The right to health equity in relation with preventable deaths and access to quality reproductive health system

By Athina Sophocleous, Jurist
A death considers preventable if, “in the light of understanding of the determinants of health at the time of death, all or most deaths from that cause could be avoided by public health interventions in the broadest sense”[1].
Every day around 830 women from all over the world die from preventable causes related to pregnancy and abortion 99 percent of these deaths taking place in developing countries, such as Africa, brazil, Asia[2]. The international human rights community recently has given its attention to maternal mortality, despite that is one of the most common human rights violations the maternal deaths.
Health inequities, such as in accessing health care, have slowly been recognized by some national courts and human rights tribunals as violations of human and constitutional rights. It is essential to refer the case of Alyne Pimetel against Brazil, a 28 years old Afro-Brazilian woman who died of complications resulting from the pregnancy, while a health center in Rio de Janeiro failed to provide appropriate and fast access to emergency obstetric care. The death of Alyne could have been prevented, if the health care center has correctly diagnosed and treated her appropriately. Through Alyne’s preventable death, a message was passed to governments worldwide[3]. Access to quality reproductive healthcare during pregnancy is a fundamental human right, and if governments failed to protect it will be held accountable. National governments have the obligation to guarantee that all women regardless of income or socio-economic status have access to timely, non-discriminatory maternal health services. Even if Alyne’s story is considered as one between thousand in Brazil and all over the world, with this decision it was marked the beginning of a new era of further protection and remoteness of gender equality. 
According to a survey of the World Health Organization, “4.000 maternal deaths in Brazil, representing one third of all maternal deaths in Latin America”. Also many women especially of Africa become victims of discrimination to health access. Indeed, South Africa’s maternal mortality ratio (MMR) was between 150 to 625 deaths per 100,000 live births between 1998 and 2007, according to government data[4]. The CEDAW Committee resulted that Brazil violated Article 12 (2) of the CEDAW Convention after 8 years passed without a definitive decision for the case and cited General Recommendation No. 28 (2010), which states “the policies of the State party must be action and result oriented as well as adequate funded”. Further, according to the General Recommendation 24 of the CEDAW Committee, maximum available resources must be mobilized to ensure women’s; right to safe motherhood and emergency obstetric services. The CEDAW Committee recommendations stressed that the States should ensure affordable access for all women to adequate emergency obstetric care and to effective judicial remedies. It also stressed that the States have to provide adequate professional training for health workers, ensure compliance by private facilities with national and international standards in reproductive healthcare, and reduce preventable maternal deaths.
The social determinants of health may be referred as   the conditions in which people are “born, grow, live, work, and age,” and which shape their health status[5]. The social determinant’s conceptualization of health reflects in the social medicine literature whereby the role of social determinants is viewed as a community attribute and as a factor that influencing individual health status. The significant socio-demographic inequalities which exist between and within countries, call for relevant policies in order to promote the mitigation and reduction of risk exposure in the most affected population groups[6].
The American philosopher Daniel Normans in his book on justice and health argues that we have to address three main questions, to understand what justice requires for health. Firstly, what is the special moral importance for health? Secondly, when are health inequalities adjust? Thirdly, how can we meet health needs fairly when we cannot meet them all? There are no easy explanations and answers to these questions[7]. The only fact is that health provides a remarkably broad and deeply engaging treatise of justice and health, which will influence both policy-makers and bioethicists for years to come.
The principles of availability, accessibility, accountability and quality are essential elements related to the right of health. Their role is to serve a diagnostic function and attention to what has to be done as national governments move towards health coverage. Governments can protect and fulfil the right to health by increasing the capacity, the quality of health care and by ensuring that these services remain accessible and affordable to everyone.
However, not all differences can be described as inequities. The term inequity includes a moral and ethical dimension. It refers to the differences which are unnecessary and avoidable, but, in addition are also considered unfair and unjust[8]. So, in order to describe a certain situation as inequitable, the cause have to be examined and judged to be unfair in the context of what is going on in the rest of the society.
To make clear the view that health disparities are a moral wrong that should be eliminated, it must first demonstrate that the existence of health disparities is morally problematic. In addition to ethical theories, there are some bioethical principles, such as the principles of:
-respect of persons (autonomy of the capable and protection of the vulnerable)
-beneficence (positive duty to benefit others),
-maleficence (act to avoid harming others)
and distributive justice (apply to offer further support for the claim that health disparities are a moral wrong.
Health disparities do not benefit the individuals on the losing side of the disparities, nor do they benefit any other individuals, violating the principle of beneficence. Health disparities instead can be said to be a significant harm in the form of poorer health, pain and suffering, violating the principle of non-maleficence[9]. Further, most conceptions of principles of distributive justice involve the notion of equity or equal access. Health disparities violate equity in that many people suffer from significantly lower health outcomes on the basis of their race/ethnicity or class.
