Protecting the right to healththrough inclusive and resilient
health care for all

Issue paper

Protecting the right to healththrough inclusive and resilient
health care for all

Issue paper publishedby the Council of Europe
Commissioner for Human Rights

Council of Europe

French edition:
Protéger le droit à la santégrâce à des systèmes de santé inclusifs
et résilients accessibles à tous
Issue papers are published by theCommissioner for Human Rights tocontribute to debate and reflection
on important current humanrights issues. Many of them also
include recommendations by theCommissioner for addressing theconcerns identified.
The opinions expressed in theseexpert papers do not necessarilyreflect the Commissioner’s positionor the official policy of theCouncil of Europe.
All requests concerning the
reproduction or translation of
all or part of this document
should be addressed to the
Directorate of Communication(publishing@coe.int).
All other correspondence
concerning this document should
be addressed to the Office of theCommissioner for Human Rights.
Issue papers are available on theCommissioner’s website:www. commissioner.coe.int
Cover photo:©Shutterstock - Sundry Photography© Council of Europe,
February 2021

Acknowledgements:
This issue paper was prepared by
Dr Rachel HAMMONDS,
J.D., Ph.D. in Medical Sciences, Law
and Development Research Group,
University of Antwerp Law Faculty.

Contents
INTRODUCTION

5THE COMMISSIONER’S RECOMMENDATIONS

9STANDARDS AND PRINCIPLES ON THE RIGHT TO HEALTH

15

1.1 The international legal framework for the right to health andhealth security

16

1.2 The European legal framework for the right to health andhealth security

17

1.3 General human rights principles

20

KEY PARTNERS FOR CO-OPERATION

25

2.1 Civil Society

25

2.2 National Human Rights Structures (NHRSs)

26

2.3 Parliaments

27

2.4 The Sustainable Development Goals (SDGs)

28

BUILDING INCLUSIVE AND RESILIENT HEALTH CARE SYSTEMSFOR ALL

29

3.1 High-quality health service delivery

29

3.2 Skilled health workforce

33

3.3 Health financing

34

3.4 Access to essential medicines and vaccines36

3.5 Health research, information and communication

37

3.6 Leadership and good governance39

THE ESSENTIAL SOCIAL DETERMINANTS OF HEALTH

41

4.1 Income security and social protection

41

4.2 Living conditions

42

4.3 Education

44

4.4 Employment and working conditions

45

ENDNOTES

47
Page 3

IntroductionT

he COVID-191 pandemic is the greatest public health crisis in
generations, placing an unprecedented strain on health care systems
globally. At the end of January 2021, one year after the World
Health Organisation (WHO) declared a public health emergency, almost
three quarters of a million persons across Europe had died of or with theCoronavirus.2 As the longer-term repercussions of the pandemic continue
to unfold, the health crisis has developed into a rights crisis, resulting inviolations not only of the right to life and the right to health, but of all
human rights. Since the onset of the crisis, the Commissioner for Human
Rights has released numerous statements highlighting emerging COVID19-related human rights challenges.3 This issue paper focuses on the often
overlooked or “taken for granted” right to the highest attainable standardof physical and mental health for all. Without it, we cannot live in dignity,and our ability to vote or enjoy other civil and political freedoms, and towork, learn or create is significantly restricted.
Council of Europe member states are home to some of the world’s best
performing health and social care systems. Yet, health equity gaps haverevealed persistent challenges to health systems’ inclusiveness across theregion and these have been shown to incur significant social, human andeconomic costs to individuals and societies.4 Even before the pandemic
struck, health data demonstrated that disparities in access to preventive
health care and treatment, based on gender, minority or socio-economic
background, were common.5 In addition, insufficient regional progresson important social determinants of health, such as education and socioeconomic status, due often to underlying and deeply embedded structuralinequalities, has increased the risk that those who are less advantaged insociety experience worse health outcomes and have shorter lives than
average.
Combined barriers to access to health care have proven lethal during
the COVID-19 pandemic.6 This shows that the right to health cannot beprotected at an individual level only. It requires effective systems thatprovide for inclusive prevention, treatment and rehabilitation for all, leaving
no one behind and ensuring that structural inequalities are not magnified
over time but pre-empted and addressed.
Page 5

Austerity measures over the past decade have atrophied health and social
systems in some states and the COVID-19 pandemic has exposed theirresulting weaknesses and lack of resilience.7 Hospitals, laboratories andpublic health agencies have been operating beyond capacity, diagnostic
capacity has been lacking in many countries, the supply of personal
protective equipment has often been insufficient and front-line healthand social care workers have faced increased risks of disease and death.
These factors have contributed to often preventable excess mortality andsuffering throughout Europe.
The dramatic toll on vulnerable and/or marginalised groups living in
long-term care facilities, and especially amongst older persons, is deeply
alarming. The Commissioner for Human Rights has repeatedly underlined
how important it is for member states to move away from the practice ofinstitutionalising older persons, persons with physical or mental healthissues or disabilities and children.8 The COVID-19 crisis demonstrates how
urgent it is to implement the international human rights commitment todeinstitutionalisation contained in Article 19 of the Convention on the
Rights of Persons with Disabilities (CRPD).9
The protection and promotion of the right to health is not an easy task.
Health care is a complex sector with many public and private actors working
interdependently. Given the dramatic situation in Europe in the wake of
COVID-19, concerted efforts must be made in many Council of Europe
member states to evaluate the state of their health systems and improvethem where necessary so as to guarantee free access to high-quality
health care that is ”guided by the needs of patients rather than profit andregardless of gender, nationality, religion or socio-economic status”.10
As we collectively learn lessons from the different country responses
to COVID-19, Council of Europe member states must co-operate andact in solidarity across borders and organisations to ensure that healthcare systems are both inclusive and resilient. To chart a path forward fora human rights-based approach to health, including in the post-COVID
recovery period, this Issue Paper is preceded by the Commissioner’s twelve
recommendations to all Council of Europe member states on how to build
inclusive and resilient health care systems for all.
The first chapter of the issue paper reviews member states’ universal andEuropean health-related commitments, clarifying standards and principles
that should underpin and guide related policies and processes.
The second chapter presents key health governance partners that canadvance co-operation and solidarity to tackle the health gaps exposed andmagnified by COVID-19.
Page 6 - Protecting the right to health

