The world we live in is a very unequal world; and the inequalities are increasing. In the last thirty years the poorest 20% has reduced its share of total production from 2.3% to 1.4%, while the richest 20% has increased its share from 70% to 85%. During the last 15 years, economic decline or stagnation has affected 100 countries, reducing the total income of 1.6 billion people - more than a quarter of the world's population (1).
Over the years a number of economic growth theories have replaced each other in efforts to explain the complex determinants of economic growth. A major conclusion from the 1996 Human Development Report (1) is that although there is no automatic link between human development and economic growth, neither of them can progress in a sustainable way without the other growing at the same time. Sustained poverty alleviation requires both human development and economic growth. More attention, however, must be given to the quality of economic growth to ensure that it is directed to supporting human development, reducing poverty, protecting the environment and ensuring sustainability. Short-term advances in human development are possible, but they will not be sustainable without further growth. Conversely, economic growth is not sustainable without human development. This is illustrated below.
Some countries, including Egypt and Brazil moved rapidly from A to B, but fell back to low economic growth, because too little had been invested in human development. Other countries, for example Tanzania and Cameroon moved from A to C, but lack of economic growth made the social service systems collapse. Countries like Korea, China and Indonesia moved via C to D and are today characterised as countries with both high economic growth and high human development.
The construct above can be generalised to other spheres of development. Development requires the satisfaction of two conditions: the achievement of a certain outcome and the establishment of an adequate process to achieve and sustain that outcome. Most of the World Summit for Children's (WSC) goals including the health and nutrition goals are specific desirable outcomes (2). Effective development demands a high quality process by which the outcome is achieved. Participation, local ownership, empowerment and sustainability are essential characteristics of a high quality process.
The choice of outcome is normally a combination of an ethical choice of desirability and a scientific recognition of possibility (content and form). The outcome is most often a result of complex interactions among underlying determinants that can be described by conceptual frameworks of causality. Deduction is the preferred method in analysing how various determinants influence the outcome.
The process is also a combination of science and ethics. In this case, however, the form is more ethical and the content more scientific. Most successful processes are iterative, adaptive and are controlled by the poor people themselves. Induction, rather than deduction is dominating such processes. The assessment-analysis-action-re-assessment (Triple A) approach that UNICEF is promoting is a good example of such a process (3).
Level of outcome and quality of process define a two-dimensional space for social action. This is illustrated below.
Most development starts at A; and the ideal final stage is D. Many development programmes have become trapped in one of the two areas represented by B or C. A good outcome at the expense of, for example, sustainability (an aspect of a good process) (B) is as useless as a good process without any significant outcome (C). Some immunization
programmes have become trapped in B; while some area-based, community-oriented programmes, that never moved to scale, have been trapped in C.
Monitoring of the achievement of human development outcomes or goals has improved considerably during the past ten years (4). The positive experience of the monitoring of immunization coverage has been applied to monitoring the progressive achievement of almost all WSC-goals. Much less progress has been achieved in efforts to monitor the quality of the process, largely because it has seldom been defined. There is an urgent need to develop appropriate indicators for criteria such as participation, women's empowerment and sustainability (5).
Efforts to progressively achieving the WSC health and nutrition goals can be analysed by this construct. Achieving the outcomes, for example reducing diarrhoea and malnutrition are necessary conditions for successful programmes and projects. But that is not sufficient. These outcomes must be achieved through processes that ensure participation, sustainability and individual and group self-reliance consistent with human dignity.
Many development programmes and projects have been either 'outcome-focussed' or 'process-focussed'. Some characteristics of these two extreme approaches are listed below:
- Emphasis on goal achievement only - Emphasis on the quality of the process only
- Monitoring limited to the achievement - Monitoring focussed on process of goals criteria
- Emphasis on science, incl. utility - Emphasis on ethics (deontological aspects)
- Risk of being short-term - Risk of being long-drawn
- Perceived by many to be too simplistic - Perceived by many to be too idealistic
Outcome-focused approaches have been preferred by many economists and development agencies. 'Utility' as an outcome is a central theme in neo-classic economics. The focus on achieving WSC-goals sometimes has also made UNICEF-supported programmes and projects relatively outcome-focused. A multi-donor evaluation of UNICEF a few years ago strongly recommended a re-orientation towards greater emphasis on the quality of process, with emphasis on sustainability and empowerment (6).
Process-focused approaches have been favoured, in contrast, by many
NGOs. Many small area-based programmes have established high quality processes,
but at a relatively high cost per person. However, few of them have expanded
to any larger scale with significant outcomes.
