After reviewing historical human rights documents that enshrine child survival and nutrition rights in international law, this paper shows how child survival and nutrition programs funded by the United States Agency for International Development (USAID) have achieved results that address fundamental human rights. It then suggests ways in which USAID can improve its development assistance under the human rights rubric. It postulates that further gains in child survival can be made by adopting a human rights approach to development. Finally, it compares and contrasts the public health and human rights approaches, underscoring questions that development agencies may wish to deliberate in shifting to a rights paradigm.
Beginning with the 1948 Universal Declaration of Human Rights, the world has recognized the need to address fundamental issues of food, health care, and shelter as rights to which every world citizen is entitled. The International Covenant on Civil and Political Rights and the International Covenant on Economic, Social and Cultural Rights, both adopted by the United Nations General Assembly in 1966 and in force in 1976, underscore these basic tenets.
In 1979, the United Nations General Assembly convened a committee to draft a new international treaty on the rights of the child. In 1989, the General Assembly adopted the Convention of the Rights of the Child (CRC), which strengthened former human rights declarations with regard to children's rights. It came into force in 1990, and has now been ratified by 190 nations. Only the United States, Somalia, and Oman have not yet ratified the convention.
Whether directly or indirectly, these international agreements consistently call for the assurance of children’s survival, especially through their good nutrition. For example, the Universal Declaration of Human Rights, in article 3, asserts that "Everyone has the right to life, liberty and security of person". The International Covenant on Economic, Social and Cultural Rights, in article 12, calls for recognition of "the right of everyone to the enjoyment of the highest attainable standard of physical and mental health" and requires that steps be taken for "The provision for the reduction of the still-birth rate and of infant mortality and for the health development of the child" and for "The creation of conditions which would assure to all medical service and medical attention in the event of sickness".
Several articles of the Convention of the Rights of the Child are directly applicable to child survival programs:
(b) To ensure the provision of necessary medical assistance and health care to all children with emphasis on the development of primary health care;
(c) To combat disease and malnutrition, including within the framework of primary health care, through, inter alia, the application of readily available technology and through the provision of adequate nutritious foods and clean drinking-water, taking into consideration the dangers and risks of environmental pollution;
(d) To ensure appropriate pre-natal and post-natal health care for mothers;
(e) To ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition, the advantages of breast-feeding, hygiene and environmental sanitation and the prevention of accidents;
(f) To develop preventive health care, guidance for parents and family planning education and services." Article 24(2)
In 1985 USAID launched its Child Survival Program to improve the health of children in developing countries. Since that time, child survival has been one of the main supporting pillars of US development assistance. Stabilizing the world's population and protecting human health remain one of the five Agency goals, with sustained reduction in child mortality as a key objective. From 1986 to 1995, USAID spent nearly $2 billion on child survival programs.
Utilizing a public health approach rooted in epidemiology, USAID addresses immunizations, oral rehydration therapy (ORT), nutrition with an emphasis on infant and child feeding, and promotion of child spacing as the basic framework of its child survival portfolio. With a goal of reducing infant mortality rates in USAID-assisted countries from the 1985 average of 97 deaths per 1000 live births to 75 deaths by the year 2000, programs throughout the world have addressed human needs in these basic areas.
Twenty-two countries with high infant mortality have been selected for emphasis. Approximately two-thirds of the world’s infant mortality takes place in these countries. The Agency has supported additional activities in at least 40 other countries. Assessments of fundamental needs, such as food, health care, and education, have guided programs and resulted in improved infant and child survival.
The Center for International Health Information examined infant mortality rates (IMR) from USAID and non-USAID assisted countries during the years 1980-95. Using simple averages, assisted countries showed a larger reduction in IMR than non-assisted countries (18.2 versus 14.6) during this time period (Table 1). Declines were most evident in the Latin American and Caribbean region, which received much higher per capita funding than other regions during this period. USAID assistance appeared to have a positive impact regardless of economic performance during the 1980s, suggesting that improvements in child health can be achieved despite sluggish or negative economic growth.
Table 1 focuses on infant mortality rates (IMR), the number of children under one year of age who die for every thousand born alive. Figure 1 presents data on children’s mortality rates (CMR), the number of deaths of children under five years of age for every thousand born alive. The figure shows that the CMR fell 21 percent in USAID emphasis countries (from 153 to 120), and only 14 percent in the rest of the developing world (from 129 to 110) during this period.
