Claudio Schuftan, MD
HEALTH CARE FOR THOSE RENDERED POOR OFTEN ENDS UP BEING POOR HEALTH CARE, SO THAT THE MORE WE TARGET BENEFITS AT THEM ONLY … THE LESS LIKELY WE ARE TO REDUCE POVERTY AND INEQUALITY. (Amrtya Sen)
We can safely say that, in the case of health, inequality is a passive outcome: ‘it happens’; conversely, equality in health must be fought-for actively. (Hernan Sandoval) [In the same vein, we have always pointed out that political rights are guaranteed; social rights must be actively proclaimed and fought-for by claim holders].
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When it comes to global health, there is no ‘them’…only ‘us’. (Global Health Council)
1. When we want to say that Primary Health Care (PHC) is a Core Human Right Obligation, we mean that it is far more than a procedural issue; it is a structural issue encompassing equitable distribution of these services, non-discrimination, and a participatory national plan of action. The only PHC intervention actually specified as a core obligation is access to essential medicines; there is no mention of the social determinants of health, i.e., minimum essential food, basic shelter, housing and sanitation, and safe water.Other substantive components of PHC are listed, but separately, as ‘obligations of comparable priority’. Here we find reproductive, maternal, and child health care actually explicitly mentioned, as well as immunization against major infectious diseases, the prevention/treatment and control of epidemic and endemic diseases, health education, access to information and appropriate training for health personnel. Let us be clear: Core obligations refer-to and demarcate ‘essential’ aspects of the right to health as a baseline of people’s protection –regardless of any given country’s shortage of national resources or international assistance.
2. Additionally, be informed that actions to realize core aspects are part of the legally binding human rights (HR) framework that was designed to have considerable normative and political implications. Primary health care as such is thus not explicitly listed as a core obligation; much of what we would expect to find in an obligation to provide essential PHC is explicitly placed outside the core obligations, i.e., under obligations of comparable priority. General Comment No. 14 does not sufficiently address the question of the resources necessary to meet core obligations; it merely emphasizes that states cannot justify non-compliance under any circumstances. The role of international assistance and cooperation is strongly reasserted in GC 14 and thus clearly applies to core obligations. Core obligations should be understood and applied as providing a universally applicable ‘bottom line’ of essential health care –in contrast to any other standards that can shift from country to country depending on available resources.
3. The focus of the right to health’s understanding of core obligations is far more on processes (e.g., non-discrimination, equitable distributions, and participatory plans of actions) than on outcomes. Core obligations do not prescribe a globally applicable and fixed set of health care benefits, but ratherprescribe a framework for action that encompasses non-discrimination (including affordability), equity and participatory decision-making. The emphasis on affordability elevates socio-economic status to one of the grounds for discrimination, meaning that any version of Universal Health Coverage (UHC) that is not affordable to all violates core obligations under the right to health.(i) (Lisa Forman et al)
(i): Note that the risk of UHC becoming targeted (rather than offering comprehensive, truly universal health care) and giving inadequate attention to health systems strengthening is great. This is not a frivolous statement since states live not in an abstract world as governed by the aspirations of the SDGs, but live in the real world, where policies to implement UHC exist alongside ongoing austerity, financial crises, free trade agreements, and pressures to commodify health services –all of which directly threaten policies on access to medicines and sustainable health financing. (L. Forman)
It is the design of a financing mechanism that determines equality in the access-to and the payment-for health care
The human rights framework does offer practical guidance for addressing the political economy challenges of health care reform.
4. A focus on the redistributive potential of health care financing recasts health reform as an economic policy intervention that can and will help fulfill broader economic and social rights obligations. For instance, a business tax directed against wage disparities can foreseeably generate the resources needed. A health system financed through equitable taxation can indeed produce significant redistributive effects thus increasing economic equality while generating sufficient funds to provide comprehensive health care as a universal public good.
5. Regressive health care financing is a significant contributor to economic inequality, producing an inverse correlation between household income and household health care spending. Conversely, a redistributive universal health care system can deliver significant financial relief to lower- and middle-income families. Health care can thus function as a strategic lever for building a more equitable society through the universal provision of the goods and services needed to exercise/fulfill economic and social rights.(ii)
(ii): The market-based insurance system in the United States demonstrates that private pre-payment schemes are neither intended nor equipped to guarantee equality in access-to and payment-for health care.
