The United Nations Universal Periodic Review (UPR), created in 2006, is one of the most important and innovative developments in global human rights monitoring and accountability. Three defining features distinguish it from other UN human rights bodies:
- it is a peer review mechanism – States’ human rights performance is reviewed by representatives of other States;
- it is universal – reviewing the human rights record of all States in each 5-year cycle; and
- it is composed of all international human rights instruments – thus it can review all internationally recognized human rights in any State, regardless of the status of ratification of human rights treaties by a given State.
Each review is based on three reports: a country report submitted by the State; a synthesis report based on information from UN bodies on the country in question; and a synthesis report drawing on information from civil society. After a dialogue between States, recommendations are made to the State-under-Review.
While there exist ample tools and processes to support monitoring of health outcomes—including maternal mortality and morbidity, health system functioning, and treatment coverage—there are limited opportunities and mechanisms to examine and hold states accountable for progress (or lack thereof) in these areas. Even under the new, equity-oriented SDG framework, states are subjected only to voluntary review. In this context, what can the UPR offer? We suggest that there are three key determinants of how this mechanism might support accountability for the progressive realization of the right to health:
- the broad and comprehensive discussion of diverse health topics in UPR recommendations and the “quality” of those recommendations in terms of their practical application;
- the level and diversity of engagement by key health stakeholders (including non-state actors); and
- the level of implementation of recommendations.
The Quantity and Quality of Health Recommendations
In setting out guiding principles for the operation of the UPR, the Human Rights Council, which oversees the procedure, recognized that economic, social and cultural rights (a category which includes the right to health) should not be neglected.
Research by the Human Rights Centre Clinic – University of Essex and the World Health Organization points to health being a prominent theme in the recommendations of the UPR during its first and second cycles (2008-12, 2012-16). A comprehensive empirical review of first cycle recommendations revealed that 22% (3,862 of 17,638 paragraphs) of recommendations made to States were health-related. A small sample review of States during the second cycle indicated that both the number and proportion of recommendations that included a health-focus actually increased between the first and second cycle.
Despite this positive picture, some difficult themes also emerge. For example, there was a significant imbalance in attention given to different health-related issues, including those that are global health priorities. While gender-based violence and maternal and child health were frequently addressed, there was virtually no attention to other issues that are prominent on the global health agenda, including critical issues of concern in many countries, such as water, sanitation and hygiene; HIV/AIDS; adolescent health; mental health; and communicable and non-communicable diseases. In addition, many recommendations were written in vague and open-ended terms, which makes an appropriate State response difficult to measure and ultimately assess.
Engagement by Key Health Stakeholders
Dialogue between rights-holders and duty-bearers is an integral dimension of accountability. However, engagement by stakeholders working on public health issues—including ministries of health, civil society organizations, and the World Health Organization—is at best inconsistent within the UPR process. This may be variously because of: limited knowledge of the procedure; a wide perception that the mechanism does not have a strong focus on health; and, at times, information that is submitted on health that is not filtered through into the review process, thus discouraging participation. Yet, the participation of health stakeholders can support the UPR to address a broad range of health issues, while drawing attention to pressing and emerging health challenges either globally or in specific settings.
Implementation of recommendations
It is through the implementation of recommendations that States can give meaning to their human rights commitments, including by giving effect to remedies to correct human rights abuses, thereby preventing their recurrence. Implementation of UPR recommendations is voluntary. States may “accept” or “note” recommendations, where acceptance indicates a voluntary pledge to implementation. A study by UPR Info found that 48% of UPR recommendations made during the first cycle were either fully or partially implemented within two and a half years, including 55% of accepted recommendations and 19% of noted recommendations. The proportion of recommendations that triggered action was highest for recommendations that focused on HIV/AIDS (78%), with those classified as “right to health” recommendations also considered highly implemented (64%).
The UPR is only one among a range of international human rights mechanisms established to hold states to account for health-related human rights. Advocates have spoken of the importance of creating a “web of accountability” for human rights, supporting global health commitments through the UPR, the UN human rights treaty bodies, and the UN Special Rapporteurs. The UN Human Rights Council, including the UPR, was intended to reinforce, rather than duplicate the accountability functions of other procedures, and it has done that, with each accountability mechanism having comparative advantages and disadvantages in a state-by-state approach to accountability. Recent efforts have also sought to enhance and simplify the complementarity of these bodies, making it easier for States to report and monitor their obligations, and for stakeholders to hold them to account for their failure to do so. From its record on health, the experience of the UPR to date has demonstrated a willingness to address health-related issues, but the need for more practically-oriented recommendations, greater engagement of a wide breadth health stakeholders, and more rigorous implementation of recommendations are works-in-progress, with great unrealized potential.
Read more about the UPR’s engagement with human rights for global health in: