Highest Attainable Standard Of Health Research Articles

The Right to Health as the Unheralded Narrative of Health Care Reform

IN PASSING THE AFFORDABLE CARE ACT, THE UNITED States took a giant, if partial, step toward joining other nations wherein the right to health constitutes an inalienable moral and legal right. Although not widely appreciated, the right of every person to enjoy the highest attainable standard of physical and mental health (the right to health for short) is not merely an abstract moral imperative. Rather, it is an established international legal precept still to be fully embraced in the United States. Even though the right to health was overshadowed during the health care debate by other narratives, such as insurance reform, cost control, and care delivery, this right remains a central if unheralded narrative of the Affordable Care Act and its legacy. What is this right that engenders these bold claims? It is an assertion of the responsibility of governments to strive for “the highest attainable standard of physical and mental health.” It is an asseveration that governments will respect, protect, and fulfill the right to health by ensuring the availability, accessibility, acceptability, and quality of the care required. It is an averment that governments will honor the tenets of accurate information, nondiscrimination and equality, and participation. It is an avouchment that governments will address the “underlying determinants of health” such as sound housing, clean water, and adequate nutrition, especially as these determinants apply to the needs of poor and other marginalized populations. As such, the right to health constitutes a concept broader than that represented by the right to health care, covering elements that the Affordable Care Act, with its focus on health care, addresses only in limited, although important, ways. The right to health—or more precisely, to health care—as a moral dictum is associated with Senator Edward Kennedy’s impassioned expression of hope “that every American— north, south, east, west, young, old—will have decent, quality health care as a fundamental right and not a privilege.” Others have echoed these sentiments, not least President Obama who framed last year’s health care debate as a core ethical and moral obligation. Americans appear to agree, evidenced by the very existence of and broad support for the Medicare, Medicaid, and CHIP public safety net programs. Moreover, 72% of Americans strongly believe that health care should be considered a human right. The right to health is also a matter of international law, one drawing on the collective force of national constitutions, international and regional treaties, and other instruments. As such, the right to health is as established as the more familiar rights to freedom of expression and religion. Leading the way were British laws as early as 1802 triggered by the health threats of the Industrial Revolution, and the Mexican Constitution of 1843, which recognized the state’s role in public health. In 1925, Chile became the first nation to incorporate the right to health into its constitution. Now more than 100 countries boast a commitment to the right to health or health care in their constitutions. Beyond these national efforts, several critical global pacts incorporate the right to health. First among them was the constitution of the World Health Organization (WHO), which in 1946 identified the “enjoyment of the highest attainable standard of health” as “one of the fundamental rights of every human being.” Two years later, the United Nation (UN) General Assembly adopted the Universal Declaration of Human Rights (UDHR), article 25 of which guarantees the right to “a standard of living adequate for the health and well-being . . . including food, clothing, housing and medical care.” Many international lawyers view the UDHR as creating a binding customary international law, including as an interpretation of the human rights commitments in the UN Charter, under which states have committed to the “universal observance of, and respect for, human rights.” In 1966, the UDHR was expanded upon by the International Covenant on Economic, Social, and Cultural Rights (ICESCR), which asserts that signatory states recognize “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” It was against this backdrop that the UN Commission for Human Rights created the mandate for a Special Rapporteur on the right of every person to enjoy the highest attainable standard of physical and mental health. The combined force of the

Social conditions, health equity, and human rights.

The fields of health equity and human rights have different languages, perspectives, and tools for action, yet they share several foundational concepts. This paper explores connections between human rights and health equity, focusing particularly on the implications of current knowledge of how social conditions may influence health and health inequalities, the metric by which health equity is assessed. The role of social conditions in health is explicitly addressed by both 1) the concept that health equity requires equity in social conditions, as well as in other modifiable determinants, of health; and 2) the right to a standard of living adequate for health. The indivisibility and interdependence of all human rights--civil and political as well as economic and social--together with the right to education, implicitly but unambiguously support the need to address the social (including political) determinants of health, thus contributing to the conceptual basis for health equity. The right to the highest attainable standard of health strengthens the concept and guides the measurement of health equity by implying that the reference group for equity comparisons should be one that has optimal conditions for health. The human rights principles of non-discrimination and equality also strengthen the conceptual foundation for health equity by identifying groups among whom inequalities in health status and health determinants (including social conditions) reflect a lack of health equity; and by construing discrimination to include not only intentional bias, but also actions with unintentionally discriminatory effects. In turn, health equity can make substantial contributions to human rights 1) insofar as research on health inequalities provides increasing understanding and empiric evidence of the importance of social conditions as determinants of health; and, more concretely, 2) by indicating how to operationalize the concept of the right to health for the purposes of measurement and accountability, which have been elusive. Human rights laws and principles and health equity concepts and technical approaches can be powerful tools for mutual strengthening, not only by contributing toward building awareness and consensus around shared values, but also by guiding analysis and strengthening measurement of both human rights and health equity.

