This week we celebrated Human Rights Day, on December 10. On December 12, the United Nations General Assembly adopted a resolution on universal health coverage, which you can find here. According to a WHO discussion paper, universal health coverage is “a practical expression of the concern for health equity and the right to health.” So one would expect the UNAIDS reference group on human rights, meeting in Geneva on December 12, to be very excited about this resolution. It was not. (Believe me, I’m one of them and I was there.) As I wrote in a previous editorial, the worlds of UNAIDS’ investment framework and WHO’s universal health coverage are two different worlds. Six months after the International AIDS Conference, nothing has changed in that respect.

The AIDS movement distrusts the concept of universal health coverage, and for good reasons. While the World Health Report 2010 about universal health coverage explicitly mentioned “the need for high-income countries to honour their commitments on official development, assistance and to back it up with greater effort to improve aid effectiveness”, the UN resolution has an entire section on “sustainable financing mechanisms for universal health coverage” that does not even mention international financial assistance. Technical assistance is there, “sharing of best practices” too, but not a word about sharing the financial burden across borders.

I don’t know why the civil society organizations that lobbied the for the UN resolution on universal health coverage have not been able to include an international commitment to financial burden-sharing across borders. Probably, wealthier countries would have been reluctant to endorse additional commitments. Another reason may be that civil society organizations themselves prefer not to rely on international assistance, simply because it is notoriously unreliable – more charity than solidarity, and nobody wants to rely on charity.

For people with AIDS living in low-income countries, however, that is a death sentence. A version of universal health coverage that is adapted to national priorities and means, and that is not structurally including international financial assistance, may not include AIDS treatment. It may not include emergency obstetric care either, for that matter.

Obviously, the AIDS movement does not like to rely on charity. For the AIDS movement, charity is the 20th Century version of international assistance. The AIDS movement counts on international solidarity based on obligations – it has to, because millions of people living because of internationally financed AIDS treatment rely on it. As expressed by the United Nations Special Rapporteur on the Right to Health Anand Grover, states should “develop a treaty-based global pooling mechanism, comprising compulsory progressive contributions from States, allocated based upon need, and driven by transparent, participatory processes”.[1] To be sure, this 21st Century international assistance is not intended to replace national obligations – most of Anand Grover’s report is about national obligations. But international obligations are an essential element of the right to health, and should be an essential element of universal health coverage if universal health coverage wants to be a practical expression of the right to health.

Now some will argue that this is wishful thinking, and that the AIDS movement may want but did not succeed in securing obligations-based international assistance. Sure, we are still far from Anand Grover’s proposal becoming reality. But if Mead Over in his blog writes about “a new class of moral entitlements overseas” it is because something fundamentally has changed already. And there are other promising evolutions. In July 2012, the African Union adopted a Roadmap on Shared Responsibility and Global Solidarity for AIDS, TB and Malaria Response in Africa. The Roadmap on Shared Responsibility refers to ‘fair shares’, ‘ability to pay’ and ‘prior commitments’. It refers to the Abuja Declaration, in which African Heads of State and Government promised to spend 15 per cent of their budgets on health, but also calls for “development partners [to] meet existing commitments and with long-term and predictable commitments that are aligned with Africa’s priorities”. The result would be a situation in which poorer and wealthier states are contractually bound to increasing financial resources.

Both the Abuja Declaration and the Roadmap on Shared responsibility came out of the global AIDS response, but are in fact about health – the commitments and the expectations are about health. And if the people of the wealthier countries of the world would finally live up to their promise to share 0.7 per cent of their wealth with the people living in the poorest countries, and allocate 15 per cent of these budgets to health, comprehensive primary health care at a cost of US$45 per person per year would be possible in the poorest countries of the world. That kind of universal health coverage could claim being a practical translation of the right to health, and ‘AIDS exceptionality’ would become ‘AIDS exemplarity’…


 [1] Find the report here; click on the E (for English) on the left to “Report to the General Assembly (main focus: health financing in the context of the right to health)”.

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