Until the 1990s much of the scholarly debate in international relations was defined by 'realism,' which assumes that states are self-interested and therefore most often behave in ways that predominantly preserve or promote their own interests.
Realism does not rule out cooperation between states intended to address transborder issues, like health problems. On the contrary, the simple fact that viruses do not respect state borders creates a solid ground for ‘international cooperation in the national interest’ (International Task Force on Global Public Goods 2006). Global health polit ics, from a realist perspective, is likely to be informed by the interests of states with the power and money to influence global health politics and therefore is likely to focus on cross-border issues that affect these states, such as the spread of infectious diseases.
[[The normative approach is from the right to health to understand governments, the descriptive approach is to start from the politicians behavior and determine the extent to which global health politics is influenced by the right to health]]
The influence of the human right to health on global health politics can be explored from numerous angles. We focus in this chapter on two distinct approaches, the normative and the descriptive, each of which answers different types of questions. ==The normative approach== employs right to health norms to depict what governments (and other actors) ought to do so as to describe how global health politics would look if the right to health drove politics. ==The descriptive approach== examines the reality of global health politics to understand why global health’s ‘politicians’ do what they do, to determine the extent to which global health politics is influenced by the right to health. Combining both approaches is more illuminating. A strictly normative approach would lead to a description of an ideal type of global health politics that bears little resemblance to the present reality. Furthermore, it would contain rpany lacunae, as the human right to [[health is]] essentially a principle that requires further crystallization through application in real life, as explained below. A strictly descriptive approach would be difficult; if we do not know what right to health compliant global health politics should look like, we cannot judge whether the world is moving toward it (or not).
This chpater is divided into two sections: the normative section briefly explores what global health politics should do to be compliant with the right to health, then discusses three main obstacles to greater compliance. First, we examine the post World War II evolution of human rights, from citizens’ rights to human rights. Second, we explore the legacy of the historical cleavage ofhuman rights into two international treaties, the [[ICESCR]], often characterized as costly entitlements, and the International Covenant on Civil and Political Rights ([[ICCPR]]), often erroneously classified as cost-free freedoms. Third, we introduce the idea ofhuman rights as a lever, not a force. The lack of ‘systematic evidence to suggest that ratification of human rights treaties in the UN system itselfimproves human rights practices’, in combination with the finding that ‘the growing legitimacy of human rights ideas in international society... provides much leverage for nongovernmental actors to pressure rights-violating governments to change their behavior’ (Hafner-Burton and Tsutsui 2005,1401), indicates that compliance by states should only be expected ifcivil society holds states accountable.
==The descriptive section explores how the human right to health has informed, and is informing, global health politics==. The most often cited example of the right to health’s influence on global health politics is the AIDS response (Mclnnes and Lee 2012). We use this case to explore, and tentatively confirm, the idea of human rights as a lever, then explain how civil society uses the right to health to formulate specific claims and to press the international community into honoring these claims. We then revisit recent history to explore why the World Health Organization’s (WHO’s) Health for All by the Year 2000 strategy (WHjO 1981), which was also explicitly grounded in the human right to health, did not influence global health politics in the way it should have (for the strategy to succeed). Finally, we turn to the new WHO strategy ofuniversal health coverage (UHC), again—but less explicitly—grounded in the human right to health, and explore what it would take to influence global health politics in a right to health compliant manner.
# The Normative Approach to Health as a Human Right
## From Citizens' Rights to Human Rights
The world wars during the twentieth century, and World War II in particular, forced a revision of the concept. ==If human rights were only citizens’ rights, then the rights of German citizens under Nazi rule may have been only those rights recognized by Hitler’s government. This was untenable==. The 1948 Universal Declaration of Human Rights (UDHR) refers to the atrocities of World War II and proclaims the human rights of‘all human beings’ (article 1), ‘everyone’ (articles 2, 3, 6, etc.), and ‘all’ (article 7). Thus, the UDHR seems to leave little ambiguity about the nature ofthe rights it proclaims: that is, human rights, not citizens’ right. However, some ambiguity remains because ofthe way the corresponding duties are allocated in the UDHR. On duties, the UDHR remains ambiguous. On the one hand, it seems to place the corresponding duties upon humanity: ‘Member States have pledged themselves to achieve, in co-operation with the United Nations, the promotion of universal respect for and observance of human rights and fundamental freedoms’. On the other hand, the UDHR calls itself‘a common stand ard of achievement for all peoples and all nations’. Thus, the duties seem to remain with states, or more precisely, ‘all peoples and all nations’.
