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volume 12, no. 1 health and human rights • 61
critical concepts
www.hhrjournal.org
international obligations through
collective rights: moving from
foreign health assistance to global
health governance
Benjamin Mason Meier and Ashley M. Fox
abstract
This article analyzes the growing chasm between international power and state respon-
sibility in health rights, proposing an international legal framework for collective rights
— rights that can reform international institutions and empower developing states
to realize the determinants of health structured by global forces. With longstand-
ing recognition that many developing state governments cannot realize the health of
their peoples without international cooperation, scholars have increasingly sought to
codify international obligations under the purview of an evolving human right to
health, applying this rights-based approach as a foundational framework for reduc-
ing global health inequalities through foreign assistance. Yet the inherent limitations
of the individual human rights framework stymie the right to health in impacting
the global institutions that are most crucial for realizing underlying determinants of
health through the strengthening of primary health care systems. Whereas the right to
health has been advanced as an individual right to be realized by a state duty-bearer,
the authors nd that this limited, atomized right has proven insufcient to create
accountability for international obligations in global health policy, enabling the deterio-
ration of primary health care systems that lack the ability to address an expanding
set of public health claims. For rights scholars to advance disease protection and health
promotion through national primary health care systems — creating the international
legal obligations necessary to spur development supportive of the public’s health — the
authors conclude that scholars must look beyond the individual right to health to create
collective international legal obligations commensurate with a public health-centered
approach to primary health care. Through the development and implementation of
these collective health rights, states can address interconnected determinants of health
within and across countries, obligating the international community to scale-up pri-
mary health care systems in the developing world and thereby reduce public health
inequities through global health governance.
introduction
The human right to health is thought to have evolved from an individual
right of persons against a single governmental duty-bearer to a collective
right of peoples against myriad duty-bearers throughout the world. Yet
in spite of this rights-based recognition of globalized determinants of
health, these evolving human rights claims remain imprecise in creat-
ing international legal obligations to meet global health priorities. With
advocates challenging all manner of powerful actors — public and pri-
vate, domestic and foreign, institutional and individual — these inchoate
claims have been unable to achieve the global health policies necessary
to realize public health improvements in developing countries through
primary health care systems.
To the extent that the developed world has assumed any responsibility
for global health, this responsibility has been asserted through political
Benjamin Mason Meier,
JD, LLM, PhD, is Assistant
Professor of Global Health
Policy at the University of
North Carolina at Chapel Hill.
Ashley M. Fox, MA, PhD, is
a post-doctoral fellow in the
Department of Global Health
and Population at the Harvard
School of Public Health.
Please address correspon-
dence to the authors c/o
Benjamin Mason Meier,
Department of Public Policy,
University of North Carolina,
Chapel Hill, NC, 27599–3435,
email: bmeier@unc.edu.
Competing interests: None
declared.
Copyright © 2010 Meier and
Fox. This is an open access
article distributed under
the terms of the Creative
Commons Attribution Non-
Commercial License (http://
creativecommons.org/
licenses/by-nc/3.0/), which
permits unrestricted non-com-
mercial use, distribution, and
reproduction in any medium,
provided the original author
and source are credited.
meier/fox
62 • health and human rights volume 12, no. 1
commitments that lack enforceability and sustainabil-
ity. With these eeting political initiatives funneled
largely through foreign assistance programs, such
policies have been crafted through rhetorical pleas
for charity rather than binding obligations of law.
As a result, developing states have faced inconsistent
commitments that have impeded the functioning of
national primary health care systems — commit-
ments that have become increasingly precarious as
the global economic crisis has deepened.
With ethicists positing moral obligations between
developed and developing countries — conceptual-
izing international development aid not as a volun-
tary, altruistic gesture, but rather as a form of redis-
tributive justice to rectify past and ongoing structural
harms — an imperative has arisen to ground these
non-binding ethical frameworks in international
law. To reassert the authoritative legal frameworks
of human rights in global health governance, it is
necessary that these frameworks incorporate col-
lective rights, complementing an individual right to
health with collective international obligations for
public health.