The third chapter explores the six key components required to deliver
inclusive and resilient health care systems.11
The final chapter lays out how good-quality, accessible health care isreinforced by the broader social determinants of health: income security
and social protection; adequate living conditions; education; and decent
labour and employment conditions.12

Introduction - Page 7

The Commissioner’s
recommendationsTo ensure that human rights form the basis for developing inclusive
and resilient health care systems and the social policy responses
needed to safeguard the right to the highest attainable standardof physical and mental health for all, including in the context of a pandemic,
and to combat health inequalities for current and future generations,the Commissioner for Human Rights calls on Council of Europe member
states to:

Enhance ratification and implementation of relevant
universal and European instruments in the area ofsocial and health rights●●●

ratify the revised European Social Charter and agree to be bound by
the Collective Complaints Procedure, and ratify the European Codeof Social Security;
make progress on the broader social rights commitments enshrinedin the European Social Charter and the European Code of Social
Security that are necessary to narrow the health equity gap andmove forward on the Sustainable Development Goals commitmentof leaving no one behind;ratify the Aarhus Convention on Access to Information, Public
Participation in Decision-Making and Access to Justice inEnvironmental Matters and participate in the UN Framework
Convention on Climate Change process.

Make progress on measures to promote universal
health coverage (UHC) with primary health care as its
foundation●

develop and maintain well-funded health systems that deliver highquality preventive, promotive and curative care to all throughout
people’s lives, without exposing them to financial hardship;
Page 9●●●

ensure that mental health services, an essential component of
UHC, are accessible to all when needed, of appropriate quality andaffordable;
ensure that all people have access to the full range of high-quality
sexual and reproductive health services, including age-appropriate,
comprehensive sexuality education for children in school;support strong emergency health preparedness and response
systems and strengthen capacities at national, regional andinternational levels, with a view among other things to mitigating
the impacts of the climate emergency on health.

Ensure that health and social systems respect theautonomy and dignity of all people
●

●

●

●

take immediate steps to ensure that health and social systems aredesigned to be people-centred and life-cycle sensitive, including
offering older persons diverse living options with a view to minimising
long-term institutional care;progressively transition to a living-in-the-community model andmove away from long-term residential care institutions for persons
with disabilities or mental health issues;enact measures and fund diverse programmes that enable persons
with disabilities or long-term or chronic illnesses to attain andmaintain maximum independence and full physical, mental, socialand vocational ability;
eliminate coercive practices in all sectors of health, including in
gynaecology, psychiatry, mental health care services and services for
persons with psychosocial disabilities.

Ensure non-discriminatory access to health services
and the underlying determinants of health for all
●

●

●
●

proactively remove existing barriers to inclusive and nondiscriminatory access to health with a view to safeguarding
effectively the health rights of all persons, including those belonging
to marginalised or disadvantaged groups;
ensure that health services are gender sensitive and respond to thebroad range of factors that affect women’s and men’s health;extend protections against age discrimination to the health sector;
provide initial and ongoing human rights and non-discrimination
training to all medical, care and administrative staff and incorporate
mandatory courses into relevant university and other professional
curricula;

Page 10 - Protecting the right to health●

ensure that monitoring and evaluation processes collectdisaggregated data with multiple stratifiers (including age, gender,
sexual orientation, gender identity and sex characteristics, disability,
geographic location and socio-economic background) in line with
European data protection safeguards, and conduct qualitative
surveys to identify and understand health service coverage gaps.

Ensure that decision-making processes prioritise
broad participation and empowerment●●●

strengthen broad participation in health and social policy related
decision-making processes to ensure that all relevant stakeholders at
local, regional and national level are effectively consulted, including
in particular national human rights structures (NHRSs) and relevant
civil society representatives;
develop systematic processes and outreach channels to engage withrepresentatives of marginalised communities with a view to ensuringthat their specific views, concerns and interests are effectively
considered in decisions affecting them and to redressing existing
structural inequalities in their access to health care;take immediate steps to implement fully the participation rightsof persons with disabilities, as enshrined in the Convention on the
Rights of Persons with Disabilities.

