The Future of Global Governance for Health
The Future of Global Governance for Health
Putting Rights at the Center of Sustainable Development
Abstract and Keywords
This chapter argues that the current global health agenda has failed to put people and their rights at the center. With communities unable to have their voices heard, challenge injustice, and hold decision makers to account, states are ill-equipped to realize the Sustainable Development Goals (SDGs), including SDG 3 to ensure healthy lives and well-being for all. The chapter articulates a shift from a discretionary development paradigm to a rights-based paradigm for global health, building on rights-based approaches that have been proven to work—as in the AIDS response. Seven reforms are proposed, addressing: (1) priority-setting, (2) systems for health, (3) data and monitoring, (4) access to justice, (5) the need to safeguard the right to health across sectors, (6) partnerships, and (7) financing. These reforms call for a broad social movement for global governance for health, advancing and operationalizing rights-based approaches across the SDGs.
Today’s volatile and unstable world—marked by conflict, climate change, a protracted global economic recession, inequality, crisis of trust in public institutions, and the greatest-ever displacement of people by war and persecution—stands in stark contrast to the transformative vision and ambition articulated in the 2030 Agenda for Sustainable Development (2030 Agenda) and its seventeen Sustainable Development Goals (SDGs). Together, the goals weave environmental, social, and economic well-being into a single, integrated global framework. As such, they can support efforts to build resilient communities and nurture a culture of prevention—critical elements in our increasingly polarized world. Moreover, they can provide stepping stones to deepen and strengthen efforts to address health in a more integrated way, recognizing the role of a range of sectors and actors.
Achieving progress on the scale and pace required to achieve the SDGs by 2030 will demand determination and structural change—between government sectors, business, international organizations, and civil society—globally, regionally, and within countries and communities. For those seeking to assure healthy lives and well-being for all, the SDGs present an opportunity to generate the reforms necessary to ensure effective global governance for health. Such reforms will entail more than working across the SDGs; they will require the engagement of a wide range of (p.88) institutions and processes of governance at all levels that may or may not have a specific health mandate, but which impact health both directly and indirectly.
The SDGs are achievable and have the potential to reach deep into the lives of people on the ground. Collectively, the global community has the resources, technical capacity, ingenuity, and power—as member states, communities, UN agencies, civil society, and, most importantly, as peoples—to generate real change and ensure that no one is left behind. Fundamentally, success will require shifting away from development approaches and funding allocations based on the interests of the most powerful actors and toward approaches that give primacy to human rights for health, ushering in equality, justice, and inclusive prosperity.
This chapter starts in Part I by exploring some of the shortcomings of the current global health agenda resulting from a failure of governance systems to put people and their rights at its center. It then focuses in Part II on seven interrelated and mutually reinforcing reform proposals to transform the agenda into a rights-based paradigm:
1. People, in particular those most affected by ill health and who are otherwise vulnerable or marginalized, must enjoy their right to participate in decision-making processes so that their needs are prioritized in implementing the SDGs.
2. The notion of health systems should be reconceptualized into overarching systems that protect people’s health and human rights, no matter where people are, who they are, or what they do.
3. Data need to be disaggregated and democratized, so that people can leverage strategic information for change from the bottom up, as well as harness existing monitoring mechanisms to review progress on the health-related SDGs.
4. Access to justice must be enhanced and the rule of law strengthened in order to secure the requisite level of accountability to meet the SDGs.
5. In this interdependent world, a strong system of health protection requires safeguarding the right to health across systems, sectors, and actors.
6. To ensure the necessary support—from the UN to governments—in implementing the health-related SDGs, the formation of innovative partnerships to promote and protect the right to health should be explored.
7. To ensure that the SDGs are financed, the structural causes blocking financing for sustainable development—from a heavy debt burden on countries to illicit financial flows—must be addressed, going beyond traditional sources of aid.
In examining these reform proposals, and to inspire and catalyze action, Part II provides concrete examples of how rights-based approaches can be operationalized—from governance mechanisms to financing—drawing in particular from the AIDS response. The chapter concludes by urging the global health community to seize the unique opportunity presented by the 2030 Agenda to make the necessary changes to enable healthy lives and wellbeing for all.
The reality of life for most people today is exceedingly harsh. Each day, 800 million people are starving and 663 million lack clean drinking water, with 1,000 children dying due to preventable water- and sanitation-related diseases (UNDP 2016b). In war zones from Afghanistan to Syria, health facilities are being bombed in blatant disregard for the core principle of international humanitarian law: affording protection to medical personnel and facilities (ICRC 2012). Across countries, health systems are fragmented, even broken. People lack trust in governments’ ability to ensure effective systems of health protection (Pew Research Center 2015; Edelman 2017). This distrust has been exacerbated by inadequate responses to recent health emergencies, including Ebola and Zika (Gostin and Ayala 2017). Moreover, other complex and pressing challenges to population health, from antimicrobial resistance (AMR) to noncommunicable diseases (NCDs), have not yet been effectively addressed—particularly due to a failure to address their structural and social determinants.
Progress on the SDGs is impeded by major contemporary barriers and historical legacies. Corporate influences challenge the global health agenda, with profound implications for population health outcomes. This is exemplified, for example, by the widening power and authority of transnational food companies, and their ability to influence trade agreements and restrict national health promotion policies, with significant consequences for the control of NCDs (Friel et al. 2013; Moodie et al. 2013). Furthermore, with strides in technological innovation, the global health community has often sought quick-fix and “vertical” solutions while shying away from addressing the structural and root causes of ill health. Many of these causes relate to poverty and inequalities, which stem from the colonial legacies that continue to determine much of our current geopolitical landscape and influence the entire enterprise of sustainable development. Of increasing concern are illicit financial flows and offshore tax havens, acting together as perhaps the greatest driver of inequality within developing countries.1
While the World Health Organization (WHO) has recognized that most of the determinants of health lie outside the health sector (CSDH 2008), its key organizational constituencies—ministries of health—often lack leverage and power to influence other government sectors or key stakeholders, including large transnational corporations (Moodie et al. 2013). Moreover, while the World Health Assembly (WHA), the decision-making body of the WHO, has underscored the centrality of equity through resolutions passed in recent years, these WHA resolutions have not translated into tangible WHO programmatic support to countries. To ensure gender equality and women’s empowerment, for example, disaggregated data by sex is crucial, yet remains in short supply in many countries (UNDP 2016a).
Health security, another topic often debated in global health governance, too often centers around a pathogen or a virus, rather than the human person and the economic, cultural, social, physical, and political environment that can enable her to thrive or (p.90) render her vulnerable. Another recent debate at the WHA, on the engagement of stakeholders beyond member states, has placed nonprofit groups with corporations under one framework for “non-state actors” (WHO 2016a). While this framework does differentiate between private sector entities and non-governmental organizations (NGOs), subsuming these disparate actors under a “one size fits all” policy nevertheless fails to (1) recognize the centrality of engaging communities because they have the right to meaningfully participate in decisions that affect them and (2) seize an opportunity to foster greater attention to equality, dignity, justice, and the right to health.
The practice of global health governance today is overly technocratic, specialized, and inaccessible to the people it is meant to serve. Clearly, a governance gap exists between the policies and practices in global health and development and the obligations of human rights (Van de Pas et al. 2017). This failure to put people and their rights at the center of global governance perpetuates and generates structures that are out of touch and out of place (Otterson et al. 2014). Consequently, governance systems and institutions are ill-equipped to respond to the diverse challenges faced today. Now is the time for the global health community to take stock, to critically revisit its values, and to consider how development approaches must be reformed to achieve the SDGs and promote the realization of human rights for global health. Experiences from the AIDS response, where people-centered governance structures have generated tangible results, can inspire wider efforts for reform.
II. Seven Transformations in Global Governance for Health toward a Rights-Based Development Paradigm
The successful implementation of the 2030 Agenda will require nothing less than transforming the highly inequitable discretionary development paradigm into one that is rights-based. To achieve the SDG targets on health, and realize the broader vision of the SDGs, governance must foster the respect, protection, and fulfillment of the right to health. It must promote the notion of “global health citizenship,” whereby individuals are empowered to claim health-related rights and demand action and answerability from decision makers (Sidibé 2015).
In contrast to the previous Millennium Development Goals (MDGs), the SDGs incorporate human rights-based principles—they are universal in nature, transformative, comprehensive, and inclusive. Based on recognition of the inherent dignity of every human person, rights-based approaches provide a set of performance standards against which duty-bearers at all levels of society—but especially organs of the state—can be held accountable (OHCHR 2008). In this regard, they can go further than the SDGs, triggering concrete governmental obligations (Boesen and Martin 2007).2 The incorporation of human rights into the SDGs therefore (p.91) provides a recognized, legitimate, and ready-made framework to underpin, operationalize, and drive accountability on the SDGs.