foreign assistance for global health
Given the persistence of entrenched poverty, devel-
oping countries continue to experience high rates of
infectious disease, shortened lifespan, and diminished
quality of life for large portions of their populations,
generating wide epidemiologic rifts between rich and
poor countries. At the end of the 20th century, 14%
of the world remained undernourished, 16% lacked
access to safe drinking water, and 40% lacked basic
sanitation — with these wanting masses overwhelm-
ingly congregated in the developing world.1 While
health trends have continuously improved at the
global level, health gains in many regions have stag-
nated in step with the increasing immiseration occa-
sioned by international development policy during
the 1980s and 1990s, an era of structural adjustment
that was characterized by health policy prescriptions
for privatization and deregulation.2
Recent attention to these global health inequalities,
precipitated by a worldwide movement for HIV
treatment access, has resulted in unprecedented
increases in health-related foreign assistance to devel-
oping countries. To this end, Ofcial Development
Assistance (ODA) — government nancing for the
economic development and welfare of developing
countries — nearly doubled between 2001 and 2007,
with health-related foreign aid growing by US$14.9
billion.3 In addition, so-called megaphilanthropists
and their foundations have begun investing unprece-
dented billions into global health programs and novel
governance systems (for example, public-private
partnerships) to develop health technologies for the
neglected diseases of the developing world.4 Turning
from what many view as their tarnished past, inter-
national nancial institutions have taken a renewed
interest in health-related development nancing
through such programs as the World Bank’s Health,
Nutrition, and Population initiative and its Multi-
Country HIV/AIDS Program.5
However, current global health policy, while a vast
improvement over the tradition of neglect that has
long plagued the world’s poor, has tended to take
programmatic form in vertical interventions directed
at select diseases — often to the detriment of hori-
zontal primary health care systems directed at under-
lying determinants of the public’s health (such as
potable water, improved sanitation, and basic health
infrastructures).6 Given that funding priorities are
driven by the strategic interests of donors, the con-
ditionalities attached to these inherently unsustain-
able foreign assistance programs have proven to be
barriers to the effective implementation of global
health policy through the strengthening of primary
health care systems.7 Further, a substantial portion of
this new global health funding has gone toward the
development of expensive and technically sophisti-
cated biomedical interventions for a fortunate few,
overshadowing the obtainable public health strategies
needed to meet basic survival needs for the common
good.8
As research has uncovered the harms of these vertical
and biomedical approaches to health policy, advocate
attention has shifted back to horizontal systems to
strengthen primary health care, addressing underly-
ing determinants of health through the provision of
public goods, such as water and sanitation systems.9
However, despite growing calls for sector-wide health
support under the mantle of “new” or “smart” aid,
foreign assistance and international lending continue
to bypass the state, with aid given directly to NGOs
or channeled through the privatized provision of
public goods.10 This uncoordinated response has the
potential to undermine the developing state, disad-
vantaging the national primary health care systems
necessary for disease prevention and health promo-
volume 12, no. 1 health and human rights • 63
critical concepts
tion.11 As a result, there are growing concerns about
how best to “improve the coordination necessary to
avoid waste, inefciency and turf wars” while main-
taining the enthusiasm for global health generated by
disease-specic political mobilization.12 While foreign
assistance remains an important source of needed
revenue for health, the current framework cannot
realize the public health needs of developing coun-
tries without increasing international cooperation and
support for national primary health care systems.
limited evolution of the right to
health in codifying international
obligations
In reducing global health inequalities through this
foreign assistance framework, scholars and advo-
cates have looked increasingly to the authoritative
obligations of international human rights law.13
Recognizing that many developing state governments
cannot realize the health of their peoples without
foreign resources, advocates have increasingly sought
to codify international obligations under the purview
of the human right to health, using this rights-based
approach as a foundation for foreign health assis-
tance. As this right to health has evolved to encom-
pass international obligations, however, it has faced
scholarly criticism for exceeding the bounds of inter-
national law and has encountered policy limitations
in inuencing foreign assistance.
This trend toward international obligations began as
early as the 1948 Universal Declaration of Human
Rights (UDHR), which established, through the
United Nations (UN), “a common standard of
achievement for all peoples and all nations.”14 The
UDHR elaborated a right to health — drawn from
negotiations for the 1948 Constitution of the World
Health Organization (WHO) — by which the state
would seek to realize for each person “a standard of
living adequate for the health and well-being of himself
and of his family, including food, clothing, housing
and medical care and necessary social services.” To
achieve this end through global action, a promise set
forth in the 1945 UN Charter, the UDHR acknowl-
edged the need for international cooperation in
realizing human rights, holding that “[e]veryone is
entitled to a social and international order in which the
rights and freedoms set forth in this Declaration can
be fully realized.”15
Drawing on this international order, the UN’s 1966
International Covenant on Economic, Social and
Cultural Rights (ICESCR) extended these interna-
tional legal obligations for achieving health rights.