Institutionalise transparency and accountability
processes throughout the policy cycle
●

●

●

●

strengthen and protect space for civil society organisations and
NHRSs such as ombudspersons, equality bodies, and human rights
commissions, to enable them to provide effective oversight over
government decision-making and monitor policy implementation;
ensure that NHRSs are endowed with sufficiently broad mandates
and the expertise and stable funding needed to cover social andeconomic rights effectively;
implement robust monitoring and accountability processes thatstrengthen the rule of law, deliver redress for human rights violations
and ensure timely, necessary policy adjustments;
ensure effective evaluation and monitoring of progress on humanrights commitments by funding adequate systems for the collectionof disaggregated data and ensuring that transparency is secured at
all levels of governance and throughout the health system.

The Commissioner's recommendations - Page 11

Enhance commitments to respect and protect therights of the health and social care workforce●●●

take immediate measures, including through education and training,to guarantee the safety of health and social care workers in theworkplace and create adequate working conditions;take all necessary measures to ensure that all members of the healthand social care workforce are treated with appropriate levels of
dignity and respect, including in terms of their contractual situation,
income security and fair compensation;
implement measures to increase diversity across the health and social
care workforce and ensure that gender disparities are eliminated.

Promote access to essential medicines for all
●

●

●

●

invest in bio-medical and pharmaceutical research that is genderinclusive and evidence-based and adequately addresses the healthneeds of the whole population throughout their lives;
engage with all relevant stakeholders, including pharmaceuticalcompanies, to increase transparency around the process ofdeveloping and bringing to the market new medicines and vaccinesthat are cost-efficient and based on the needs of patients rather thanprofit;engage in collaborative forums and processes, including within theCouncil of Europe Committee on Bioethics, to facilitate the exchange
of information and jointly promote effective responses to global
health challenges, including anti-microbial resistance and equitableglobal distribution of medical products and vaccines;
take effective steps to protect secure supply chains for the productionof essential medicines and medical products to ensure that they areavailable to the population at all times.

Ensure access to accurate, up-to-date healthinformation for all●●

strengthen information transparency and trust by engaging in
open, evidence-based communication and dialogue, including withrespect to remaining data gaps and ongoing research;promote health literacy through initiatives in formal and non-formal
education settings, providing a plurality of independent, evidencebased information related to health promotion, including preventive
campaigns, information on healthy lifestyles and nutrition, andcomprehensive sexuality education;

Page 12 - Protecting the right to health●●

ensure that health information is readily available to the whole
population and presented in a variety of accessible formats andlanguages;
provide regulatory oversight of health information to ensure that it isaccurate, impartial and communicated in neutral language.

Ensure adequate levels of public financing to deliver
the right to health for all●●●commit to safeguarding appropriate financial support for the healthand social care sectors as austerity impacts on the resilience andinclusiveness of health care undermining access to health rights for
all and leading to higher costs in the long term;
ensure that public funding of health care systems promotes universal
access to primary health care by responding to population level dataon existing affordability obstacles to access to preventive, curativeand promotive physical and mental health care services;
engage in participatory, rights-based budgeting that covers a broadcross-section of society.

Ensure a comprehensive, coherent approach to healthand social policy making
●

●

●

●

implement measures to promote national, regional and international
health commitments to reducing health inequality by adopting a
Health in All Policies approach to systematically ensuring that public
policies across sectors are coherent;
integrate the economic, social, environmental and governancedimensions of health at all stages of policy making to avoid harmful
health effects and align with broader social protection efforts;
address fragmented social protection systems and build consensus
between health and other social programmes by engaging in intersectoral dialogue with diverse partners on issues including the
reduction of unemployment, supporting renewable, clean energy
schemes and increasing access to affordable housing;
adopt a “One Health” approach in public health preparedness
and global health security, accepting the interactions between
animals, humans and the environment as integral factors in disease
prevention, detection and response, and strengthen national andinternational efforts to protect the ecosystems that underpin human,
animal and environmental health.

The Commissioner's recommendations - Page 13

Lead efforts to promote international solidarity andmultilateral approaches to health governance
●

●

●

●

pursue solidarity and international co-operation, including in
generation of scientific knowledge of benefit to humankind, tostrengthen health systems’ resilience;commit to and strengthen multilateral leadership to address global
health challenges by supporting an empowered and accountable
World Health Organisation;
provide continued support for ongoing efforts to reform andstrengthen the International Health Regulations with a view toensuring their responsiveness to future health emergencies;
participate in and contribute to international co-operation anddevelopment assistance programmes that promote human rights forall.

Page 14 - Protecting the right to healthChapter 1

Standards and principles on
the right to healthThe COVID-19 pandemic has challenged European and international
commitments on human rights including the right to health with
unprecedented speed and intensity, testing the resilience of healthsystems in all Council of Europe member states. Most member states have
responded with emergency measures restricting freedom of movement,such as hard and soft “lock-downs” or stay-at-home requirements.13
Such measures may be necessary to prevent health care systems frombecoming overwhelmed and slow down virus transmission, but they also
have a significant impact on access to essential services, including healthcare, education and social services, and on the economy.14 COVID-19
has highlighted the interconnected nature of rights and showcased thefundamental nature of the right to health as a precondition for accessing
and enjoying other human rights.
Resilient health systems contribute to the right to health and individualand collective health security by reducing the vulnerability of societies tohealth threats that spread across national borders.15 They are robust andadaptable, able to adjust to shocks, respond and reorganise, and to ensurethat they maintain their ability to protect human life and produce good
health outcomes for all, even during a public health crisis.16 International
and European frameworks related to building resilient health systems focus
on enhancing preparedness and response capacity prior to an emergency
and on strengthening health systems after an emergency. Health system
resilience requires co-operation, communication and solidarity acrosscountries and international organisations,17 as provided for in European andinternational human rights treaties, the International Health Regulations(IHR) and the Sustainable Development Goals (SDGs).
This Chapter presents the most relevant standards and principles forinclusive and resilient health care systems, as set out in universal andEuropean human rights and health security treaties.

