Eric A. Friedman

A Retrospective and Prospective Analysis of the West African Ebola Virus Disease Epidemic: Robust National Health Systems at the Foundation and an Empowered WHO at the Apex

The Ebola virus disease outbreak in west Africa is pivotal for the worldwide health system. Just as the depth of the crisis ultimately spurred an unprecedented response, the failures of leadership suggest the need for innovative reforms. Such reforms would transform the existing worldwide health system architecture into a purposeful, organised system with an empowered, highly capable WHO at its apex and enduring, equitable national health systems at its foundation. It would be designed not only to provide security against epidemic threats, but also to meet everyday health needs, thus realising the right to health. This retrospective and prospective analysis offers a template for these reforms, responding to the profound harms posed by fragile national health systems, delays in the international response, deficient resource mobilisation, ill defined responsibilities, and insufficient coordination. The scope of the reforms should address failures in the Ebola response, and entrenched weaknesses that enabled the epidemic to reach its heights.

Ebola: A Crisis in Global Health Leadership

At the core of the present Ebola crisis in West Africa is a lack of global health leadership. WHO should be the global health leader, following its constitutional charge, yet it is significantly under-resourced, having a direct effect on its rapid response capacity. The Organizations response to this crisis has been constantly behind, from low funding appeals to its delay in declaring this outbreak to be a Public Health Emergency of International Concern under the binding International Health Regulations (2005) (IHR). The IHR themselves have proven insufficient, as countries have failed to cooperate in building the public health capacities that the IHR requires, reflecting the absence of incentives, sanctions, or a clear allocation of responsibility.The United States and United Nations have sought to fill this leadership vacuum. The United States is deploying military assets to utilize their logistics, engineering, and similar capacities. Yet a single state cannot fill the significant governance gaps, mobilizing and coordinating global efforts. The United Nations has now assumed this leadership role. The UN Security Councils resolution has raised the political profile in a way that WHO could not even as the resolution left unclear the exact duties required of states. The UN Secretary-General initiated the UN Mission for Ebola Emergency Response.Going forward, the United Nations must maintain its leadership, from the Security-General identifying states that fail to contribute fairly to the global response -- or that strip other health and development funding to do so -- to the Security Council being prepared to pass another resolution, this one with unambiguous binding authority and clear allocation of responsibility. Looking further ahead, the Security Council should interpret its mandate for maintaining international peace and security broadly, encompassing human security. States should give WHO the funding and other support the Organization requires, as WHO undertakes reforms necessary for it to be a global health leader. The UN Secretary-General and WHO Director-General should establish an independent commission to comprehensively review the response and recommend what is needed to prevent future global health emergencies. National and institutional leaders must respond to Ebola by enacting the far-reaching reforms required for genuine global health leadership, exercising the political will and leadership whose absence enabled the current Ebola outbreak to turn into a global crisis.

The Joint Action and Learning Initiative: Towards a Global Agreement on National and Global Responsibilities for Health

Lawrence Gostin and colleagues discuss their work on the Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI), which aims to secure a global health agreement (such as a Framework Convention on Global Health) that would inform post-Millennium Development Goal global health commitments.

Is universal health coverage the practical expression of the right to health care

The present Millennium Development Goals are set to expire in 2015 and their next iteration is now being discussed within the international community. With regards to health, the World Health Organization proposes universal health coverage as a ‘single overarching health goal’ for the next iteration of the Millennium Development Goals.The present Millennium Development Goals have been criticised for being ‘duplicative’ or even ‘competing alternatives’ to international human rights law. The question then arises, if universal health coverage would indeed become the single overarching health goal, replacing the present health-related Millennium Development Goals, would that be more consistent with the right to health? The World Health Organization seems to have anticipated the question, as it labels universal health coverage as “by definition, a practical expression of the concern for health equity and the right to health”.Rather than waiting for the negotiations to unfold, we thought it would be useful to verify this contention, using a comparative normative analysis. We found that – to be a practical expression of the right to health – at least one element is missing in present authoritative definitions of universal health coverage: a straightforward confirmation that international assistance is essential, not optional.But universal health coverage is a ‘work in progress’. A recent proposal by the United Nations Sustainable Development Solutions Network proposed universal health coverage with a set of targets, including a target for international assistance, which would turn universal health coverage into a practical expression of the right to health care.

Universal Health Coverage Anchored in the Right to Health

This editorial was published in the Bulletin of the World Health Organization [© 2013 Bulletin of the World Health Organization] and the definite version is available at: http://www.who.int/bulletin/volumes/91/1/12-115808/en/

