The COVID-19 pandemic has concentrated minds about the resilience of our health care systems and it is challenging member states’ health policies and their effectiveness. In addition, doctors, medical staff and health care staff are under unprecedented pressure. Do we have sufficient medical facilities and supplies to respond to the emergency even when strict containment measures are in place? Can our human right to the enjoyment of the highest attainable standard of physical and mental health be fulfilled under the current circumstances? Are health care workers sufficiently protected and can they manage the immense responsibility placed on their shoulders? In the midst of this tragic pandemic we cannot pretend to have all the answers to these existential questions. But we can highlight some of the fundamentals of a health care system which seeks to meet the needs of the entire population and which builds resilience in order to respond to public health emergencies.
It is obvious that all people have the right to the protection of their health against the pandemic. Universal health coverage creates the basis for this. Broader social protection measures are necessary to address entrenched health inequalities. A focus on gender plays a central role in effective responses. The development of inclusive and resilient health care systems, which is likely to take place under conditions of renewed austerity, should eschew the negative effects on the right to health experienced during the economic crisis of the previous decade.
Universal health coverage
The fulfilment of the right to health is often viewed as an issue about access to health care. During my visit to Greece in 2018, I observed the negative impact of long-term austerity measures on the availability and affordability of health care. I urged the authorities to remove obstacles to accessing universal medical coverage and to increase their efforts to recruit health care staff. The achievement of universal health coverage is one of the targets of the United Nations’ Sustainable Development Goal 3 (ensure healthy lives and promote well-being for all at all ages). According to the World Health Organisation (WHO), universal coverage means that all individuals and communities receive the health services they need without suffering financial hardship. It includes the full range of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care.
Efforts to achieve universal health coverage received a boost on 10 October 2019 with the UN General Assembly’s adoption of a high-level political declaration “Universal health coverage: moving together to build a healthier world”, following its approval by world leaders in September. The declaration recognises that health contributes to the promotion and protection of human rights and makes a commitment to covering one billion additional people by 2023 with quality essential health services, with a view to covering all people by 2030. The declaration stresses that strong and resilient health systems, capable of reaching people in vulnerable situations, can ensure pandemic preparedness and effective responses to any outbreak.
It is significant that the declaration specifically covers mental health and well-being as an essential component of universal health coverage and stresses the need to fully respect the human rights of people experiencing mental health problems. Mental health professionals have pointed out that the current pandemic is resulting in a parallel epidemic of fear, anxiety, and depression. The highly stressful environment and the containment measures taken out of necessity place a significant burden on the mental health of the general population. Existing mental health conditions may also worsen further, and opportunities for regular outpatient visits are narrowing. People treated in psychiatric institutions find themselves in an especially vulnerable situation, with diminishing access to care and additional risks of infection. Public Health England has issued detailed guidance on preserving mental health and wellbeing during the coronavirus outbreak.
Civil society representatives have expressed concern that the UN Declaration does not in fact reaffirm the right to health as an entitlement and that it leaves too much discretion to governments in determining the extent of universal health coverage with reference to “nationally determined sets”. Measures to address the needs of migrants, refugees, internally displaced persons and indigenous peoples have also been qualified to be applied “in line with national contexts and priorities”. In addition, NGOs have highlighted funding gaps for universal coverage and the essential role of public health systems in meeting the health care needs of vulnerable populations. It is crucial that the current gaps in universal coverage are not allowed to become obstacles to a comprehensive response to the coronavirus pandemic and the availability of care for all.
In Europe, the unaffordability of health care has been an important barrier to the full realisation of universal health coverage. Significant out-of-pocket payments can result in unmet needs or financial hardship for service users. According to the WHO, this may be the case in the majority of European countries. In my 2019 report on Armenia, I made a connection between low public health expenditure and the difficulties experienced by older people in obtaining specialised treatment and palliative care. During my visit to Estonia in 2018, I noted that 1 in 4 persons above 65 in poor health could not afford care. Doctors of the World (Médecins du Monde) has pointed out that many people belonging to disadvantaged groups may also face issues about health insurance entitlement.
