EqUALITy AND ADEqUACy Of SERVICES

1 4 6 I N D I G E N O U S T R I B A L P E O P L E S ’ R I G H T S I N P R A C T I C E – A G U I D E T O I L O C O N V E N T I O N N O . 1 6 9 countries is invariably lower than that of the overall population, 4 and available data shows wide disparities between the health status of indigenous peoples and that of other population groups. Traditional health systems have developed over generations to meet the particular needs of indigenous peoples within their local environment. In all regions of the world, traditional healing systems and biomedical care co-exist, and the WHO estimates that at least 80 of the population in developing countries relies on traditional healing systems as their primary source of care. 5 Similarly, most indigenous communities have traditional systems for providing social security to its members, including mechanisms for distributing wealth, sharing food resources and providing labour and assistance in case of misfortune. Very little information exists about the importance of such systems, but it must be assumed that they play a major role, for example, with regards to the distribution of remittances from indigenous workers who have migrated outside their communities. All over the world, traditional healing and social security systems have been gradually undermined by lack of recognition, environmental disintegration 4 http:www.who.intmediacentrefactsheetsfs326enindex.html. 5 The Health of Indigenous Peoples - WHOSDEHSD99.1 and social disruption. Also, traditional healing and social security systems may have dificulties in responding to new challenges related to changes in, for example, livelihood systems, introduction of new diseases, social values and roles related to gender and age. In parallel, indigenous peoples are often marginalised in terms of access to public health and social security services, and in many cases the services provided are not adequate or acceptable for indigenous communities. For example, public health workers may have discriminatory attitudes towards indigenous cultures and practices and are often reluctant to be stationed in remote areas; there may be linguistic barriers; the infrastructure is often poor and services expensive. Right to basic health care is a fundamental right to life and States have an obligation to provide proper health services to all citizens. Convention No. 169 stipulates in Articles 24 and 25 that indigenous peoples must have equal access to social security schemes and health services, while these should take into account their speciic conditions and traditional practices. Where possible, governments should provide resources for such services to be designed and controlled by indigenous peoples themselves. Status of Scheduled Tribes compared to the rest of the national population in Key Health Indicators 1998-99, India 1 1 NFHS, 1998-99, quoted in Planning Commission, 2005, Table 2.11 HEALTH INDICTOR SCHEDULED TRIBES ALL DIffERENCE Infant Mortality Neo-natal mortality Child Mortality Under-5 mortality ANC check-up Institutional deliveries Women with anemia Children undernourished Weight for Age Full immunisation 84.2 53.3 46.3 126.6 56.5 17.1 64.9 55.9 26.4 67.6 43.4 29.3 94.9 65.4 33.6 51.8 47.0 42.0 24.5 22.8 58.0 33.4 13.6 49.1 25.2 18.7 37.1 1 4 7 x I . H E A LT H A N D S O C I A L S E C U R I T y ILO Convention No. 169: Article 24 Social security schemes shall be extended progressively to cover the peoples concerned, and applied without discrimination against them. Article 25 1. Governments shall ensure that adequate health services are made available to the peoples concerned, or shall provide them with resources to allow them to design and deliver such services under their own responsibility and control, so that they may enjoy the highest attainable standard of physical and mental health. 2. Health services shall, to the extent possible, be community-based. These services shall be planned and administered in cooperation with the peoples concerned and take into account their economic, geographic, social and cultural conditions as well as their traditional preventive care, healing practices and medicines. 3. The health care system shall give preference to the training and employment of local community health workers, and focus on primary health care while maintaining strong links with other levels of health care services. 4. The provision of such health services shall be co-ordinated with other social, economic and cultural measures in the country. The UN Declaration on the Rights of Indigenous Peoples has similar provisions: Article 211 Indigenous peoples have the right, without discrimination, to the improvement of their economic and social conditions, including, inter alia, in the areas of education, employment, vocational training and retraining, housing, sanitation, health and social security. Article 23 Indigenous peoples have the right to determine and develop priorities and strategies for exercising their right to development. In particular, indigenous peoples have the right to be actively involved in developing and determining health, housing and other economic and social programmes affecting them and, as far as possible, to administer such programmes through their own institutions. 1 4 8 I N D I G E N O U S T R I B A L P E O P L E S ’ R I G H T S I N P R A C T I C E – A G U I D E T O I L O C O N V E N T I O N N O . 1 6 9 Some of the operational implications of indigenous peoples’ rights to social security and health care are: Development of mechanisms for participation • at decision-making levels health and social security policies, programmes; Allocation of speciic resources in order • to overcome the wide disparities between indigenous peoples and other population groups; Focus on capacity building; training of • indigenous health workers and strengthening of indigenous institutions to ensure local ownership of health institutions and culturally appropriate approaches to health and social security services; Recognition of indigenous peoples’ intellectual • property rights to traditional knowledge and traditional medicines; Regular and systematic gathering of • disaggregated quality information to monitor the situation of indigenous peoples and the impact of policies and programmes; Formulation of a research agenda identifying • priorities, e.g. traditional healing practices and systems, mental health, substance abuse, links between land loss and poor health, the health impact of macro policies; Development of speciic approaches to • address indigenous women and children as they are in many cases seriously affected by bad health conditions. 6 The UN World Conference Against Racism, Racial Discrimination, Xenophobia and Related Intolerance, 2001 in its Programme of Actions has urged States to adopt action-oriented policies and plans, including afirmative action, to ensure equality, particularly in relation to access to social services such as housing, primary education and health care. 7 6 Tool Kit: Best Practices for Including indigenous peoples in sector programme support, Danida, 2004. 7 Report of the World Conference Against Racism, Racial Discrimination, Xenophobia and Related Intolerance, Durban, 2001.

