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S o l i d a r i t y, e q u i t y a n d r i g h t s - b a s e d a p p r o a c h e s t o h e a l t h p r o v i s i o n The fundamental rationale for reviving PHC was a democratic one – that ‘people expect their health systems to be equitable’, obliging governments to reform systems to achieve ‘universal access to health services with social health protection’ (WHO, 2008: p. 23). Inequality, policy drift and the fate of health solidarity Amid growing acknowledgement of the economic and human costs of inequality, Göran Therborn (2013) powerfully argues that inequality is a ‘killing field’, reproducing vital inequalities of life and health via mechanisms of ‘distanciation’ that polarise ‘winners’ and ‘losers’ in the social system. Whitehead and Popay (2010) suggest that efforts to address inequalities are ‘swimming upstream’ against powerful countervailing currents of power and vested interest. In comparison to the earlier proposals for transformative PHC, the current ‘umbrella’ concept of UHC may be obscuring a significant drift in arguments and rationales. There is tension between the original PHC aim of universally accessible, peoplecentred health services and the newer aim of financial risk protection that is contingent on socialised forms of risk-sharing. Questions about the social nature of health risk protection have become more complex, couched within increasingly individualised, financialised and globalised insurance mechanisms. The answers may complicate and confound the requirements of public health, leading to the persistent under-provision of public health goods as the very understanding of collective health becomes more commodified and conflicted. Houtepen and ter Meulen (2000) analyse the challenges of health solidarities, writing from the perspective of a relatively strong, equitable and efficient health system with UHC: the Netherlands. Defining solidarity as a mixture of social justice and a set of cultural values and ascriptions, they show how health solidarities evolved from limited forms of mutual aid towards a comprehensive welfare state offering collectively financed universal health services. Mutual solidarities gradually transformed into national citizenship rights, with the government co-ordinating the collective responsibility for health, and guaranteeing universal coverage and accessibility. However, since the 1990s, financial pressure has led to changing conceptions of justice and more restricted notions of solidarity within the welfare state. Individual responsibility for health is more emphasised, focusing on healthy behaviours and lifestyles. As health insurance was privatised, solidarity declined. Given the health care gap caused by rising service demands and strict cost controls, longer waiting lists and waiting times have resulted. As government and citizens have turned to private solutions, public attitudes towards solidarity have changed. Lower solidarity is correlated with lower public trust in the health care system as a whole, and there are worries that the effectiveness and quality of the overall health system may be affected. In European social democracies like the Netherlands, market-based health reforms have been limited, while social solidarity has been quite strictly reinforced by the government (for example, by compelling universal social insurance, prohibiting risk selection and strictly controlling the quality of services). There is a strong awareness that public measures must maintain solidarity in order to ensure that higher income groups contribute to health care services for lower income groups. Potentially more important than income solidarity, however, is risk solidarity as the ‘inverse care’ trend means that the most expensive ten per cent of patients in the curatively concentrated health system consumed some 70 per cent of the total health costs in 2001 (ter Meulen and Maarse, 2008: p. 271). Ageing societies mean that inter-generational solidarity must necessarily increase, as more costs attach to curing and caring for the diseases of ageing. While the right to health highlights what people are entitled to and explains what dutybearers must respect, protect and fulfil, public health perspectives point to important examples of collective goods requiring protection. The public health ethos itself requires forms of solidarity that cannot be secured by individual responsibility, while necessary levels of trust and quality depend on collective attributes of the health system and its staff. Blood and organ donation and herd immunity arising from mass vaccination are examples of health solidarities where the larger population takes responsibility for an overall, systemic outcome that cannot be reduced to individual responsibility. The right to health The right to health appears indirectly as a ‘development’ issue within Article 25 of the Universal Declaration of Human Rights (UDHR), while the ‘social determinants’ of health are broadly captured in the phrase ‘adequate standard of living’. This leads on to Article 11 of the International Covenant on Economic, Social and Cultural Rights (ICESCR), defining the Right to an Adequate Standard of Living as ‘adequate food, clothing and housing, and to the continuous improvement of living conditions’. As Craven notes, the right to an adequate standard of living is wide-ranging and general, but it is paramount, ‘not least because at minimum levels it presents a question of survival’, even if ‘it is also true to say that the right to an adequate standard of living has been violated more comprehensively and systematically than probably any other right’ (1995: pp. 287–288). The 1946 WHO Constitution, which pre-dated the UDHR (1948) and ICESCR (1966, Article 12) address the right to health specifically, yet expansively, as the right to ‘the highest attainable standard of health as a fundamental right of every human being’. The right to health is included in a number of regional rights conventions, including the American Declaration of the Rights and Duties of Man (Article 11), the 1981 African Charter on Human and Peoples’ Rights (Article 16), and the 2000 European Union Charter of Fundamental Rights (Article 35). The basic feature of a rights-based approach is that it defines duties, criteria and standards that states and non-state actors have duties to respect, protect and fulfil as a matter of international laws and norms. While it does not mean that everyone automatically has the right to be healthy, the right to health obliges governments to ensure that timely, acceptable and affordable health care is available to all, without discrimination, that care is aligned with medical ethics, is culturally appropriate and is of appropriate quality (i.e. safe and medically appropriate). The non-discrimination aspect is active and positive in the sense that special provisions exist to ensure that the vulnerable, needy and disadvantaged are accorded priority. Pregnant women and children are afforded special protection, while occupational health and disease control are also prioritised (UN Economic and Social Council, 2000). Commonwealth Health Partnerships 2015 129


Commonwealth Health Partnerships 2015
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