Nowadays, public health and the right to health have come to mean too many things to different people
15. Public health is a specialty in which health practitioners should have to turn to past proven achievements for enlightenment. But do they? When health services become a merchandise they apply to its practice the laws of the market,* not the principles of public health. Health thus starts with its market price and only eventually travels backwards to public health. So, when profitability is the name of the game, too many human rights-based health concerns are relegated to the back burner. (Claudio Sepulveda)
*: Measures proposed by international financial institutions (IFIs) to improve efficiency when following the laws of the market are: Budget caps for hospitals, screening out unnecessary services, gate-keeping for all referrals to higher levels of care, shifting costs to local governments, greater competition between insurers and providers, greater reliance on contracting out to private services, moving away from simple reimbursement of providers using longer term contracting, having incentives for providers to minimize their waste, payments based on diagnostic related groups (DRGs) with treatment protocols and price schedules, higher co-payments in public insurance schemes, expanding the role of private insurance, bonus payments for physicians based on clinical outcomes, rationing high technology equipment and giving users more information about the quality and prices of particular services. IFIs purport that the introduction of market mechanisms can be powerful and that tightening of budget controls and greater central oversight can increase the responsiveness to patient needs while taming spending of the health care system. Calls are also made for smoking, alcohol, exercise, safe driving and regular check-ups related issues–all with preventive measures centered around individual behaviors. (F+D , 48:1. March 2011, pp 42-45)
16. For us HR activists, by treating health as a human right, we acknowledge the need for a strong social commitment to good health. There are few things as important as that in the contemporary world. The idea of human rights serves not as a “child of law”, but more as a “parent of law” in guiding needed ad-hoc legislation and regulations. A human rights focus serves as a parent not only of law, but also of many other ways of advancing the cause of that right. There are political, social, economic, scientific, and cultural actions that we need to take to advance the cause of (good) health for all. (Amartya Sen)
17. But we know we should and cannot wait for laws to be passed. Instead of leaving it to the legislative and judiciary powers to define and enforce people’s rights, it is health policy-makers that must ensure that human rights principles are incorporated into health programs from the outset; and, for HR activists, this is a tactical priority that means actively involving claim holders.
18. To put the above in context, note that: More than 30 countries have not yet ratified the International Convention on Economic, Social and Cultural Rights (ICESCR) and 60 countries do not recognize the right to health in their national constitutions. (The Right to Food is recognized in 22 constitutions).
19. WHO has for long avoided to use the term and concept right to health and, instead, uses human rights and health or health and human rights. WHO staff often uses the term health as a human right.**
**: These are the different terms I have found in WHO documents: Right to health services, Right to basic health services, Right to health care, and Right to be healthy.
I cannot understand this avoidance by WHO: Is something feared here? A fear to be held accountable for the global defense of the RTH? What does WHO actually avoid, I ask, by not using ‘right to health’? I have brought this up at several occasions in meetings with WHO, and I never get a clear answer. (Note that the UN special Rapporteur consistently uses ‘right to the enjoyment of the highest attainable standard of health’).
20. The question is: Do ‘Human right to health’ and ‘Health as a human right’ have different connotations or are they interchangeable? I tend to think they are different since the former relates to a specific, concrete covenant and to a General Comment, and the latter not. (General Comment 14 on the RTH interprets article 12 of ICESCR; it confirms that the RTH has both individual and collective dimensions, and that collective rights are critical in the field of health as modern public health policy relies heavily on prevention and promotion approaches directed primarily towards groups).
21. WHO uses the legal recognition of health as a human right as an indicator of a government’s commitment to improving access to essential medicines though.*** Access to essential medicines has thus become one of five UN indicators to measure progress in the progressive realization of the right to health.
***: Some consider that politics should be maintained out of WHO and would prefer to see its role reduced to that of a purely technical body. But politics has been invariably embedded in WHO throughout its history. The challenge is not to somehow remove politics from the organization, but rather to ensure its healthier political functioning. (Kelley Lee)
22. While constitutional recognition of the right to access to essential medicines is an important sign of national values and commitment, it is neither a guarantee nor a key step taken by many countries. Enforcement is what counts.