Page 15

1.1 The international legal framework for the right tohealth and health security
1.1.1 Universal human rights instruments
The 1946 WHO proclaims that “the enjoyment of the highest attainable
standard of health is one of the fundamental rights of every human being
without distinction of race, religion, political belief, economic or social
condition.”18 Health is defined expansively as “a state of complete physical,
mental and social well-being and not merely the absence of disease or
infirmity.” Article 25 of the 1948 Universal Declaration of Human Rights(UDHR),19 which asserts universal values and lists the human rights that all
people are entitled to, establishes a universal commitment to health rights.
The International Covenant on Economic Social and Cultural Rights
In 1966, two legally binding Covenants were adopted, the International
Covenant on Economic, Social and Cultural Rights (ICESCR) and theInternational Covenant on Civil and Political Rights (ICCPR). All Council ofEurope member states are parties to these two universal human rights
treaties and committed to promoting the rights listed in them. Echoing the
WHO Constitution, Article 12 of the ICESCR asserts a right “to the enjoymentof the highest attainable standard of physical and mental health” (the rightto health). Article 12-2(c) contains a clear obligation for states to takemeasures to prepare for and address epidemic diseases, like COVID-19.20
General Comment 14 on the right to healthGeneral Comment 14, adopted by the United Nations Committee on
Economic, Social and Cultural Rights (UN Committee), clarifies that states’commitments include the obligations to respect, to protect and to fulfil theright to health.21 It specifies that the right to health is an inclusive rightthat contains two key components: health care and the underlying social,environmental, economic and commercial determinants of health.22 Statescommit to taking steps to ensure non-discriminatory access to quality
health care systems and the full range of the underlying determinants or
preconditions of health. Progress is measured by assessing the extent towhich they move forward on those overlapping commitments. The UN
Committee further specified that states have “minimum core obligations”
to ensure satisfaction of minimum essential levels of social and economic
rights for all, which are non-derogable.23 The concept of minimum coreobligations is especially important during a crisis like the COVID-19
pandemic as it establishes a minimum standard below which no government
should fall, even when resources are scarce.24 Inquiries have been launched
Page 16 - Protecting the right to healthin several European states as to the extent to which these standards havebeen adhered to and what improvements should be made.25
Specialised United Nations human rights conventions
Specialised UN human rights treaties have subsequently emphasised andelaborated on the unique and often overlooked health needs of women,children and persons with disabilities.26 Women should be provided
with health services equal to those of men and meeting their uniquehealth needs. As a result, Universal Health Coverage (UHC) packages
include accessible and affordable sexual, reproductive, maternal, newborn, child and adolescent health services. States have also committed
themselves to actively consulting and involving persons with disabilities
and their representative organisations in planning and monitoring theimplementation of measures that affect them.

1.1.2 International health security
The 2005 International Health Regulation is an international healthtreaty that serves as a legal foundation for international health security
measures.27 All WHO members are bound by the IHR and its provisions
governing emergency preparation and responses to the declaration of a
Public Health Emergency of International Concern, such as COVID-19.28
The excess mortality experienced globally and in many Council of Europe
member states over recent months as a result of the pandemic raises
important concerns about the health security measures taken by states.

1.2 The European legal framework for the right tohealth and health security
1.2.1 European human rights instruments
The European human rights framework guarantees a broad range of civil,
political, social and economic rights, including the right to health. While
the European Convention on Human Rights does not specifically guarantee
a right to health, health-related cases have been brought before theEuropean Court of Human Rights and have most frequently been argued
under Article 2 (right to life), Article 3 (right to freedom from cruel, inhumanor degrading treatment), and Article 8 (right to respect for private life).29
For European Union member states, the Charter of Fundamental Rights
establishes the right of access to preventive health care and medical
treatment under the conditions established by national laws and practices.30
The European Pillar of Social Rights adopted in 2017 by the European
Chapter 1 – Standards and principles on the right to health - Page 17