In only six years (1984-1990), USAID, working together with UNICEF, WHO and other global partners, helped raise vaccination coverage rates worldwide from 44 percent to the 80 percent target, saving an estimated three million lives every year. USAID was the major foreign donor supporting the effort to eradicate polio in the Western Hemisphere region, certified polio-free in 1994. USAID is now working toward the eradication of polio in South Asia and sub-Saharan Africa, and is supporting efforts to eliminate measles from the Americas. To enable local governments to assume managerial and financial responsibility for their own programs, USAID shifted part of its resources from the immediate task of vaccinating children to supporting sustainable immunization programs. Efforts now focus on strengthening the capacity of local governments and indigenous non-governmental organizations to plan and manage their immunization programs; on training health workers and supervisors; on maintaining the refrigeration "cold chain"; and on ensuring a reliable vaccine supply. This new strategy is one of the main reasons for the continued high immunization coverage levels in most developing countries since 1990.
Oral Rehydration Therapy
Oral rehydration therapy (ORT) has been a proven means of averting diarrheal deaths for several decades. The worldwide use of oral rehydration salts (ORS) or similar home solutions during dehydrating diarrhea has saved nearly 1.5 million lives a year. USAID financed the basic scientific research on ORT, and continues to ensure that ORS is available and used correctly around the world. Between 1986 and 1993, the use of prepackaged salts or home solutions to treat diarrhea doubled. Usage increased even faster in countries where USAID concentrated its efforts. The rate tripled in Indonesia, Peru, and Morocco, and increased even more dramatically in Ghana and Kenya.
USAID strategies originally designed to address severe malnutrition have been expanded during the past decade to include mild to moderate malnutrition. Programs include efforts to improve feeding practices, breastfeeding promotion, and micronutrient interventions, particularly vitamin A. Hundreds of health professionals have been trained, technical assistance has been provided for dozens of countries, and social marketing programs and community support networks have been established throughout the developing world. Nearly 80 percent of all hospitals designated by UNICEF to be "baby-friendly" can be attributed to USAID's efforts to promote breastfeeding. USAID has implemented vitamin A programs in approximately 50 countries. Projects provide vitamin A capsules and reinforce supplementation with communications efforts and, in some areas, food fortification. As illustrated by a case study in Niger:
Thus, USAID's approach to child survival, based on a public health approach and utilizing the most advanced technology available throughout this period, has helped to lower infant and child mortality. And in this respect, these programs have addressed fundamental human rights, such as the right to life, the right to the highest attainable standard of health, and the right to development.
USAID programs have also incorporated a participatory approach to development, which some experts deem the "essential oil" of a human rights approach to development assistance. Adopting a "bottom up" approach to program design, USAID has sought to build activities around the expressed needs of the people themselves. It also encourages host country governments to adopt a similar approach to decentralized interventions.
However, USAID programmatic impact could feasibly be strengthened by adopting the human rights paradigm. Rather than viewing development and human rights as separate entities, this paradigm would view development as integral to the human rights spectrum. Incorporating the democracy and governance sector into the rest of development assistance would base interventions in the foundation of international law. Reconciling domestic law with international commitments would strengthen development assistance by providing a legal basis for interventions and underscoring host governments' obligations to address basic human rights. Such an integrated model would more easily advance a comprehensive development agenda, and would integrate democracy and governance throughout the foreign assistance portfolio.
A public health approach basically examines a given problem through the discipline of epidemiology, and then seeks to address different aspects of this problem with health-based solutions. It identifies health-related problems and devises solutions specific to each situation. With regard to malnutrition, public-health based interventions could include food distribution, nutrition education, iodization of salt, or micronutrient supplementation. They would typically not include human rights education, or even address fundamental problems that marginalize disadvantaged groups and thus depress nutritional status.
Consider maternal anemia as an example. The public health approach would address this problem through a variety of methods, including prenatal supplementation and nutrition education. The target population would be pregnant women, and interventions would focus on them and the problem of anemia, irrespective of other factors in the environment. A simple needs assessment would typically obtain data (either from clinical records or from population-based surveys) on hematocrit or hemoglobin values. An investigation into current nutrition interventions by the medical community would be undertaken. Optimally, data regarding the amount and quality of dietary iron intake by women during their reproductive years, with a special focus food habits during pregnancy, would be included. Information on parasitic infestations could also be collected or made available. Based on this array of findings, interventions would certainly include a prenatal supplementation distribution program (usually incorporated with clinic-based services), possibly nutrition education (often through medical practitioners or community health workers teaching women about food sources high in iron), and perhaps an environmental component. A small-scale gardening project might be included in this type of intervention scheme.
Such an approach could well result in improved iron status of a particular group of pregnant women. Yet it would do little to address the underlying causes which might have led to their anemia. It would not, for example, educate women on their children's right to "adequate nutritious foods and clean drinking-water, taking into consideration the dangers and risks of environmental pollution". If maternal anemia were related to inadequate financial resources to purchase iron-rich foods, these interventions would fail to assist women in addressing fundamental economic constraints. If their anemia resulted from environmental toxins (such as lead), it would do little to help them advocate for removal of this pollutant from their environment. In these respects, the intervention would meet the immediate goal of improved iron nutriture for a given population. But ultimately this program would be unsustainable. As soon as the iron supplements were discontinued, prenatal anemia would probably return. Neglecting the underlying causes of this nutritional problem--which could well be rooted in the failure of the national government to address fundamental human rights--would ultimately result in a poor development decision.
