27/20 Application of the technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce preventable maternal mortality and morbidity - Report of the Office of the United Nations High Commissioner for Human Rights

GE.14-06809 (E)

*1406809*

Human Rights Council Twenty-seventh session Agenda items 2 and 3 Annual report of the United Nations High Commissioner for Human Rights and reports of the Office of the High Commissioner and the Secretary-General Promotion and protection of all human rights, civil, political, economic, social and cultural rights, including the right to development

Application of the technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce preventable maternal mortality and morbidity

Report of the Office of the United Nations High Commissioner for Human Rights

Summary Taking into consideration information received from Member States, United Nations agencies, civil society groups and other relevant stakeholders, the present report discusses initiatives to implement the technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce preventable maternal mortality and morbidity. The report documents efforts in a variety of areas, including dissemination and utilization of the technical guidance. It also examines challenges in the implementation of the guidance and offers recommendations to support further implementation.

Contents Paragraphs Page

I. Introduction............................................................................................................. 1–10 3

II. Dissemination and promotion activities.................................................................. 11–22 5

III. Utilization of the technical guidance....................................................................... 23–57 8

A. Assessing and influencing legislation, policies, strategies and programmes.. 24–33 8

B. Capacity-building ........................................................................................... 34–41 10

C. Planning, programming and strategic vision .................................................. 42–46 12

D. Convening multi-stakeholder processes ......................................................... 47–49 13

E. Development of tools ..................................................................................... 50–57 13

IV. Challenges for the implementation of the technical guidance................................. 58–67 15

A. Time required ................................................................................................. 59–60 15

B. Dissemination ................................................................................................. 61–62 15

C. Multi-stakeholder processes and coordination ............................................... 63–64 16

D. Advocacy and capacity development ............................................................. 65–67 16

V. Recommendations................................................................................................... 68–69 17

I. Introduction

1. The technical guidance on the application of a human rights-based approach to the implementation of policies and programmes for the reduction of preventable maternal mortality and morbidity (A/HRC/21/22), hereinafter referred to as the “technical guidance”, was requested by the Human Rights Council in its resolution 18/2 and was presented to the Council at its twenty-first session, in September 2012. In its resolution 21/6, the Council welcomed the technical guidance and called upon “all relevant actors, including Governments, regional organizations, relevant United Nations agencies, national human rights institutions, and civil society organizations to disseminate the technical guidance and apply it, as appropriate, when designing, implementing and reviewing policies and evaluating programmes to reduce preventable maternal mortality and morbidity”. Also in resolution 21/6, the Office of the United Nations High Commissioner for Human Rights (OHCHR) was requested to prepare “a report on how the technical guidance has been applied by States and other relevant actors”. The present report is submitted in accordance with that request.

2. The present report provides details of various activities and initiatives related to the implementation of the technical guidance. It also highlights barriers to implementation and recommendations for future actions. The report is based on submissions that were shared with OHCHR in response to a note verbale circulated on 28 January 2014,1 as well as on information obtained from relevant stakeholders via reports and correspondence. The report is not an exhaustive list of all activities relating to the technical guidance or rights-based approaches to maternal health. Rather, it provides illustrative examples of how the technical guidance has been utilized in a variety of contexts.

3. The technical guidance was the third in a series of reports to the Human Rights Council on the issue of maternal mortality and morbidity.2 It aims to assist States and other stakeholders in moving from theory to practice in operationalizing human rights in the area of maternal health, including sexual and reproductive health. As such, it presents concrete guidance, organized according to the policy cycle of planning, budgeting, implementation, monitoring, review and remedies, and international cooperation.

4. A human rights-based approach is premised on creating environments that enable rights holders to claim their entitlements and duty bearers to meet their legally binding human rights obligations. It represents a shift away from passive delivery of services to a culture of accountability for internationally guaranteed human rights. Understanding maternal mortality and morbidity as a matter of human rights requires recognition that the death and grievous injuries sustained by women during pregnancy and childbirth are not inevitable events but rather a direct result of discriminatory laws and practices, failures to establish and maintain functioning health systems and services, and a lack of accountability.

5. The notion that maternal mortality and morbidity is a human rights concern has gained considerable traction in recent years. Civil society and other experts have analysed maternal health, and wider sexual and reproductive health issues, through a human rights

1 Submissions were received from Argentina, Colombia, Cuba, Estonia, Germany, Guatemala,

Lebanon, Mexico, the Republic of Moldova, Serbia, Slovakia and Switzerland, and from the United Nations Population Fund (UNFPA), Center for Reproductive Rights, Grupo de Información en Reproducción Elegida (GIRE Mexico), International Budget Partnership, International Initiative on Maternal Mortality and Human Rights, and Ipas.

2 The first two reports were A/HRC/14/39 and A/HRC/18/27.

lens for many years. In 2006, this issue was placed on the human rights agenda of the United Nations, when the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health devoted part of his report to the General Assembly to this topic. Subsequently, the Human Rights Council organized a panel discussion in 2009 on this issue, and the three reports of the High Commissioner were produced in the following years.

6. Importantly, the recognition of maternal health as a human rights concern has not been restricted to the human rights sphere. Recent years have also witnessed increased collaboration between the health and human rights communities on maternal health. The 2010 Global Strategy for Women’s and Children’s Health, led by the Secretary-General, which focused on acceleration towards the achievement of Millennium Development Goals 4 and 5, explicitly recognizes the human rights dimensions of maternal and child health. The work that has followed on from that Global Strategy, including through the recommendations of the Commission on Information and Accountability for Women’s and Children’s Health, and the work of the independent Expert Review Group on Accountability for Women’s and Children’s Health, has continued to emphasize that maternal health cannot be treated solely as a public health issue but must be understood as a human rights concern. Furthermore, the Partnership for Maternal, Newborn and Child Health (PMNCH) has played an important role in convening policy networks that extend across normally disparate elements of research, policy, practice and the public, thus contributing to the widening of partner networks for reproductive, maternal, newborn and child health and human rights.