We side with the soft version of the claimability condition: a human right can only be a human right if it is possible, at least in principle, to identify people and institutions who can, together, ensure that right to all human beings. If no institution or collective of institutions is able to ensure a given right to all humans, the claim is void. If it is possible to imagine how institutions could ensure a given right to all humans, the claim has substance. Of course it is a problem if the corresponding duty bearers have not been identified (yet), but the claim makes sense and requires identifying duty bearers. We argue that it would be more problematic if the duty bearers were being identified in such a way that the best imaginable version of the enjoyment of the human right is either meaningless or very different for different human beings.
Unfortunately that is what happened when the UDHR was translated into legally binding treaties because UDHR is a declaration, not a treaty; it had to be ‘translated’, and further elaborated, into a treaty. Furthermore, the [[UDHR contains two different kinds of rights: ‘freedoms’ and entitlements’]]. Freedoms are claims to non-interference in some important aspects of a person’s private life: going where one wants to go, thinking what one wants to think, and believing what one wants to believe. Entitlements are claims to active support, when needed, for a person to subsist in dignity: the provision of water, food, housing, education, healthcare, and so forth.
[[Insights]] Is this what happened to every declaration before [[Pandemic Treaty]] as well? The declaration that COVID-19 vaccine is public goods must be followed by a
legally binding treaty?
Two international covenants (treaties) were elaborated, one on civil and political rights (freedoms), the other on economic, social, and cultural rights (entitlements). ==This division became one of the ideological battlegrounds of the Cold War: the ICCPR became ‘the human rights treaty of the West’, while the ICESCR became ‘the human rights treaty ofthe Eastern Bloc’.== Even ifmost Western states ratified both the ICCPR and the ICESCR, they only took the freedoms seriously (as human rights): freedom of political opinion, freedom of press, freedom of religion, and free dom from arbitrary arrest. The most famous non-governmental organizations (NGOs) in human rights were (and to a large extent still are) focused on freedoms.
Human rights depends not only on capacity but also on the willingness of duty bearers]. Considering how World War II inspired the UDHR, it does not seem plausible that Hitler’s government organized the Holocaust because ofthe lack of ability to respect human rights (or because there was no UDHR or other legal text clarifying the content of human rights). The Holocaust was the result of an unwilling ness to ensure human rights, an intentional exclusion of specific groups of people from citizenry.
Article 2(1) of the ICESCR proclaims: ‘Each State Party to the present Covenant undertakes to take steps, individually and through international assistance and co-operation, especially economic and technical, ==to the maximum of its available resources, with a view to achieving progressively the full realization of the rights recognized in the present Covenant==.’ Like Article 2(1) ofthe ICCPR, article 2(1) of the ICESCR also locates the corresponding duties with states, but it contains two qualifiers. First, the corresponding duty is to take steps, to the maximum of a state’s available resources, which means explicitly that the substance of the human rights proclaimed under the ICESCR differs between humans, depending on the state they live in. (For example, ifyou have cancer and you happen to live in a country that is wealthy enough to provide cancer treatment to all citizens who need it, your right to health includes cancer treatment. But ifyou happen to live in a country that is too poor to provide cancer treatment, your right to health does not include a legitimate claim to cancer treatment.) Thus the ICESCR is quite explicitly a treaty about citizens’ rights. However, the second qualifier mitigates that and turns the ICESCR into a treaty about rights that are somewhere in between citizens’ and human rights: states must take steps, individually and through international assistance. (If you have cancer and live in a country that is unable to provide cancer treatment to everyone who needs it, you maybe tempted to use the ICESCR as the basis ofa claim upon the international community.)
[[Insights]] [[There are two qualifiers from ICESCR to the corresponding state regarding the right to health]]. First, the state is to take steps to the maximum of a state's available resources. However, the second qualifiers mitigates that and place the right somewhere in between citizens' and human rights.
