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What Do Core Obligations Under the Right to Health Bring to Universal

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What Do Core Obligations Under the Right to Health Bring to Universal HHr Health and Human Rights Journal What Do Core Obligations under the Right to HealthHHR_final_logo_alone.indd 1 10/19/15 10:53 AM Bring to Universal Health Coverage? lisa forman, claudia beiersmann, claire e. brolan, martin mckee, rachel hammonds, and gorik ooms Abstract Can the right to health, and particularly the core obligations of states specified under this right, assist in formulating and implementing universal health coverage (UHC), now included in the post-2015 Sustainable Development Goals? In this paper, we examine how core obligations under the right to health could lead to a version of UHC that is likely to advance equity and rights. We first address the affinity between the right to health and UHC as evinced through changing definitions of UHC and the health domains that UHC explicitly covers. We then engage with relevant interpretations of the right to health, including core obligations. We turn to analyze what core obligations might bring to UHC, particularly in defining what and who is covered. Finally, we acknowledge some of the risks associated with both UHC and core obligations and consider potential avenues for mitigating these risks. lisa forman is Canada Research Chair in Human Rights and Global Health Equity, and Assistant Professor at the Dalla Lana School of Public Health at the University of Toronto, Canada. claudia beiersmann is a researcher in the working group “Global Health Policies and Systems” at the Institute of Public Health, Heidelberg University, Germany. claire e. brolan is a postdoctoral fellow at the Dalla Lana School of Public Health at the University of Toronto and research fellow at the School of Public Health, Faculty of Medicine and Biomedical Sciences, University of Queensland, Australia. martin mckee is Professor of European Public Health at the London School of Hygiene and Tropical Medicine, United Kingdom, and Director of Research Policy at the European Observatory on Health Systems and Policies. rachel hammonds is a post-doctoral researcher in the Law and Development Research Group at the University of Antwerp’s Law Faculty, Belgium. gorik ooms is Professor of Global Health Law and Governance at the London School of Hygiene and Tropical Medicine, United Kingdom. Please address correspondence to Lisa Forman. Email: [email protected]. Competing interests: None declared. Copyright © 2016 Forman, Beiersmann, Brolan, McKee, Hammonds, and Ooms. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited. DECEMBER 2016 VOLUME 18 NUMBER 2 Health and Human Rights Journal 23 l. forman, c. beiersmann, c. e. brolan, m. mckee, r. hammonds, and g. ooms / UHC and Human Rights, 23-34 Introduction mains that UHC explicitly covers. We then engage with relevant interpretations of the right to health, Can the right to health, and particularly the core including core obligations. We turn to analyze what obligations of states specified under this right, core obligations might bring to UHC, particularly assist in formulating and implementing universal in defining what and who is covered. Finally, we health coverage (UHC), now included in the post- acknowledge some of the risks associated with both 2015 Sustainable Development Goals (SDGs)?1 This UHC and core obligations and consider potential question has driven research under the Go4Health avenues for mitigating these risks. Consortium, which seeks to embed rights-based approaches in the post-2015 SDG health agenda. The Go4Health Consortium, of which all authors UHC and the right to health are a part, focuses on what the right to health of- Given that the goal of UHC has strong synergies fers discursively and substantively to this agenda with the commitment to universalism enshrined and aims to clarify the contributions of the core within the right to health, UHC should be rooted obligations that flow from the right to health.2 explicitly within this right.7 This view is shared by Rights language frames health—not as an exter- the World Health Organization (WHO) and other nality, investment, or issue of compassion but as a institutional actors, who see UHC as a “practical legal entitlement and fundamental matter of social expression of health equity and the right to health” justice.3 Thus, framing global health as a question and “deeply embedded” in international law.8 In of human rights guides our understanding of it, 2012, the United Nations (UN) General Assembly identifying the actors that must be engaged and the legally prescribed measures needed to achieve endorsed this view when it called on states to realize 9 it.4 In this paper, we examine how core obligations UHC while reaffirming the right to health. More under the right to health could lead to a version recently, WHO has expanded on this conception: of UHC that is more likely to advance equity and To support the goal of universal health coverage is rights. In adopting so specific a focus on core ob- also to express concern for equity and for honoring ligations and UHC, we do not intend to obscure or everyone’s right to health. These are personal and delegitimize important investigations of what the moral choices regarding the kind of society that peo- larger right to health canon brings to elaborating ple wish to live in, taking universal coverage beyond and implementing UHC. Indeed, the current the technicalities of health financing, public health 10 authors have produced a significant amount of and clinical care. scholarship focused on this question, exploring what right-to-health components and mechanisms However, at a practical level, what does the right to (such as progressive realization and indicators) health imply for UHC, particularly regarding the bring to UHC.5 This paper adopts a far narrower crucial questions of the type of health care required focus on what core obligations might offer to UHC, to advance the right to health? This has been less since irrespective of their interpretive deficits and clear, not least because of a lack of clarity around scholarly contestation, core obligations remain a what is meant by UHC.11 fundamental component of contemporary inter- 6 pretations of the right to health. To this extent, Changing definitions of UHC this analysis complements discussions of the right to health’s broader contribution to formulating and The 2005 World Health Assembly resolution call- implementing the SDGs. ing for UHC had a strong focus on financing and To explore the question of what core obligations insurance (as its title suggests), defining UHC as bring to UHC, we first address the affinity between “access to key promotive, preventive, curative and the right to health and UHC as evinced through rehabilitative health interventions for all at an af- changing definitions of UHC and the health do- fordable cost, thereby achieving equity in access.”12 24 DECEMBER 2016 VOLUME 18 NUMBER 2 Health and Human Rights Journal l. forman, c. beiersmann, c. e. brolan, m. mckee, r. hammonds, and g. ooms / UHC and Human Rights, 23-34 It urged member states “to ensure that health-fi- criminatory access seeks to ensure that UHC does nancing systems include a method for prepayment not simply lead to aggregate gains at the expense of of financial contributions for health care, with the poor; at the same time, it is important to avoid a view to sharing risk among the population and the risk that an exclusive focus on the poor and avoiding catastrophic health-care expenditure and vulnerable will lead to services that are selective— impoverishment of individuals as a result of seeking and thus potentially of poor quality—rather than care.”13 The 2010 World Health Report did little to comprehensive.18 clarify the content of these services but brought the This trajectory from key to basic to essential UHC cube, originally designed by Reinhard Busse services is reflected in the somewhat terser final et al., to a wide audience.14 The cube identified three SDG 3.8 formulation, which commits states to key dimensions around which to measure prog- “achieve universal health coverage, including fi- ress toward UHC: the range of services available, nancial risk protection, access to quality essential the proportion of costs of services covered, and health-care services and access to safe, effective, the proportion of the population covered. While quality and affordable essential medicines and the report acknowledged that funding constraints vaccines for all.” While the inclusion of UHC in would mean “trade-offs between the proportions of the health SDG reflects a victory for its proponents, the population to be covered, the range of services there are nonetheless questions about the priority to be made available and the proportion of the total accorded this target vis-à-vis the other nine targets costs to be met,” it reiterated that UHC nonetheless associated with this goal. Moreover, the definition meant that the “entire population in all these coun- of UHC in the SDGs raises more questions than tries has the right to use a set of services (prevention, it answers: What does financial risk protection 15 promotion, treatment and rehabilitation).” encompass? Can UHC be achieved through selec- The UN General Assembly resolution in 2012 tive health care rather than comprehensive health offered a fuller, multidimensional definition of
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