Commission enshrines 20 principles on interconnected determinants ofhealth, including equal opportunities and access to the labour market, fairworking conditions, and social protection and inclusion.31
The European Social Charter (the Charter) and the Revised Charter, the key
regional instruments for the advancement of social and economic rights,
enshrine the right to protection of health (Article 11), the right to social
security (Article 12) and the right to social and medical assistance (Article13). In addition, they safeguard broad protection of other social rights,
including protection against poverty and exclusion (Article 30) and theright to housing (Article 31).32 Implementation of the Charter is overseenby the European Committee of Social Rights (ECSR), which is made up of 15
independent and impartial members and has issued important conclusions
and decisions on member states’ obligations with respect to the rights
enshrined in the Charter, including on the right to health.33 In April 2020,
the ECSR issued a statement of interpretation on the protection of the rightto health in times of pandemic.34
The introduction of a collective complaints procedure by the Additional
Protocol adopted in 1995 (entry into force in 1998) enhances theeffectiveness, speed and impact of the implementation of the Charter byenabling social partners and non-governmental organisations to apply
directly to the ECSR for rulings on possible non-implementation of theCharter by States Parties.35 A number of collective complaints regarding
access to the right to health and social and medical assistance are currently
pending, often in conjunction with Article E (non-discrimination).36
The Charter echoes the WHO Constitution, broadly defining the right tohealth as the “state of complete physical, mental and social well-being andnot merely the absence of disease or disability”. The Charter recognisesthat all rights are interrelated and that progress on the right to healthrequires advances on a wide range of factors that contribute to a healthy
life, including healthy working and environmental conditions and genderequality.
The protection of the human rights of persons deprived of their liberty ismonitored by the Committee for the Prevention of Torture and Inhumanor Degrading Treatment or Punishment (CPT). The CPT, established under
the European Convention against Torture, which guarantees protection
from ill treatment,37 has the broad remit to monitor conditions in all places
where people are deprived of their liberty including prisons, immigration
detention centres, psychiatric hospitals, social care homes and quarantine
zones. It has outlined ten principles to ensure that the health and safety

Page 18 - Protecting the right to healthstandards of all persons deprived of their liberty, and those that work withthem, are respected and protected during the COVID-19 pandemic.38
In recognition of the importance of the social determinants of health(explored in Chapter 4) the Council of Europe has long advocated forenhanced social security protection. In addition to Article 13 of theEuropean Social Charter, which extends the right to urgent social andmedical assistance to all present on a member state territory, documented
or not,39 the European Code of Social Security establishes a higher level ofsocial security protection for Council of Europe member states.40 Creating asocial security model based on social justice, it deems the state responsible
for establishing and maintaining a stable and financially sound social
security system, which guarantees a decent standard of living for those
who cannot earn their own living because of sickness, unemployment,
old age, employment injury, occupational disease, maternity, invalidity, or
death of the breadwinner, going far beyond the model advocated by theInternational Labour Organisation.
The 1997 Oviedo Convention, the only international legally binding
instrument on the protection of human rights in the field of biology andmedicine including biomedical research,41 establishes fundamental
principles applicable to daily medical practice and is often viewed as aEuropean treaty on patient’s rights. It is especially important in the lightof the intense biomedical research required to respond to the COVID-19
pandemic, and the ethical issues related to equity of access to health careraised by its impact on available resources.

1.2.2 European health security commitments
Article 11(3) of the European Social Charter echoes the IHR approach tohealth security, providing that States Parties must demonstrate their ability
to cope with infectious diseases by means of arrangements for reportingand notifying diseases and by taking all the necessary emergency measuresin the event of epidemics.42
Co-operation on research and exchanging information and health dataenhance health systems’ resilience and health security.43 This means thatstates should engage in collaborative forums and processes, such as
the ECSR and the Committee on Bioethics, to facilitate the exchange of
information and jointly promote effective pandemic responses along withother collaborative efforts regarding global health challenges, including
anti-microbial resistance.

Chapter 1 – Standards and principles on the right to health - Page 19

1.3 General human rights principles
International and European human rights instruments enshrine four key
human rights principles that fundamentally underpin access to social andeconomic rights, including the right to health.

1.3.1 Non-discrimination
Non-discrimination is a cross-cutting human rights principle that applies
to all human rights and is an obligation of immediate application. The rightto health does not invoke a judicially enforceable “right to be healthy” butan obligation of member states to provide access to the highest attainable
standard for health. This must of course be provided for all persons undera state’s jurisdiction, irrespective of their age, gender, sexual orientation,
gender identity and sex characteristics, disability, geographic location orsocio-economic background.
Gender can have a major impact on health equality. The different healthstatuses and needs of women and men are not related solely to biologicaldifferences but to the impact of societal gender norms and stereotypes. All
health efforts must therefore be gender-responsive, taking gender norms
and inequalities into account and acting to reduce their harmful effects.
Progress towards gender equality can have a positive impact on the healthof both women and men, ultimately helping to transform norms andstructures that act as barriers to achieving healthy lives and well-being foreverybody.44
It is well-documented that discrimination, whether direct or indirect, canact as a significant barrier to health equity. It can lead to specific groupsof people being systematically disadvantaged in accessing their healthrights owing to factors such as their religion, economic status, ethnic
origin, migration status, age, gender, sexual orientation, gender identity,
sex characteristics, health status or other similar grounds.45 Studies from
Sweden and France also show that perceived discrimination is separately
associated with a tendency to refrain from seeking medical treatment.46
Moreover, discrimination and racism are also known to have a powerful
impact on victims’ mental health.
In many member states, Roma women face long-standing discriminationin accessing quality reproductive health care services.47 Throughout
Europe, discriminatory barriers to health care facilities, goods and related
services are a contributing factor to the lower life expectancy of Romaand Traveller groups.48 Lesbian, gay, bisexual, transgender and intersex(LGBTI) people experience multiple, diverse barriers to accessing healthcare throughout Europe, which exacerbate inequalities and discrimination,
Page 20 - Protecting the right to healthultimately impacting negatively on both their physical and mental health.49
In relation to mental health, research suggests that, in comparison to thegeneral population, LGBTI people are at higher risk of poor mental healthincluding higher rates of suicidal thoughts, anxiety and deliberate self‐harm
stemming from intersecting vulnerabilities and discrimination.50
Disaggregated data on the impact of COVID-19 show that people with
African, Asian and other minority backgrounds are at increased risk ofcontracting and dying of COVID-19 due in part to housing deprivationand high rates of employment in essential public-facing jobs.51 Continued
reports of racially discriminatory attitudes amongst some health care staff
resulting in denial of access to essential services are deeply alarming.52 In
some countries, minority groups, including LGBTI people, undocumented
migrants and Roma, have even been scapegoated by politicians andmembers of authorities as sources of the virus.
Data also show that persons with disabilities as a whole had significantly
worse health outcomes during the pandemic.53 There are also studies
placing long-term unemployed people at an 84% higher risk of developing
complications following a Coronavirus infection.54 Over 95% of COVID-19
deaths in the WHO Europe region occurred among people over 60 yearsof age. When resources including intensive care beds and ventilators were
scarce, some countries limited access based on age.55
The promotion of inclusive and non-discriminatory access to health care
for all must therefore be an absolute priority for Council of Europe member
states and special efforts must be made to be proactive in ensuring that therights of persons belonging to particular groups that face access barriers,
including women, Roma, persons with disabilities, older persons, LGBTI
persons, prisoners, persons with migrant backgrounds or migrants, areeffectively safeguarded.

1.3.2 Participation and empowerment
Participation is another cross-cutting human rights principle that affects
the quality and effectiveness of health policies and programmes and is avital means of addressing any structural problems that impede inclusive
access to health.56 Participatory priority setting, policy design and decision
making helps ensure that national public health strategies and plans ofaction are based on input from a wide range of citizens, researchers andpatients, not just on epidemiology, disease patterns, or arguments of costeffectiveness.57
Where a health problem disproportionately affects members of a vulnerable
or marginalised population, it is vital for them to take part fully in decision
making to ensure that adequate and sustainable solutions are found.
Chapter 1 – Standards and principles on the right to health - Page 21

Meaningful participation by members of the LGBTI community, for instance,in health policy discussions and implementation plans will help ensure thata health system is inclusive and respectful of difference, including duringcrisis situations.58
Patient groups have so far been excluded from European decision making
on COVID-19.59 The COVID-19 response also highlights the importance ofbroad-based gender inclusive participation in health governance, including
during a public health crisis. Despite numerous global and national
commitments, women’s input has been largely absent from COVID-19
decision making. A survey of 115 COVID-19 decision-making and expert task
forces found that a mere 3.5% had gender parity in their membership while
85.2% had a majority of men.60 Emergency public health measures, like
lockdowns, have had unattended human rights consequences, including
an increase in gender based violence (GBV).61 Widespread measurestaken to “shield” and protect older persons, persons with disabilities andothers deemed to be at higher risk of death from COVID-19 have led totheir increased social isolation, which is strongly associated with anxiety,depression, self-harm and suicide throughout the course of people’s lives.62
These examples highlight the importance of ensuring that relevant
decision-making processes provide effective and systematic opportunities
for the participation of those that are most affected by resulting policies
and measures, as prescribed by the CRPD and required by the Committeeof Ministers Recommendation on the promotion of human rights of older
persons.63

1.3.3 Progressive realisation and non-retrogression
Not all countries have the means to provide access to the highest-quality
health care, and the right to health does not provide an immediate, universal
entitlement to the best available health care system in the world.64 Instead,states have committed themselves to realising the right to health for all ina progressive manner, including through the development of an effective
health care system. As a result, economic constraints will affect the scope ofthe health and related social services that are offered by any given country,
but there is a reasonable expectation that access to care and services will
gradually become better and more inclusive, rather than the opposite.
During a pandemic, states must therefore be particularly mindful of the
impact that their choices will have on groups with heightened vulnerabilities
and on other persons, including their families in particular, who shoulder
the heaviest burden in the event of institutional shortcomings.65

Page 22 - Protecting the right to health1.3.4 Accountability and transparency
Accountability, as an ongoing process that is broader than judicial
accountability, is a core human rights principle that underpins progress on
inclusive and resilient health systems. Accountability mechanisms can play a
key role in addressing discrimination and help drive forward the protection
and implementation of the policy measures required to advance the right tohealth. As part of European efforts to advance right to health commitments,
the 53 member states of the WHO European Region launched the European
Health Equity Status Report (HESR) Initiative in 2019. It works to collect andanalyse disaggregated data on health and the underlying determinants ofhealth, which help to expose shortcomings and inform health and social
policy processes.66
Unfortunately, health care systems have been and continue to be spaces
where serious and irreversible human rights violations take place, including
forced sterilisations or coercive practices in psychiatry, which must be
eliminated.67 It is crucial to establish full accountability in these cases inorder to foster trust in the system and ensure that such practices are notrepeated. European monitoring mechanisms, including the CPT, play animportant role in drawing attention to human rights violations and offering
ways to address them. In many countries, prisoners and refugees, asylum
seekers and migrants continue to live in poor detention conditions incramped, overcrowded cells with poor access to quality health services
and high rates of infectious and chronic diseases, including tuberculosis,
diabetes and HIV, highlighting the urgent need for increased attention to
the health and human rights of detainees and relevant staff.68
Corruption is a substantial barrier to health care access. According to OECDestimates, 45 percent of global citizens believe that the health sector
in their country is corrupt or very corrupt.69 Corruption can take various
forms, including unofficial payments to a health professional to avoid being
placed on a long waiting list for an operation or simply a consultation. Low
salaries for health professionals, combined with a lack of ethics training,
non-transparent systems of financing by the national health system andunderfunded clinics, can create fertile ground for bribery,70 contributing
to inequality in access to health care adversely affecting those who lacksufficient means and potentially having a different impact on men andwomen.71 Research suggests that countries with high levels of corruption
are less able to provide health care for their citizens and are least equipped
to handle crises.72 The COVID-19 crisis has particularly increased corruption
risks in the health sector, owing to surges in the immediate need for medical
supplies and the simplification of procurement rules, overcrowded medical
facilities and overburdened medical staff. The Council of Europe’s Group ofStates against Corruption (GRECO) has published guidelines addressed to
Chapter 1 – Standards and principles on the right to health - Page 23