Access to essential medicines in national constitutions

Access to essential medicines is well founded in international law as part of the right to the highest attainable standard of health (“the right to health”). The International Covenant on Economic, Social and Cultural Rights adopted in 1966 calls for States Parties to take steps to ensure access to medical services for all. General Comment 14, added in the year 2000, applies the principles of accessibility, availability, appropriateness and assured quality to goods and services, including essential medicines as defined by the World Health Organization’s (WHO’s) Action Programme on Essential Drugs. One important success factor for the legal enforcement of access to essential medicines is the incorporation of right-to-health principles into national constitutions. In one study, in 11 out of 12 middle-income countries in which successful court cases in support of access took place there was supportive constitutional language and, in the twelfth country, international treaties ratified by the State acquire the status of national law.1 Constitutional recognition of the right to access to medical products and technologies has therefore become a country progress indicator in WHO's Medium-term strategic plan for 2008–2013.2 WHO recently published a first baseline study for this indicator, including a database and analysis of all health-related texts in national constitutions.3 The study reports that 135 (73%) of 186 national constitutions include provisions on health or the right to health. Of these, 95 (51%) constitutions mention the right to access health facilities, goods and services, 62 (45%) include in-text reference to equity and non-discrimination and 111 (82%) include one or more article(s) mandating the right to be treated equally or freedom from discrimination. Four national constitutions (2%) specifically mention universal access to medicines. In Mexico, “(women) are entitled to medical and obstetrical attention, medicines, nursing aid and infant care services. Members of a worker's family shall be entitled to medical attention and medicines, in those cases and in the proportions specified by law”. In Panama, “the State is primarily obligated to (…) supply medicines to all the people”. In the Philippines, “the State shall (…) endeavour to make essential goods, health and other social services available to all people at affordable cost”. In the Syrian Arab Republic, “the State protects the citizens’ health and provides them with the means of protection, treatment and medication”. Some constitutions, such as those of Cuba, Nicaragua and South Africa, use very clear text to describe access to health care, goods and services in more general terms, using words like “without exclusions”, “everyone” and “all citizens regardless of …”. Some texts focus on poor and disadvantaged groups, e.g. those of Nicaragua, the Philippines and Viet Nam. The constitutions of Ecuador and Panama specify that national medicine policies shall be established and implemented to achieve the constitutional obligations. There are at least three different routes through which the right to health can be recognized in national legal frameworks. The strongest government commitment is created by including the right to essential goods and services in the national constitution. The second approach is constitutional recognition that international treaties ratified by the State override or acquire the status of national law. This option is available to 31 countries and was already used in a landmark court decision in Argentina.4 The third option, inclusion of health rights in other national legislation, is easier to create but also easier to change or cancel. This is the subject of another study currently under way. The full range of strategies to promote universal access to essential medicines through rational selection, affordable prices, sustainable financing and reliable health systems is described in many other documents.5,6 Constitutional recognition of the right to access essential medicines is an important sign of national values and commitment, but is neither a guarantee nor an essential step – as shown by those countries that have failing health systems despite good constitutional language, and those that have good access without it. Yet the many court cases in the Americas have shown that constitutional recognition creates an important supportive environment, especially in middle-income countries where health insurance systems are being created and patients are becoming more aware of their rights and are more vocal in demanding them.1 More recent constitutional texts seem to include stronger commitments, possibly reflecting the positive influence of the global development of the right to health in the past 50 years. Political opportunities to update a country’s constitution present a chance to align national values and aspirations with international human rights standards. The new constitutional texts should then consider key human rights principles, and specifically the right to health and equitable access to essential medical goods and services. Constitutional frameworks can thus become valuable aspirational statements on which to base other legislation and policies. The examples identified in the recent WHO study could serve as a model.

Are Drug Companies Living Up to Their Human Rights Responsibilities? The Merck Perspective

The human rights responsibilities of drug companies have been considered for years by nongovernmental organizations, but were most sharply defined in a report by the UN Special Rapporteur on the right to health, submitted to the United Nations General Assembly in August 2008. The "Human Rights Guidelines for Pharmaceutical Companies in relation to Access to Medicines" include responsibilities for transparency, management, monitoring and accountability, pricing, and ethical marketing, and against lobbying for more protection in intellectual property laws, applying for patents for trivial modifications of existing medicines, inappropriate drug promotion, and excessive pricing. Two years after the release of the Guidelines, the PLoS Medicine Debate asks whether drug companies are living up to their human rights responsibilities. Sofia Gruskin and Zyde Raad from the Harvard School of Public Health say more assessment is needed of such responsibilities; Geralyn Ritter, Vice President of Global Public Policy and Corporate Responsibility at Merck & Co. argues that multiple stakeholders could do more to help States deliver the right to health; and Paul Hunt and Rajat Khosla introduce Mr. Hunt's work as the UN Special Rapporteur on the right to the highest attainable standard of health, regarding the human rights responsibilities of pharmaceutical companies and access to medicines.

Are Drug Companies Living Up to Their Human Rights Responsibilities? The Perspective of the Former United Nations Special Rapporteur (2002-2008)

The human rights responsibilities of drug companies have been considered for years by nongovernmental organizations, but were most sharply defined in a report by the UN Special Rapporteur on the right to health, submitted to the United Nations General Assembly in August 2008. The "Human Rights Guidelines for Pharmaceutical Companies in relation to Access to Medicines" include responsibilities for transparency, management, monitoring and accountability, pricing, and ethical marketing, and against lobbying for more protection in intellectual property laws, applying for patents for trivial modifications of existing medicines, inappropriate drug promotion, and excessive pricing. Two years after the release of the Guidelines, the PLoS Medicine Debate asks whether drug companies are living up to their human rights responsibilities. Sofia Gruskin and Zyde Raad from the Harvard School of Public Health say more assessment is needed of such responsibilities; Geralyn Ritter, Vice President of Global Public Policy and Corporate Responsibility at Merck & Co. argues that multiple stakeholders could do more to help States deliver the right to health; and Paul Hunt and Rajat Khosla introduce Mr. Hunt's work as the UN Special Rapporteur on the right to the highest attainable standard of health, regarding the human rights responsibilities of pharmaceutical companies and access to medicines.

Are drug companies living up to their human rights responsibilities? Moving toward assessment.

The human rights responsibilities of drug companies have been considered for years by nongovernmental organizations, but were most sharply defined in a report by the UN Special Rapporteur on the right to health, submitted to the United Nations General Assembly in August 2008. The "Human Rights Guidelines for Pharmaceutical Companies in relation to Access to Medicines" include responsibilities for transparency, management, monitoring and accountability, pricing, and ethical marketing, and against lobbying for more protection in intellectual property laws, applying for patents for trivial modifications of existing medicines, inappropriate drug promotion, and excessive pricing. Two years after the release of the Guidelines, the PLoS Medicine Debate asks whether drug companies are living up to their human rights responsibilities. Sofia Gruskin and Zyde Raad from the Harvard School of Public Health say more assessment is needed of such responsibilities; Geralyn Ritter, Vice President of Global Public Policy and Corporate Responsibility at Merck & Co. argues that multiple stakeholders could do more to help States deliver the right to health; and Paul Hunt and Rajat Khosla introduce Mr. Hunt's work as the UN Special Rapporteur on the right to the highest attainable standard of health, regarding the human rights responsibilities of pharmaceutical companies and access to medicines.

Stigma, Ethik und das Recht auf Opioidsubstitution

Drug addicts are stigmatised and consecutively discriminated. This has a negative impact on their health. Societal stereotypes still hinder that society recognises addiction as a disease, despite the fact it is classified in ICD-10 and DSM IV-TR. One of the reasons is that addiction as a bio-psycho-social condition is still lacking a proper conceptualisation. According to the psychoanalytical model of Rado (1926) drugs change the Ego functions and the Ego gets under the influence of the Id. This concept is consistent with the newer findings from neuro-sciences and psychology. These findings show that self-control is impaired and that the Ego undergoes “Ego-depletion”. These changes vary over time, thus addicts are able to give an informed consent to a treatment, which has to fulfil the conditions of a modern bio-ethic (respect for autonomy, beneficence, non-maleficence, and justice of distribution). Opioid substitution treatment has proven to be an effective measure in heroin addiction. The constitution of the WHO declares “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being”, the Universal Declaration of Human Rights adds a right for treatment and social support, further specified by the International Covenant on Economic, Social, and Cultural Rights. From this derives the obligation of the state to take positive steps to realise the right for health. Heroin addicts have thus a right for substitution. The same applies to prisoners according to the resolution of the UN General Assembly 45/111.

