The Right To Health In Population: The Nurse An Underserved As An Advocate By Dr. Patience Edoho Samson-Akpan
The Right To Health In Population: The Nurse
An Underserved As An Advocate
Dr. Patience Edoho Samson-Akpan (associate professor; b.sc., mph, phd, fWcn)
department of nursing science, university of calabar, calabar, cross river state, nigeria.
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PRESENTATION OUTLINE |
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•Introduction •Concept of health •The right to health and health care •Human rights principles that guide actions and policy positions •Protection of human right to health •The underserved populations •The nurse as an advocate •A 10″step advocacy framework •The nurses’ advocacy role in protecting the right to health in an underserved population |
Introduction
Human right to health means that everyone has the right to the highest attainable standard of physical and mental health, which includes access to all medical services, sanitation, adequate food, decent housing, healthy working conditions, and a clean environment (United States National Economic & Social Rights Initiative, nd; World Health Organization – WHO, 2008).
However, there are population of individuals, including urban minorities, who have historically been outside the purview of arts and humanities programs due to factors such as a high incidence of income below the poverty line or geographic isolation (Budget of the U.S. Government, Fiscal Year 2014) that are not accessible to medical care and basic needs, which mandates the nurse to act as an advocate in order to address their health care needs and access to basic needs.
- Most cultures have health as a common theme.
Concept of health
- Most communities have their concept of health as part of their culture.
- In some cultures health is seen as being in harmony with oneself, the community and the deities.
- Modern medicine is so much preoccupied with the study of diseases at the expense of health.
- Therefore, people tend to be ignorant about health and its determinant.
One of the oldest definitions of health is that “health is the absence of disease”. This definition is unacceptable.
Although individuals, communities, government are aware of the need for health but it is often neglected for others e.g. power, prestige, political benefits, security among others.
Nevertheless, in past decades, there has been a reawakening that health is a fundamental human right and should be a world-wide social goal.
This development is essential for the satisfaction of basic human needs and a channel to an improved quality of life, which must be attained by all people irrespective of race, colour, creed, ethnic affiliation among others.
In 1977, the 30th World Health Assembly declared that the main social target of government and WHO in the coming decades should be “the attainment by all citizen of the world by the year 2000 (which beyond has been added) of a level of health that will permit them to lead a socially and economically productive live.
This was tagged “health for all by the year 2000” (WHO, 1978).
United Nations in 1979 adopted health as an integral part of socio-economic development, while health is seen as an end by itself it is also a major instrument of overall socio-economic development and the creation of a new social order (WHO, 1979).
However, it was the failure of developing countries to realise ‘health for all by the year 2000’ which led to the MDGs which also missed a number of large-scale targets.
This again led Goals (SDGs),
to the shift to Sustainable Development the vision 2030 agenda.
With the SDGs, WHO has a mandate to cover the whole health agenda and has taken a leading role in supporting countries to set their own national targets and strategies (WHO, 2015).
World Health Organization (1948) defines health as a state of complete physical, mental and social well-being and not merely an absence of disease or infirmity.
This definition was an acknowledgement that health is more than non-disease despite the shortcoming of not proposing a measureable goal for which strategy for achievement can be devised.
This is the most widely acceptable definition of health, although it is being criticized as being utopic, idealistic and not achievable.
Health is not a “state” but a dynamic process, adjusting to changing demands of living and of the changing meanings we give to health.
Therefore, WHO (1986) altered health as a “state” to reflect health as a “resource.”
Thus “health is the extent to which an individual or group is able, on one hand, to realise aspirations (goals, objectives) and satisfy needs and on the other hand to change or cope with the environment.
Health is seen as a resource for everyday life, not the objective of living, it is a positive concept emphasizing social and personal resources as well as physical capacities.”
The right to health and health care
According to WHO (2018), “The right to the highest attainable standard of health” implies a clear set of legal obligations on states to ensure appropriate conditions for the enjoyment of health for all people without discrimination.