Rather than embarking on an overview of all the opinions and posi tions, it is more instructive to cite concluding remarks formulated by Tobin (2012,368), who explored the issue in relation to the right to health:
> The meaning of the international obligation to co-operate for the purpose of realizing the right to [[health is]] far from settled. But its ambiguity and contested nature, especially in the context ofinternational assistance, are not sufficient grounds to relegate this obligation to the periphery in any discussions concerning the right to health. On the contrary it must occupy a more central place given that co-operation between states is critical to ensuring the effective enjoyment of the right to health. The challenge, however, is to provide a persuasive interpretation that can outline the concrete measures’ required for its effective implementation.
In conclusion, while the UDHR advanced toward human rights (and away from citizens’ rights), the ICCPR was a step toward citizens’ rights, and the ICESCR did not represent a step toward or away from human rights. In practice, the benefits of human rights remain a kind of '[[From a global health policy perspective, it makes little sense to draw too categorical a distinction between private goods with large positive externalities and the pure public good case|passport lottery]]’; not only the enjoyment of human rights, but even the substance of the claims, remains to a large extent defined by the willingness and the ability ofstates to provide for them.
One of the critiques regarding the current human rights regime is how the state-centeredness often shortfall of its duty and only encompass extreme human right violations, eg, genocide, war crimes, ethnic cleansing, and crimes against humanity.
For example, the wealthier states showed little hesitation in dealing and trading with states that were notorious human rights (freedoms) violators; such were 'the politics of [[liberalism]] in a realist world' (Forsythe 2006, 251).
In the 1990s, genocides in Rwanda and then in the former Yugoslavia.
With regard to health, it is important to note that at the beginning of the twenty-first century the international community implicitly (not explicitly) accepted collective responsibility for the provision of antiretroviral (ARV) medicines for people living with AIDS in low- and middle-income countries. ==If wealthier states did not explicitly acknowledge their status as duty bearers across state borders, they certainly behaved as such.== We explore this further below.
The main point is that if one takes the approach of a [[constructivist]] and looks at the right to health as a norm that may have guided global health politics so far, or that may provide guidance for global health politics in the future, looking beyond the ‘face value’ of the human right to health may be somewhat disappointing. This is because international human rights law addresses mainly how states ought to behave at the domestic level. However, by taking a historical perspective, ranging from the eighteenth-century American and French declarations to the 1948 UDHR, 1966 ICCPR, and ICESCR and continuing to present-day state behavior in response to domestic human rights issues, there is some evidence of a gradual shift from an idea of rights that people have by virtue of being citizens to an idea ofrights that people have by virtue of belonging to the human species. This is not much, but it is something to build on.
## Freedoms versus Entitlements: Implications for Global Health Politics
> For many global health scholars, [[stating that health is a human right makes little sense]]. It sounds as though all humans have an entitlement to be healthy, and that is like saying that all human beings have an entitlement to be happy.
The right to health, for example, does require the freedom to criti cize a health authority not doing what it should do, but it mostly requires entitlements to positive efforts. And this difference—somewhat artificial and somewhat real—has con sequences when it comes to exploring international duties.
## The Human Right to Health as a Lever, Not a Force
> Ratification of human rights treaties does not in itself improve human rights practices, in combination with the finding that human rights ‘provide leverage for nongovernmental actors to pressure rights-violating governments to change their behavior’.
As Tobin (2012,340) notes, several states have argued that ‘although the need for international co-operation and assistance reflected an “important moral obligation”, it was “not a legal entitlement”’ Third, all these states have interests that may be at odds with global health politics aligned with the right to health: ==to avoid being obliged to pay for healthcare for other states’ citizens, but also, for example, to continue recruiting health workers from countries where they are needed more, without being labeled a human rights violator.== Therefore, we should not expect these states to live up to their international duties unless non-governmental actors pressure them into it.
