What does human rights have to add to discussions about universal coverage? A L I C I A E LY YA M I N LECTURER ON GLOBAL H E A LT H , A N D DIRECTOR, H E A LT H R I G H T S O F W O M E N AND CHILDREN PROGRAM H A R VA R D S C H O O L O F P U B L I C H E A LT H Universal Coverage as a Human Rights Issue “The vision of UHC is rapidly becoming a reality, with access to health care no longer the privilege of a few, but the birthright of many.” Lancet editorial, The Struggle for Universal Health Coverage, September 8, 2012 UN Resolution on Child’s Right to Health (Human Rights Council, 2013) 44. Recognizes that effective and financially sustainable implementation of universal health coverage is based on a resilient and responsive health system that provides comprehensive primary health-care services, with extensive geographical coverage, including in remote and rural areas, and with a special emphasis on access to populations most in need, and has an adequate skilled, well-trained and motivated workforce, as well as capacities for broad public health measures, health protection and addressing determinants of health through policies across sectors, including promoting the health literacy of the population; 45. Acknowledges that universal health coverage implies that all children have access, without discrimination, to nationally determined sets of the needed promotive, preventive, curative and rehabilitative basic health services and essential, safe, affordable, effective and quality medicines, while ensuring that the use of these services does not expose the users to financial hardship, with special emphasis on the poor, vulnerable and marginalized segments of the population; 46. Recognizes the responsibility of Governments to urgently and significantly scale up efforts to accelerate the transition towards universal access to affordable and quality health-care services. Right to Health “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” - Preamble of the Constitution of the WHO (1946) Rights-based Approach to Health Systems Item Conventional Approach Task Force (HR) Approach Primary unit of analysis Specific diseases or health conditions, with focus on individual risk factors Health system as core social institution Driving rationale in structuring the health system Commercialization and creation of markets, seeking financial sustainability and efficiency through the private sector Inclusion and equity, through cross-subsidization and redistribution across the system Patients/users Consumers with preferences Citizens with entitlements and rights Role of state Gap-filler where market failure occurs Duty-bearer obligated to ensure redistribution and social solidarity rather than segmentation that legitimizes exclusion and inequity Equity strategy Pro-poor targeting Structural change to promote inclusion UN Millennium Project, Task Force on Child Health and Maternal Health, 2005 Norms under International Law IMPLICATIONS FOR MOVING TOWARD UNIVERSAL COVERAGE International Covenant on Economic, Social and Cultural Rights (1966/entered into force 1976) Article 12(1): right to the “highest attainable standard of physical and mental health.” Article 12(2) sets out steps states should take toward progressive realization: a) The provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child; b) The improvement of all aspects of environmental and industrial hygiene; c) The prevention, treatment and control of epidemic, endemic, occupational and other diseases; and d) The creation of conditions which would assure to all medical service and medical attention in the event of sickness. Protocol of San Salvador, article 10 (1999) 1. Everyone shall have the right to health, understood to mean the enjoyment of the highest level of physical, mental and social well-being. 2. In order to ensure the exercise of the right to health, the States Parties agree to recognize health as a public good and, particularly, to adopt the following measures to ensure that right: a. Primary health care, that is, essential health care made available to all individuals and families in the community; b. Extension of the benefits of health services to all individuals subject to the State's jurisdiction; c. Universal immunization against the principal infectious diseases; d. Prevention and treatment of endemic, occupational and other diseases; e. Education of the population on the prevention and treatment of health problems, and f. Satisfaction of the health needs of the highest risk groups and of those whose poverty makes them the most vulnerable. Some General Principles “Progressive Realization” in accordance with “maximum available resources”; retrogression presumed inconsistent (Colombia, 2004; Spain , 2012 cases) Interdependence with C/P rights (e.g., information, equal protection, etc; also TCIDT proscriptions); multi-sectoral (e.g., education; Colombia, 2008) Constitutional enforceability or legislative recognition; Principles for Moving Toward UC AAAQ: “Health facilities, goods and services need to available, accessible, acceptable and of adequate quality.” (CESCR, GC 14, para 12) Process for setting priorities: core obligation to adopt and implement a national public health strategy and plan of action. Process shall be evidence-based, participatory and transparent, and include affected groups. (CESCR, GC 14, para 43f) Principles for Including More People “All human beings are born free and equal in dignity and rights” (Universal Declaration of Human Rights) Special concern for marginalized and vulnerable groups (e.g., prisoners, children, pregnant women, persons with disabilities, elderly, PLWAs) Those who lack access because of economic or physical reasons, or any form of discrimination Non-discrimination and Equality “Prohibited grounds” (including: sex, race, ethnicity, caste, HIV status, religion, national origin, disability) Formal equality and universality (e.g., TAC case v. Soobramoney) Substantive equality: when effective enjoyment of rights requires differential treatment. (e.g. Alyne da Silva Pimentel v Brazil; disability rights) Concluding Reflections: Context Matters _______________ _______________ _______________ 80 20 50 50 20 80 Percent (%) of population Based on L. Tempkin, Inequality (New York: Oxford University Press, 1993), p. 297.