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Colombia is a country marked by extreme social inequalities and high levels of violence, with a government that has brutally repressed social movements and dissidents, including health workers’ unions. Notwithstanding the repression, various social sectors have gone to enormous lengths to denounce violations of the right to health produced in the current health system. These groups have proposed ways to overcome barriers to access and even alternatives to the present health system, which is based on a managed care system devised by technocrats in the early 1990s. Nevertheless, in this context, the Colombian Constitutional Court (the Court) has played an extraordinarily activist role — unparalleled in any other country in the world — in promoting greater economic and social rights and the rights of minorities, and in placing some restraints upon the executive branch.

In my Critical Concepts article in the forthcoming issue of Health and Human Rights, “Suffering and powerlessness: The significance of participation in rights-based approaches to health” (available online in PDF or HTML format), I refer in passing to a sweeping judgment by the Court in July 2008. This ruling, in taking seriously the enforceability of the right to health, called for the government to restructure that country’s health system. However, recognizing that it did not have the expertise or legitimacy to determine which treatments and services should be included in the social insurance scheme, the Court called for a broad participatory process to determine the content of a newly revised and unified benefits scheme. In a Perspectives piece in this issue, “Democratic deliberation or social marketing?” (PDF, HTML) which is forthcoming in Spanish in a Colombian journal, my co-authors and I explore in much greater detail the degree to which the Colombian government has met the criteria for participation set out by the Court. We conclude in large measure that it has not and that, as a consequence, the reforms being put in place are at risk of not being accepted by the Colombian public. In turn, people may continue to flood the courts with lawsuits that undermine the financial sustainability of the system, although this is precisely the result that the Court’s structural judgment sought to avoid.

The case of Colombia puts into sharp relief the potential strengths and limitations of a court-initiated process of health reform that calls for — and indeed requires — meaningful participation in a context of relatively low social mobilization and a highly autocratic regime. Furthermore, it vividly illustrates both what is at stake in defining participation, and the risks of participatory processes that serve only to provide a patina of legitimacy to decisions taken beyond any public decision-making arena. We are flooded with new forms of “rights-based participatory mechanisms” all the time in public health — for example, “observatories,” “round-tables,” and “multi-sectorial committees.”  Yet we must not uncritically accept these as advances in rights-based approaches to health lest rights-based approaches devolve into the same kinds of feeble, managerialist participation that have plagued health and development arenas for decades and do nothing to genuinely empower those who are most marginalized.

Community health worker administering medicine in Rwinkwavu. Photo courtesy of Partners in Health.

[Editor's note: In addition to Dr. Binagwaho, Dr. Fidele Ngabo, Cathy Mugeni, and Niloo Ratnayake also contributed writing to this post.]

Access to care in resource-constrained countries has three major barriers to overcome: finances, infrastructure, and geography. Community health workers (CHWs) are an unavoidable solution for both infrastructure and geography. The Government of Rwanda has recognized that CHWs are necessary in order to improve access to health in rural communities. By using CHWs, with their approach to health at the community level, Rwanda hopes to solve 80% of health problems in the country.

Rwanda has set up a system where each village (100 to 150 households) elects two volunteers to act as CHWs for the general population. Because each community votes on one woman and one man to serve the village in this capacity, becoming a CHW is now a position of respect, raising gender equity throughout Rwanda.

These two CHWs are then trained to monitor growth and development in children, to care for people living with HIV, and to refer sick patients to the nearest health facility. Their training is designed by the Ministry of Health, which enables them to provide services in a harmonized manner throughout the country. By sensitizing the local village and making themselves available, they improve access to care; because of CHWs, a greater number of previously unreachable Rwandan citizens now have access to care. The CHWs trained this year to provide services to their villages are trained to treat certain diseases using amoxicillin and to distribute family planning tools (condoms, contraceptive pills, and injectable contraception). Read more

The president’s 2010 budget for the Indian Health Service, the organization that provides federal health services to American Indians, tops $4 billion. This includes an increase of $454 million. But Kathleen Sebelius, head of the Department of Health and Human Services, which oversees the IHS, said in a June interview that that’s not enough to provide the agency with what it needs. This was after she called our efforts in American Indian healthcare a “historic failure.”

One day before Sebelius’s interview, another AP piece detailed the shortcomings of the painfully underfunded IHS. Operating with half the necessary funds, some understaffed clinics can’t provide preventive care services, and others can’t handle the high disease rates. Patients recount what they rightly see as subpar care: clinicians dismissing a patient’s pain from advanced frostbite until she threatened suicide; being unable to make appointments; diagnosing a five-year-old who had complained of stomach problems with depression. (After many months, several more clinic visits, and a collapsed lung, she was diagnosed with terminal cancer at a Denver hospital and died weeks later.)

The dismal statistics of American Indian health disparities are well documented (go here, here, here, and here for starters). President Obama cites a couple of the more startling ones on his website, including that men living on South Dakota’s Pine Ridge and Rosebud reservations have the second-lowest life expectancy in the western hemisphere. The health disparities are, as Sebelius says, “unconscionable.” But so are the funding disparities. Read more

The non-profit organization, Physicians for Human Rights (PHR), published a report in January of 2009 on the cholera outbreak and related health crises in Zimbabwe. Outlining the outbreak in painful detail, the report suggests that the scope of the disaster, largely due to government mismanagement and neglect on a national scale, constitutes crimes against humanity.  PHR thoroughly examined the wide-spread public health crisis in the context of the 28 year rule of Robert Mugabe and urges further investigation and involvement from the international community and possibly the International Criminal Court.

Article 7 (1) (k) of the Rome Statute of the International Criminal Court describes crimes against humanity to include “other inhumane acts of a similar character intentionally causing great suffering, or serious injury to body or to mental or physical health.” Zimbabwe is not a signatory of the Rome Treaty.  However PHR asserts that crimes against humanity, as defined by the Rome Treaty, are within the bounds of customary international law. Because Zimbabwe has disregarded the epidemic and openly blocked international aid resulting in the deaths of thousands, PHR believes this constitutes a crime against humanity.

The situation in Zimbabwe dire. During August of 2008, the country saw the beginning of a cholera outbreak that the World Health Organization has categorized as “explosive.” Cholera is easily treated with fluids administered orally or intravenously while the infection runs its course. Without this simple intervention, cholera leaves its victims with severe dehydration that can lead to death. An update published by the World Health Organization on February 20, 2009 listed nearly 80,000 cases and almost 4,000 as recorded by Zimbabwe’s Ministry of Health and Child Welfare (MoHCW). The WHO did provide some encouraging data as it estimated the epidemic peaked in November of 2008. Read more