If the substance ofthe human right to health remains somewhat vague; if, a fortiori, the substance ofthe international duties for the realization ofthe right to health remain vague; and if on top of that, we can only expect states to act upon their international duties if NGOs use the right to health as a lever for their claims, then [[International NGOs, media, or expert bodies wield normative power to influence and shape beliefs about what is ethical, appropriate, or socially acceptable|the role of NGOs]] in advancing the right to [[health is]] more than a strategic one. It becomes a defining one. The successful right to health claims advanced by NGOs upon the global health politics of influential states are not only contributing to the realization of the human right to health, they are also defining the substance of the right to health. For example, before HIV/AIDS activism claimed that access to ARVs is an essential element of the right to health, before UNAIDS and the Office of the High Commissioner on Human Rights (OHCHR) confirmed this claim in 2002 (UNAIDS and OHCHR 2006), before ARVs were added to WHO’s essential medicines list (also in 2002, and under HIV/AIDS activist pressure) (Laing et al. 2003), and before the creation of a mechanism that allowed the practical international cooperation required (again in 2002, i.e., the Global Fund), few lawyers would have unequivocally confirmed that access to ARVs is an essential and universal element of the right to health. Since then access to ARV therapy has been cited as a textbook example of the right to health (Wolff 2012; Tobin 2012; Griffin 2008; Chapman 2016).
The 2000 General Comment (United Nations International Committee on Economic, Social and Cultural Rights 2000) contributed greatly to clarifying the contours of the right to health; however, it leaves many important issues unsettled (Forman et al. 2013). As ==Chapman (2016) argues, the human right to [[health is]] an emergent human right; it has not fully crystallized yet, and that is particularly true for its international dimension.==
# The Descriptive Approach to Health as a Human Right
## HIV/AIDS, the Right to Health, and Global Health Politics
One ofthe first issues on the agenda ofthe emerging global HIV/AIDS activism net work was the World Trade Organization’s (WTO) Trade-Related Aspects ofIntellectual Property Rights (TRIPS) Agreement. TRIPS was an annex to the Final Act of the Uruguay Round of Multilateral Trade Negotiations, which also included the 1994 Agreement Establishing the World Trade Organization (Gervais 2012). Thus, TRIPS was part of a package deal, a part strongly promoted by many industrialized countries and reluctantly accepted by most low-income countries, as a price to be paid for WTO mem bership (Correa 2000). The agreement obliged WTO members to adopt minimum standards for intellectual property protection. This in turn had a direct effect on the cost ofARV medicines. In the words of Stiglitz (2008,181), when the trade ministers signed the trade agreement in Marrakech in April 1994, they were in effect signing the death warrants for thousands of people in Africa and other developing countries’.
[[Insights]] [[TRIPS Agreement]] was born because of HIV/AIDS activism to demand the right to ARV treatment
According to Barnard (2002,167), the framing ofthe lawsuit’s withdrawal as a victory of the requirements ofjustice and respect for human rights’ was ‘seriously misleading’, because ==most countries in Africa were too poor to provide ARV treatment even at reduced costs==.
Did AIDS activism create’ a new and universal right to health entitlement? That would be at odds with the concept of human rights: ‘rights held by individuals simply because they are part of the human species’ (Ishay 2008) and therefore not dependent on the willingness (or not) of states to ensure their enjoyment. In our opinion, AIDS activism ‘clarified’ one element ofthe right to health, helping one element ofthe right to health to ‘emerge’ from the ambiguities and weaknesses of the international treaties’ texts. Other elements are waiting to be ushered in.
## Health for All, the Right to Health, and Global Health Politics
Those who wrote the Declaration of [[Alma Ata]] were aware that PHC would cost more than many countries could afford. The proposed solution was not a global fund for PHC, but a call for ‘economic and social development, based on a [[New International Economic Order (NIEO)]]’, as being ‘of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and devel oped countries’ (International Conference on Primary Health Care 1978).
In 1979 Walsh and Warren proposed replacing PHC with [[selective PHC]], as an ‘interim strategy’. Their argument was that too many countries were unable to afford PHC as set out in the Declaration of Alma Ata (Walsh and Warren 1979). [[UNICEF moved away from the comprehensive primary care principles espoused by the Alma Ata declaration, prioritising a selective approach towards primary care interventions which created tensions with the World Health Organisation|UNICEF]], WHO’s main partner in supporting PHC, soon embraced selective PHC, with resource scarcity as the main rationale. According to Packard (2016), Executive Director [[James Grant]] of UNICEF was a ‘surprising’ advocate of selective PHC consider ing his earlier career and statements. However, Grant was impatient. He refused to sit by and watch millions of children die from preventable deaths while the world built effective primary health-care systems’ (Packard 2016,257).
