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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