The international human rights system that emerged from the ashes of World War Two largely reflected the prevailing Westphalian norm of state sovereignty a. This sovereignty norm holds that the obligation of sovereign states to realise rights exists within their borders. However, the seeds of a new norm of shared international responsibility can also be found in the various international human rights treaties that the vast majority of nations have ratified in the past seventy years. With respect to economic, social and cultural rights, article 2.1 of the International Covenant on Economic, Social and Cultural Rights (the Covenant), enshrines this norm of shared responsibility under which nation states commit to taking steps individually and through “international assistance and cooperation, especially economic and technical” to realise Covenant rights, including article 12 the right to the highest attainable state of physical and mental health . This article examines this norm of shared responsibility for realising the right to health, what we shall term a global right to health norm . We define the global right to health norm as affirming the existence of a shared responsibility to respect, protect and fulfil the right to health, which challenges the dominant norm of exclusive national self-reliance . To be clear, the emerging global right to health norm asserts the primacy of the state as the key duty bearer, charged with realising rights on its territory, but adds what lawyers term the transnational or extraterritorial dimension, the obligations of the international community to ensure that health rights do not remain the privilege of a minority of the world’s population .
Progress on scaling up health interventions in low-income countries to narrow the health equity gap often requires technical and financial co-operation (bi-lateral and/or multi-lateral) with the international community, a shared commitment to realising health rights, exemplified by what we term the global right to health norm. The power of this emerging norm in mobilising a global response to addressing the HIV epidemic has been well-documented and researched [6, 7]. The huge scale up of financing and roll out of AIDS treatment from 2001–2010 is one example of how the international community has worked with national governments in low-income highly affected countries to jointly implement an element of the shared obligation to fulfil the right to health; universal access to anti-retroviral treatment (ART) [8, 9]. This is one reason the global response to HIV/AIDS is termed “exceptional” and is arguably evidence of the emerging global right to health norm in action . Further, access to ART offers an example of how shared responsibility for realising the right to health can be approached; albeit with important caveats, including the limited focus on one disease.
The research and analysis reported in this paper focuses on an area in which this emerging global right to health norm has been arguably less successful to date, maternal health. Preventable maternal mortality and morbidity remain a glaring example of global inequity where the role of the international community in addressing these issues has been arguably less ambitious and more complex [11, 12]. Recent World Health Organization research into the impact of human rights on maternal and child health highlights the importance of viewing health through a human rights lens. The study includes example from Brazil, Nepal, Malawi and Italy finding that “applying human rights to women’s and children’s health interventions not only helps governments comply with their binding obligations, but also contributes to improving the health of women and children ”.
The limited progress on achieving two key health related sexual and reproductive health Millennium Development Goals (MDGs), namely reducing maternal mortality by three quarters and providing universal access to reproductive health by 2015, is well-documented. The most recent evidence clarifies that of the approximately 287 000 women who die in pregnancy or childbirth annually, 99% of these deaths occur in developing countries and over half in sub-Saharan Africa alone . The limited advances reflected in these figures are clear evidence of the impact of global health inequity which fatally undermines the human dignity of women and the prospects of building families and societies on principles of justice .
The majority of maternal deaths stem from four direct conditions; obstetric haemorrhage, hypertensive disorders, complications of unsafe abortion and puerperal related sepsis. All of these can be either largely prevented or managed by effective clinical interventions and in particular through access to quality emergency obstetric care (EmOC) . Despite the strong evidence base testifying to its importance, EmOC has never garnered the attention, or the controversy, of other reproductive health issues like family planning or abortion. Further, evidence suggests that progress in prioritising and scaling up such an important intervention remains limited [17–20].
Our study focuses on progress in advancing universal access to quality EmOC because from a medical perspective it is a key evidence-supported intervention that significantly decreases maternal mortality and morbidity . Additionally, from an international human rights law perspective it is an obligation of comparable priority to a core right to health obligation, requiring immediate action by national governments, and when necessary, the international community; giving rise to extraterritorial obligations of assistance . As Lynn Freedman, of Columbia’s Averting Maternal Death and Disability Programme (AMDD) notes, “In a human rights analysis, EmOC is not just one good idea among many. It is an obligation ”.
The history of the limited progress on addressing maternal mortality as a shared responsibility at the global level reveals multiple causal factors. An important 2007 Lancet article by Jeremy Shiffman and Stephanie Smith, examining the role of the safe motherhood advocacy community in advancing global priority for maternal health, argued that difficulties relating to the actors and the nature of safe motherhood itself meant that safe motherhood was still in its infancy as a global health initiative. However, they concluded on an optimistic note that “2007 could present a window of opportunity to generate political support for the cause ”.
Since their study the United Nations Human Rights Council has recognised preventable maternal mortality as a human rights violation, a potentially important step towards the solidification of a new global right to health norm, specifically the shared responsibility for maternal health [25, 26]. Given that discussions about maternal health rights now figure prominently in the global human rights community we decided to examine the role of the right to health in shaping political priority for maternal health [27, 28]. We posit that the right to health, as an emerging global norm, has the potential to assist policy communities in framing the obligations of the domestic state and the international community and mobilizing political priority and funding, as it did with AIDS. Our research asks: if the global right to health is an emerging norm with the potential to assist policy communities, what role has it played in maternal health advocacy? By examining the global policy process around maternal health rights, with a focus on universal access to EmOC, our study seeks to contribute to explaining the role of the global right to health norm in attracting global policy priority and funding. We conclude by briefly examining how the global right to health norm could help shape the discussions about shared obligations for realising maternal health in the post-2015 global agenda.