Searching for the Right to Health in the Sustainable Development Agenda

Abstract

The United Nations (UN) Sustainable Development Agenda offers an opportunity to realise the right to health for all. The Agenda’s "interlinked and integrated" Sustainable Development Goals (SDGs) provide the prospect of focusing attention and mobilising resources not just for the provision of health services through universal health coverage (UHC), but also for addressing the underlying social, structural, and political determinants of illness and health inequity. However, achieving the goals’ promises will require new mechanisms for inter-sectoral coordination and action, enhanced instruments for rational priority-setting that involve affected population groups, and new approaches to ensuring accountability. Rights-based approaches can inform developments in each of these areas. In this commentary, we build upon a paper by Forman et al and propose that the significance of the SDGs lies in their ability to move beyond a biomedical approach to health and healthcare, and to seize the opportunity for the realization of the right to health in its fullest, widest, most fundamental sense: the right to a health-promoting and health protecting environment for each and every one of us. We argue that realizing the right to health inherent in the SDG Agenda is possible but demands that we seize on a range of commitments, not least those outlined in other goals, and pursue complementary openings in the Agenda – from inclusive policy-making, to novel partnerships, to monitoring and review. It is critical that we do not risk losing the right to health in the rhetoric of the SDGs and ensure that we make good on the promise of leaving no one behind.

Last year (2015) the world set an agenda to guide and influence universal sustainable development for the next 15 years. Unconstrained by the narrow confines of the predecessor Millennium Development Goal (MDG) commitments, contributors to the SDGs agenda had the opportunity to establish the parameters for an ambitious, inclusive and progressive plan for a fairer world. The outcome of the most comprehensive process of consultation that the United Nations (UN) has ever undertaken, was a framework of 17 goals and 169 targets – providing a veritable cornucopia of aspirations. While described by some as ‘unremittingly utopian,’¹ according to the UN Secretary-General, with its commitment to “leave no-one behind,” the SDG agenda amounted to ‘blueprint for a better future.’²

It is to the process of goal and target development in the SDGs that Forman and colleagues turn their attention.³ Applying a human rights analysis to both the overall process and four of the most important interim and outcome documents, the authors recognise that the discourse surrounding their formulation is likely to have played a major role in the priorities set. Taking a constructivist lens to study the activities of international organisations is not a new idea,⁴ including in global health,^5,6 and the authors delve deeper into constructivist methodologies by further applying an empirical analysis to the use of human rights-focused language in the SDG process and outcome documents. They find that while the four major documents from the global goals process are cognisant of human rights language, there is variation in the construction and expression of the right to health. This matters, they argue, since the language used in these documents is likely to frame subsequent policy responses both globally and nationally.

There can be no doubt that the language and discourse associated with these documents reflect historical and current concerns, reveals interests of actors, and may also have the ability to shape future priorities, resource allocation decisions and approaches to development challenges. An absence of any human rights language in the texts would have been a source of major concern, and it is, therefore, welcome that the opening paragraphs of the final SDG outcome document state upfront that the “17 SDGs and 169 targets…seek to realise the human rights of all.”⁷ While the right to health is not spelled out per se, the placing of human rights centre stage in the preamble to the outcome document recognises them as fundamental to achieving sustainable development for people, planet and shared prosperity and acknowledges that transformative and universal agendas can only be secured when human rights are promoted, protected and realized.

What does the centrality of rights-based discourse mean for health? Forman and colleagues express the view that the concept of universal health coverage (UHC) is fundamental to the right to health and a major step towards equity, including in health financing. And it is, therefore, the reference to UHC in the documents to which the authors attach greatest significance as they search for mention of the right to health in the agenda. There is little to argue with a concern for UHC; indeed there is much to commend it. However, the significance of the SDGs lies in their ability to move beyond a biomedical approach to health and healthcare, and instead to seize the opportunity for the realization of the right to health in its fullest, widest, most fundamental sense: the right to a health-promoting and health protecting environment for each and every one of us.

The SDGs are presented as “interlinked and integrated”⁷ – which represents a major conceptual shift in thinking on the foundations of development and health. The SDGs, with their emphasis on intersectoral collaboration, offer the most promising avenue yet to consider how we might promote good health and well-being through ensuring that the determinants of illness are addressed, rather than limiting our vision to only ensuring access to illness-treatment or management.⁸ Moreover, the SDGs are concerned with an extremely wide range of structural drivers, risk factors and diseases. Gone is the narrow focus of the MDGs with its overwhelming emphasis on maternal and child health and a small (but burdensome) number of infections. The SDGs, in contrast, reflect more of the epidemiological transitions that have occurred in the last 20 years and seek to address a much broader range of conditions limiting human well-being, including the non-communicable diseases, mental health, violence and environmental risks which contribute the bulk of the global burden of disease.⁹