To realize the ICESCR’s right to health, dened as
a “right of everyone to the enjoyment of the highest
attainable standard of physical and mental health,”
the ICESCR committed states “to take steps individ-
ually and through international assistance and cooperation,
especially economic and technical, to the maximum
of its available resources.”16 With an understanding
that such international obligations were necessary for
the full realization of human rights, the UN’s special-
ized agencies took the lead in directing this economic
and technical cooperation within their respective
areas of competence.17
In moving forward from the ICESCR under this
UN mandate, WHO’s “Health for All” strategy pro-
vided an institutional framework for global efforts
to expand the normative development of the right
to health, accommodating international health obli-
gations through the 1978 Declaration of Alma-Ata.
In order to realize human rights to health and devel-
opment through international health assistance and
cooperation, WHO and UNICEF brought together
representatives from 134 state governments for an
international conference on primary health care.
Under the Declaration’s rights-based goal of “health
for all by the year 2000,” representatives sought
international cooperation to reduce inequalities in
health status between developed and developing
countries, encouraging governments to work toward
establishing a “New International Economic Order”
that would prioritize disadvantaged groups through
national primary health care systems.18
With the advent of economic structural adjustment
policy in the 1980s, however, the Declaration of
Alma-Ata failed to achieve its goals for primary health
care, leading WHO to postpone its “Health for All”
mission, remove the language of “by the Year 2000”
from its “Health for All” campaign, and rename its
delayed vision of health justice “Health for All in the
21st Century.”19 Despite efforts to reach consensus on
international cooperation in the 1986 UN Declaration
on the Right to Development and the 1993 Vienna
Declaration and Programme of Action, these procla-
mations of a new world order did not translate into
international health obligations.20 At this nadir in global
health governance, WHO’s leadership under the right
to health was displaced by the expanding inuence of
international nancial institutions, with WHO’s author-
ity for global health policy dispersed among other
meier/fox
64 • health and human rights volume 12, no. 1
international organizations.21 Rather than addressing
global health threats through the world’s premier pub-
lic health organization, states sidelined WHO through
the creation of The Joint United Nations Programme
on HIV/AIDS (UNAIDS) and The Global Fund to
Fight AIDS, Tuberculosis and Malaria (The Global
Fund) as parallel programs to coordinate vertical inter-
ventions for high-prole diseases. Even as the harmful
ramications of the structural adjustment paradigm
compelled a return to WHO’s “Health for All” strat-
egy, weaknesses in the international legal framework
for health enabled the dismantling of national health
systems through economic austerity programs, exacer-
bating health inequalities within and between countries
with little regard for the human rights consequences.22
In response to these weaknesses in the rights-based
approach to health, public health advocates ral-
lied around non-obligatory political commitments
through the 2000 Millennium Development Goals
(MDGs), which were designed to serve as a moral
framework for a large-scale global campaign to
advance human development through eight goals to
be achieved by 2015. Introducing the MDGs, states
recognized that “in addition to our separate responsi-
bilities to our individual societies, we have a collective
responsibility to uphold the principles of human dig-
nity, equality and equity at the global level.”23 Given
this proclaimed “duty to all the world’s people, espe-
cially the most vulnerable,” four of the eight MDGs
invoke commitments to global health — including
the reduction of maternal and infant mortality, pre-
vention of HIV infection, and eradication of hunger
— with the nal goal calling for the creation of “a
global partnership for development.” Yet, although
the MDGs provide hortatory indicators in global
health — delineating aspects of international partner-
ships necessary for development — they do so in a
way that is focused on foreign assistance, untethered
to human rights, and wanting for legal obligations.24
As a result, the MDGs have failed to develop legal
accountability for health obligations on international
duty-bearers.25 Without unprecedented coordination
in health investments from developed states — a
commitment not even broached by the international
community — it is highly unlikely that any substantial
number of developing states will meet their public
health goals.