7. More recently, the Commission on the Status of Women recognized that failures to protect reproductive rights were hampering efforts to achieve Millennium Development Goal 5 on maternal health (E/CN.6/2014/L.7, para. 23), and the Commission on Population and Development, in its resolution 2014/1, linked the “promotion, respect, protection and fulfilment of all human rights” to the elimination of preventable maternal mortality and morbidity (E/2014/25-E/CN.9/2014/7, para. 11).

8. In discussions around the post-2015 development agenda, there has also been an emphasis on sexual and reproductive health and rights, including the human rights dimensions of maternal mortality and morbidity. For example, the report of the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda paid specific attention to sexual and reproductive health, including maternal health, and remarked that “universal access to sexual and reproductive health and rights is an essential component of a healthy society”.3

9. These developments signal that there is increased understanding of maternal mortality and morbidity as a matter of human rights. The contribution of the technical guidance, based on this recognition, is to offer assistance to relevant stakeholders on the actions required to address maternal health in line with human rights obligations, and to put in place processes for the development of policies and programmes that respect human rights principles, including participation, non-discrimination and accountability.

10. It is important to note that some Governments, United Nations agencies and civil society organizations, and other entities, were already applying rights-based approaches to maternal health before the technical guidance was adopted, and continue to implement these important projects and programmes. The High Commissioner welcomes these efforts and encourages further uptake of rights-based approaches. The technical guidance is a tool

3 A New Global Partnership: Eradicate Poverty and Transform Economies through Sustainable

Development, p. 39.

that can assist existing efforts and can encourage a common understanding of what is required by a rights-based approach.

II. Dissemination and promotion activities

11. Since September 2012, considerable efforts have been invested to ensure wide dissemination of the technical guidance. News about the technical guidance, as well as the Council’s resolution on the topic, were posted on a variety of list serves and circulated to networks of organizations working in the area of sexual and reproductive health and rights. Information about the technical guidance was also distributed via articles in journals targeting specific audiences, such as health policymakers, health service providers, and the human rights community.

12. For instance, the High Commissioner authored an article in The Lancet, one of the world’s leading medical journals, describing the technical guidance and promoting the use of the technical guidance.4 An article about the technical guidance, by Alicia Yamin, was published in the International Journal of Gynaecology and Obstetrics, which explains the content and the significance of the technical guidance.5 The Center for Economic and Social Rights, a human rights organization that focuses especially on economic, social and cultural rights worldwide, featured the technical guidance in its October 2012 newsletter. The technical guidance was also promoted through the regular blog of the White Ribbon Alliance, an international coalition of individuals and organizations in over 100 countries promoting safe pregnancy and childbirth. PMNCH has also promoted the technical guidance among its network of over 500 members. In addition, the International Budget Partnership, a civil society organization that focuses on influencing budget policy, has engaged in efforts to circulate the technical guidance to several networks, including its own list serve, as well as to the Global Movement for Budget Transparency, Accountability and Participation, which is composed of over 100 national and international budget groups from around the globe.

13. The importance of reaching diverse audiences to share information and guidance about rights-based approaches cannot be understated. Effective implementation of rights- based approaches depends heavily on the engagement of stakeholders from diverse sectors and disciplines.

14. Sessions about the technical guidance were also held at major global conferences on maternal health. For instance, at the Global Maternal Health Conference, held in Arusha, United Republic of Tanzania, from 15 to 17 January 2013, which brought together over 700 people, the technical guidance was presented at a panel session entitled “Promoting rights- based accountability for maternal health”. The panel session served as a launch event for a knowledge summary produced by PMNCH on accountability and human rights, for which the technical guidance was a key resource. At other panel sessions — on rights-based approaches and on budget monitoring tools — the technical guidance was raised during the discussions as an important tool to be aware of. At the Women Deliver conference held in in Kuala Lumpur from 28 to 30 May 2013, which brought together over 4,500 people, the technical guidance was presented at a panel session entitled “Applying a human rights-

4 Navanethem Pillay, “Maternal mortality and morbidity: a human rights imperative”, The Lancet,

vol. 381, issue 9873 (April 2013), pp. 1159 and 1160.

5 Alicia Yamin, “Applying human rights to maternal health: UN technical guidance on rights-based

approaches”, International Journal of Gynaecology and Obstetrics, vol. 121, issue 2 (May 2013), pp. 190–193.

based approach to maternal mortality and morbidity”; and the panellists shared experiences about how the technical guidance could be used in their work.

15. At the regional level, the Asia-Pacific regional office of UNFPA prepared a series of thematic briefs in preparation for the sixth Asian and Pacific Population Conference, held in September 2013. Two of the briefs — on the human rights elements of the International Conference on Population and Development (ICPD) and on maternal health — made specific reference to the technical guidance; they were circulated among all delegates and observers at the sixth Asian and Pacific Population Conference. The Conference recognized “the critical role of policymakers, parliamentarians, community leaders and media in fostering an enabling environment for the full and equal enjoyment of human rights, including sexual and reproductive health and rights” (E/ESCAP/APPC(6)/3).