2. A RIGHTS-BASED APPROACH
Both outcome-focused and process-focused approaches, taken alone, must be avoided. A rights-based strategy does that by combining the two, actually making full use of the synergism between them. This is possible because outcome and process are not independent of each other. Outcomes/goals can be chosen and defined in such a way that the quality of the process is enhanced; and processes can be so designed as to reinforce and sustain these outcomes/goals. Most of the WSC-goals are 'moral minima' (7), representing `a cross-cultural moral consensus' (8), which can be pursued in a way that stimulates a process of participation. On the other hand, a process that recognizes people as key actors is likely to answer ethical criteria.
The achievement of such goals constitutes a necessary condition for the realisation of the corresponding right. This achievement, however, is not sufficient. The goal must be achieved through processes that are participatory, empowering and sustainable. To be healthy and well-nourished today reflects satisfied needs; to be sure that the same condition will prevail is a realised right.
A rights-based strategy aims at an optimal balance of moving more directly from A to D. It is not either outcome or process; it is both. It is not either monitoring of outcomes/goals or monitoring of process. It is both. Those who emphasize quality of process often defend such a position by using ethical criteria. The assumed contradiction between goals and process therefore reflects the historical division between goal -and duty-based ethical theories (9). In a rights-approach the two are not contradictory, they are mutually reinforcing. The ideal path to move on the "ridge" from A to D seems difficult. Nevertheless this is exactly the path most successful development programmes have followed. A recent study of twenty-one successful community-based nutrition programmes/projects in South Asia confirmed this hypothesis. They managed to strike a balance between ensuring an adequate outcome through a satisfactory process throughout the programme/project implementation (10).
A right is characterised by its content, scope and strength (11). The content of a right defines whatever it is a right to, e.g. adequate nutrition or good health. The scope of a right both defines the subjects of the right (i.e. those who hold the right) and the objects of the right (i.e. those against whom the right is held). The strength of a right refers to the importance that this right will be realised.
Rights defined in UN covenants and conventions are conventional rights. Conventional rights are different from moral rights, because the former are conferred or assigned by systems of conventional rules. UN human rights basically regulate the relationships between the individual and the state. The state has obligations. The degree to which this type of human rights assigns duties to individuals, in the way that moral rights do, is intensively debated among philosophers (12). In many cases, including the CRC, these rights refer to, and require a level of action by individuals in relation to others, for which the state serves as guarantor and enforcer. The CRC, for example, assumes certain duties by the family in caring for the child.
State obligations can be grouped into four categories:
- the obligation to respect
- the obligation to protect
- the obligation to facilitate
- the obligation to fulfil
These categories have been defined in the following way.
The obligation to respect obliges the state to avoid depriving a person of a right that the person already has realised. A law ensuring that all people have equal access to basic preventive health services or an attitude that girls should not be discriminated against are examples.
The obligation to protect obliges the state to prevent third parties from depriving a person of a right that the person already has realised. Regulations and institution that prohibit the sale of infected foods or the use of child labour are examples.
The obligation to facilitate and fulfil oblige the state to secure that people whose rights are violated get their rights realised. Distribution of land to the land-less will facilitate adequate dietary intakes, where distribution of food more directly fulfills the same need.
The promotion, protection, facilitation and support to breastfeeding reflect the four categories of state obligation in relation to the right to be breastfed. In practice, this means, for example, legislation on maternity leave, protection against commercial advertisement of breastmilk substitutes, facilitating the work of mother-support groups, and training in lactation management.
The state must meet all four categories of obligations. This reflects the indivisibility of human rights. The obligation to respect does not take time and does not cost much. It is basically a question of political choice. The obligation to protect requires more time and resources, while the obligations to facilitate and fulfil may take even more time and often require substantial resources. This is posing serious problems for most developing countries, which face real resource constraints. This issue, however, goes beyond resource constraints per se. There are different positions regarding the state's obligation to address civil/political rights (CPRs) and social/economic/cultural rights (SECRs). The former require primarily the state to respect and protect (most are freedoms from state interventions) while the latter often require the state to facilitate and fulfil (most are rights to something, that require state's intervention). While most people require that the state does not make their child ill, some people do not expect the state to make their sick child healthy.
Although the tradition in the UN rights system emphasise the indivisibility of rights, i.e. that all rights are equal, this difference is obvious in most UN conventions, including the
CRC. In Article 4 it is stated that "With regard to social, economic and cultural rights,
state parties shall undertake such measures to the maximum extent of their available resources .........". P. Alston summarises the difference by stating that the state has an obligation of result as far as CPRs are concerned, while only an obligation of intent as far as SECRs are concerned (13).
