Transcript Right to Health*Does it Matter? - View the full AIDS 2016 programme

Empirical impact of constitutional rights
protections on health systems and
availability of essential medicines
AIDS2016, Durban RSA
Matthew M. Kavanagh
University of Pennsylvania
Health & Health
Equity
Within & Between
Countries
HIV mortality
Philadelphia life
expectancy by zip
code

Most, but not not all of this is disparity is amenable to
political/state action.


What are the political institutions that improve health?
Do rights matter?
Countries w/ Constitutional Right to Health
Number of Constitutions
200
180
160
140
120
52%
Have a Right to
Health
100
44%
80
Rapid growth
60
30%
40
20%
17%
20
9%
5%
0
0%
2020
2010
2000
1990
1980
1970
1960
1950
1940
1930
1920
1910
1900
Year
Total
Constitutions
Which countries have a right to health ?
Region
% w RtH
Frequency
Africa
44 %
20
61 %
20
Income Group
% w RtH
Low Income
55%
Latin
America
20%
5
Lower Middle
Income
69%
US/Europ
e/Canada
92%
26
Upper Middle
Income
58%
Eastern
Europe
56 %
10
Upper
22%
Middle
East
S. Asia
43 %
3
E, Asia
59%
10
Oceana
15%
2
Southern “institutional” innovation
Two questions
1.
Is this ‘constitutionalization’ good, bad or
meaningless for health equity?
2.
how? Why?
Quantitative & Qualitative evidence
Skeptics worry: False Promise
Democracy

master political institution that matters for health
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Information, Incentives for public goods, accountability
Left & Social Pacts not rights (e.g. Scandinavia)
Are rights anti-democratic?
Courts & rights: negative or no effect

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Courts & law : bastion of the wealthy
Judges & lawyers will distort polycentric health policy
Rights are too individualistic, demobilizing
But constitution writers, ethicists…
Insufficient Empirical Evidence
1.
QUANTITATIVE: Cross-national comparison
Neoliberal Paradigm
Social Determinants of health…
Preston estimates that only about 15 percent of the increase in life
expectancy between the 1930s and 1960s was a result of increases
in income alone
 Education (Pritchett 2005, Gakidou et. al 2010.)
 Democracy: (Besly & Kudamatsu, M. (2006).
 Ethnic Fractionalization: Easterly, W. (2001); Alesina, A., Baqir, R.,
& Easterly, W. (1999).
 Inequality: Deaton 2003, Wilkinson 1992, Lynch et al. 1998
 Geography: Sachs et al,
 Population Density & Urbanization: Herbst
Impact of the Right to Health: 144 countries 1970-2010
Under 5 Mortality (log, per 1,000 births)
1. Wealth & Social
2. Democracy
Determinants Matter
3. Rights
Health Right
-0.082**
Democracy
-0.017**
(0.011)
-0.017**
(0.005)
(0.005)
-0.443**
-0.467**
-0.482**
(0.018)
(0.019)
(0.019)
-0.280**
-0.297**
-0.305**
(0.023)
(0.023)
(0.023)
0.093**
0.102**
0.095**
(0.036)
(0.033)
0.026**
(0.033)
0.026**
0.027**
(0.006)
(0.006)
(0.006)
0.107**
0.120**
0.144**
(0.018)
(0.018)
(0.018)
-0.117**
-0.116**
-0.110**
(0.022)
(0.022)
(0.022)
yes
yes
yes
3,723
3,610
3,584
148
144
144
0.881
0.896
0.892
GDP per capita
(LOG)
Women's Education
(years)
Ethnolinguistic
Fractionalization
Inequality
Urbanization
Population Density
Year & regional
Observations
Number of Countries
R2
** p<0.01, * p<0.05
Under 5 Mortality (log, per
1,000 births)
INTERACTION BETWEEN
HEALTH & DEMOCRACY
Health Right
-0.075**
(0.011)
Health Right X
Democracy
-0.006**
Heath Rights & Democracy INTERACT
(0.001)
Democracy
0.002
(0.001)
GDP per capita
(LOG)
-0.299**
(0.012)
Women's Education
-0.082**
(years)
Ethnolinguistic
Fractionalization
(0.006)
0.344**
(0.121)
Inequality
-0.002**
(0.001)
Urbanization
0.006**
(0.001)
Population Density
-0.000**
(0.000)
Year dummies
yes
Regional dummies
yes
Observations
Number of Countries
R2
3,584
144
0.894
** p<0.01, * p<0.05
 Do
countries with a right to health
seem to provide more of what matters
for the poor?
Effect of Rights on Services
Mulitlevel
regression,
random effects
Availability of
Public Health Public Health
Out of Pocket
Immunization Medicines in
Expenditures Expenditures (% Exp (% Total Skilled Birth (% (% 1-year
the Public
(% GDP) Total Health Exp) Health Exp)
Attended)
DTP3)
Sector (2004)
Health Right
Democracy
Log GDP (pc)
Ethnolinguistic
Fractionalization
0.087
2.573**
-1.713+
3.780**
7.657**
29.775*
(0.103)
(0.963)
(0.921)
(1.212)
(0.992)
(11.559)
0.449**
3.783**
-3.578**
7.444**
2.740**
-13.736*
(0.073)
(0.733)
(0.809)
(0.928)
(0.665)
(5.073)
0.017*
0.162*
-0.109
0.173*
0.099
2.703**
(0.008)
(0.072)
(0.071)
(0.082)
(0.061)
(0.773)
-1.130*
-6.741
2.796
-20.361**
-16.426**
-91.192**
(0.471)
(4.856)
(5.708)
(6.663)
(4.433)
(20.477)
-0.016**
-0.256**
0.068
0.042
-0.228**
2.004
(0.006)
yes
1,309
(0.052)
yes
1,756
(0.049)
yes
1,323
(0.060)
yes
607
(0.055)
yes
2,857
(1.293)
yes
15
111
143
113
124
144
15
Inequality
Year Control
Observations
Number of Countries
R2
0.577
0.393
0.352
0.526
0.377
Models 1-5: Random effects model on 1970-2009 data, with controls for regional and year effects dummies.
Model 6: OLS regession on 2004 data with controls for regional effects dummies.
0.821.
** p<0.01, * p<0.05 +p<0.1
HOW?
1.
Qualitative: Process tracing case studies
Are rights really at work?

