide effect in terms of health services provision, the change of attitude of the Ministry officers was significant (especially in regard to their relationships with civil society). This most likely also contributed to the Ministry’s decision to launch a National Campaignon Health Rights. Much of these advances were apparently lost with the establishment of a new government in 2006, but there is sound evidence that the norms set in place in the Ministry of Health are still playing an active role. The public officers trained in health rights and gender equity by the Program continue to operate, and the explicit reference to health rights now included in most Ministry proposals has a positive, if uncertain effect on the public debate.

4- What do you believe can be done to ensure the quality and sustainability of bottom-up mechanisms?

For participation to be ‘transformative’ a focus on the quality of participation not just the quantity is important. For example, the quantity of participation is being improved through Perú’s on-going decentralization process, which is “installing more chairs at the regional and local decision-making tables”. In the health sector, representatives of health organizations and civil society now convene Regional Health Councils for coordinating health related issues and discussing regional health policy. However, the hegemonic presence of health providers (they are often represented by six of the council’s eight members, while social organizations are represented by only one) poses questions about how professional or group interests could limit democratic decision-making processes and affect the quality of the mechanisms.
In addition to this, considering the “quality” of citizen participation implies a number of abstract but determinant questions, such as:

• How are the “rules of the game” defined in the policy dialogue forums and structures created by the state?
• What issues are to be covered?
• Are health providers and authorities engaging with citizens' representatives as equals, or are they just using the forum to legitimize their actions?
• How are the outcomes from these mechanisms taken up by formal policy institutions or pursued by civil society organizations?

We have also learned the importance of supporting civil society networks without leading or directing them. It is very difficult to instill a sense of autonomy and ownership in such mechanisms if these qualities are not present from the very beginning.   Another aspect of this is the importance of making strategic alliances with existing organizations, instead of trying to create “artificial bodies” which will only last as long as the program lasts. Identifying and strengthening the action of key partners improves the ownership, the scope and the richness of dialogue.

5- Much of your work has focused on participation, how have you managed to match this with the complementary human rights principle of accountability?

CARE Perú has supported a variety of social reporting mechanisms to promote public accountability.  These have included a 2006 civil society shadow report to UN Special Rapporteur on his Health Rights Recommendations to the Peruvian Government in 2004, a nationwide report on the Actionability of Sexual and Reproductive Rights and Access to HIV / Aids Treatment, and a study on maternal mortality, developed by Physicians for Human Rights  (2007).  These reports, as well as studies, launched with national academic and research institutions, have been important for promoting specific issues in public debate. They  have also provided important tools for advocacy. 
More generally, we have supported the development of citizen and civil society-based accountability mechanisms.  Generally, we have approached these activities through partnerships, such as that between the ForoSalud and Regional Ombudsman’s offices to create civilian surveillance on regional health services, and the partnership with the national Ombudsman and Health Council to monitor how politicians followed up on their commitments to health rights made during elections.

6- How important are global policy and institutional principles for a human rights based approach, and how do they get translated into work  “on the ground”?

CARE International programmatic principles* are paramount for a better understanding of our identity and development practices.  There has been a concentrated institutional effort to ensure that our technical and administrative teams have a clear understanding of our programmatic principles, the reasons we apply them and how we apply them in the field.   This has helped us to see that we need to complement our “empowerment” work with efforts to change inequitable power relations and strategies for accountability. Performance management tools have also helped us monitor and evaluate the way we are implementing our programmatic principles.
On the other hand, promoting the concept of health rights in rural communities demands a medium-to-long term process, especially if we are linking with rural and indigenous communities. Our main strategy is then to build on people's knowledge and experience, rather than to replace it. In the Quechuan language, for example, there is not a synonym for the word “rights”: and we had to inter-change information and build knowledge on the basis of the concept of “what should happen” and “what must be”, using mechanisms of popular education, theater on the community life, drawings, etc.

7- How does this program engage with other international development actors working in the same areas or sectors?

The Health Rights Program supports the creation of “integrated task forces” that bring together national and international actors on key issues for our work, such as health decentralization and maternal mortality. The purpose of these integrated task forces is both to strengthen our common “voice” for advocacy, and also to profit from the experience and knowledge of our partners. We also make a point of targeting multinational financial institutions with our best practices, and hope that organizations such as the World Bank,  the Inter-American Development Bank and the European Union adopt our approaches in their activities in Perú, so that those approaches will then naturally be adopted in the Peruvian public sector.  Our first achievement in this regard has been to co-ordinate with EU to secure EU funds (near US$ 300,000) to support the Ministry of Health in implementing the Integral Health Care of Children with a Rights Based-Approach and to strengthen the Shared Administration Program nation-wide.