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Learning from the pandemic to better fulfil the right to health

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The COVID-19 pandemic has concentrated minds about the resilience of our health care systems and it is challenging member states’ health policies and their effectiveness. In addition, doctors, medical staff and health care staff are under unprecedented pressure. Do we have sufficient medical facilities and supplies to respond to the emergency even when strict containment measures are in place? Can our human right to the enjoyment of the highest attainable standard of physical and mental health be fulfilled under the current circumstances? Are health care workers sufficiently protected and can they manage the immense responsibility placed on their shoulders? In the midst of this tragic pandemic we cannot pretend to have all the answers to these existential questions. But we can highlight some of the fundamentals of a health care system which seeks to meet the needs of the entire population and which builds resilience in order to respond to public health emergencies.

It is obvious that all people have the right to the protection of their health against the pandemic. Universal health coverage creates the basis for this. Broader social protection measures are necessary to address entrenched health inequalities. A focus on gender plays a central role in effective responses. The development of inclusive and resilient health care systems, which is likely to take place under conditions of renewed austerity, should eschew the negative effects on the right to health experienced during the economic crisis of the previous decade.

Universal health coverage

The fulfilment of the right to health is often viewed as an issue about access to health care. During my visit to Greece in 2018, I observed the negative impact of long-term austerity measures on the availability and affordability of health care. I urged the authorities to remove obstacles to accessing universal medical coverage and to increase their efforts to recruit health care staff. The achievement of universal health coverage is one of the targets of the United Nations’ Sustainable Development Goal 3 (ensure healthy lives and promote well-being for all at all ages). According to the World Health Organisation (WHO), universal coverage means that all individuals and communities receive the health services they need without suffering financial hardship. It includes the full range of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care.

Efforts to achieve universal health coverage received a boost on 10 October 2019 with the UN General Assembly’s adoption of a high-level political declaration “Universal health coverage: moving together to build a healthier world”, following its approval by world leaders in September. The declaration recognises that health contributes to the promotion and protection of human rights and makes a commitment to covering one billion additional people by 2023 with quality essential health services, with a view to covering all people by 2030. The declaration stresses that strong and resilient health systems, capable of reaching people in vulnerable situations, can ensure pandemic preparedness and effective responses to any outbreak.

It is significant that the declaration specifically covers mental health and well-being as an essential component of universal health coverage and stresses the need to fully respect the human rights of people experiencing mental health problems. Mental health professionals have pointed out that the current pandemic is resulting in a parallel epidemic of fear, anxiety, and depression. The highly stressful environment and the containment measures taken out of necessity place a significant burden on the mental health of the general population. Existing mental health conditions may also worsen further, and opportunities for regular outpatient visits are narrowing. People treated in psychiatric institutions find themselves in an especially vulnerable situation, with diminishing access to care and additional risks of infection. Public Health England has issued detailed guidance on preserving mental health and wellbeing during the coronavirus outbreak.

Civil society representatives have expressed concern that the UN Declaration does not in fact reaffirm the right to health as an entitlement and that it leaves too much discretion to governments in determining the extent of universal health coverage with reference to “nationally determined sets”. Measures to address the needs of migrants, refugees, internally displaced persons and indigenous peoples have also been qualified to be applied “in line with national contexts and priorities”. In addition, NGOs have highlighted funding gaps for universal coverage and the essential role of public health systems in meeting the health care needs of vulnerable populations. It is crucial that the current gaps in universal coverage are not allowed to become obstacles to a comprehensive response to the coronavirus pandemic and the availability of care for all.

In Europe, the unaffordability of health care has been an important barrier to the full realisation of universal health coverage. Significant out-of-pocket payments can result in unmet needs or financial hardship for service users. According to the WHO, this may be the case in the majority of European countries. In my 2019 report on Armenia, I made a connection between low public health expenditure and the difficulties experienced by older people in obtaining specialised treatment and palliative care. During my visit to Estonia in 2018, I noted that 1 in 4 persons above 65 in poor health could not afford care. Doctors of the World (Médecins du Monde) has pointed out that many people belonging to disadvantaged groups may also face issues about health insurance entitlement.

