Human rights and applied budget work Current trends, gap analysis, costing and related advocacy strategies Jorge Romero Leon Accountability and Monitoring in Health Initiative Costing for Change Seminar Poiana - Brasov, Romania October 27th, 2011

Contents Human Rights Framework Obligations of the state Principles of interpretation Minimum core obligations Applied budget work Types of applied budget work Why applied budget work with a human rights framework? Examples from the field Principles that apply to palliative care Costing for change?

Human Rights Framework Economic, Social and Cultural Rights Food Health Education Decent work Housing Social protections Adequate standard of living Cultural rights Environment Water Sexual and reproductive Civil and political rights To a life free of torture To a life free from violence Freedom of expression Access to information Personal integrity and security Equal access to justice Due process Minority right

The obligation to respect requires the state to abstain from interfering in the enjoyment and fulfilment of rights. It entails banning certain actions and behavior through which governments may directly or indirectly curtail the enjoyment of rights. State obligations: To respect To protect To fulfill

The obligation to protect requires that States protect individuals against abuse by non-state actors. State obligations: To respect To protect To fulfill

The obligation to fulfill requires that the state take all necessary legislative, administrative, budgetary, judicial and other appropriate measures for the complete fulfillment of rights. The obligation demands the adoption of proactive measures to guarantee that human rights can be enjoyed. State obligations: To respect To protect To fulfill

Obligations of result Requires that States achieve specific targets to satisfy a detailed substantive standard To ensure the full realization of rights Obligations of conduct Obligations of the State Respect Protect Fulfill

Obligations of resultObligations of conduct Requires action reasonably calculated to realice the enjoyment of a particular right. Entails reference parameters that allow for an assessment of State actions regarding specific rights. Obligations of the State Respect Protect Fulfill

Principles Maximum use of available resources Progressive realization Non retrogression Non discrimination Equality Minimum core obligations Comprehensiveness Citizen participation Transparency, access to information and accountability Human Rights ►Obligations of result ►Obligations of conduct Obligations of the state Respect Protect Fulfill

While all the rights under the Covenant are meant to be achieved through progressive realization, States have some minimum core obligations which are of immediate effect. These immediate obligations include the guarantees of non-discrimination and equal treatment, as well as the obligation to take deliberate, concrete and targeted steps towards the full realization of rights, such as the preparation of a national public health strategy and plan of action to address the gaps in palliative care.

Progressive realization means that States have a specific and continuing obligation to move as expeditiously and effectively as possible towards the full realization of rights. In this regard, costing, trend analysis, comparison of allocations and actual expenditure within a program (such as palliative care) or across programs and sectors affords a road map to effective implementation of policies to address States’ obligations

International Human Rights Treaties (art 12 ICESCR, CEDAW, etc.) Regional Human Rights Treaties (art 16 ACHPR, art 10 APACHR, etc.) National constitutions and bills of health National health plan and health policies National and sub- national budgets Service delivery General Comment 14

Applied budget work Applied budget work is undertaken with the explicit intention of advancing policy goals Links budget research--including costing, trend analysis, comparison and cost effectiveness assessments to advocacy Great variation in origin, leadership, focus, methods and targets

Statistical information Budgetary information Policy and program indicators, $ allocations Policy implementation and impact over rights fulfilment Results Conduct

Types of budget work Building budget literacy and engagement Assessing gaps in policy through costing and comparison Drafting stage: Resource tracking, procurement monitoring & priority setting Approval stage: Macro expenditure & revenue analysis; legislature training Execution stage: Trend analysis and monitoring of allocation, comparison of over and under-spending by program and across sectors; expenditure tracking Evaluation stage: Social audits, performance audits, audit tracking & impact monitoring

Why applied budget work with an HR framework? This is a frame on the basis of which demands regarding access to palliative care can be clearly articulated in relation to the States’ obligations; on the basis of which feasible alternatives can be put forth and their cost assessed for immediate or gradual implementation; and on the basis of which misallocation of resources or lack or prioritization of palliative care policies can be legally challenged.

Examples from the field

Mariana Pérez, Fundar, Progressive allocation of resources = progressive realization? Budget of the health insurance (mill. pesos)

Non-discrimination? Population without social security vs. beneficiaries of the health insurance (2007) Percentage of population without social security Percentage of health insurance beneficiaries Mariana Pérez, Fundar, 2008.

Non-discrimination? % of rural population without social security vs. % of rural beneficiaries of health insurance (2007) Percentage of rural population within the total pop. without social security Percentage of rural health insurance beneficiaries Mariana Pérez, Fundar, 2008.

Use of maximum available resources? Special fund for infrastructure ( ) 3 billion pesos have been earmarked for infrastructure from , only 30% has been used. Mariana Pérez, Fundar, 2008.

Current expenditure in medical treatment and healthcare as a percentage of average expenditure per household by income decile – constant 2000 currency

Minimum core obligations regarding Palliative Care Types of analysis by obligation Obligations of conduct: Public financing levels aimed at establishing essential access levels and palliative care coverage, costing of policy gaps, comparative analysis of allocations by type of coverage. Obligations of result: Percentage of population with access to Palliative Care.

Minimum core obligations regarding Palliative Care Specific recommendations Basic legislative reforms to afford access to pain relief and development of a national strategy to address coverage and quality of care gaps; Creation of a baseline of palliative care that affords humane treatment to the dying, on the basis of agreed upon and broadly promoted standards (WHO, IPCI); Carrying out training of health professionals for understanding the demands of palliative care and immediately adjusting the model of treatment.

Principles that apply to Palliative Care Progressive realization and non retrogression Obligations of conduct: Monitoring of expenditure on institutionalized care, cost-effectiveness comparison of models of care, monitoring of national strategy implementation, trend analysis of allocation problems. Obligations of result: analysis of increased allocation for coverage of pain relief and new model of care, monitoring of spending in training and human resource development

Principles that apply to Palliative Care Non discrimination and equality Obligations of conduct: Comparison of expenditure and type of care by population group, by type of health coverage, geographical analysis of excluded population groups and spending in available services. Obligations of result: Analysis of coverage gaps.

Principles that apply to Palliative Care Participation, transparency and accountability Obligations of conduct: Transparent allocation processes, mechanisms for access to information, clearly established responsibilities Obligations of result: ATI regime, clear accountability mechanisms encoded in law

Transformation of the model of care Status quo Limited access model of care, high cost, ineffective, limited access to pain relief, no national strategy and limited training Costing more effective, identifies GAPS Education, discussion of alternative models, changes in legislation to introduce access to essential medicines Policy changes, adoption of standards, adoption of variety of models; training and implementation of new policies Budget monitoring, cost comparison, auditing of implemented standards; costing of new activities Transformation and institutional adoption of new model of care Gradual implementation of effective, inclusive model of care with in-patient services, home and community care, increased coverage and exhaustive training Monitoring of allocation for advanced implementation, trend analysis and program auditing

Costing for change? Costing is important at several stages of the transformation of policy and model of care, but especially at the initial stages, because it identifies existing gaps in legislation, care and coverage; it makes feasible policy alternatives visible and connects them with a failure to comply with international standards (WHO) or human rights obligations. Making the alternative models of care visible, and their cost common currency, allows for a more nuanced discussion of the road map needed to carry out necessary changes. It also eases resistance from policy makers and health care providers.

Why applied budget work with an HR framework? Demands are clearly articulated in relation to the States’ obligations. Feasible alternatives advanced and advocated, cost assessed for immediate or gradual implementation. Misallocation of resources and lack of prioritization of palliative care policies can be legally challenged.