On foreign aid, corruption, democracy and development: implications for the human right to health.
1. For the Global South to achieve truly universal health care coverage, I posit that, from now on, human rights and the right to health must simply be actively incorporated into all health care reform initiatives.
2. International aid is purported to be helping in this effort. But the crucial flaw of international aid (or overseas development assistance, ODA) is that states cannot be made to work from the outside. So, are external funders spinning their wheels?
3. Aid in health has become more politically skewed –often moving away from the lowest income countries. Moreover, it is becoming a window dressing since, rich countries give roughly half as much foreign aid as they did in the 1960s.
4. Corruption is importantly linked to foreign aid. The more corrupt a country, the more its internal tax revenue tends to decline when it receives grant aid.
5. But uprooting corruption is not a solution to human rights (HR) violations per-se. Rights-respecting democracy requires more than that –and more than just formal elections. Unfortunately, governance-by-manipulative-means is endemic in many societies with large populations rendered marginalized where the institutional tools of formal democracy do not function, precisely because of the poverty, economic dependence and powerlessness of the many.
6. So, yes, democracies are flawed and imperfect. Under such circumstances, I purport that, too often, democracies end up engaging in trial and error. But true reform processes in health that take HR as a compass take more than that. Giving potential claim holders legitimate-forceful and enforceable-claiming-capabilities thus depends on whether we can provide the impoverished with new powers –and this is a political task.
7. The corollary of this is that building participative systems of social decision-making in health is the way ahead to revert existing HR violations. Beneficiaries may not always ‘know best’ but, given their life experience, they sure do know best who is likely to gain or lose from reforms in the making –and that is critical. We must, therefore, not give-in in these efforts. (Interestingly, the progressive control of more of the needed resources for health through active social mobilization has been said to be a ‘weapon of mass salvation’ by no other than Geoffrey Sachs).
8. States do not fail, health leaders and systems do, either because they are corrupt, or are incapable, or because they claim ‘underlying conditions are too unfavorable’…But the latter must always be looked at critically by claim holders to prove them true or false.
9. Reforms in the right to health (RTH) area have too often been implemented top-down, piecemeal, tried out on a small scale and, most often, not expanded if they work. It is also true that in RTH one size does not fit all; what works depends on a country’s initial conditions.
10. We often fail to realize that institutions that we have to oppose in RTH work are often a proxy (just a front) for the political and economic forces behind them. Too often, these institutions try to make us accept that resources constraints are immutable, so we wrongly engage in various forms of pat solutions. This, when we rather must:
• become directly engaged in the ongoing, local political debate, and
• struggle for the health reforms that tackle the redistribution of those resources.
Social and human rights changes come best from public argument rather than from dispensed privileged advice (Amartya Sen)
11. Our closest partners in RTH work are thus, I contend, above all, people’s movements (particularly women’s) and organized communities, trade unions, health workers unions, teachers unions, civic associations, public interest and consumer groups, and other such.
12. Our allies are not the 3,000+ CEOs of the world’s transnational corporations and business-interest NGOs or their proxies that meet at the yearly World Economic Forum. UNICEF and WHO, for instance, should be at PHM’s People’s Health Assemblies and at the World Social Forum meetings and not at the Davos meeting every year.
13. Furthermore, WHO country representatives need to be made to understand by the Director General that not only governments and ministries of health are their working partners, but they also have to work with local public interest CSOs and local people’s movements.
14. It is our turn to make the difference. With no grassroots involvement, we will go nowhere; with it, we can stop or launch anything. So, if the determinants of health and of nutrition are social and political, so must be the remedies.(*)
*: Adapted from Development and Cooperation (D+C) 31:11, Nov. 2004; 31:12, Dec. 2004; 32:1, Jan. 2005; 32:2, Feb. 2005; and 32:3, March 2005; and from Finance and Development (F+D) 41:3, Sept. 2004; and 41:4, Dec. 2004.
Unfortunately, we live in a world in which the violations of the RTH do not call for concrete international sanctions
15. In international law, a violation of HR is deemed to be an offence, not only against the state, but also against all members of the international community. But regrettably, this does not necessarily imply an international crime, so that many RTH violations do not actually call for worldwide action. Ergo, sanctions cannot be used in the case of despondency towards clear-cut human rights violations. For example, the question arises: Does the international community have the responsibility to intervene legally in cases of clear violations of the right to health? In a utopian world, perhaps yes. However, HR are applied ‘softly’ (if at all) by international development organizations.
From unenforceable laws come no rights!
16. This vagueness in the language of international law is problematic, because it allows for the manipulation of this inexactly-defined-body-of-laws. There is an urgent need for further codification of this body of international law as related to the RTH. But, in today’s world, such a codification of international law is a reality we can only dream about. Moreover, the US, for example, is consistently disrespecting international law by not ratifying key HR treaties it has signed. The US will certainly veto any codification of international law that may hold it responsible for its actions, both domestically (e.g., CO2 emissions) and overseas (e.g., the International Court of Crimes Against Humanity). This begs the question: If there is no codification and no means of enforcing it, what is the point of this aspect of international law?
17. International law is subject to individual countries’ recognition of each norm as being a legally binding norm. Because the international community lacks a central authority, the creation of international law is consensual through treaties. Treaties are documents bilaterally or multilaterally signed that are agreements by governments who consent to be bound by their contents. Treaties fall into the category of ‘soft law’ (documents that are not directly enforceable in courts and tribunals, but that nonetheless, have an impact on international relations). Many such international agreements may prove useful and may serve as a basis for future legally binding agreements.
A promise is different from a right!
18. However, the name given to these ‘soft laws’ is inherently problematic, because soft law is not law really. Essentially, soft law is comprised of declarations of principles, codes of practice or conduct, recommendations, guidelines, standards, charters and resolutions –and in health and nutrition we have many such. These instruments have no legal authority, but there is an expectation they will be respected and followed by those countries and governments who have signed them.
19. One problem with non-legal instruments is that countries can sign-on to them without the fear of having to be held accountable –legally. Pressure comes (or is supposed to come) from the international community (whatever that monster is…). But it is only an assumption that, if a treaty is signed, a country will do ‘everything in its power’ to maintain the integrity of the contract. (Noah Levinson)
Claudio Schuftan, Ho Chi Minh City
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