Debate: Limitations on universality: the "right to health" and the necessity of legal nationality.

BackgroundThe "right to health," including access to basic healthcare, has been recognized as a universal human right through a number of international agreements. Attempts to protect this ideal, however, have relied on states as the guarantor of rights and have subsequently ignored stateless individuals, or those lacking legal nationality in any nation-state. While a legal nationality alone is not sufficient to guarantee that a right to healthcare is accessible, an absence of any legal nationality is almost certainly an obstacle in most cases. There are millions of so-called stateless individuals around the globe who are, in effect, denied medical citizenship in their countries of residence. A central motivating factor for this essay is the fact that statelessness as a concept is largely absent from the medical literature. The goal for this discussion, therefore, is primarily to illustrate the need for further monitoring of health access issues by the medical community, and for a great deal more research into the effects of statelessness upon access to healthcare. This is important both as a theoretical issue, in light of the recognition by many of healthcare as a universal right, as well as an empirical fact that requires further exploration and amelioration.DiscussionMost discussions of the human right to health assume that every human being has legal nationality, but in reality there are at least 11 to 12 million stateless individuals worldwide who are often unable to access basic healthcare. The examples of the Roma in Europe, the hill tribes of Thailand, and many Palestinians in Israel highlight the negative health impacts associated with statelessness.SummaryStateless individuals often face an inability to access the most basic healthcare, much less the "highest attainable standard of health" outlined by international agreements. Rather than presuming nationality, statelessness must be recognized by the medical community. Additionally, it is imperative that stateless populations be recognized, the health of these populations be tracked, and more research conducted to further elaborate upon the connection between statelessness and access to healthcare services, and hence a universal right to health.

Using human rights for sexual and reproductive health: improving legal and regulatory frameworks

This paper describes the development of a tool that uses human rights concepts and methods to improve relevant laws, regulations and policies related to sexual and reproductive health. This tool aims to improve awareness and understanding of States' human rights obligations. It includes a method for systematically examining the status of vulnerable groups, involving non-health sectors, fostering a genuine process of civil society participation and developing recommendations to address regulatory and policy barriers to sexual and reproductive health with a clear assignment of responsibility. Strong leadership from the ministry of health, with support from the World Health Organization or other international partners, and the serious engagement of all involved in this process can strengthen the links between human rights and sexual and reproductive health, and contribute to national achievement of the highest attainable standard of health.

The Right to Health

This article argues that the development of the right to health and mental health in international human rights law critically informs the Convention on the Rights of Persons with Disabilities. In particular, the continuity and complementarities between civil and political rights on the one hand, and economic, social and cultural rights on the other, underscores the Convention's injunction to provide a comprehensive range of health, mental health and social services that are acceptable to the person, culturally appropriate, and provided on a voluntary basis. This article discusses the application of the Convention with a focus on the developing content of the right to health, the adoption of a social model of health in the Convention, and the significance of Article 24 on the right to enjoyment of the highest attainable standard of health.

The unconscionable health gap: a global plan for justice

Health has special meaning and importance to individuals and communities. WHO's Constitution states that “the enjoyment of the highest attainable standard of health” is a fundamental human right. International law, moreover, requires states to guarantee the right to health. The UN has specified the norms and obligations of the right to health, and appointed a Special Rapporteur.1

Are cancer registries unconstitutional?

Population-based cancer registration, mandated throughout the United States, is central to quantifying the breadth and impact of cancer. It facilitates research to learn what causes cancer to develop and, in many cases, lead to death. However, as concerns about privacy increase, cancer registration has come under question. Recently, its constitutionality was challenged on the basis of 1) the vagueness of statutory aims to pursue public health versus the individual privacy interests of cancer patients, and 2) the alleged indignity of one's individual medical information being transmitted to government authorities. Examining cancer registry statutes in states covered by the US National Cancer Institute's SEER Program and the US Centers for Disease Control and Prevention's National Program of Cancer Registries, we found that cancer registration laws do state specific public health benefits, and offer reasonable limits and safeguards on the government's possession of private medical information. Thus, we argue that cancer registration would survive constitutional review, is compatible with the civil liberties protected by privacy rights in the U.S., satisfies the conditions that justify public health expenditures, and serves human rights to enjoy the highest attainable standards of health, the advances of science, and the benefits of government efforts to prevent and control disease.

