Statement by Dainius Puras, Special Rapporteur on the Right of everyone to the enjoyment of the highest attainable standard of physical and mental health

Seventy-fourth session of the General Assembly
Item 70 (a-d)

NEW YORK
29 October 2019

Mr. Chairperson,
Distinguished Delegates,
Ladies and Gentlemen,
 
A few weeks ago, the world reaffirmed its commitment to Universal Health Coverage at the first ever UN High-Level Meeting dedicated to this topic.

The final declaration reaffirms the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, without distinction of any kind. It also recognizes, primary care as the cornerstone of sustainable health systems and as the most inclusive, effective and efficient approach to enhance people’s physical and mental health, as well as social well-being.

Mr. Chairperson,

The goals and commitments adopted by all Member States in September will only be achieved with substantive and strategic investment in the global health workforce with a rights-based approach.

The report that I present today elaborates on the crucial aspect of the health workforce, their education and how human rights can help redirect attention to primary health care and achieve better health outcomes for everyone.

Mainstreaming human rights into health education enriches conventional medical education which historically has been based on an outdated medical hierarchy, the predominance of a biomedical paradigm and a reliance on tertiary care hospitals. Human rights expands education to look at the determinants of health and their impact on health outcomes.
These determinants include not only the material preconditions for individual health such as access to water, food or nutrition, but also the social, environmental, and political issues, as well as the role of discrimination within each.

Health education must pay attention to the conditions in which people are born, grow and live, and should emphasize the need for good primary health care in the communities where people are; otherwise imbalances may arise and problems in health care may exacerbate. Some of these problems include undermining the principle “do no harm”, the excessive use of medicalization, and power asymmetries between physicians and patients, as well as between physicians and other health-care workers.

To overcome these challenges, the workforce should be educated not only on how to diagnose, treat and cure diseases or biomedical pathologies. They should also receive a rights-based education that emphasizes the determinants that promote poor health and how determinants contribute to health inequities.

Distinguished Delegates,

Medical schools, often strongly influenced by specialized university hospitals, have glorified medical specialties and subspecialties, promoting the position and power of specialists, including in health education.

The exacerbated focus on medical specialization has reinforced biases away from providing care to those in the most vulnerable and marginalized situations, including people living in poverty, persons with disabilities, those requiring palliative care, and those who use drugs, or experience mental health issues.

To avoid these biases, health education should recognize that ill health does not always require a medical response involving physicians exclusively, but may often involve mid-level heath care.

Mid-level health-care workers have been often undervalued and under-used; for example with strict regulations that forbid them from performing minor procedures that they could be trained to do. Moreover, the power asymmetries that often start with medical education leave these workers powerless to work effectively or to change the system and its regulations.

But mid-level health-care workers can deliver care as effectively as physicians and are often more responsive to users’ expectations. I call on States to make a better use of mid-level workers for a more efficient mix of skills able to mitigate the effects of workforce shortages and better achieve Universal Health Coverage.

Mr. Chairperson,
Distinguished Delegates,

A rights-based health education can additionally help reshape health systems to become more participatory, equitable, inclusive, non-discriminatory and responsive. It gives everyone involved a voice, including users of services, and enables the workforce to perform optimally by using their training and experience more fully and ultimately making health services more available.

Mainstreaming human rights in health systems further reduces the power imbalances between medical doctors and other cadres of health-care workers, contributing to a more resilient and sustainable workforce.

In my report, I give a special mention to mental health workers and education. I do so because mental health differs from physical health in that biological markers for diagnosing mental health conditions do not exist. The demarcation between health and ill-health are in large part defined by culture and context, and health determinants such as poverty, inequality, discrimination and violence result in chronic stressors that lead to distress.

Unfortunately, mental health education continues to over-rely on the biomedical model to explain emotional distress and to favour pharmacological treatment. Mental health workforce training should be adapted to emphasize the social and underlying determinants of health and equip health-care workers with the attitudes, knowledge and skills necessary to build relationships and avoid the inherent paternalism of the system.

Mr. Chairperson,

We need to learn lessons from the past, when science and the practice of medicine was exercised without a human rights imperative, resulting in an unbalanced workforce that is now failing many people around the world, especially those in vulnerable, poor, and marginalized situations. This starts with education.

I call on States to ensure rights-based policy responses to health education both in the curricula and health strategies. States should guarantee that medical and health training curricula provide a balance between different competencies, including human rights, public health, community and social medicine, mental health promotion and care, palliative care, medical ethics, medical law, and managerial and communication skills.

We need a more balanced workforce of healthcare that represents a broad cross-section of society and are ready to work in remote settings and care for the most vulnerable. A rights-based approach in practice would encourage Graduates to work in primary health care and in rural or remote settings.

Schools of medicine, public health, and all colleges that train health-care workers should ensure that the health curricula is firmly grounded in a right to health framework, reflecting national strategies and emerging priorities.

Candidates that come from situations of vulnerability should be selected for all levels of health education training; and mental health education should be recalibrated to explore alternative service models that are non-coercive and prevent over-medicalization and institutionalization.

Ladies and Gentlemen,

Empowering all health-care workers with rights-based competencies and skills not only prevents human rights violations in the care of patients. It also promotes and protects the rights of health-care workers, as it reduces power asymmetries within the workforce, prevents corruption in the health sector and contributes to decent working conditions and a climate of mutual trust and respect within and beyond health care systems.

It establishes the transformative foundation for a 21st century health workforce that is fit for purpose—one that the global community is entitled to receive.

Thank you.