By contrast, the human rights approach would look for causative factors which keep women anemic in a given situation, and identify which particular right would be at issue. Underlying factors might include lack of clean food and water supply resulting in parasitic diseases; lack of resources to purchase iron-rich foods; lack of schooling which would help women to understand the relationship between food, parasitic infection, and nutritional status, lack of access to health services which theoretically could provide iron supplementation. It would then work directly with women and others interested in this problem to address not only anemia (which is a result of many societal factors working together to cause the problem), but the fundamental inequalities existing in the society which are related to the problem of anemia. Women themselves would identify the barriers faced to their own health and development, and press their governments for change.
This is not to say that the public health approach to development has been ineffective. USAID programs demonstrate that this approach has worked in many settings. But public health programming in and of itself cannot address the fundamental problems within a society which result in poverty, malnutrition, and ill health. The human rights approach views attention to fundamental, underlying causes of problems of health and nutrition as pivotal to development.
Economic, social, and cultural rights are an integral part of international law. They are fundamental to the way that countries relate to one another, and therefore should have a direct impact on the bilateral aid relationship.
The human rights approach offers redress to the imbalance between society's privileged and disempowered members. Rights establish legal obligations for states to provide services to individuals that are not able to obtain or provide them on their own. Reconciling national laws with international human rights agreements, and assuring implementation of those laws, would provide a legal basis within a given country enabling all citizens to realize their fundamental human rights.
Integrating development into the human rights framework allows governments to more fully address the tenets of participation, grass-roots involvement, economic restructuring, and democratic principles. Sustainable change will be more likely to occur when fundamental inequities within a given society are addressed and when people are empowered to advocate for their basic human rights.
Adopting a human rights approach to development assistance for child survival and nutrition would involve a fundamental paradigm shift from a public health, problem-oriented method to a people-centered, rights perspective. Incorporating a cross-sectoral approach by infusing health and nutrition programs with concern for democracy and governance would base programs in international law, and would help reconcile domestic laws and standards to these international commitments. Educating citizens on their human rights and providing them the skills to advocate for those rights would support a participatory approach to development. Such a sectoral combination would enhance health programs and ultimately result in lasting change.
USAID has recently begun serious efforts to address democracy and governance issues. Interventions include assistance with drafting legislation or regulations protective of human rights, assisting governments in establishing and developing official institutions for the protection of human rights, and helping build consensus and coalitions for advocating greater state adherence to legal, constitutional and international human rights commitments. Moreover, USAID actively partners itself with non-governmental organizations (NGOs) which advocate for human rights, and helps citizens attain legal literacy through community legal education programs.
One example (of many) is a grant to a Croatian women's NGO. Be Active, Be Emancipated (B.a.B.e.) aims to expand its existing network of human rights activists in Croatia and develop similar alliances within the former Yugoslav states. Using the framework of human rights education with a focus on training activists, this project will enhance the capacity of new democratic women's organizations to develop local actions which address women's basic rights of economic security, legal equity, reproductive health, improved nutrition, and violence prevention and political participation.
These represent beginning efforts to address human rights within the democracy and governance programmatic portfolio. This strategy should be integrated throughout the remainder of USAID's development assistance--including child survival and nutrition programs.
This paper has presented the basic tenets of the relationship between human rights and development programs, asserting that USAID, in its child survival/nutrition programs, implicitly addresses fundamental issues of human rights. It also argues that these health programs would be more effective if they explicitly adopted a rights approach to development, thereby combining health with the democracy and governance sector, and integrating development programs into the human rights framework. Programs would have more impact and be more sustainable if such an approach were universally accepted throughout the donor community.
However, several key questions must be addressed before such a shift in approach is undertaken. How can it be pragmatically operationalized? Initial assessment and project design would need to account for adherence to human rights principles before activities could begin. Firm legal guidelines would need to be established that would hold governments accountable for child welfare. How would such projects be carried out; how would they be monitored and evaluated? Would they be more costly?
Without adapting such an explicit rights approach, USAID programs are already addressing human rights. Three decades of progress in development theory--from a human welfare approach (1950s) to participatory development (1990s)--have continued to move us closer to a human rights paradigm. What added value would development programs achieve if this paradigm were adopted, and at what cost? Careful examination of data from both the human rights and the traditional development arena may begin to answer these questions as we continue to move forward in this debate.
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