23. Inequality and discrimination in the access to essential medicines remain the key public health challenge of our times. Therefore, five questions should be asked to assess if a rights-based approach in national essential drugs programs is working; they are:
i) Which medicines are covered and committed-to by the Government?
ii) Have all beneficiaries of the medicines program been consulted?
iii) Are there mechanisms to assure transparency and accountability?
iv) Do all vulnerable groups have equal access to essential medicines? How
does one know this?
v) Are there safeguards and redress mechanisms in case the human right to
medicines is violated?
24. Collecting and publishing disaggregated statistics and targeted surveys to monitor the access to essential medicines by gender and by vulnerable groups remains a priority so that results can be reported regularly on the progressive realization of this right (e.g., every two years). It is to be insisted that only on the basis of disaggregated statistics on access to essential medicines will we be able to assess progress.
25. Such progress should be reported by NGOs when they prepare shadow (parallel) reports to international HR monitoring bodies on country progress towards the fulfillment of the right to health; standard access indicators developed by WHO can be used for this. Therefore, monitoring and holding governments accountable in relation to their human rights responsibilities and access to medicines is equally indispensable.
The long struggle over user fees is only introductory to the practical dilemmas associated with a rights-based commitment to universal health coverage
26. Total individual expenditure on health (public and private including out of pocket expenditure ) has, as we all know, increased pretty much worldwide. Nevertheless, this increment has not resulted in greater access to health care services, but has rather destroyed the institutional scaffolding of the public health sector. The result has been the resurgence of diseases that were earlier under control and a drop in preventive health activities such as immunizations. (Asa Cristina Laurell)
27. The 2010 World Health Report documented the widespread “financial catastrophe associated with direct payments for health services” and argued that “even when relatively low, any kind of charges imposed directly on households discourages using health-care services or pushes people living close to poverty under the poverty line.” In the view of many observers, co-payments are not in fact a financing mechanism, but rather a rationing strategy that results in lowering demand for services that, in turn, drives local health care institutions to non sustainability.
28. We know health care is the most expensive element of any package of state interventions to guarantee the human right to health and, no doubt, the conundrum of health care financing is at the very core of human rights.
The advent of so-called global health initiatives over the last decade has not succeeded in squaring the circle. Should equity, i.e., universal health coverage be a broadly normative target? If we determine that rationing health care services is unacceptable, then the question of costs immediately comes to the fore. The onus will have to shift to the financing of services for those presently excluded.
29. To put the above in context, note that: Among six emerging economies, the public health spending ratio fell by 6% between 1995 and 2007. In those that this spending rose, it did so at 1/3 the rate of advanced economies. (F+D , 48:1. March 2011)
30. A human rights perspective removes actions to relieve poverty-with-its-inability-to-pay from the voluntary realm of charity … to the (not really voluntary) domain of international and national law. To tackle health inequalities, one has to push for aggressive social policies –and international human rights instruments provide not only the framework, but also explain the legal obligation that policies have to allow an equal opportunity to be healthy –an obligation that necessarily requires considering poverty and social disadvantage from a structural perspective. (Paula Braveman)
Like the right to health, the right to nutrition is important intrinsically, also because of how it impacts on so many aspects of life
31.The realization of both the human right to health and to nutrition implies the empowerment of disadvantaged (often remote) communities to exercise the greatest possible control over the factors that determine their health and nutrition.****
****: A caveat here is that the assumption that decentralization in health systems necessarily empowers claim holders is questionable.
32. The abstract concept of the human rights to health and to nutrition looks attractive in the political and academic discourse and in ad-hoc publications. But if it is not put into practice through claim-holders claiming, the concept has little value. Ergo, the human rights discourse can significantly empower people, but more so when they decide to use the right to health and to nutrition argument in their struggle. (FIAN)
33. Bottom line here is that the period in which health and nutrition professionals felt able to make recommendations chiefly based on knowledge of human biology, now feels like a vanished Eden. (WPHNA)
Claudio Schuftan, Ho Chi Minh City
cschuftan@phmovement.org