Audrey R. Chapman
I first became involved with right to health issues around the time of the launching of the Health and Human Rights Journal when I became director of a human rights program at the American Association for the Advancement of Science. Having spent nearly 10 years in Africa, I gravitated toward economic and social rights and then the right to health naively believing the human rights rhetoric that all rights are considered interdependent and equal in status and respect. When I became aware that it was not the case, particularly in the United States, where economic and social rights were, and still often are, relegated to the status of aspirational goals, I thought that better conceptualizing the scope and content of states’ obligations would confer more respect. To that end, I organized several projects and worked with members of the United Nations Committee on Economic, Social and Cultural Rights who were engaged in developing a general comment on the right to health. The general comment, which was adopted in 2000, contributed toward the goal of better understanding the conceptual scope of the right to health and related state obligations. But obviously, it was not the magic wand encouraging governments to take the right to health more seriously that I had assumed it would be. Nor have been the many significant articles published in the Health and Human Rights Journal. Yet both have contributed toward a better understanding of health and human rights issues.
I now see the challenges to implementing the right to health quite differently. I understand far better that the political, social, and economic environment in which we live, more specifically the neoliberal policies that have dominated many countries and international agencies during the past 35 years, present significant obstacles to the realization of economic and social rights. I wrote in Global Health, Human Rights, and the Challenges of Neoliberal Policies, that ironically, as the right to health has evolved and become more widely recognized as an appropriate normative foundation and ethical requirement for health policy development, there has been a global paradigm shift engendered by the increasing hegemony of neoliberal ideology and policies.[1] Neoliberalism contends that markets are the appropriate basis for organizing all areas of economic and social life regardless of their deleterious effects on human welfare and dignity. In contrast with a human rights approach, which conceptualizes health to be a social good contributing to human welfare, neoliberal policies consider health service to be an economic commodity. As such, the availability of health services depends on having the resources to pay for them. Human rights vest fundamental responsibility for realizing human rights obligations in the state and thereby requires a strong and effective state apparatus able to realize human rights obligations. In contrast, neoliberalism promotes political policies minimizing the role of the state and advocates transferring the provision of health and other social services to the private sector on a for-profit basis. All of this makes the realization of human rights goals far more difficult to achieve.
Today there is an apparent consensus on the importance of achieving universal health coverage, which is a major right to health commitment. This goal has been affirmed in a 2011 WHO resolution, serves as the central target in the comprehensive health goal in the Sustainable Development Goals and most recently was the subject of the political declaration signed by all countries participating in the September 2019 High Level Meeting on Universal Health Coverage. [2] However, according to recent WHO statistics, in 2017 only between one third and half of world’s population was covered by essential health services, and many more did not have access to clean water, sanitation, or education, all of which are important social determinants of health. Moreover, globally and in many countries the pace of progress toward universal health coverage has slowed since 2010. Troublingly, financial protection, a key component of universal health coverage, as well as the right to health, is going in the wrong direction. Impoverishment related to healthcare expenses is increasing. The incidence of catastrophic health expenditures increased between 2000 and 2015. WHO’s Universal Coverage Monitoring Report states that nearly one billion people spent more than 10 percent of household income on basic healthcare in 2015 and 210 million spent more than 25 percent.[3]
So how can right to health advocates counter these trends? I believe that directly challenging the assumptions and key ideological premises of neoliberalism that have contributed to these outcomes is key to doing so. To that extent, I agree with some of the critics of human rights like Samuel Moyn who have taken the human rights community to task for not opposing neoliberalism more forthrightly, although I would disagree with him on many other of his claims.[4] Currently, the human rights literature critiquing neoliberalism and its impact on achieving human rights goals is relatively sparse. Paul O’Connell and Ted Schrecker early sounded the alarm in their publications.[5] Alicia Yamin has published a number of important articles, some in this journal.[6] Gillian MacNaughton and Diane Frey have recently published an edited volume, Economic and Social Rights in a Neoliberal World that has essays documenting the impact of neoliberalism on a wide range of countries and international agencies.[7] There needs to be many more.
I intend this reflection to be a call to arms to the human rights community, particularly those committed to improving health access and outcomes, to more vigorously oppose neoliberalism and its deleterious impacts on health and the human welfare. Research and writing of course is one way. But I think that we need individually and as a community, to the extent there still is a human rights community, to also become more involved in the formulation of policy priorities and policy implementation to counter neoliberalism.
Audrey R. Chapman is Healey Professor of Medical Ethics, UConn School of Medicine.
Please address correspondence to achapman@uchc.edu.
References
[1] Audrey R. Chapman, Global Health, Human Rights and the Challenge of Neoliberal Policies, Cambridge: Cambridge University Press, 2016.
[2] World Health Assembly, “Sustainable Health Financing, Universal Coverage and Social Health Insurance,” Sixty-Fourth World Health Assembly, 2011, WHA64.9,A64/VR/10, para 2; Transforming our World: the 2030 Agenda for Sustainable Development resolution, Adopted by the General Assembly on 25 September 2015, UN Doc. A/RES/70/1; Political Declaration, September 2019 High Level Meeting on Universal Health Coverage, https://www.un.org>sites>2019/05>UHC-PoliticalDeclaration>FINAL-draft-UHC-Political-Declaration.
[3] World Health Organization, Universal Coverage Monitoring Report, 2019, https://www.who.int>healthinfo>universal-health-coverage.report, Geneva: World Health Organization, pp. 1-3.
[4] Samuel Moyn, Human Rights in an Unequal World, Cambridge: MA, 2018.
[5] Paul O’Connell, “On Reconciling Irreconcilables: Neoliberal Globalisation and Human Rights,” Human rights Law Review, 2007 7 (3): 483-509; Ted Schrecker, “The Health Case for Economic and Social Rights AgaInst the Global Marketplace, “ Journal of Human Rights, 2011, 10 (2): 151-177; Ted Schrecker, Audrey R. Chapman, Ronald Labonté, and Roberto De Vogli, “Advancing health equity in the global marketplace: How human rights can help,” Social Science and Medicine, 2010, doi:10.1016/j.socscimed.2010.06042.
[6] See for example, Alicia Ely Yamin, “Will We Take Suffering Seriously? Reflections on What Applying a Human Rights Framework to health Means and Why We Should Care,” Health and Human Rights Journal (2008), 10 (1): 45-63; Struggles for Human Rights in Health in an Age of Neoliberalism: From Civil Disobedience to Epistemic Disobedience,” Journal of Human Rights Practice (2019) 11 (2): 357-379.
[7] Gillian MacNaughton and Diane F. Frey, Economic and Social Rights in a Neoliberal World, Cambridge, UK: Cambridge University Press, 2018.