Health inequalities and social determinants of health   

The concerns about the gaps in the reach of universal health coverage in Europe are related to health inequalities between and within countries, and the broader issues of poverty and social determinants of health. The right to health is closely interconnected with other social rights such as the rights to social security and protection, and the right to housing. Since the WHO Constitution defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, it is unlikely that universal health coverage alone would be effective in addressing health needs in a sustainable manner. A broader social rights approach is required.

The landmark health equity status report by WHO Europe from 2019 reveals that health inequalities in Europe have remained the same or have worsened over the last 10-15 years. Although average life expectancy across the WHO European region of 52 countries has increased for both women (82 years) and men (76 years), significant health inequities remain between social groups. Women’s life expectancy is cut by up to 7 years and men’s by up to 15 years if they find themselves among the most disadvantaged groups. Regional inequalities in life expectancy continue to persist or worsen within most countries. It is also worrying that health gaps between socioeconomic groups increase with age.

The report makes a highly useful contribution in identifying social determinants and drivers of the health gap and in so doing maps means of improving the situation. In addition to universal access to health care, social protection, housing, education and employment are significant factors in improving health status. The report recommends integrated solutions based on a combination of interventions. Remarkably, it argues that the most cost-effective means of closing the health divide is increased investment in housing and community amenities.

Unfortunately, affordable housing is in short supply in Europe and the overall spending by governments on social housing stood at only 0.66% of the European GDP in 2017, as I noted in an article in January this year. In December 2019, the UN Special Rapporteur on the right to housing, Leilani Farha, sounded the alarm about the current global housing crisis and published guidelines for the practical implementation of the right to adequate housing.

In March, she pointed out that housing had become the front-line defence against the coronavirus as governments relied on people to stay home to prevent the spread of the pandemic. The Rapporteur expressed special concern at homeless people and those living in grossly inadequate housing, often in overcrowded conditions or lacking access to water and sanitation, making them particularly vulnerable to the virus. It is obvious that homeless people should not be penalised for not being able to stay at home during the pandemic. In Scotland, local authorities have made unoccupied student flats and hotel rooms available to rough sleepers in the current situation. A similar positive initiative was undertaken by the UK government in England. Long-term housing solutions for homeless people remain necessary. They will make our societies more resilient against crises and pandemics.  

Gender-responsive approaches to health and equality

Gender is another determinant of health. The differences in health status and needs between women and men are not simply related to biological differences but to the impact of societal gender norms and stereotypes. The WHO has pointed out that factors affecting notions of masculinity and femininity and the way gender roles are defined in societies can have a massive effect on the health of men and women. We need gender-responsive approaches to health which take gender norms and inequalities into account and act to reduce their harmful effects. Progress towards gender equality should have a positive impact on the health of both women and men. Ultimately, gender-responsive approaches based on equality can help transform the gender roles, norms and structures which act as barriers to achieving healthy lives and well-being for everybody.  

The higher average life expectancy of women in comparison with men is usually referred to as the “mortality advantage”. 70% of the European population over 85 are women. However, the additional years are often accompanied with ill health or disability. Women in Europe live on average 10 years in ill health while the figure for men is 6 years. The WHO report on women’s health and well-being in Europe highlights cardiovascular diseases, mental health problems, gender-based violence and cyber-bullying as prevalent health issues among women. Breast, cervical, lung and ovarian cancers pose significant burdens to women’s health. Women consider themselves less healthy than men and report more illness. They are less represented in clinical trials making it more difficult to determine safe dosage ranges and possible side effects of medicines for women. Sexual and reproductive health is another area where gender-specific and human rights-based responses are necessary.    

Norms around masculinity and socio-economic factors are related to men’s risk-taking behaviours and underuse of health services across many European countries. The WHO report on men’s health and well-being in Europe points out that men have unhealthier smoking practices and dietary patterns, heavier alcohol drinking habits and higher rates of injuries and interpersonal violence than women. 86% of all male deaths can be attributed to noncommunicable diseases and injuries, especially cardiovascular diseases, cancers, diabetes and respiratory diseases. Raised blood pressure is a leading risk factor with a higher prevalence than in women. Suicide rates among 30-49-year-old men are five times higher than among women of the same age. Yet men report better subjective health than women and use health services less often than them.

