Individual and Group Rights to Health Care in Rural Health Settings: Bedouin in the North East Region of Jordan
G.Lewando Hundt,1 F. Hasna2, S. Alzaroo,1 M.Alsmeiran2
1. University of Warwick, UK
2. University of Philadelphia, Jordan
Corresponding author
Gillian Lewando Hundt
Institute of Health,
School of Health and Social Studies
University of Warwick,
Coventry CV4 7AL
Individual and Group Rights to Health Care in Rural Health Settings: Bedouin in the North East Region of Jordan
Abstract : Rural health care provision poses a challenge to health care providers. This case study of health care for Bedouin in Jordan is based on data collection in 2007-8 involving clinic providers, policymakers and Bedouin. It explores to what extent the right to health as set out in General Comment 14 can provide a framework for considering the availability accessibility and acceptability of current provision in a rural setting in Jordan. Health care is provided by the Ministry of Health and the Royal Medical Services to a dispersed population living in encampments and villages over a large rural area. There are dilemmas in availability between many poor quality small clinics or fewer higher quality larger clinics and issues of physical, information and economic accessibility and issues of acceptability in relation to the lack of local and female staff, lack of cultural competencies and poor communication. However, the two main providers have a developing partnership that could potentially address the challenge of provision to this rural area which addresses the right to health of this population in Jordan. Applying the concept of health care justice is a way in which a more equitable distribution of resources and adjustment of differential access and availability could be undertaken. This has particular relevance to the needs of populations living in remote and rural areas such as the Bedouin in Jordan.
Keywords: right to health, bedouin, rural health care, Jordan
Individual and Group Rights to Health Care in a Rural Setting: Bedouin in the North Eastern Region of Jordan
G. Lewando Hundt, F. Hasna, S. Alzaroo, M.Alsmeiran
Introduction
The right to health is often debated, discussed and critiqued in the light of the UN General Comment 14 (2000). This is a comment relating to the implementation of substantive issues of Article 12 of the UN Covenant on Economic Social and Cultural Rights. UN General Comment 14 states that ‘ everyone has the right to the enjoyment of the highest attainable standard of health conducive to living a life in dignity’ ( 14.pdf). The UN General Comment 14 addresses both health care and the wider determinants of health – food, shelter, water. Paragraphs 14 and 18 specifically address the right to health care services that are available, acceptable, accessible physically and economically; and are non discriminatory and there is specific mention of rural settings and indigenous or marginalized groups.
This paper engages with the General Comment 14 in relation to these paragraphs on health care provision - availability, accessibility, acceptability, quality and non discrimination. The way in which the right to health in these areas is operationalised by governments, health providers, communities and individuals is diverse. Social and political contexts differ and the relations between a state and its citizens are shaped by policies, legislation and financial and political constraints. A comparative contextual approach using extended case studies is a way forward in elucidating and problematizing the right to health and how this is exercised in differing settings. The focus of this paper, is the ways in which the right to health care is being and can be realized in a remote rural setting, namely through a case study of the Bedouin living in the North Eastern Desert (Badia) of Jordan.
The 1948 Universal Declaration of Human Rights (UDHR) of the UN Assembly included in Article 25 the right to health and well being including medical and social care services. The UDHR has been critiqued in terms of its universalism and its western and individualistic emphasis (Meijer 2001, Chowdhury 2008) and one attempt to deal with this was the development of the Universal Islamic Declaration of Human Rights (UDIHR) developed by the Islamic Council of Europe in 1981. It does not directly address the right to health, however aspects of the right to health are alluded to indirectly. Human life is deemed sacred and requiring protection under Article 1 the Right to Life, Article III on the Right to Equality prohibits discrimination as does Article IV on the Right to Justice, and Article XVIII the Right to Social Security states that ‘every person has the right to food, shelter, clothing, education and medical care consistent with the resources of the community’(9:1981) with this applying in particular to those with temporary or permanent disability.
Robinson and Clapham state that although the majority of nations ratified the International Covenant on Economic, Social and Cultural Rights in 2000 in which ‘the right to health is an international legal obligation that must be progressively realized at the national level, the reality is that the right to health is still not universally recognized as a fundamental human right.’(Robinson & Clapham 17:2009). The importance of disaggregated health indicator data in terms of age, ethnicity, gender is pinpointed by Robinson and Clapham (2009) to be important in order to track this progressive realisation. The UN Special Rapporteur on the right to the highest attainable standard of health 2002-2008, Paul Hunt, has clarified that the progressive realization of this right is subject to resource availability, imposes some obligations of accountability on states to have indicators and benchmarks of progress in this area and presents new opportunities and challenges to national policy makers, health and human rights professionals (Hunt 2006, 2010).
