Lawrence O Gostin, Eric A Friedman, Paulo Buss, Mushtaque Chowdhury, Anand Grover, Mark Heywood, Churnrurtai Kanchanachitra, Gabriel Leung, Judith Mackay, Precious Matsoso, Sigrun Møgedal, Joia S Mukherjee, Francis Omaswa,Joy Phumaphi, K Srinath Reddy, Mirta Roses Periago, Joe Thomas, Oyewale Tomori, Miriam Were, Debrework Zewdie
The Lancet – The next WHO Director-General faces major challenges: 1 operational responsibilities for epidemic response, universal health coverage (UHC), and the rise of non-communicable diseases. Given the vast gap between daunting health challenges and WHO funding, what should be the Director-General’s foremost priority? The answer lies in the organisation’s main constitutional pillar, the right of everyone to the highest attainable standard of health. WHO’s next leader should bring human rights to the forefront, ensuring the universal right to health.
A Framework Convention on Global Health (FCGH)2—supported by civil society and global leaders3—should become the centrepiece of this endeavour (panel). It would reform global governance for health to enhance accountability, transparency, and civil society participation and protect the right to health in trade, investment, climate change, and other international regimes, while catalysing governments to institutionalise the right to health at community through to national levels. It would usher in a new era of global health with justice—vast improvements in health outcomes, equitably distributed.4
Framework Convention on Global Health
Why a Framework Convention on Global Health (FCGH)?
Global health with justice requires international co-operation and shared international and domestic responsibilities, based on human rights, with precise standards and compliance mechanisms.
Four problems with governance for health
Lack of systemwide accountability. The FCGH would establish health accountability frameworks, including multistakeholder participation, rigorous monitoring, transparency, and redress.
Persisting inequalities. The FCGH would reinforce norms against discrimination and catalyse health equity strategies.
Insufficient financing. The FCGH would establish a robust health-financing framework.
Detrimental effects of non-health sectors. The FCGH would protect the right to health in all sectors, including through right to health impact assessments.
Sustainable Development Goals (SDGs)
The FCGH would help implement the SDGs and fill gaps in the post-2015 agenda and beyond.
The FCGH would establish actionable norms while facilitating international co-operation, modelled on the Framework Convention on Tobacco Control. It could borrow innovative features from the Paris agreement on climate change and WHO’s Pandemic Influenza Preparedness Framework, including continually strengthening national health and equity targets, and using creative ways to hold corporations accountable. Like the UN Convention on the Rights of Persons with Disabilities, marginalised populations and civil society must be centrally involved in developing the FCGH.
National and global systems today suffer from pervasive structural deficiencies, making them incapable of achieving global health with justice. These structures enable inequities to persist, fail to ensure accountability, and permit health and non-health sectors to undermine the right to health.
Vast disparities in wealth and political power leave countries and marginalised populations with far worse health outcomes than in wealthier states and among well-off populations. Income inequality and global threats (eg, climate change, mass migrations) risk worsening disparities. Legal frameworks and social practices perpetuate marginalisation of women, immigrants, indigenous people, and ethnic and sexual minorities. Yet the Sustainable Development Goals (SDGs) do not adequately prioritise marginalised populations. WHO’s new Framework of Engagement with Non-State Actors5 fails to empower civil society to effectively participate in the organisation’s governance.
Global accountability often relies on self-reporting, typically voluntary, based on poor-quality data. Legal or political consequences are rarely imposed on state and non-state actors for non-compliance with global norms. 70% of states, for example, have not met surveillance and response capacities required under the International Health Regulations.6 Nor have higher-income states offered international assistance required under that treaty. Weak health systems and harmful travel restrictions resulted in a tragedy for west Africa during the Ebola outbreak, and deficient public health systems again amplify the harm from Zika. Health financing is insufficient and fragmented. Human rights accountability mechanisms (eg, human rights courts and commissions, state and shadow reporting to treaty bodies, and special rapporteurs) are helpful but often ignored.
Health is a multisector, co-operative endeavour. Yet WHO has not vigorously engaged other sectors to defend the right to health. Treaties on trade, investment, and intellectual property often undermine public health. International financing co-operation is needed to reduce a 200-fold public health spending disparity between low-income and high-income countries,7 but no shared financing framework exists.