16. Another initiative in Asia is the work of the Asia Pacific Alliance for Sexual and Reproductive Health and Rights. This organization presented the technical guidance at the Regional Workshop on the Promotion of Maternal Health and Reduction of Maternal Mortality, organized by the ASEAN Intergovernmental Commission on Human Rights and held on 27 and 28 March 2014 in Manila. The workshop’s outcome document, the “ASEAN Intergovernmental Commission on Human Rights action plan to promote maternal health and reproductive rights”, reaffirms the human rights of women, and references the technical guidance, among other human rights instruments.

17. Going beyond simple dissemination, certain organizations took proactive steps to raise awareness about the technical guidance, organizing webinars to enhance understanding of the content of the technical guidance. For instance, in February 2013, UNFPA held a webinar in which 36 of their field presences participated, with several offices committing themselves to pursuing implementation of the guidance at the national level. Ipas, an organization working on four continents to end unsafe abortion, organized a webinar for its staff to increase awareness and promote utilization of the technical guidance.

18. Specific efforts were also made to enhance understanding of the technical guidance among experts. For instance, in its first report, the independent Expert Review Group on Accountability for Women’s and Children’s Health recognized that robust implementation of the technical guidance would be an important tool for reaching Millennium Development Goal 5, on maternal health,6 and acknowledged the important interface between the health and human rights communities. As a result, OHCHR and the World Health Organization (WHO) organized a briefing for these treaty body experts and independent Expert Review Group on Accountability for Women’s and Children’s Health experts, during which the main elements of the technical guidance were presented. The subsequent report of the independent Expert Review Group on Accountability for Women’s and Children’s Health again referred to the technical guidance as an important practical tool.7 Another example is the Permanent Forum on Indigenous Issues, which held an expert group meeting in January 2014 on sexual health and reproductive rights, where the technical guidance was used as a resource. The report of that meeting builds on the guidance, particularly with regard to ensuring that sexual and reproductive health services for indigenous women and girls are available, accessible, acceptable and of good quality.

19. The technical guidance was also presented at the eleventh International Conference of National Human Rights Institutions, held in Amman from 4 to 7 November 2012, where

6 Independent Expert Review Group on Accountability for Women’s and Children’s Health,

Every Woman, Every Child: From Commitments to Action (2012), p. 45.

7 Independent Expert Review Group on Accountability for Women’s and Children’s Health,

Every Woman, Every Child: Strengthening Equity and Dignity through Health (2013), p. 57.

the main theme was the human rights of women and girls. The Amman Declaration and Programme of Action that came out of the conference contain explicit recommendations to national human rights institutions on the protection and promotion of reproductive rights, including rights related to maternal health. OHCHR has received information since then that certain national human rights institutions are working with the technical guidance. In Mexico, the Human Rights Commission of Mexico City, in its 2013 annual report concerning maternal health and obstetric violence, refers to the technical guidance, among other international human rights instruments protecting maternal health and other relevant human rights. In India, an article on the technical guidance appeared in the Journal of the National Human Rights Commission in 2013.8

20. In addition, numerous stakeholders have reported to OHCHR that the technical guidance has been disseminated at the national level. In Switzerland, for example, the technical guidance was distributed through the organization Santé Sexuelle Suisse, which is the main organization in the country working on the promotion of sexual and reproductive health and respect for sexual rights. The Government of the Republic of Moldova reported that the technical guidance had been presented to relevant experts in the Ministry of Health, and that the guidance was the subject of regular discussion among national experts in the field of reproductive health. In Mexico, 32 women’s institutions at the State level disseminated the technical guidance to the health sector in their respective States and also to the municipal women’s institutes. Furthermore, the technical guidance was presented and circulated at a national-level meeting held by the Committee for Safe Motherhood in Mexico City in September 2013 to raise awareness about safe pregnancy as a human right that entails obligations across various sectors. The Burundi office of UNFPA reported that it had disseminated the technical guidance to a network of journalists, in order to raise awareness among the media about the applicability of rights-based approaches.

21. The technical guidance has also informed discussions around the ICPD beyond 2014 review process. In July 2013, an international conference on human rights was held in the context of the ICPD beyond 2014 review process, in order to identify positive human rights developments over the past 20 years, remaining gaps and challenges, and emerging issues and priorities for the future. The issue of accountability, as explained in the technical guidance, was an important discussion point at the conference. This understanding of accountability requires attention to all phases of the policy cycle, and to ensuring transparency and effective participation. The report of the operational review of the implementation of the programme of action of the ICPD and its follow-up beyond 20149 is explicitly oriented around the obligation to realize human rights, and it supports the application of rights-based approaches, including in regard to the question of maternal mortality and morbidity. In connection with the Human Rights Council’s resolutions on maternal mortality and morbidity, he explains that the ICPD beyond 2014 review process affords an opportunity to reflect the expansion and strengthening of a human rights-based approach to health.

22. Knowledge about the technical guidance has also been spread more widely, thanks to its citation in a number of articles and publications.10

8 Jashodhara Dasgupta, “Maternal health: promotion and protection of human rights of women”,

Journal of the National Human Rights Commission, India, vol. 12 (2013). 9 Launched by the Secretary-General of the United Nations and the Executive Director of UNFPA on 12

February 2014.

10 See, for example, African Union policy brief, “Using human rights to advance accountability for

women and children’s health”, August 2013. Available from http://www.who.int/pmnch/media/events/2013/au_policy_brief_human_rights.pdf;

III. Utilization of the technical guidance

23. Information gathered via OHCHR’s existing work, via the submissions for the present report and via interviews with key stakeholders working with the technical guidance reveal that the technical guidance is being used in various ways — all directed towards the ultimate end of ensuring women’s human rights, especially sexual and reproductive health and rights.

