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).

Taking lessons from the work done by the associations of persons living with HIV/AIDS at the community level, Rwanda dedicated two other village-elected CHWs, one woman and one man, to dealing solely with end-of-life issues. These CHWs are responsible for caring for people in the late stages of any disease, which helps ease the burden on family members. Their care also decreases the number of dying patients brought to the hospital.

CHW explaining how to feed children and the meaning of the growth chart outside a house. Photo by Cathy Mugeni.

As there continues to be a high maternal morality rate in Rwanda, the Government is also training traditional birth attendants as CHWs to promote birth delivery at health facilities. CHWs are paid for every delivery they transfer to the local health center.

All activities are included in the health reporting system through reports that CHWs give to the Executives Secretary of each Sector, who in turn report activities to the Director of Health at the District level. At present, CHWs are all volunteers, but the Government of Rwanda is working on compensating these workers with performance-based financing and helping them to create cooperatives.

In conclusion, the five CHWs per village create community ownership, since it is the community who elected them. They also improve access to care and decrease hospitalization through what they manage at the community level. The harmonized training of all CHWs throughout the country is key. Community health workers are a smart and unavoidable solution that enables effective health care to bypass a lack of infrastructure in a resource-constrained country.

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.

This report from the U.S. Commission on Civil Rights compared spending on American Indian healthcare to other groups for whom the government provides care. The numbers are telling: In 2003, the government spent $6,000 for each Medicare recipient, $5,200 for every veteran using the VA, and $3,725 for federal prisoners. American Indians: $1,600 per person. IHS spends less on its patients than any other group providing public care – and about 60 percent less than average per capita healthcare costs nationwide. From the report: “This disparity in spending is amplified by the poorer health conditions of many in the Native American community and represents a direct affront to the legal and moral obligation the nation has to improve Indian health status.”

That “legal and moral obligation” dates back to 1787. Many treaties and much legislation has been passed to ensure healthcare for American Indians, notably the Snyder Act and the Indian Health Care Improvement Act, which states, “It is the policy of this Nation in fulfillment of its special responsibilities and legal obligation to the American Indian people, to assure the highest possible health status for Indians and urban Indians and to provide all resources necessary to effect that policy” [emphasis added].

The 2010 HHS budget is $828 billion ($872 billion after additional funding from the American Recovery and Reinvestment Act of 2009) - the amount spent on American Indian healthcare will make up approximately 0.5% of that. And if we funded the IHS at the levels officials say it requires – around $7 billion – that would still make up less than 1% of the entire budget. Obama’s $454 million bump provides the IHS with just over half of “all resources necessary”- ensuring that our historic failure isn’t coming to an end anytime soon.

For more reading:

Native Health Needs and Federal Apathy Are Told at an IHS Conference

Indian Health Care Needs Patient Information and Funds

Tribal Leaders Seek Health Care Reform

State Treasury Must Help Pay What Indian Health Service Doesn’t Provide

The History and Politics of US Health Care Policy for American Indians and Alaskan Natives

Redeeming Hollow Promises: The Case for Mandatory Spending for American Indians and Alaskan Natives

“If You Knew the Conditions”: Health Care to Native Americans

CDC Office of Minority Health and Health Disparities

Office of Minority Health

U.S. Senate Committee on Indian Affairs

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.

As PHR detailed, the epidemic spread with unusual vigor because of inadequate or non-functioning sewer and sanitation systems. In December of 2008, the New York Times described a scene of children playing in “streets that flow[ed] with raw sewage.” Further exacerbating the epidemic has been the near complete collapse of the public health system, caused in part by the rapidly declining economic situation.  The Zimbabwe dollar is now worthless due to hyperinflation. In January of 2009, the country released a 100 trillion Zimbabwe dollar note that at the time was worth a mere 37 US dollars. Health care workers stopped showing up for work in the fall of 2008 as the monthly salary ceased to cover the cost of transportation to work for a single day. Hospitals lacking essential staff shut their doors.  Patients that need treatment either cannot get treatment or must pay hundreds of US dollars in fees for private healthcare.

Despite the recent decline in deaths, there remain significant challenges in protecting the right to health of all citizens of Zimbabwe. There are significant barriers to access to health care including the high cost of private health services and a public health system that has completely collapsed. The nation will continue to be in danger of a resurgence of an outbreak as long as the sanitation and sewer systems remain in ill repair. The high prevalence of HIV and widespread malnutrition makes the population particularly susceptible to infections such as cholera.

Finally, this epidemic has the potential to lead to serious problems, not only for the people of Zimbabwe, but for the entire region. Already neighboring countries have reported an increase in the number of reported cases of cholera as people flee from Zimbabwe to escape political turmoil and seek medical care. Clearly, a drastic intervention is needed to protect the right to health of so many.

Additional Resources:

NYTimes Video: Confronting Rape on Zimbabwe’s Border

NYTimes Op-Ed: Zimbabwe is Dying

UNICEF: Widespread Collapse of Social Services Creates “Twin Disaster” in Zimbabwe

UNICEF: The Tragedy of Zimbabwe’s Cholera Outbreak

The Zimbabwean: Who Controls the Water Determines the Severity of the Cholera