Realizing the right to health within the SDG framework will mean utilizing the full range of commitments, conventions and covenants already in existence that promote, protect and ultimately realize rights in relation to the determinants of health. Take, for example, the International Covenant on Economic, Social and Cultural Rights, which enshrines: the right to work for fair wages and within a safe and healthy working environment; to education; to safe potable water, adequate sanitation, adequate and safe nutrition; the right to non-discrimination and to gender equality in the enjoyment of the rights.¹⁰ It is arguable that, as the Commission on Social Determinants of Health concluded, realizing the rights to healthy environments through addressing the underlying determinants of illness and inequity, will have a substantial and sustained impact on overall population levels of good health and health equity.¹¹ It is precisely the focus of the sustainable development agenda on goals and targets for poverty eradication, redressing inequality, promoting quality education, food security, decent work, safe cities as well as on inclusive institutions and access to justice which, if achieved, will ultimately have the greatest impact on population health levels – and hence determine whether the right to health is realized or not for the majority of the population.

Nonetheless, if we are to get serious about the realization of the right to health within the SDGs, we need to move beyond the rhetoric of goals and targets and establish realistic, feasible and responsible plans for action. Given the breadth of conditions the SDGs aim to cover, this will include a need to include plans for rational prioritization of resources and activities – a process that is potentially divisive among different health actors, but will be necessary to ensure that resources are targeted where needed and where impact is likely greatest.¹²

Critically, there can be little doubt that where progress was achieved in the MDGs it was in part due to the monitoring and reporting mechanisms which served to attract political attention and resources and to generate accountability.^13,14 In the AIDS response, for example, National AIDS Commissions were often placed in senior political bodies at national level (eg, office of Prime Minister or President).¹⁵ Annual progress on commitments are discussed annually by all stakeholders from all sectors, formal monitoring mechanisms include non-state actors and reporting is transparent and conveyed to the the UN General Assembly. In the domain of women’s and children’s health, the UN Commission on Information and Accountability (COIA) was strengthened by the establishment of an independent Expert Review Group which reported directly to the UN Secretary General.¹³

While the SDG agenda refers to accountability, it does not outline any explicit strategies for achieving and sustaining it. Moreover, the SDG agenda provides flexibility for national level decision-making around goals and targets–thus leading to the possibility that countries may decide that certain elements of a global framework are not appropriate to their national context. For example, Goal 3 (health), sets a target to “strengthen the implementation of the WHO Framework Convention on Tobacco Control in all countries, as appropriate.” The lack of binding commitments within the Agenda, combined with the explicit assertion of national sovereignty, leads to the possibility of so-called ‘discretionary development’ occurring, with countries having the tractability to pick and choose which elements of the agenda they deem appropriate to them, or to set targets which lack the overall ambition inherent in the SDG agenda. In this case, stronger mechanisms for local priority-setting which is both rational and inclusive of, and accountable to, relevant stakeholders, need to be enhanced.¹¹

What the SDG framework currently, and crucially, lacks is a serious and explicit commitment to accountability for the goals, targets and even the underlying principles (such as the human rights principle). If we are to see human rights promoted, protected and realized, and populations and people achieving the highest attainable levels of health, then, as Paul Hunt and others have noted, the health sector urgently needs to establish a “web of accountability” with an independent monitoring and review of the social determinants of health in addition to accountability for the more narrow functions of the health system itself.¹⁶

The significance and legacy of the sustainable development agenda for the right to health lies in the possibility that the ambition of the global goals reaches far beyond rolling out of UHC to one that gives impetus to action on the range of social determinants of health. The challenge and opportunity for the international community is to advocate to ensure that the commitment to health is matched by commensurate levels of investment, to link the health sector to other sectors to pursue shared goals, to articulate robust implementation plans through inclusive processes and support resolute action through new accountability structures that welcome independent inputs, at global, national and subnational levels—otherwise we risk losing the right to health in the rhetoric of the SDGs.

Ethical issues

Not applicable.

Competing interests

Authors declare that they have no competing interests.

Authors’ contributions

KB and SH co-conceived and co-authored all aspects of the paper. Both authors read and approved the final manuscript. The views expressed in this paper do not necessarily reflect those of UNAIDS, Geneva, Switzerland.

Authors’ affiliations

¹Faculty of Pop Health Sciences, Institute for Global Health (IGH), University College London, London, UK. ²United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland.

Citation: Hawkes S, Buse K. Searching for the right to health in the sustainable development agenda: Comment on "Rights language in the sustainable development agenda: has right to health discourse and norms shaped health goals?" Int J Health Policy Manag. 2016;5(5):337–339. doi:10.15171/ijhpm.2016.21