A. Assessing and influencing legislation, policies, strategies and programmes

24. Several stakeholders report using the technical guidance as an assessment or monitoring tool to examine existing policies. For instance, the submission from the Government of Mexico included a detailed table comparing the provisions of the technical guidance to existing policy provisions, in order to assess compliance. The submission from Guatemala also included details about how certain aspects of its action plan to reduce maternal and child mortality are aligned with the principles of the technical guidance.

25. The Committee for the Promotion of Safe Motherhood, in Mexico, which is a government and civil society network, has embarked on efforts to strengthen its human rights focus, explicitly on the basis of the technical guidance. In this regard, the Committee is monitoring national programmes such as the Health Sector Programme, the National Programme for Equal Opportunity and Non-Discrimination against Women, the Education Sector Programme and the Specific Action Programme on Maternal and Perinatal Health, on the basis of the provisions in the technical guidance. Committees have also been formed at the State level, which have exposed various human rights concerns relating to pregnancy and childbirth.

26. The technical guidance has been used at the working level by staff of the Danish International Development Agency (DANIDA) in order to reflect upon their existing support to the health sector. It was reported that assessing existing Danish support against the provisions of the technical guidance helped to better value, and improve upon, the contribution a rights-based approach to providing pooled funds to the sector. In particular, the technical guidance highlighted to the staff of the Agency the importance of supporting sector- and system-wide improvements as a core human rights obligation. This required attention to improved planning, budgeting and reporting processes; ensuring more equitable

World Health Organization, Ensuring Human Rights in the Provision of Contraceptive Information and Services: Guidance and Recommendations (2014); World Health Organization and Partnership for Maternal, Newborn and Child Health, A Policy Guide for Implementing Essential Interventions for Reproductive, Maternal, Newborn and Child Health (2014); Partnership for Maternal, Newborn and Child Health, Knowledge summary #23: human rights and accountability (2013); and Knowledge summary #27: death reviews: maternal, perinatal and child (2013); Rebecca Cook, “Human rights and maternal health: exploring the effectiveness of the Alyne decision”, Journal of Law, Medicine and Ethics, vol. 41, issue 1 (April 2013), pp. 103–123; Louise Finer and Johanna Fine, “Abortion law around the world: progress and pushback”, American Journal of Public Health, vol. 103, issue 4 (April 2013), pp. 585–589; Paul Hunt and Tony Gray, eds., Maternal Mortality, Human Rights and Accountability (Routledge, 2013), pp. 150–155; Alicia Yamin, “From ideals to tools: applying human rights to maternal health”. PLOS Medicine, vol. 10, No. 11 (2013).

service delivery; and strengthened accountability and transparency mechanisms. Discussions around the technical guidance contributed to a broadened understanding of rights-based approaches, by challenging the notion that human rights exist only in respect of discrete issues or population groups.

27. UNFPA has reported using the technical guidance to inform its advice on legal and policy development at both the national and regional levels. Regionally, UNFPA supports a programme entitled Intercultural Reproductive Health for Indigenous Women, in the Plurinational State of Bolivia, Ecuador, Guatemala, Honduras and Peru. This programme, which is aligned with the technical guidance, has brought about a better understanding of the human rights requirement of acceptable health services for indigenous women. Building on this project, a set of basic standards for intercultural maternal health services is being developed by the health ministries of the Plurinational State of Bolivia, Ecuador and Peru, the Andean Commission of Intercultural Health, and the South American Network of Indigenous Women. UNFPA in Malawi has reported that the technical guidance informed its analysis of several gender and youth sector policies, budgets and programmes, through its Gender Equality and Women Empowerment Programme, in order to ensure gender responsiveness and to ensure that such programmes meet human rights standards.

28. Civil society organizations have pointed out how the technical guidance can be used to monitor State policies and programmes relating to sexual and reproductive health. In Nigeria, the Centre for Reproductive Rights and the Women Advocates Research and Documentation Centre have reported using the technical guidance in order to assess practices in Nigeria relating to pregnancy and childbirth and have presented recommendations to the Government on how to address human rights concerns in this regard.

29. In East Africa, the Open Society Institute has used the technical guidance to design tools to assess how maternal health services are being implemented and to review whether laws, policies and practices incorporate human rights-based approaches. These tools have been used to review the strategic plans of four countries — Kenya, South Sudan, Uganda and the United Republic of Tanzania — and the outcome of this assessment will be shared with relevant stakeholders in the region to assist them in advocating for more robust adoption of human rights-based approaches. Linked to this initiative, in February 2014, in Uganda, the Center for Health, Human Rights and Development, in collaboration with the FXB Center for Health and Human Rights at the Harvard School of Public Health, organized a regional meeting for civil society organizations from East Africa. The meeting focused on the value of human rights-based approaches to maternal health and the implementation of the technical guidance. The participants identified areas of work necessary for implementing the technical guidance at the community level, and each country identified a community-based organization that will follow up on such implementation.

30. Similarly, Ipas Brazil reported that the technical guidance had provided a useful human rights framework for an assessment mission, sponsored by a network of civil society organizations and social movements, on the status and the availability of emergency obstetric care services and women’s access to good-quality care at public health services in underprivileged municipalities of Rio de Janeiro. The findings had been presented at a public hearing of the Brazilian Senate. Civil society organizations are also exploring ways to use the technical guidance in efforts to monitor the Government’s implementation of, and to work with the Government in connection with, the decision of the Committee on the Elimination of Discrimination against Women in the case of Alyne da Silva Pimentel Teixeira, the first international human rights case where a maternal death was found to be a human rights violation.

