“HEALTH PROTECTION AND HUMAN RIGHTS”

“HEALTH PROTECTION AND HUMAN RIGHTS”

Training assessment within the framework of agreement between the Human Rights Commissioner of the Uzbek Supreme Assembly (Ombudsman), Ministry of Health of the Republic of Uzbekistan and World Health Organization (WHO)
Acknowledgment

This report has been prepared by a working group within the framework of cooperation among the World Health Organization, Health Ministry of the Republic of Uzbekistan and Uzbek Supreme Assembly Commissioner for Human Rights (Ombudsman). The working group members express their thankfulness to the Health Ministry of Uzbekistan, Ombudsman and the WHO representative office in Uzbekistan for the opportunity given and support in the assessment and analysis of a series of training seminars “Health protection and human rights”. They would also like to express gratitude to the heads of regional health departments, Ombudsman’s regional representatives and other organizations that took part in the action.

The working group members:

1. D. Gulyamova, coordinator, member of Ombudsman commission for observation of constitutional rights and freedoms of citizens

2. M. Usmanov, head of Ombudsman Secretariat

3. R. Salikhodjayeva, principal officer of the Health Ministry management

4. D. Kamilova, leading expert of the Health Ministry control group

5. G. Pulatova, leading expert of the Chief Board for organizing treatment-and-disease-prevention service of the country
Contents:

Introduction 4
Interaction between Ombudsman, Ministry of Health and WHO office in Uzbekistan 5
Evaluation of the training and analysis to prepare recommendations 8
Summary 11
Recommendations 13
Attachment 1. Trainings on “Health care and human rights” 15
Attachment 2. Training evaluation form 17
Attachment 3. Proposals and comments 20

Introduction
For any society health of its citizens is one of the major indices of the level of development of a given state and its readiness to recognize, preserve and protect that common human value. Globally man’s right to health was acknowledged by Article 25 of the Universal Declaration of Human Rights (1945) and that was the first International document that Uzbekistan joined after declaring state independence.
One of the priority directions of social policy of the Republic of Uzbekistan is to improve the health care system through reaching the level of developed countries in the sphere of medical aid to the population. A state programme of reforming the health care system has been successfully under way in Uzbekistan for the last decade aimed at ensuring the citizens’ constitutional right to get high-quality medical care and social security; also organizational, economic and legal conditions are being created to raise the quality of medical services.
Under the presidential decree № VII-2107 of 10 November 1998 “On the State Programme of Reforming the Health System” stage-by-stage reforms have been carried out in the country leading to the formation of a national model of health protection with an aim to improve the quality and efficiency of medical aid to people and develop material and technical basis of the health system based on availability and safety of medical services within the framework of guaranteed range of medical and sanitary services.
On the initiative of the Uzbek president an institution of Supreme Assembly Commissioner for Human Rights (Ombudsman) was founded in the country in 1995 as a sign of adherence to ideals and values of human rights. One of the Ombudsman activities is to carry out a parliamentary control over the observance of patients’ rights.
Interaction between Ombudsman, Ministry of Health and WHO office in Uzbekistan

