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The International Health Regulations (ihr), of which the World Health Organization is custodian, govern how countries collectively promote global health security, including prevention, detection, and response to global health emergencies such as the ongoing covid-19 pandemic. Countries are permitted to exercise their sovereignty in taking additional health measures to respond to such emergencies if these measures adhere to Article 43 of this legally binding instrument. Overbroad measures taken during recent public health emergencies of international concern, however, reveal that the provision remains inadequately understood. A shared understanding of the measures legally permitted by Article 43 is a necessary step in ensuring the fulfillment of obligations, and fostering global solidarity and resilience in the face of future pandemics. In this consensus statement, public international law scholars specializing in global health consider the legal meaning of Article 43 using the interpretive framework of the Vienna Convention on the Law of Treaties.

The International Health Regulations, 2005 revision; IHR (2005) govern how countries address collective threats in global solidarity; yet international travel bans can drive countries apart through economic isolation, trade disruptions, discriminatory restrictions and rights violations. This editoria discusses under which conditions travel restrictions can be legally justified.

In imposing travel restrictions against China during the current outbreak of 2019 novel coronavirus disease (COVID-19), many countries are violating the IHR. We—16 global health law scholars—came to this conclusion after applying the interpretive framework of the Vienna Convention on the Law of Treaties and reaching a jurisprudential consensus on the legal meaning of Article 43 of the International Health Regulations (2005).

Like other contributors to this special issue and beyond, I believe we are at a critical inflection point in human rights and need to re-energize our work broadly to address growing economic inequality as well as inequalities based on different axes of identity. In relation to the constellation of fields involved in ‘health and human rights’ specifically—which link distinct communities with dissonant values, methods and orthodoxies—I argue that we also need to challenge ideas that are taken for granted in the fields that we are trying to transform. After setting out a personal and subjective account of why human rights-based approaches (HRBAs) are unlikely to be meaningful tools for social change as they are now generally being deployed, I suggest we collectively—scholars, practitioners and advocates—need to grapple with how to think about: (1) biomedicine in relation to the social as well as biological nature of health and well-being; and (2) conventional public health in relation to the social construction of health within and across borders and health systems. In each case, I suggest that challenging accepted truths in different disciplines, and in turn in the political economy of global health, have dramatic implications for not just theory but informing different strategies for advancing health (and social) justice through rights in practice.

Health risks in the 21st century are beyond the control of any government in any country. In an era of globalisation, promoting public health and equity requires cooperation and coordination both within and among states. Law can be a powerful tool for advancing global health, yet it remains substantially underutilised and poorly understood. Working in partnership, public health lawyers and health professionals can become champions for evidence-based laws to ensure the public's health and safety. This Lancet Commission articulates the crucial role of law in achieving global health with justice, through legal instruments, legal capacities, and institutional reforms, as well as a firm commitment to the rule of law. The Commission's aim is to enhance the global health community's understanding of law, regulation, and the rule of law as effective tools to advance population health and equity. The term law throughout is used to mean legal instruments such as statutes, treaties, and regulations that express public policy, as well as the public institutions (eg, courts, legislatures, and agencies) responsible for creating, implementing, and interpreting the law. By establishing the rules and frameworks that shape social and economic interactions, laws exert a powerful force on all the social determinants of health. Well designed laws can help build strong health systems, ensure safe and nutritious foods, evaluate and approve safe and effective drugs and vaccines, create healthier and safer workplaces, and improve the built and natural environments. However, laws that are poorly designed, implemented, or enforced can harm marginalised populations and entrench stigma and discrimination. This Commission brings together global leaders in the fields of health, law, and governance. We make the case for better, more strategic linkages between health and law, and the professionals who work in both fields. We begin by providing a short explanation of legal terms and concepts, and the actors and institutions that govern health. Our report is structured around four legal determinants of health, each of which powerfully affects health outcomes. We use the term legal determinants of health because it demonstrates the power of law to address the underlying social and economic causes of injury and disease. These four legal determinants show how law can substantially influence health and equity. We do not endeavour a systematic review of law in global health, but rather to advocate for, and demonstrate, the crucial value of law in advancing global health with justice. Finally, drawing on identified areas for reform, as well as principles of good governance and the right to health, we offer seven concrete recommendations for action.

