[Adapted from Anchoring Universal Health Coverage in the RTH: What difference would it make? Policy Brief, WHO, 2015, G. Ooms and R. Hammond Editors].
Preamble:
The human right to health is indispensable for the exercise of other human rights.
1. The link between an individuals’ state of health and his/her access to health care services is clear. It needs no saying that the most vulnerable people have the greatest needs, but have extremely limited, or even practically non-existent, access to health care services and yet health is an inalienable human right (HR)*.
*: The right to health (RTH) is enshrined in the Universal Declaration of Human Rights of 1948 (Art. 25) and in the International Covenant on Economic, Social and Cultural Rights of 1966.
2. For WHO, the RTH is to enshrine both freedoms and rights: the right to control one’s own health and one’s own body (for example sexual and reproductive rights); the right to physical integrity (for example the right not to be subject to torture and not to be subject to any medical experimentation without consent) and the right to access a health protection system which guarantees equal possibilities to all to enjoy the best possible state of health.
So what does the human right to health actually mean?
3. In the year 2000, the UN Committee on Economic, Social and Cultural Rights adopted its General Comment 14 on the right to the highest attainable standards of health. It states that:
• A health system must function properly: Accordingly, the key to health is a functional/ing health care system, one that is available, accessible and acceptable to all without any form of discrimination and is of high quality. Let us see what this entails:
o • Available means that the facilities, goods, public health programs and health care services are functional and in sufficient supply.
o • Accessible means that the facilities, goods and health care services are accessible to all without any form of discrimination. Accessibility includes four interdependent dimensions: non-discrimination, physical accessibility, economic accessibility (being sufficiently affordable) and free access to information.
o • Acceptable means that all facilities, goods and services in the domain of health care must respect medical and commensurate ethics from a cultural point of view. In other words, they are to respect the culture of communities, individuals and minorities and be receptive to the specific requirements linked to sex and to the different stages of life. They must further be designed to respect confidentiality and to objectively/measurably improve people’s state of health.
o • Quality means that, as well as having to be acceptable from a cultural point of view, installations, medicines, goods and services in the domain of health care must also be scientifically and medically appropriate and of a high quality.
• But acting on the other determinants of health is as indispensible, i.e.,
the RTH extends beyond the health care system. It covers an array of factors that help individuals to live a healthy life and improve the way in which the same is promoted. The Committee on Economic, Social and Cultural Rights refers to this using the term ‘underlying determinants of health’. These comprise: a) drinking water; b) adequate living conditions; c) nutritiously safe food; d) appropriate housing conditions; e) a healthy environmental and healthy working conditions; f) health education and information; g) information relating to sexual and reproductive health; and, last but not least, h) gender equality.
4. Now, as the deeply ethical and political principles of the Alma Ata Declaration were disregarded and sidestepped for decades, the international community is adding the latest attempt to bring health to all in the seemingly catch-all and ill-defined initiative of Universal Health Coverage. But is this a step in the direction of the RTH? Let us see:
Any claim to Universal Health Coverage that does not serve the purpose of the human right to health is simply not truly universal (!)
5. Efforts towards achieving universal health coverage (UHC) do engage in some, but not necessarily all of the efforts required from governments for the realization of the right to health (RTH). The RTH covers more than the right to health care. At present, much debate surrounding UHC remains focused on health care services.
UHC leaves too much leeway for the inclusion of private-for-profit providers and does not sufficiently emphasize the responsibility of governments
6. As enshrined in the International Covenant of Economic, Social and Cultural Rights (ICESR), the RTH makes no mention of the role of private providers in realizing this or any other rights. The state is the primary duty bearer. If the state relies on private providers, it must ensure these providers fulfill their role on behalf of the government (!).
7. As often pointed out in these Readers, health equality is in many respects an ideational sibling of the RTH. Equality is the principle of being fair to all persons. The RTH is somewhat better defined than health equality though.
8. The RTH perspective insists on no discrimination and adds that non-discrimination is not optional, but a matter of legal obligation. However, often-used-cost-effectiveness-criteria do push things below the limits that are acceptable from a HR perspective –particularly as regards discrimination.
9. UHC has little to say about the principle of shared responsibility. It does not mention that foreign assistance is also a matter of legal obligation. UHC does not imply a minimum level of core contents as the RTH does. Shared (national and international) responsibility for UHC is not clearly mentioned in the norms underpinning UHC.
10. The RTH insists that countries have to allocate maximum available resources, but, when it comes to domestic financing, UHC provides very little, if any guidance on this. If a state does not use the maximum of its available resources for the realization of the RTH, it is in violation of its obligations.
11. It is too often taken for granted that any form of pooling financial resources for UHC contributes to the rich subsidizing the poor; it does not (!).
If UHC is not anchored in the RTH it risks not being universal (!)
12. Like in the case of the RTH, progress towards UHC is about the journey, not the destination. UHC anchored in the RTH requires that authorities engage with those who are excluded and come up with policies that include them in deliberations about the directions the health system should take.
Note: The Policy Brief here summarized has a very good table on the ‘OPERA HR framework and methodology’: For a summary of the same, also see HR Readers 310 and 311 at www.claudioschuftan.com
Claudio Schuftan, Ho Chi Minh City
schuftan@gmail.com
Postscript/Marginalia
-I sincerely hope that we will all write an obituary to that type of health education which has been concerned with telling people how to act and that, instead, health education will emphasize taking due consideration of the social forces that bring them to act as they so negatively do. (posthumously by Halfdan Mahler)
-Somebody proposed to, on World Health Day each month of May, send an annual letter to both the WHO Director General and minsters of health the world over complaining about the unfulfilled promises on the RTH. …worth considering.