A belated attempt to revitalize the rights-based
approach to primary health care was made in 2000,
when the UN Committee on Economic, Social and
Cultural Rights (CESCR) took up the evolving deni-
tion of a right to health in its 14th General Comment
on the ICESCR. Drawing on previously elaborated
obligations of “international assistance and coopera-
tion,” General Comment 14 reinterpreted these obli-
gations for application to the right to health, further-
ing the consensus of the Declaration of Alma-Ata to
highlight the international obligations of developed
countries to “facilitate access to essential health
facilities, goods, and services in other countries, when-
ever possible, and provide the necessary aid when
required.”26 In reiterating the international obliga-
tions of the ICESCR, the CESCR stated that:
For the avoidance of any doubt, the
Committee wishes to emphasize that
it is particularly incumbent on States
parties and other actors in a posi-
tion to assist, to provide ‘international
assistance and cooperation, especially
economic and technical’ which enable
developing countries to fulll their core
and other obligations.27
Extending this reasoning to international nancial
institutions, the CESCR advised that “[s]tates par-
ties which are members of international nancial
institutions, notably the International Monetary
Fund, the World Bank, and regional development
banks, should pay greater attention to the protec-
tion of the right to health in inuencing the lend-
ing policies, credit agreements and international
measures of these institutions.”28 Advocates have
pushed forward in advancing these international
health obligations despite criticisms that 1) extrater-
ritorial obligations do not exist under the ICESCR,
2) the CESCR has limited “international assistance
and cooperation” in health to “facilities, goods,
and services” rather than underlying determinants
of health, and 3) General Comment 14 “go[es] far
beyond what the treaty [ICESCR] itself provides
and what the states parties believe to be the obliga-
tion they have accepted.”29 The advocacy to advance
these obligations has accelerated even as developed
states have neglected rights-based approaches to
foreign assistance and developing states have faced
hobbling budgetary uncertainties in their progres-
sive realization of health goals.
With growing recognition of the rights-based impact
of globalized forces on primary health care systems
in the developing world, there has been increasing
volume 12, no. 1 health and human rights • 65
critical concepts
analysis of international health obligations follow-
ing the 2002 appointment of the rst UN Special
Rapporteur on the right to the highest attainable
standard of health, who sought to “give practical
guidance about the application of the human rights
responsibility of international assistance and cooper-
ation in health.”30 Under his mandate to recommend
measures to promote and protect the right to health,
the Special Rapporteur found that:
[s]tates are obliged to respect the enjoy-
ment of the right to health in other
jurisdictions, to ensure that no inter-
national agreement or policy adversely
impacts upon the right to health, and
that their representatives in internation-
al organizations take due account of the
right to health, as well as the obligation
of international assistance and coopera-
tion, in all policy-making matters.31
Although the rst Special Rapporteur enumerated
general principles to guide states in the nancial
allocations and global policies necessary to realize
international health assistance and cooperation, both
he and the second Special Rapporteur have faced
difculties in applying these expansive international
obligations to developed states and international
organizations.32
collective rights as a means to
international obligations
Despite this normative evolution of the right to
health, the inherent limitations of the individual
human rights framework stymie the right to health
in impacting the development processes that are
most crucial for realizing underlying determinants
of health through primary health care.33 Because the
right to health has been advanced as an individual
right, one to be realized by a state duty-bearer, this
limited, atomized right has proven insufcient to
create accountability for international obligations in
global health policy, leaving in its wake deteriorat-
ing national health systems that lack the capacity to
address an expanding set of public health claims.34
Although individuals have found success against
their own governments in select claims for a right of
access to essential medicines, this national litigation
model has little salience to underlying determinants
of health, many of which are structured by actors
and forces beyond the sovereignty of the state.35 As
recognized by legal analysts:
International human rights law, caught
within its framework of state respon-
sibility for human rights violations, is
unable to deal fully with the changes to
state sovereignty accelerated by the pro-
cess of globalization. Where the viola-
tor of human rights law is not a state
or its agent but a globalized economic
institution or a transnational corpora-
tion, international human rights law
nds it difcult to provide any redress
to the victim.36
As such, national enforcement of the right to health
has been limited in challenging the global institution-
al arrangements that structure the ability of states
to realize public health through primary health care
systems.37 With large proportions of health-related
funding owing through foreign assistance programs,
a growing chasm is evident between international
power and domestic responsibility in health rights.
This chasm highlights the utility of collective health
rights — rights of states and peoples that can reform
international institutions to account for international
obligations to realize underlying determinants of
health through primary health care.
Collective rights to realize global public goods
Collective rights can give meaning to underlying
determinants of health in the human rights system,
and through the scaling up of primary health care
systems, provide for the realization of public health.