31. The technical guidance has also been used in engagement with the courts. For example, Uganda’s Center for Health, Human Rights and Development has reported that the technical guidance influenced the preparation of the petition that it and other partners filed in the Constitutional Court. The petition seeks to establish that the non-provision of essential maternal health commodities in a government health facility, leading to the death of some expectant mothers, is an infringement on the right to health. The Centre explained that the emphasis placed by the technical guidance on accountability and judicial remedies provided a supportive framework for this work. It also explained that the filing of this case had led to the filing of other health-related cases, which were assisted by the technical guidance.11

32. SAHAYOG, an Indian civil society organization working in the areas of maternal health, sexual and reproductive health and rights, and gender equality, used the technical guidance in its joint work with the national human rights institution on monitoring the Government’s commitments following the second universal periodic review of India. The actions identified include ensuring access to contraceptive services, maternal health services and safe abortion services; simplifying the grievance mechanisms; and ensuring community participation in the governance of the public health system. Many of these actions require engagement with parliamentarians, which is SAHAYOG’s next step, after the May 2014 elections.

33. The technical guidance also informed the development, by the Pan American Health Organization (PAHO), of model legislation on maternal health from a human rights perspective. This model legislation is presented in a publication by PAHO entitled Reproductive Health and Healthy Motherhood: Aligning National Legislation with International Human Rights Law. The publication is the product of two regional meetings for parliamentarians organized by PAHO. The first meeting took place in March 2013 in Santo Domingo and the second took place in December 2013 in Brasilia. For the second meeting, PAHO financed the translation of the technical guidance into Portuguese and the technical guidance was presented. Model legislation provides important illustrations and examples of how legislation may meet human rights standards.

B. Capacity-building

34. Various interlocutors have reported using the technical guidance as a way to enhance understanding of the actions required under a rights-based approach, particularly through capacity-building initiatives. For instance, Colombia reported that the technical guidance has contributed to a better understanding of the requirements of a rights-based approach, which has been particularly relevant in Colombia since the Constitutional Court decision of 2006 regarding the grounds on which abortion should be permitted.12

35. UNFPA in Brazil has reported that the technical guidance has been used in training activities, especially with regard to a workshop on the intersectionalities of race, gender and age in public policies and budgets, which focused on the health of women of African descent. The workshop reportedly provided a basis for constructive engagement between government officials, civil society, academia and United Nations agencies, and led to action that was effective in framing maternal health as a human rights issue.

11 See, for example, CEHURD and others v. Nakaseke District Local Government (civil suit No. 111 of

2012) and CEHURD v. Executive Director of Mulago National Referral Hospital (civil suit No. 212 of 2013).

12 Decision C-355/06 (10 May 2006).

36. OHCHR has used the example of maternal mortality in its staff training on human rights budgeting, using the technical guidance as a tool. Bringing together about 30 OHCHR staff members, the training included a session that examined the budget chapter of the technical guidance and considered the application of these principles in the national context.

37. The International Federation of Gynaecology and Obstetrics considers the adoption of a human rights-based approach to be very important in improving women’s health and has reported that the technical guidance has been a useful tool for its work in this area. In particular, the technical guidance has provided input into the work of its Committee for Women’s Sexual and Reproductive Rights, which has developed a curriculum on women’s rights to reproductive and sexual health. The curriculum will be introduced at the executive board meeting being held in Tokyo in July 2014, and will also feature at other upcoming Federation conferences at the national, regional and international levels. The Federation is also examining the possibility of introducing the curriculum in medical schools. The aim of the curriculum is to raise awareness among gynaecologists and obstetricians around the world of the importance of women’s human right to health. The curriculum highlights case studies where women’s rights have been jeopardized. It addresses the questions of access to facilities and services, the treatment of health-care providers, and quality of care, among many other aspects.

38. In South Africa, the Equinet network, together with the Society of Midwives of South Africa, is working to build the capacity of midwives to apply rights-based approaches, focusing strategically on educators. In KwaZulu Natal province, a task team has been established to examine the midwifery curriculum and integrate a human rights- based approach, drawing on the technical guidance. Discussions are also under way with midwifery colleges in Eastern Cape, Western Cape and Free State, as well as at the national level, to expand these efforts to incorporate a rights-based approach into the curriculum.

39. Uganda’s Center for Health, Human Rights and Development has reported that the technical guidance has been a useful tool in the development of an action research project on community participation in the realization of the right to health, which was implemented in partnership with the Learning Network for Health and Human Rights at the School of Public Health and Family Medicine of the University of Cape Town, South Africa. The project explores the experiences of community members in the Kiboga and Kyankwanzi districts of Uganda with regard to the health unit management committees — the institutional structures established by the Government for community members to participate in health governance.

40. In Peru, CARE Peru is working together with PAHO to engage national health authorities and policymakers on dissemination and capacity-building with regard to the implementation of the technical guidance. In that connection, CARE Peru is producing a publication entitled Methodology for Training Citizens for Local Citizen Monitoring: Legislative and National Norms Framework to Promote Citizen Monitoring for Health Rights.

