Aida Ghazaryan

2003 International Policy Fellow

 

 

 

Original Research Proposal for the 2003-2004 International Policy Fellowships (IPF)

Policy Priorities in Public Health


"REPRODUCTIVE RIGHTS AND HEALTH

 IN ARMENIA"

Background

All persons have reproductive rights, which are based on principles of human dignity and equality and constitute fundamental human rights. Women have a unique role to play in human reproduction. Moreover, reproductive rights form a vital aspect of the women's empowerment agenda and are key to the achievement of gender equality.

The 1990s was a key decade in linking the provisions in existing human rights treaties and women's reproductive rights. Women’s reproductive health began to be viewed and monitored through the lens of human rights. Yet today, eight years from the United Nations International Conference on Population and Development (ICPD), the objectives of the Cairo Programme of Action are a long way from being realized.

Current Situation

Despite acknowledgement of prioritizating reproductive health, the application of human rights to reproductive health in Armenia is embryonic. The fall-down of the Soviet Union and transition period destroyed existing structure of health sector. The ongoing health care reform advances slowly and encounters serious difficulties both in terms of institutional changes and funding. The privatization, optimization and decentralization of the system, complicated social-economic situation and lack of stable health strategies have affected women’s health status, especially what regards the reproductive health. Moreover, reproductive rights lack from women's empowerment and policies/programs in Armenia.

Development of national policy in sexual and reproductive health (SRH) in Armenia started in 1994.  The first analysis on “Women’s Health Profile, Armenia, 1994” was published following the participation in World Health Organization (WHO) Conference in Vienna “Investments into Women’s Health”. Further after the Cairo Conference where Armenia presented its first national report on RH and demography, the Ministry of Health collegium approved the concept of launching a National Programme on Reproductive Health Improvement. Following the Beijing conference, with WHO and United Nations Population Fund (UNFPA) support the National Programme was designed with step-by-step of implementation of its components in Armenia and has been in execution since 1997.

Despite the positive developments, health services are not entirely consistent with women's human rights, including the rights to autonomy, privacy, confidentiality, informed consent, choice and other human rights principles.  

The situation with reproductive health, in particular, antenatal and perinatal care, in Armenia is alerting.
Among the priority needs are: to increase birth and growth rates, reduce high abortion rates, improve prenatal medical care, family planning services and prevent sexually transmitted infections (STIs)/HIV. Within the disproportionate burden of ill health certain population groups are at particular risk- adolescents, sex workers, refugees, migrants and other vulnerable groups.   

Reproductive health services do not meet the required standards because, inter alia:
-    Women in poverty cannot afford visiting RH service cabinets,
-    Insufficient budget allocations to health personnel,
-    Lack of minimum medical supplies and basic equipment,
-    Outdated and poor knowledge of medical personnel and the population on reproductive care and rights,
-    Inadequate education on reproduction, sexuality and rights;
-    Obstacles in introducing new concepts and approaches related to the overall mentality and traditional ideology on women’s status and reproductive health issues.

Armenia is a small country, however the situation of reproductive health and rights is even more deteriorated in regions- impoverished population, poorer conditions of maternal health facilities, shortage of basic medical equipment, less educated and experienced medical personnel, inadequate rapid emergency medical assistance, very low awareness level of population and traditional mentality on reproductive health and rights issues.  
Moreover, the border zone regions adjacent to Georgia, Azerbaijan and Turkey have many migrant workers, high incidence of STIs/HIV, prostitution and trafficking, which adds to the reproductive health concerns in the country and Caucasus.

The financing of reproductive health care represents a major area of concern, since it is heavily dependent on central budget transfers. The area in need of financial support among the maternal and child health care facilities is their renovation, procurement of necessary equipment and medication. The salaries of medical personnel are another concern affecting the quality of institutional operation, leading to the full dependence on patients’ payments and widespread corruption of health care system.
There are problems with women’s access to medical and family planning services because of financial reasons. Abortion and means of contraception are payable. Formally, delivery services are free, but in fact people very often have to pay for them. The system of state payment for poor population groups has not justified itself. On the other hand, the hospitals are unable to deliver services properly because of insufficient medical equipment. The situation is even worse for women from rural areas.  

