Resolving the Contradictions of Growth and Capabilities: A rights-based approach to health
GLOBAL HEALTH WRITES
Citizen Journalist: Bianca van Bavel
Applying a human rights approach often calls into question a series of contradictions; particularly when it is introduced by the nation’s President to open up public discourse on health system reform against a backdrop of economic austerity.
In this manner, the second meeting of the President of Ireland’s Ethics Initiative got under way on Friday February 6th, hosted in partnership by the Irish Centre for Human Rights and the College of Medicine, Nursing and Health Sciences at NUI Galway. It was an inclusive gathering of certain expertise, disciplines and generations. Representatives from across legal, ethical, medical, civil, academic and governmental institutions engaged with one another to question ideologies and share perspectives on the right to health.
The human right to health declares that all people, regardless of economic, political, social, cultural, mental, or physical vulnerability, have equal legal right to the highest attainable standard of health, as put forth by the UN Committee on Economic, Social and Cultural Rights (General Comment NO. 14, 2000). This intends the right to choice, reasoned agency, and public engagement. Otherwise put so eloquently by President Michael D. Higgins, as ‘a right to participate, without shame’.
President Higgins, himself opened the meeting, referencing the economist and philosopher Amartya Sen and his theoretical transformation of applying a human rights framework to economic development. In seeking to apply the same principle to health and its underlying determinants, we must struggle against the fact that applying a rights-based approach cannot be taken in isolation of greater economic and political powers. Passionately sifting through his hand-written notes, President Higgins reminded us that within the current global economic context, the very nature of Democracy (in so much as peoples’ right to participation in these decision making processes) is under threat. Instead of the general masses, it is a small number of the selected few, who hold the voice in decision making. The naturalisation of neo-liberalism, in which the current economic conditions and political environment continues to disproportionately support its wealthy creditors at the cost of its global citizens, is anything but democratic. Structural, political and ideological pathologies are changing the way citizens engage and relate to each other and their institutions. Not least of all is the effect seen on health systems.
‘It is long past the time to move the Human Rights discourse out of the fiscal shadow’—President Michael D. Higgins
So how do we seek solutions that will release collective goods, such as health care, from the confines of a market economy? AND what would we need to move forward and enable equitable participation and the achievement of these rights ‘without shame’?
Chaired by Professor Michael O’Flaherty, Director of the Irish Centre for Human Rights, and Dr. Diarmuid O’Donovan from the School of Medicine (NUIG), the meeting’s panel discussions stimulated solutions to these challenges.
In his key note address, Professor George Ulrich of the Riga Graduate School of Law, also eluded to the pressures of a privatised market economies and declining public commitment, and what this means in practice for the ethics of human rights. He ended with an enticing idea that perhaps, a paradoxical solution could exist through greater engagement with public-private-partnerships. Professor Ulrich spoke about adapting a Kantian notion of International Human Rights Law towards the respect, protection and fulfilment of the persons, be it self or other, within the constellation of human rights. This enables a recognition of the right to health and its underlying determinants (such as: education, access to clean water, reproductive choice and sexual safety) as necessary ends in and of themselves.
Yet, even if this weren’t the case, and we engaged independently with the political conventions of quantifiable returns and interest rates, surely the failure to recognise these rights is also economically unfavourable as it is socially detrimental. For example, recent initiatives are coming forward to highlight the social and economic costs of violence against women and girls; including direct health care costs, losses in income and productivity at both the local and global level. Therefore a reduction in the prevalence and incidence of such violence is not only a means towards economic and social betterment, but also a vital end in itself. The recognition of human capabilities, protection of fundamental rights and fulfilment of equitable inclusion have immense social and economic impacts on health.
‘After all, there are no influences as strong in raising the productivity of labour as health, education and skill formation’—Amarty Sen
If we look within the social objective of universal health care (UHC) economic austerity and poverty are not reason enough for countries to forgo the provision of health and insurance to citizens. If that was the case, how is it possible that countries suffering from greater political instability and economic inequality (such as: Cuba, Rwanda, Costa Rica, Thailand) have managed to achieve, or at least attempt to introduce, UHC? Take Rwanda for example, a once devastated country, now transformed through the implementation of a community-based health insurance programme enacted in 2011. Signs of a stimulated shared economy can be attributed to this increased access to health services and goods. With such access, people can develop capabilities and pursue longer, more productive lives.
The right to the highest attainable standard of health, requires a commitment to ensuring the accessibility, availability, acceptability, quality (AAAQ Framework) of health related facilities, goods and services. ‘We must do more than simply improve upon the paternalism of the past’, declared Professor Peter Bartlett from the University of Nottingham. Professor Sofia Gruskin of the University of Southern California explored the challenges of moving from ethical theory towards the practical application of a rights-based approach in health systems. She proposed the solution of more inter-disciplinary collaboration, across sectors, to create ethically informed programmes and effective health indicators.
Dr. Sara Burke of the School of Health Policy at Trinity College Dublin, vibrantly followed, illustrating these issues of access and eligibility within the Irish health system. Discussions regarding the classification of marginalised populations were considered using a comprehensive definition of what it means to be on the periphery, removed from sharing public spaces. Dr. Burke directed the conversation at building a national health system that would avail services to everyone, regardless of individual capability. She suggested that while the reality of the Irish system was appalling, particularly when compared with other EU countries, the opportunity of reform could be presented by looking through windows within health system policies.
Professor Bartlett closed the day’s panel discussions with a blaringly difficult question: Why can’t we provide the care that people want?
Despite many of the overwhelming challenges on the path towards realising health as a human right, it may not be a question of ‘why can’t we’, as much as ‘why don’t we’ provide the necessary and desired care for people? Ireland’s inability to implement, or even introduce, any kind of UHC-related policy reform is unacceptable. Regardless of the fiscal circumstances, health and the attainment of the highest standards of care, require equally inherent political and social commitments. While we cannot ignore the impact that political and economic environments have on the realisation of rights, neither should we succumb to the pressures of privatised market transformations. We need to support each other and the demand for our public institutions.
Perhaps with a little help from our friends, policy makers and intellectual leaders questioning these underlying contradictions, we can move further out from the shadows and into a space where imagined participation, without shame, and health for all becomes a realisation.
Bianca van Bavel is the Editorial Intern for the IFGH and heads our new Global Health Writes initiative.
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