its 50 member states to help prevent corruption in the context of the healthemergency.73
Overall, COVID-19 has highlighted the importance of transparent decision
making and accountability in numerous areas that have impacted on healthand society, from lockdown measures to public spending. Older people havesuffered disproportionately during the COVID-19 crisis and accountability
for the consequences of the failure to fulfil the positive obligations related
to protecting the right to health and life of older persons and care facility
workers is being pursued through legal action in several countries includingFrance, Italy and Spain.74
In addition, public procurement failings in numerous countries haveunderscored the importance of exercising oversight to ensure that legally
mandated processes are followed.75 While emergency-related adaptations
to procurement processes may be necessary in some circumstances, theyrequire close scrutiny to ensure lawfulness.76

Page 24 - Protecting the right to healthChapter 2

Key partners for co-operationIn their effort to ensure and promote access to the highest attainable
standard of health for all, health authorities depend on close cooperation with important human rights bodies who raise awarenessand trust in society, advise national authorities, ensure that measures
are proportionate vis-à-vis their impact on other rights and provide lowthreshold complaints avenues for individuals.

2.1 Civil Society
Civil society organisations (CSOs) play multiple key roles in ensuring that
individuals and communities understand their rights and seek redress forhuman rights violations occurring within health systems.
CSOs advocate on behalf of individuals and help ensure that the interestsof all affected groups are considered when health policies are being
devised. Involving women’s rights organisations which represent the viewsof survivors of gender-based violence, for instance, will help ensure that
effective protective and preventive contingency measures are put in placeand communicated widely ahead of further lockdown processes.77 During
the COVID-19 crisis, CSOs have continued to advocate for the rights of those
whose voices often go unheard, like undocumented migrants.78
CSOs also assist individuals and groups, including those who are
marginalised or disadvantaged, to ensure that their rights are respected,
protected and fulfilled through judicial and other accountability processes.
As representatives of directly affected groups who see the impacts ofdiverse rules and measures on the ground, members of civil society can also
be drivers for inter-disciplinary research and outreach that can enhance theeffectiveness and sustainability of health strategies.
In the United Kingdom, for example, CSOs have highlighted thedisproportionate impact of COVID-19 on certain groups, including thegovernment’s handling of the situation of older persons in care homes.79
Concerns from civil society also provided impetus for a parliamentary
Page 25

inquiry into the impact of COVID-19 on the access of, among others, persons
with disabilities to health care services.80 As regards the latter group, it was
revealed later that two thirds of COVID-19 deaths in the first half of March
2020 were persons with disabilities.

2.2 National Human Rights Structures (NHRSs)
NHRSs such as ombudsmen institutions, national human rights
institutions, human rights commissions and equality bodies are essential
in the protection and promotion of the right to health. As statutory andindependent advocates of human rights and equality, they are key inensuring human rights-compliant responses to health matters, including
public health crises, and help ensure that comprehensive approaches
towards human rights commitments drive the development of inclusive
health care policies.
NHRSs can take an active role in assessing policies and budgets according
to human rights standards, such as by engaging in human rights impact
assessments and monitoring the implementation of health-related
measures. As accessible, low-threshold human rights complaints bodies,
they also help individuals in making their concerns heard and facilitate
constructive dialogue between civil society and the relevant authorities
working towards the attainment of better health outcomes for all. NHRSs
also embed participation and accountability into the health policy process,including through formal co-operation with regional mechanisms , including
ENHRI (European Network of European Human Rights Institutions).
NHRSs have denounced the discriminatory impacts of COVID-19 response
measures and have called on governments to address structural inequalities
and respect their human rights commitments towards all.81 In the midstof the crisis, NHRSs in Europe have continued their important monitoring
work and publicised the impacts on people’s rights to health, housing,education, labour and social protection, giving advice to policymakers
and informing the public about their rights.82 The UK Equality and Human
Rights Commission was explicitly acknowledged as a major contributor to
the above-mentioned parliamentary inquiry into the unequal impact of the
COVID-19 pandemic on certain groups.
Equality bodies have called for a continued focus on the human rights
principles of equality and non-discrimination and the importance ofprotecting the human rights of disadvantaged and marginalised groupsof people who have often been hit hardest by the crisis.83 This work
demonstrates that NHRSs can inform national and regional responses to
COVID-19, building a bridge between national, regional and international
Page 26 - Protecting the right to healthhuman rights protection systems. Member states should strengthen
the effectiveness and independence of NHRSs in line with the European
Commission against Racism and Intolerance (ECRI) General Policy
Recommendation No. 2 on Equality Bodies, the updated Recommendationof the Committee of Ministers on the development of the Ombudsman
institution, and the upcoming Recommendation on National Human Rights
Institutions, so that they are empowered to perform their critical role insafeguarding a comprehensive approach to the right to health, including intimes of crisis.84 It is particularly important that national authorities consult
NHRSs on policy and legislative developments related to the right to healthand that they implement their recommendations promptly and thoroughly.

