HRW Notes Global Failures On Healthcare Funding

 New data from the World Health Organization (WHO) shows that many governments around the world did not meet public healthcare spending benchmarks amid the Covid-19 pandemic, Human Rights Watch said today. The new information indicates possible violations of countries’ obligations to the human right to health.

WHO’s Global Health Expenditure Database, released in December 2023, shows that most governments did not spend more than 5 percent of Gross Domestic Product (GDP) or 15 percent of their national budget on health care through public means in 2021. These two benchmarks are common and important tools for assessing whether countries are on track to ensure universal health coverage, an international policy target grounded in the human right to the highest attainable standard of health. Despite a global surge in spending related to the Covid-19 pandemic, about 80 percent of the world’s population lived in countries that met neither spending benchmark.

“When governments neglect to invest in their healthcare systems, people and families end up shouldering the burden,” said Matt McConnell, economic justice and rights researcher at Human Rights Watch. “While more spending is not enough on its own to ensure universal access to high quality healthcare services, it can help shift this burden, which causes the most harm for people with the fewest resources.”

The Human Rights Watch analysis of healthcare spending in more than 190 countries around the world, available in a summary table at the end of this document, also found that:

• Despite a mass increase in healthcare spending across the globe in response to the pandemic, 38 governments spent less on health care in 2021, as a share of their GDP, than the year before it began.
• Despite governments’ commitments to reduce out-of-pocket expenditures, individuals and their households collectively paid the equivalent of about US$1.68 trillion for health care out of their own pockets in 2021, a figure comparable to the annual GDP of Australia or the Republic of Korea.
• At the height of the pandemic, out-of-pocket payments covered the costs of more than 20 percent of health care in 119 countries. Only high-income countries averaged less than 20 percent in 2021 (17 percent), while upper-middle (29.9 percent), lower-middle (34.6 percent), and low-income (39.1 percent) countries averaged far more.
• In 47 countries in 2021, individuals and their households collectively paid more out-of-pocket for health care than their governments spent on it.
• Twenty years after agreeing to the Abuja Declaration and committing to spend at least 15 percent of their national budgets on health care, only 2 of the African Union’s 55 member countries met this target in 2021: Cabo Verde (15.75 percent) and South Africa (15.29 percent). On the whole, countries in the African Union spent an average of 7.35 percent of their national budgets on health care that year.
• Eighty-three governments paid more per person to service their external public and publicly guaranteed debts in 2021 than on health care.

The International Covenant on Economic, Social and Cultural Rights requires countries to dedicate the maximum available resources toward the progressive realization of economic, social, and cultural rights, which includes ensuring universal access to quality healthcare services. They should also avoid, unless fully justified, any backward steps, including through budget cuts.

The next few months will provide multiple opportunities for governments to do more than just renew their rhetorical commitments to the realization of the right to health, including at the 77th World Health Assembly in May, at the United Nations Summit of the Future in September, and at the fourth International Conference on Financing for Development in 2025.

Governments should, among other things, set spending benchmarks such as the equivalent of at least 5 percent of GDP or 15 percent of general government expenditures on health care through domestically generated public funds, or an amount that otherwise ensures the maximum available resources for the realization of rights, including the right to health.

Many governments could increase their revenues to fund health care by levying progressive taxes, stemming tax abuses, and tackling public corruption. Wealthier creditor governments should also deliver on their commitments to international assistance and cooperation by ensuring that public debt repayments do not hinder debtor governments’ ability to adequately fund health care.

The coming months also provide an opportunity to address the impact of debt payments on the ability of governments to fund human rights obligations. At the 2024 spring meetings of the World Bank Group and International Monetary Fund, creditor governments and institutions should commit to conducting assessments of such impacts and to considering debt restructuring or relief where appropriate to ensure that debtor governments can adequately protect rights, including health.

“The pandemic showed the vulnerability of healthcare systems around the world to external shocks,” McConnell said. “But it also exposed just how many of these systems were already failing people. Governments need to put their money where their mouth is and commit to financing more resilient, more sustainable, and more rights-realizing healthcare systems for all.”

Health Budgets Under International Human Rights Law

International human rights law includes obligations to respect, protect, and fulfill economic, social, and cultural rights, which includes the right to health.

Governments have the duty to make constant progress toward realizing these rights, and to do the best within their capacities (an obligation to use “the maximum of their available resources”) to reach the highest possible standards of these rights. Retrogressive measures, which can include a decrease in funding for realization of a right, are presumptively a violation of this obligation unless fully justified, such as in some cases of natural catastrophe or financial crisis.

The ultimate measure of progress is the impact of spending on people’s health. For example, the United States spent about 9.6 percent of its GDP on health care through public means in 2021, about 2.56 percentage points above the average among countries in the Organization for Economic Co-operation and Development (OECD). But the impact of this spending on healthcare outcomes was low when compared with other OECD countries, with the US having the lowest life expectancy at birth, the highest death rates for avoidable or treatable conditions, among the highest suicide rates, and among the worst maternal mortality within the OECD in 2021.

There are many reasons why the US healthcare system is expensive, complicated, and does not work for the vast majority of people in the US. But as recent Human Rights Watch research has illustrated, its expensive, largely market-based healthcare system and failure to appropriately regulate pharmaceutical companies and private healthcare serviceproviders produces immense disparities of access and quality that disproportionately affect people with lower incomes and people with medical conditions.

Funding is a key indicator of a government’s priorities, though how much a government spends on health care also does not necessarily capture all its efforts, or lack thereof, to realize the right to health. This includes other indicators, such as laws and policies that effectively address structural or other discrimination, or efforts to improve the social determinants of health with better food, water, housing, and education. Additionally, the reliability and accuracy of official records and other government data, upon which the WHO’s estimates largely depend, can differ, particularly among countries that are less transparent and publicly accountable.