「健康権」「健康への権利」定義
Health Systems and the Right to Health: An Assessment of 194 Countries
The Lancet 372(9655):2047-85 · January 2009
Gunilla Backman, Paul Hunt, Rajat Khosla, Camila Jaramillo-Strouss
What is the right to health?
The right to the highest attainable standard of health encompasses medical care, access to safe drinking water, adequate sanitation, education, health-related information, and other underlying determinants of health;36 it includes freedoms, such as the right to be free from discrimination and involuntary medical treatment, and entitlements, such as the right to essential primary health care.36 Like other human rights, the right to health has particular concern for disadvantaged people and populations, including those living in poverty. The right to health requires an effective, responsive, integrated health system of good quality that is accessible to all.37 International human-rights law recognises that the right to the highest attainable standard of health cannot be realised overnight; it is expressly subject to both progressive realisation and resource availability.4 Put simply, progressive realisation means that a country has to improve its human-rights performance steadily; if there is no progress, the government of that country has to provide a rational and objective explanation. Because of their greater resource availability, more is expected of high-income than of low income countries. However, the right to health also imposes some obligations of immediate effect, such as non-discrimination,4 and the requirement that a state at least prepares a national plan for health care and protection.36 Furthermore, the right to health requires that there are indicators and benchmarks to monitor progressive realisation36 and that individuals and communities have opportunities for active and informed participation in health decision making that affects them.36 Under international human rights law, developed countries have some responsibilities towards the realisation of the right to health in developing countries.36 Because the right to health gives rise to legal entitlements and obligations, effective mechanisms of monitoring and accountability are needed.36 Although the right to health adds power to campaigning and advocacy, it is not just a slogan, it has a concise and constructive contribution to make to health policy and practice. Health workers can use the right to devise equitable policies and programmes that strengthen health
systems and place important health issues higher up national and international agendas.37,38 Medicine, public health, and human rights have much common ground. To one degree or another, each field stresses the importance of the underlying determinants of health and good-quality medical care, looks beyond the
health sector, struggles against discrimination and disadvantage, demands respect for cultural diversity, and attaches importance to public information and education.
The right to health cannot be realised without the interventions and insights of health workers; and the classic, long-established objectives of public health and
medicine can benefit from the newer, dynamic discipline of human rights. A few enlightened people understood these relations when the WHO Constitution was drafted in 1946 9 and when the Declaration of Alma-Ata was adopted in 1978,10 affirming the right to the highest attainable standard of health.
However, until recently, the right to health was only dimly understood and attracted limited support from civil society or any other sector. The understanding and practice of health and human rights has improved since the Alma-Ata conference.35,39–43 One vital part of this process has been a deepening understanding of the right to health. But it was not until 2000 that an authoritative understanding of the right to health emerged when the UN Committee on Economic, Social, and Cultural Rights,
working in close collaboration with WHO and many others, drafted and adopted general comment 14. 36 Although neither complete, perfect, nor binding, general comment 14 is compelling and groundbreaking. The comment shows a substantive understanding of the right to health that can be made operational and improved
in the light of practical experience. The influence of Alma-Ata on general comment 14 is explicit and clear. Although much more work is needed to grasp all the implications of the right to the highest attainable standard of health, the general comment confirms that the right cannot be dismissed as a rhetorical device. General
comment 14 provides a common right-to-health language for talking about health issues and sets out a way of Eric Miller/World Bank
Right to Health www.thelancet.com Published online December 10, 2008 DOI:10.1016/S0140-6736(08)61781-X 3 analysing the right to health, making it easier for policy makers and practitioners to use.27 Panel 1 summarises general comment 14, including the requirement that health facilities and services be available, accessible, and culturally acceptable.
The right-to-health analysis can be used to identify and expose, for example, the lack of available mental-health facilities properly serviced by trained staff.44 Health-related facilities and services, including mental-health facilities with properly trained staff, must be available in adequate number throughout a country. Of course, the need is subject to resource availability: more and better facilities are required of Canada than of Chad. Few nations, however, devote adequate funds to mental health.44,45 On a routine basis, mental-health facilities are neglected, workers untrained, and patients uncared for.44 Poor mental health gives rise to other profound problems, not least discrimination and stigmatisation, important to the
right to health.
The test of availability can also be applied to harm-reduction initiatives.46 Provision of injecting drug users with comprehensive and integrated treatment, counselling, and clean needles and syringes is good for public health, reduces avoidable suffering, saves lives, and is cost-effective.47 An appropriate harm-reduction initiative is also a right-to-health initiative. However, most countries do not provide harm-reduction services for people who use drugs, and those that do, such as Sweden, provide a limited and scattered service.48 The right to health requires all countries to have an effective, national, comprehensive harm-reduction policy and plan, delivering essential services. A high-income country such as Sweden is expected to provide more than the essential services.
