29 - 31 janvier 2020
African Perspectives on the (human) Right to (health) care
- Ngosso Thierry
- Luyckx Valerie
Facts are appalling: depending on her country of birth, the life expectancy of a human being could range from 83.6 years in Japan or to around 51.4 years in Sierra Leone or Central African Republic (World Mortality Report, 2017). While some in the global North enjoy a longer and healthy life in part because of a better access to health care from childhood, others in the global South die earlier, facing daily structural challenges and diseases, and struggling to access health care. The situation is particularly concerning in sub-Saharan African countries where the medical gaps relative to most countries in the West in terms health expenditure, physician and other health workers’ availability, medicine (Kruk et al., 2018) and accessibility persist on a background of pervasive social and structural challenges (poverty, education, gender discrimination, employment, environment, unrest etc.) which impact health. For instance, in 2015 the World Bank statistics (insert link or reference) showed that per capita health expenditures per year were less than 85 USD in sub-Saharan Africa (compared to 1001 USD as the global average). Extremes range from 16.6 USD in the Central Africa Republic to 9800 USD in Switzerland. Moreover, the average number of doctors per 1000 individuals in sub-Saharan African Africa ranges from 0.022 in Tanzania (2014) to 2.003 in Mauritius (2015) which are low compared to the global average, with Cuba having the highest number at 7.519 (2015). This situation is partly caused and worsened by the physicians’ brain drain which directly and negatively impacts access to vaccination, medicines or care in resource-poor settings (Eyal & Hurst, 2008).
Regarding medicine (in)accessibility, the HIV pandemic illustrates the significant medical gap. Two thirds of the global new infections occur in Africa, where 25.7 million people are living with HIV (see WHO HIV Fact sheet: https://www.who.int/news-room/fact-sheets/detail/hiv-aids). HIV prevalence, infection, illness and fatality over 30 years of the pandemic have been highest in sub-Saharan Africa and it has decimated a significant proportion of the working generation. Sub-Saharan African countries are also those with the least access to anti-retroviral medicines, which have turned AIDS into a chronic disease in most Western countries. Even if medicines have become many fold cheaper in recent years, and HIV mortality is decreasing, largely due to interventions of global actors such as the Gates Foundation and the Global Fund, treatment remains inaccessible for many African patients in the region, with only 60% being on therapy in 2017 (see World Bank Antiretroviral Therapy Coverage: https://data.worldbank.org/indicator/SH.HIV.ARTC.ZS). Similarly, access to chronic care and cheap generic medication for non-communicable diseases (NCDs) is poor in resource poor countries, superimposing a high burden of “new” diseases in regions where infections already overburden health systems (NCD Countdown 2030, 2018; Kruk, 2018). Development funding for NCDs, in contrast to HIV, has been extremely low over the past 2 decades (See Public Spending on Health: A Closer Look at Global Trends: https://apps.who.int/iris/bitstream/handle/10665/276728/WHO-HIS-HGF-HF-WorkingPaper-18.3-eng.pdf?ua=1). Declining external aid and reliance therefore on insufficient domestic funding and out-of-pocket payments for NCD care have contributed to the growing global epidemic, which has displaced infections as the primary cause of death. Increasingly, patients in sub-Sharan Africa are suffering from the “syndemics” of NCDs, HIV, poverty and depression, which require a holistic and sustainable approach (Mendenhall et al., 2017)
The least one can say is that health outcomes are profoundly different depending on one’s country of birth and sub-Saharan African countries are obviously the poor relatives in terms of fighting epidemics of all kinds and access to health care and health care workers. Although the human right to health is recognized by the African Charter of Human Rights and most constitutions of African countries, sub-Saharan African countries remain the most vulnerable in this respect. The significant amount of resources and financing and the political infrastructure that is required are most often not within the reach of most sub-Saharan Africa countries. Therefore, the human right to health raises at least two main concerns in Africa: the huge inequality with the West and the inaccessibility of basic medicines whose consequences, as in the cases of the AIDS epidemic and NCDs for example, expand to economic issues and threaten even the political stability of some states (Joseph, 2003; Blake et al., 2018).
It therefore follows with no controversy that philosophers are increasingly concerned with global health inequalities and how principles of global justice may contribute to address them. In this regard, three theoretical frameworks seem to emerge. One refers to utilitarianism and the idea that we may address global health inequalities by framing our moral obligations in terms of the responsibility moral agents have to contribute to the maximum happiness for the greatest number of people. Another refers to humanitarianism and the idea that we may address global health inequalities by framing our moral obligations in terms of imperfect duties we have to help the most vulnerable of our global community. The third framework refers to human rights and the idea that we may address global health inequalities by grounding our moral obligations on the human right to health that each human being deserves, especially those who are the most vulnerable.
This Workshop project focuses on this third theoretical framework. It aims to explore, in an interdisciplinary manner, both the meaning and the justification of the human right to health by providing an African perspective and relying on an African context on one hand, and on the other hand its normative and practical implications of the responsibility and obligations of individuals, public agents and private agents from African societies in addition to the global obligations of other non-African actors.
Two sets of scientific questions will be addressed in this regard:
1. Is health a human right? Should we move from a human right to health to a human right to health care? What is the meaning of the (human) right to health (care)? Are there normative tools in African intellectual traditions to justify such a right?
2. If health (care) is indeed a (human) right, what should be the obligations of citizens, states, and other private agents of African societies and global actors themselves?
The first set of questions is at the heart of political philosophy debates and refers to both the conceptual understanding and the normative justification of the human right to health. Although the human right to health is a legal or conventional human right in the sense that it is recognized as “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health” by the State Parties to the International Covenant on Economic, Social and Cultural Rights in Article 12, there is debate among political philosophers about what this right really means and if this is a legal right or is also, or instead, a moral right. A legal right is a right proclaimed or recognized by a legal instrument. It is an institutionalized right. A moral right is an outcome of a strong philosophical justification. It is a pre-institutionalized right. Human rights are moral rights because they are universal and pre-institutional. They apply to all individuals by virtue of their humanity and are independent of any legal instrument, although legal instruments can integrate them. For a right to be a moral right and hence a human right, it requires a high bar of moral justification.
Some philosophers question the fact that economic and social human rights, like the human right to health, meet such a standard. They consider that the human right to health lacks the satisfactory and strong normative justification that ground political and civil human rights. This class of rights should only be considered ‘aspirational’, not ‘human rights proper’. Criticisms of the human right to health focus among others on the inconsistency of its normative justification (O’Neill, 2005; Preda, 2012), its vagueness (O’Neill, 2005; Preda, 2012), its improper allocation of duties (O’Neill, 2005) its economic inefficiency (Easterly, 2009) or its potential damaging outcomes (Easterly, 2009).
Regarding the justification, there is some inconsistency for those who advance either luck egalitarian justifications (Segall, 2010) or fair equality of opportunity arguments (Daniels, 2008) for the human right to health. It is inconsistent to ground a moral justification of the human right to health, that would entail equal outcomes in terms of health for all, on luck egalitarian theories which claim that people should not suffer hardship consequences of actions they are not responsible for. This would mean denying such a right to all those who bear some responsibility in their illness and who cannot afford to cure it. In contrast, if we consider the fair equality of opportunity as grounds for justification of the human right to health, based on the significant contribution that health plays in allowing people to enjoy several other opportunities in their lives, this could be inconsistent with how we understand, for example, the human right to health of the elderly.
Regarding the conceptual understanding of the human right to health, there are issues not only regarding what health really means, and, if it means at least in part health care, but also with what the covenant understands by the highest attainable standard of health. Applying the same standard to the world is aspirational, but at present seems almost unrealistic, and if it applied to each country, it seems certainly if not immoral, at least insufficient. Even though the human right to health raises some legitimate concerns, philosophers like Jonathan Wolff have argued convincingly that the language of human rights, because of its relative universal consensual basis and its significant motivational power, can help address health inequalities and health care inaccessibility in a more efficient way. Even if the standard of health may vary between and within countries, we can mostly agree that people should be protected from significant threats to their health “which is to say that where it is possible to prevent or treat illness in a routine manner, then each of us has a right to expect this” (Wolff, 2012:234) from relevant institutional actors.
All in all, issues relating to the right to health are at the forefront of research in many disciplines, including political philosophy, given the numerous publications devoted to these questions in recent years. The current state of research shows that significant progress has been made in understanding and justifying this right as a human right and in formulating solutions to inequalities in health, such as Pogge’s Health Impact Fund, which, acting as a complementary and parallel TRIPS legal framework, would ensure equal access for all to the most essential drugs (Pogge, 2012). But the persistence or even aggravation of global inequalities in health and inaccessibility of basic health care, as well as pervasive structural and social determinants of health, especially in sub-Saharan African countries, shows that research on these issues still has a long way to go, especially by researchers from sub-Saharan Africa themselves. The general scientific goal of this workshop will be to develop an African perspective of these respective issues.
The current debate is mostly taking place among Western scholars, where the human right to health has its supporters as well as its critics. The enquiry and attention of the workshop will be to investigate whether shifting the focus to the African context, where arguably the relevance of this question is most acute, can help to move the debate in one direction or another. In addition, consideration of the African context will involve exploring the relationship between African values and human rights, where human rights are often regarded as a hegemonial and political notion, as well as exploring local interpretations of what human dignity entails and how it applies to health. To address these issues comprehensively the expertise of philosophers, legal scholars, sociologists and anthropologist are needed in addition to health care practitioners.
Focusing on the African context will also advance research in the area of understanding obligations and responsibilities of African societies themselves regarding the (human right to) health of their own citizens. In this respect, a parallel focus of the workshop will be to explore the distinction between health and health care especially because, in the context of Africa, the lack of resources precedes and impacts issues of distributive justice as well as priority setting and currently creates dependence on external funding and interests. Moreover, if the human right to health is understood as at least a human right to a minimum package of services and goods related to health care that enables individuals to live their “healthiest” lives, this may shed some light on the identification of all agents who have a responsibility to contribute to addressing barriers to health, including African societies themselves, governments and external actors.
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