6. Therefore, in the design of a financing mechanism, the three principles of universality, equality, and accountability can be achieved if: a) financing is be based on health needs and is sufficient to meet all needs; b) equitable financing is ensured through progressive taxes and guarantees free access to care at the point of service; and c) the mechanism is public so as to secure full accountability for the effective and efficient use of resources necessary to fulfill the human right to health.(iii)
(iii): It is clear: The proactive engagement with the question of health system financing places right to health campaigners squarely in the territory of budget and revenue policies.
7. The human rights-based framework requires budgeting for health to begin with a participatory assessment of needs to then develop a needs-based budget that calls for the mobilization of the maximum amount of resources in an equitable way to meet these budget obligations. Assessing the needs, accountable decision-making based on the depth of need(iv), mobilizing public funds through equitable taxation, and strengthening public sector capacity, are all prerequisites to fulfill the economic and social rights obligations pertaining to health. Promoting needs-based, equitable taxation as a rights-based instrument for achieving universal health coverage, opens up an economic and social rights perspective on health policy.
(iv): Universal health coverage is quintessentially a needs-based system. Human rights activists cannot afford to stand on the sidelines of the political economy debates over UHC. (Anja Rudiger)
We have to put states on notice that they remain accountable for the right to health and health care in the private sector (Audrey Chapman)
8. An identification of the various components of UHC, on the one hand, and the right-to-health framework, on the other, reveals many close connections between the two. For example, while affordability is a key component of the right to health, it also underpins UHC. As the primary duty bearers, governments have a responsibility to ensure that health care services (even if privately provided) are available, accessible, acceptable, and of good quality. They must ensure that mechanisms are in place for patients to seek legal redress if they have received inadequate or untimely care. The HR obligation to protect is of particular significance in this context since it requires government’s active monitoring of the activities of third parties.(v) When certain services fall into private hands, there is a shift from the state respecting and fulfilling the right to the state’s obligation to protect which includes the obligation to regulate; the obligation to monitor; the obligation to ensure that there is accountability for violations committed; and the obligation to ensure the population’s participation in health care decision-making. (Regulatory efforts have to cover the provision and financing of health care, as well as the manufacturing and equitable distribution of all health care goods).
(v): For example, in terms of geographic access, the operation of private hospitals should not mean that health services are available only in affluent areas. Human rights law provides an authoritative set of legal tools for assessing the consequences of private sector involvement. (Birgit Toebes)
9. A focus on the redistributive nature of health systems recasts health care reform as a broader economic policy intervention. There are though a range of policy and political obstacles, e.g., the specific power relations producing these obstacles and the systemic factors contributing to human rights denials.
10. Only anchored in local movement building efforts and social mobilization will the momentum for universal health care reform continue to grow. It is mass organizing that will eventually tackle political resistance through rights-based redistribution models. (A. Rudiger)
Claudio Schuftan Dr MD
I grew up in Chile, got my medical degree there, began an academic career in 1970, and left for the USA due to the military coup in early 1974. My first job in the USA was working as a public nutrition professor in the international programme of Meharry Medical College in Nashville, Tennessee.
I started to travel to Africa in 1975, and worked a year in Cameroun in 1980 helping to prepare their five-year nutrition plan. I then moved to New Orleans, to Tulane University’s School of Public Health, and taught in the department of nutrition for ten years, before moving to Nairobi where I was an advisor in the Ministry of Health. Seven years there got me into extensive consulting in Africa, often on nutritional issues. In 1995 moved to Vietnam where I worked for two and a half years in the Ministry of Health as a senior primary health care advisor.
Many years of touching the reality on the ground, in Latin America, then the USA, then Africa and Asia, has made me understand that the real challenge is in the social and political determinants of malnutrition. I have devoted my writings and teaching to that. Over the years, I have found an important shift in my colleagues’ attitude and understanding towards acknowledging the basic causes of malnutrition. But yet I see little happening as a result. I submit that it is our guild’s lack of experience in the political arena that explains this dichotomy. I devote much of my energy to bridge this gap, and am a fervent advocate of empowering claim holders to demand needed changes from duty bearers. Nutrition is a perfect port of entry for that. Equity, social justice and people’s empowerment in a human rights sense is what really will make a difference.
There is no alternative but to deal with nutrition problems as indivisibly linked to social, political and environmental problems. We need to address them as such. The question is: are we all prepared to do that? The answer, in my view, decides whether we are part of the solution or part of the problem. Travelling and living in different parts of the world has reinforced my conviction that we need to get down from our academic ivory towers, and need to change the curricula of our young and upcoming colleagues, to give them the tools to act in such a context. To me, public health nutrition cannot be anything but that.