The right to health is one of a set of internationally agreed human rights standards, and is inseparable or ‘indivisible’ from these other rights.
This means achieving the right to health is both central to, and dependent upon, the realisation of other human rights, to food, housing, work, education, information, and participation (WHO, 2018).
The World Health Organization further reiterates that the right to health, as with other rights, includes both freedoms and entitlements:
Freedoms include the right to control one’s health and body (for example, sexual and reproductive rights) and to be free from interference (for example, free from torture and non-consensual medical treatment and experimentation).
Entitlements include the right to a system of health protection that gives everyone an equal opportunity to enjoy the highest attainable level of health
The human right to health means that everyone has the right to the highest attainable standard of physical and mental health, which includes access to all medical services, sanitation, adequate food, decent housing, healthy working conditions, and a clean environment.
The human right to health guarantees a system of health protection for all.
Health care must be provided as a public good for all, financed publicly and equitably (National Economic & Social Rights Initiative, n.d; The Peoples’ Movement for Human Rights Education – PDHRE, n.d) ; the
The human right to health care means that hospitals, clinics, medicines, and doctors’ services must be accessible, available, acceptable, and of good quality for everyone, on an equitable basis, where and when needed (National Economic & Social Rights Initiative, n.d; The Peoples’ Movement for Human Rights Education – PDHRE, n.d).
The design of a health care system must be guided by the following key human rights standards according to National Economic & Social Rights Initiative:
Universal Access: Access to health care must be universal, guaranteed for all on an equitable basis. Health care must be affordable and comprehensive for everyone, and physically accessible where and when needed.
Availability: Adequate health care infrastructure (e.g. hospitals, community health facilities, trained health care professionals), goods (e.g. drugs, equipment), and services (e.g. primary care, mental health) must be available in all geographical areas and to all communities.
Acceptability and Dignity: Health care institutions and providers must respect dignity, provide culturally appropriate care, be responsive to needs based on gender, age, culture, language, and different ways of life and abilities.
- There must be respect for medical ethics and protection of confidential information.
Quality: All health care must be medically appropriate and of good quality, guided by quality standards and control mechanisms, and provided in a timely, safe, and patient-centred manner.
The human procedural rights:
right to health also entails principles, which apply to
the following all human
Non-Discrimination: Health care must be accessible and provided without discrimination (in intent or effect) based on health status, race, ethnicity, age, sex, sexuality, disability, language, religion, national origin, income, or social status.
Transparency: Health information must be easily accessible for everyone, enabling people to protect their health and claim quality health services.
- Institutions that organize, finance or deliver health care must operate in a transparent way.
Participation: Individuals and communities must be able to take an active role in decisions that affect their health, including in the organization and implementation of health care services.
Accountability: Private companies and public agencies must be held accountable for protecting the right to health care through enforceable standards, regulations, and independent compliance monitoring.
´The Human Right to Health is protected in:
´Article 25 of the Universal Declaration of Human Rights ´Article 12 of the International Convention on Economic,
´Article 24 of the Convention on the Rights of the Child ´Forms of Racial Discrimination the Elimination of All ´Articles 12 & 14 of the Convention on the Elimination of
´Article XI (11) of the American Declaration on Rights
´Article 25 of the Convention on the Rights of Persons
Initiative, n.d; The Peoples’ Movement for Human Rights
Underserved population
´Patient Protection and Affordable Care Act(2010) defined ‘underserved population’ as the population of an area designated by the Secretary as an area with a shortage of elder justice programs or a population group designated by the Secretary as having a shortage of such programs.
´Such areas or groups designated by the Secretary may include –
´‘‘areas or groups that are geographically isolated (such as isolated in a rural area);
´‘‘racial and ethnic minority populations; and
´‘‘Populations underserved because of special needs (such as language barriers, disabilities, alien status, or age).
