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The COVID-19 pandemic has focused minds on the resilience of our health care systems and is challenging member states’ health policies and their effectiveness. Furthermore, doctors, medical personnel and health care personnel are under unprecedented pressure. Do we have enough medical facilities and supplies to respond to the emergency, even when there are strict containment measures? Can our human right to the enjoyment of the highest attainable standard of physical and mental health be fulfilled in the current circumstances? Are health workers sufficiently protected and can they handle the immense responsibility they have on their shoulders? In the midst of this tragic pandemic, we cannot claim to have all the answers to these existential questions. But we can highlight some of the foundations of a health care system that seeks to meet the needs of the entire population and that creates resilience to respond to public health emergencies.
It is obvious that all people have the right to protect their health against the pandemic. Universal health coverage creates the basis for this. Broader social protection measures are needed 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 avoid the negative effects on the right to health experienced during the economic crisis of the previous decade.
Universal health coverage
Compliance with the right to health is often seen as a problem about access to medical care. During my visit to Greece in 2018, I observed the negative impact of long-term austerity measures on the availability and affordability of medical care. I urged the authorities to remove the obstacles to accessing universal health coverage and increase their efforts to recruit health care personnel. Achieving universal health coverage is one of the goals of United Nations Sustainable Development Goal 3 (guarantee a healthy life and promote the well-being of all at all ages). According to the World Health Organization (WHO), universal coverage means that all people and communities receive the health services they need without suffering financial difficulties. It includes the full range of quality and essential health services, from health promotion to prevention, treatment, rehabilitation and palliative care.
Efforts to achieve universal health coverage received a boost on October 10, 2019 with the adoption by the UN General Assembly of a high-level political declaration “Universal Health Coverage: Moving Together to Build a More World healthy, “after its approval by world leaders in September. The declaration recognizes that health contributes to the promotion and protection of human rights and is committed to covering an additional 1 billion 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 underscores 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 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 shrinking. People treated in psychiatric institutions are in a particularly vulnerable situation, with decreased access to care and additional risks of infection. Public Health England has released a detailed guide to preserving mental health and well-being during the coronavirus outbreak.
Civil society representatives have expressed concern that the UN Declaration does not reaffirm the right to health as a right and leaves too much discretion to governments to determine the scope of universal health coverage with reference to “sets determined at the national level”. Measures to address the needs of migrants, refugees, internally displaced persons and indigenous peoples have also been rated for implementation “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 current gaps in universal coverage do not become obstacles to a comprehensive response to the coronavirus pandemic and the availability of care for all.
In Europe, the inaccessibility of medical care has been a major barrier to the full realization of universal health coverage. Significant out-of-pocket payments can cause unmet needs or financial difficulties for service users. According to the WHO, this may be the case in most European countries. In my 2019 report on Armenia, I made a connection between low public health spending and the difficulties older people experience in obtaining specialized treatment and palliative care. During my visit to Estonia in 2018, I noticed that 1 in 4 people over 65 in poor health were unable to pay for care. Doctors of the World (Médecins du Monde) has pointed out that many people who belong to disadvantaged groups may also face problems regarding the right to health insurance.
Health inequalities and social determinants of health.
Concerns about gaps in the scope of universal health coverage in Europe are related to health inequalities between and within countries, and broader problems of poverty and social determinants of health. The right to health is closely related to 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 simply the absence of illness or disease, universal health coverage alone is unlikely to be effective in addressing the needs of health in a sustainable way. A broader approach to social rights is required.
The landmark 2019 WHO Europe Health Equity Status report reveals that health inequalities in Europe have remained the same or worsened over the past 10-15 years. Although the average life expectancy in the WHO European region of 52 countries has increased for both women (82 years) and men (76 years), significant inequities in health persist among social groups. The life expectancy of women is reduced by up to 7 years and that of men by up to 15 years if they are among the most disadvantaged groups. Regional inequalities in life expectancy continue to persist or worsen in most countries. It is also worrying that health gaps between socioeconomic groups increase with age.
The report makes a very useful contribution to identifying the social determinants and drivers of the health gap and in doing so the maps mean to improve the situation. In addition to universal access to health care, social protection, housing, education and employment are important factors in improving health status. The report recommends integrated solutions based on a combination of interventions. Surprisingly, he argues that the most cost-effective means of closing the health gap is increased investment in housing and community services.
Unfortunately, affordable housing is scarce in Europe and overall government spending on social housing was only 0.66% of 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, raised the alarm about the current global housing crisis and published guidelines for the practical implementation of the right to adequate housing.
In March, he noted that housing had become the front-line defense against coronavirus, as governments hoped that people would stay home to prevent the spread of the pandemic. The Rapporteur expressed special concern for the homeless and people living in extremely inadequate housing, often in overcrowded conditions or lack of access to water and sanitation, which makes them particularly vulnerable to the virus. It is obvious that homeless people should not be penalized for not being able to stay home during the pandemic. In Scotland, local authorities have made vacant student floors and unoccupied hotel rooms available to hard sleepers in the current situation. A similar positive initiative was launched by the UK government in England. Long-term housing solutions for the homeless are still necessary. They will make our societies more resilient against crises and pandemics.