41. At the Harvard University School of Public Health, the technical guidance was studied in a course entitled “The right to health in resource-poor settings: maternal health in Tanzania”. The course examined the implications of adopting a rights-based approach to maternal health for multiple actors across the policymaking, implementation and review cycle, as well as with respect to enforcement mechanisms and international assistance and cooperation. The students undertook interviews with a wide range of stakeholders, such as government officials, donors, representatives both of United Nations agencies and of civil society organizations, and patients, and visited facilities, in order to explore the obstacles to, and the implications of, implementing rights-based approaches.

C. Planning, programming and strategic vision

42. The commitment to implementation of the technical guidance specifically, and to a rights-based approach to sexual and reproductive health, including maternal health, is also evident in the way in which some stakeholders have effectively included rights-based approaches in their planning and strategy processes. In line with the strategic plans of both UNFPA and OHCHR, a Framework of Cooperation was signed on 3 March 2014 by both organizations which provides a framework for further implementation of the technical guidance. In particular, as the technical guidance is aimed at action at the country level, this framework commits both organizations to advancing the integration of human rights standards and principles into national policies, programmes and budgets relating to sexual and reproductive health and rights, including in the areas of maternal health and family planning. It also has the objective of supporting development of the capacity of national human rights institutions and civil society organizations to monitor sexual and reproductive health and rights obligations, including those related to maternal health, and to follow up on the relevant recommendations of international human rights mechanisms.

43. PMNCH has reported that its involvement in the process leading to the adoption of the technical guidance has assisted it in strengthening partnerships, including with OHCHR, to implement rights-based approaches. Furthermore, involvement in the technical guidance process has contributed to the strengthening of PMNCH’s conceptual approach to integrating human rights into its work. Human rights is now a major feature of the work of PMNCH on promoting accountability for reproductive, maternal, newborn and child health, which focuses on enhancing linkages and alignment between accountability mechanisms for human rights and for health, and developing and disseminating tools for human rights- related advocacy. PMNCH has also reported that integrating human rights into its work has had an impact in several ways, including the way in which data are collected and indicators are identified, and the way in which concepts are defined. Other impacts include bringing new perspectives, evidence and solutions to challenges and identifying new areas where further research is required.

44. The technical guidance has also been used to inform national planning processes. For example, UNFPA in Bhutan (a One UN country) reported that the technical guidance had contributed directly to the formulation of the country’s United Nations Development Assistance Framework (UNDAF). Specifically, the technical guidance was useful for the Essential Social Services cluster, which has outcomes and outputs that relate to maternal health services. The integrated analytical framework, which encompassed concepts of equity, a human rights-based approach, gender, capacity development and results-based management, was used to ensure a more rigorous and systematic analysis across all cross- cutting areas when formulating areas of intervention, outcomes or outputs. Moreover, a human rights-based approach guided the formulation of interventions for maternal health, especially to address the disparity in access to reproductive health services and commodities, including for adolescents.

45. UNFPA in Uganda used the technical guidance directly at a planning meeting for 11 districts that had been chosen for fast-tracking of maternal and newborn health in the UNDAF for 2014–2015. The first day of the meeting included an orientation session on the principles behind a human rights-based approach, as well as a dedicated session on the technical guidance. The added value of using the technical guidance was the acknowledgement by the participants that more than 88 per cent of maternal deaths are preventable and that actions need to be taken at all levels of the continuum of care, from the household and community level to the health facility level to the national and international level, and across all the other sectors beyond the health-care sector. The obligations of the Government were emphasized, even when health services provision is decentralized. The need to strengthen accountability mechanisms was also discussed, and some districts intend

to support by-laws to engage men in maternal health issues. The districts came up with their own action plans, and some innovations, such as pregnancy mapping and door-to-door mobilization, as well as follow-up. Furthermore, the technical guidance is explicitly mentioned in the Consolidated District Priority Interventions for Maternal and Newborn Health 2014–2015.

46. The technical guidance has also contributed to the strategic planning carried out by donors. Staff at the Danish International Development Agency pointed out that the technical guidance was helping in the formulation of the next cycle of support (for 2015 to 2020) for the health sector in one of the African countries where the Agency is active. For example, the standards of availability, accessibility, acceptability and quality that are highlighted in the technical guidance, as well as in other human rights instruments, helped the Agency to consider how its support could contribute to reducing discrimination and strengthening broader accessibility to facilities, goods and services.

D. Convening multi-stakeholder processes

47. As a result of the collaboration between organizations in developing the technical guidance, OHCHR, PMNCH, WHO and UNFPA are working together to strengthen the application of rights-based approaches to maternal, newborn and child health, including to related sexual and reproductive health issues. As part of this joint work, a regional workshop was held in Lilongwe from 18 to 20 November 2013, bringing together representatives of governments, national human rights institutions, United Nations country teams and civil society, from four countries, namely Malawi, South Africa, Uganda and the United Republic of Tanzania. The aim of the workshop was to build the capacity of participants to assess their legal and policy environment, in order to integrate human rights into laws, policies and programmes relating to maternal, sexual and reproductive health, and newborn and child health, and to understand the implications for States in the areas of planning, budgeting, implementation, monitoring, review and remedies.

48. At the workshop, participants worked in country groups to identify specific action points to follow up on in their countries; these were considered strategic opportunities for applying rights-based approaches in the areas of maternal and child health. The action points included efforts to integrate human rights into revisions of existing policies relating to sexual and reproductive health, efforts to bring human rights analysis into the UNDAF process, and providing human rights expertise to law reform processes. Following on from this workshop, efforts are under way to produce situational assessments on human rights and maternal and child health, including sexual and reproductive health, which can be used as inputs into national planning and programming processes through multi-stakeholder initiatives.