Health-related facilities and services can be available within a country but inaccessible to all those who need them. For example, access to essential medicines is an indispensable part of the right to health with several dimensions.49 First, medicines must be accessible in remote rural areas as well as in urban centres, which has major implications for the design of medicine supply systems. Second, medicines must be affordable to all, including those living in poverty, which has obvious implications for funding and pricing arrangements. Third, given the fundamental human-rights principles of non-discrimination and equality, a national medicines policy must be designed to ensure access for disadvantaged individuals and communities, such as women and girls, people living with HIV/AIDS, elderly people, and people with disabilities. Because equal access is not always secured by equal treatment, a state must sometimes take measures in favour of disadvantaged people. As far as possible, data must be disaggregated to identify marginalised groups and monitor their progress towards equal access. Fourth, reliable information about medicines must be accessible to patients and health workers so they can take well-informed decisions and use medicines safely.
Health-related facilities and services may be available and accessible but be insensitive to culture and gender. For example, improving the access to sexual and
reproductive health care is not simply about scaling up Panel 1: Some important points from general comment 14 Article 12 of the International Covenant on Economic, Social, and Cultural Rights very briefly sets out the right to the highest attainable standard of health. General comment 14 provides the UN Committee on Economic, Social, and Cultural Rights’ interpretation of article 12. Although not legally binding, the comment is highly authoritative.
• Encompassing physical and mental health, the right to health places obligations on governments in relation to health care and the underlying determinants of health—these obligations include provision of clean water, adequate sanitation, nutritious food, adequate shelter, education, a safe environment, health-related information, and freedom from discrimination.
• Governments have, for example, obligations regarding maternal, child, and reproductive health; healthy natural and workplace environments; the prevention, treatment, and control of diseases; health facilities, services, and goods.
• Governments have an obligation to give particular attention to marginal individuals, communities, and populations, creating a need for as much disaggregation of data as possible.
• Within a country, health facilities, services, and goods must be available in sufficient quantity, accessible (including affordable) to everyone without discrimination, culturally acceptable (eg, respectful of medical ethics and sensitive to gender and culture), and of good quality.
• The right to health is subject to progressive realisation and resource availability.
• Nonetheless, governments must take deliberate, concrete, and targeted steps to ensure the progressive realisation of the right as expeditiously and effectively as possible.
• However, core obligations are subject to neither progressive realisation nor resource availability. Expressly taking into account the Declaration of Alma-Ata, they include obligations to ensure access to health facilities, goods, and services to everyone, including marginal groups, without discrimination; to ensure everyone is free from hunger; to ensure access to basic shelter, housing and sanitation, and an adequate supply of safe and potable water; to provide essential drugs, as defined under the WHO action programme on essential drugs; to ensure equitable distribution of all health facilities, goods, and services; and to adopt and implement a national public-health strategy and plan of action, by way of a participatory and transparent process.
• The right to health requires opportunities for as much participation as possible by individuals and communities in health-related decision making.
• Governments have an obligation to ensure that non-state stakeholders are respectful of the right to health (eg, do not discriminate).
• Developed states, and others in a position to assist, should provide international assistance and cooperation in health to developing countries (eg, economic and technical assistance to help developing countries fulfil their core obligations). All states “have an obligation to ensure that their actions as members of international organizations take due account of the right to health”.
• Monitoring, accountability and redress are essential. Given progressive realisation, indicators and benchmarks are indispensable if governments are to be held to account.
• The right to health is closely related to, and dependent upon, numerous other human rights, such as the rights to life, education, and access to information.
• In narrowly defined circumstances and as a last resort, the enjoyment of some human rights may be interfered with to achieve a public health goal. For example, quarantine for a serious communicable disease, such as ebola fever, may, under certain circumstances, be necessary for the public good, and lawful under human rights, even though it limits an individual’s freedom of movement. Right to Health
4 www.thelancet.com Published online December 10, 2008 DOI:10.1016/S0140-6736(08)61781-X technical interventions or making them affordable. A Peruvian project that studied indigenous communities with very high maternal mortality found an acute reluctance within the population to use the health facilities offered by the state, partly because they did not take account of local cultural conceptions of health and sickness. In close consultation with the indigenous communities, culturally sensitive facilities and services were introduced, such as sturdy ropes in delivery rooms so that women could give birth squatting and gripping the rope, as they were accustomed to. These changes led an increase in deliveries in local health centres,50 and the success of these local initiatives helped to generate a corresponding change in national health policy on deliveries in all primary health-care facilities.51
