Globalisation and health inequalities: Can a human rights paradigm create space for civil society action?

https://doi.org/10.1016/j.socscimed.2011.03.022Get rights and content

Abstract

While neoliberal globalisation is associated with increasing inequalities, global integration has simultaneously strengthened the dissemination of human rights discourse across the world. This paper explores the seeming contradiction that globalisation is conceived as disempowering nations states’ ability to act in their population’s interests, yet implementation of human rights obligations requires effective states to deliver socio-economic entitlements, such as health. Central to the actions required of the state to build a health system based on a human rights approach is the notion of accountability. Two case studies are used to explore the constraints on states meeting their human rights obligations regarding health, the first drawing on data from interviews with parliamentarians responsible for health in East and Southern Africa, and the second reflecting on the response to the HIV/AIDS epidemic in South Africa. The case studies illustrate the importance of a human rights paradigm in strengthening parliamentary oversight over the executive in ways that prioritise pro-poor protections and in increasing leverage for resources for the health sector within parliamentary processes. Further, a rights framework creates the space for civil society action to engage with the legislature to hold public officials accountable and confirms the importance of rights as enabling civil society mobilization, reinforcing community agency to advance health rights for poor communities. In this context, critical assessment of state incapacity to meet claims to health rights raises questions as to the diffusion of accountability rife under modern international aid systems. Such diffusion of accountability opens the door to ‘cunning’ states to deflect rights claims of their populations. We argue that human rights, as both a normative framework for legal challenges and as a means to create room for active civil society engagement provide a means to contest both the real and the purported constraints imposed by globalisation.

Highlights

► A neglected aspect of health systems analysis is the role of human rights approaches in strengthening pro-poor protections. ► Human rights paradigms can strengthen parliamentary oversight over the executive to advance health equity. ► Human rights paradigms can enable civil society agency critical to hold states accountable for the right to health. ► ‘Cunning states’ selectively disown accountability for socio-economic rights under diffused systems of global governance. ► By increasing state accountability, human rights can counter the negative consequences of globalization for health equity.

Section snippets

Background

Despite increasing technological innovation and advances in scientific knowledge, the health status of the world’s people remains threatened by high morbidity and mortality from long-existent infectious diseases such as malaria and tuberculosis, alongside new epidemics such as HIV/AIDS and avian flu (Boutayeb, 2006, Folch et al., 2003) as well as a seemingly relentless growth in non-communicable diseases related to trauma, chronic diseases and cancer, amongst others (Boutayeb, 2006). These

What does a human rights framework imply?

Human rights are entitlements people can claim because of their inherent humanity. Typically, they take the form of social or material claims that are universal across cultures and settings and are codified in national and international law. Human rights address fundamental needs and originated in concerns to protect people from an abusive state by limiting state power over individuals. The ‘modern’ human rights institutional framework guarantees for all of us, irrespective of the countries we

Human rights and health systems

The hallmark of a human rights approach to health systems is a set of principles (Table 1), which Chapman (2009) argues run contrary to the rationale of neoliberalism. For example, while neoliberalism focuses on the market, treats the conditions needed for health as commodities and benefits the most economically advanced, a human rights approach is based on the recognition of the inherent dignity and worth of the human person, frames the social determinants of health as public goods and focuses

States and human rights obligations under globalisation

What might be expected from governments committed to human rights when facing threats to human health from the consequences of globalisation? Logically, governments should use regulation to pursue economic policies that prioritise the needs of the most vulnerable of its people and approach policy negotiations regarding international cooperation from that same perspective.

