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UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Visit to Poland, 5-11 May 2009

Preliminary conclusions and observations

Warsaw, 11 May 2009

Members of the press, ladies and gentlemen, let me begin by warmly thanking the Government for inviting me to Poland and for facilitating a rich and interesting programme of meetings and visits in Warsaw and Gdansk. To its credit, the Government of Poland has extended a standing invitation to Special Procedures, thus showing its commitment to comply with the United Nations human rights monitoring system. During my visit, I have met with the senior Government officials of the Ministry of Health and Ministry for Foreign Affairs, health professionals’ organizations, representatives of the international organizations, and civil society. Throughout my visit, I have been met with warm hospitality, courtesy and openness. I take this opportunity to thank all those who have given my colleagues and me the benefit of their time and experience.

You will find in this room a short document in Polish that explains my UN responsibilities as Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (for short the Right to Health). In brief, I am an independent expert who reports to, and advises, the UN Human Rights Council and UN General Assembly. Although appointed by the Human Rights Council, I am not employed by United Nations and the position I hold is honorary. As an independent expert, I exercise my professional judgement and report directly to the Member States of the United Nations.

Today, I would like to confine myself to a few preliminary and provisional remarks on some of the issues that, along with others, will be explored in more detail in the final report once I have studied materials and documents that I have gathered and been referred to. The report will be presented at the 14th session of the Human Rights Council, which will be held in June 2010.

As indicated in my Note, the purpose of the mission is to understand, in the spirit of co-operation and dialogue, how Poland has implemented and how it endeavours to implement the right to health, the measures taken for its successful realization and the obstacles encountered. The focus of the mission was on three major issues that I find of particular importance: sexual and reproductive health rights, HIV and harm reduction, drug dependence treatments and relevant laws, policies and practices, and their impact on the enjoyment of the right to health.

At the outset, I would like to note Poland’s commendable work in the last two decades to improve the health system as a whole and its commitment to ensure access to healthcare for all. A functioning health system is the basis for the exercise of the right to health. The lives, health and human rights of Polish people depend upon the Government, which must make the maximum use of its available resources to implement the right to health. I also warmly welcome Poland’s decision to support the joint statement on maternal mortality submitted to the Human Rights Council in March, which shows Poland’s commitment to contribute to its efforts to ensure access to health care for women before, during and after pregnancy and childbirth.

I must commend the resolve of the office of the Patient’s Ombudsmen, to overcome obstacles and provide the urgently needed health care services in difficult and dire circumstances. I hope and trust that with the adoption of the new law on patient’s rights ombudsmen, this dedication and devotion of rights of people to the enjoyment of the right to health will continue with even more enthusiasm and rigour.

Despite these achievements, there are still issues of concern that the Government of Poland needs to address and make efforts to overcome obstacles, in particular those regarding sexual and reproductive health rights, HIV and harm reduction, and drug dependence treatment.

Sexual and reproductive health rights (SRHR) are integral elements of the right to health. They encompass both freedoms, such as freedom from discrimination or freedom to control one’s health and body, and entitlements, such as a right to a functioning health system. As you know, SRHR raise extremely important issues, which might be seen as quite controversial.

Without doubt, these issues represent a central feature of the right to health and give rise to binding obligation on States. The Cairo and Beijing Conferences as landmark events, the declarations of which the Polish Government has repeatedly expressed its commitment to implement, coupled with the rights based approach, can help overcome obstacles and also help to identify effective, equitable and evidence-based policies to address complex issues around sexual and reproductive health.

The respect of physical integrity and freedom to control their own bodies, is one of the fundamental rights of all human beings, including women. Undoubtedly, the ultimate decision on whether or not to give birth should be made by the women concerned, who should have the means of enjoying that right effectively.

Despite the Polish Government’s ratification of numerous human rights treaties, access of women to certain reproductive health services, such as contraception, pre-natal testing and abortion, is seriously impeded. For example, reports and personal testimonies indicate that women, even when abortion is legal, encounter serious difficulties to have it performed. I appreciate that Poland is a country with long and deeply rooted traditions, and I understand that the question of abortion raises complex issues for the Government to which there are no quick solutions. However, these issues need to be addressed.

A woman’s need to have abortion is not dependant on whether abortion is legal or not. However, her access to safe abortion is impacted by criminalization of abortion. I must emphasize and add that - when abortions are legal, they must be, apart from being safe, made accessible. In this context, the role of health professionals, both doctors and nurses, is of great importance. I am glad that I met representatives of their associations who shared with me their concerns.

However, I note with particular concern numerous reports, and personal testimonies from women who indicated that some doctors, invoking conscientious objection, refuse to perform a legal abortion. In addition, I am also concerned about reports indicating that non-State actors are interfering with the access to legal and safe abortions. Health providers have a right to respect for their freedom of thought, conscience or religion. In such cases, it is a guiding principle that the State has a legal obligation to ensure the enjoyment of the human right, without hindrance or bureaucratic delay. The State is obliged to have in place a system, which while respecting the conscientious objector, will ensure the access to safe abortion, where legal.

