The Right to Healthcare
Multinational Monitor, October
International Law is clear on the meaning
of the right to health, and it is time that right be made real.
The International Covenant on Economic,
Social, and Cultural Rights, one of the two core covenants adopted
under the Universal Declaration of Human Rights, recognizes "the
right of everyone to the enjoyment of the highest attainable standard
of physical and mental health."
Although the United States is not a party
to the covenant, most other countries are.
The United States is not a party to the
economic and social rights treaty in part because the agreement
contains what are considered affirmative rights the right not
only to be free of government interference (such as the right
not to have the government interfere with speech rights, or the
right not to be tortured), but a positive obligation by government
to provide certain conditions so they people may live free of
fear or want.
One criticism of affirmative rights is
that they are ephemeral. Governments face real resource constraints,
and a right that demands a government spend money it does not
have serves no purpose, the argument runs.
But human rights advocates are not just
International legal bodies have worked
out a sensible framework for balancing a government's duty to
guarantee people with an decent standard of living, including
adequate food, clothing and housing, healthcare and education,
with their real resource constraints.
The basic rule is that governments first
must not impose obstacles to realization of this right, and second
that they must also take all appropriate measures what they can
reasonably do, given realistic constraints - to fulfill their
affirmative rights obligations.
When it comes to healthcare, what all
this means in practice is that governments cannot rely on the
market to deliver healthcare. Experience in rich and poor countries
alike shows that market mechanisms will work to deny people care
- and, indeed, the best profit opportunity for private insurers
comes from maneuvering to avoid providing insurance to those most
likely to become sick.
The sick should not be penalized for needing
healthcare. It is penalty enough being sick in the first place.
Providing healthcare costs money. In poor
countries, it actually does not cost that much. In rich countries,
it does. Whatever the cost, all people of a country should share
in those costs - they should not be apportioned to the ill and
all people should be able to get access to care.
For developing countries, perhaps the
most the most pressing policy implication of that principle is
the abolition of user fees charges for using healthcare services.
There is an abundance of evidence that such charges - even when
they are as low as a dollar or two deter people from getting care
that they need.
It certainly means expanding the role
of the public sector in health provision. The Venezuelan approach
that Peter Maybarduk recounts in this issue is resource-intensive
and probably replicable only in middle-income countries. But the
real lesson from Venezuela is transferable to poorer developing
countries: with political commitment, major improvements in providing
access to primary healthcare can be achieved, and quickly.
Unfortunately, under pressure from the
International Monetary Fund and World Bank, as well as government
donors, industry lobbies and market fundamentalist economists
and policy advisers, too many developing countries are moving
in the opposite direction. Celia Iriart, Howard Waitzkin and Emerson
Merhy document the disturbing trend of multinational insurers
gaining an ever-expanding foothold in Latin America, and the deleterious
At least in developing countries, resource
constraints are a plausible explanation of failure to deliver
healthcare to all. What possible excuse does the richest country
in the world, the United States, have?
Forty-five million people in the United
States do not have health insurance. Another 50 million have inadequate
insurance. And even those with decent insurance coverage frequently
have to confront bureaucratic hassles and decisions that can interfere
with the provision of care and at the very least induce a migraine
The market-based health insurance system
in the United States has failed totally.
As Rose Ann DeMoro and Claudia Fegan argue
in interviews in this issue, it must be replaced entirely. The
solution is simple: a single-payer system, where the federal government
takes over the role of providing health insurance.
The economics are quite simple, as Fegan
explains: "We could take the amount of money that we're spending
on healthcare today, and provide coverage for everyone. We could
do that if we eliminated the 25 to 30 percent of every healthcare
dollar that goes to overhead for the insurance industry. Publicly
administered plans take less than 5 percent in administrative
In the process, the level of care could
actually be improved, with healthcare funding decisions based
on public health needs, not distorted as they now are by the profit-based
priorities of health insurers and other profit-maximizing actors
in the healthcare field.
Making the right to health real through
such policy reforms, of course, is not primarily a matter of making
good arguments. It is a matter of overcoming the vested and ideological
interests that stand in the way.