However, there is evidence to the contrary (Katz, 2004, Katz, 2002; Loewenson, 2001, Meier and Fox, 2008). The normative

Methods

We explore this contradiction through a case study approach, which seeks to investigate a ‘phenomenon within its real-life context, especially when the boundaries between phenomenon and context are not clearly evident’ (Yin, 2003: 13). The propositions examined are that states renege on meeting obligations to the poorest of their peoples because of both unwillingness and failure of oversight; further, that civil society action is essential to both accountability and oversight of states for

Institutional accountability and the ‘Cunning State’

In both case studies, therefore, institutional accountability emerges as critical to the success or failure of human rights as a vehicle for health equity. It has been argued that public policy is being removed from “national legislative deliberation” and that the increasing rhetoric of accountability, in the form of attention to good governance, has gone hand-in-hand with increasing unaccountability of transnational corporations, international finance and trade organisations (Randeria, 2003:

Civil society: social movements and the right to health

Drawing from the Alma Ata declaration on Primary Health Care, the role of community participation in health is widely recognised. Less widely accepted, though, is its normative role within a rights framework, given conflicts over cost-effectiveness and evidence-based policies. Participation becomes key to the realization of the right to health through fair, transparent and meaningful procedures that engage relevant stakeholders and which generate both equitable outcomes and processes (Potts,

Conclusion

It is in the context of this dance of donors and states, in which donors know that states accept human rights standards they have no intention or capacity to implement but to which donors turn a blind eye, that civil society calls for a strong state as a bulwark against globalisation represents a challenge to the idea of the state as being the only site of norm production. Where states manifestly subordinate the health claims of people, particularly marginalised communities, human rights

Acknowledgements

The empirical data on parliamentary experiences in Southern and Eastern Africa was drawn from research funded by the Swedish International Development Cooperation Agency (SIDA) and conducted with the support of Southern and East African Parliamentary Alliance of Committees of Health (SEAPACOH) and the Regional Network for Equity in Health in East and Southern Africa (EQUINET). The assistance of Mr Boitumelo Ngkudi and Dr Nayna Manga in data entry and analysis is acknowledged as is the

References (57)

  • R. Balakrishnan et al.

    Auditing economic policy in light of obligations of economic and social rights

    Essex Human Rights Review

    (2008)
  • A. Butler

    South Africa’s HIV/AIDS policy, 1994–2004: how can it be explained?

    African Affairs

    (2005)
  • A.R. Chapman

    Globalization, human rights, and the social determinants of health

    Bioethics

    (2009)
  • G.A. Cornia

    Globalisation and health: results and options

    Bulletin of the World Health Organisation

    (2001)
  • W. Easterly

    Human rights are the wrong basis for healthcare

    Financial Times

    (2009)
  • D. Fassin et al.

    The politics of AIDS in South Africa: beyond the controversies

    British Medical Journal

    (2003)
  • L. Forman

    “Rights” and wrongs: what utility for the right to health in reforming trade rules on medicines?

    Health and Human Rights

    (2008)
  • L. Forman

    Justice and justiciability: advancing solidarity and justice through South Africans’ right to health jurisprudence

    Medical Law

    (2008)
  • A.M. Fox et al.

    Health as freedom: addressing social determinants of global health inequities through the human right to development

    Bioethics

    (2009)
  • S. Fukuda-Parr et al.

    Measuring the progressive realization of human rights obligations: An index of economic and social rights fulfillment

    (August 2008)
  • L. Gable

    The proliferation of human rights in global health governance

    Journal of Law, Medicine and Ethics

    (2007)
  • S. Gloppen

    Litigation as a strategy to hold governments accountable for implementing the right to health

    Health and Human Rights

    (2008)
  • M. Heywood et al.

    Confronting AIDS: human rights, law and social transformation

    Health and Human Rights

    (2000)
  • M. Heywood

    Preventing mother-to-child HIV transmission in South Africa: background, strategies and outcomes of the treatment action campaign case against the minister of health

    South African Journal of Human Rights

    (2003)
  • M. Heywood

    South Africa's treatment action campaign: combining law and social mobilization to realize the right to health

    Journal of Human Rights Practice

    (2009)
  • P. Hunt et al.

    Health systems and the right to the highest attainable standard of health

    Health and Human Rights

    (2008)
  • M. Kamupira et al.

    An audit of human rights commitments relevant to heath made by member states of the Southern African Development Community (SADC): Implications for advocacy for health equity and the realisation of the right to health

    (2005)
  • A. Katz

    AIDS, individual behaviour and the unexplained remaining variation

    African Journal of AIDS Research

    (2002)
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