"Operation Helping Hands": Massachusetts health and medical response to Hurricane Katrina.

As Hurricane Katrina bore down on New Orleans in August 2005, the city's mandatory evacuation prompted the exodus of an estimated 80% of its 485,000 residents. According to estimates from the US Centers for Disease Control and Prevention (CDC), at least 18 states subsequently hosted more than 200,000 evacuees. In this case study, "Operation Helping Hands" (OHH), the Massachusetts health and medical response in assisting Hurricane Katrina evacuees is described. Operation Helping Hands represents the largest medical response to evacuees in recent Massachusetts history. The data describing OHH were derived from a series of structured interviews conducted with two leading public health officials directing planning efforts, and a sample of first responders with oversight of operations at the evacuation site. Also, a literature review was conducted to identify similar experiences, common challenges, and lessons learned. Activities and services were provided in the following areas: (1) administration and management; (2) medical and mental health; (3) public health; and (4) social support. This study adds to the knowledge base for future evacuation and shelter planning, and presents a conceptual framework that could be used by other researchers and practitioners to describe the process and outcomes of similar operations. This study provides a description of the planning and implementation efforts of the largest medical evacuee experience in recent Massachusetts history, an effort that involved multiple agencies and partners. The conceptual framework can inform future evacuation and shelter initiatives at the state and national levels, and promotes the overarching public health goal of the highest attainable standard of health for all.

Global science and social movements: towards a rational politics of global health

Tropical medicine as a discipline was originally limited to those diseases that are the consequence of the ecology of disease in the tropics. Over the past 100 years we have come to realise that this limitation was the consequence of an historical snapshot. The commonality of human experience throughout the world speaks to our common biology and has led to the articulation of Global Health. We lack a coherent understanding of Global Health but its reach is beyond that of governments and entails concepts of justice and humanity as well as biomedicine and all the attendant semi-congruent disciplines. The development of Global Health will redefine the roles of all the stakeholders in the international health community be they individuals, institutions, agencies or medical journals. At present the gestation of Global Health involves the chaotic tumbling, rumbling and knocking together of ideas and aspirations. The hope must be that the outcome will be the highest attainable standard of health for all if not the perfectibility of humankind.

Drug Control, Human Rights, and the Right to the Highest Attainable Standard of Health: By No Means Straightforward Issues

There has been increasing attention to the importance of respecting the human rights of addicts with regard to illicit drug trafficking and abuse. The debate is multifaceted, encompassing issues involving drug control as it relates to criminal justice, the death penalty, mandated treatment, and, most prominently, the right to the highest attainable standard of health. This article addresses each of these issues, focusing on the right to the highest attainable standard of health, including the ongoing international debate surrounding controversial “harm reduction” measures. The applicability of this right to drug control is not as straightforward as is often presented, and some of the arguments put forward come dangerously close to stating that there is a “right to abuse drugs,” which the author disputes.

Leadership in public health.

ConclusionThe modern public health model for leadership will unlikely be the omniscient figure with easy answers.51 Rather the public health leader of the future may well be the transcendent, collaborative «servant leader»50,52 who knits and aligns disparate voices together behind a common mission. They pinpoint passion and compassion, promote servant leadership, acknowledge the unfamiliar, the ambiguous, and the paradoxical, communicate succinctly to reframe, and understand the «public» part of public health leadership. By working between and above the levels of leadership of self, others and organizations, these transcendent leaders can ultimately shift the paradigm from «no hope» to «new hope» and create a renewed sense of community.Such leadership will be vital as the 21st century progresses. Beginning the journey to new hope may start by motivating underdogs who nurture the spirit, discover a passion to serve, cultivate interdependence, and create uncommon bonds. These emerging leaders can tap into their unique talents, passion, and compassion to promote a mission of «the highest attainable standard of health» for all, in every community.