Continuous analysis of citizens’ appeals as well as monitoring results of the legislation in force called to protect and guarantee the rights of citizens to health care, made by Ombudsman in various parts of the republic, helped to reveal reasons and conditions causing the violation of citizens’ right to get high-quality medical care.
Rights of patients are mainly violated due to imperfect mechanisms of providing of the rights of patients of medical institutions as compared to international standards in the given sphere as well as unawareness of both patients and medical workers of the citizens’ right to health protection and also the lack of a single mechanism of enlightening activities in this field.
A monitoring of observation of patients’ rights has resulted among others in a closer cooperation with health care organizations in the field of observing and ensuring the citizens’ rights to health protection and get high-quality medical aid. In 2005 Ombudsman signed a cooperation agreement with the Health Ministry. Ombudsman’s joint activities over the last five years under that agreement helped to develop recommendations concerning the need to improve normative and legislative bases in the field of health protection and to create a system of monitoring the quality of medical care. Special attention is paid to expanding informational and enlightening work in the field of ensuring and protection of patients’ rights.
WHO provides support to member-countries in the field of understanding and acknowledgement of human rights in order to improve mechanisms of ensuring the rights of patients of medical institutions in accordance with the world standards, and that was the basis for cooperation between Ombudsman and WHO office in Uzbekistan.
In this direction a conference “Health protection and human rights” was held in November 2008 on the occasion of the 60th anniversary of the adoption of the Universal Human Rights Declaration. The action was organized jointly with the Ministry of Health, WHO office and office of “European House” in Uzbekistan. Experts in human rights from WHO headquarters in Geneva took part in the conference that planned to hold a series of actions in this direction in various regions of the country.
In 2009 six joint seminars on “Health protection and human rights” were held in various regions including the city of Tashkent and towns of Andijan, Samarkand, Urgench and Karshi. The final seminar was held in Tashkent at the Ministry of Health on 22 September 2009.
The aim of the seminars was to improve knowledge of medical workers, civil society institutions, law-enforcement agencies and courts about the right of man to health protection and to help ensure the rights of patients through the formation and development of human rights standards in the work of these structures.
The seminars were scheduled for two years to cover all parts of the country. Representatives of Ombudsman, health care organizers and promoters, heads of specialized medical and educational institutions, agencies dealing with the state protection of patients (prosecutor’s offices and courts), citizens’ self-government bodies, NGOs (Women’s Committee, chamber of lawyers, “Kamolot” Youth Movement), Medical service departments of the Chief Board of the Execution of Punishments of the Internal Affairs Ministry and mass media participated at these meetings.
Along with national experts WHO-recommended foreign specialists also made reports.

Uzbek Supreme Assembly Commissioner for Human Rights (Ombudsman) S. Rashidova, head of Ombudsman secretariat M. Usmanov and regional representatives as well as Ombudsman for the rights of patients made reports on the following issues:

• state policy in the field of ensuring the citizens’ rights and freedoms;
• forms and methods of Ombudsman’s parliamentary control over observation of citizens’ rights in the sphere of medical care;
• civil and state mechanisms of protection of patients’ rights;
• interaction between Ombudsman and health system;
• International standards of Ombudsman activities in guaranteeing the rights of patients and prisoners;
• monitoring of the rights of patients and prisoners.

Minister of Health of Uzbekistan A. Ikramov mentioned in his report issues of the health care system to ensure the rights of patients such as guaranteeing the citizens’ constitutional rights to get high-quality medical care, their equal access to medical care and the development of preventive health protection. He also informed about the implementation of the state programme on health care system reform.

Head of WHO office in Uzbekistan Dr. Michel Tailhades made a report in the form of questions and answers on: “Human Rights and WHO”. The participants in the seminar had a chance to get comprehensive answers to such questions as why WHO deals with human rights issues and how WHO can act in the field of health and human rights. The report also explained ways of a broader approach to issues of health and the three goals of WHO activities in the fields of health and human rights.

A number of subjects of the seminar were devoted to International standards of both humanitarian law and rights of patients of penal system. Doctor of International Red Cross Committee mission in Uzbekistan Kapeel Sharma in his report “Health Protection and Human Rights in Penal System” referred to various adopted international documents and spoke about regional and national standards of arrest and imprisonment of people, the role of medical personnel, requirements concerning the prisoners’ maintenance (living, water, sanitary conditions and hygiene), food products and meals.

An officer of WHO office in Uzbekistan I. Ismailov made a report entitled: “WHO legal bases and standards of fighting HIV/AIDS” about international regulation of human rights issues in the field of HIV/AIDS as well as regulation of rights of HIV-infected patients in Uzbekistan.

Head of Medical and Sanitary Department of the Chief Board of Execution of Punishments of the Internal Affairs Ministry B. Yusupov said in his report that HIV/AIDS treatment and prevention work in Uzbek penal system is in general similar to other civic health protection activities and is carried out according to the law of the Republic of Uzbekistan jointly with corresponding civic health protection institutions. He spoke about measures to prevent and reveal in time STIs and TB and to do a voluntary test for HIV/AIDS; the progress on fight against TB within a single national programme in accordance with International standards, and assistance of international organizations in this direction.

