Background
There has been a growing commitment in recent years to the goal of achieving universal health coverage (UHC). UHC has been identified as potentially the third global health transition, the first being public health improvements such as basic sewage and sanitation and the second, the epidemiological transition that reduced the toll of communicable diseases [
1]. Major health and development organizations, including the World Health Organization, the World Bank Group, the Rockefeller Foundation, Oxfam, the Gates Foundation, the International Labour Organization, and the United Nations Children’s Fund (UNICEF), have endorsed initiatives promoting UHC [
2]. Dr. Margaret Chan, the World Health Organization (WHO) Director General, has described universal health coverage as the single most powerful concept that public health has to offer [
3].
Thus it is not surprising that UHC was selected as one of the health targets in the United Nations Sustainable Development Goals (SDGs) adopted in September 2015 to implement the inclusive health goal (Goal 3), “to ensure healthy lives and promote well-being at all ages” [
4]. Target 3.8 is to “achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all” [
5]. Although universal coverage is only one of nine substantive targets and four additional targets labeled as means of implementation that are related to Goal 3, it is considered to be the target that underpins and is key to the achievement of all the others [
6]. UHC also receives special attention in the Declaration for Transforming Our World endorsed by heads of government that precedes the identification of the SDGs: UHC is linked with the central commitment in the SDGs to leave no one behind: “To promote physical and mental health and well-being, and to extend life expectancy for all, we must achieve universal health coverage and access to quality health care. No one must be left behind” [
7].
Although a human rights approach also has a commitment to UHC, various paths to UHC and the way the goal is conceptualized are not necessarily consistent with international human rights principles. This article evaluates the extent to which the UHC target in the SDGs conforms with the requirements of the right to health as enumerated in the International Covenant on Economic, Social and Cultural Rights [
8] (ICESCR) and the Convention on the Rights of the Child [
9] and interpreted in key documents, particularly the United Nations Committee on Economic, Social and Cultural Rights in its 2000 general comment interpreting the right to health [
10]. It does so as a means to identify strengths and weaknesses in the framing of the UHC target that are likely to affect its implementation.
The human rights community generated some of the most sustained criticism of the manner in which the Millennium Development Goals (MDGs), the predecessor set of international development goals to the SDGs, were designed, framed, and monitored. Human rights critiques went beyond the failure of the MDGs to explicitly incorporate human rights norms and commitments. One concern was that the globally fixed targets in the MDGs would allow middle-income countries to evade major responsibility for implementation. Another was that by failing to require disaggregation in monitoring and reporting the MDGs encouraged governments to focus solely or primarily on raising national percentages. In the process, states were tempted to cherry-pick implementation by focusing on more advantaged groups which were easier and cheaper to reach to the exclusion of minorities, persons with disabilities, or the poorest of the poor. Others believed that the MDGs focused on achieving quantified targets at the expense of quality. Another strand of criticism cited the inadequacy of the indicators selected to monitor the MDGS which then became used as planning tools at the expense of human rights commitments [
11]. These criticisms and concerns anticipated deficiencies that affected the implementation of the MDGs. The analysis in this article suggests that the SDGs have many of the same problems.
There are various rhetorical commitments to human rights in the SDGs. The Declaration preceding Transforming our world: the 2030 Agenda for Sustainable Development envisions a world of universal respect for human rights and human dignity [
12]. It also states that the Agenda is grounded in the Universal Declaration of Human Rights and international human rights treaties [
13]. In addition, the Declaration “reaffirms the importance of the Universal Declaration of Human Rights, as well as other international instruments relating to human rights and international law” and “the responsibility of all states in conformity with the Charter of the United Nations, to respect, protect and promote human rights without distinction as to race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth, disability or other status” [
14].
Of the various targets related to Goal 3, the universal health coverage target arguably reflects the right to health the most closely. UHC has been termed “a practical expression of the right to health” [
15]. It is explicitly enumerated as a core obligation related to children’s right to health [
16], and the commitment to universality in access to key health services is implicit in other international and regional human rights instruments. Indeed, some health and human rights advocates had earlier proposed replacing the various health-related goals in the MDGs with a single overarching health goal of UHC in the SDGs, provided that the goal would include a straightforward confirmation that international assistance is essential, not optional [
17]. Significant progress toward UHC, consistent with the requirements of the right to health, could have the potential of enabling the approximately one billion people currently estimated to not have access to the health services they need the opportunity to obtain them and to do so affordably.
Nevertheless, the 2030 Agenda for Sustainable Development is not and does not purport to be a human rights document. Despite the commitment to the principle “no one left behind,” none of the SDG goals or targets, including target 3.8, is framed as a human rights entitlement. While the four components of target 3.8 overlap with dimensions of the right to health, as interpreted in UN Committee on Economic, Social and Cultural Rights’ General Comment No. 14 (GC 14) [
18], there are important human rights omissions as well. The failure to incorporate the human rights principles noted below is likely to weaken and perhaps undermine the achievement of UHC.
There were efforts to promote a human rights orientation to the SDG health goal, most notably by the Go4HealthProject, a consortium of academics and civil society members tasked with advising the European Commission on the international health-related goals to follow the MDGS. In addition, WHO published a policy brief “Anchoring universal health coverage in the right to health: What difference would it make?” The paper states that for WHO UHC is a practical expression of the concern for health equity and the right to health and thus advances the overall objective of the WHO, the attainment by all peoples of the highest possible standard of health as a fundamental right. Without specific reference to the SDGs, which may not have as yet been adopted, but presumably with the SDGs in mind, the paper argues that efforts toward achieving UHC promote some, but not all, of the efforts required to achieve the right to health [
19].
A Go4Health study based on interviews in 2013 and 2014 with participants from key multilateral and other organizations which played an important role in the framing of the post-2015 health goals identified several reasons why the right to health and for that matter other human rights failed to to be incorporated in the SDGs. Some respondents expressed concern that attempting to integrate human rights into the post-2015 document would result in decision-making delays. There was unease around sexual and reproductive health rights as a ‘fault line’ and especially to its connection to debates around the rights of lesbian, gay, bisexual, and transsexual communities. An overarching post-2015 right to health goal was seen to be too broad to be defined despite acknowledgement by at least some that the right to health was well-articulated in international law. Even if a right to health goal was incorporated, it was considered too difficult to operationalize and practically to implement [
20].
Acknowledgments
I appreciate the stimulation given by the discussions of related topics at a consultation at Georgetown University Law Center in June 2016 about the development of an upcoming report by the Special Rapporteur on the Right to Health on the Sustainable Development Goals. However, there was no contribution from anyone at this meeting to the drafting of this paper. I also appreciate the recommendations made by the two reviewers of the initial draft.