At this year’s World Health Assembly (May 22–31, 2017), member states will vote for a new Director-General to lead the World Health Organization (WHO) over the next five years. At this critically important time in global health—as the world looks to WHO for leadership in the face of globalized pandemics, health insecurity, mass population displacement and protracted humanitarian crises, climate change, and the looming threat of anti-microbial resistance—we asked each of the three Director-General candidates how they view the role of human rights in global health governance.
The candidates are
- David Nabarro, from the UK, sustainable development adviser to United Nations Secretary-General Ban Ki-moon
- Sania Nishtar, Pakistan’s former health minister
- Tedros Adhanom Ghebreyesus, Ethiopia’s foreign minister and former health minister
WHO’s 1948 Constitution declared that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being,” and this mandate has framed the organization’s work to advance human rights in global health over the past 70 years.
WHO has long worked to address human rights as part of its organizational efforts to direct and coordinate global health, developing health-related human rights through the United Nations (UN) and implementing human rights in its own institutional practices. Affirmed in Resolution 23.41, the World Health Assembly identified “the right to health as a fundamental human right,” stating that “the health aspect of human rights … is within the competence of the [WHO].” States have repeatedly reaffirmed this commitment to health as a human right, with the World Health Assembly developing over 60 subsequent resolutions that address human rights on a variety of WHO programs, including health development, women’s health, reproductive health, child and adolescent health, nutrition, HIV/AIDS, tobacco, violence, mental health, essential medicines, indigenous peoples’ health, and emergencies.
With the UN seeking for the past 20 years to “mainstream” human rights across its programs, policies, and activities, the UN Secretary-General has confirmed that “human rights must be incorporated into decision-making and discussion throughout the work of the Organisation.” WHO has sought to realize this system-wide commitment to human rights through a “rights-based approach to health,” with the World Health Assembly and Executive Board both endorsing such an approach. Building from WHO’s evolving work to advance a rights-based approach to health, the 2012 creation of WHO’s gender, equity and rights team has helped the organization mainstream gender, equity, and human rights across all organizational activities.
HHRJ: How should WHO’s constitutional recognition of the right to health inform the organization’s response to global health challenges?
Dr. Nabarro: WHO has a constitutional mandate to advocate for all people’s right to health. The right to health offers us a powerful lens through which to examine responses to global health challenges. When we use the right to health lens, we know that we will encounter difficult issues. Who is left behind? Who is unable to access good-quality care? Who is not included in actions for public health? The right to health lens can be applied globally, regionally, or in individual settings. It can be applied to the work of governments, civil society, and international organizations.
The 2030 Sustainable Development Agenda is often portrayed as a contract between people and their states—a social contract. It is based on human rights principles, something I have defended and upheld throughout my career. From a human rights perspective, people being put at risk of financial ruin as a result of illness or being excluded from health care services that they need are both unacceptable and in my view reflect violations of people’s rights.
I am committed to leading a WHO whose work in health will make a major contribution to the realization of rights and, particularly, to universal health coverage. In this respect, universal health coverage seeks to achieve better health outcomes through access to all required services along with financial protection. In addition, it provides a universal standard for people’s entitlements and explicitly sets out the choices nations need to make if they are progressively to realize that standard. Universal health coverage offers indicators for the measurement of progress toward that standard, which serve as metrics for accountability.
Dr. Nishtar: The WHO Constitution states that the enjoyment of the highest attainable level of health is a fundamental right of every human being; as a result, adopting a human-rights based approach to health is critical to achieving health for all.
While member states have the primary responsibility for protecting the human rights of their populations, and for ensuring that health rights are enshrined in domestic constitutional provisions and legislation, they have mandated the Secretary-General and the UN system to help them achieve the standards set out in the UN Charter and the Universal Declaration of Human Rights.
WHO is bound both by its mandate as a UN agency and by its own Constitution to be the champion and steward of the right to health for all. WHO must therefore integrate a human-rights based approach to health into its scope of work at all levels—human rights should be a lens through which the organization views its policies and programs.
As elaborated in my book Choked Pipes, it should also be noted that the Universal Declaration of Human Rights forms the basis of understanding for the concept of socioeconomic rights and the question of their enforcement. The declaration was initially intended as one instrument but was later bifurcated into two distinct and different covenants, namely the International Covenant on Civil and Political Rights (ICCPR) and the International Covenant on Economic, Social and Cultural Rights (ICESCR). Many states that supported the separation were of the opinion that the two sets of rights could not be equated and that social and economic prerogatives of citizens could not be the basis of binding obligations in the way that civil and political rights needed to be. This split allowed states to adopt some rights and not the others. Recently, however, there has been a burgeoning international trend toward a progressive interpretation of rights, including adoption of normative frameworks, such as the landmark resolution by the UN Human Rights Council acknowledging preventable maternal mortality as a human rights issue.
Dr. Tedros: I have always been inspired by WHO’s constitutional recognition of the right to health. It entails that every person, regardless of who they are or where they live, has access to quality health care that is timely, acceptable, and affordable. These principles and WHO’s mandate are just as relevant today as they were at its founding. However, the challenges in global health and development today are drastically different from what they were seven decades ago. To address these, WHO must evolve and adapt, put the right to health at the core of its functions, and be the global vanguard to champion them.
I believe that focusing on, driving toward, and ultimately achieving universal health coverage is our best path to live up to WHO’s constitutional commitment to the right to health. And if I am elected Director-General, my topmost priority will be universal health coverage. The growing momentum around universal health coverage—combined with the global commitment to sustainable development and its motto of “leaving no one behind”—offers unique opportunities to advance equity in health.
HHRJ: How do you see the right to health and rights-based approaches guiding WHO’s work with national governments and civil society?
Dr. Nabarro: I anticipate that WHO will continue to reflect the directives of its governing bodies and support the use of human rights-based approaches in planning and programming across everything the organization seeks to achieve. Disaggregated data on health trends provide an important measure through which to identify persons and population groups who are at greatest risk (in terms of health outcomes) and tend to be excluded from responses. This group tends to include refugees, migrants, and around 10 million people (of whom 3 million are children) who are stateless in their own country or liable to be forcibly displaced. But more specific information is needed for effective tracking of who is being left behind and the measures being taken to address the situation.
Civil society organizations that can provide additional insights (for example, on inequities and discrimination) have important contributions to make. Under my leadership, WHO will encourage accurate and impartial reporting of all health data. The information will be made available to human rights treaty bodies as they conduct individual country reviews.
Dr. Nishtar: The 2030 Agenda and Sustainable Development Goals reaffirm the responsibility of member states to “respect, protect and promote human rights, without distinction of any kind as to race, colour, sex, language, religion, political or other opinions, national and social origin, property, birth, disability or other status,” signaling a renewed commitment to human rights. In line with this, WHO has developed a roadmap to integrate equity, gender, human rights, and social determinants into ongoing activities—a welcome step. I will build further on that.
In terms of engagement with national governments, it must be appreciated that WHO has a dual role. It is a member-state-governed organization and, as such, must execute policy set by member states. But on the other hand, it is also the global guardian of health, and therefore there are situations in which it must stand firm to promote a rights-based approach to health.
As for civil society, WHO has an explicit mandate to engage as agreed by member states through the Framework of Engagement with Non-State Actors. Civil society has a comparative advantage in relation to advocacy and accountability, which is where strategic engagement with civil society can help promote a rights-based approach to health.
I come from a civil society background and have been a longstanding and strong promoter of the rights-based approach to health. The dedication of my last book, Choked Pipes, epitomizes my commitment: “Dedicated to the silent and unjustified suffering of millions of individuals for whom the right to health remains unrealized—and whose lives I strive and aspire to touch.” Choked Pipes provides a blueprint for how low- and middle-income countries can move toward universal health coverage from a mixed health system. In aspiring to lead WHO, I aspire to lead an organization that positions health as a wider reflection of a broad social policy vision and a universal right rather than a commodity.
Throughout my work as a doctor, in government, in civil society, in academia, and with international agencies, I have always based my work on the rights-based foundation. It was this strong grounding that led me to set up an innovative financing facility in Pakistan that helps the poorest and most marginalized communities avoid catastrophic expenses when accessing health. I will continue to walk the talk on the right to health as Director-General of WHO.
Dr. Tedros: Every year, hundreds of millions of people go without essential health care or fall into poverty trying to pay for it. That is a violation of the human right to health that demands our full attention and urgent action. All of us—national government leaders, members of civil society, health workers, patients and families, and religious and community leaders—have critical roles to drive progress on universal health coverage. Developing technical policies to ensure universal health coverage is an important start, but policies alone will not be sufficient. Implementation of those policies is much more difficult and requires collaboration and partnership across stakeholders.
