| General
Recommendation No. 24 - Women and Health (Article 12)
(Twentieth session, 1999)
1. The Committee
on the Elimination of Discrimination against Women, affirming that
access to health care, including reproductive health, is a basic
right under the Convention on the Elimination of All Forms of Discrimination
against Women, decided at its twentieth session, pursuant to article
21, to elaborate a general recommendation on article 12 of the Convention.
Background
2. States parties' compliance with article 12 of the Convention
is central to the health and well-being of women. It requires States
to eliminate discrimination against women in their access to health-care
services throughout the life cycle, particularly in the areas of
family planning, pregnancy and confinement and during the post-natal
period. The examination of reports submitted by States parties pursuant
to article 18 of the Convention demonstrates that women's health
is an issue that is recognized as a central concern in promoting
the health and well-being of women. For the benefit of States parties
and those who have a particular interest in and concern with the
issues surrounding women's health, the present general recommendation
seeks to elaborate the Committee's understanding of article 12 and
to address measures to eliminate discrimination in order to realize
the right of women to the highest attainable standard of health.
3. Recent United
Nations world conferences have also considered these objectives.
In preparing this general recommendation, the Committee has taken
into account relevant programmes of action adopted at United Nations
world conferences and, in particular, those of the 1993 World Conference
on Human Rights, the 1994 International Conference on Population
and Development and the 1995 Fourth World Conference on Women. The
Committee has also noted the work of the World Health Organization
(WHO), the United Nations Population Fund (UNFPA) and other United
Nations bodies. It has collaborated with a large number of non-governmental
organizations with a special expertise in women's health in preparing
this general recommendation.
4. The Committee
notes the emphasis that other United Nations instruments place on
the right to health and to the conditions that enable good health
to be achieved. Among such instruments are the Universal Declaration
of Human Rights, the International Covenant on Economic, Social
and Cultural Rights, the International Covenant on Civil and Political
Rights, the Convention on the Rights of the Child and the Convention
on the Elimination of All Forms of Racial Discrimination.
5. The Committee
refers also to its earlier general recommendations on female circumcision,
human immunodeficiency virus/acquired immunodeficiency syndrome
(HIV/AIDS), disabled women, violence against women and equality
in family relations, all of which refer to issues that are integral
to full compliance with article 12 of the Convention.
6. While biological
differences between women and men may lead to differences in health
status, there are societal factors that are determinative of the
health status of women and men and can vary among women themselves.
For that reason, special attention should be given to the health
needs and rights of women belonging to vulnerable and disadvantaged
groups, such as migrant women, refugee and internally displaced
women, the girl child and older women, women in prostitution, indigenous
women and women with physical or mental disabilities.
7. The Committee
notes that the full realization of women's right to health can be
achieved only when States parties fulfil their obligation to respect,
protect and promote women's fundamental human right to nutritional
well-being throughout their lifespan by means of a food supply that
is safe, nutritious and adapted to local conditions. To this end,
States parties should take steps to facilitate physical and economic
access to productive resources, especially for rural women, and
to otherwise ensure that the special nutritional needs of all women
within their jurisdiction are met.
Article 12
8. Article 12 reads as follows:
"1. States parties shall take all appropriate measures to eliminate
discrimination against women in the field of health care in order
to ensure, on a basis of equality of men and women, access to health-care
services, including those related to family planning.
"2. Notwithstanding the provisions of paragraph 1 of this article,
States parties shall ensure to women appropriate services in connection
with pregnancy, confinement and the post-natal period, granting
free services where necessary, as well as adequate nutrition during
pregnancy and lactation."
States parties are encouraged to address the issue of women's health
throughout the woman's lifespan. For the purposes of the present
general recommendation, therefore, "women" includes girls
and adolescents. The general recommendation will set out the Committee's
analysis of the key elements of article 12.
Key elements
Article 12
(1)
9. States parties are in the best position to report on the most
critical health issues affecting women in that country. Therefore,
in order to enable the Committee to evaluate whether measures to
eliminate discrimination against women in the field of health care
are appropriate, States parties must report on their health legislation,
plans and policies for women with reliable data disaggregated by
sex on the incidence and severity of diseases and conditions hazardous
to women's health and nutrition and on the availability and cost-effectiveness
of preventive and curative measures. Reports to the Committee must
demonstrate that health legislation, plans and policies are based
on scientific and ethical research and assessment of the health
status and needs of women in that country and take into account
any ethnic, regional or community variations or practices based
on religion, tradition or culture.