11.2. PRACTICAL APPLICATION: HEALTH AND SOCIAL SECURITy

Nicaragaua: Decentralisation of the health system The Health Act states that the Ministry of Health MINSA is the governing body for the health sector in Nicaragua; however, in compliance with the guidelines of the 2008-2015 National Human Development Plan, MINSA is moving forward with the decentralisation process. As part of the process, in November 2008, MINSA signed a Framework Agreement on Coordination of the Regionalisation of Health Care in the Autonomous Regions of the Nicaraguan Caribbean coast. This agreement provides for the institutional implementation of the regionalisation of health care, delegating to the Regional Councils and Regional Autonomous Governments of the RAAN and RAAS the jurisdiction and responsibility for the autonomous organisation, direction, management and delivery of services, as well as management of the sector’s human, physical and inancial resources. The essence of this agreement is that the integration, development and strengthening of traditional and natural medicine will be directed regionally, so as to promote complementarity and integration of services and roles between the agents of natural and traditional medicine and Western medicine. Case prepared by Myrna Cunningham. Tanzania: Restocking through traditional social security system. The Danish-supported ERETO project in Tanzania addresses indigenous Maasai pastoralists in the Ngorongoro Conservation Area NCA. It aims to improve access to water for people and livestock, provide veterinary services and restock poor pastoral households. ERETO builds directly on the Maasai concept and measurement of poverty and on a clan-based mechanism for social security and redistribution of wealth, which is used as the key implementation mechanism for restocking. As heads of households, women play a key role in the restocking, which has so far beneited 3,400 households. It has reversed the trend of marginalisation and restored these households to pastoralism, which to them is more than just an economic system but is a heritage, spirituality and a determinant of identity. 1 4 9 x I . H E A LT H A N D S O C I A L S E C U R I T y Danida: Tool Kit: Best Practices for Including Indigenous Peoples in Sector Programme Support, 2004. Nepal: Creation of social security and afirmative action programmes There is broad political agreement that the existing inequality between indigenous peoples and dominant communities in Nepal needs to be addressed. Indigenous peoples in Nepal in general have lower wealth, educational achievement, health and political inluence than the national average. However, there is also signiicant diversity among the indigenous groups in Nepal. Some groups, such as the Thakali and the Newar, are actually above the national average in most statistics, while others, such as the Chepang or the Raute are severely marginalized. To deal with the large diversity and target support to those groups that need it most, the indigenous peoples’ umbrella organization, Nepal Federation of Indigenous Nationalities NEFFIN, independently started dividing indigenous peoples into ive categories, ranging from advantaged to endangered. Government and donors have since adopted this categorization also. The Ministry of Local Development, for example, started providing cash transfers to individuals from the highly marginalized and endangered indigenous groups in 2008. Some indigenous organizations are calling for generalized ethnic-based afirmative action to beneit all indigenous people. This is complicated somewhat by the very substantial socio-economic differences among the groups. While the ive categories are useful in differentiating the indigenous peoples, the system is based on neither objective criteria nor recurrent data collection. Therefore, some voices are now calling for a more dynamic system, in which afirmative action would be based on a regularly reviewed set of socio-economic criteria. Thus, disadvantaged indigenous groups would qualify based on their level of disadvantage, rather than on the basis of their status as indigenous people. However, these discussions are ongoing in the constitution-making process, and no comprehensive policy has yet been devised. Programme to Promote ILO Convention No. 169, project reports Nepal, 2008-9; Bennett, Lynn and Parajuli, Dilip 2007. Nepal Inclusion Index: Methodology, First Round Findings and Implications for Action. Draft paper. United States: Suicide prevention programs Suicide accounts for nearly one in ive deaths among Native American and Alaskan Native youths 15- 19 year olds; a considerably higher proportion of deaths than for any other ethnic groups within the United States. In fact, differences in suicide rates between Native American and Alaskan Native youths and other ethnic youths have been noted for over three decades. Suicide prevention programmes that are culturally appropriate and incorporate culturally speciic knowledge and traditions have been shown to be the most successful and well received by Native American and Alaskan Native indigenous communities. Such prevention programmes are largely successful because they incorporate positive messages regarding cultural heritage that increase the self-esteem and sense of mastery among Native American and Alaskan Native youths, and focus on protective factors in a culturally appropriate context. They also teach culturally relevant coping methods such as traditional ways of seeking social support. http:indigenousissuestoday.blogspot. com200802suicide-native-american-and-alaskan. html. Brazil: Enawene Nawe The Enawene Nawe are a small Amazonian indigenous people who live in the forests of Mato Grosso, Brazil. They were irst contacted in 1974, when they numbered only 97 individuals. Today their population is around 500. The Enawene Nawe have refused to get closer to the towns and hospitals because of the health problems and suffering they have experienced when they came in contact with the outsiders. They are also aware that they should not rely on outsiders for healthcare. Therefore, in addition to their herbalists, shamans and mastersingers, community members are receiving training in Western healthcare and medicines. The new specialists are called “Baraitalixi” or “little herbalists”. The training is conducted in the longhouses in their language and in the presence of everyone. The Baraitalixi,