What Duties Do Poor Countries Have for the Health of Their Own People?

Abstract

The global health community has struggled to answer a pivotal question involving social justice: What do rich countries owe to the world's least healthy people? (1) In my last column, for example, I examined the responsibility of the world's rich to equitably share influenza A (H1N1) vaccines with developing countries. (2) But there is another important question that is rarely asked: What duties do low-income countries have for the health of their own populations? In many ways, this is the more important question because the state must owe the primary obligation to serve the needs of its population. This places clear responsibilities on public officials in low- and middle-income countries. But it also requires the United States to adopt policies and programs that empower, rather than emasculate, poor countries. President Obama's Global Health Initiative views global health investment as a national security smart power strategy that engages all U.S. government agencies--an all-of-government approach. It provides an opportunity to change direction, using global health diplomacy to strengthen the autonomy and capacity of poor countries to steer their own course. Three kinds of responsibilities are crucial for understanding what countries owe to their people. First, political leaders have a duty to spend a reasonable portion of their national budgets on health services as part of their international human rights obligations. Second, they must govern justly, openly, and without conflicts of interest. Finally, although they have a range of discretion, political leaders must allocate resources fairly among competing health priorities. 1) States have the responsibility to provide adequate health resources within their capacity. The international human right to health posits that governments must ensure a minimum package of essential services, (3) which includes sanitation, nutritious food, clean water, and primary health care. (4) Many low- and middle-income countries also have constitutional entitlements to health and life that require the provision of basic health services. The South African Constitutional Court, for example, ruled that the state must provide antiretroviral medication to pregnant women living with HIV/AIDS. (5) Despite these domestic and international norms, developing countries' health expenditures, as a proportion of total government spending, are significantly lower than the global average (below 6 percent, compared with above 14 percent). Foreign assistance accounts for more than 30 percent of total health expenditures, rising as high as two-thirds in many low-income countries. Worse still, developing countries often reduce their domestic health spending for every dollar they receive in foreign aid--the so-called substitution effect. (6) These data suggest that low-income countries could do much more to meet the basic survival needs of the population. Certainly, rich states must help build health system capacity in the developing world, but this does not obviate the responsibility of governments to meet their population's basic health needs. 2) States have a responsibility to govern well, with honesty, transparency, civic deliberation, and accountability. The concept of good governance--introduced by the World Bank--sets ethical standards for national management of economic and social resources for development. Those who exercise authority to expend resources and make policy have a duty of stewardship--a personal responsibility to act on behalf, and in the interests, of those whom they serve. Sound governance is honest. It avoids the systemic corruption exemplified by public officials who seek personal gain or divert funds from their intended purposes. It is also transparent; institutional processes and decision-making should be open and comprehensible to the people. It is deliberative, in the sense that government consults with stakeholders and the public in a meaningful way, giving them the right to provide genuine input into policy formation and implementation. …