A national officer of WHO office in Uzbekistan, F. Nizamov, made a report “Health of mother and child is consistent part of human rights” noting the importance of good health of every mother and child. The report presented a list of international documents showing the efforts of the international community to guarantee good health of mothers and their children, priorities, strategy and aims of the public health system to protect health of mothers and their children.

Representatives from prosecutor’s offices and courts told the participants about the role of prosecutor’s offices in defending the patients’ rights and practice of court hearings concerning compensations for damages caused to health.

The programme of seminars included reports by participants, discussion and exchange of views; and working in small groups on ways of ensuring and protection of patients’ rights and analysis of cases when these rights are violated.
Evaluation of the training and analysis to prepare recommendations

At the end of the seminars a working group was formed to analyze the training consisting of a member of the Ombudsman commission for observation of constitutional rights and freedoms of citizens, head of the Ombudsman secretariat and representatives of the Ministry of Health.
The aim of the analysis was to assess the training; collect information for analysis and develop recommendations for further activities in this direction.
A questionnaire was drafted with regard of recommendations and terms of reference set by WHO office in Uzbekistan (attachment 2 – training evaluation form). The questionnaire was distributed among the participants of the seminars for anonymous questionnaire was conducted by means of self-recording.

Results of the analysis
In all 212 people representing various spheres of activity took part in the six seminars held. Taking into account that the number of listeners from various spheres varied in the seminars the number of respondents to take part in the questionnaire and the number of participants was taken in the ratio of 30 per cent (Supplement 2).

The total of 63 filled-in forms making 29.7 per cent of all listeners (212 people) were received; 27 (43 per cent) of them represented medical spheres of activity, 36 (57 per cent) – various other spheres including Ombudsman institution, prosecutor’s offices and interior agencies, courts, public structures and NGOs; the forms were all quantitatively processed and analyzed by contents.

Results of quantitative analysis of the forms

About the course – the majority of the respondents/participants assessed the seminar “Health protection and human rights” as “good” - 46 per cent (29) and as “excellent” – 25 per cent (16). 32 per cent (20) of the respondents said the tasks of the seminar “were completely fulfilled”, 65 per cent (41) of them – “fulfilled as a whole”, 3 per cent (2) of them said “not quite fulfilled”.
30 per cent (19) of the participants said about the seminar that their personal expectations were justified “in full”, 68 per cent (43) said “justified as a whole” and 1,5 per cent (1) said “not quite justified”.
Answering the question: “Was there enough time to practice skills and knowledge obtained?” 40 per cent (25) of the respondents said “enough”, 30 per cent (19) said “not enough” and 30 per cent (19) found it difficult to answer.
Answering the question whether they were sure to use at their work the skills and knowledge obtained at the seminar 65 per cent (41) of the respondents said they “were sure”, 32 per cent (20) said “partly sure” and only 3 per cent (2) – “not sure”.
Out of 63 respondents 97 per cent (61) said “they obtained all necessary materials and the handouts were clear and understandable”.

About the content
Concerning some reports and presentations:
More than 80 per cent of the respondents think that information concerning the following three themes was sufficient and quite new for various spheres of activity:
• “About human rights activities of the Ombudsman institution in the field of securing citizens’ right to get high quality medical care (84 per cent)
• “On task of the Uzbek Health Ministry and its regional bodies to ensure the patients’ rights (82 per cent)
• “The World Health Organization and the rights of patients” (80 per cent); representatives of various spheres of activity think that information completely new for them.

Over 40 per cent of the respondents need additional information about: legislation in the sphere of health care, availability of specialized medical care to vulnerable sections of the population, the work of WHO office in Uzbekistan.
As to reports:
• “International standards of Ombudsman activities to guarantee the rights of patients and prisoners and monitoring of their rights” (66 per cent)
• “The WHO role in supporting the protection of rights of inmate-patients in penal structures” (61 per cent) the respondents find information sufficient and still think it necessary to include more detailed information in the seminar plans.