Health inequalities and social determinants of health
The concerns about the gaps in the reach of universal health coverage in Europe are related to health inequalities between and within countries, and the broader issues of poverty and social determinants of health. The right to health is closely interconnected with other social rights such as the rights to social security and protection, and the right to housing. Since the WHO Constitution defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, it is unlikely that universal health coverage alone would be effective in addressing health needs in a sustainable manner. A broader social rights approach is required.
The landmark health equity status report by WHO Europe from 2019 reveals that health inequalities in Europe have remained the same or have worsened over the last 10-15 years. Although average life expectancy across the WHO European region of 52 countries has increased for both women (82 years) and men (76 years), significant health inequities remain between social groups. Women’s life expectancy is cut by up to 7 years and men’s by up to 15 years if they find themselves among the most disadvantaged groups. Regional inequalities in life expectancy continue to persist or worsen within most countries. It is also worrying that health gaps between socioeconomic groups increase with age.
The report makes a highly useful contribution in identifying social determinants and drivers of the health gap and in so doing maps means of improving the situation. In addition to universal access to health care, social protection, housing, education and employment are significant factors in improving health status. The report recommends integrated solutions based on a combination of interventions. Remarkably, it argues that the most cost-effective means of closing the health divide is increased investment in housing and community amenities.
Unfortunately, affordable housing is in short supply in Europe and the overall spending by governments on social housing stood at only 0.66% of the European GDP in 2017, as I noted in an article in January this year. In December 2019, the UN Special Rapporteur on the right to housing, Leilani Farha, sounded the alarm about the current global housing crisis and published guidelines for the practical implementation of the right to adequate housing.
In March, she pointed out that housing had become the front-line defence against the coronavirus as governments relied on people to stay home to prevent the spread of the pandemic. The Rapporteur expressed special concern at homeless people and those living in grossly inadequate housing, often in overcrowded conditions or lacking access to water and sanitation, making them particularly vulnerable to the virus. It is obvious that homeless people should not be penalised for not being able to stay at home during the pandemic. In Scotland, local authorities have made unoccupied student flats and hotel rooms available to rough sleepers in the current situation. A similar positive initiative was undertaken by the UK government in England. Long-term housing solutions for homeless people remain necessary. They will make our societies more resilient against crises and pandemics.
Gender-responsive approaches to health and equality
Gender is another determinant of health. The differences in health status and needs between women and men are not simply related to biological differences but to the impact of societal gender norms and stereotypes. The WHO has pointed out that factors affecting notions of masculinity and femininity and the way gender roles are defined in societies can have a massive effect on the health of men and women. We need gender-responsive approaches to health which take gender norms and inequalities into account and act to reduce their harmful effects. Progress towards gender equality should have a positive impact on the health of both women and men. Ultimately, gender-responsive approaches based on equality can help transform the gender roles, norms and structures which act as barriers to achieving healthy lives and well-being for everybody.
The higher average life expectancy of women in comparison with men is usually referred to as the “mortality advantage”. 70% of the European population over 85 are women. However, the additional years are often accompanied with ill health or disability. Women in Europe live on average 10 years in ill health while the figure for men is 6 years. The WHO report on women’s health and well-being in Europe highlights cardiovascular diseases, mental health problems, gender-based violence and cyber-bullying as prevalent health issues among women. Breast, cervical, lung and ovarian cancers pose significant burdens to women’s health. Women consider themselves less healthy than men and report more illness. They are less represented in clinical trials making it more difficult to determine safe dosage ranges and possible side effects of medicines for women. Sexual and reproductive health is another area where gender-specific and human rights-based responses are necessary.
Norms around masculinity and socio-economic factors are related to men’s risk-taking behaviours and underuse of health services across many European countries. The WHO report on men’s health and well-being in Europe points out that men have unhealthier smoking practices and dietary patterns, heavier alcohol drinking habits and higher rates of injuries and interpersonal violence than women. 86% of all male deaths can be attributed to noncommunicable diseases and injuries, especially cardiovascular diseases, cancers, diabetes and respiratory diseases. Raised blood pressure is a leading risk factor with a higher prevalence than in women. Suicide rates among 30-49-year-old men are five times higher than among women of the same age. Yet men report better subjective health than women and use health services less often than them.
