Testing the OPERA framework to monitor the right to health in Uganda

Universal health coverage - which means access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines - is the cornerstone of the United Nations Sustainable Development Goal on health, which governments committed to achieve by 2030. For the World Health Organisation, universal health coverage is a practical expression of the human right to health. The right to health can help civil society organisations hold their governments accountable for advancing universal health coverage. However, human rights law and explanations of human rights law are often formulated in a language that is difficult for people without legal training to understand. Furthermore, the right to health applies to all countries of the world - from the wealthiest to the poorest - and is therefore not specifically geared towards any particular country context. These two challenges make it especially difficult for people in developing countries to push their government to roll out universal health coverage which is essential for the right to health.

The Center for Economic and Social Rights developed a tool - the OPERA framework - to help civil society organisations 'break open' human rights, by giving concrete advice on how to claim human rights more effectively. Applying the OPERA framework can help civil society organisations develop specific demands or monitor government policy (for example, the government's health budget or health workforce plan) to ensure the government complies with its human rights obligations. However, to be useful it needs to be adapted to local conditions as each country has its own human rights challenges. As a low-income country in Africa, Uganda faces particular challenges: the government budget for healthcare is only about £10 per person per year; there is a shortage of health workers; the poorest people living in rural areas benefit much less from health services than wealthier people living in the cities.

In this project, UK based researchers will work with Ugandan civil society organisations so that they can to use the OPERA framework to monitor the government's policy and activities related to universal health coverage in Uganda. This two-year project will examine the introduction of one framework aimed to support advocacy and monitoring of human rights for health, the OPERA framework. Introducing this framework through a participatory method, we will rigorously assess how CSOs take up, use and adapt health based rights for Universal Health Coverage.

Civil society organisations can continue to use, and modify, this Uganda specific OPERA framework to ensure that the Ugandan government respects its health rights commitments by continuing its efforts on universal health coverage. By working together this project will allow Ugandan civil society and UK researchers to use their combined knowledge to improve advocacy and monitoring of progress towards universal health coverage for Ugandans. Finally, we hope that the lessons learned while conducting this project can be adapted to other low-income countries in Africa. We will invite civil society organisations from other low-income countries in Africa to our end of year one meeting to explore opportunities for future co-operation. We are optimistic that this will lead to the spread of OPERA framework based monitoring and advocacy for advancing universal health coverage.

The OPERA framework, constructed by the Center for Economic and Social Rights, was developed to help civil society organisations (CSOs) advocating for human rights 'entitlements' (as different from 'freedoms'), by encouraging them to look beyond outcomes, to policy efforts and resource allocation within a proper assessment of the context. For health, that means looking beyond the problems of access to health care, to the policies and resource constraints that result in health systems producing unequal or insufficient access to health care. We will combine OPERA with participatory action research (PAR) to provide a methodology through which entitlement based advocacy for universal health coverage (UHC) can be realised.

The theoretical framework of this research begins with international norm dynamics, which draws on international law, international relations, sociology and political science. One element of international norm dynamics is internalisation, which studies how and why national governments comply with international norms (or not). Localisation of human rights is a form of internalisation, "making human rights more locally relevant by interpreting existing global norms in light of needs identified by community organisations" (De Feyter K (2006) Localizing Human Rights). This project responds to the need to combine disciplinary approaches to take account of the complexity of the intersections between health and human rights as they are localised. Combining anthropological theory with law, it conceptualises human rights as a global assemblage; the rationalities, forms of organisation, politics and philosophy, expertise and physical environments that combine as actors to analyse social problems and devise strategies to act upon them. Over a two year period, we will follow the debates and action by CSOs trained in OPERA + PAR to assess its impact. We will map, describe and theorise how it supports a process of human rights localisation and with what effect.

To explain the expected impact of this project, we need to explain, first, the difference between human rights 'freedoms' and human rights 'entitlements'. Freedoms are also known as negative rights, because the corresponding obligations for the government are predominantly negative: to not imprison a person for expressing their opinion. Therefore, when a human rights freedom is violated, it is fairly straightforward to identify the authorities that are responsible, and most advocacy will focus on these authorities. Entitlements are known as positive rights, because the corresponding obligations are positive: to provide health care, for example. The provision of health care, however, is the result of a long chain of political decisions, including decisions about taxation and government revenue, about health insurance, about stewardship of private providers, about training of health workers and their work conditions, about purchasing and distributing medicines. When the right to health is violated, many authorities are responsible. Therefore, focusing on the most visible part of the violations of the right to health (the person who did not receive the health care she or he needed and was entitled to) may be ineffective and at times even counter-productive. The OPERA framework will encourage civil society organisation (CSOs) to look beyond Outcomes and examine the political decisions that shape Policy Efforts and Resources, within a broad Assessment of the health system in the context of Uganda.

A crucial element of both the OPERA framework and the participatory action research (PAR) methodology is that the participants (in this case, the CSOs), take the lead. It is therefore not possible to predict the issues they will identify. Nevertheless, we expect that the project will:
* Unite CSOs with different priorities around a shared assessment of the structural challenges (policies and resources (or lack thereof);
* Encourage cooperation between CSOs, sharing the workload of assessment;
* Unite CSOs with different priorities around a common advocacy agenda, addressing systemic weaknesses of the health system rather than focusing on problematic outcomes;
* Encourage cooperation between CSOs, deciding together on a common advocacy agenda;
* Unite CSOs with different priorities around a common monitoring agenda, following up progress (or lack thereof) in the issues they have selected;
* Encourage cooperation between CSOs, sharing the workload and the findings of continued monitoring.
Thus we expect that civil society advocacy for health in Uganda will become more effective, lead to more effective policies and increasing public resources.

At the third workshop, the project will invite leading CSOs from 3 other LICs in Africa, to share the experience, and to prepare a multi-country project, which would allow for the development of 4 tailor-made versions of the OPERA framework and a 'blueprint' that would be useful in most LICs.