´The bulk of this underserved population live in the rural areas of developing countries and in diverse terrains where barriers to their development and fulfilment regional disparities, limited access to education, employment and other public goods are at the highest (Population Reference Bureau, 2010).
´Serving vulnerable and underserved population (2017) states that underserved populations include consumers who share one or more of the following characteristics.
´Here are some characteristics of vulnerable and underserved populations:
Characteristics of vulnerable and underserved populations
Vulnerable populations
- Have a high risk for multiple health problems and/or pre-existing conditions
- Have limited life options (e.g., financial, educational, housing)
- Display fear and distrust in accessing government programs or disclosing sensitive information about family members
)
Underserved Populations • Receive fewer health
care services.
- Encounter barriers to accessing primary health care services (e.g., economic, cultural, and/or linguistic).
Characteristics of vulnerable and underserved populations
Vulnerable
- Have a limited ability to understand or give informed consent without the assistance of language services (e.g., consumers with language barriers or cognitive impairments
- Have mobility impairments, lack of access to transportation services
- Have a lowered capacity to communicate effectively
- Face any type of discrimination
Underserved
- Face a shortage of readily available providers.
- Have a lack of familiarity with the health care delivery system.
´The term vulnerable is often used interchangeably with underserved.
´While underserved consumers have limited access to health care services, vulnerable consumers tend to experience additional barriers to getting care.
´For example, an individual with limited English proficiency (LEP) is considered vulnerable but might not be underserved (e.g., the consumer might have access to high-quality care).
´Keep in mind that there’s considerable overlap among vulnerable and underserved populations. Many consumers of health being served may fall into both categories.
´Nigeria is one of the developing countries with the largest human population in Africa, the underserved populations are found almost in all geographical terrains but most especially in the rural and hard to reach areas where over 70% of the population reside (Sanusi & Awe 2009, Anyene 2012; Egbe, 2014).
´Population Reference Bureau (2010) posits that this population lives on less than US$2.00 a day; suffer from inequity in access to quality health services as well as basic needs of good water, roads, housing and sanitation.
´Therefore, the advocacy role of the nurse cannot be underestimated in helping the underserved to enjoy the right to health and health care.
Despite its oil reserves, the delta remains one of the poorest and underserved regions in Nigeria. Most live on $1 or less a day and are without power, potable water and other basic services.
DARREN FOSTER (2007)
´The nurse as an advocate
´ The role of patient advocacy Historically, patient advocacy obligation for nurses.
is not new for nurses. has been a moral
´Recently, nursing literature has been focused on the advocacy role and nursing professions has adopted the term ‘patient advocacy’ to denote an ideal of the practice.
´Globally, nurses practice within a unique legal and institutional framework.
´The legal framework provides for a degree of communication and synergy between areas of the legislation.
´ For example, the human rights as previously highlighted.
´The institutional framework provides ethical code of conduct required for the practice of Nursing (Barnett-Davidson, 2013; Dada, 2013).
´In Nigeria the existing statutory mechanism regulating the nursing midwifery profession in Nigeria is the Nursing and Midwifery (Registration, etc) Act, 1979, Cap No.143 Laws of the Federation of Nigeria (Dada, 2013).
´This lays the foundation for ensuring that all people are treated equally and that each person is afforded basic rights.
´These rights are contained in the patient bill of rights in the constitution of the Federal Republic of Nigeria which must be adhered to at all times.
´The role of the nurse in advocacy is therefore subsumed
´The ICN Code makes it clear that inherent in nursing is
´choices and also supports i their role as advocates. ´Benner (1996) describes advocacyl as “the kind of power
´Elaborating on the definition of advocacy ICN (2008)
politics, self-initiated, evidence-based, strategic action
whichl shapei their patients’ behaviours and choices,
´Advocacy is usually employed by someone powerful on behalf of someone who has no power.
´In situations of vulnerability, powerlessness, or being involved in difficult circumstances or being an underserved population, the group or individual needs advocacy.
´Failure to do so may put the person’s rights, welfare or basic needs in danger.