At the international level, health-related human rights are codified centrally in the UN Charter (UN 1945), the WHO Constitution (WHO 1948), the Universal Declaration of Human Rights (UN General Assembly 1948), and the International Covenant on Economic, Social and Cultural Rights (ICESCR) (UN General Assembly 1966). As outlined in chapters 1 and 2, these human rights form part of a universally recognized legal framework that can, as analyzed in chapter 3, frame robust governance systems for health and cross-sectoral action.
In operationalizing health-related human rights, the AIDS response provides a strong platform for action on which to build. It is one of the best examples, as discussed in chapter 13, where a rights-based approach has been effective and has empowered people most affected—in this case people living with and affected by HIV—to drive and demand change. As they were in the AIDS response, rights-based approaches will be necessary to transform the language and even the culture surrounding global health away from “expense” to “investment,” from “client” to “rights-holder,” from “charity” to “justice,” and from “health systems” to “systems for health.” Implications for action include identifying and addressing root causes of poverty, ill health, and injustice; empowering rights-holders to claim their rights; and enabling duty-bearers to meet their obligations.
It will be a challenging journey to address the world’s institutional arrangements, values, priorities, and cultural norms, all of which reflect deeply embedded power structures that ultimately govern the distribution of people’s opportunities and health outcomes. However, there is no other choice; there is no shortcut, and global governance must heed perhaps the most central lesson learned from the AIDS response—that a rights-based approach is a necessary ingredient for success (UNAIDS 2015a). The story of AIDS is pertinent not only to show how health-related human rights can be operationalized in a meaningful, pragmatic, and actionable way but also as a model for rights to drive action and new governance approaches across the SDGs. Lessons in global governance for health learned in the AIDS response—including but not limited to bringing many stakeholders together to crowdsource solutions and taking a multi-sectoral, rights-based, and evidence-led approach—are highly relevant for addressing the interlinked and complex challenges of health-related SDGs.
Building on this platform set by the AIDS response, a rights-based system of global governance for health will require, as indicated in Figure 4.1, striving for seven interrelated and mutually reinforcing transformations.
A. Priority-Setting by People, for People
As Amartya Sen pointed out, “progress on the SDGs is not about numbers. It requires a rich human conversation about how to reach the SDGs” (Victorero 2015). Who gets to participate in this conversation, where it takes place, and on (p.92) what terms will be determining factors for success. To ensure that no one is being left behind, at every step of this conversation, it is necessary to engage vulnerable and marginalized groups so that priorities are set by people for people through community-led governance. As set out in SDG 16, “transparent and participatory decision-making processes, backed by accountable and inclusive institutions” are critical at all levels (UN 2015a). By effectively engaging communities, a vital exchange between civil society, policymakers, scientists, and service providers can take place that can help identify, through a transparent and participatory process, priorities that are equitable, evidence-informed, and responsive to needs on the ground. Indeed, the principle “Nothing About Us Without Us,” coined by the disability rights movement during the 1990s, has been central to progress in the AIDS response, where people living with and affected by HIV have been at the forefront of breaking down the legal and social barriers to HIV prevention and treatment (UNAIDS 2016c). The right to participation, as promoted by the Joint UN Programme on HIV/AIDS (UNAIDS), is increasingly becoming operationalized in other parts of the UN system, as seen, for example, with the establishment of the UN Permanent Forum on Indigenous Issues.
History attests to the fact that community engagement cannot be taken for granted. It needs to be nurtured, not least among young people, who are already leading on the SDGs in their communities. This means that civil society needs substantial, consistent, and predictable funding support as well as political space and freedom to act (UNAIDS 2015b). It also requires building the capacity of young people to demand their rights, starting with raising awareness of their range of health-related rights—including those governing sexual and reproductive health; education and employment; and an adequate standard of living and social security. Supporting civil society actors, ensuring a space for them at the policy table, and promoting young people’s awareness of their rights represent a few of the many potential avenues which can enable meaningful participation in decision-making and priority-setting by people, for people.
B. Rights-Based Systems for Health
Many health systems around the world are deeply dysfunctional and mired with challenges: priorities are often skewed toward biomedical interventions and fail to address the concerns of poor, vulnerable, and marginalized communities; services are vertical and fragmented; out-of-pocket spending remains high; and corruption is rampant. As people are becoming more aware that they are rights-holders and actively demanding the right to health, a surge in rights-based litigation is occurring, which has, in places like Colombia, catalyzed reform of the entire health system (Mora 2014).
