Gostin et al
Reviewed by RVDP
This article, drafted by a group of researchers and health activists from different regions of the world represents an inspiring and promising basis for more just and accountable governance for global health. Current global health governance models, like the international health partnership plus related initiatives or the millennium development goals framework have worked on harmonisation and effectiveness efforts with both recipients and donors of international aid. Accountability of these funds can be improved, as allocation and length of these funding can be earmarked, conditional and sometime volatile to a national health system. The authors argue that under international human rights law, this development assistance must not be seen as a temporary ‘charity’ but is basically a human right that can be demanded to the respective duty-bearers, meaning national governments and that it is a moral responsibility (a so called global public good) of the international community to assist national governments in realising the right to health of their citizens when they do not have the resources. The ultimate goal is a treaty, a framework convention on global health (FCGH) that sets clear priorities, clarifies and creates accountability for national and international responsibilities. To disentangle the questions and open the pathway towards a framework convention, the authors raise 4 questions that will be discussed separately.
- What are the services and goods guaranteed to every person under the human right to health? Core obligations of the right to health offer benchmarks to assess progress towards universal coverage. It includes non-discrimination, equitable distribution of health facilities, and essential services for all, including those addressing underlying determinants of health. This is where moral difficulties of prioritisation rise; what are ‘key’ health interventions that should be fully covered for a country population? And what are the fundamental human needs, the so called essential determinants of health that should also be covered by governments? This is where the right to health in intrinsically interlinked with other human rights, e.g. the right to clean water and sanitation. States must progressively move forward to fully realizing the right to health, but the services and socioeconomic determinants that must and can be guaranteed are highly contextualised to local needs. I would argue that the determinant ‘democratic participation to define local and national needs’ is an equally important requirement when exploring this question further. There is not ‘a magic bullet’ core package that must be globally defined as human needs for health differ so much over the world. A core package could justify the creation of selective cost-effective health packages that do not address needs of specific groups like for instance disabled persons or indigenous persons. The authors acknowledge this by mentioning that ‘specific services will be determined nationally through participatory processes.
- What responsibilities do all states have for the health of their population? The right to health places the prime responsibility of governments to ensure needs of their inhabitants. But what if this state does not have sufficient resources to guarantee this right? 131 countries have a reference to the right to health in their constitution, and African heads of state guaranteed inAbuja in 2001 to spend at least 15% of their national budgets to the health sector. A majority of African states still fails to do so. One can see here that this benchmark of 15% then collides with other national macro-economic and development priorities that often lead to a reduced spending on public services. These policies are still strongly influenced by IMF and World Bank policies on public sector expenditure. What is the real decision space by leaders in low and middle income countries to increase its national health sector spending and guarantee the right to health? Accountability mechanisms at national level, of whichIndia andBrazil are mentioned as an example, are important basic requirements for citizens’ participation and demands for attaining the right to health.
- What duties to states owe to people beyond their borders in securing the right to health?Probably the most difficult question asked by this paper, as guaranteeing economic, social and cultural human rights is often regarded as a duty by national governments. Currently international aspects of this right are ill defined. In a recent paper, Gorik Ooms and colleagues explain the confusion around countries having the obligation to provide international assistance to “the maximum of its available resources”(http://www.itg.be/itg/Uploads/Volksgezondheid/wpshsop/SHSOP%20WP%202%20Ooms%20Global%20Health.pdf). The moral dilemma is such that countries can interpret this as first advancing their own domestic needs improving health of their citizens. This is in contrast to a more global view that governments have a responsibility to secure health as a global public good and should strive that all people around the world will benefit from exactly the same effort. It is because these international obligations are not legally binding, that the authors advocate to more strict and international regulations that can be legally enforced.
- What kind of global governance is needed to ensure that all states live up to their mutual responsibilities? This section refers to an ongoing heated debate on the poor coordination, fragmentation and lack of transparency related to global health priority setting and leadership. The authors refer to WHO as the leading and constitutional mandated authority to direct governance for global health and guaranteeing the right to health. Secondly, the authors advise a health-in-all policy approach and policy coherence at national level to assure that ‘good governance starts at home’ before international further regulations are made.
This article and the JALI is a first step and exploration towards more binding agreements on global health and improved governance for global health. The right to health approach provides effective possibilities to mobilize people to demand this right, as the Treatment Action Campaign has demonstrated inSouth Africa.
The JALI was represented by several authors in a May 2011 consultation in Delhiwith a broader group of organisations and constituencies. This consultation led to the Delhistatement that ‘supports the exploration of and research into a binding framework convention on global health’ (http://www.medico.de/en/themes/health/documents/time-to-untie-the-knots-the-who-reform-and-the-need-for-democratizing-global-health/1177). Some persons present hade some critical remarks of the JALI concept. Anand Grover, the UN Special Rapporteur on the right to health, reminded that the needs of people at grassroots level must always be addressed and represented in the development of such a convention. Armando de Negri fromBrazil raised the comment that the right to health should not be seen in isolation from broader social protection measures. David Legge from the people’s health movement advocated for more modest objectives and to create regulation on specific global health themes, Eg a framework convention on the rational use of medicines.
It can also be argued that the JALI approaches global health in a ‘reductive’ manner, without addressing wider political-economic issues that are the structural causes of unfair distribution of resources between peoples.
The JALI will develop over the coming period. The long process towards more legal binding global health agreements can provide momentum for more fair governance and distributions of resources for global health. The path it takes might be possibly more important than the eventual framework convention on global health itself.