But is there a moral right to health care? Such a right may be established by the application of ethical theories and principles. Additional support can be drawn from statements such as article 25 of the Universal Declaration of Human Rights and from documents such as Healthy People 2000 and Healthy People 2010. The system of injustices, as a result of a repeating old system based on race, ethnicity and class is clearly an ethical issue; thus, States which perpetuate these injustices are likely ethically problematic as well.
However, there is a distinction between the right to equal access to health care and the duty to address health disparities. Even if a moral right to health care can be established, that right would not necessarily entail a duty to address health disparities; a moral right to equal access to health care only entails the duty to ensure that the access to health care is provided to all.
Significant disparities exist among the universe and health care has a primarly role to play in achieving health equity. While healthcare organizations do not  have the ability to achive this equity alone or they do not have the power to improve all the social determinals, they have the power to address disparities at the point of care and to impact all these determinals that create disparities[10].
States could promote health equity and eraticate health disparities by:
-Creating a health care system through necessary health care reform is primarily a moral issue, even though it is also political and economic in nature. The principle of justice calls for a sustainable health care system where patients could be treated without discrimination by medical professionals.
-Providing a health care system that one of the main goals is to obtain the main duties of medicine, which include the physician's duties to promote health, cure disease, and prevent suffering. Also a health care must include significant emphasis on prevention and wellness promotion as well as innovative and efficient practice mechanisms.
The concept of social covenant which reflects community-oriented values regarding with each person, is also relevant to conceptualizing health care and health care reform measures. The social covenant also engages humanitarian concerns for global health.
-Providing universal coverage in the form of affordable and effective health care for all human beings, regardless of sex, economic or social status.
-Ensuring the removal of all barriers to women's access to healthcare services, education and information, including in the area of sexual and reproductive health, and, in particular, allocating resources for programmes relating to adolescents for the prevention and treatment of sexually transmitted diseases, including HIV/AIDS.
-Prioritizing the prevention of unwanted pregnancy through family planning and sex education and reduce maternal mortality rates through safe motherhood services and prenatal assistance.
-Requiring from all the health services to respect the women’s human rights, including the rights to autonomy, privacy, confidentiality, informed consent and choice.
A society that values autonomy, equality and considers the ethical principles that are integral to the Universal Declaration of Human Rights[11]  as fundamental to its moral framework, will design its healthcare system differently from a society that considers utility and efficiency as primary values and whose ethical perspective is driven by the principle of the greatest good for the greatest number. The greatest challenge for the future remains the complementary development of institutions, interpretations, and strategies at the local level within the broad framework set up by international law.  If we wish to use the framework of rights to empower women and eradicate discriminative actions, we must therefore understand the limitations as well as the potential of rights. The interaction between legal, economic, and cultural institutions is a key factor in shaping these differences and a great deal of social science research needs to be done to enrich our understanding of these relationships.
[1] Amendable and Preventable health statistics. Available at: http://ec.europa.eu/eurostat/statisticsexplained/index.php/Amenable_and_preventable_deaths_statistics  Accessed November 7, 2017.
[2] World Health Organization, fact sheet No 348, May 2012.
[3] In the name of Alyne: A historic human rights victory. Available at: https://www.reproductiverights.org/feature/in-the-name-of-alyne-a-historic-human-rights-victory,Accessed November 6, 2017.
[4]  World Health Organization, Available at: http://www2.ohchr.org/english/law/docs/CEDAW-C-49-D-17-2008_en.pdf  Accessed November 6, 2017.
[5] Chapman, A.R., “The Social Determinals of Health: Why We Should Care?” American Journal of Bioethics 15:3 (2015):46-7 Available online.
[6] World Health Organization, Social Determinals of Health. Available at:http://www.who.int/social_determinants/advocacy/UN_Platform_FINAL.pdf?ua=1 Accessed November 12, 2017.
[7] Daniels Norman, Just Health: Meeting Health Needs Fairly, Cambridge: Cambridge University Press 2008.
[8] Margaret Whitehead, “The concepts and principles of equity and health,” Health Promotion International, Volume 6, Issue 3, Oxford University Press 1991, pp217-228.
[9] Cynthia, M. Jones, “The moral problem of health disparities”, American Journal of Public Health, 2010 April 1, 100 Suppl 1: S47-51.
[10] Achieving Health Equity: A Guide for Health Care Organizations. Available at: http://www.ihi.org/resources/Pages/IHIWhitePapers/Achieving-Health-Equity.aspx Accessed November 12, Accessed November 12, 2017.

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