Furthermore, determination, substantiation and significance of priorities in Armenia in the sphere of health care greatly depend on the political situation. The Ministry of Health is on a relatively low level in the political hierarchy and thus reforms in the health care and enforcement of fundamental human rights are not paid adequate attention.
Currently, the major efforts of the Government are aimed at focusing external assistance on maternal and child health (MCH) field- WHO, UNFPA, UNICEF, WB, USAID, MSF, UNAIDS, AFHA and other international NGOs.

Key Issues

•     The lack of awareness is one of the main obstacles preventing women from fully enjoying their rights. In Armenia while women are more or less informed on family planning issues given the incorporation of that component into external assistance programs, these projects inadequately or hardly ever cover the aspect of reproductive rights.
•    Human rights education incorporated recently in the school programs in Armenia does not include reproductive rights. Due to cultural and ideological beliefs supported by policy environment, the girls remain uninformed and untaught on how to make free and informed decisions concerning reproduction and sexuality. Recently the use of various technologies, including electronic media, Internet and television, enhanced dissemination of information and increased the awareness of the public about SRH issues and services.
•    Women’s equality The hardships of post-independence years and the consequences of transition to a market economy significantly affected the gender structure of the Armenian society and had a negative impact on the status of women, their role and standing in society.  
•     Another interrelated issue is domestic violence against women. The number is likely higher than indicated by the statistics. All cases are not reported to the police because of mentality, cultural traditions, financial dependence from spouse and still appears to be a subject of taboo. Embarrassment and concerns for family honor make the problem particularly sensitive and difficult to quantify.  
•     As for human rights guarantees in Armenia, the Constitution and certain laws include them but in fact women cannot exercise fundamental human rights and health related rights, including reproductive rights. Yet protection of human rights, informed decision-making and confidentiality may all have a bearing on health care. Following the independence in 1991 Armenia has taken many steps towards building a democratic and civil society, however it still faces challenges in human rights protection. Especially that now Armenia acceded to the Council of Europe and signed the European Convention on Human Rights it will have to fulfill the obligations from membership to the European structure.  
•     Armenian legislation permits induced abortion, pregnancy, childbirth planning, receiving information and usage of any contraceptives, however there is a lack appropriate enforcement mechanisms. Economic, political, ideological and institutional factors in their turn hamper the exercise of the reproductive rights. In existing legislative statutes and acts the stipulated rights and national norms are introduced with the main emphasis on standards and not the legitimate rights, which means that the success of such provisions will depend upon the quality of mechanisms and procedures.  
•     Despite some positive changes in respect of knowledge and use of modern contraceptive methods, abortion remains the most popular method of fertility regulation. In addition, a number of family planning and reproductive health programmes by international organizations have encountered obstacles and constraints to implementation and have been challenged in Armenia. For example, in 1995-1997 big uproar was raised against family planning cabinets and their advertisements on national television.
•     There is a need for capacity building and generation of knowledge. The training of the medical personnel on reproductive choice and rights is an essential element in strategies to improve reproductive health care and foster rights promotion.

Purpose

The goal of this Project is to explore the issue of reproductive rights and human rights related to reproductive health, to evaluate the current situation with reproductive health and rights in Armenia with consideration of internationally recognized human rights; to contribute to the discourse of the reproductive rights promotion and improvement in Armenia; to increase the knowledge of professionals and society at large on the reproductive rights as well as to provide policy recommendations for relevant policy-makers and agencies.

Objectives 

 

The objectives of the project under the following units are:

International Human Rights: Reproductive Rights  
-    Examination of the basic legal concepts of reproductive rights, human rights aspects of reproduction and reproductive technologies, women’s rights in clinical interaction, overview of human rights applicable to the reproductive health;
-    Overview of chronological developments of reproductive rights on international agenda;
-    Outline and analysis of experience of other countries that have taken measures in promoting reproductive rights (inter alia, legislation, policies, practices, advocacy, etc.);
-    Reveal the ways reproductive rights are violated and show best practices in policymaking and advocacy, considering policy implications of the 1994 UN Cairo Program for Action, 1995 Fourth World Conference on Women in Beijing, the 1999 follow-up Cairo + 5 and Beijing + 5 in 2000.

