Beyond cost-effectiveness: Why we need a human rights approach to universal health coverage

The world having agreed to universal health coverage as a key target of the Sustainable Development Goals, a basic question becomes: Coverage of what?

A traditional approach to answering this question is to focus on cost-effectiveness. Start with a given resource envelope. Then choose the set of health interventions that will buy the most health for the population. Under this approach, health is typically measured by disability-adjusted life years (DALYs). Run the numbers – the cost of different interventions, the expected benefits in DALYs – and include the most cost-effective interventions within the funds available. There is your universal health coverage benefit package.

A human rights approach differs dramatically. The first difference is the question we ask. It is no longer a straightforward matter of determining how to get the greatest health gain for the dollar based on straightforward formulas. “Coverage of what?” is only one question of many. The questions extend to the very process of answering this question, and include such questions as how are the benefits distributed across the population, how health systems can deliver on the chosen priorities, what are the resources available, and more.

As we explore here all that a human rights approach adds, we recognize that cost-effectiveness is itself an element of a human rights approach, part of the rational, evidence-based approach that the right to health incorporates. People will not enjoy “the highest attainable standard of physical and mental health” – the right to health – if states fail to spend resources effectively and efficiently. Moreover, in general, the more cost-effective interventions will be ones that benefit large numbers of people, including poorer, disadvantaged people who previously may have been unable to access even low-cost interventions. In this way, cost-effectiveness can promote equity. As General Comment 14 of the Committee on Economic, Social and Cultural Rights states, “investments should not disproportionately favour expensive curative health services which are often accessible only to a small, privileged fraction of the population, rather than primary and preventive health care benefiting a far larger part of the population” (para. 19).

Yet even here, under a human rights approach, neither cost nor effectiveness is a fixed variable to be plugged into an algorithm. Cost may be negotiated down, in effect expanding the resource envelope, enabling more services to be covered. And how effective an intervention is depends not on theoretical constructs but on such factors as how well, in real life, patients adhere to the intervention and health providers follow proper protocol. As welcomingly recognized in a WHO and World Bank report on tracking progress on universal health coverage, preferably progress on universal health coverage will be measured by such indicators as whether people’s hypertension is under control, not simply whether people are prescribed medicine to control their blood pressure.

The ways that a human rights-based approach to universal health coverage improve upon straight-forward cost-effectiveness continue:

• Beyond discrete interventions
  • A strong health system: Cost-effective interventions will do little to help people if the health system cannot deliver them. The human rights approach looks beyond individual interventions to the overall health system, with the right to health demanding health services that are available, accessible, acceptable, and of good quality (para. 12).
  • Public health measures and underlying determinants: A cost-effectiveness focused approach, often used to define a discrete benefit package to which a person is entitled, with associated financial protections, risks giving short thrift to population-based public health measures, such as tobacco and alcohol control, and vector abatement. Yet these are critical to people’s health (and indeed, are often highly cost-effective), and so prime considerations under the right to health. A rights-based approach also opens up the conversation to such underlying determinants of health as clean water, decent sanitation, and nutritious food, all of which should be universally guaranteed and are under the right to health and related rights (as well as the SDGs), yet are typically considered outside the scope of universal health coverage.
• Expanding the resource envelope: Cost-effectiveness takes the funding available as a given. The right to health does not.
  • Domestic: The right to health demands that states dedicate “the maximum of [their] available resources” to health and other rights. The level of funding must be carefully interrogated, and if the state could provide more funds (such as by mobilizing greater revenue and increasing the share of the budget to health and other social sectors), it is obliged to do so, thus making more health available to its people.
  • International: All those who, fifteen years ago, said that AIDS treatment was simply too expensive for Africa would not have considered it a cost-effective treatment. What a tragedy it would have been if people living with HIV/AIDS had accepted that. They did not. Instead, they demanded treatment as part of their right to health, and they forced the world to listen.International funding, primarily from PEPFAR and the Global Fund, combined with lower drug prices to bring AIDS medication to millions. This illustrates another element of the how to increase the funding available under the right to health: the international obligation to provide assistance, and the obligation of countries in need of external support to seek it. The ICESCR obligation to provide and countries to make use of “international assistance and co-operation” (article 2), the UN Charter commitment of all states to cooperate towards achieving the universal observance realization of human rights, and the long-standing UN target of economically advanced countries to dedicate at least 0.7% of their gross domestic product to official development assistance all point to this obligation. A determination of the health services to be ensured for the entire population should include not only domestically available resources, but also those that might be secured from the international community.
• Core obligations and a robust standard for all: Under a cost-effectiveness approach, the extent of coverage is determined by the level of resources. For a very poor country, absent significant external funding, this might mean a minimal package, leaving many health needs still unmet. Under a right to health approach, this is unacceptable. While the exact floor is necessarily indeterminate at a global level – it must take national factors into account, including the needs of vulnerable and marginalized populations, and be developed through an inclusive, participatory process – General Comment 14 (paras. 43-44) provides some guidance. Core and comparable obligations include, among other health services, providing essential medicines based on WHO’s essential drugs list; ensuring reproductive, maternal, and child care, and; taking measures to prevent and treat epidemic and endemic diseases. Core obligations also encompass the underlying determinants of health. Moreover, states must develop and implement national public health strategies that addresses the concerns of their whole population.
• Progressive realization: People’s needs change over time, as does a country’s epidemiological profile. And as countries’ economies grow, health systems improve, and policies evolve, countries can expand the level of health services available to all. Whatever level of services a country initially ensures for its entire population, that level must improve over time based on the human rights principle of progressively realizing the right to health and other rights. A cost-effectiveness approach lacks this dynamism, saying nothing about how frequently services covered must be re-examined, and so may lag behind a country’s epidemiological, economic, social, and other realities.
• Equity and non-discrimination: Except through the happenstance that cost-effective interventions will generally disproportionately benefit poorer populations, cost-effectiveness is neutral as to the distributional effects of the choice of interventions. We should not be. All people share equal dignity, and are entitled to the same level of health. Justice requires that health systems are designed to guard against discrimination, and beyond that, to proactively respond to the health and societal inequalities that lead to inequitable access to health services and disparate health outcomes.This is precisely what the human rights approach requires. At the most basic level, whatever health services guaranteed for one part of the population must be ensured for all; different sets of services for the well-off and the poor, or formal and informal workers, are unacceptable. So is discrimination of any sort, such as against undocumented or other immigrants. Beyond this, the selection of health services ensured through universal health coverage – as well as the health systems designed to deliver them – must be made with priority to the needs of marginalized and vulnerable populations, even if this entails greater expense (for example, possibly expensive rehabilitative devices for people with disabilities). Critically, the core obligations also include “ensur[ing] equitable distribution of all health facilities, goods and services” (para. 43).In other words, universal health coverage must be a mandate for combatting entrenched inequalities within the health sector and, to the extent they affect people’s health, beyond the health sector as well, helping to foster social inclusion that could in turn empower people in all facets of their lives. The health sector could drive social transformation.
• Valuing people’s perspectives: Health matters not simply because enabling people to live longer, healthier lives is an abstract good, or even that from economic productivity to the protection of the public health, we all benefit from healthy populations. Health also matters because people value it. This basic truth has little connection to a cost-effectiveness approach to universal health coverage, but is central to the human rights approach.
  • Participation: Respecting people’s right to health means ensuring their central role in their health and the decisions that affect it, from informed consent as to their own personal treatment to helping shape national and global health policies. People’s priorities may affect what services are guaranteed through universal health coverage, ensuring that the health issues that most affect their well-being are addressed. Furthermore, people’s right to participate entails a comprehensive system of participatory mechanisms, from the community level on up. Achieving universal health coverage is unlikely to be possible without such mechanisms, through which people can identify barrier, and associated solutions to effective coverage, such as language barriers, lack of transportation, distance to health facilities, inadequate clinic hours, absent health workers, and so forth. A human rights approach insists that these participatory mechanism enable meaningful participation – where not only do people talk, but authorities listen – and that all people, including the most marginalized, are able to participate.
  • A people-centered approach: People-centered health services, integral to a rights-based approach (p. 42-43), will entail actions that may receive little attention when universal health coverage is viewed through a narrow cost-effectiveness lens, yet are needed for effective health services. Health workers need to be trained and sensitized to ensure non-discrimination and cultural competency, for example. The quality of patients’ experiences, affecting whether they access health services and affected by such factors as wait time and whether they are treated respectfully, must be considered and shortcomings improved. Drugs may be cost-effective, but only if people take them properly. A people-centered approach would include improving prescription drug labeling so people understand when they are to take which medicines, leading to better adherence.
  • Life beyond health: Human rights looks beyond DALYs to the real world impact of ill health and efforts to prevent and ameliorate it. Considering how poor health affects people’s lives – including any number of rights – may capture benefits that a straightforward cost-effectiveness analysis would miss, possibly underestimating the benefits of expensive treatments, such as AIDS medication. For example, as HIV/AIDS primarily strikes people in their economically productive years, not providing medication (whether for treatment or post-exposure prophylaxis to prevent the disease) on purported cost-effectiveness grounds would leave families unable to afford children’s education, infringing upon the right to education, and if the family is impoverished, harming rights such as to nutritious food, decent housing, and an adequate standard of living.
• Accountability: Policies to provide universal coverage of cost-effective interventions, however many, will do little to improve people’s health if these policies are not implemented. Human rights demand mechanism to ensure that policies are implemented and interventions delivered, that money is not squandered or stolen, that cost-effective drugs are not false or adulterated, that health workers are accountable for discriminatory behavior. From local health committees and community scorecards to judicial remedies, parliamentary hearings, and national human rights commissions, a rights-based approach to universal health coverage will establish a robust, comprehensive regime of accountability, with particular attention to the participation, needs, and experiences of marginalized populations, to whom governments might otherwise be least accountable, whose voices governments are least likely to listen to, and who face the greatest obstacles to health services.

Beyond all of these benefits of a human rights approach to universal health coverage, though, is what our colleague Mark Heywood at SECTION27 in South Africa taught us: activism is a social determinant of health. Indeed, it is one of the most important, because it has the ability to shape all others. The right to health, and the social movements that can – and have – coalesced around it can ensure that the road towards universal health coverage is a transformative one, igniting political and social change.

Social movements will determine whether the commitment to universal health coverage catalyzes incremental progress or a revolution in health, achieving a little more health for a few more people or, decades after the Declaration of Alma-Ata (1978), finally brings health for all. Committing to universal health coverage as a means towards the right to health is one of the surest steps we can take towards true transformation.

With this importance of the right to health, we must use the right to health platforms that we now have, even as we build upon them to construct even stronger ones – such as a new global treaty, a Framework Convention on Global Health, to reinforce the right to health, to clarify its standards, to provide for the pathways to towards this transformation – and in so doing, to further unleash the awesome power of human beings who will not be content until they succeed in claiming their rights.