Gender-sensitive approaches to health and equality
Gender is another determinant of health. Differences in health status and needs between women and men are not simply related to biological differences but to the impact of social norms and gender stereotypes. The WHO has pointed out that factors that affect notions of masculinity and femininity and how gender roles are defined in societies can have a massive effect on the health of men and women. We need gender-sensitive approaches to health that take into account gender norms and inequalities and act to reduce their harmful effects. Progress towards gender equality should have a positive impact on the health of women and men. Ultimately, gender-sensitive approaches based on equality can help transform gender roles, norms and structures that act as barriers to achieving healthy lives and well-being for all.
The higher average life expectancy of women compared to men is generally known as the “mortality advantage”. 70% of the European population over 85 years are women. However, the additional years are often accompanied by health problems or disability. Women in Europe live on average 10 years with health problems, while the figure for men is 6 years. The WHO report on the health and well-being of women in Europe highlights cardiovascular disease, mental health problems, gender-based violence and cyber bullying as frequent health problems among women. Cancers of the breast, cervix, lung, and ovary represent an important burden on the health of women. Women consider themselves less healthy than men and report more illnesses. They are less represented in clinical trials, making it more difficult to determine safe dosage ranges and possible side effects of medications for women. Sexual and reproductive health is another area where gender-specific and human rights-based responses are needed.
Norms on masculinity and socioeconomic factors are related to men’s risk behaviors and the underutilization of health services in many European countries. The WHO report on men’s health and well-being in Europe notes that men have unhealthy smoking practices and dietary patterns, heavier drinking habits, and higher rates of injury and interpersonal violence than women . 86% of all male deaths can be attributed to non-communicable diseases and injuries, especially cardiovascular disease, cancers, diabetes and respiratory diseases. High blood pressure is a major risk factor with a higher prevalence than in women. Suicide rates among men ages 30-49 are five times higher than among women of the same age. However, men report better subjective health than women and use health services less frequently than they do.
Coronavirus is reported to have gender differential effects. The mortality rate for men appears to be up to twice that of women. Although we don’t yet know the cause of this, it has been suggested that both biological factors and gender risk behaviors, such as smoking, may be relevant. Gender is also important in responses to the pandemic. Social distancing or blockages in the home carry a specific danger to women’s health in terms of an increased risk of domestic violence. Many women victims of violence may experience additional difficulties seeking help in shelters that have closed or choose not to seek medical care for fear of contagion. Women’s exposure to the coronavirus is compounded by the fact that they are a clear majority among health care personnel and as informal and family caregivers. It is essential that prioritization of the availability of health services during the pandemic does not discriminate on the basis of gender. This also applies to access to sexual and reproductive health care, including abortion.
The European WHO region is the first WHO region to implement strategies on the health and well-being of women and men in a coordinated manner and following a human rights-based approach. Ireland was the first country in Europe to prepare a health policy directed specifically at men as early as 2008. Health policies that address the health of women and men in a gender-specific way through different stages of life They mutually reinforce each other and highlight gender as a central determinant of health.
Exit from the crisis
The pandemic is a danger to us all, but there are many groups of people who are in a particularly vulnerable or highly exposed position. Older people are in a high-risk group and intergenerational solidarity is now in high demand. Many people with disabilities rely on the support of others in their daily activities, and the continuity and security of that support must be ensured during the crisis. People living in institutions or in detention face a high risk of infection and should receive protective measures. I have highlighted the situation of immigration detainees and prisoners specifically. Homeless people are extremely vulnerable as stated above. The living conditions of many Roma remain inadequate with limited access to water and sanitation. Large numbers of refugees and migrants find themselves in a similar situation.
In response to the COVID-19 pandemic, all population groups should be able to access health care, including drugs and vaccines, without discrimination. Any absolute need for prioritization in terms of limited resources should be based on sound medical evidence and the individual urgency of the required treatment. The human dignity of all must be respected without questioning the fundamental equality of each person’s life. Focused efforts are required to preserve mental health during the crisis and to ensure continuity and safety of treatment.
Positive measures should be applied to mitigate the health risks of the pandemic for groups that are particularly vulnerable or exposed to the coronavirus. Such measures should be effective and proportionate and could include, for example, improved social support, provision of adequate housing, access to water and sanitation, deinstitutionalization, early release from custody, facilitated access to protective equipment and testing for coronavirus, provision of additional means of communication and availability of information in accessible formats, among others. Gender responsiveness should be seen as a regular aspect of the means to counter the pandemic.
I urge governments to ease the enormous pressure that health professionals, most of whom are women, face 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 tests, and psychosocial support. Health workers and their families should have the right to child care arrangements and social protection measures to cover their occupational risks. Any extraordinary care task for health professionals who are not on active duty must be necessary and accompanied by strict guarantees to guarantee their safety and well-being.
Ultimately, Member States must build resilient healthcare systems that meet the needs of the entire population and enable robust responses to health emergencies. Achieving universal and affordable health coverage, including mental health, is central to this effort. No one should be left behind in the right to medical care. There is a special need to promote deinstitutionalization, outpatient services, and primary health care.
I urge governments to apply a gender perspective in the implementation of health policies. They must identify and address gender-based health needs and aspire to change unhealthy behaviors that are related to harmful gender stereotypes. It is necessary to unlock the potential of health promotion and protection as an effective tool to improve gender equality for both women and men.
The widening of inequalities in health status must be addressed through a broader approach to social rights. 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 that combine universal coverage with protection against poverty, the eradication of homelessness, inclusive education and training and access to employment. Specific efforts must be made to implement adequate, affordable and long-term housing solutions.
European council
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