Benjamin Mason Meier, Paul Henry Brodish, and Meri Koivusalo
From June 10-14, the World Health Organization (WHO) and Finland’s Ministry of Social Affairs and Health will host the Eighth Global Conference on Health Promotion in Helsinki, Finland.1 The Global Conference will highlight Health in All Policies (HiAP), an approach that evolved over the past quarter century and arose out of a focus on primary health care in the 1978 Alma Alta Declaration. The approach emphasizes intersectoral action on underlying determinants of health in the 1986 Ottawa Charter.2,3 In reviewing national experiences with the HiAP approach and establishing guidance for implementation at all levels of governance, this conference presents an opportunity to advance HiAP through the application of human rights, applying human rights to justify the mainstreaming of health in the development, and implementation of public policy. Viewing HiAP as instrumental to a rights-based approach to health, it is necessary for the Global Conference to consider the beneficial application of “health-related rights” to the HiAP approach.
Defining HiAP
In drafting a definition of HiAP for the Global Conference, ongoing debates are taking place regarding the appropriateness of language on health-related rights. Positing human rights as a normative framework for the HiAP approach, the initial working definition for the conference noted:
Health in All Policies is a systemic and sustained approach to taking into account the impacts of public policies on health determinants and health systems across sectors…in order to realize health-related rights and to improve accountability for population health and health equity.4
Following debates on this working definition, it was revised in May 2013 to add a distinct sentence on health-related rights:
Health in All Policies (HiAP) is an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity. A Health in All Policies approach is founded on health-related rights and obligations. It improves accountability of policymakers for health impacts at all levels of policy-making. It includes an emphasis on the consequences of public policies on health systems, determinants of health, and well-being. It also contributes to sustainable development.5
With the finalization of this approach less than a month away, the challenge for the conference is whether this human rights focus will remain a part of how HiAP is understood and how it is positioned as part of policy-making. With human rights justifying intersectoral policy reform, HiAP can prove relevant to assessing how policies affect population health, health systems, and health-related goals, furthering the UN General Assembly’s commitment to universal health coverage and focus on the policies that underlie public health.6,7
Role of human rights
Without an understanding of the overlap between intersectoral policy reform and the rights-based approach, states will be unable to realize the promise of the WHO Constitution, which recognizes “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being” and that “governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures.” In the development and implementation of the HiAP approach, human rights have the capacity to offer (1) norms for policy development and (2) accountability for policy implementation.
Human rights provide a powerful normative framework for HiAP, shifting policy development from a focus on technical interventions to an agenda for social justice.8 With the WHO Commission on Social Determinants of Health failing to examine common ground with human rights obligations, omissions characterized as missed opportunities, it is both necessary and possible to reengage human rights in developing the HiAP approach.9,10 Through parallel frameworks, the intersectoral arrangements inherent in the HiAP approach mirror the interconnectedness across health-related rights. Because the rights-based approach seeks to bring together rights—recognizing all rights as interdependent and interrelated—this understanding of rights can give normative legitimacy to HiAP’s broader approach to health.11 Such health-related human rights justify action on determinants of the public’s health, raising the political standing of health across sectors and recognizing that public policy must focus on the prerequisites of health in order to sustain health systems.12
In facilitating accountability for HiAP, human rights provide powerful mechanisms to advance justice in health, shifting policy implementation from social justice to legal realization. Framing government responsibilities under international law, rights-based approaches secure a basis for managing differences in power in the policymaking process, countering vested opposition to health promotion policy and empowering the most marginalized to challenge the conditions underlying morbidity and mortality.13 As states have incorporated health-related rights under national law, this rights-based approach is explicitly shaping accountability for government efforts—framing the legal and policy environment, integrating core principles into policy and programming, and evaluating systematic implementation of programs and budgets.14 National legal advocacy and international rights assessments offer implementation standards by which to frame accountability to secure necessary policy reforms for the progressive realization of human dignity and the internalization of health considerations across public policy.15
Conclusion
The Global Conference holds great promise for developing human rights norms in HiAP and implementing human rights accountability for health in all policies. Recognizing the linkages between interconnected human rights and intersectoral determinants of health, human rights offer unparalleled justification for the development and implementation of the HiAP approach. As a means to conceptualize future challenges in health promotion and health systems, the inclusion of “health-related rights” as an essential and explicit part of HiAP would provide continuing operational legitimacy to public health in global governance.
References
1. World Health Organization, 8th Global Conference on Health Promotion. Available at http://www.who.int/healthpromotion/conferences/8gchp/en/index.html.
2. T. Ståhl, M. Wismar, E. Ollila, et al., Health in All Policies: Prospects and Potentials (Helsinki: Ministry of Social Affairs and Health, 2006).
3. T. Melkas, “Health in all policies as a priority in Finnish health policy: A case study on national health policy development,” Scand J Public Health 41 (2013), pp. 3-28.
4. Action: SDH, Health in All Policies Approach (Geneva: World Health Organization, 2012). Available at http://www.actionsdh.org/Contents/Action/Governance/Building_governance/Health_in_All_Policies_approach3.aspx.
5. World Health Organization and Ministry of Social Affairs and Health, Framework and Statement: Consultation on the drafts of the “Health in All Policies Framework for Country Action” and the Conference Statement of 8th Global Conference on Health Promotion (May 8, 2013). Available at http://www.healthpromotion2013.org/conference-programme/framework-and-statement.
6. United Nations General Assemby. Document A/67/L.36. Global health and foreign policy. New York: United Nations; 2012. Available at http://www.un.org/ga/search/view_doc.asp?symbol=A/67/L.36.
7. M. Koivusalo, R. Labonte, T. Schrecker, “Globalization and policy space for health and social determinants of health,” in R. Labonte, T. Schrecker, C. Packer, V. Runnel (eds), Globalization and Health: Pathways, Evidence and Policy (New York and London: Routledge, 2009), pp. 105-30.
8. A. Sen, “Why and how is health a human right?” Lancet 372 (2008), p. 2010.
9. A. Chapman, “Missed opportunities: The human rights gap in the report of the Commission on Social Determinants of Health,” Journal of Human Rights 10 (2011), pp. 132-50.
10. P. Hunt, “Missed opportunities: human rights and the Commission on Social Determinants of Health,” Global Health Promotion 16 (2009), pp. 36-41.
11. UN Committee on Economic, Social, and Cultural Rights, General Comment No. 14, The Substantive Issues Arising in the Implementation of the International Covenant on Economic, Social, and Cultural Rights, UN Doc. No. E/C.12/2000/4 (2000).
12. K. Rasanathan, J. Norenhag and N. Valentine, “Realizing human rights-based approaches for action on the social determinants of health,” Health Human Rights 12 (2010), pp. 49-59.
13. J. Wolff, The Human Right to Health (New York: W. W. Norton & Company, 2012).
14. G. Backman, P. Hunt, R. Khosla, et al. “Health systems and the right to health: an assessment of 194 countries,” Lancet 2008; 372(9655): pp 2047-85.
15. M. Wismar, D. McQueen, V. Lin, et al., “Rethinking the politics and implementation of health in all policies,” Israel J Health Policy Res 2013; 2:17.