Human rights should be “front-loaded” into governance, reforming and aligning systems and institutions so that they serve people from the outset rather than relying on litigation to spur health sector reform when rights are not met. Designing systems for health that are rights-based means using health-related human rights norms and principles—including the right to health and rights-based principles of equality, non-discrimination, participation, transparency, and accountability—to shape policies in the health sector and beyond (WHO 2011). Building on the history of using a human rights framework to drive accountability in the AIDS (p.94) response, UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) are leading efforts, as discussed in chapter 19, to operationalize rights-based systems for health by supporting countries in integrating human rights principles in their HIV prevention, testing, and treatment programs. For example, UNAIDS provides actionable guidance on how human rights approaches are critical to addressing barriers to HIV services and to achieving HIV targets (UNAIDS 2017); and the Global Fund encourages grant applicants to include programs addressing human rights and gender-related barriers to HIV services and advises on the implementation and monitoring of rights-based approaches to HIV (Global Fund 2017). These coordinated efforts to integrate human rights into national HIV responses can provide inspiration for programming rights-based approaches at the national level for health and beyond to achieve the SDGs. In addition, to ensure that policies and programs enhance gender equality, harmful gender norms must be addressed and systems designed to be gender transformative (Ibid; WHO 2011). Overall, creating rights-based systems for health requires ensuring consistency in laws, policies, and practices across government so that actions undertaken by other sectors (such as finance, planning, and trade) comply with the right to health as an obligation of the government as a whole, fostering robust and comprehensive systems for health that work for all, including marginalized communities.
Practical arrangements must be made to reinforce the interface between service providers and communities to help ensure that services are accessible to all, paying particular attention to people who are being left behind due to rural residence, poverty, prejudice, or discriminatory laws. This requires investing in community-based organizations, which, as seen in the context of HIV, are often best placed to reach people (UNAIDS 2016c). Community engagement has produced health benefits across diverse countries, as shown in Figure 4.2, including improved knowledge and safer behavior, increased use of health services, and decreased incidence of HIV and other sexually transmitted infections (STIs) (Rodriguez-Garcia et al. 2013).
Evidence shows that community health workers can fill critical service gaps, particularly in low- and middle-income countries and in contexts where formal health professionals are scarce (AU 2017; UNAIDS and Stop AIDS Alliance 2015). UNAIDS shares the vision of the Global Health Workforce Alliance on the transformative potential of health workers (Campbell 2014) and advocates for increased investment into strengthening community health work and systems (UNAIDS 2016d). Supporting community health workers through budget incentives, remuneration, essential supplies, supervision, clear career pathways, and training (ideally via an accredited curriculum) are ingredients for a sustainable model that can yield gains across a range SDG targets, including SDG 3.8 on universal health coverage and SDG 8.5 on employment and decent work for all.
C. Democratizing Data and Strengthening Monitoring
One of the most powerful tools of accountability for the realization of human rights is strategic information. This was seen in the AIDS response, where the progress of UN member states has been monitored against ambitious targets set at high-level UN General Assembly meetings (Taylor et al. 2014). The Global AIDS Monitoring (p.95) indicators and the National Commitments and Policy Instrument, an online data collection system, supports the monitoring process and enjoys one of the highest state reporting rates in global health (UNAIDS 2016b). Importantly, this tool goes beyond epidemiological data collection to include reporting on laws and policies, with civil society representatives and other nongovernmental partners completing one part of the instrument to help validate and bring critical perspective to national reports from governments (Torres et al. 2017). Another unique data collection exercise that emerged in the context of HIV is the People Living with HIV Stigma Index. Led by people living with HIV, it identifies how discrimination manifests in the social environment, such as work and access to health services, as well as the level of knowledge among communities about rights, HIV testing, and treatment (Stigma Index 2017). These data collection experiences can inspire efforts to monitor health-related rights in the SDGs in ways that are participatory and that seek to understand and address the legal and social environments that determine risk, vulnerability, and people’s dignity.