It is reported that the coronavirus has gender-differential effects. The fatality rate for men appears to be up to twice as high as for women. Although we do not yet know the cause for this, it has been suggested that both biological factors and gendered risk behaviours, such as smoking, may be relevant. Gender matters in responses to the pandemic, too. Social distancing or lockdowns at home bear a specific danger to women’s health in terms of a higher risk of domestic violence. Many women victims of violence may experience additional difficulties in seeking help in shelters which have closed down or decide not to seek medical attention for fear of contagion. Women’s exposure to the coronavirus is aggravated by the fact that they are in the clear majority among health care staff and as informal and family carers. It is essential that the prioritisation of the availability of health services during the pandemic does not discriminate on the ground of gender. This also applies to access to sexual and reproductive health care, including abortion.

The WHO European region is the first WHO region to implement strategies on the health and well-being of both women and men in a coordinated way and following a human rights-based approach. Ireland was the first country in Europe to prepare a health policy specifically targeting men already in 2008. Health policies which address both women’s and men’s health in gender-specific ways through the different stages of life are mutually reinforcing and highlight gender as a central determinant of health.

Way out from the crisis

The pandemic is a danger to all of us but there are many groups of people who are in an especially vulnerable position or highly exposed to it. Older persons find themselves in a high-risk group and inter-generational solidarity is now in high demand. Many persons with disabilities rely on the support of others in their daily activities and the continuity and safety of such support must be guaranteed during the crisis. People living in institutions or detention face a high risk of infection and should be afforded protective measures. I have highlighted the situation of immigration detainees and prisoners specifically. Homeless people are extremely vulnerable as stated earlier. The living conditions of many Roma remain inadequate with limited access to water and sanitation. A great number of refugees and migrants find themselves in a similar situation.  

In the response to the COVID-19 pandemic, all population groups should be able to access health care, including medicines and vaccines, without discrimination. Any absolute necessity for prioritisation in terms of limited resources must be based on sound medical evidence and the individual urgency of the required treatment. Everyone’s human dignity must be respected without putting into question the fundamental equality of every person’s life. Focused efforts are required to preserve mental health during the crisis and to ensure the continuity and safety of treatment.  

Positive measures should be applied to mitigate the risks of the pandemic on the health of groups who are particularly vulnerable or exposed to the coronavirus. Such measures should be effective and proportionate and could include, for example, enhanced social support, provision of adequate housing, access to water and sanitation, deinstitutionalisation, anticipated release from custody, facilitated access to protective equipment and coronavirus testing, provision of additional means of communication and the availability of information in accessible formats, among others. Gender-responsiveness should be considered as a regular aspect of the means to counter the pandemic.

I urge governments to alleviate the enormous pressure health professionals, the majority of whom are women, are facing in their work against the pandemic. Their safety at work is crucial and they must have access to effective protective equipment, regular coronavirus screening and antibody testing, and psychosocial support. Health workers and their families should be entitled to childcare arrangements and social protection measures to cover their work-related hazards. Any extraordinary care duties for health professionals not in active service must be necessary and accompanied by strict safeguards for ensuring their safety and well-being.

In the long run, member states should build resilient health care systems which cater to the needs of the entire population and enable robust responses to health emergencies. The achievement of universal and affordable health coverage, including for mental health, is critical for this endeavour. No one should be left behind in health care entitlement. There is a special need to promote deinstitutionalisation, outpatient services and primary health care.     

I urge governments to apply a gender-responsive approach in the implementation of health policies. They should identify and address gender-based health needs and aim to change unhealthy behaviours which are related to harmful gender stereotypes. It is necessary to unleash the potential of health promotion and protection as an effective tool for improving gender equality for both women and men.

Widening inequalities in health status must be addressed through a broader social rights approach. As people’s health and well-being are closely related to the social determinants of health, it is necessary to promote health through integrated approaches which combine universal coverage with protection against poverty, the eradication of homelessness, inclusive education and training, and access to employment. Focused efforts should be made to implement adequate, affordable and long-term housing solutions.

Council of Europe

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New Social Compact

An Analysis on Marshall McLuhan’s concepts

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Marshall McLuhan is an important scholar who has made major contributions to communication discipline through introducing new concepts like “global village” and “medium is the message”. It can be said that ideas of McLuhan can be applied to new technologies and social media discussions today.