Case Study: Armenia
-    Analysis of the present situation of reproductive health and human rights protection in Armenia in general and reproductive rights, in particular;
-    Overview of the existing Armenian legislation, policies and regulations relevant to reproductive health and rights in the light of international human rights principles;
-    Review the current status of the national school health and human rights education policies and programs;
-    Assessment of awareness among clinicians engaged in reproductive health services delivery on the reproductive rights;
-    Investigate in- and out-patient women’s attitudes and beliefs regarding reproductive rights;
-    Identification of obstacles to reproductive rights protection according to the key policy-makers  and clinicians;  
-    Outline of social, economic, political and cultural barriers in enforcement of reproductive rights.

Policy Recommendations

The comprehensive analysis and findings will form a basis for recommendations and policy measures with the consideration of the local particularities.   

-    Development of enforceable effective legislation solving the above-specified key problems and strategies ensuring the exercising of internationally endorsed reproductive rights;
-    Increasing the awareness of professionals and general population on reproductive health and related rights;
-    Ensuring that the concept of reproductive rights is included in health education programs and school human rights courses;
-    Strengthen the machinery at domestic level for the enjoyment and advancement of women’s reproductive rights;
-    Advancing the active collaboration of governmental agencies, non-governmental organizations and human rights activists in promoting the protection of women’s reproductive and sexual health rights.
-    Integrate the perspective of women's human rights and gender equality into ongoing policy-making and reproductive health initiatives and projects.

Methodology

To ensure qualified policy recommendations the proposed project will use:

* A detailed analysis via multiple printed and on-line resources (library database, IRTEK- database of Armenian legislation, Internet, official reports of governmental and non-governmental agencies, governmental documents, internal memoranda, statistical reports, press releases, and other research resources) as well as communication with professionals and materials obtained from attending training programs, conferences, seminars or other professional activities.
* In-depth survey on the perceptions of reproductive rights among women through questionnaires and personal interviews with the stakeholders, including (1) in- and outpatient women; (2) medical personnel from maternal health facilities/women’s consultancies; (3) public officials; and (3) activists of relevant local and international organizations.
*  Investigation of the available previous and current projects and sociological surveys on reproductive health and rights.

Significance and Dissemination of Results

Based on the findings of the empirical research it is planned:

1.    To prepare and publish a White Paper on the reproductive rights and health in Armenia and present  it to the key policy makers, representatives of the related ministries, local and international organizations;
2.    To develop and publish a compilation of human rights documents, legislation relating to reproductive and sexual health and, considering accession of Armenia to Council of Europe, the case-law selected from the work of treaty bodies and court within the European Human Rights System to assist the further research on this topic;
3.    To organize a series of round tables and seminars on reproductive rights for reproductive health community representatives;
4.   To prepare a handbook  “Reproductive Rights” for distribution to primary maternal health facilities and relevant governmental and non-governmental agencies;
5.    To prepare a set of short newspaper articles for the Armenian press articles in newspapers, and cover the issue via other mass media broadcast activities;
6.    To post a shorter version of the policy-paper with practical recommendations on the OSI home page.

 
PRELIMINARY BIBLIOGRAPHY

Case Law

1.    Roe v. Wade, 410 U.S. 113 (1973)
2.    D. v. Berkshire County Council (1987)
3.    Davis v. Davis (Ellen Alderman, Caroline Kennedy: The Rights to Privacy Vintage 1997)
4.    In the Matter of Baby M., 537 A.2d 1227 (N.J.1988)
5.    Kelly v. Kelly (1997)
6.    Paton v. BPAS (1979)