The realization of human rights through the health-related SDGs will require information, monitoring, and accountability at several levels, and it is essential that national authorities are supported in collecting disaggregated data to ensure that no one is being left behind (WHO 2016b). Support should also be provided for independent monitoring, for example by investing in community-based information (p.96) management systems to foster transparency and address corruption. Accountability for commitments and continuous improvement of interventions must be evaluated by stakeholders at all levels—from disadvantaged populations represented through civil society groups to parliamentary committees and international human rights institutions—often with support for data collection from academic partners (Bustreo and Hunt 2013; Hawkes and Buse 2016). Civil society has already gained experience in monitoring government budget processes to assess inclusiveness and accountability (International Budget Partnership 2014). Innovation to harness information technology must continue to be promoted in ways that can improve governance for health, for instance, in detecting and responding to outbreaks and emergencies (Making All Voices Count 2014). Underpinned by sound methodologies and innovative communications technologies, the inclusion of alternative data sources (e.g., from research institutions, think tanks, civil society, or crowdsourcing) can help fill data gaps and complement official data. Real-time data collection and reporting can help bring maximum returns on resources invested—to better prioritize and tailor programs that will have the greatest impact (UNAIDS 2016a).
While the global health agenda is relatively rich on data, it is weak on institutional mechanisms to scrutinize the performance of governments in improving the health of their peoples.3 In contrast, the human rights system, as discussed in Section V of this volume, contains a range of international monitoring mechanisms for assessing the realization of health-related human rights. Framing the global health agenda as a human rights enterprise opens the opportunity to engage with these mechanisms to facilitate greater rights-based accountability for health, which can help boost progress on the health-related SDGs. Such mechanisms range from UN human rights treaty bodies, as described in chapter 23, to relevant supervisory bodies of the International Labor Organization (ILO), outlined in chapter 9, to the Universal Periodic Review (UPR) process of the UN Human Rights Council (HRC), as analyzed in chapter 24. With its three-stage process and regular review cycle, the UPR is proving to be an effective tool in ensuring that rights-based actions are taken by governments on health issues across countries and regions (UPR Info 2012). As seen in the issue of female genital mutilation, UPR recommendations have resulted in legal and policy reforms, prevention strategies, and program investments (Gilmore et al. 2015).
At the national level, a range of human rights mechanisms—from national human rights institutions and ombudspersons offices to parliamentary committees—can champion the right to health and help ensure that governments and other powerful actors are monitored in their efforts to realize health-related human rights. Indicators constitute a vital tool in this regard, and national human rights institutions have recently stepped up efforts to identify appropriate indicators for monitoring economic and social rights, as, for example, in the case of Nepal, where the lack of fulfillment of such rights was considered a precursor of the 1996–2006 armed conflict (OHCHR 2011b).
At the regional level, states may be more inclined to exchange experiences and subject themselves to higher levels of scrutiny, which may represent an opportunity (p.97) to strengthen peer review across states for the realization of health-related human rights. For example, the African Union’s (AU) African Peer Review Mechanism (APRM), established in 2003 within the framework of the New Partnership for Africa’s Development (NEPAD), is a mutually agreed policy diagnostic and self-monitoring instrument among AU member states to assess conformity with shared political, socioeconomic, and corporate governance values. The APRM’s inclusion of health and human rights issues provides an opportunity to further advance health-related human rights in the region (Maina 2015), particularly as this instrument is repositioned to evaluate progress on the SDG and AU Agenda 2063 targets.
D. Ensuring Access to Justice and the Rule of Law
Experience from the field of human rights demonstrates that enabling legal environments and effective national democratic institutions are critical determinants of progress on health and development (Sagasti 2013). While governments have committed to take ownership of the SDGs and to work closely on their implementation with regional and local authorities (UN 2015a), the central human rights principle of accountability demands a legal framework that enables people to challenge governments and other duty-bearers and to hold them accountable if, and when, promises are broken.
The global health community must enter what may be uncharted waters and work to create enabling legal environments to ensure healthy lives and well-being for all—from regulating the formulation and marketing of unhealthy products to ensuring both that health care providers adhere to set standards and that social safety nets are accessible and protect against all forms of discrimination (WHO 2017). To achieve this, a broad range of actors that impact health, or can impact health, but often fall outside of traditional involvement in the “health sector,” must be mobilized—including community activists, judges, and parliamentarians. Future work in global health must involve training law enforcement agents, supporting law reform and legal literacy programs, and building the capacity of civil society to engage in strategic litigation. Such litigation, particularly in countries with strong constitutional provisions on the right to health, has in many instances helped reframe laws, policies, and practices to safeguard health-related human rights (KELIN 2016).
(p.98) SDG 16 on accountability has targets dedicated to the rule of law and access to justice, providing an opportunity for the global health community to strengthen its engagement with the legal community. Indeed, SDG 3 will not achieve its health targets with a “business-as-usual” approach or by relying on the standard public health arsenal of science and epidemiology alone. Legal and justice systems play an important role in shaping policy and social and behavioral norms in society, determining whether society strives to ensure: inclusion or exclusion; access to justice or lack thereof; and accountability or impunity. It is within this wider social construct of prevailing norms that health systems and services operate, and global health governance cannot afford to ignore law in efforts to achieve SDG 3.