McLuhan introduced the idea of “medium is the message” in his book called Medium is the Message that was published in 1967. According to McLuhan, what is said by the message is not very significant. The media actors which can be regarded as the medium hold a more major influence on the masses than the message it presents.

The medium (or media in other terms) does not only have the role of being the carrier of the message but it is also the message that shapes people’s views and perceptions (McLuhan, 1967). McLuhan, based on the idea of “medium is the message” gave examples to support his claim in his book Understanding Media: The Extensions of Man published in 1964. According to McLuhan, the content of any medium is always another medium. For instance, the content of writing is speech; the written word is the content of print; and print can be seen as the content of the telegraph (McLuhan, 1964).

Another important concept coined by McLuhan is “global village”. This concept was introduced in the 1960s to say that mass media will spread all over the world and make the world become a global village (McLuhan, 1962). According to McLuhan, the electronic interdependence of today’s world produces a world in the sense of “global village”. The global village has been created by the instant electronic information movement according to McLuhan.

McLuhan believed in the usefulness of communication technologies. One of the most important emphases McLuhan made was about drawing attention with his findings about the global communication revolution. According to McLuhan, TV has been a critical invention that ensures that nothing remains a secret, and that eliminates privacy, and he believed that the change of societies is possible with the development of communication tools in various forms. McLuhan made one of the most important predictions of the 20th century. This was  the Internet.

In contemporary world, social media is used by millions of user all over the world. New technologies have turned the world into a “global village” Although McLuhan said almost 60 years ago, his ideas about media (medium is the message) and the “global village” concept are still relevant today.

References

  • McLuhan, M. (1962), The Gutenberg Galaxy: The making of typographic man.   London: Routledge.
  • McLuhan M. (1964), Understanding Media: The Extensions of Man by Marshall McLuhan, McGraw Hill
  • McLuhan, M. (1967). The Medium is the Massage: An Inventory of Effects.  London: Penguin Press.

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Leaving no one behind with Fiqh for person with disability

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As I watch the new Netflix documentary, Crip Camp: A Disability Revolution produced by former President Barrack Obama and Michelle Obama, I realize thatthere is an urgent need for grassroot activism to support disability religious rights to pave the way towards greater equality. The movie highlights disabled summer campers who fight for the realization disability rights in 1970s, at the time when they were largely ignored by the state.

And does Indonesia need A Disability Revolution?

According to a study by Monash University, it is estimated that the disability prevalence rate in Indonesia is between 4% and 11%. There are several causes of disability, ranging from malnutrition, diseases, ageing population, natural disaster, and accident. Unfortunately, due to social stigma in the society against people with disability, the disability statistical figures may be underreported.

The Indonesian government has been actively involved in international convention by ratifying United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) in 2007 and issued the law no. 8 of 2016 on rights of persons with disabilities to comply with human rights standards. But, at the same time the law faces some stagnate situation regarding improved well-beings of people with disabilities because disability prejudices are still at the heart of this tension. 

For example, disabled children are less likely to attend formal education because of lacking inclusive schools. In public places, ramps and accessible information are not easily available. Zooming into the workforce, Indonesian 2010 census reported that only 26,4% people with severe disabilities were employed in formal sectors. This resulted in high rate of self-employment among people with severe disabilities. Many people with mental disability, such as bipolar disorder, have to conceal their condition for the fear of losing jobs.

A research found that discriminations against people with disabilities in developing countries, including Indonesia, caused a loss of up to 7% of Gross Domestic Product(imagine : what if a genius with severe disability like the late Professor Stephen Hawking had never been employed at university?).

Women with disabilities even suffered more from double prejudices, by their gender and their disabilities. What makes thing more difficult for disabled citizens is that, despite of some disabilities laws and ministerial decrees, they were poorly enforced. This explains the urgency of ending this discrimination from a social-economic developmental perspective.

As the largest Muslim majority country in the world, Fiqh (Islamic jurisdiction) for person with disability remains important to safeguard equal religious rights. As a non-disabled Muslim woman, being able to perform Islamic prayer (shalat) properly help me increase my mental wellbeing during this unprecedented time.