Books, Articles and Reports

7.    Eugene B. Brody, Human Rights Aspects of Reproductive Technology, in: Eugene B. Brody, Biomedical Technology and Human Rights, Dartmouth, UNESCO Publishing, ISSC, WFMH, 1993
8.    Ewa Letwska, Liberal concept of human rights in Central and Eastern Europe, Institute of Public Affairs, Center for Constitutionalism and Legal Culture, Warszawa 1998
9.    Freeman, M.D.A., Responding to the Reproduction Revolution: Law Reform- Dilemmas and Difficulties in McLean, S.A.M. (ed.); Law Reform and Human Reproduction, Dartmouth, 1992.
10.    H.J.J. Leenen, J.K. M. Gevers, G. Pinet, The Rights of Patients in Europe: A Comparative Study, Kluwer Law and Taxation Publishers, Deventer, Boston, 1993
11.    J.K. Mason, R.A. McCall Smith, G.T. Laurie, Law and Medical Ethics, Butterworths, London, 1999
12.    Jonathan Montgomery, Health Care Law, Oxford University Press, 1997
13.    Lockwood, M., “When does a life begin?” in Lockwood, M. (ed); Moral Dilemmas in Modern Medicine, Oxford: Oxford University Press, 1985
14.    Maria E. Sokalska, Changes in Health Law in Central and Eastern Europe, EUROPEAN JOURNAL OF HEALTH LAW 1, Kluwer Academic Publishers, Netherlands, 1994
15.    McLachlan, H.V., Bodies, Rights and Abortion, (1997) 23 Journal of Medical Ethics
16.    National Program of Reproductive Health Improvement, Perinatal Medical Aid Program, 2000-2005, Ministry of Health of Republic of Armenia, Department of Mother and Child Health Protection, Center of Perinatology, Obstetrics and Gynecology, Yerevan 1999
17.    Oddens B.J., Vemer H.M., Everaerd W.TH.A.M., Towards a better understanding of contraceptive practice in Western countries: characterization of contraception users, 1991
18.    R.B. Saltman & J. Figeyras, Reformi Sistemi Zdravokhranenia  v Evrope, Analiz Sovremennikh Strategiy (European Health Care Reforms: Analysis of Current Strategies), World Health Organization Regional Office for Europe, 'Geotar Medicine', Moscow, 2000
19.    Rebecca Wallace, International Human Rights, Sweet & Maxwell, 1997
20.    Shaw, M. Conditional Prospective Rights of the Fetus, (1984) 5 Journal of Legal Medicine
21.    T.Kh. Tulchinsky & E.A. Varavikova, Novoe Obshestvennoe Zdravokhranenie, Vvedenie v Sovremenuju Nauku, (The New Public Health, Introduction), Hemed Press, Jerusalem, 1999
22.    The Szeged Declaration. Assessment of Research and Service Needs on Reproductive Health in Eastern Europe-concerns and commitments, Human Reproduction, Vol. 9, No. 4, 1994
23.    Tido von Schoen-Angerer, STD-HIV Harm Reduction in the Bagratashen/Sadakhlo Cross Border Trading Market, Report, Medicins Sans Frontieres (MSF)- Belgium in Armenia, January 2001
24.    Vanderhoeven, Robert Rowies, General Assessment on Reproductive Health Care in Berd Region, Internal Report, Medicins Sans Frontieres (MSF)- Belgium in Armenia, June 2001

International Instruments and Publications

25.    Beijing Declaration and the Platform for Action, Fourth World Conference on Women, UN Doc. A/CONF.177/20 (1996), Beijing, China, September 4-15 1995  
26.    Country Reports on Human Rights Practices- 2001, Released by the Bureau of Democracy, Human Rights, and Labor March 4, 2002, URL: http://www.state.gov/g/drl/rls/hrrpt/2001/eur/8221.htm.
27.    Human Rights- A Compilation of International Instruments, United Nations Publication, Sales No. E.88XIV.1, 1988
28.    Panos Briefing No 32, WOMEN'S HEALTH, Using Human Rights to Gain Reproductive Rights,
December 1998
29.    Programme of Action of the International Conference on Population and Development, UN Doc. A/CONF.171/13/Rev.1, U.N. Sales No. 95. XIII.18 (1995), Cairo, Egypt, September 5-13, 1994  
30.    Vienna Declaration and Programme of Action, World Conference on Human Rights, UN Doc. A/CONF.157/23 (1993), Vienna, Austria, June 14-25, 1993
31.    World Health Organization, WHO Regional Strategy on Sexual and Reproductive Health, Reproductive Health/Pregnancy Programme, Copenhagen, Denmark, EUR/01/5022130, uned., November 2001

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