´Generally, advocacy aims to promote or reinforce a change in one’s life or environment, in program or service, and in policy or legislation.
´In healthcare delivery, these activities focus on health conditions, healthcare resources, and the needs of patients and the public.
´The American Nurses Association (ANA) stresses the importance of patient advocacy in its Code of Ethics and lists three core values that form its basis: preserving human dignity, patient equality, and freedom from suffering.
´These core values are embedded in human right to health.
´ The Nursing and Midwifery Council of Nigeria Code of Nursing Ethics is also in line with ANA Code of Ethics.
´As with the definition offered by Benner (1996), the role of collaboration with patients, other healthcare providers, and society is evident in these statements from the ICN Code of Ethics for Nurses:
“In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected. The nurse ensures that the individual receives sufficient information on which to base consent for care and related treatment. The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations” (ICN, 2006).
´These statements and others in the ICN Code describe the advocacy role of the nurse in broad terms that encompass direct action as well as collaboration; the active role of the nurse in collaboration with the patient is evident.
´The nurse shares responsibility with society for promoting healthy environments and for acting to support the health of individuals and communities.
´ In the ICN Code, the nurse is more than a watchdog who vigilantly evaluates the practice of others.
´The nurse as advocate in this view takes up protection as an outgrowth of an active caring practice:
´“The nurse, in providing care, ensures that use of technology and scientific advances are compatible with the safety, dignity and rights of people.”
A 10″step advocacy framework ´Advocacy is about:
- Taking action—overcoming obstacles to action;
- Selecting your issue—identifying and drawing attention to an issue;
- Understanding your political context—identifying the key people you need to influence;
- Building your evidence base—doing your homework on the issue and mapping the potential roles of relevant players;
- Engaging others—winning the support of key individuals/organisations;
- Developing strategic plans—collectively identifying goals and objectives and best ways to achieve them;
- Communicating messages and implementing plans—delivering your messages and counteracting the efforts of opposing interest groups;
- Seizing opportunities—timing interventions and actions for maximum impact;
- Being accountable—monitoring and evaluating process and impact; and
- Taking a developmental approach—building sustainable capacity throughout the process. (WHO, 2008).
´The nurses’ advocacy role in protecting right to health in an underserved population
´‘Advocacy’ assumes that people have rights and that these rights are enforceable; for example, the right to voice opinions openly and to organise, as well as the right to adequate health care, pollution-free environments, employment and housing.
´Advocacy often focuses on ensuring that these rights are exercised, respected and addressed.
´Advocacy is only potentially effective in political environments where:
´Policy-makers can be influenced by public opinion; and/or
´governments can and do take action to protect the rights of their citizens; and/or
´there is an open and free media through which people can express themselves/find a voice (ICN, 2008, WHO, 2008).
´There are a wide variety of ways in which professionals may engage in system-level work:
health advocacy
´a representative role (speaking for people), ´an accompanying role (speaking with people),
´an empowering role (enabling people to speak for themselves),
´a mediating role (facilitating communication between people),
´a modelling role (demonstrating practice to people and policy-makers),
´a negotiating role (bargaining with those in power), ´a networking role (building coalitions).
´This may be achieved by working with hospital or community-based groups, their professional associations, or with other health care related interest groups (Gordon, 2002).
´The right to health refers to the right to the enjoyment of a variety of goods, facilities, services and conditions necessary for its realisation.
´This is why it is more accurate to describe it as the right to the highest attainable standard of physical and mental health, rather than an unconditional right to be healthy (WHO, 2008).
´Good health is a major resource for social, economic and personal development and an important dimension of quality of life.
´Political, economic, social, cultural, environmental, behavioural and biological factors can all favour health or be harmful to it (WHO, n.d.).