Article 4 should, however, be seen in the perspective of the Limburg Principle, that states
"The obligation to achieve progressively the full realisation of the
rights requires states parties to move expeditiously as possible towards
the realisation of the rights. Under no circumstances shall this be interpreted
as implying for states the right to defer indefinitely efforts to ensure
full realisation. On the contrary, all states parties have the obligation
to begin immediately to take steps to fulfil their obligations under the
3. FROM A BASIC NEEDS TO A HUMAN RIGHTS APPROACH
In a Human Rights Approach basic health and nutritional needs are met through processes that are participatory, empowering and sustainable. Some people perceive any deprivation as a violation of rights. This leads to an 'inflation' of rights which dilutes the particular potential of a rights-based approach. There are many needs that are not recognised as rights by any UN Convention. This is particularly true for social, economic, and cultural needs.
All needs can be translated into outcomes or goals, i.e. to satisfy the needs. Rights imply needs and goals, but needs and goals do not imply rights (15). Children have physical, cognitive, emotional, spiritual and other needs. Some needs are specific and quantifiable, such as nutritional requirements; others are less specific or easy to quantify, such as the need for stimulation. Most people agree that all needs, at least the 'basic needs' of the child should be satisfied; and that the fulfilment of these needs represent valid claims. In the World Summit for Children (WSC) the world's leaders signed a 'social contract' with the world's children, in which a number of the needs of children were recognized as valid claims. The satisfaction of these needs was translated into a number of quantifiable and time-bound goals (targets). The political leaders promised a 'first call for children'. Making this promise meant a moral obligation, but not a legal one.
Countries which have ratified the Convention on the Rights of the Child (CRC) recognize most of these needs and several others as rights. Rights impose corresponding legal obligations on the state and moral obligation on parents and child care-takers.
There are a number of differences between a Needs Approach and a Rights Approach. This is reflected in the language normally used to describe them.
The most important difference between a Basic Needs Approach and a Human Rights Approach is that in the former the child is most often seen as a 'passive object', a recipient of protection and care, while in the latter the child is recognised as an 'active and participatory subject'. A Human Rights Approach means that the child is a citizen with citizen rights. The opinion of the child must therefore always be taken into consideration in all matters affecting the child.
In a Needs Approach goals can be partial, while in a Rights Approach goals always must be 'total', i.e. elimination, 100% coverage etc. In a Rights Approach States are obligated to state the date at which the goal will be achieved in accordance with the Limburg Principle. Targets for interim years may be determined, but the date of final achievement must be identified. Many partial goals were agreed upon in the WSC reflecting the dominant needs approach.
Needs can be more or less 'basic', while UN Conventional rights are both universal and indivisible. Of course, that does not rule out a prioritization of which violation should be addressed first.
In a Rights Approach all must be included. Instead of monitoring the number who have their needs met, the number of those who have their rights violated is measured.
Perhaps the most controversial is the acceptance of charity in a Basic Needs Approach. At least in most European traditions, charity is seen as obscene in a human rights perspective.
In a Basic Needs Approach reference is often made to the need to mobilise 'political will'. Lack of 'political will' is often seen as a major constraint in the allocation of resources, necessary for the fulfilment of basic needs of the people. In a Human Rights Approach, for countries that have ratified the CRC, for example, the language must change. If governments do not allocate adequate resources, they have chosen not to stand up to their obligations. 'Political choice' rather than 'political will' reflect such a situation.
A list of these differences is presented below:
|Needs||Rights (UN Conv.)|
4. A FRAMEWORK FOR ACTION
We assume a situation where an 'outsider', for example UNICEF, wants to contribute to an improved health/nutrition condition of children in a country. Such an effort should consist of six phases, outlined below.
4.1 Causal Analysis
When the problem has been identified, for example disease and malnutrition of children, the causes of the problem should be identified. This work is facilitated by the use of an explicitly formulated conceptual framework of causality. Such a framework should only consist of causality relationships, identifying a hierarchy of causes at immediate, underlying and basic (or structural) level. The UNICEF promoted conceptual framework for nutrition is an example of this (see fig.1). In a particular context it is important to reduce any more general framework to one which only contains the most important causes. The analysis of causes should start from the final outcome (e.g. malnutrition) and work 'downwards' in the framework to identify only those immediate, underlying and basic causes that are important for the final outcome.
An analysis of causes provides a number of potential 'entry-points' for actions, at different levels of causality. Actions at the immediate cause level are normally easy to undertake but more difficult to sustain. On the other hand, actions at the basic cause level are more complex and difficult, but will result in more sustainable changes. This provides the first dimension.
4.2 Stakeholder Analysis
In this particular case the child is the focal point. The first step will be to identify what the first level of support can and should do. The prime child care-giver, normally the child's mother, is the first level of support. There are certain things the prime care-giver can and should do. There are other necessary actions, however, that the prime care-giver cannot do. This moves us into the next level of support, normally the rest of the household. With the same logic successive 'layers' of support need to be analysed, including the extended family, the
community, district and finally the national level. This provides the second dimension.
A simple matrix with the type of causes as one dimension and the level of society as another dimension is useful. It provides a table which shows which causes could or should be addressed at what level of society.