The field of international public health has long been engaged with health inequalities but only more recently has begun to frame issues of poverty and health equity in relation to human rights and health. As Braveman and Gruskin wrote ‘An equity framework focuses attention on socially disadvantaged, marginalized, or disenfranchised groups within and between countries, including but not limited to the poor.’(Braveman and Gruskin 4: 2003).
Socio-legal scholars argue that ‘in a human rights framework, health is a matter of justice (Yamin 46:2008), and that this framework using a rights based approach (RBA) enables the relabeling of ‘problems’ as ‘violations’ (Yamin 48:2008). The distinguished international human rights scholar, Baxi (2010) has distinguished between human rights to health and healthcare justice. He postulates that human rights to health talk is utilised on the level of global and national social policy whilst healthcare justice can be engaged with ‘in terms of fair distribution of healthcare opportunities and facilities’ and includes both justice and care (2010:4).
Within the field of public health, human rights and healthcare justice approaches, have the potential to result in different priorities for health planning and delivery at the national and community levels with a different distribution of resources to address disadvantage and marginalisation (Farmer 2008).
Nancy Fraser (2007) the philosopher has written extensively on theories of justice and sets out a three dimensional approach to justice involving representations, distribution and recognition. Fraser has argued also that today justice claims can be within territorial states as part of a ‘Keynesian-Westphalian frame’ applying to citizens within the state (2007:17), in this case Jordan, or can be part of global governance, in this case the UN General Comment 14 on the Right to Health.
Detailed case studies in different country settings can provide a way forward for clarifying the scope of the right to health and in this way, move debate beyond rhetoric to pragmatic progressive realization of the right to health and further the development of healthcare justice.
.For instance Article 27 of the South African constitution on health care, food, water and social security states that “everyone has the right to have access to health care services, including reproductive health care, sufficient food and water and social security, including, if they are unable to support themselves and their dependants, appropriate social assistance.” It continues: “the state must take reasonable legislative and other measures within its available resources, to achieve the progressive realisation of each of these rights” (Bill of Rights Article 27, Constitution of the Republic of South Africa 1996:12). The South African constitution has been described ‘as a transformative Constitution’ (Liebenberg 2007) and has been used in the courts to develop social rights to health and social benefits. The progressive realisation of the right to health and health care is also part of the UN Comment 14.
This paper addresses rights to health care in a rural setting through a case study of the Bedouin in the North Eastern Region (Badia) of Jordan. This case study of the provision of health care to these Jordanian Bedouin explores how a rights based approach can reveal a lack of congruity between the individual and group rights to health of this population living in a remote rural area of Jordan. It also examines the dimensions of access and how these are and could be addressed as part of a right to health mediated by the notion of health care justice by the state, health providers and individuals.
Access to health care has a number of dimensions such as distance, cost, quality of care provision (ie availability of drugs, communication, staffing and equipment). Underpinning this notion of access to health care as part of the right to health, is the idea of equitable non discriminatory provision (General Comment 14 Para 18,19),
The geographical or spatial dimension to access to care impinging on the right to health is a feature of accessing rural health care provision in many countries and this often involves socially disadvantaged communities such as indigenous peoples. This has particular implications for women in childbirth and the issue is not only distance but access to vehicles, good roads, and health care provision that is open as well as within reach. The difficulties of negotiating decision making within the household is also an aspect of access to care as is the financial resources to pay for it. In some settings, the attitude of health care staff is also an aspect of access and the right to health and this is particularly so, when the population is socially disadvantaged, indigenous or there are linguistic problems. This results in communication problems that may also be compounded by lack of cultural competencies or discrimination. In addition, the resourcing of rural health care is often in terms of facilities and staffing more patchy and of poorer quality so that the staff/patient ratios are low and do not bear comparison with those in major cities in the same country. The resourcing required to address this inequitable provision, is a challenge for policymakers and government. Access to health care is not equitably distributed in any country and this impinges on the rights to health of individuals and communities.
These questions of health care justice and the progressive realisation of the right to health in terms of rural health care provision are not unique to this setting. Rural health care poses challenges in many countries and a recent WHO International Health Bulletin has been devoted to the issue of the difficulties of attracting and retaining health care professionals to work in remote rural settings. Governments are being urged to address these issues at a national central level with financial incentives and support (Chen 2010). A review of the retention of health care staff in remote and rural settings (Lehmann et al 2008) identified that strategies included financial incentives, regulation, education and management and social support systems. A multi-country study involving Kenya, South Africa and Thailand (Blaauw et al 2010) reported different incentives attracting staff such as the type of health facility or financial incentives and a recent WHO document (WHO 2009) gives an overview of this issue. Clearly staffing is only one of the issues in terms of rights to health for this particular remote rural population.