I note with regret that even though bound by treaties bearing closely upon duties of health professionals, Polish health professionals do not have the opportunity to receive education and training in human rights. I would recommend that the educational institutions which impart health care education include that within their curriculum.

Regrettably, authorities could not provide information on the extent of illegal abortions and their effects on women. Official statistics available only show that legal abortions are less accessible in public medical centres. However, the estimates on illegal abortions performed in Poland that I have received are very worrying as the number varies between 80,000-180,000 of terminations of pregnancies per year.

I am very grateful for the opportunity to meet with the Agent representing the Government of Poland before the European Court for Human Rights. I welcome the steps taken by the Government to comply with the judgment on the European Court in the Tysiac case. However, the Government is yet to fully implement the Court’s decision of instituting regulations governing fair procedures to ensure women’s access to a legal abortion.

I am also concerned about lack of information on sexual and reproductive health rights among children and adolescents. Reproductive health education is taught at schools (primary and secondary schools) under the rubric of Education for life in the family. According to the Ministry of Education, these courses are compulsory, but courses on sexual education are not. I would like to underline that, in order to make informed decisions, children and adolescents must have access to evidence-based, scientific and age-appropriate education. Provision of non-judgmental sex and relationship information and education, as well as better funded contraceptive services are fundamental for the implementation of adequate sexual and reproductive health rights strategies and policies.

I am concerned with the fact that while according to the Government officials the vision of the Narcotics law is to treat rather than punish those with drug addictions, the law still penalizes for the possession of small and minute amounts of narcotics and psychotropic substances. I am saddened to receive reports that people undergoing treatment have been arrested and detained by officials for possession of methadone.

I commend the government’s realization that substitution methods of treatment are urgently needed to address drug dependence. Evidence from all over the world demonstrates that substitution therapy is more efficacious and less costly to treat drug dependence. Methadone in this regard, is available in a number of cities throughout the country. Furthermore, while I am happy to note that the National Drug Bureau aims to increase accessibility of methadone to 20% of those in need by 2010, it must be realized, that such a goal is only minimal and efforts must continue to be ensured in order to make methadone more widely available and accessible. Therefore, targets must be set to ensure that those who are in need of methadone get it as soon as possible.

Moreover, drug free centres in certain areas remain the norm. As a result people using drugs from Gdansk who need methadone, for example, have to travel to Warsaw or Krakow to receive the treatment they desperately need. The Pomeranian Region, is the sole region in the country, where drug free treatment centres (therapeutic centres) operate and the regional government is allocating up to 7 million zlotys today on these centres.

While in Gdansk, I received a number of complaints about the lack of methadone maintenance treatment for persons using drugs. After long discussion with local authorities, I was pleased to note the change in the approach to this vexed issue. I therefore, warmly welcome the indication that the local authorities have committed to provide a methadone maintenance programme in Gdansk starting in September 2009, for which final logistic decision will be taken next week. I am looking forward to hearing from both the local and national authorities that this positive decision has indeed been taken and that the centre will become operational in September.

Furthermore, in regards to HIV/AIDS, I commend the government’s commitment to ensure access to necessary ARVs for People Living with HIV (PLHIVs) who need them. Through the national health fund, the government has made sure to respect its obligation to make necessary ARVs available to the population. However, while a majority of funds are spent on treatment of HIV, I am concerned with the fact that there remains a gap in available funds and work on HIV prevention. This impacts prevention services including harm reduction measures. In this regard I urge the government to scale up such preventive services, including harm reduction services.

Moreover, I am glad to note that the Government recognizes that HIV is associated with stigma and that HIV positive people and those perceived to be HIV positive or at risk, such as people using drugs, men having sex with men, and sex workers face discrimination and continue to be marginalized in society at large. I would like to highlight the fact that the fundamental basis for human rights and the right to health is embedded in the principle of non-discrimination and equality. With this in mind, while I commend the efforts of the National AIDS Centre to collaborate with various organizations to raise awareness about HIV/AIDS and address issues relating to stigma and discrimination, such programmes need to be targeted towards the inclusion of marginalized groups in society. In this regard, it is necessary to reiterate that medical services and goods are available and accessible to all on the basis of equality and non-discrimination, regardless of one’s status. This can be achieved by ensuring the participation of PLHIVs and marginalized groups in the campaigns.

Moreover, I highly recommend that the government take positive steps towards the enactment and implementation of a comprehensive anti-discrimination and equality legislation to help ensure that the right to health continues to be protected and that services are provided on a basis of equality and non-discrimination to all within the state.

Despite these concerns I remain convinced that continuing dialogue will promote the understanding of human rights and in particular of the right of everyone, without discrimination, to the enjoyment of the highest attainable standard of health. I look forward to monitoring the progressive realization of the right to health in Poland in the future.

Thank you.