E. Safeguarding the Right to Health across Sectors and Actors
In a globalized and increasingly interdependent world, the SDGs cannot be realized at the national level unless and until the right to health is recognized and operationalized across all sectors influencing human development. In aligning stakeholders on development, foreign investment, trade, and remittances are becoming more important to low-income countries than development assistance (Bhushan 2013; Lubambu 2014). Yet, a few rich countries have the power to set the rules when it comes to the debt system, structural adjustment, trade agreements, tax evasion, and tax avoidance.
Fortunately, in recent years, the right to health, in different forms and manifestations, has come to be reflected in multilateral agreements—from the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) (WTO 2001) to the Paris Agreement on the UN Framework Convention on Climate Change (FCCC 2015). Anchoring the SDG-oriented global health and development efforts in the right to health can help to navigate trade and investment treaties to assure that they do not undermine development progress. At the 2017 UN High-Level Political Forum on sustainable development, major stakeholder groups—including NGOs, workers, and trade unions—called for greater attention to the intersections between trade and human rights and proposed that human rights impact and sustainability assessments be undertaken with respect to all trade and investment agreements (ECOSOC 2017a). Indeed, right-to-health impact assessments and other tools may provide critical information on how actions by corporations, investors, and government sectors may impact progress toward SDG 3 (Götzmann et al. 2016). Moreover, concrete ways to remedy policy and institutional incoherence need to be explored—as was the case between trade and intellectual property, the right to health, and public health objectives identified by the UN Secretary-General’s High-Level Panel on Access to Medicines (UN 2016b).
Although the specific roles of the private sector are contested within the global health community, the private sector is encouraged to take a more active role in sustainable development under the 2030 Agenda (UN 2015a). Undoubtedly, the global health agenda is rampant with private sector interests: universal health coverage and health insurance companies; access to medicines and pharmaceutical firms; obesity and companies that formulate and market foods overly rich in sugar, trans fat, and salt; road safety and the auto manufacturing industry; and climate change, (p.99) considered the leading threat to human health (Costello et al. 2009), and the entire enterprise of human consumption. When governance systems explicitly grounded in human rights are inadequate, it becomes difficult to establish effective “rules of the game” to address conflicts of interest in work with the private sector, thereby generating mistrust and inefficiency rather than robust, strong, and transparent partnerships that can help exercise the required society-wide leverage to ensure progress on the health-related SDG targets.
The Guiding Principles on Business and Human Rights provide a framework to underpin engagement with the private sector. Such Principles, directed to states and multinational corporations, aim to improve compliance based on three interdependent pillars: (1) the state duty to protect; (2) the corporate responsibility to respect; and (3) the access to remedial actions (OHCHR 2011a). Strengthening the implementation of other international legal instruments that support governments in regulating the private sector in relation to specific health issues, such as the International Code of Marketing of Breast-Milk Substitutes (WHO 1981) and the WHO Framework Convention on Tobacco Control (WHO 2009), is also critical. These international legal instruments will continue to play an important role in helping to ensure that the private sector acts in support of the achievement of SDG 3 and in synergy with the realization of human rights.
F. Ensuring a United Nations Fit for Results
Achieving the SDGs will require integrated action on a dramatically different scale than previous development targets (UN Secretary-General 2017a), demanding major shifts in work within, across, and beyond the UN system and challenging the UN to be nimble and adapt to different contexts in supporting countries. In meeting this challenge, existing silos need to be broken down and work should be performed horizontally across the organization, recognizing the interdependence and interrelatedness of rights and how the SDGs—including on health, education, food security, and nutrition—span the UN’s mandate.
To truly embody the aim of leaving no one behind, national and regional development progress must be monitored through reliable disaggregated data and a stronger commitment to ending exclusion. While increased peace, resilience, and equity represent three of the many dividends that will be brought about by achieving the SDGs, it must be acknowledged that sustainable and inclusive development, grounded in human rights, is an end in itself (Ibid.). In this context, UN Secretary-General António Guterres is urging the UN system to be more focused “on people and less on process, more on results for the most poor and excluded and less on bureaucracy, more on integrated support to the 2030 Agenda and less on ‘business as usual’ ” (UN Secretary-General 2017b).