That approach guided Ethiopia’s pursuit of equitable health access when I was minister of health. We maintained a firm commitment to the principle that health is a basic human right by dramatically expanding coverage of primary health care services. We achieved success by (1) directing new domestic investments in primary health care to people in areas where the need was greatest, including rural and pastoralist areas; (2) engaging communities as partners in local health governance; and (3) building political commitment and promoting accountability at all levels and across all stakeholder groups.
Reflecting these experiences, I believe WHO can and must play an enabling and catalytic role to help all governments achieve universal health coverage and, in turn, advance the human right to health, and I believe it must engage a diverse set of partners, including civil society, in these efforts to ensure success.
HHRJ: How can WHO organizational reform (of staff, resources, and partnerships) strengthen UN system-wide efforts to “mainstream” human rights in public health programming? How can a WHO human rights unit support these organizational efforts?
Dr. Nabarro: A focus on the realization of the right to health is not an optional add-on to WHO’s work; it is fundamental to it. We face a broad range of global health challenges—too many to cover comprehensively in a short response—which demonstrate that human rights work in WHO must be mainstreamed throughout the organization. There will be a need for the development and application of tools that enable right to health considerations to be incorporated in WHO’s work and to be shared with the other bodies with whom WHO works to advance health for all. There will also be a need for all staff to have appropriate human rights capabilities—in country offices, regions, and headquarters. They will be expected to advocate for, articulate, and report on human rights aspects in their respective areas of expertise. To this end, I will seek to ensure that there is appropriate health and human rights advice available for all parts of the organization. This will include appropriate reporting arrangements that enable me to appreciate what is happening in this aspect of our work and to understand whether additional emphasis is needed as I take responsibility for driving policy across WHO.
Dr. Nishtar: Too often, when health experts are asked about human rights or gender in their work, they pass off the questioner to a human rights or gender expert. From my perspective, this is simply unacceptable. A human rights approach, like the social determinants and life course approach, must be part of the organizational DNA and “everybody’s business.”
To deliver a rights-based approach in our work, we must exemplify the change we want to see in terms of transparency, accountability, and impartiality. My whole life’s work has been based on these attributes. In terms of WHO reform, this also means adopting a transparency and accountability framework that is straightforward to enforce and is guided by independent voices. In my “10 Pledges for a New WHO,” I have committed to delivering on this premise as a priority.
For this reason, in addition to supporting work to further national commitment to the covenants mentioned above (ICCPR and ICESCR), WHO must support countries in the implementation of all international commitments that outline actions and mechanisms for a rights-based approach to health, including the Convention on the Rights of the Child, the Convention on the Elimination of All Forms of Discrimination against Women, the Declaration of Alma Ata, the Programme of Action of the International Conference on Population and Development, and the Beijing Platform for Action.
Human rights, as well as gender and equity, should not be stand-alone programs; rather, they should be integrated into organizational ethos and everyday work and should cut across all programming. While we must have a unit of highly qualified technical experts, they cannot work in a silo and should not carry the burden of full accountability for this area of work.
As a critical part of my tenure, I will establish a delivery unit and priority metrics, which will regularly assess organizational and institutional performance. To this end, while the gender, equity, and human rights group will provide expert support, there would be accountability and responsibility of each and every staff member to make sure these perspectives are appropriately integrated into all areas—from strategy to daily work.
Dr. Tedros: I am committed to transforming the way that WHO operates. A more effective and efficient WHO will strengthen the entire UN system. As we reform WHO’s infrastructure and ways of operating, we will make sure that the core principles of health as a human right and universal health coverage for the most vulnerable are at the forefront of all our work. Too often, human rights and gender equity are secondary considerations when UN organizations develop programming. This is outdated and must change.
When it comes to rights issues in the reform, importantly, it’s not so much the design of the processes or structures that will make a difference. Far more important is ensuring that health as a human right is engrained into the mindset and attitudes of staff. We need to make sure WHO staff take this core value of the organization to heart and truly believe in it. That is how I believe we will most effectively mainstream human rights in WHO’s public health programming.
Given WHO’s mandate, it will be important to strengthen the existing human rights unit to ensure there are dedicated resources and focus on this issue. That said, as the ultimate guarantor of the right to health, WHO requires more than a single unit in its organizational structure devoted to human rights.
Human rights should be the responsibility of each and every unit. In order to reach this point, we have to effectively mainstream human rights throughout the organization and regularly evaluate to see what impact the mainstreaming is having. That is what I will do if elected Director-General.