It has long been recognized by public health scholars
that “public health and safety are not simply the aggre-
gate of each private individual’s interest in health and
safety … . Public health and safety are community or
group interests.”38 As a result, public health — based
upon its non-rivalrous and non-excludable properties
— is a public good that, by its very nature, has mean-
ing only at a collective level.39 Working as a shared
public good, a collective whole that is greater than
the sum of its parts, primary health care systems can
lead to positive externalities — in this case, health for
all. Where this public good “benets all of mankind,”
its realization becomes the “collective responsibility
of all nations.”40 With global health determinants
implicating such international responsibility for pri-
mary health care, collective rights become necessary
meier/fox
66 • health and human rights volume 12, no. 1
to address these international obligations for global
public goods.
The rise of collective rights to challenge global
institutions
Although human rights were initially conceived fol-
lowing the Second World War solely as individual
rights — with an individual rights-bearer left to
make claims against a national duty-bearer (and pro-
vide external restraint against a presumably tyranni-
cal sovereign) — the rise of developing states and
development debates has forced a re-examination
of this individualistic conception of human rights.41
Viewing traditional human rights frameworks as an
extension of imperialist domination, developing
states advanced collective rights as a means of freeing
their peoples from the neocolonial binds of interna-
tional relations and establishing a “New International
Economic Order.”42 Following the supremacy of
individual rights in early UN treaties, collective
rights received their rst explicit recognition in
regional human rights systems, wherein developing
states advanced economic development rights in the
1972 UN Conference for Trade and Development
(UNCTAD III) and African states memorialized
communal rights in the 1976 Universal Declaration
of the Rights of Peoples.43 Since that time, scholars
and advocates have put forward arguments for collec-
tive rights to, inter alia, development, environmental
protection, humanitarian assistance, peace, common
heritage, and public health.44
Often referred to as “third-generation” rights, a rhetor-
ical remnant of Cold War typologies, collective rights
operate at an international level to assure public goods
that can only be enjoyed in common with similarly-sit-
uated individuals and thus cannot be realized through
individual rights claims against the state.45 Rather than
restraining the state — a woefully inadequate obliga-
tion for states struggling to provide for their peoples
in a globalizing world — these collective rights seek
to empower the state to realize rights outside of its
control. Despite the inherent conceptual weaknesses
attendant to such nascent rights frameworks, collec-
tive rights claims have shown themselves effective in
responding to national changes brought about by insa-
lubrious development, shifting the balance of power in
international relations and creating widely recognized,
if not always realized, entitlements within the interna-
tional community.46
employing collective rights for global
health governance
Collective rights offer an extant legal framework
by which to restructure international institutions
to meet global justice imperatives for public health.
Through a vector of rights and duties, collective
rights can address interconnected determinants of
health within and between countries, obligating states
and the international community to scale up primary
health care systems in the developing world and
thereby reduce inequities in global health. Reecting
sovereign inequalities, international dependencies,
and cooperation imperatives, the developing state can
be reconceptualized as both duty-bearer and rights-
holder.47 While developing states would still bear a
duty to realize individual health rights, they would
also hold collective health rights — where they are
unable to realize public health alone — to call on the
international community for cooperation and assis-
tance. By providing a framework for a national rights-
holder in a globalized world, collective rights can be
invoked to alter the global forces that structure the
developmental and distributive policies underlying
the public’s health.48 As such, collective rights in
public health can complement the individual right to
health, examining systemic problems engendered by
global development processes and working alongside
the right to health to mobilize national and interna-
tional resources for primary health care.
In framing these international obligations, the duty-
bearer for such collective rights would be the inter-
national community — including individual states,
international organizations, and public-private part-
nerships. It was once thought that such obligations on
the international community could not exist because
state sovereignty obviated transnational rights viola-
tions. As Louis Henkin noted in The Age of Rights,
The failure of the international human
rights movement to address the respon-
sibility of a state for human rights of
persons in other states may reect only
the realities of the state system. States
are not ordinarily in a position either to
violate or to support the rights of per-
sons in other states.49
Globalization has laid bare such hermetic concep-
tions of sovereignty. While such international obliga-
tions undeniably impinge upon both the developing
and developed state’s sovereignty, these tensions pose
volume 12, no. 1 health and human rights • 67
critical concepts
little conict where developing nations are incapable
of realizing the health rights of their peoples alone,
and developed nations need not shoulder these trans-
national obligations individually.