It is reported that the coronavirus has gender-differential effects. The fatality rate for men appears to be up to twice as high as for women. Although we do not yet know the cause for this, it has been suggested that both biological factors and gendered risk behaviours, such as smoking, may be relevant. Gender matters in responses to the pandemic, too. Social distancing or lockdowns at home bear a specific danger to women’s health in terms of a higher risk of domestic violence. Many women victims of violence may experience additional difficulties in seeking help in shelters which have closed down or decide not to seek medical attention for fear of contagion. Women’s exposure to the coronavirus is aggravated by the fact that they are in the clear majority among health care staff and as informal and family carers. It is essential that the prioritisation of the availability of health services during the pandemic does not discriminate on the ground of gender. This also applies to access to sexual and reproductive health care, including abortion.
The WHO European region is the first WHO region to implement strategies on the health and well-being of both women and men in a coordinated way and following a human rights-based approach. Ireland was the first country in Europe to prepare a health policy specifically targeting men already in 2008. Health policies which address both women’s and men’s health in gender-specific ways through the different stages of life are mutually reinforcing and highlight gender as a central determinant of health.
Way out from the crisis
The pandemic is a danger to all of us but there are many groups of people who are in an especially vulnerable position or highly exposed to it. Older persons find themselves in a high-risk group and inter-generational solidarity is now in high demand. Many persons with disabilities rely on the support of others in their daily activities and the continuity and safety of such support must be guaranteed during the crisis. People living in institutions or detention face a high risk of infection and should be afforded protective measures. I have highlighted the situation of immigration detainees and prisoners specifically. Homeless people are extremely vulnerable as stated earlier. The living conditions of many Roma remain inadequate with limited access to water and sanitation. A great number of refugees and migrants find themselves in a similar situation.
In the response to the COVID-19 pandemic, all population groups should be able to access health care, including medicines and vaccines, without discrimination. Any absolute necessity for prioritisation in terms of limited resources must be based on sound medical evidence and the individual urgency of the required treatment. Everyone’s human dignity must be respected without putting into question the fundamental equality of every person’s life. Focused efforts are required to preserve mental health during the crisis and to ensure the continuity and safety of treatment.
Positive measures should be applied to mitigate the risks of the pandemic on the health of groups who are particularly vulnerable or exposed to the coronavirus. Such measures should be effective and proportionate and could include, for example, enhanced social support, provision of adequate housing, access to water and sanitation, deinstitutionalisation, anticipated release from custody, facilitated access to protective equipment and coronavirus testing, provision of additional means of communication and the availability of information in accessible formats, among others. Gender-responsiveness should be considered as a regular aspect of the means to counter the pandemic.
I urge governments to alleviate the enormous pressure health professionals, the majority of whom are women, are facing in their work against the pandemic. Their safety at work is crucial and they must have access to effective protective equipment, regular coronavirus screening and antibody testing, and psychosocial support. Health workers and their families should be entitled to childcare arrangements and social protection measures to cover their work-related hazards. Any extraordinary care duties for health professionals not in active service must be necessary and accompanied by strict safeguards for ensuring their safety and well-being.
In the long run, member states should build resilient health care systems which cater to the needs of the entire population and enable robust responses to health emergencies. The achievement of universal and affordable health coverage, including for mental health, is critical for this endeavour. No one should be left behind in health care entitlement. There is a special need to promote deinstitutionalisation, outpatient services and primary health care.
I urge governments to apply a gender-responsive approach in the implementation of health policies. They should identify and address gender-based health needs and aim to change unhealthy behaviours which are related to harmful gender stereotypes. It is necessary to unleash the potential of health promotion and protection as an effective tool for improving gender equality for both women and men.
Widening inequalities in health status must be addressed through a broader social rights approach. As people’s health and well-being are closely related to the social determinants of health, it is necessary to promote health through integrated approaches which combine universal coverage with protection against poverty, the eradication of homelessness, inclusive education and training, and access to employment. Focused efforts should be made to implement adequate, affordable and long-term housing solutions.