Setting
80% of Jordan’s total area is Badia, anArabic word used to describe arid to semi- arid regions where rainfall averages less than 200mms. It extends from north to south along the eastern portion and contains about 5% of the Jordanian population. This study has been conducted in the North Eastern Badia of Jordan, in the governorates of Mafraq and Zarqa (Fig 1) that are 26,435 square kilometers (10207 square miles) and 4,080 square killometers (1,575 square miles) respectively. The population was 245,665 in 2007 with 4.5% of Jordan's population and a population density of 9.3 per kilometre (DOS, 2003). Mafraq governorate covers the second largest area in Jordan, but has the second smallest population density.
Figure 1
The rural population (almost entirely Bedouin in this area) constitutes 66.9% of the Mafraq governorate and 4.7 of the Zarqa governate. Therefore, most of the study population lived in the Mafraq governorate. This has a young population with 31% being under 15 years of age and 10% being over 50 years of age. The national mortality rate was 19 and the fertility rate 3.6 (DOS 2008). 48% of employed men in Mafraq governorate worked in the army or in the public administration and 8% in Education (Department of Statistics 2008). Historically, Bedouin have not been disaggregated from the general rural population in official reports, however a recent survey (Masarweh 2009) from a DHS sub-sample in 2007 is the first study to do so. This is a sample of 2034 Bedouin families including 1556 every married women from 15-49 years of age and shows how the majority are settled with over 90% having electricity, sanitation and running water. The table below summarises the differences between the Bedouin and the rest of the population.
Table 1
These data indicate that family size is larger with more low birthweight and higher illiteracy. The figures for infant and child mortality seem lower than the rest of the population and we would suggest that these reflect under reporting, a possible lack of representativeness of Bedouin who live in more remote areas, and also possibly that Bedouin although living in remote rural areas are arguably less socio economically disadvantaged than some urban poor such as Palestinian refugees living in the camps.
The study site included semi-nomadic, recently settled and long settled Bedouin.who are inhabitants of the ‘Badia’ (semi arid desert regions). They are referred to as ‘alarab’ amongst themselves but in relation to village (fellaheen) and city dwellers (mandaneen) as Bedouin (badoo/bedu). They historically lived in the Arabian Peninsula coming to Jordan and the surrounding countries in the 6th century AD. Prior to this time, they were also living in the area during the period of Nabatean and Byzantine settlement when the trade caravans from the Arabian peninsular would cross the region transporting spices, salt and other goods from the Mediterranean Red Sea ports. Bedouin have a lifestyle and culture that is ancient and adapted to the harsh environment they live in, requiring movement in search of pasture and water, few possessions and a code of honour and hospitality. Traditionally, a nomadic lifestyle is based on herding livestock (camels, sheep and goats) with some cultivation of crops irrigated from winter rains.. Socially, the Bedouin lived in segmentary structures with tribal confederations, with tribes, sub-tribes and extended families (Chatty 2006, 2010,). Alliances were made and the Bedouin were known as noble warriors and excellent smugglers. With the establishment of nation states with secure borders, Bedouin had to modify their nomadism. During the 20th century, the development of new technologies for cultivating semi arid areas, the development of towns, and the loss of grazing areas for agricultural, industrial, military and conservation purposes, has meant that the majority of Bedouin throughout the Middle East have become settled in villages and towns. A minority continue to be nomadic, and although many retain small flocks, the majority are employed in different types of wage labour and have a mixed household economy. Most today live in houses although some continue to live in encampments in goats hair tents in winter that are warm and impermeable and tents from sacking in summer that provide shade and ventilation. Only an estimated 5 – 10% of the Bedoun remain nomadic in Jordan, whilst the majority of the population is now permanently settled in villages. There are many small villages and encampments both along the one main road in the region as well as along non asphalted roads.
Whilst Bedouin are viewed as embodying Arab tradition, aspects of their lifestyle today are often despised by those living in cities and towns with little knowledge of desert life who aspire to be modern. They may be seen as uneducated with a particular lifestyle and their difference is not always construed positively. They live in the North and South of Jordan and this case study focuses on those living in the North Eastern Badia in the Mafraq and Zarqa Governorates. Their dispersion poses a challenge for the provision of health care.
The Jordanian Ministry of Health (MoH) offers primary health care services at three different levels – comprehensive health centres, primary health centres and village health centres. A comprehensive health centre is be open 24 hours a day, has X Ray and laboratory facilities and provides Immunization, Emergency, Dental. Maternity and Obstetric services, with family doctors and visiting specialists. Medical care would be free till 2pm and then would be charged for in the afternoon and evening for cases not considered as emergencies. A primary health centre is open daily and has nurses and family doctors. A village health centre would be open for a few hours several times a week, staffed by a practical nurse with a visiting family physician.