10. States parties
are encouraged to include in their reports information on diseases,
health conditions and conditions hazardous to health that affect
women or certain groups of women differently from men, as well as
information on possible intervention in this regard.
11. Measures
to eliminate discrimination against women are considered to be inappropriate
if a health-care system lacks services to prevent, detect and treat
illnesses specific to women. It is discriminatory for a State party
to refuse to provide legally for the performance of certain reproductive
health services for women. For instance, if health service providers
refuse to perform such services based on conscientious objection,
measures should be introduced to ensure that women are referred
to alternative health providers.
12. States parties
should report on their understanding of how policies and measures
on health care address the health rights of women from the perspective
of women's needs and interests and how it addresses distinctive
features and factors that differ for women in comparison to men,
such as:
(a) Biological
factors that differ for women in comparison with men, such as
their menstrual cycle, their reproductive function and menopause.
Another example is the higher risk of exposure to sexually transmitted
diseases that women face;
(b) Socio-economic
factors that vary for women in general and some groups of women
in particular. For example, unequal power relationships between
women and men in the home and workplace may negatively affect
women's nutrition and health. They may also be exposed to different
forms of violence which can affect their health. Girl children
and adolescent girls are often vulnerable to sexual abuse by older
men and family members, placing them at risk of physical and psychological
harm and unwanted and early pregnancy. Some cultural or traditional
practices such as female genital mutilation also carry a high
risk of death and disability;
(c) Psychosocial
factors that vary between women and men include depression in
general and post-partum depression in particular as well as other
psychological conditions, such as those that lead to eating disorders
such as anorexia and bulimia;
(d) While
lack of respect for the confidentiality of patients will affect
both men and women, it may deter women from seeking advice and
treatment and thereby adversely affect their health and well-being.
Women will be less willing, for that reason, to seek medical care
for diseases of the genital tract, for contraception or for incomplete
abortion and in cases where they have suffered sexual or physical
violence.
13. The duty
of States parties to ensure, on a basis of equality of men and women,
access to health-care services, information and education implies
an obligation to respect, protect and fulfil women's rights to health
care. States parties have the responsibility to ensure that legislation
and executive action and policy comply with these three obligations.
They must also put in place a system that ensures effective judicial
action. Failure to do so will constitute a violation of article
12.
14. The obligation
to respect rights requires States parties to refrain from obstructing
action taken by women in pursuit of their health goals. States parties
should report on how public and private health-care providers meet
their duties to respect women's rights to have access to health
care. For example, States parties should not restrict women's access
to health services or to the clinics that provide those services
on the ground that women do not have the authorization of husbands,
partners, parents or health authorities, because they are unmarried
[11] or because they are women. Other barriers to women's access
to appropriate health care include laws that criminalize medical
procedures only needed by women punish women who undergo those procedures.
15. The obligation
to protect rights relating to women's health requires States parties,
their agents and officials to take action to prevent and impose
sanctions for violations of rights by private persons and organizations.
Since gender-based violence is a critical health issue for women,
States parties should ensure:
(a) The enactment and effective enforcement of laws and the formulation
of policies, including health-care protocols and hospital procedures
to address violence against women and sexual abuse of girl children
and the provision of appropriate health services;
(b) Gender-sensitive training to enable health-care workers to detect
and manage the health consequences of gender-based violence;
(c) Fair and protective procedures for hearing complaints and imposing
appropriate sanctions on health-care professionals guilty of sexual
abuse of women patients;
(d) The enactment and effective enforcement of laws that prohibit
female genital mutilation and marriage of girl children.
16. States parties
should ensure that adequate protection and health services, including
trauma treatment and counselling, are provided for women in especially
difficult circumstances, such as those trapped in situations of
armed conflict and women refugees.
17. The duty
to fulfil rights places an obligation on States parties to take
appropriate legislative, judicial, administrative, budgetary, economic
and other measures to the maximum extent of their available resources
to ensure that women realize their rights to health care. Studies
such as those that emphasize the high maternal mortality and morbidity
rates worldwide and the large numbers of couples who would like
to limit their family size but lack access to or do not use any
form of contraception provide an important indication for States
parties of Possible breaches of their duties to ensure women's access
to health care. The Committee asks States parties to report on what
they have done to address the magnitude of women's ill-health, in
particular when it arises from preventable conditions, such as tuberculosis
and HIV/AIDS. The Committee is concerned about the evidence that
States are relinquishing these obligations as they transfer State
health functions to private agencies. States and parties cannot
absolve themselves of responsibility in these areas by delegating
or transferring these powers to private sector agencies. States
parties should therefore report on what they have done to organize
governmental processes and all structures through which public power
is exercised to promote and protect women's health. They should
include information on positive measures taken to curb violations
of women's rights by third parties and to protect their health and
the measures they have taken to ensure the provision of such services.
