PERSPECTIVES

The value of a human rights perspective in health and foreign policy

Mary Robinson

Realizing Rights: The Ethical Globalization Initiative, New York City, USA (www.realizingrights.org). Correspondence to Mary Robinson (email: info@eginitiative.org)

What could public health advocates do more effectively to encourage governments to act on underprioritized global health concerns? One important component largely missing from current strategies is the international human rights framework. Human rights principles and standards, including the right to the highest attainable standard of health, offer powerful moral arguments which can reinforce calls for action made on humanitarian grounds. In addition, the human rights framework brings into play established systems of national and international legal obligations and tools to assess performance by governments and international institutions. This enables the private sector and civil society to hold accountable all actors involved in achieving sustainable progress on major health challenges.

Health's roles in foreign policy

The effectiveness of the global response to the severe acute respiratory syndrome (SARS) and avian influenza outbreaks demonstrates that where health challenges pose a global and immediate risk, governments have been prepared to take rapid coordinated action to prevent or mitigate them. In contrast, international efforts to combat human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) were initially painfully slow because governments perceived the disease to be confined both geographically and in terms of populations at risk. By the time governments recognized that these assessments were misguided it became extremely difficult to contain the spread of the disease around the world.

Though the global impacts of HIV/AIDS are now understood, the response remains inadequate. Expensive, targeted AIDS treatment programmes reach large numbers of people in rich countries because viable pharmaceutical markets coincide with well-resourced health systems. At the same time, in the vast majority of developing countries, where self-financing markets and robust health systems are not in place, millions are perishing for want of treatments that could be made available if adequate resources were brought to bear. Despite the enormous advocacy efforts and commitment of some public and private actors, the need for additional strategies to confront the disease remains.

Numerous other health threats have received even less global attention. More than one billion people do not have access to safe water, one of the fundamental determinants of health. Some 2.6 billion lack access to sanitation, 10 million children die of preventable diseases each year and one of every 16 African women dies as a consequence of pregnancy. Despite the horrific statistics, these threats to health rarely make the international political agenda.

Growing awareness of the long-term impacts of health inequities on regional and global stability have led to initiatives such as the UN Millennium Development Goals, debt cancellation and increased international development assistance commitments. But lack of access to the basic determinants of health doesn't present an immediate threat to wealthy countries' national interests. And those suffering the most from these health problems - poor people in general and poor women in particular - lack the political voice and resources needed to demand change at home and on the international stage.

The lesson seems to be: where awareness and interests coincide, effective international responses to health threats are possible. But where only one of these is present, significantly less action is taken, and in cases where neither occurs, no coordinated approach is likely to emerge.

Rights: from principles to practice

How can the human rights framework move foreign policy concerns towards greater focus on global health challenges where no immediate threats to national security or economic interests are at stake?

First, human rights can help decision-makers assess risk. The human rights framework - by focusing attention on vulnerable populations, minorities, the rural poor and women especially, who are most often neglected and marginalized - forces those in authority to ask hard questions about whose needs are not being met, and whose voices are not being heard. Equally important, human rights provide standards against which government performance is measured over time. Today the right to health, or, in some cases, the more limited right to health care, first affirmed at the international level by WHO in 1946, is constitutionally recognized and protected in nearly 100 countries. That means governments have voluntarily committed to progressively realizing the right to health, and can be criticized for not achieving sustained progress.

Second, human rights principles and legal obligations can be used by advocates and authorities to help diagnose the effectiveness of current health policies and develop new approaches. Human rights organizations have become skilful, at both national and international levels, in using documentation and other evidence to highlight the impact of policies on vulnerable or marginalized groups and to demand changes which can promote health. The efforts to frame HIV/AIDS as a human rights issue, for example, by emphasizing how the spread of the disease has been affected by rights violations such as discrimination and gender inequalities, have played a key role in strengthening public health responses. By focusing on principles like participation, transparency, accountability and nondiscrimination, human rights provide an overarching framework in which detailed decisions can be made in light of national and local priorities.

Two projects that my colleagues and I at Realizing Rights: the Ethical Globalization Initiative are developing, in cooperation with WHO and other partners, seek to take these lessons forward. These efforts aim to raise awareness of how a rights-based approach can work in practice and to help forge common interests and solutions to major health challenges.

The first project, the Ministerial Leadership Initiative for Global Women's Health, is a new network of female health ministers from around the world who represent an untapped, powerful force to highlight the right to health and the importance of prioritizing health for women and girls worldwide. One of our aims is to build support for using the human rights framework to address broader development questions between donor and recipient countries.

A recent study by the Organisation for Economic Co-operation and Development (OECD) shows that donor-country policies are increasingly integrating human rights both as guiding principles and as operational priorities for development programmes.¹ But more must be done, particularly in the area of health. We will convene a group of health and finance ministers from developing countries with senior development officials from key donor countries that have prioritized health funding. By examining development assistance trends, such as the move to greater general budget support, through a human rights lens, we see the need for intensified support to parliamentarians and civil society groups. These actors can hold their governments accountable for policies that progressively implement without discrimination rights to health, education and food security, among others. We hope this type of analysis will raise awareness and test the degree to which policy priorities in donor and recipient countries are changed by attention to the rights of the most vulnerable.

The second project addresses the issue of health worker migration from developing to developed nations. Growing public concern about the movement of health professionals from poor to rich countries has not been matched by effective joint government action. Some steps have been taken, such as the Commonwealth code of conduct aimed at curtailing unethical recruitment, but leadership on this issue is still lacking. In cooperation with the Global Health Workforce Alliance and WHO, we are seeking to encourage policy dialogue and joint action between sending and receiving countries on the health worker crisis. Our aim is to forge a greater sense of shared responsibility for addressing this growing problem and to promote agreements that take account of the human rights implications for sending and receiving countries, as well as the right of individual health workers to migrate. The challenge is to advance realization of the right to health while protecting health workers' rights to seek employment in fair conditions.

Human rights: shared values, shared obligations

The increasing links between domestic and foreign policy, and the growing prominence of health in both, raise new questions about national interest and national security in an interconnected world. Notions of human security and global public goods have been enormously helpful in shifting debate away from narrow and short-term thinking. No one is suggesting that greater attention to human rights as part of health and foreign policy discussions will move issues of marginal strategic importance for the richest countries to the centre of the global agenda. Clearly, human rights cannot provide all the answers or make easier difficult public health choices concerning priorities and distribution of goods and services. But what other framework offers any detailed ethical, moral or legal guidance to policy-makers?

Human rights are the closest thing we have to a shared values system for the world. We should take every opportunity to see them not simply as shared goals, but as legal obligations and policy-making tools that can assist those charged with making complex decisions - whether in the areas of foreign policy, trade, security or public health.

References

1. Integrating Human Rights into Development: Donor Approaches, Experiences and Challenges. Paris: OECD Development Dimension Series; 2006.

(Submitted: 15 January 2007 - Accepted: 2 February 2007)