As an innovative, rights-based global health treaty, the FCGH could respond to these failings. An FCGH based on the right to health is well within WHO’s constitutional powers, with the Framework Convention on Tobacco Control demonstrating proof of concept. The FCGH could incorporate innovative governance of the Paris agreement on climate change, such as national target-setting with regularly scaled-up goals.8 The FCGH would bring the following reforms:
Establish accountability mechanisms, with high-quality disaggregated data and community participation. National health accountability strategies could span community to national levels, encompassing courts, legislatures, and ministries, with transparency and civil society voice throughout.9 An FCGH global accountability framework could include indicators, transparency, monitoring, independent evaluations, civil society engagement, and detailed plans for redress. It would reinforce key health commitments including the right to health norms, funding, SDG health targets (eg, UHC, non-communicable diseases, and HIV/AIDS), and health-rights in UN commitments (eg, Declaration on the Rights of Indigenous People).
Focus on health justice, elevating the voices, priorities, and ultimately the power of marginalised populations. The FCGH would mandate national health equity strategies, identifying obstacles to equality with funded plans of action.10 The treaty would set standards on disaggregated data, non-discrimination, equitable resource distribution, and pro-poor pathways to meet health targets.
Establish a national and global health-financing framework to ensure UHC, including underlying determinants of health, and reduce health-financing disparities. The FCGH would reach beyond the health sphere, with right to health impact assessments and public health participation in negotiating and adjudicating international agreements. Critically, health drives development in all sectors, and requires action. The convention would embed responsibility for health outcomes in planning, implementation, and monitoring across all sectors, including agriculture, education, energy, water, sanitation, and trade.
The FCGH would reinvigorate WHO’s global health leadership, breathing new life into its founding principles. It could become the platform for reforming WHO as a rights-based 21st century institution, with badly-needed reforms, such as community participation, new priorities favouring social determinants of health, and a culture of transparency and accountability.
We call upon a new Director-General to seize the potential of the FCGH, incorporating it into a bold vision for WHO. The next Director-General should launch a historic effort to align national and global governance for health with human rights, bringing the world closer to global health with justice.
We declare no competing interests.
- Horton, R. The next Director-General of WHO. Lancet. 2016; 387: 1790
- Platform for a Framework Convention on Global Health. A rights-based framework for the SDGs and beyond: a Framework Convention on Global Health. http://www.jalihealth.org/documents/a-rights-based-framework-for-the-sdgs-and-beyond.pdf. ((accessed July 23, 2016).)
- UN Secretary-General. On the fast-track to ending the AIDS epidemic: report of the Secretary-General, UN Doc. A/70/811. United Nations, New York;2016http://www.un.org/ga/search/view_doc.asp?symbol=A%2F70%2F811&Lang=E. ((accessed July 26, 2016).)
- Gostin, LO. Global health law. Harvard University Press, Cambridge; 2014
- WHO. Framework of engagement with non-state actors, WHA 69.10; May 28, 2016.http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_R10-en.pdf. ((accessed July 25, 2016).)
- WHO. WHO implementation of the International Health Regulations (2005): report of the review committee on second extensions for establishing national public health capacities on IHR implementation: report by the Director-General. World Health Organization, Geneva;2015http://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_22Add1-en.pdf. ((accessed July 26, 2016).)
- WHO. World health statistics 2015. World Health Organization, Geneva;2015http://www.who.int/gho/publications/world_health_statistics/EN_WHS2015_Part2.pdf. ((accessed July 26, 2016).)
- United Nations. Paris Agreement. United Nations, Paris;2015http://unfccc.int/files/essential_background/convention/application/pdf/english_paris_agreement.pdf. ((accessed July 24, 2016).)
- Friedman, EA. An independent review and accountability mechanism for the Sustainable Development Goals: the possibilities of a Framework Convention on Global Health. Health Hum Rights. 2016; 18: 129–140https://cdn2.sph.harvard.edu/wp-content/uploads/sites/13/2016/06/Friedman1.pdf. ((accessed July 23, 2016).)
- Friedman, EA and Gostin, LO. Imagining global health with justice: in defense of the right to health. Health Care Analysis. 2015; 23: 308–329http://link.springer.com/article/10.1007%2Fs10728-015-0307-x. ((accessed July 28, 2016).)