18. The issues
of HIV/AIDS and other sexually transmitted diseases are central
to the rights of women and adolescent girls to sexual health. Adolescent
girls and women in many countries lack adequate access to information
and services necessary to ensure sexual health. As a consequence
of unequal power relations based on gender, women and adolescent
girls are often unable to refuse sex or insist on safe and responsible
sex practices. Harmful traditional practices, such as female genital
mutilation, polygamy, as well as marital rape, may also expose girls
and women to the risk of contracting HIV/AIDS and other sexually
transmitted diseases. Women in prostitution are also particularly
vulnerable to these diseases. States parties should ensure, without
prejudice or discrimination, the right to sexual health information,
education and services for all women and girls, including those
who have been trafficked, even if they are not legally resident
in the country. In particular, States parties should ensure the
rights of female and male adolescents to sexual and reproductive
health education by properly trained personnel in specially designed
programmes that respect their right to privacy and confidentiality.
19. In their
reports, States parties should identify the test by which they assess
whether women have access to health care on a basis of equality
of men and women in order to demonstrate compliance with article
12. In applying these tests, States parties should bear in mind
the provisions of article 1 of the Convention. Reports should therefore
include comments on the impact that health policies, procedures,
laws and protocols have on women when compared with men.
20. Women have
the right to be fully informed, by properly trained personnel, of
their options in agreeing to treatment or research, including likely
benefits and potential adverse effects of proposed procedures and
available alternatives.
21. States parties
should report on measures taken to eliminate barriers that women
face in access to health-care services and what measures they have
taken to ensure women timely and affordable access to such services.
Barriers include requirements or conditions that prejudice women's
access, such as high fees for health-care services, the requirement
for preliminary authorization by spouse, parent or hospital authorities,
distance from health facilities and the absence of convenient and
affordable public transport.
22. States parties
should also report on measures taken to ensure access to quality
health-care services, for example, by making them acceptable to
women. Acceptable services are those that are delivered in a way
that ensures that a woman gives her fully informed consent, respects
her dignity, guarantees her confidentiality and is sensitive to
her needs and perspectives. States parties should not permit forms
of coercion, such as non-consensual sterilization, mandatory testing
for sexually transmitted diseases or mandatory pregnancy testing
as a condition of employment that violate women's rights to informed
consent and dignity.
23. In their
reports, States parties should state what measures they have taken
to ensure timely access to the range of services that are related
to family planning, in particular, and to sexual and reproductive
health in general. Particular attention should be paid to the health
education of adolescents, including information and counselling
on all methods of family planning.[12]
24. The Committee
is concerned about the conditions of health-care services for older
women, not only because women often live longer than men and are
more likely than men to suffer from disabling and degenerative chronic
diseases, such as osteoporosis and dementia, but because they often
have the responsibility for their ageing spouses. Therefore, States
parties should take appropriate measures to ensure the access of
older women to health services that address the handicaps and disabilities
associated with ageing.
25. Women with
disabilities, of all ages, often have difficulty with physical access
to health services. Women with mental disabilities are particularly
vulnerable, while there is limited understanding, in general, of
the broad range of risks to mental health to which women are disproportionately
susceptible as a result of gender discrimination, violence, poverty,
armed conflict, dislocation and other forms of social deprivation.
States parties should take appropriate measures to ensure that health
services are sensitive to the needs of women with disabilities and
are respectful of their human rights and dignity.
Article 12
(2)
26. Reports should also include what measures States parties have
taken to ensure women appropriate services in connection with pregnancy,
confinement and the post-natal period. Information on the rates
at which these measures have reduced maternal mortality and morbidity
in their countries, in general, and in vulnerable groups, regions
and communities, in particular, should also be included.
27. States parties
should include in their reports how they supply free services where
necessary to ensure safe pregnancies, childbirth and post-partum
periods for women. Many women are at risk of death or disability
from pregnancy-related causes because they lack the funds to obtain
or access the necessary services, which include antenatal, maternity
and post-natal services. The Committee notes that it is the duty
of States parties to ensure women's right to safe motherhood and
emergency obstetric services and they should allocate to these services
the maximum extent of available resources.
Other relevant
articles in the Convention
28. When reporting on measures taken to comply with article 12,
States parties are urged to recognize its interconnection with other
articles in the Convention that have a bearing on women's health.