Over 50 per cent of the respondents think information on the following themes was sufficient:
• “Work of the regional Ombudsman representatives aimed at improving the people’s knowledge in the field of health protection and human rights” (54 per cent)
• “Providing for the health of people in penal system institutions” (53 per cent),
• “Consideration at courts of cases concerning compensations for damages caused to health” (52 per cent)
• “Professional training of specialists and rights of patients” (52 per cent)
• “On the protection of the right of inmate-patients of penal system structures to medical care” (51 per cent).

Over 20 per cent of the participants stressed the need of additional information on: increasing the role of lawyers in considering the cases of violation of patients’ rights, implementation of court decisions on compensations for a damage caused to health, introduction of quality standards of medical care into health protection practice, international experience in enlightening activities in the fields of health protection and human rights.

Concerning the following three themes of the seminar:
• “Role of prosecutor’s offices in defending the patients’ rights” (33 per cent)
• “The WHO role in supporting the protection of patients’ rights in penal system” (34 per cent)
• “Humanitarian law standards in penal system” (35 per cent) respondents need additional information. It is necessary to extend and deepen the themes adding information about: form and methods of work of prosecutor’s offices concerning the law observance in health care system, international experience, practice and role of independent physical examination in the protection of patients’ rights, conformity of maintenance conditions with international standards of humanitarian law at penal structures of various countries, international experience and TB prevention practice in remand centres, the WHO role in maintaining health of women and children in penal structures.

As for the trainers who conducted the seminar, 21 per cent (13) of the respondents assessed them as “excellent”, 35 per cent (22) as “very good” and the majority of the participants - 44 per cent (28) as “good”. Not a single listener gave them “unsatisfactory” mark.

Organization of the seminar (premises, food, etc.) was assessed by 14 per cent (9) of the respondents as “excellent”, by 27 per cent (17) – “very good” and by the majority (59 per cent (37) – as “good”.
Summary

As a whole, the seminars were of current importance and in great demand because of inadequate knowledge of both patients and medical workers about medical law and lack of information and education in the field of ensuring and protection of patients’ rights.

Reports made at the seminars showed that despite success achieved in ensuring the citizens’ right to get a high-quality medical care in the course of reform in this field, “the patient’s position remains weak”. So, time of great changes in health protection demands that timely and comprehensive explanatory work be carried out among the population as a result of which every citizen will develop a sense of responsibility for his/her own health. Every citizen educated on about the state policy in the sphere of health protection can take an active part in the process of reform aimed at ensuring his/her constitutional rights and accessibility of medical and social care guaranteed by the state. It is necessary by all means available to inform the population about the measures being taken by the state at various stages of the health system reform to ensure their right to health protection.

Joint efforts of Ombudsman, the Uzbek Health Ministry and WHO aimed at organizing and holding these seminars are prompted by the need to improve legal awareness of the patients, medical workers, lawyers and the public in accordance with international standards.

Analysis of the questionnaires helped to make the following conclusions:

1. The working group members assessed the seminar in general as “good” and “excellent”.

2. Personal expectations of the participants in the seminar have in general been justified.

3. The majority of the respondents (65 per cent) believe that they will use the skills and knowledge obtained at the seminar although they think that time for practical classes was not enough (60,3 per cent) and propose to introduce interactive methods.

4. The themes of the seminars reflect expectations of the listeners and the task as a whole was fulfilled.

5. Most of information presented was new and the subjects raised have been adequately developed. According to respondents from public organizations and NGOs, national experience and Ombudsman activities to ensure the patients’ rights, information about the course of reform in health care and legal systems, health protection of prisoners, international experience and Ombudsman practice of protecting the rights of patients, including inmates of penal structures were also quite new for them. For the listeners from the law-enforcement agencies, courts and the chamber of lawyers new and timely was information about the development of diagnostics and treatment standards to be introduced in all stages of medical aid as well as about reforms in the primary level of health care.

6. Analysis of the respondents’ proposals on the contents of reports showed that over 75 per cent of the themes contain sufficient information. Respondents’ proposals of additional information to themes do not mean an addition to or development of a concrete subject and can be assumed as a basis for further recommendations and taken into account when drafting the programme for future seminars (attachment 3).

7. Proceeding from their occupations and sphere of activity the participants intend to translate the knowledge obtained into practice: at court examinations, in the work of prosecutor’s offices to ensure the observance of the legislation in the field of health protection, when considering people’s appeals, defending patients’ rights in case of their violation and in informational and enlightening work concerning man’s right to health protection.

8. 98.6 per cent of the respondents received all necessary materials related to the theme of seminars and they find the handouts clear and understandable and think advisable to include in the list of handouts a collection of materials about the health system reform and International Classification of Diseases (ICD-10). Proposals made by the participants concerning handouts of future seminars are given in part “Comments” (attachment 3).

9. The work of trainers is assessed as “excellent” and “good”.
Recommendations

Proceeding from the seminar assessment results, to improve the system of teaching human rights in the field of health protection and develop mechanisms of ensuring the rights of patients of medical institutions the following is recommended:
- to create an efficient and flexible model of a legal education system in the field of health protection based on common principles and international experience through a stage-by-stage improvement of awareness and growing potentials.

For this purpose:
• to study international experience and practice of informational and enlightening activities in issues of health protection and human rights and adapt them to local conditions;

• to provide for preparing national trainers in accordance with international standards in order to raise the quality and efficiency of the seminars organized (possible practical trainings and education within the framework of study tours abroad);

• taking into account the lack of a public structure to defend the patients’ rights at this stage of civil society it is advisable to use experience and capacities of the Ombudsman institution in informational and enlightening work among patients, medical workers and lawyers in the capital and regions;

• to cover large groups of population with informational and enlightening activities Ombudsman and the Uzbek Health Ministry with the support of WHO office in Uzbekistan need to arrange cooperation with mass media with a follow-up development of a joint plan of action and more widely use media opportunities in this direction;

• it is advisable to continue holding a series of seminars scheduled for two or more summer periods (it is possible to outline a long-term strategy within WHO competence attracting other partner- and international organizations);

• when drawing up a programme and choosing subjects for the seminars it is necessary to take into account proposals made by representatives of different spheres of activity who took part in the seminar assessment (Supplement 4);

• the programme of seminars should spare enough time for exercising the skills obtained and also envisage the introduction of interactive and distance education methods;

• representatives of civil society institutions (media and NGOs) should be included in the list of target groups of the seminars;

• for the assessment of the seminars a questionnaire survey is to be conducted among listeners;

• to provide for a broad access of the population to information on man’s right to health protection it is reasonable to hold the second round of training on the level of district branches of the public health system in regions of the country. For example, three days each in Syrdarya (area less-visited by international organizations) and Khorezm (ecologically unfavourable area due to the Aral Sea problem) regions. At first three certain districts in each of the regions should be chosen for the seminars (and then fully cover the whole region) with participants from nearby areas invited.

The following should be envisaged within the framework of the training:
• broad enlightening activities with preliminary notification of local mass media across the territory covered about theme of the seminars (create special columns in radio, TV and the press, on seminar days organize appearances of Ombudsman representatives, health care organizers, public and lawyers) also on the sites of Ombudsman, Uzbek Health Ministry and WHO office in Uzbekistan;

• visits of the participants in the seminars to concrete primary level institutions, open doors days organized for the patients and students of medical educational establishments with media coverage of these actions (interviews and reports);

• conducting polls and questionnaire surveys among the population and medical workers.
Attachment 3. Proposals and comments

Proposals on subjects to be included in the programme of future trainings and circulation of information as well as comments by already trained listeners

Analysis of proposals and comments received helped to divide them by spheres of activity of the listeners.