The Independent Panel on Pandemic Preparedness1 released on 11 May adds to the mounting calls for a new Pandemic Treaty that would address gaps in the global governance of threats to global health security. The emerging debate has quickly turned to focus on questions of structure and forms—a United Nations treaty or a framework convention under the auspices of the WHO, and verification and enforcement mechanisms—as well as on issues of process regarding who will have voice and how the negotiations will proceed.2 3 But we must not lose sight of its purpose and key objectives, and what we mean by ‘global health security’. Indeed, the treaty discussions provide an opportunity and an imperative to rethink the paradigm of global health security that has shaped the current international response to the COVID-19 pandemic. The prevailing paradigm is antithetical to the core purpose of global pandemic preparedness and response for five reasons. First, global health security needs to focus on the security of people, not national borders. The concept of ‘global health security’ emerged with the increasing transnational spread of disease in the late 20th century in the context of neoliberal economic globalisation, the rise in biosecurity threats, and increased migrations due to climate change, instability and armed conflicts.4 5 It led to a reframing of infectious diseases as a national security threat, bringing the language and thinking of the security sector, concerned with defending national borders, not human health. As Senators …

Goran Tomson and colleagues argue that our ability to control pandemics requires global action to counter inequalities from demographic, environmental, technological, and other megatrends

Amid frenzied national responses to COVID-19, the world could soon reach a critical juncture to revisit and strengthen the International Health Regulations (IHR), the multilateral instrument that governs how 196 states and WHO collectively address the global spread of disease.1, 2 In many countries, IHR obligations that are vital to an effective pandemic response remain unfulfilled, and the instrument has been largely side-lined in the COVID-19 pandemic, the largest global health crisis in a century. It is time to reimagine the IHR as an instrument that will compel global solidarity and national action against the threat of emerging and re-emerging pathogens. We call on state parties to reform the IHR to improve supervision, international assistance, dispute resolution, and overall textual clarity.

Overcoming continuing polarization regarding judicial enforcement of health rights in Latin America requires clarifying divergent normative and political premises, addressing the lack of reliable empirical data, and establishing the conditions for fruitful inter-sectoral, inter-disciplinary dialogue. Fil: Yamin, Alicia Ely. Harvard University; Estados Unidos Fil: Pichón-riviere, Andres. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Bergallo, Paola. Universidad Torcuato Di Tella; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina

Driven by the need to better understand the full and intergenerational toll of maternal mortality (MM), a mixed-methods study was conducted in four countries in sub-Saharan Africa to investigate the impacts of maternal death on families and children. The present analysis identifies gender as a fundamental driver not only of maternal, but also child health, through manifestations of gender inequity in household decision making, labor and caregiving, and social norms dictating the status of women. Focus group discussions were conducted with community members, and in depth qualitative interviews with key-informants and stakeholders, in Tanzania, Ethiopia, Malawi, and South Africa between April 2012 and October 2013. Findings highlight that socially constructed gender roles, which define mothers as caregivers and fathers as wage earners, and which limit women's agency regarding childcare decisions, among other things, create considerable gaps when it comes to meeting child nutrition, education, and health care needs following a maternal death. Additionally, our findings show that maternal deaths have differential effects on boy and girl children, and exacerbate specific risks for girl children, including early marriage, early pregnancy, and school drop-out. To combat both MM, and to mitigate impacts on children, investment in health services interventions should be complemented by broader interventions regarding social protection, as well as aimed at shifting social norms and opportunity structures regarding gendered divisions of labor and power at household, community, and society levels.

As health policy-makers around the world seek to make progress towards universal health coverage they must navigate between two important ethical imperatives: to set national spending priorities fairly and efficiently; and to safeguard the right to health. These imperatives can conflict, leading some to conclude that rights-based approaches present a disruptive influence on health policy, hindering states’ efforts to set priorities fairly and efficiently. Here, we challenge this perception. We argue first that these points of tension stem largely from inadequate interpretations of the aims of priority setting as well as the right to health. We then discuss various ways in which the right to health complements traditional concerns of priority setting and vice versa. Finally, we set out a three-step process by which policy-makers may navigate the ethical and legal considerations at play.

Contains fulltext : 176827.pdf (Publisher’s version ) (Open Access) Progressive realisation is invoked as the guiding principle for countries on their own path to universal health coverage (UHC). It refers to the governmental obligations to immediately and progressively move towards the full realisation of UHC. This paper provides procedural guidance for countries, that is, how they can best organise their processes and evidence collection to make decisions on what services to provide first under progressive realisation. We thereby use 'evidence-informed deliberative processes', a generic value assessment framework to guide decision making on the choice of health services. We apply this to the concept of progressive realisation of UHC. We reason that countries face two important choices to achieve UHC. First, they need to define which services they consider as high priority, on the basis of their social values, including cost-effectiveness, priority to the worse off and financial risk protection. Second, they need to make tough choices whether they should first include more priority services, first expand coverage of existing priority services or first reduce co-payments of existing priority services. Evidence informed deliberative processes can facilitate these choices for UHC, and are also essential to the progressive realisation of the right to health. The framework informs health authorities on how they can best organise their processes in terms of composition of an appraisal committee including stakeholders, of decision-making criteria, collection of evidence and development of recommendations, including their communication. In conclusion, this paper fills in an important gap in the literature by providing procedural guidance for countries to progressively realise UHC.