Towards a framework convention on global health

A global health treaty, a Framework Convention on Global Health (FCGH) – grounded in the right to health, with the central goal of reducing immense domestic and global health inequities – could serve as a robust global governance instrument to underpin the United Nations post-2015 Millennium Development Goals (MDGs). It would ensure for all people the three essential conditions for a healthy life – public health, health care, and the positive social determinants of health – while advancing good governance, responding to drivers of health disadvantages for marginalized populations, elevating health in other legal regimes, and enhancing peoples ability to claim their rights.The legally binding nature of the FCGH would enhance accountability and compliance through rigorous monitoring and reporting, domestic human rights litigation, and international incentives. It would overcome the collective action problem of global health financing through a health financing framework with clear domestic and international obligations.Stakeholders have made thoughtful critiques of the FCGH, such as the opportunity costs of advocacy, the time and expense of treaty negotiations, and reporting burdens. Nevertheless, these costs could be turned into opportunities through civil society participation in negotiations, by taking advantage of extensive reporting and monitoring requirements to expand accountability around and strengthen strategies to respond to health inequities, and through non-binding frameworks on the way towards the treaty.The greatest challenge in achieving an FCGH is the political obstacles it will face. Social justice movements united behind an FCGH, to secure the treaty and to ensure its implementation, are vital to the success of an FCGH – and the right to health. With its aim of securing this right, the FCGH could unite disparate health-related movements, all of which should contribute to developing the treaty and taking ownership of its realization.

The Sustainable Development Goals: One-Health in the World’s Development Agenda

The Sustainable Development Goals (SDGs), adopted by the UN General Assembly in September 2015, embody a One-Health strategy — healthy people living on a habitable planet. Extending beyond the social development emphasis of the Millennium Development Goals (MDGs), which accelerated progress globally, though unequally, the SDGs also encompass a range of environmental and economic goals, with a health goal that is far more comprehensive than the infectious diseases and maternal/child health focus of the MDGs.To be achieved, the SDGs require resources and political commitment that is yet to be demonstrated. With a cost that could reach

Universal Health Coverage and the Right to Health: From Legal Principle to Post-2015 Indicators.

5 trillion for the SDGs overall, achieving health targets will require a mix of increase domestic resources, including taxes on unhealthy foods and products, international assistance, and innovative financing. Annual reviews should identify and monitor threats to the SDGs, both internal contradictions and contradictory government policies such as discriminatory laws, and the necessary rights-based pathways forward. To improve accountability, health information systems with disaggregated data should be prioritized, along with independent monitoring and key governance indicators. Ambitious national benchmarks, drawing on WHO strategies and action plans, could provide markers of success for presently vague health targets.Three early indicators of progress on the health SDGs could be: 1) whether countries establish clear policies on universality, encompassing all people without discrimination, identifying and prioritizing populations with the least access; 2) whether universal health coverage fully incorporates population health; and 3) whether countries provide rapid and sustained increased funding for such necessities as adequate sanitation and nutritious food. A Framework Convention on Global Health, a global health treaty based in the right to health, could fill in critical gaps in the SDGs, creating accountability through capacity-building and compliance-enhancing mechanisms, establishing a financing framework, and ensuring right to health assessments and health in all policies. It could help establish a path forward based on equity and the right to health that would be truly transformative.

What could a strengthened right to health bring to the post-2015 health development agenda?: interrogating the role of the minimum core concept in advancing essential global health needs

Universal Health Coverage (UHC) is widely considered one of the key components for the post-2015 health goal. The idea of UHC is rooted in the right to health, set out in the International Covenant on Economic, Social, and Cultural Rights. Based on the Covenant and the General Comment of the Committee on Economic, Social, and Cultural Rights, which is responsible for interpreting and monitoring the Covenant, we identify 6 key legal principles that should underpin UHC based on the right to health: minimum core obligation, progressive realization, cost-effectiveness, shared responsibility, participatory decision making, and prioritizing vulnerable or marginalized groups. Yet, although these principles are widely accepted, they are criticized for not being specific enough to operationalize as post-2015 indicators for reaching the target of UHC. In this article, we propose measurable and achievable indicators for UHC based on the right to health that can be used to inform the ongoing negotiations on Sustainable Development Goals. However, we identify 3 major challenges that face any exercise in setting indicators post-2015: data availability as an essential criterion, the universality of targets, and the adaptation of global goals to local populations.

Health, equity and the post-2015 agenda: raising the voices of marginalized communities

BackgroundGlobal health institutions increasingly recognize that the right to health should guide the formulation of replacement goals for the Millennium Development Goals, which expire in 2015. However, the right to health’s contribution is undercut by the principle of progressive realization, which links provision of health services to available resources, permitting states to deny even basic levels of health coverage domestically and allowing international assistance for health to remain entirely discretionary.DiscussionTo prevent progressive realization from undermining both domestic and international responsibilities towards health, international human rights law institutions developed the idea of non-derogable “minimum core” obligations to provide essential health services. While minimum core obligations have enjoyed some uptake in human rights practice and scholarship, their definition in international law fails to specify which health services should fall within their scope, or to specify wealthy country obligations to assist poorer countries. These definitional gaps undercut the capacity of minimum core obligations to protect essential health needs against inaction, austerity and illegitimate trade-offs in both domestic and global action. If the right to health is to effectively advance essential global health needs in these contexts, weaknesses within the minimum core concept must be resolved through innovative research on social, political and legal conceptualizations of essential health needs.SummaryWe believe that if the minimum core concept is strengthened in these ways, it will produce a more feasible and grounded conception of legally prioritized health needs that could assist in advancing health equity, including by providing a framework rooted in legal obligations to guide the formulation of new health development goals, providing a baseline of essential health services to be protected as a matter of right against governmental claims of scarcity and inadequate international assistance, and empowering civil society to claim fulfillment of their essential health needs from domestic and global decision-makers.