1. Ombudsman and his representatives:

• to improve informational and enlightening work concerning man’s right to health protection and get high-quality medical aid;

• international experience and practice of legal education in the field of medical law for patients, medical workers and lawyers (representatives of courts, investigatory powers, defence lawyers and advisors);

• foreign experience and public control practice in ensuring quality and safety of medical aid, creation and realization of quality control;

• to introduce international standards of diagnostics and treatment in primary level health institutions;

• to monitor the quality of medical aid in primary level health institutions;

• to create mechanisms of providing for high quality and safety of medical preparations in the Republic of Uzbekistan;

• role of mass media in improving the knowledge of population about man’s right to health protection.

Comments:

a) local media representatives should be included in target groups;

b) handouts should include: brochures about man’s right to health protection, a collection of materials about the reform and its course in the health system.

2. Medical workers

• to continue broad-scale series of seminars in rural areas of the country;

• to promote preparation of national trainers in accordance with international standards in order to raise the quality of seminars and also learn international experience in legal education of the population in the field of health protection;

• legal aspects of ensuring the rights of patients and medical workers;

• monitoring of the observance of patients’ rights in penal structures of the country;

• correspondence of medical aid quality in penal system structures to international standards of humanitarian law of various countries;

• role of public organizations and media in popularization of knowledge about man’s right to health protection and formation of a healthy way of life among people.

Comments:

a) to include in the curricular of medical educational institutions such themes as: “Health protection and human rights”, “Rights of patients”, “Rights and obligations of medical workers”, “Balance between the rights of patients and medical personnel”;

b) prepare and issue brochures, booklets and collections “Health and human rights”;

c) to organize “Open doors days” within the framework of seminars at concrete medical institutions (specialized and primary level ones).

3. Medical Service Department of the Chief Board of the Execution of Punishments of the Internal Affairs Ministry:

• to continue the cycle of seminars, broadly inform the population about this issue and widely use media opportunities;

• international experience in TB/HIV prophylaxis in remand centres;

• drug addiction rehabilitation programme “12 steps”.

Comments:

a) The Ministry of Health of the Republic of Uzbekistan is to issue a collection of materials on International classification of diseases with its follow-up distribution also among penal structures of the Uzbek Interior Ministry.

4. Public organizations – Women’s Committee, “Mahalla” foundation, Chamber of lawyers, Federation of Consumer Rights societies of Uzbekistan:

• to continue a series of such seminars attracting mass media in order to provide for accessibility of information to broad sections of the population;

• on WHO role in maintaining health of women and children in penal structures;

• on state guarantees of medical and social aid to the population;

• rights of patients as consumers of medical care set in the Law of the Republic of Uzbekistan “On Consumer Rights in the Republic of Uzbekistan”

• on social security of socially vulnerable sections of the population in the field of ensuring their right to high-quality medical aid proceeding from monitoring results;

• mechanisms of ensuring availability of high-quality medical aid to socially vulnerable sections of the population;

• rules of rendering medical aid to socially vulnerable sections of the population in non-governmental clinics;

• forms and methods of supervision by prosecutor’s offices over the observance of laws in the field of health protection;

• problems with the protection of patients’ rights;

• on international experience, practice and role of independent medical examination in the protection of patients’ rights;

• on execution of court decisions concerning compensations for the damage caused to health;

• role of lawyers at court hearings of violations of patients’ rights, international experience.

Comments:

a) It is necessary to issue a collection of book “Health and Human Rights” including its CD version, and place it on Internet sites of seminar organizers (possibly in Uzbek, Russian and English languages)

5. Representatives of law-enforcement agencies and judges:

• role of independent medical examinations in the protection of patients’ rights;

• international standards and criteria of the damage caused to health and actions of medical personnel;

• problems in protecting the patients’ rights and ways of their solution, national and international practice.

Comments:

a) A group of respondents from among the law-enforcement and court structures as well as the chamber of lawyers think it useful for them to take part in these seminars.

About the place for holding seminars:
• according to the majority of the respondents it would be advisable to organize seminars on the level of district structures of various regions attracting broad masses of the population and institutions.

12.06.2010