4.3 From un-met needs to violated rights
As shown above (4.1) malnutrition and disease are results of a number of causes, hierarchically related. In most cases the causes reflect the violation of a right. If, for example, any of the rights to food, care or health is violated the right to nutrition is violated. Good nutrition in a rights-perspective does not only mean that all nutritional requirements are met (as needs) but that these needs are met in a sustainable and dignified way. Nutrition as a right therefore implies the realisation of the child's rights to food, care and health. Similarly the realisation of these rights implies the realisation of the right to basic education, the right to the minimum amount of resources and the right to information. Further, the realisation of these rights require the realisation of a large number of civil, political, social, economic and cultural rights reflecting the level of basic or structural causes.
With this in mind the first dimension of level of causes can be transformed to a dimension of violated rights. The matrix mentioned above (4.2) will now reflect violations vs. level of society.
4.4 Obligations and Duties
As mentioned earlier UN conventional rights imply obligations for the State. Through various forms, including the legal systems, these obligations at State level may confer duties for communities, households and individuals. (cf. the duties of parents referred to in the CRC). The obligation to respect, protect, facilitate and fulfil represent a third dimension.
With these three dimensions two additional matrices can be constructed.
For each specific violated right a two-dimensional matrix can be constructed
with the type of un-met obligation or duties as one dimension and the level
of society (stake-holder) as the other. For each level of society another
matrix can be constructed with the type of un-met obligations/duties as
one dimension and the different rights-violations as the other dimension.
An example of the first type of matrix is shown below for the violation
of the right to be free from disease (only examples are given).
|Attitude and practice against any discrimination of girls
Children brought for vaccination
Fathers giving support to pregnant and lactating mothers
Mothers breastfeeding their children
|Attitude that children have rights
Maintenance of a child register
Community financing of health services
Transport to emergency obstetric care
|Law against violation of the BMS code
Free vaccination of children
Law allowing community financing of health services
Free curative health services
4.5 Support to sustainable processes
In order to meet the obligations and the duties actions need to be taken
at different levels of society. At each level stake-holders are engaged
in decisions over how to use the human, economic and organisational resources
they control. These decision-making processes can be seen as Triple A process.
At each level of society processes should be strengthened or initiated by which the actors will improve their capabilities to assess the situation, analyse the causes of the problem and design and implement resource-relevant actions, followed by a re-assessment (monitoring), better analysis and more effective actions (Triple A approach). At the community level poor people themselves should be recognised as the key actors, rather than passive beneficiaries of transfers of commodities and services. The key actors at different levels of society will have been identified in the stake-holder analysis (phase 2).
The Triple A process can be summarised in the simple construct below.
4.6 Operational Framework
The most important generic strategies for an 'outsider' to support high quality processes at any level of society are the following:
(3) Education Capacity Building
(5) Service delivery
All strategies affect the capabilities to assess, analyse and act, but
normally to a different degree. Advocacy and social mobilisation is most
important in influencing ethical choices, i.e. the identification or priority
problems. Information improves the assessment; education improves the analysis;
and training and service delivery directly affects action. This is illustrated
The types of strategy represent a fourth dimension. In principle these additional two-dimensional matrices can be constructed.
a. Type of strategy vs. type of obligation/duty, at a given society level and level of cause/violation (immediate, underlying, basic).
b. Type of strategy vs. level of cause/violation at a given society level and type of obligation.
c. Type of strategy vs. level of society at a given level of causes/violations and type of obligation/duty.
Of course, all these two-dimensional matrices are special cases of a general four- dimensional matrix with the following dimensions.
1. level of causality/violation (immediate, underlying, basic)
2. level of society (stake-holders) (individual, household, community, national, international)
3. type of obligations/duties (respect, protect, facilitate, fulfil)
4. type of strategy (advocacy, capacity-building, service-delivery)
One of the more useful matrices is the one that shows type of strategy
vs. type of obligation/duty (matrix (a) above). In general the role of
the different types of strategies are similar for most types of violations
at most levels of society. This is illustrated below.
An example from the promotion, protection and support of breastfeeding
is shown below, using this matrix.
||Legislation about marketing of BMS||'BFHI'||Information about Code implementation|
||Legislation about Maternity leave||Lactation Management Training||Pre/post natal Health Service|
Out of the four dimensions, the first three are useful for an assessment
and an analysis of the problem. This will result in an identification of
which rights are violated, by what stake-holder and in which form (lack
of respect, protection, facilitation or fulfilment). The fourth dimension
represents strategies for action. In order to choose the most appropriate
strategies the Triple A processes in which the stake-holders are involved
must be understood. It is then possible to identify those strategies that
most effectively will improve the stake-holders effort to respect, protect,
facilitate and fulfil the rights of children.
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