Fukuda-Parr and Yamin explore the effects of global goal setting on international development agendas and thinking. They present a condensed synthesis of the “Power of Numbers” project, an independent research initiative, led by them, and involving 17 scholars. The project analyzed the influence of MDGs and associated indicators on policy priorities and development narratives, their diverse incentives, and both intended and unintended consequences. The authors recommend that both positive and negative lessons from experience be kept in mind in the design of the post-2015 agendas.

This paper explores the intended and unintended consequences of the selection of MDG 5 as a global goal, together with its respective targets and indicators, and places what happened to MDG 5, and sexual and reproductive health and rights more broadly, into the context of the development model that was encoded in the MDGs. Over the last decade, as the MDGs increasingly took centre stage in development and their use evolved, they were inappropriately converted from global goals into national planning targets. This conversion was particularly detrimental in the case of MDG 5. It not only created a narrowing in terms of policies and programming, but also had an enormous impact on the discourse of development itself, reshaping the field in terms of the organization and dissemination of knowledge, and underscoring that the process of setting targets and indicators is far from neutral but encodes normative values. Looking forward, it is not adequate to propose an MDG+ framework based on the same structure. Sexual and reproductive health and rights must be placed back into the global discourse, using development to empower women and marginalized populations, and to address structural inequalities that are fundamental to sustained social change. The new development framework should include a strong narrative of social transformation in which fit-for-purpose targets and indicators play a role, but do not overtake or restrict the broader aims of advancing social, political, and gender justice.

The full impact of a maternal death includes consequences faced by orphaned children. This analysis adds evidence to a literature on the magnitude of the association between a woman's death during or shortly after childbirth, and survival outcomes for her children. The Ifakara and Rufiji Health and Demographic Surveillance Sites in rural Tanzania conduct longitudinal, frequent data collection of key demographic events at the household level. Using a subset of the data from these sites (1996-2012), this survival analysis compared outcomes for children who experienced a maternal death (42 and 365 days definitions) during or near birth to those children whose mothers survived. There were 111 maternal deaths (or 229 late maternal deaths) during the study period, and 46.28 % of the index children also subsequently died (40.73 % of children in the late maternal death group) before their tenth birthday-a much higher prevalence of child mortality than in the population of children whose mothers survived (7.88 %, p value

Background The consequences of maternal mortality on orphaned children and the family members who support them are dramatic, especially in countries that have high maternal mortality like Ethiopia. As part of a four country, mixed-methods study (Ethiopia, Malawi, South Africa, and Tanzania) qualitative data were collected in Butajira, Ethiopia with the aim of exploring the far reaching consequences of maternal deaths on families and children. Methods We conducted interviews with 28 adult family members of women who died from maternal causes, as well as 13 stakeholders (government officials, civil society, and a UN agency); and held 10 focus group discussions with 87 community members. Data were analyzed using NVivo10 software for qualitative analysis. Results We found that newborns and children whose mothers died from maternal causes face nutrition deficits, and are less likely to access needed health care than children with living mothers. Older children drop out of school to care for younger siblings and contribute to household and farm labor which may be beyond their capacity and age, and often choose migration in search of better opportunities. Family fragmentation is common following maternal death, leading to tenuous relationships within a household with the births and prioritization of additional children further stretching limited financial resources. Currently, there is no formal standardized support system for families caring for vulnerable children in Ethiopia. Conclusions Impacts of maternal mortality on children are far-reaching and have the potential to last into adulthood. Coordinated, multi-sectorial efforts towards mitigating the impacts on children and families following a maternal death are lacking. In order to prevent impacts on children and families, efforts targeting maternal mortality must address inequalities in access to care at the community, facility, and policy levels.

One of the most significant transformations to occur in the landscape of struggles for health justice since this journal was originally launched relates to the increasing judicialization of health-related rights, and economic, social, and cultural rights (ESC rights) more broadly. Indeed, the articles in this issue go far toward debunking outdated conceptions about health rights as merely "programmatic rights," which are not justiciable. Over the last 20 years, and increasingly in the last decade, we have seen that health and related rights are in fact being enforced by courts around the world, from South America to South Asia, Eastern Europe to East Africa. And increasingly, even in low-income countries, important demands for health-related entitlements are being framed in terms of legally enforceable claims.