The global health architecture, in which the UN plays an integral role, needs to be reformed so that it can better support tangible results in countries to achieve SDG 3. The global health ecosystem is extremely complex, difficult to navigate, and perhaps least accessible to the marginalized communities that stand to benefit most from global health institutions functioning effectively. (p.100) Calls have been made to streamline global health institutions to become more efficient (Sidibé and Buse 2013). While the process of reform may face resistance, institutions must rise to this challenge, as achieving progress on the SDGs demands simplification.
In considering simpler institutional models for realizing the SDGs, global governance must build upon what exists and what has been shown to work. Issue-based partnerships around a common strategy and vision, as examined in chapter 14, present a model that can foster unity of purpose and stress a focus on results for people. UNAIDS, the first and only co-sponsored program of the UN, is an example of such a partnership, uniting eleven co-sponsoring agencies in providing global leadership for the AIDS response (ECOSOC 2017b). While many called for another UN agency when establishing UNAIDS, states instead adopted an entirely new way to collaborate across the UN. As analyzed in chapter 13, AIDS was recognized as a social, and not exclusively medical or health issue, with explicit human rights and gender dimensions (Knight 2008). As a result, the skill sets of UNAIDS staff are more diverse than those of traditional public health professionals, and the organization’s division of labor among co-sponsoring agencies has enabled UN support to countries and communities across a broad range of government sectors. Equally broad outreach and skill sets are needed to address not only the determinants of health but also acute health crises, which require coherent and integrated multi-sectoral action.
As learned from the AIDS experience, the global community must come together to advance the 2030 Agenda in a broad social movement that thinks and acts politically to grasp the many opportunities necessary to transform the global health agenda through a rights-based paradigm. The UN is the ultimate guardian and custodian of human rights and needs to exercise unwavering leadership for rights across global governance institutions to help make the health-related SDG ambitions a reality. With the UNAIDS model serving as an inspiration, a coordinated multi-sectoral approach to defend the right to health could be a timely initiative to spur progress on (p.101) the health-related SDGs, ensuring that the UN is both fit for purpose and effective in supporting countries to reach the SDGs.
G. Financing the Health-Related SDG Targets from a Rights Perspective
Fostering inclusive economic growth, protecting the environment, and promoting social inclusion are indispensable strategies for achieving the SDGs. As part of efforts to strengthen the framework to finance sustainable development, the Addis Ababa Action Agenda (AAAA) of the Third International Conference on Financing for Development encourages countries to set national spending targets for essential public services (UN 2015b). Under human rights law, the investment of government resources to fulfill human rights is a legal obligation (OHCHR 2008). The principle of progressive realization, articulated seminally in Article 2 of the ICESCR, mandates that governments use the maximum available resources, and engage in international assistance and cooperation, to achieve progressively the full realization of rights (Ibid.). Countries such as Brazil, Mexico, and Thailand, all state parties to the ICESCR with strong constitutional and legal provisions on the right to health, have built domestic health financing systems by prioritizing general government investment in health (Oxfam 2013).
Africa now hosts ten of the twenty-five fastest growing economies in the world (IMF 2017) and has increased domestic investments in health, yet only a handful of African countries have met the Abuja Declaration (OAU 2001) target of allocating 15 percent of public expenditure toward health (UNAIDS 2013, 5).4 Adequate government determination and strategic approaches render the Abuja target achievable. For example, domestic HIV investment nearly tripled from 2006 to 2014 (domestic sources accounted for 57 percent of all HIV investment resources in 2014) (UN General Assembly 2016, 26). As seen in the context of HIV, however, such increases can neglect to cover programs focused on key populations (UNAIDS 2015d),5 which are critical to safeguard the protection of human rights (UN General Assembly 2016, 26). Thus, increasing investment in health is not enough; human rights approaches demand questioning how priorities are set within health budgets. Investments into equity—a principle at the heart of the SDGs—also lead to greater returns, as analyses suggest that immunization and antenatal care programs, which specifically target the impoverished, save more lives more cost-effectively (Watkins 2017). The global community can and must do better in prioritizing health, and within health, prioritize prevention and other interventions that maximize benefits for everyone, with particular attention to populations who are being left behind.