While the global AIDS response benefitted from fear among powerful states that the disease could evolve into a global security threat (Lisk 2010), the Health for All strategy did not. However, if we understand the human right to health as an ‘emergent right’ (Chapman 2016) and the international duties it entails as ‘far from settled’ (Tobin 2012), and if we understand human rights as potential levers for civil society, not as a force in itself, then we can conclude that the [[Health For All by 2000 was never achieved because several prominent member states viewed the program as unrealistic and unattainable|lack of concrete claims hindered the traction of the health for all strategy]].
## [[Universal Health Coverage]], the Right to Health, and Global Health Politics
The World Health Report: Primary Health Care (Now More Than Ever) signaled WHO’s return to the aspirations of the Declaration of Alma Ata (WHO 2008; Chan 2008). This report introduced the concept of UHC to a wider audience. WHO presented UHC as ‘a practical expression ofthe concern for health equity and the right to health’ (WHO 2012).
Not everyone agrees. According to Birn, Pillay, and Holt (2017, 500),
> ‘UHC—unless explicitly focused on public health care systems strengthening—is a misguided approach, justified by certain legitimate concerns around catastrophic health spending, but offering the likelihood of large-scale rapacious health care system penetration by and channeling of resources to—private interests that reinforce health care system inequity and stratification.
We have argued that UHC could be the practical expression of the right to health if national and international responsibilities are clearly articulated (Ooms et al. 2014). Thus far, they are not. UHC is most often presented as a domestic technical and financial challenge (WHO 2016), which means that [[UHC is unlikely to influence global health politics|UHC ‘as is’ is unlikely to influence global health politics]].
Furthermore, some of UHC’s strongest supporters among NGOs based in high-income countries—assumed to be the most influential when it comes to global health politics—have made an explicit choice to focus on domestic [[resource mobilisation as one of the defining characteristics of policy networks|resource mobilization]] rather than international financing. In a collective blog, representatives of Save The Children, PAI, and Global Health Advocates (Wright et al. 2016) argue for ‘a paradigm shift toward domestic resource mobilization (DRM)’. Their main arguments are that ‘[[DAH is primarily, although not entirely, driven by the interests of high-income countries|aid budgets are unreliable and often restricted to donor priorities]], are now stagnating or reducing.’ They commit to and invite others to take a ‘75:25 DRM Pledge’: ‘We call for the UHC2030 meeting and the events happening worldwide for UHC Day to dedicate at least 75 percent of their time and attention to national domestic resources.’
While we sympathize with the arguments, we fear that if only 25 percent of the time and energy spent on UHC in international fora will focus on the global health politics of UHC, UHC may follow the same path as PHC: national or domestic resource constraints will be used as the argument to advocate for selective UHC. The right to health could be an important lever for increasing domestic resource allocation, but if NGOs based in high-income countries fail to use the right to health to demand their governments contribute to international financing, the argument will have reduced value for their [[NGO]] counterparts in low- and middle-income countries. Furthermore, international financing will not come to a halt; it will continue to be used for the priorities of the states providing it (for infectious disease control, as realists would predict).
# Conclusion
Looking for a norm to which all or a majority of states will adhere or could adhere, and that could convince them to steer global health politics beyond the narrow self-interests of the most influential states, the right to health seems an obvious candidate. It is enshrined in treaties that the vast majority of states have signed and ratified. However, ==there are serious obstacles to using the right to health in that way==.
First, although human rights are said to be rights everyone has by virtue of being a human being, ==the original concept was intended to describe rights people have by virtue of being citizens of given societies==. The understanding and acceptance of international duties is still in its infancy (Vandenhole 2015).
Second, the right to [[health is]] an entitlement right; it is shorthand for a basket of freedoms and entitlements, but that basket is filled with mostly entitlements. Accepting international duties for human rights entitlements comes with a cost for wealthier states, and they are reluctant to accept that cost.
Third, human rights work as a lever, not as a force; their power depends on how they are being used by civil society organizations. Global HIV/AIDS activism successfully used the right to health to make influential states adopt concrete measures: allowing low- and middle-income countries to purchase generic medicines, generating an international funding stream, and making the [[World Bank (WB)]] and the [[International Monetary Fund (IMF)]] accept increased public expenditure. In contrast, the Alma Ata movement did not demand concrete measures from the international community, as it was focused on domestic responsibility. If one wants to use the right to health as a lever for global health politics that enable UHC, one of the main challenges will be to build a coalition ofcivil society organizations around concrete measures.