Unfortunately, there are still some Muslims who believe that disabilities are by-products of witchcrafts (sihr) or demons (syaitan) which can be healed only by involving spirits and enchanting some quranic verses. Further, in Islamic law per se, there is no specific term which can encompass all disabilities.

“Fiqh for person with disability is very important because the society has yet to accommodate special needs for people with disabilities in performing religious rituals. For example, how does Islam regulate the wudlu(ablution) taken by a man/woman without arms? Considering that Islamic law obligates that someone must wash one’s arm up to elbow during wudlu. And will the wheelchair be considered as najis(impure) inside the mosque?” said Mr. Bahrul Fuad, a disabled person and board member of AIDRAN (Australia-Indonesia Disability Research and Advocacy Network).

Mr. Ahmad Ma’ruf, the Disability Program Team Leader of Muhammadiyah, the second largest and most influential Islamic organization in Indonesia after Nadlatul Ulama (NU), even posed critical questions:“What if persons with hearing impairment wish to get married and say ijabqabul (Islamic marriage vows), will they use sign language? Because religious court has yet to regulate the sign language issue. And who has the authority to validate the sign language as “legally correct” in Islamic marriage?  What if a man with wheelchair wishes to be an imam (leader of a congregational prayer)? Is he allowed to do that, given the fact that many people still interpret explicitly the regulation that makmum (member of a congregational prayer) must follow movements of imam? What if there is no accessible ablution facility in a mosque? Should a person with disability performs tayamum (dried ablution)?”

To address this issue, NUand Muhammadiyah issued Fiqh for person with disability and raise awareness of the public concerning equality for disabled communities. NU even collaborated with the Ministry of Religious Affairs to disseminate the Fiqhto mosques nationwide.

Fiqh for person with disability will fulfil civil rights of disabled community comprehensively, ranging from ubudiyah(religious rituals),muamalah(interpersonal relation), to sahusiah(public policy). This Fiqh will also protect rights of disabled women, as the most marginalized group.

To ensure the smooth implementation of the Fiqh, the government, civil societies, disabled people organizations, religious leaders, and experts of Islamic law should collaborate for accountable monitoring and evaluation. Regular capacity buildings for judges, teachers, and village officials should also be organized.

Finally, political buy-in through Perda(regional regulation)and guidelines should be issued to strengthen government officials’ commitment to enforce the Fiqh. For example, the Special Province of Aceh under Syariah law have regularly issued qanun(regional regulations subjected to Islamic stipulations).

Historically speaking, during the Umayyad Caliph era in the 700s, the Caliph Al-Waleed ibn ‘Abdul Malik accommodated health treatment needs for his population with disabilities through the provision of health care clinics within all his jurisdictional provinces. This idea was emulated by Caliph Umar Bin Abdul Aziz who hired support services workers for people with disabilities. This initiative resulted in social and legal impacts worldwide, in which a broad array of laws on disabilities were enacted.

In making public policy for citizens with disabilities, the government of Indonesia should not paint disabilities situation with a broad brush. Rather, Fiqhfor persons with disabilities must be taken into consideration seriously. Otherwise, there will be far-reaching consequences on well-beings of people with disabilities in the long run.

This Fiqhis a beacon of hope for future generations, to leave no one behind.

As put forward by a member of Crip Camp: “If you don’t demand what you believe for yourself, you’re not gonna get it”.

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Good Parenting Reduces the Divorce Rate

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Divorce is a very stressful event. Apart from having a bad impact on children, divorce has a major impact on the survival of the husband and wife who experience it. Divorced couples visit psychiatric clinics and hospitals more than couples from intact families. Divorced couples experience anxiety, depression, feelings of anger, feelings of incompetence, rejection, and loneliness.

In Indonesia, the divorce rate from year to year shows an increasing trend. The Ministry of Religious Affairs of the Republic of Indonesia reports that since 2015 until now there has been an increase in the divorce rate. In 2015 there were 394,246 cases, in 2016 it increased to 401,717 cases, then in 2017 it increased to 415,510 cases, as well as in 2018 it continued to increase to 444,358 cases, and by 2020, per August the number had reached 306,688 cases.

