The right to health: From legal principle to post-2015 indicators Universal health coverage (UHC) is widely considered to be a key component for the post-2015 health goal. In this article, we complement the World health organisation (WHO)/World Bank approach by grounding UHC in the right to health framework, which is a valuable starting point to develop measurable and achievable indicators of both process and outcome that can inform the ongoing post-2015 global negotiations and implementation, as well as national debates on how to integrate UHC into domestic policies. Based on the International Covenant (ICESCR) and the General Comment of the Committee on Economic, Social and Cultural Rights, which has the responsibility for interpreting and monitoring the ICESCR, we have identified six key legal principles that should underpin UHC based on the right to health: minimum core obligation, progressive realisation, costeffectiveness, shared responsibility, non-discrimination and equality, participatory decision-making and prioritising vulnerable or marginalised groups. Yet, while these principles are widely accepted, they are criticised for not being specific enough to operate as post-2015 indicators for reaching the target of UHC. In this article we propose measurable and achievable indicators for UHC based on the right to health that can be used to inform the ongoing negotiations on Sustainable Development Goals. However, we have identified three major challenges that face any exercise setting indicators post- 2015: data availability as an essential criterion, the universality of targets and the adaptation of global goals to local populations. Six principles derived from the right to health Our indicators of UHC are based on six principles pertaining to the right to health, as specified in General Comment 14 of the Committee on Economic, Social and Cultural Rights, which is tasked with monitoring compliance with the International Covenant on Economic, Social and Cultural Rights (UN CESCR, 2000). This approach means that we can draw on a body of jurisprudence and authoritative interpretation of international human rights law that identifies the rights of individuals and the obligations of those who should secure their rights. The first principle is that all states, no matter how poor, should offer a minimum core level of provision that should include ‘at least the following obligations: (a) to ensure the right of access to health facilities, goods and services on a non-discriminatory basis, especially for vulnerable or marginalised groups; … (d) to provide essential drugs, as from time to time defined under the WHO Action Programme on Essential Drugs; (e) to ensure equitable distribution of all health facilities, goods and services; (f) to adopt and implement a national public health strategy and plan of action, on the basis of epidemiological evidence, addressing the health concerns of the whole population’ (ibid: pp. 15–16). The second principle is progressive realisation of the right to health. This requires countries to move forward towards the right to health and, by implication, not to adopt measures that are regressive. In addition, each state should make progress ‘to the maximum of its available resources’ (ibid: p. 17). This implies an explicit comparison of what is being provided and what resources are available. If states claim they cannot provide health care to a level seen elsewhere, they are obliged to demonstrate why. And if states are able to move beyond their core obligations, they have a legal obligation to do so: core obligations constitute a universal floor, not a ceiling. The third principle is that interventions should be cost-effective to maximise the benefit from available resources, derived from nondiscrimination. ‘Expensive curative health services, which are often accessible only to a small, privileged fraction of the population, rather than primary and preventive health care benefiting a far larger part of the population’, have been qualified as ‘inappropriate health resource allocation that can lead to discrimination that may not be overt’ by the Committee on Economic, Social and Cultural Rights (ibid: pp. 7–8). The fourth principle is that of shared responsibility among states. Article 2(1) of the ICESCR prescribes that states ‘take steps, individually and through international assistance and co-operation, especially economic and technical, to the maximum of their available resources’ and, when the committee elaborated states’ core obligations arising from the right to health, it explicitly referred to international assistance: ‘For the avoidance of any doubt, the Committee wishes to emphasise that it is particularly incumbent on States, parties and other actors in a position to assist, to provide “international assistance and cooperation, especially economic and technical”, which enable developing countries to fulfil their core and other obligations’ (ibid: p. 16). Thus, there is an obligation on rich states to prioritise health care in their international assistance programmes. The fifth principle is the imperative for participatory decision-making, the second derived from non-discrimination. National public health Commonwealth Health Partnerships 2015 21 Devi Sridhar and Go4Health co-researchers Go4Health co-researchers: Martin McKee, Gorik Ooms, Claudia Beiersmann, Eric Friedman, Hebe Gouda, Peter Hill and Albrecht Jahn. From an article for the International Journal of Health Services (forthcoming May 2015). Adapted by kind permission. This analysis was undertaken as part of Go4Health, a research project funded by the European Union’s Seventh Framework Program, grant HEALTH-F1-2012-305240, and by the Australian government’s NH&MRC–European Union Collaborative Research Grants, grant 1055138. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Commonwealth Health Partnerships 2015
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