49. In Mexico, OHCHR is involved in efforts to implement the technical guidance, in close collaboration with the Committee for the Promotion of Safe Motherhood; these are focused on the States of Jalisco and Oaxaca. In May 2014, a range of stakeholders gathered, including from the Government, the legislature, human rights institutions, civil society organizations and academia, to raise awareness about the technical guidance, with a view to developing an implementation plan. The guidance was presented to the authorities and, as a result, in Jalisco, an agreement has been reached to establish an intersectoral committee.

E. Development of tools

50. Since the adoption of the technical guidance in September 2012, numerous stakeholders have pointed out the need for more detailed guidance. In response to these

requests, several initiatives are under way. OHCHR, with support from PMNCH, WHO and UNFPA, is developing modular guidance on the application of a rights-based approach to maternal and child health. It is recognized that a diversity of actors needs to be involved. The modules are aimed at different stakeholder groups, and aim to provide key questions for reflection on the role that different stakeholders play in putting a rights-based approach into practice. After the technical guidance has been presented to different stakeholder groups, a common question that arises is “what do I need to do?” — as a health policymaker, a national human rights institution, a parliamentarian, a donor country, a representative of the media, and so on. The first two modules are in the process of being finalized; they focus on the role of health policymakers and of national human rights institutions. Further modules are expected to be produced in 2014, focusing on other stakeholder groups.

51. UNFPA and OHCHR, together with the Danish Institute for Human Rights, have produced a handbook on reproductive rights for national human rights institutions, which provides extensive guidance on applying rights-based approaches and on human rights standards in the area of sexual and reproductive health and rights, including those related to maternal health. Additionally, UNFPA has developed a guidance note to support national human rights institutions in conducting national inquiries and country assessments on sexual and reproductive health and rights, which is based on the methodological framework for situational analysis and assessment of States’ obligations that is provided in the technical guidance.

52. PMNCH is working to develop a reproductive, maternal, newborn, child health and multisectoral processes policy assessment tool, which will build on the policy compendium that it launched in 2014, informed by the technical guidance.

53. In March 2014, WHO launched guidance and recommendations on ensuring human rights in the provision of contraceptive information and services. The technical guidance on maternal mortality contributed to that guidance on contraception, particularly in terms of describing what is required in order to ensure participation and accountability. WHO and UNFPA are following up on this work by developing an implementation guide on contraceptive services that is targeted at service providers and policymakers.

54. Civil society organizations are also planning to develop training tools based on the technical guidance. For example, the Asia Pacific Alliance for Sexual and Reproductive Health and Rights is developing an advocacy tool based on the technical guidance to make the guidance more accessible for civil society currently working on sexual and reproductive health and rights and maternal health in the South-East Asia region. In addition, it is planning to conduct a training for civil society organizations to equip them with the necessary information to advocate with governments in the region. One of the objectives of the training will be to serve as a bridge between groups in the region working on sexual and reproductive health and rights, and groups working on maternal health, which often work in silos.

55. An accessible version of the guidance for decision makers has been developed in Mexico by the Committee for the Promotion of Safe Motherhood, Ipas, the Instituto de Liderazgo Simone de Beauvoir, International Initiative on Maternal Mortality and Human Rights, OHCHR, the MacArthur Foundation and the Norwegian Agency for Development Cooperation. The objective of this tool is to guide policymakers working in different sectors on how to integrate a human rights-based approach into the design, implementation and evaluation of programmes and strategies, as well as in accountability mechanisms. This simplified version of the technical guidance outlines the necessary steps for incorporating human rights approaches into maternal health.

56. The technical guidance has also influenced the development of the Human Rights and Gender Mainstreaming Manual for Health Professionals, produced by the Ministry of Health of Uganda with the technical support of the Center for Health, Human Rights and Development. The manual seeks to integrate a human rights-based approach into policies, programmes and services.

57. Another signal of the positive reception for the technical guidance has been the request by the Human Rights Council for the development of technical guidance on applying a human rights-based approach to the implementation of policies and programmes to reduce and eliminate preventable mortality and morbidity in children under 5 years of age, which envisions a process similar to that carried out with the maternal mortality technical guidance. There are well-recognized links between maternal mortality and child mortality, and considerable efforts have been invested to ensure that the two technical guidances are complementary and harmonious.

IV. Challenges for the implementation of the technical guidance 58. The diversity of stakeholders engaging with the technical guidance, as well as the wide variety of contexts in which the technical guidance is being utilized, is encouraging. In order to promote further implementation of the guidance, and rights-based approaches more broadly, several challenges can be noted for further work.

A. Time required

59. Implementing a rights-based approach is a long-term process, for several reasons. In many contexts, applying a rights-based approach is a new way of operating, and shifting working methods and mentalities requires time. By its nature, a rights-based approach requires extensive consultation, which is also a lengthy endeavour. Specifically, it must be borne in mind that planning cycles at the national and international levels vary from anywhere between 4 and 10 years, which means that the strategic moments for integrating a rights-based approach are not always imminent. However, in the meantime, much capacity- building work may be undertaken. In addition to the time required to put rights-based policies and programmes in place, it will take many more years for the health outcomes of such policies to be properly measured and understood.

60. The technical guidance was presented to the Council in September 2012, and the present report was finalized in June 2014, leaving less than two years to examine how the technical guidance is being implemented. At this early stage, many promising initiatives have been started, but assessing the implementation of the guidance would only be possible with more time.