´The nurse should use advocacy and professional skills – nursing assessment and diagnoses including research evidence to plead the cause of the underserved population with the government/politicians/community leaders to ensure that government policies and actions focus on the following prerequisite for health:
´Safe drinking water and adequate sanitation; ´ Safe food;
´Adequate nutrition and housing;
´Healthy working and environmental conditions; ´Health-related education and information; ´Gender equality.
A CROSS SECTION OF CHILDREN IN IDP CAMP IN NORTH EASTERN NIGERIA
Rector (2018) posits that advocacy can be employed both at an individual level as well as political advocacy. For example:
- nurses can use their role and power as a professional to cut through bureaucratic red tape
- connect clients with available community resources (human and material resources)
- support clients in reaching their health goals,
- make their expertise available, and •being a client resource as someone
who is open and “available”.
The right to health contains freedoms.
´These freedoms include the right to be free from non -consensual medical treatment, such as medical experiments and research or forced sterilization, and to be free from torture and other cruel, inhuman or degrading treatment or punishment (WHO, 2008; PDHRE, nd).
´ ICN Code of Ethics for Nurses reiterates the need for nurses to provide care and also promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected (ICN, 2006).
´The underserved in the rural areas need information that will ensure protection from harm; therefore, the advocacy role of the nurse will include sharing of information.
´As the nurse advocates for an underserved population and significant others, the nurse consistently and respectfully communicates and collaborates with the client and other healthcare professionals to promote, uphold, and protect the client’s rights, their interests and their choices even when the nurse and/or other members of the healthcare team may not agree with these choices.
´The role of the nursing care team members as client advocates include the inalienable rights of the client in terms of autonomy, self-determination and autonomous, independent decision making.
´The client has intrinsic and legal right to accept and reject any and all treatments.
´The nurse identifies and utilizes resources that can facilitate and enhance advocating for the individual client, significant others, families, groups and underserved populations (American Association of Critical-Care Nurses, 2006).
´The right to health contains entitlements. ´These entitlements include:
´The right to a system of health protection providing equality of opportunity for everyone to enjoy the highest attainable level of health;
´The right to prevention, treatment and control of diseases; ´Access to essential medicines;
´Maternal, child and reproductive health; ´Equal and timely access to basic health services;
´The provision of health-related education and information;
´Participation of the population in health-related decision making at the national and community levels.
´Advocating [for] and protecting the underserved population include[s] questioning goals of care when there is a misalignment between patient-family and medical team goals.
´ Incorporating safeguards in the form of standards of nursing practice into daily practice is another avenue to protect underserved population.
´Protecting the underserved population also means identifying and reporting potential harm from a colleague, whether it is a nurse, physician, healthcare professional or Non-Governmental Organizations’ workers.
In the statements of ANA and AACN, the nurse who takes up advocacy is encouraged to focus on protecting the patient from potential harms inflicted by the substandard practice of other nurses and/or members of the healthcare team.
These statements from ANA and AACN can be interpreted as describing healthcare as a dangerous situation in which patients need a nurse-advocate to critically evaluate the practice of others in relation to the goals of the patient and the patient’s family and determine their safety and effectiveness.
With this image of the healthcare situation as fraught with danger, advocacy taken up as primarily concerned with protection and attention to safety starts from a position of mistrust.
Nurse advocates can assist patients and service users, especially those from disadvantaged groups, to receive more public recognition for their problems, as well as more equitable distribution of resources and opportunities to solve these problems.
´The nurse advocate for the right of the underserved population especially in the war torn North Eastern Nigeria to prevent prevalent diseases through health education, informing government with evidence of morbidity and mortality to provide vaccines for women and children improved access to potable water supply and good sanitation, treatment and control of diseases in the Internally Displaced Peoples’ (IDP) Camps.
´ The nurse can plead with drugs agencies and government to supply drugs for the underserved at a subsidized rate. The nurse also ensures that the supplied drugs are accessible to the underserved in the rural communities and hard to reach areas.
´The advocacy role of the nurse in primary health care involves raising awareness and pleading with the government on the need to collaborate with the rural communities and hard to reach areas with 70 to 80% of the people living there to establish primary health care centres for underserved population.
