1. Toebes, May 2010 Human rights, health sector commercialisation and corruption Dr Brigit Toebes, The University of Aberdeen School of Law b.toebes@abdn.ac.uk

2. Toebes, May 2010 Framework for discussion: UN General Comment 14 on the Right to the Highest Attainable Standard of Health www.ohchr.org

3. Toebes, May 2010 Right to health Not a ‘right to be healthy’ Not a ‘right to be healthy’ Two dimensions: Access to health care Access to health care Access to underlying conditions for health Access to underlying conditions for health

4. Toebes, May 2010 Right to health Three tools: ‘AAAQ-AP’ ‘AAAQ-AP’ Obligations to ‘respect, protect and fulfil’ Obligations to ‘respect, protect and fulfil’ Minimum core obligations Minimum core obligations

5. Toebes, May 2010 AAAQ-AP Availability Availability Accessibility AccessibilityNon-discrimination Physical accessibility Affordability Information accessibility Acceptability Acceptability Quality Quality Accountability Accountability Participation Participation

6. Toebes, May 2010 Tri-partite typology of State Obligations Obligations to respect Obligations to respect Obligations to protect Obligations to protect Obligations to fulfil Obligations to fulfil

7. Toebes, May 2010 Minimum core obligations A ‘minimum package’ of health services Programme of Action ICPD Programme of Action ICPD Primary Health Care WHO Primary Health Care WHO Millennium Development Goals Millennium Development Goals

8. Photo: Global Corruption Report 2006, Transparency International Health care commercialisation

9. Toebes, May 2010 Terminology Privatisation? Privatisation? Commercialisation? Commercialisation?

10. Toebes, May 2010 Why privatise? Reduce rising costs caused by Developed countries Inefficiency Inefficiency Ageing of the population Ageing of the population Improvements of medical techniques Improvements of medical techniques Rising expectations Rising expectations Over-consumption? Over-consumption? Developing countries Inefficiency Inefficiency General poverty on the part of the government General poverty on the part of the government Pressure from IFI’s and TNC’s Pressure from IFI’s and TNC’s

11. Toebes, May 2010 The promise: Enhance the consumer’s range of choice

12. Toebes, May 2010 Trends health insurance health insurance health care provision health care provision multinational expansion multinational expansion out-of-pocket expenditure out-of-pocket expenditure

13. Toebes, May 2010 British Medical Association 2006 ‘There should be no further involvement of the commercial private sector in providing NHS care. The BMA will campaign to restore an integrated publicly provided health service in England.’

14. Toebes, May 2010 The public health perspective Mackintosh and Koivusalo: Better health care at birth when more of GDP spent by government or social insurance funds on health care Better health care at birth when more of GDP spent by government or social insurance funds on health care Greater exclusion of children from treatment when ill when higher primary care commercialisation Greater exclusion of children from treatment when ill when higher primary care commercialisation

15. Toebes, May 2010 Their conclusion: ‘Health systems are part of the public policy sphere’ ‘Health systems are part of the public policy sphere’ ‘Policies towards commercialization within health systems should and can be within national and local democratic control’ ‘Policies towards commercialization within health systems should and can be within national and local democratic control’

16. Toebes, May 2010 The human rights perspective Neutral, yet Neutral, yet Serious human rights consequences Serious human rights consequences

17. Toebes, May 2010 Relevant human rights Rights to information and political participation Rights to information and political participation Right to health Right to health Right to a remedy Right to a remedy Right to privacy Right to privacy

18. Toebes, May 2010 AAAQ-AP Availability Availability Accessibility AccessibilityNon-discrimination Physical accessibility Affordability Information accessibility Acceptability Acceptability Quality Quality Accountability Accountability Participation Participation

19. Toebes, May 2010 State obligations to respect, protect and fulfil Emphasis on State obligations to protect: Regulate Regulate Monitor Monitor Provide redress Provide redress

20. Toebes, May 2010 The human rights impact assessment Availability more efficiency? more efficiency?Accessibility cost of health care? cost of health care? Patients accepted? Patients accepted?Acceptability Medical data protected? Medical data protected?Quality Effects on the adequacy of the services? Effects on the adequacy of the services?Accountability Regulatory mechanisms in place? Regulatory mechanisms in place? Means of redress? Means of redress?Participation Public informed and consulted? Public informed and consulted?