At the international level, developing states could
operationalize these collective rights to enforce glob-
al health commitments, channel foreign assistance
toward primary health care, and ensure cooperation
in global health policy. Since the ability of states to
realize their human rights obligations at the domestic
level is constrained by the actions and institutional
arrangements of the international community, the
realization of collective rights will require a restruc-
turing of international institutions and national for-
eign assistance programs, allowing developing states
to enter public health debates not merely with a plea
for charity, but with a right to assistance and coopera-
tion.
Developing human rights claims against the
international community: Respect, protect, and fulll
Based upon General Comment 14’s delineation
of state obligations pursuant to the right to health
— drawn from the CESCR’s approach to “respect,
protect, and fulll” all economic, social and cultural
rights — it is possible to extend these dimensions of
health obligation from the domestic to the interna-
tional sphere.50
Under this analogous tripartite framework, the inter-
national community has an obligation to respect the
rights of developing states by not infringing upon
these states’ autonomy to develop functioning pri-
mary health care systems. This would place legal
responsibility on developed states and international
nancial institutions to refrain from such actions as
enforcing trade regimes with inequitable subsidies,
preventing parallel importation of essential medi-
cines, and privatizing services in ways detrimental
to sustainable health systems.51 In this sense, col-
lective rights can be viewed as restoring sovereignty
to developing states to meet the basic public health
needs of their peoples without interference, thereby
creating an enabling environment for states to realize
their domestic obligations for economic, social, and
cultural rights, including the right to health.
Similarly, the international community has an obliga-
tion to protect developing states through the regulation
of transnational private actors that undermine state
governance in public health. In particular, transnational
corporations (TNCs) — whose pursuit of increasingly
exible labor markets and deregulated policy environ-
ments has resulted in a “race to the bottom” in national
regulations — have limited states’ ability to govern in
the absence of global coordination.52 Further imped-
ing national health care administration, pharmaceutical
TNCs have prevented developing states from direct-
ing nite resources to the procurement of affordable
essential medicines and health services.53 To protect
states from these deregulatory and monopolistic prac-
tices that harm the public’s health, the international
community can promulgate international public health
standards, creating global public health frameworks to
prevent TNCs from seeking safe haven for harm in
any country.54
Finally, as the realization of collective rights in a
globalized world requires cooperation across the
international community, WHO can be viewed as a
natural institutional mechanism to fulll the obliga-
tions of the international community for global pub-
lic health. WHO, as the leading authority in global
health policy and “the only organization with the
political credibility to compel cooperative thinking”
on public health, can serve a dual role in fullling
international obligations pursuant to collective rights
— promoting international cooperation to support
global public goods (such as preventing the transna-
tional spread of infectious disease) and coordinating
funding efforts to strengthen national primary health
care systems (such as developing research agendas
for the chronic and neglected diseases of developing
countries).55 Where such leadership necessitates the
incorporation of collective public health obligations
in treaty law, WHO — drawing on its constitutional
mandate for health and human rights — can reestab-
lish its rights-based legitimacy in global health policy
by codifying such obligations through the recently-
proposed Framework Convention on Global Health
— galvanizing engagement across the global health
architecture to overcome collective threats to global
health, heralding global consensus on primary health
care, and creating a lasting legacy of public health in
international law.56
Implementing human rights claims through
international organizations: International and
intranational institutional reforms
Yet even among those who advocate international
human rights obligations for health, there remain
meier/fox
68 • health and human rights volume 12, no. 1
doubts as to the implementation mechanisms that
would be necessary to operationalize these obliga-
tions under international law.57 Where individual
human rights have long relied on goodwill and
shaming to effectuate national policy change, collec-
tive health rights provide a set of legal claims and
accountability mechanisms that can be institutional-
ized through international organizations. In imple-
menting this collective rights framework through the
international community, collective health rights may
be implemented through both international and intra-
national means.