´The primary health centres with primary health care components will therefore address maternal, child and reproductive health problems, provide access to basic health services; and provide health-related education and information among others.
´The advocacy role in terms participating in population health-related decision making at the national and community levels ensures that health related policies covers the underserved population for instance insurance coverage for rural communities, people in difficult circumstances and the poor of the society.
´In Nigeria, there is community based insurance scheme which advocacy include empowerment through creating awareness and increased knowledge about such programmes.
´Advocacy goods and
for the provision of health services, facilities to all without any discrimination.
´Non-discrimination is a key principle in human rights and is crucial to the enjoyment of the right to the highest attainable standard of health.
´The Ottawa Charter on health promotion (WHO, 1986) identified key areas that action must be taken to address inequalities in health:
´strengthening individuals and communities; ´improving access to facilities and services; ´encouraging a health public health policy.
´Advocacy to strengthen individuals including the underserved populations means ensuring that people have information and skills so as to be able to make informed decisions.
´It implies taking account of different material circumstances and constrains on choice e.g. nurses collaborating with others and advocating for the need to have parenting programmes and assertive skills for the underserved population especially where cultural barriers influence equality especially in the Northern part of Nigeria.
´The nurse as an advocate to strengthen communities connotes supporting or standing by the underserved people in their communities to make decisions about health issues affecting them; for instance lack of potable water supply; and using community mobilization and advocacy to ensure availability of water in the community.
´Improving access to facilities and services involves mediating between underserved people and service providers in order to ensure that needs are met e.g. the nurse advocates for quality services and ensures that outreach services are provided in local communities and settings that are accessible to the poor; groups and culture friendly services with no linguistic barriers.
´Advocacy part which
for a healthy public policy is an important buttresses other areas.
´Wider social and economic change reduces poverty and ensures that the environment and living conditions are conducive to health e.g. the nurse advocate for income support, integrated transport system, food safety among others for the underserved population (Naidoo & Wills, 2009).
´The nurse advocates for all services, goods and facilities to be available, accessible; acceptable and of good quality.
´ These issues are all embedded in the principles of primary health care which is the strategy to address inequality and ensuring health for all populations.
´Functioning public health and health-care facilities, goods and services must be available in sufficient quantity within a State.
´They must be accessible physically (in safe reach for all sections of the population, including children, adolescents, older persons, persons with disabilities and other vulnerable groups) as well as financially and on the basis of non-discrimination.
´Accessibility also implies the right to seek, receive and impart health- related information in an accessible format (for all, including persons with disabilities), but does not impair the right to have personal health data treated confidentially.
´The facilities, goods and services should also respect medical ethics, and be gender-sensitive and culturally appropriate. In other words, they should be medically and culturally acceptable.
´Finally, they must be scientifically and medically appropriate and of good quality. This requires, in particular, trained health professionals, scientifically approved and unexpired drugs and hospital equipment, adequate sanitation and safe drinking, water WHO, 2008).
Conclusion
Health advocacy is an individual and collective approach that health professionals can use to turn these ideas into generalised realities and to create positive health and social change.
The health professions see advocacy as a core competence of professional practice, alongside scientific knowledge, clinical and inter-personal skills.
The ethical basis for health professional advocacy is articulated and enshrined in many international and national professional association codes for instance the ICN, ANA code of ethic for nurses and National code of ethics.
The UN Universal Declaration of Human Rights states that “everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control” (UN 1948).
Therefore, the role of the nurse includes a representative role (speaking for people), an accompanying role (speaking with people), an empowering role (enabling people to speak for themselves), a mediating role (facilitating communication between people), a modelling role (demonstrating practice to people and policy-makers) among others.
The recognition of these roles by the nurses is pertinent if nurses must partake in the global goal of ‘health for all at all ages’, the third goal of the 2030 agenda for sustainable development.
