GA 2018-PlS Presentation Puras-Oct2018

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Towards full realization of the right to health:
challenges and opportunities
Dainius Pūras
UN Special rapporteur on the right to health
WMA General Assembly
Reykjavik, October 6, 2018
RIGHT TO HEALTH MANDATE
• Mandate established in 2002. Paul Hunt (2002-2008), Anand Grover
(2008-2014)
• This mandate is a part of UN Special Procedures mechanism
• Objectives:
– Promote and clarify right to health and rights-based approach to health
– Identify good practices, inform about challenges and obstacles, provide
recommendations
• Not right to be healthy, but right to the enjoyment of the highest attainable
standard of physical and mental health
• Not just right to medical care, but also right to determinants of health
• Working methods: country missions, thematic reports to UN GA and
HRC, communications, non-mandated activities
• http://www.ohchr.org/EN/Issues/Health/Pages/SRRightHealthIndex.aspx
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The right to health normative
framework
• Freedoms and entitlements
• Progressive realization / immediate effect
• Participation
• Non-discrimination
• Healthcare (AAAQ)
• Social determinants
• Obligations: respect, protect and fulfil
• Accountability
• International cooperation
“The human rights framework provides a
more useful approach for analyzing and
responding to modern public health
challenges than any framework thus far
available within the biomedical tradition.”
Jonathan Mann
Health and human rights, HIV/AIDS physician & advocate
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THEMES (2002-2014)
• Indicators and benchmarks
• Health systems
• Health and human rights movement
• Access to essential medicines
• Sexual and reproductive rights
• Vulnerable groups – HIV/AIDS, LGBT, disability,
substance use, elderly, migrants
• Underlying determinants
WAY FORWARD (2014 – 2020 ):
CHALLENGES AND OPPORTUNITIES
• Address existing imbalances and power asymmetries within and
beyond healthcare systems
• Transition from Millennium Development Goals (MDGs) to
Sustainable Development Goals SDGs). Agenda 2030. Universal
health coverage. Report to UN GA (2016)
• Life Cycle Approach – importance of investing in health of children
and adolescents. Reports to UN HRC and GA (2015).The need to
move beyond sheer survival. Investing in services and interventions
that promote the right to healthy emotional and social development is
not a luxury. Importance of early childhood and adolescence.
• Mental health and emotional well-being for all in all ages
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WAY FORWARD (2014 – 2020 ):
CHALLENGES AND OPPORTUNITIES
• Report on corruption in health sector and right to health (2017
– GA). Making healthcare policies and systems transparent
and accountable, to ensure equitable healthcare. “Choosing
wisely” initiative – preventing excessive use of medical
interventions.
• Report on deprivation of liberty (detention) and right to health
(2018 – HRC)
• Report on people on the move (refugees, asylums seekers)
and right to (mental) health (2018 – GA)
• Next reports – on social determinants of mental health, on
role of investing in health workforce and role of academic
medicine and medical education
Issues of importance to medical
doctors and their organizations
• Dual loyalty
• Importance of human rights based approach (HRBA)
• Migration of doctors
• Criminalization of impartial healthcare
• Primary care vs specialized medicine
• Initiative to prevent excessive use of diagnostic and
curative interventions (e.g., “choosing wisely”)
• Palliative care
• Special issues: solitary confinement, forced feeding
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Mental health as a new priority
• The need to invest more – but how?
• Main principles of the CRPD
• Psychiatry and human rights – issues of coercion and
overuse of biomedical interventions
• Importance of psychosocial interventions
• Different understanding of human rights and dignity
• Social determinants of mental health
• What about psychiatry and medicine as a social
science? (R.Virchow)
Mental health promotion
• Social and environmental determinants of mental health (including
psychosocial/emotional environment)
• All forms of inequalities and violence have negative impact to mental
health
• States need to invest in enabling non-discriminatory and non-violent
environments in all settings (family, school, workplace, community,
healthcare services, society at large)
• Full implementation of a human rights based approach is an obligatory
pre-condition of effectively investing in mental health (including
promotion, prevention, treatment, rehabilitation, recovery)
• Crucial role of civil society, including organizations of users and ex-users
of mental health services
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Convention on the right of persons with
disabilities (CRPD)
• Dignity and autonomy
• Equality and non-discrimination
• Effective participation and inclusion
• Respect for difference and acceptance of persons with
disabilities as part of human diversity and humanity
• Equality of opportunity
• Social vs medical model: obstacles are outside, they
need to be removed through empowerment, inclusion,
participation and non-discrimination
A need for meaningful debate: dignity, substitute
decision making, deprivation of liberty and involuntary
treatment
Prevailing view among psychiatric
profession and policy makers:
Psychiatrists as experts decide when they
should step in with using non-consensual
measures (coercion) for the purposes of
medical necessity or prevention of
dangerousness. This is their duty, even if
against will, and thus to secure right to
health. Psychiatry is a specific field, in
which such exceptions are unavoidable.
Only through providing treatment it can
be ensured that persons with
psychosocial disabilities continue living
in dignity.
Special cases of emergencies are
emphasized
Prevailing view among human rights
advocates and UN mechanisms:
Substituted decision making, deprivation
of liberty and forced treatment, based on
the CRPD, should be banned. Alternative
approaches should be developed and
replicated. There should be no
exceptions, as exceptions, allowed by the
law, use to turn into the rule and pave the
way to the global situation when mental
healthcare services continue to be an
unacceptable space for systemic human
rights violations.
Dignity cannot be compatible with
practices of forced placement and
treatment which may amount to ill-
treatment and torture.
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Actions to be prioritized on the way to moving
towards elimination of non-consensual measures
• (a) Mainstream alternatives to coercion in policy with a view
to legal reform;
• (b) Develop a well-stocked basket of non-coercive alternatives
in practice;
• (c) Develop a road map to radically reduce coercive medical
practices, with a view to their elimination, with the
participation of diverse stakeholders, including rights holders;
• (d) Establish an exchange of good practices between and
within countries;
• (e) Scale up research investment and quantitative and
qualitative data collection to monitor progress towards these
goals.
Issues for serious debate and search of
rights-compliant solutions
• If there is no hierarchy of rights, and if a right to receive effective treatment and a
right to be free from violence and ill-treatment are equally important, how then to
proceed in situation of psychiatric emergencies?
• Changes in normative framework in post – CRPD era. No need for mental health
laws?
• Is the argument of applying too often non-consensual measures because of
“dangerousness” strong enough?
• Is the argument of applying too often non-consensual measures because of “medical
necessity” strong enough?
• Supported vs. substitute decision making
• Mental health disorders, conditions or diversities?
• What could be a new role and mission of psychiatry in the new paradigm of right-
compliant mental health services?
• WHO Comprehensive mental health plan 2013-2020
• WHO Quality rights initiative
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Conclusion
• Human rights based approach (HRBA) is effective
way for realization of the right to health
• Social, economic, cultural, civil and political rights
are equally important for realization of the right to
health
• Universal declaration of human rights (1948) – 70
years
• In the “post-truth” era it is of vital importance to
strengthen HRBA and public health approach based
on evidence