Internationally, collective rights can be implemented
to restructure existing international institutions by
incorporating human rights clauses into the inter-
national legal structure of these institutions and by
developing multilateral governance institutions to
ensure reciprocal conditionalities as obligations of
the international community.58 Rather than allow-
ing states to hide behind the veil of international
institutions to absolve themselves of human rights
obligations, states would bear duties through their
membership in these organizations. For example,
within the WTO — a forum for state negotiation
and adjudication of free-trade principles, often to
the detriment of public health — collective rights
could be asserted by developing states to incorpo-
rate health rights into trade negotiations or dispute
resolution mechanisms; thus, collective rights could
harmonize regulations to protect the public’s health
and reverse the burden of proof to show that trade
agreements are not violating health standards.59 In
addition, given an obligation of states to provide
foreign assistance through international organiza-
tions, collective health rights could be invoked 1)
against idle members to meet their unfullled com-
mitments to global health and 2) on behalf of devel-
oping state members to heighten their participation
in these organizations. To ensure that such health
assistance is channeled into projects that strengthen
primary health care, international assistance could
be coordinated through a central body such as
WHO — as discussed above, under obligations
of the international community to fulll collective
rights — thereby reducing inefciency and redun-
dancy in contribution efforts in a manner similar to
that of The Global Fund but cutting more broadly
across health conditions and their determinants.60
Intranationally, to address developing country sources
of global health inequalities — that is, inequalities in
structural capacity that reinforce the dependence of
developing states on ODA for vertical health pro-
grams — collective rights can be implemented to
ensure that both bilateral and multilateral assistance
is channeled through general budgetary support and
sector-wide approaches to national primary health
care systems.61 Whereas current health assistance
tends to “crowd out” the public sector while creat-
ing funding distortions in national health policy,
general budgetary support would overcome these
bottlenecks in donor-driven priority setting by pro-
viding developing states with greater autonomy to
address national public health priorities through
ofcial needs assessments. Realizing the collective
health rights of states in such country-led develop-
ment assistance, sector-wide approaches (SWAps)
could overcome the tendency toward verticalization
of health programs and create integration across sec-
tors that underlie health.62 Through this channeling
of assistance via general budget support, SWAps may
be reformulated to cut across determinants of health
(for example, education, infrastructure, environment,
water and sanitation systems, and social insurance),
strengthening state capacity for providing public
goods by way of primary health care. As a result, pri-
mary health care could then be assured domestically,
through individual rights claims against the state, and
internationally, through human rights assessments of
foreign assistance.
Thus, collective rights would provide a legal frame-
work for states to seek or provide international
assistance and cooperation in accordance with their
respective capabilities.63 With the massive inux of
funds invested in health and health-related develop-
ment projects, it is critical that global health partner-
ships — including intergovernmental, governmental,
and nongovernmental organizations — coordinate
this health assistance to meet international public
health goals and strengthen national primary health
care systems. As interpretations of global social jus-
tice increasingly recognize imperatives to address
power imbalances that give rise to an unjust social
order, rather than merely increase assistance to offset
the harms generated by global institutional arrange-
ments, collective rights can be leveraged to bolster
global institutions at the international level and chan-
nel development aid at the national level.64 By assur-
ing that health assistance is directed toward efcient
cross-sectoral channels through primary health care
systems, collective rights could appreciate the path-
ways and synergies between development commit-
volume 12, no. 1 health and human rights • 69
critical concepts
ments and underlying determinants of health. To
that end, states could employ collective health rights
to institute a “development compact” in global health
as a mechanism for “ensuring the recognition among
all stakeholders of the ‘mutuality of the obligations’
so that the obligations of developing countries to
carry out these rights-based programs are matched
with reciprocal obligations of the international com-
munity to cooperate in order to enable the implemen-
tation of those programs.”65 Such a compact would
offer a means for developing states to reshape the
international community for health promotion, to
raise public health obligations in economic develop-
ment planning, and to increase national resources to
realize primary health care for all.
conclusion
So long as states can argue that their foreign assistance
is elective, “health for all” will remain an elusive goal
— one more regret upon the altar of failed political
commitments. Realizing the rights-based promise of
international obligations for global health will require
sustainable international structures for facilitating
coordination and cooperation across the interna-
tional community. These structures can be created
through the frameworks of collective human rights,
developed and implemented through the structures
outlined above and illustrated in Figure 1.
Figure 1: A collective rights-based approach to
global health governance
In this way, collective rights offer a framework for
developing structures of global health governance.
With human rights providing normative resonance to
social mobilization and legal standards in global pol-
icy, the language and obligations of collective rights
can prove instrumental in achieving the public health
goals that have been incompletely realized under the
aegis of the individual right to health. Through the
complementary advancement of individual and col-
lective health rights, states can create the optimum
synergy of global efforts — at the national and inter-
national level — and give meaning to human rights as
they address collective vulnerabilities to the realiza-
tion of the public’s health.
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