Drawing on a case in Peru this article examines four strategies used by human rights NGOs in their work. In so doing it connects external challenges to the promotion of economic social and cultural (ESC) rights with internal challenges to the way the human rights movement chooses to see itself. First the value of using data and indicators in documentation has not been widely realized. Second important advances have been achieved with respect to enforcing ESC rights but there are limitations to court-centric approaches which are relevant to all human rights. Third shifting advocacy beyond the adversarial dyad with the state to address more systematically the roles of non-state actors implies rethinking some underlying assumptions. Fourth strategies for promoting participation and building alliances call for reexamining traditional ideas about politicization. (authors)

Maternal mortality and morbidity are the leading causes of premature death and disability among women of reproductive age in developing countries. 99% of pregnancy-related deaths occur in developing countries. Moreover according to the World Bank although men and women aged 15-44 years lose approximately the same number of years of healthy life due to disease there is no single cause of death and disability for men that comes close to the magnitude of maternal death and disability. This article provides an overview from a public health standpoint of the scope and determinants of maternal morbidity and mortality together with the issues involved in their detection treatment and measurement. It also explains how the UN Guidelines for monitoring national programs can be used as human rights tools to monitor a states compliance with respect to aspects of the right to health under various international treaties.

BackgroundLittle is known about the interconnectedness of maternal deaths and impacts on children, beyond infants, or the mechanisms through which this interconnectedness is established. A study was conducted in rural Tanzania to provide qualitative insight regarding how maternal mortality affects index as well as other living children and to identify shared structural and social factors that foster high levels of maternal mortality and child vulnerabilities.Methods and findingsAdult family members of women who died due to maternal causes (N = 45) and key stakeholders (N = 35) participated in in-depth interviews. Twelve focus group discussions were also conducted (N = 83) among community leaders in three rural regions of Tanzania. Findings highlight the widespread impact of a woman's death on her children's health, education, and economic status, and, by inference, the roles that women play within their families in rural Tanzanian communities.ConclusionsThe full costs of failing to address preventable maternal mortality include intergenerational impacts on the nutritional status, health, and education of children, as well as the economic capacity of families. When setting priorities in a resource-poor, high maternal mortality country, such as Tanzania, the far-reaching effects that reducing maternal deaths can have on families and communities, as well as women's own lives, should be considered.

The case of Haiti's devastating earthquake and the reactions it has elicited sharply illustrate an array of seemingly dichotomous ways of understanding obligations of "international assistance and cooperation," which are taken up by authors in this issue. First, there is a tension between dealing with immediate humanitarian needs and addressing underlying structural causes. Second, there is the related dichotomy between compassion/charity and the accountability for legal obligations that a human rights approach to health and development demands. Third, within a framework for accountability, there is a tension between an ahistorical understanding of international responsibility - based purely on the self-evident need of fellow human beings - and a contextually-rooted accountability. Finally, the situation of Haiti begs the question of whether we can address immense human suffering in the world through a strongly statist model or whether we require a more cosmopolitan understanding of ethical and legal obligations across borders. Drawing on the Critical Concepts articles in this issue, this essay briefly explores some of these tensions, and the potential contributions and limitations of applying a human rights framework to advance global health.

Accountability is a central feature of any rights-based approach to health because it converts passive beneficiaries into claims-holders and identifies states and other actors as duty-bearers that can be held responsible for their discharge of legal, and not merely moral, obligations. This article reviews what we mean by accountability, how courts and other mechanisms are being engaged to promote accountability, and what we should understand as the central obligations of states and other actors if we are concerned with obligations of progressive realization relating to health and development goals. The first part of the article sets out a number of mutually-reinforcing dimensions of accountability, examines different duty-bearers, and discusses mechanisms for enforcement, with a focus on courts. The second part of the article explores how we might define the obligations of progressive realization for which we seek accountability. I argue that there are three aspects of accountability with which a human rights approach to health as a social policy and development issue should be concerned: (1) what the state is doing; (2) how much effort the state is expending; and (3) how the state is going about the process. Although the focus is on national obligations, I argue that donor states and other actors have parallel obligations.

The foundational princple of human rights is that all human beings are equal in rights, dignity, and worth. Yet we live in a world ravaged by social inequalities both within and between countries, which have profound implications for the distribution of population health as well as the unequal enjoyment of economic and social rights and of human rights generally. It is far from clear that we have a consensus in the human rights community about which inequalities in health constitute inequities or how egalitarian a society must be to conform to the requirements of a social order in which all human rights can be realized. Further, the conversations in the world of human rights have largely been divorced from those in the worlds of development and public health. In this article, I attempt to bring those two conversations together. I first set out how concepts of formal and substantive equality and non-discrimination are defined under international law and might be applied in practice to questions we face in public health today. I argue that the application of these concepts is far from formulaic; interpretations of equality and non-discrimination necessarily reflect deeply held understandings about justice, power, and how we are the same and different from one another. I then explore how far a human rights framework can guide us in terms of some of these underlying questions in health and development polity, particularly in relation to how much priority should be given to the worst off in society, what kind of equality we should be seeking from a human rights perspective, and how we should evaluate who is worst off in terms of health. In conclusion, I argue that the great power of applying a human rights framework to health lies in denaturalizing the inequalities that pervade our societies and our world and in establishing that all people--by virtue of being human--have both a claim for redress when they are treated unfairly and a right to participate in determining what equity and equality require in a given context.