21. Photo: Global corruption report Transparency International, 2006 Health Sector Corruption

22. Toebes, May 2010 Health sector corruption Transparency International: Global Corruption Report 2006 – Corruption and Health

23. Toebes, May 2010 Actors in the health sector State actor: Governments and all their agents Governments and all their agents Non-state actors: Healthcare providers (hospitals, health workers) Healthcare providers (hospitals, health workers) Health insurers Health insurers Consumers / patients Consumers / patients Suppliers (pharmaceutical industry) Suppliers (pharmaceutical industry) Health researchers and educators Health researchers and educators

24. Toebes, May 2010 Why is the health sector prone to corruption? Uncertainty Uncertainty Asymmetric information Asymmetric information Large numbers of actors Large numbers of actors

25. Toebes, May 2010 Does it matter how a health sector is organised? Tax based Tax based Insurance based Insurance based public health care provision public health care provision private healthcare provision private healthcare provision Decentralisation Decentralisation

26. Toebes, May 2010 A definition of corruption The misuse of entrusted power for private gain

27. Toebes, May 2010 UN Convention on Corruption - 2003 Bribery of national and foreign public officials Bribery of national and foreign public officials Bribery in the private sector Bribery in the private sector Embezzlement of property by a public official Embezzlement of property by a public official Trading in influence Trading in influence Abuse of functions Abuse of functions Illicit enrichment Illicit enrichment

28. Toebes, May 2010 ‘HEALTH SECTOR CORRUPTION CAN AMOUNT TO VIOLATIONS OF THE RIGHT TO HEALTH’

29. Toebes, May 2010 Human rights and health sector corruption Right to health Right to health Right to life Right to life Non-discrimination Non-discrimination Rights to information and political participation Rights to information and political participation Right to a remedy Right to a remedy

30. Toebes, May 2010 ‘Regulators’: the State and all its agents ‘AAAQ-AP’ ‘AAAQ-AP’ Obligations to respect, protect and to fulfil Obligations to respect, protect and to fulfil

31. Toebes, May 2010 AAAQ-AP Availability Availability Accessibility AccessibilityNon-discrimination Physical accessibility Affordability Information accessibility Acceptability Acceptability Quality Quality Accountability Accountability Participation Participation

32. Toebes, May 2010 State obligation to respect Refrain from: Bribery of officials in relation to health sector Bribery of officials in relation to health sector Illicit enrichment Illicit enrichment Misappropriation of funds Misappropriation of funds Trading in influence in the health sector Trading in influence in the health sector Abuse of function Abuse of function Diverting drugs destined for country back to international drug market Diverting drugs destined for country back to international drug market

33. Toebes, May 2010 Obligation to protect Regulate the behaviour of: State / regional and local governments State / regional and local governments Health insurers Health insurers Hospitals Hospitals Health workers Health workers Pharmaceutical industry Pharmaceutical industry Consumers / patients Consumers / patients

34. Toebes, May 2010 State obligation to fulfil Adopt a coherent national policy to minimise the risk of corruption throughout the entire health system.

35. Toebes, May 2010 Non-state actors Hospitals, health insurers, pharmaceutical companies ‘AAAQ-AP’ ‘AAAQ-AP’ Respect, protect, fulfil Respect, protect, fulfil

36. Toebes, May 2010 Human rights violations? States States Non-state actors Non-state actors

37. Toebes, May 2010 States embezzlement and stealing money from the health budget misappropriation of funds that had been allocated to the health sector accepting a bribe in exchange for the construction permit for a hospital

38. Toebes, May 2010 Hospitals Theft from hospital budget Theft from hospital budget Unnecessary medical interventions Unnecessary medical interventions Preferential treatment Preferential treatment

39. Photo: Global corruption report Transparency International, 2006 Health workers Informal payments?

40. Toebes, May 2010 Health Insurers Adverse selection practices Adverse selection practices Refusal of patients on the basis of their health status, age, etc. Refusal of patients on the basis of their health status, age, etc. Illegal billing of health care providers Illegal billing of health care providers

41. Toebes, May 2010 Pharmaceutical Industry Influencing health care providers Influencing health care providers Excessive promotion of drugs Excessive promotion of drugs Exerting pressure on drug selection process Exerting pressure on drug selection process

42. Toebes, May 2010 Thank you