Policy process approach
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Don’t assume judicial orders are what matters
“Shadow of the law” affect
Identify which policies saw “right to health” mobilized?
Start with public policy processes before rights
mobilization
Trace what difference rights make
South Africa: Challenging health environment

SA background factors (would lead us to expect health
policy challenges and inequity—
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GDP growth and comparative strong govt commitment
High democracy score
but…
Inequality
Fractionalization
state capacity, education challenges.,..
legacies of colonialism + apartheid
Rapid urbanization after end of apartheid
Yet also: labor/state pact, avowed ‘social democracy’
1996 Constitution: Section 27-Right to Health
Mobilized across the public policy cycle
Table 6: South African: Policy Issues Where the Right to Health Was Mobilized in the Policy Cycle
Agenda setting
Eastern Cape Emergency
Services: human rights
commission & rights
mobilization put the issue of
lack of emergency
transportation for poor,
Black rural communities on
the priority agenda of local
health officials and demand
accountability for failure to
deliver.
Private Sector Health
Inquiry: Competition
commission engages right
to health as reason for
compelling information from
health industry.
TB in Prisons
(see above right)
Policy formulation
HIV Treatment: Activists
and the Constitutional
Court address
government refusal to
craft a science-based
AIDS policy and roll out
HIV treatment.
National Health
Insurance: Constitutional
right to health empowers
pro-health actors to take
neoliberal proposals off
the table on basis of
inequity likely to result.
Drug pricing: Courts &
Competition commission
compel pharmaceutical
companies to allow
generic competition on
key essential medicines.
Adoption
Implementation
Eliminate User Fees:
mobilization of the right to
TB in Prisons: Court
health to break through
cases compel release of
federalism limitations and information by Department
ensure the removal of
or Corrections and spur
user fees in the mid
implementation of TB
1990s, even as the global prevention and treatment
policy zeitgeist was
programs, including
encouraging user fees on application to Global Fund
health.
Silicosis & TB in Mines:
Activists intervene in
class action to establish
broader public interest
health regulation
principles for large
corporations
Migrants access to
health: In- and out-ofcourt settlements to force
local officials to provide
healthcare to
undocumented migrants
Eastern Cape
(see above left)
Eastern Cape
(see above left)
Mobilized across the public policy cycle
Table 6: India: Policy Issues Where the Right to Health Was Mobilized in the Policy Cycle
Low
High
India
Drug
Pricing
Private
Healthcare
Regulation
Charit
hospitals
Emerg
Medical
Care
Rural
Health
Irrational
Medicines
Maternal
Health
Clinical
Trials
LGBTI/
Sodomy
Laws
Intellectual
Property &
Access to
Medicine
HIV
Treatment
Some health policy issues result in landmark
cases, but not most…
Landmark cases

Soobramoney
 Treatment Action Campaign v MOH
 Dudley Lee
(Pietrus)
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
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Early free healthcare
ARV roll out, not just Neverapine
Access to medicines
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Prisons
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Access cases
Private sector inquiry

and beyond…
Minister using rights language?
Migrant health
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TAC, Sonke amici
NHI
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SAHRC
Silicosis
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ART, TB
Eastern Cape
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PMA vs. Mandela
Hazel Tau
Address inequality & private sector?
Policy Process: what’s happening?
Policy Change to improve health, equity


Improvements in health = translate technology into practice
(Angus Deaton)
Improving health equity  distribution  policy change
Elections & Democracy is supposed to give us:
1.
2.
3.
Incentives for public goods provision—elected leaders want to
promise & deliver
A way to punish those who don’t deliver
Information: Government knows when there’s health
problems, voters know whether government addresses them
Public policy change in practice…
Often a “policy monopoly” (Baumgartner & Jones) in which the
bureaucracy + interests make critical decisions in subsystem that excludes most
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Resists change
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Negative Feedback, contains impact of policy entrepreneurs
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“Policy image” reflects attention of macro politics

U.S. example: HIV medicines = supposed to be the most
political
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ADAP waiting lists in a dozen states a few years ago… folks sick. Not on
treatment = new infections.
Complex negotiation between insurance companies + drug companies +
US Patent Office + insurers
Elections solve it?
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No elections turn on the issue
Information is sparce, doesn’t change government action, hard to find the
person to blame
Right to Health: Policy Change Model
Bargaining, Policy Entrepreneurship
Policy Monopoly
Destruction of
Policy Monopoly
Policy change blocked
(or unchecked)
Right to Health Mobilization
New language for demands
‘Expand the conflict’
to new policy venues
• Coalition formation
• New actors including
lawyers & judges
Power shift: Bargaining
Endowments
Attention of macropolitics sphere
Information: flows
expanded
Accountability: Decisionmakers forced to justify
Incentives shift
Same benefits ascribed to
democracy
Optnty
for
Policy
Change
Bargaining,
Policy
Entreprene
urship
Emergency Health Services in the Eastern
Cape
•Ambulances
•Policy monopoly
•Decades of failure of
democracy
•Rights mobilization
•-Bulungula Xhora Mouth
•SECTION 27 + TAC
•Human Rights
Commission
= new political attention
•Budget
•… Maybe ambulances in
October?
The right to health



RtH linked to better health outcomes (equity)
Improved services needed by poor
One Mechanism: destruction of policy monopolies
that hinder health policy change
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India
South Africa
Thailand
Meaning for IP & Access to Meds
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Policy monopolies
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National level IP policy dominated by pharma + a few
activists
Framed as technical
Venue shift to change power
More aggressive stance
Rights mobilization on health rights
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Judicial compulsory license?
Reasonable policy
Force balancing of rights on health and rights on IP
Question…
Thank you….
[email protected]
Supported by grants from National Science
Foundation Law & Society Program, Leonard Davis
Institute
Work in progress, advice and ideas please…