B. Dissemination

61. Many stakeholders reported that the technical guidance has not been widely disseminated and thus is not widely known. Ensuring that documents agreed at the international level reach the policymakers and other stakeholders who are concerned is a larger issue, which many could have a role in addressing. As detailed above, considerable efforts have been deployed to ensure broad dissemination of the technical guidance, but more are required if the technical guidance is to be more widely utilized. Governments play an important role in sharing information among ministries and other national and subnational authorities to ensure that there is coherence between international-level commitments and national-level action. The United Nations can also help to ensure

effective dissemination of information about rights-based approaches, including the technical guidance on maternal mortality and morbidity. The submission of UNFPA, which details plans to roll out the technical guidance, is a promising step in the right direction.

62. As further dissemination is pursued, there is also a need to put the technical guidance into more accessible language in order for it to be useful to the wide diversity of stakeholders involved in applying rights-based approaches. Such an effort would assist in strengthening the cross-sectoral and multi-disciplinary work that is required for applying a rights-based approach, as further elaborated below.

C. Multi-stakeholder processes and coordination

63. Applying a rights-based approach inherently involves multi-stakeholder processes. In many areas of development, including the health sector, work has taken place in a fragmented manner, with too little attention to the importance of ensuring cross-sectoral and cross-disciplinary linkages. A rights-based approach is a holistic approach which hinges on this cross-sectoral and cross-disciplinary cooperation. However, one challenge reported is the collision between efforts to ensure the comprehensive approach required by human rights and the current reality in many places where there are vertical approaches that separate different areas of sexual and reproductive health (e.g. contraceptive services are often funded separately from maternal and child health, or funding is received for certain pathologies such as HIV/AIDS but not for wider health concerns).

64. Coordination among the various stakeholders is essential at the earliest stages of planning and implementation. It is essential that applying human rights-based approaches does not lead to parallel processes, but effectively impacts the way that existing policies are designed, implemented and evaluated. Effectively triggering and supporting a multi- stakeholder process requires political will, and frequently a champion who is personally committed to the aims of the process.

D. Advocacy and capacity development

65. Enhancing understanding of rights-based approaches as applied to maternal health requires further capacity-building on how to put a rights-based approach into practice. In many places, there are positive, human rights-based policies, but in order to implement these policies, there is a need for increased understanding that human rights is not business as usual, but a process of empowerment and claiming entitlements. Ensuring this knowledge and capacity among a critical mass of decision makers, practitioners and advocates helps to effect the shift from human rights theory to building a culture of rights and accountability. Some efforts are under way to develop this further guidance, but more support is needed in order to ensure that such guidance is accessible and practical for those who would use it.

66. For those who are advocating for the implementation of rights-based approaches, more support is needed to bolster evidence and justifications for this approach. The human rights-based approach is grounded in the human rights obligations that all States have signed up to. In addition to this legal obligation, there are powerful health, economic and social justifications for implementing rights-based approaches, which can be persuasive in discussions with relevant stakeholders. Ensuring that these health, economic and social benefits are documented and are widely available to advocates is key to ensuring the further spread of rights-based approaches.

67. The challenge of capacity-building also relates to the need to enable rights holders to claim their rights. In many contexts, individuals are unaware of their rights and

entitlements, and thus do not demand their rights. Rights are more likely to be respected, protected and fulfilled where there is a culture of accountability, which depends greatly on civic engagement and awareness of rights. More work is required in order to ensure that all people are knowledgeable about their human rights and how to claim them.

V. Recommendations

68. The High Commissioner observes that further time is needed in order to assess the impact of the utilization of the technical guidance and to understand how efforts to apply rights-based approaches to maternal health can be more robustly supported. In this regard, the High Commissioner recommends that the Council remain seized of this important issue and continue to receive information on the implementation of the technical guidance, in order to advance understanding about the operationalization of human rights.

69. The following recommendations are offered to States and other stakeholders, as relevant:

(a) Disseminate the technical guidance widely, including by ensuring its distribution to relevant ministries and other organizations working in the area of sexual and reproductive health and rights. In addition, stakeholders should explore additional modalities for making the technical guidance available in more accessible formats.

(b) Organize briefing sessions, webinars, or other meetings, to discuss how the technical guidance can be used at the national level and to enhance understanding of rights-based approaches.

(c) Identify opportunities for implementing the technical guidance, and support its implementation, in national-level processes, including law reform, sector policy reviews, UNDAFs, monitoring and evaluation processes, and accountability processes.

(d) Convene and support multi-stakeholder groups to discuss the application of a rights-based approach to maternal health and sexual and reproductive health more broadly, and prioritize areas for action.

(e) Ensure coordination of multi-sectoral and cross-disciplinary processes in order to achieve a comprehensive approach to sexual and reproductive health and rights, including maternal health, as required by a human rights-based approach.

(f) Engage in capacity-building for different stakeholders (including policymakers, legislators, national human rights institutions, United Nations agencies, and service providers, among others) in order to support efforts to apply rights-based approaches to sexual and reproductive health.

(g) Support efforts to convey the technical guidance in formats that are more accessible to a wide variety of stakeholder groups.

(h) Engage in capacity-building for rights holders to enable them to claim their rights and contribute to a culture of accountability for delivering on sexual and reproductive health and rights.

(i) Where programmes and other initiatives already apply a rights-based approach to maternal health, consider using the technical guidance as an assessment tool to evaluate the comprehensiveness of such approaches.

(j) Document challenges in implementing rights-based approaches, in order for future guidance and advice to effectively respond to such challenges.

(k) Place human rights, including sexual and reproductive health and rights, at the centre of the post-2015 development agenda, in order to ensure policy coherence with human rights obligations.