Health impact assessment: The contribution of the right to the highest attainable standard of health

There are growing demands for governments to carry out human rights impact assessments prior to adopting and implementing policies. This article outlines a preliminary human rights impact assessment methodology, using the right to the highest attainable standard of health as the case study. The authors recommend a mainstreaming approach, which involves integrating human rights into existing impact assessment methodologies. Accordingly, they identify considerations that, from a human rights perspective, governments should incorporate into existing impact assessment methodologies in order to comply with their legal obligations to realize human rights. To test the mainstreaming methodology, the authors propose integrating the right to the highest attainable standard of health into health impact assessment.

The spectrum of ‘new racism’ and discrimination in hospital contexts: A reappraisal

In keeping with the United Nations Declaration of Human Rights, all people have the right to the highest attainable standard of health. Despite the universal right to health, people of minority racial and ethnic backgrounds experience commonplace and significant unjust inequalities in their health and health care. A key reason for this rests on what might be described as 'the illusion of non-racism in health care' -- an illusion that rests on the frequently articulated belief that 'racism is not an issue any more'. Although there has been increasing recognition in recent years that race and racism have a particular, consistent and complex independent negative effect on the health and health care of racial and ethnic minority groups, racism per se still tends to be under-recognised and poorly addressed in health and nursing care domains. In this paper, it is suggested that a key reason racism in health care has been Largely ignored is because of its 'changing face', making new and different forms of it difficult to recognise and manage. A key premise on which this paper rests -- and also its ultimate conclusion -- is that the problem of racism (to be distinguished from 'culturally insensitive' and 'culturally incongruent' care) needs to be unmasked and managed so that those most at risk of being discriminated against on racialised grounds can rest assured that when in need, they will receive the equitable, safe and quality care they are entitled to receive.

Introduction: Mental Health and Human Rights: Social Policy and Sociological Perspectives

Recognition of the effects of social, economic, political and cultural conditions on mental health and the personal, social and economic costs of a growing global mental health crisis (WHO, 2001; EC, 2005) mean that mental health and well-being are a current feature of social policy agendas at UK, European and world levels, with debate increasingly becoming framed in human rights terms. In the UK, policy drives to address social exclusion and health inequalities as key social and economic rights issues have encompassed attention to mental health and distress (DoH, 2003; Social Exclusion Unit, 2004) and mental health has been identified as a priority area for the new Equality and Human Rights Commission (Diamond, 2007; DRC, 2007). At the European level too, rights-based social policy approaches to promoting social cohesion (European Committee for Social Cohesion, 2004) and policy directives on the ‘right to health’ (Commission of the European Communities, 2007) have been centrally concerned with mental health and well-being, and have been accompanied by a European strategy on mental health for the EU (EC, 2005). At a global level, the World Health Organisation has declared enjoyment of the highest attainable standard of health to be a fundamental human right (WHO, 2006). It has launched a new appeal on mental health which draws attention to the impact of human rights violations and cites social isolation, poor quality of life, stigma and discrimination as central issues for those with mental health needs (Dhanda and Narayan, 2007; Horton, 2007; WHO, 2007).

Participation and the Right to Health: Lessons from Indonesia

The right to participation is the "the right of rights"--the basic right of people to have a say in how decisions that affect their lives are made. All legally binding international human rights treaties explicitly recognize the essential role of participation in realizing fundamental human rights. While the substance of the human right to health has been extensively developed, the right to participation as one of its components has remained largely unexplored. Should rights-based health advocacy focus on participation because there is a relationship between an individual's or a community's active involvement in health care decision-making and the highest attainable standard of health? In the context of the human right to health, does participation mean primarily political participation, or should we take the right to participation to mean more specifically the right of persons, individually and as a group, to shape health care policy for society and for themselves as patients? Decentralization of health care decision-making promises greater participation through citizen involvement in setting priorities, monitoring service provision, and finding new and creative ways to finance public health programs. Between 1999 and 2008, Indonesia decentralized health care funding and delivery to regional governments, resulting in substantial exclusion of its poor and uneducated citizens from the health care system while simultaneously expanding the opportunities for political participation for educated elites. This article explores the tension between the right to participation as an underlying determinant of health and as a political right by reviewing the experience of Indonesia ten years after its decision to decentralize health care provision. It is ultimately argued that rights-based advocates must be vigilant in retaining a unified perspective on human rights, resisting the persistent tendency to separate and prioritize the civil and political aspects of participation over its social component.