(p.102) Raising and allocating government revenue for health is an inherently political process. Populism, neoliberal orthodoxies, austerity politics, and competing priorities have hampered efforts to bolster domestic investment in health (as well as development cooperation for health). Fundamentally, there needs to be structural reforms in global governance, such as debt relief, so that indebted countries can invest in development and in tax justice to address the negative human rights implications of corporate tax avoidance (Tax Justice Network 2014). The global community must work collectively to support countries in strengthening their tax audit capacities and in taxing corporations, for example, by imposing a global minimum tax on corporate income to eliminate the incentive for corporations to use tax havens (Hickel 2017). A modest financial transactions tax among developed countries, as already implemented in 2012 in France, represents another revenue source which could help to address global health funding gaps (UNAIDS 2012).
Yet even with effective tax collection, the social compact envisaged in the AAAA to finance the 2030 Agenda cannot be met in many countries (Migiro 2015). Factoring in current aid levels, even if low-income countries could maximize their revenue capacity and allocate 50 percent of public spending to health, education, and social protection, these countries would still require an additional $73 billion annually to meet the social compact under the AAAA (Watson 2016). To realize the health-related SDG targets and health-related human rights, therefore, greater sums of finance (public and private; domestic and international) are needed. The SDGs, including SDG 16 on peaceful and inclusive societies and SDG 17 on means of implementation, and the indicators proposed for their monitoring, touch upon many structural issues that will make or break the realization of SDG 3 (UN 2016a). In the same way that the SDGs are indivisible and interconnected, so too must financing responses be integrated, coherent, multi-sectoral, and always focused on pursuing social justice through human rights.
To achieve the health-related SDG targets, people and their rights must be at the center of global governance for health, with “global health citizens” empowered to voice their concerns, challenge injustices, and hold decision makers to account. Too (p.103) many decisions are driven by fear of what might happen, rather than a vision of what should happen. The bold vision offered by the 2030 Agenda can act as a unifying force for action among diverse stakeholders in global health. Indeed, the backbone of success achieved in the AIDS response has been a united vision and an unwavering commitment to, and operationalization of, human rights. This commitment and effort must be extended across the entire spectrum of structural determinants of health included in targets set out in the 2030 Agenda beyond SDG 3.
The ultimate measure of success is whether the poorest, the most marginalized, and the most vulnerable benefit from the SDGs. This requires acknowledging and operationalizing how health is impacted by gender equality, access to justice, multi-sectoral partnerships, and beyond. It requires going upstream and addressing the causes of exclusion and ill health, in specific contexts and for specific populations.
The onus is now on the global health community to seize the opportunity presented by the SDGs—to shift the paradigm of global health from a needs-based to a rights-based framework. This framework will allow states to hold true to universal values; enable institutions to be more effective in addressing systemic and interrelated problems of governance, power structures, and determinants of health; and shift energy and resources from managing crises to preventing them. The AIDS response provides a model for action to get there. In the age of sustainable development, the journey toward 2030 represents a new beginning to realize global governance for health that is community-led and in which people and their rights are firmly at the center.
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(*) Thanks to Ruth Blackshaw, Laetitia Bosio, and Annemarie Hou, our UNAIDS colleagues, for input and other support in the development of this chapter.
(1.) Tax havens—where up to $32 trillion is stored, around one-sixth of world’s total private wealth—are causing governments to lose $3 trillion in revenues every year (Global Financial Integrity 2016).
(2.) A discretionary development paradigm, by contrast, is rooted in the realm of charity, allowing countries to pursue development goals selectively, in an optional manner that lacks the ambition and integration of the SDGs (Hawkes and Buse 2016). This discretionary paradigm can lead to approaches that address the health symptoms of hunger, disease, and other development challenges without paying sufficient attention to root and structural causes of these harms such as harmful gender norms and discriminatory laws and policies. Of concern, a discretionary framework treats affected communities more as passive recipients rather than as active agents requiring freedom and support to effectuate meaningful and sustainable change (Ibid.).
(3.) This is the case even in the few areas where multilateral treaties underpin monitoring, such as the WHO Framework Convention on Tobacco Control (WHO 2009).
(4.) Health funding in AU member states has increased from 9 percent to 11 percent of public expenditures from 2001 to 2011. Six countries (Liberia, Madagascar, Malawi, Rwanda, Togo, and Zambia) have achieved the 15 percent target, and a number of other countries (e.g., Djibouti, Ethiopia, Lesotho, and Swaziland) are within reach (UNAIDS 2013).
(5.) UNAIDS considers the main key populations to include gay men and other men who have sex with men, sex workers, transgender people, and people who inject drugs, but it acknowledges that prisoners and other incarcerated people also are particularly vulnerable to HIV and frequently lack adequate access to services (UNAIDS 2015c).