The health care system can be defined as the mechanism in any society that transforms or metabolizes inputs of knowledge, human and financial resources into outputs of services relevant to the health concerns in that society. Health is not the domain of the health care system alone. Other systems (or sectors) in every society have a bearing on the health of the population, which may be, and in fact in many cases are, more important than that of the health care system. Society grants the health care system the „legitimacy‟ to function and the resources to operate. In this „social contract‟, society expects a return. The highest expectation is the human right to health, “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.”
Reproductive health care is a part of general health care. There are, however, special considerations and special challenges, which set it apart from general health care. Reproductive health care providers deal with mostly healthy people, they deal mostly with women, they often have to take into consideration the interests of more than one “client” at the same time, and they have to deal and interact with society.
In spite of major expansions and improvements in health care and development, health care systems have been unable to meet the health needs of large segments of the world population. Shortcomings of health care systems vary from country to country and even within the same country. Among shortcomings that need to be addressed are an imbalance in available services, inefficient utilization, and lack of responsiveness to women‟s expectations and perspectives.
Basically, one can differentiate three patterns of inefficiency: deficiency, under-utilization, and over-medicalization.. These patterns of inadequacy apply to the whole field of health care, but they are particularly prominent in the area of reproductive health.
Lack of awareness or gender blindness frequently leads to gender bias in the health care system and to the prioritization of male interests in decision-making. The mainstreaming of gender concerns is vital in policy formulation, health planning, health service delivery, monitoring and evaluation.
For implementation of reproductive health care, the health care system needs to unpack the reproductive health package. This has to be handled with care, because some components are fragile and more sensitive than others. Different components of the package pose different challenges in implementation. The system is challenged to meet new and emerging needs, to serve new customers and to develop cost-effective interventions for currently expensive and less affordable services.
Laws and policies may facilitate or inhibit women‟s access to reproductive health care. Systems of health law and policies that restrict women‟s reproductive choices are usually based on historical connections between sexuality and morality. Many restrictive policies reflect the idea that women‟s sexuality and access to birth control endanger morality and family security. Providers and their professional associations may invoke laws, particularly human rights laws, to advocate for better reproductive health services on behalf of their patients.
Health care systems now represent one of the largest sectors in the world economy. However, the resources devoted to health care systems are very unequally distributed, and not at all in proportion to the distribution of health problems. Lack of resources is not always a valid excuse for governments not to invest in health. There is no country that is so poor that it cannot do something to improve the reproductive health of its people. Dollar for dollar spent on health, many countries are falling short of their performance potential. The result is a large number of preventable deaths and lives stunted by disability. The impact of the failure is borne disproportionately by the poor.
Setting priorities among health problems for allocation of resources is not an easy task. Priority-setting has to take into consideration not only the magnitude of the burden of disease, but also the availability of cost-effective interventions. In setting priorities, it should be recognized that reproductive health is special and cannot be simply ranked with disease problems. Although we may not know exactly how much money it will cost to provide reproductive health services for all, we have a better idea about what it will cost in women‟s lives and health if we do not make reproductive health care universally available.
The United Nations in 1999 re-affirmed that governments should strive to ensure that, by 2015, all primary health-care and family planning facilities are able to provide, directly or through referral, the widest available range of safe and effective family planning and contraceptive methods; essential obstetric care; prevention and management of reproductive tract infections, including sexually-transmitted diseases, and barrier methods (such as male and female condoms and microbicides if available) to prevent infection.1 By 2005, 60% of such facilities should be able to offer this range of services, and by 2010, 80% of them should be able to offer such services.
B. The health care system and the right to health
Health care systems trace their origin to the mystical beginnings of medicine. Throughout recorded history, societies have sought relief from physical and mental suffering through the institutionalization of roles, the functions of which have been to minister to the suffering. Health personnel and health facilities operate within the context of a „health care system‟. The health care system can thus be defined as the mechanism in any society that transforms or metabolizes inputs of knowledge, human and financial resources into outputs of services relevant to the health concerns in that society.
The health care system is one of several differentiated systems that serve needs of societies. It has to compete with these other systems for often scarce resources. The competition is not only at the level of governments (and donors) when they are allocating resources to different sectors, but also at the level of the family and individuals when they make decisions on how much to spend on health.
Health is not the domain of the health care system alone. Other systems (or sectors) in every society have a bearing on the health of the population which may be, and in fact in many cases are, more important than that of the health care system. Agriculture (nutrition), education, housing, transportation and the general economic level, among other factors, all have their bearing on health.
In recognition of the role of other systems in health, the World Health Organization uses the term “health system” to include all the activities whose primary purpose is to promote, restore or maintain health.3 Health care services fall within these boundaries. So is home care of the sick, which is how somewhere between 70% and 90% of all sickness is managed. Other interventions like road and environmental safety improvement are also part of the system. Beyond the boundaries of this definition are those activities whose primary purpose is other than health- education, for example- even if these activities have a secondary, health-enhancing benefit.
Society grants the health care system the „legitimacy‟ to function and the resources to operate. People are investing in the system, whether directly by out-ofpocket payments, indirectly by paying insurance premiums and social security contributions, or almost unknowingly when their paid taxes are used to finance the system. In this „social contract‟, society expects a return. Social expectations from the health care system vary and are affected by the value system of a society. The highest expectation is the human right to health.
The human right to health is recognized in numerous international instruments (Part III, 4). Article 25.1 of the Universal Declaration of Human Rights affirms that: “everyone has the right to a standard of living adequate for the health of himself and of his family, including food, clothing, housing and medical care and necessary social services.” According to the International Covenant on Economic, Social and Cultural Rights, in Article 12.1, State Parties recognize “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.”
The right to health is an inclusive right, extending not only to timely and appropriate health care but also to the underlying determinants of health, such as access to safe and potable water and adequate sanitation, an adequate supply of safe food, nutrition and housing, healthy occupational and environmental conditions, and access to health-related education and information, including on sexual and reproductive health. A further important aspect is the participation of the population in all health-related decision-making at the community, national and international levels.
The right to health is not to be understood as a right to be healthy. The right to health contains both freedoms and entitlements. The freedoms include the right to control one‟s health and body, including sexual and reproductive freedom, and the right to be free from interference, such as the right to be free from torture, non-consensual medical treatment and experimentation. By contrast, the entitlements include the right to a system of health protection that provides equality of opportunity for people to enjoy the highest level of health (see Part III.6.c.).
The health care system has obligations to people‟s right to health. It has the obligations to respect, to protect and to fulfill the right to health. It has to respect and protect the “freedoms” and to fulfill the “entitlements” embodied in the human right to health. The health care system can be held in violation of the right to health through acts of commission and through acts of omission. The obligation to respect requires the system to refrain from interfering directly or indirectly with the enjoyment of the right to health. The obligation to protect requires the system to prevent third parties from interfering with the freedom of people to enjoy their right to health. The obligation to fulfill requires the system to ensure that people have access to a system of health care that provides equal opportunity for everyone.
Further discussion on the implications of the human right to the highest attainable standard of health is presented in chapter 6.
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