Rights or privileges? Fiscal commitment to the rights to health, education and food in Guatemala (2009)

Topic: An investigation into child malnutrition, maternal mortality and low primary school completion—and the particular role of tax and budget policies in addressing these deprivations.

Monitoring techniques used: This report, published by CESR and ICEFI in 2009, adopts CESR's OPERA Framework. So called because it triangulates evidence gathered on Outcomes, Policy Efforts and Resources before making an overall Assessment, this assessment framework articulates the relevant human rights standards and principles to take into account when monitoring ESCR fulfillment, clustering them around these four key dimensions. It also offers practical guidance on which tools and techniques might be employed to evaluate them. To carry out the analysis under each step of the framework, the study adopted a multidisciplinary approach which combined a range of research techniques drawn from the fields of human rights law, public policy analysis and development economics that were quantitative as well as qualitative.  In particular, it incorporated:

• simple, descriptive statistics and data that were not overly complex or technical judged against indicators developed by the UN and regional human rights bodies;
• key informant interviews with experts from relevant fields such as public heath, who shared the standards and guidelines that could give greater meaning to binding human rights standards;
• techniques of budget analysis to interpret the state’s fiscal policy;
• consultations and testimony with indigenous communities. 

Summary of findings:

• Outcomes: Analyzed the maternal mortality ratio. Found that Guatemala had among the worst and most unequal maternal mortality in Latin America, with indigenous women three times more likely to die than non-indigenous women. Over 50% of deaths were caused by post-partum hemorrhaging; largely preventable with skilled care.
• Policy efforts: Identified indicators to evaluate services such as emergency obstetric care, skilled birth attendants and family planning services; combined with personal testimony from service users.  Found that despite a strong legal and policy framework, basic emergency obstetric care were well below WHO/UNFPA guidelines. Guatemala, a middle income country, had the same proportion of births attended by skilled personnel as Sierra Leone, one of the world’s poorest.
• Resources: Analyzed budgetary information obtained from the Ministry of Finance. Found investment in the health sector had remained around 1% of GDP since the end of the war in 1996. Per capita health spending was three times higher in the capital than the poorest region. Low social spending directly linked to the low tax base, which was mostly generated through regressive indirect taxes that disproportionately affect the poor.
• Assessment: Adopted a qualitative approach to identifying contextual factors. Found that the lack of adequate investment in the realization of economic and social rights resulted not simply from the state’s incapacity or inefficiency in gathering and reassigning public resources, but from a historical co-option of the state by elites huge economic power and influence in politics, which had resulted in weak regulatory structures and an economic context hostile to reform. Concluded Guatemala was not doing all it reasonably could to generate the resources available to improve maternal health, in effect discriminating against poorer, indigenous women.

Advocacy and Impact: Framing maternal mortality as a human rights issue, and linking it explicitly to fiscal policy, gave renewed force to ICEFI’s demands for both health and fiscal reform. The government welcomed the findings and pledged to introduce progressive tax and budget reforms, but these were thwarted following opposition from conservative business sectors. Nevertheless, the approach taken in the report was embraced by other bodies, including the Observatorio de Salud Reproductiva (Reproductive Health Observatory, OSAR), a network of 21 supervisory bodies set up by Congress in association with civil society organizations that monitor maternal health at the departmental level. Members of Congress linked to OSAR presented a new maternal health law, which was adopted in September 2010. The law affirms the right to health without discrimination and prioritizes efforts to reduce maternal mortality among rural, indigenous women. Importantly, it mandates that necessary resources be provided, including through earmarked funding for reproductive health generated by specific direct taxes.

Competing issues on the political agenda have slowed progress in the implementation of the 2010 law, and OSAR has had to focus much of its energy on awareness raising in response. In particular, the comprehensive fiscal reforms that would enable the government to adequately invest in maternal health are still needed; ICEFI has continued its advocacy efforts to this end. The transformative effective of the collaboration with CESR can be seen in their uptake of human rights arguments in their work. Prior to the project, ICEFI didn’t identify itself as a human rights organization and now it very much does.