               The increase in the divorce rate from year to year has serious consequences in families. Conflict during the process of parental divorce and separation has a negative impact on the physical and psychological well-being of all family members. Quite a number of research results show that divorce has a negative effect on all family members, especially children. The results of Amato’s research in 2011 with a meta-analysis approach to 67 study results showed that children from divorced families had lower academic achievement, behavior, psychological adjustment, self-concept and social relations than children from intact families.

               Based on In the author’s empirical observation, the ending of marital status for a particular family also brings several social impacts, for example: narrowing social networks which results in a lack of social support, causes negative life experiences and psychological suffering, and causes economic hardship for women.

Thus rather than that, a marriage which basically originates from an agreement between two parties, so if there is a divorce, it is certain that both parties will suffer losses. Even children from marriages who divorce will share such losses. Then, what factors cause divorce? In my opinion, the substantial cause of divorce is the parenting concept of a married couple.

Good Parenting

               Parenting, generally known by the public as a pattern of parenting parents towards their children. This assumption is not completely wrong, but it must be straightened out that parenting is an ideal household conceptualization. Of course, you have to move from a husband and wife long before you have children. A husband and wife have had to discuss it long ago so that in various desired manifestations it can be carried out harmoniously together.

Parents (married couples), basically forming their children until they reach maturity will not be separated from the influence of their world. The mode of reflection on the relationship between parent and child is a complex activity that includes many specific attitudes and behaviors that work separately and collectively to influence the child’s outcome and the emotional bonds in which parental behavior is expressed.

In this case, parenting can be explained in terms of two components, namely parental responsiveness and parental demandness. Parents’ demands are the extent to which parents set guidelines for their children and how their discipline is based on these guidelines. Parental responsiveness is an emotional characteristic of parenting. Responsiveness continues to the extent to which parents support their children and meet the children’s needs. Both responsive and demanding parenting have been linked to securing attachment to children. Referring to Baumrind (1971), he identifies three parenting styles, namely: authoritative, authoritarian, and permissive with responsive and demanding concepts in mind.

Authoritative parentingis a condition of authoritative parents as a combination of demands and responsiveness. They make logical demands, set boundaries and demand children’s obedience, while at the same time, they are friendly, accept the child’s point of view, and encourage children’s participation in decision-making and often seek their children’s views in family considerations and decisions. This type of parent is then referred to as the type of parent who monitors and disciplines their children fairly, while being very supportive at the same time.

Authoritarian parenting, a demanding and unresponsive parental condition. They engage in little reciprocal interaction with children and expect them to accept adult demands without question. Strict socialization techniques (threads, commands, physical strength, love withdrawal) are used by parents who are authoritarian and withhold self-expression and independence. Authoritarian parents tend to set high standards and guidelines and require compliance. Authoritarian parents attribute love to success and not nurturing like the other two parenting styles.

Permissive parenting, consists of several clear and predictable rules due to inconstant follow-up and neglected bad behavior, neutral or positive affective tone. They give children a high degree of freedom and do not restrain their behavior unless physical injury involves. Permissive parenting shows an overly tolerant approach to socialization with responsive and non-demanding parenting behavior. These parents are nurturing and accepting, but at the same time they avoid imposing demands and controls on the child’s behavior. They have little or no hope for their children and often see their children as friends and have few boundaries.

Based on the three parenting models above that the author has reviewed and conducted a literature review, it is clear that the Good Parenting pattern that must be applied by a husband and wife is authoritative parenting. This concept implies a condition in which a positive influence on the realm of a child’s life until he grows up on the aspects of education and psychological well-being is formed.

A positive parent-child relationship illustrates that the family will survive in harmony so that it becomes the foundation of a healthy home and community environment. The influence of the parents on the whole life of the child means the influence from birth to adulthood due to the parents. Children spend most of their time at home and the attitudes, behavior, standard of living, and communication of parents with their children have a major impact on the child’s future life. If their parents are too strict or too obedient, it has a negative impact on their life. But the supportive, caring and flexible attitude of the parents results in a psychologically and mentally healthy child.

Parents (a married couple) should adopt an authoritative parenting style and practically apply it when dealing with their children. They are the backbone of a nation and the nation’s future depends on their psychosocial development. Healthy parents can produce healthy children in exchange for a healthy nation. On the other hand, unhealthy parents (husband and wife) will have a bad influence, a small example is divorce. And this is a burden for the nation.

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