Those articles include article 5 (b), which requires States parties
to ensure that family education includes a proper understanding
of maternity as a social function; article 10, which requires States
parties to ensure equal access to education, thus enabling women
to access health care more readily and reducing female student drop-out
rates, which are often a result of premature pregnancy; article
10 (h), which requires that States parties provide to women and
girls access to specific educational information to help ensure
the health and well-being of families, including information and
advice on family planning; article 11, which is concerned, in part,
with the protection of women's health and safety in working conditions,
including the safeguarding of the reproductive function, special
protection from harmful types of work during pregnancy and with
the provision of paid maternity leave; article 14, paragraph 2 (b),
which requires States parties to ensure access for rural women to
adequate health-care facilities, including information, counselling
and services in family planning, and (h), which obliges States parties
to take all appropriate measures to ensure adequate living conditions,
particularly housing, sanitation, electricity and water supply,
transport and communications, all of which are critical for the
prevention of disease and the promotion of good health care; and
article 16, paragraph 1 (e), which requires States parties to ensure
that women have the same rights as men to decide freely and responsibly
on the number and spacing of their children and to have access to
the information, education and means to enable them to exercise
those rights. Article 16, paragraph 2 proscribes the betrothal and
marriage of children, an important factor in preventing the physical
and emotional harm which arise from early childbirth.
Recommendations
for government action
29. States parties
should implement a comprehensive national strategy to promote women's
health throughout their lifespan. This will include interventions
aimed at both the prevention and treatment of diseases and conditions
affecting women, as well as responding to violence against women,
and will ensure universal access for all women to a full range of
high-quality and affordable health care, including sexual and reproductive
health services.
30. States parties
should allocate adequate budgetary, human and administrative resources
to ensure that women's health receives a share of the overall health
budget comparable with that for men's health, taking into account
their different health needs.
31. States parties
should also, in particular:
(a) Place
a gender perspective at the centre of all policies and programmes
affecting women's health and should involve women in the planning,
implementation and monitoring of such policies and programmes
and in the provision of health services to women;
(b) Ensure
the removal of all barriers to women's access to health services,
education and information, including in the area of sexual and
reproductive health, and, in particular, allocate resources for
programmes directed at adolescents for the prevention and treatment
of sexually transmitted diseases, including HIV/AIDS;
(c) Prioritize
the prevention of unwanted pregnancy through family planning and
sex education and reduce maternal mortality rates through safe
motherhood services and prenatal assistance. When possible, legislation
criminalizing abortion should be amended, in order to withdraw
punitive measures imposed on women who undergo abortion;
(d) Monitor
the provision of health services to women by public, non-governmental
and private organizations, to ensure equal access and quality
of care;
(e) Require
all health services to be consistent with the human rights of
women, including the rights to autonomy, privacy, confidentiality,
informed consent and choice;
(f) Ensure
that the training curricula of health workers include comprehensive,
mandatory, gender-sensitive courses on women's health and human
rights, in particular gender-based violence.
Notes
* Contained in document A/54/38/Rev.1, chapter I.
1. General Assembly resolution 217 A (III).
2. General Assembly resolution 2200 A (XXI), annex.
3. General Assembly resolution 640 (VII).
4. Report of the World Conference on Human Rights, Vienna, 14-25
June 1993 (A/CONF.157/24 (Part I)), chap. III.
5. Report of the Fourth World Conference on Women, Beijing, 4-15
September 1995 (A/CONF.177/20 and Add.1), chap. I, resolution 1,
annex I.
6. See Official Records of the General Assembly, Forty-third Session,
Supplement No. 38 (A/43/38), chap. V.
7. CCPR/21/21/Rev.1/Add.7, 27 August 1996.
8. 96/694/EC, Brussels, 2 December 1996.
9. European Commission document V/1206/96-EN (March 1996).
10. See paragraph 141 of the Platform for Action adopted by the
Fourth World Conference on Women, held at Beijing from 4 to 15 September
1995 (A/CONF.177/20, chap. I, resolution 1, annex II). See also
paragraph 134, which reads in part: "The equal access and full
participation of women in power structures and their full involvement
in all efforts for the prevention and resolution of conflicts are
essential for the maintenance and promotion of peace and security".
11. See Official Records of the General Assembly, Forty-ninth Session,
Supplement No. 38 (A/49/38), chapter I, section A, General recommendation
21, para. 29.
12. Health education for adolescents should further address, inter
alia, gender quality, violence, prevention of sexually transmitted
diseases and reproductive and sexual health rights.
More
details of General Recommendations
1-10, 11-18,
19, 20,
21, 22,
23, 24,
25
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