Print version ISSN 0042-9686
Bull World Health Organ vol.88 n.2 Genebra Feb. 2010
Human rights and health go hand-in-hand
Professor Savitri Goonesekere recently worked with the World Health Organization on a human-rights-based assessment of Sri Lanka's laws, regulations and policies on adolescents' access to reproductive and sexual health information and services. She spoke to Sarah Cumberland about the importance of taking a human rights approach to health.
Q: On 20 November 2009, it was the 20th anniversary of the United Nations Convention on the Rights of the Child (CRC). Sri Lanka is often cited as a model for its work in reducing child and maternal mortality and in improving literacy. How has the CRC contributed to this?
A: Sri Lanka has a good record of achievement with regard to children. In my country, we have had visionary policies on health and education, meaning that every child has had the right to go to school and the right to basic health and that has been reflected in very good social indicators for children even before the CRC. In a sense, politicians had put rights in place through these policies but they weren't written into the 1978 Constitution's Bill of Rights.
Q: What changes followed the CRC in Sri Lanka?
A: Before the convention, we did not consider "rights" were necessary for all children, and child abuse was addressed only from the point of view that they are "children in difficult situations". The convention linked the concept of good governance and state accountability. Giving access to health and education for all children, recognizing gaps in coverage and the need to prevent disparities in health delivery are now state obligations. Protecting children from abuse and exploitation must also receive high priority. The CRC is a powerful accountability measure for ensuring an effective public health system.
Q: Is the CRC really necessary for a country with sound laws and policies?
A: Implementing all the standards on child rights in the CRC is not an easy task. An ideal situation does not prevail in any country, not even developed countries. Some argue that if "the health policies are in place, why do we need to put them in the constitution and other laws?" The reason is clear. Political systems are very fragile. All it takes is a change in a health minister. If someone comes in with a different attitude, everything can change. If a right is not in place in a law or constitution, it's very easy to pull it back.
Q: Is there cynicism about what human rights can achieve?
A: There is a cynicism about rights and what they can do, especially in developing countries. This just encourages states not to implement the treaties they have signed. Human rights laws create a culture of support for implementing health policies by helping the community to monitor the state's actions and programmes. They can't get away with saying "we can't help this situation". Even in a country such as ours, which has some fairly sound laws and policies on health systems and a fairly good administrative system for health delivery, there are gaps and weaknesses. Examples are the regional variations in health and education services and child abuse.
Q: You have completed an assessment of adolescents' rights of access to reproductive and sexual health information and services in Sri Lanka. What did you find?
A: We found that Sri Lanka's focus on child protection has benefited children in the younger age group, but has largely neglected young people. The problem is that we group adolescents as either children or young people but their needs are quite specific. Adolescents' health problems are becoming more complex. Health providers need to acknowledge adolescents have a right to basic health services in some neglected areas such as reproductive health based on access to information and the right of choice.
Over the years, problems have emerged including exploitation of children, particularly young girls who work in domestic service when they should be in school, sexual abuse of adolescents within the family and in the community. Teenage pregnancy is an emerging problem.
Q: Sri Lanka has an exceptionally good record in the region for its attempts to eliminate child marriages. Why do they still occur?
A: Our laws and policies on access to education helped in the implementation of minimum age laws. Although the legal age of marriage is now 18 years, educational opportunities for girls have been disrupted in areas affected by years of armed conflict. There is recent evidence of corruption in registration of under-age marriages. Girls under 18 are being married and sometimes sent to work in foreign employment by illegal agencies.
Q: Are older adolescents in Sri Lanka likely to get the right to make their own health decisions?
A: I am currently on a committee working on family law reform. I hope that we will be able to recommend a law that will specifically guarantee an adolescent "age of discretion" above 16 years of age so that this group has the choice to make decisions on their health. Our research found that, though some court cases and criminal laws have recognized that an adolescent over 16 has decision-making rights, schools and hospitals are not aware that adolescents have this right as there is no specific legislation.
Q: If abortion is legal in Sri Lanka, why is there such a high incidence of "backstreet" abortions?
A: Abortion is legal in an extremely limited situation (only to save the life of the mother) so there is a high incidence of illegal abortion in Sri Lanka. This is an area in which the laws are actually contributing to ill health and even death. The very limited access to legal abortion means that many young women and adolescents turn to backstreet abortionists.
Q: How can viewing this issue from a human rights perspective assist?
A: We need to look at abortion in terms of the public health implications of unsafe abortions on the mother, not in terms of pro-life issues. Women should have the right to health, and viewing this issue from a human rights perspective can help. Some doctors and health professionals are now planning to use the human rights framework in terms of women's health to create support for law reform.
Q: Do adolescents have access to contraception?
A: Family planning has had success in giving adolescents access to contraception. It is now available in hospitals and they can also buy condoms over the counter. But, in cases of sexual violence such as rape, where young women or adolescents may need emergency contraception, they do not always obtain services. Teen pregnancy is also partly due to a lack of focus on sex education.
Q: What is being done to improve sex education in schools?
A: There is a tremendous reluctance to take on sexual health because it is considered by some policy-makers to be too culturally sensitive. At the same time, adolescents and young people are flooded with potentially harmful messages from the Internet and other sources which do not give proper information or encourage responsible sexual behaviour.
Our research recommended that sex education must be integrated in schools with sensitivity. The problem is that education authorities can produce teaching modules but teachers do not want to teach them. A nongovernmental organization with which I work is planning a project to train a group of teachers who understand adolescent problems and have the sensitivity and capacity to develop an effective school programme. One principal of a boys school asked us not to come to his school because his personal perspective was that sex education would give the boys the wrong ideas. Can you imagine how they would teach this subject with these attitudes?
Q: Now that the assessment has been done, what is the next step?
A: We hope that the Ministry of Health will take our report and the recommendations into account as they plan their responses. We also hope that this study will motivate other developing countries to integrate a human-rights based approach into health policy formulation and service delivery.