2.3 Parliaments
National parliaments enable the right to health through their legislative
work and their provision of democratic oversight over government action.
The European Parliament has not only issued reports and recommendations
on diverse health-related topics but has also conducted several surveys on
European citizens’ opinions regarding measures taken in response to thehealth crisis.85
National parliaments work with CSOs and NHRSs to ensure that policy andprogramme development take rights commitments forward. Additionally,as part of their obligations under international and European human rights
treaties, they are required to engage in periodic reporting on their progress.
At European level the Parliamentary Assembly of the Council of Europe(PACE) plays an important and multi-faceted role in promoting rights byengaging in dialogue with international organisations, governments,
national parliaments and civil society. Its wide-ranging powers include
conducting investigations into human rights violations and drafting
recommendations that help to set priorities across the Council of Europe
region and beyond.86
Already in 2016, PACE adopted a Resolution on the handling of publichealth crises, calling on all stakeholders to co-operate closely tostrengthen international emergency preparedness, with an empowered,well-governed and accountable WHO at its apex and efficient, equitable
and resilient national health systems at its foundation.87 PACE has been
particularly active during the COVID-19 pandemic, highlighting the impactof the pandemic on a wide range of human rights and engaging withWHO to ensure that parliamentarians bring their skills and influence to the
COVID-19 response.88

Chapter 2 - Key partners for co-operation - Page 27

2.4 The Sustainable Development Goals (SDGs)
The SDG commitments link the Council of Europe and national parliaments
to the broad range of global goals enshrined in the UN’s 2030 Agenda oninternational co-operation and the realisation of social and economic rights
for all.89 The SDG Framework includes extensive multi-annual monitoring
and accountability processes that transcend national frameworks andencourage international co-operation on cross-border challenges.
The third SDG, which is to ensure healthy lives and promote well-being for
all at all ages, includes universal health coverage (UHC), considering it to
be one of a number of inter-related and necessary components. The SDG
monitoring framework, which all Council of Europe member states reporton, helps to drive accountability for UHC by setting targets and indicatorsand establishing regular monitoring, evaluation and reporting.
Council of Europe member states reiterated their commitment towards
achieving UHC in the 2019 UHC Declaration. This asserts that mental
health and well-being are essential components of UHC and stresses theimportance of strong and resilient health care systems as a prerequisite toreach all people and ensure pandemic preparedness. 90

Page 28 - Protecting the right to healthChapter 3

Building inclusive and resilient
health care systems for all

Realising the right to health for all requires the development of
inclusive and resilient health care systems. Health care systems
consist of “all public and private organisations, institutions andresources mandated to improve, restore or maintain health.”91 The essential
components of good quality public health and health care systems are longdefined, and comprise: high-quality health service delivery; a skilled healthworkforce; health financing; access to essential medicines and vaccines;
health research and information systems; and leadership and good
governance.92 These six inter-connected constituent parts must function
together within the political and institutional framework of a country todeliver a health care system that is effective, inclusive and resilient.

3.1 High-quality health service delivery
A health system should deliver affordable, accessible, high-quality healthservices to all, where and when needed.
Access to care is a key aspect of the fundamental right to health. Yet,inequalities in access to health care are growing in the Council of Europe
member states due to financial, geographical and language barriers,
corruption, socio-economic inequalities, certain migration and security
policies, and the economic crisis of 2008 and ensuing austerity measures,
which had repercussions on health systems.93 Despite extensive efforts
to promote universal health coverage, health inequities among groupsof people remain either the same or have worsened over the past ten to
fifteen years in many of the 53 countries in the WHO EURO region.94

3.1.1 Affordability
Universal health coverage signifies that the entire population is covered for
a comprehensive range of health care benefits.
Gaps in public health care coverage or differences in benefits lead toPage 29

out-of-pocket payments and result in affordability problems for some. These
inequalities lead to a phenomenon of non-recourse or delayed recourse tocare which can have disastrous implications for both individual and publichealth and lead in the long term to an increase in health expenditure. In
many states, mental health care, family-planning services or dental careare excluded from universal health packages. Out-of-pocket payments
also have a gendered impact on men’s prevention and treatment-seeking
behaviours as evidence shows a strong correlation between a higher levelof payments for health services and men’s premature mortality from cardiovascular diseases.95 In countries where financial protection is relatively
weak, unforeseen health spending is mainly driven by out-of-pocket
payments for outpatient medicines. This undermines equity because thehealth financing structure shifts costs to poor people and regular users ofhealth care, including people with chronic health conditions.96 User fees
also encourage inefficient use of health services as people delay preventive
and promotive care.
States should therefore strive to ensure that the range of services offeredby various health providers is comparable for all people, including a mix of
hospital care, outpatient primary and specialist care, and pharmaceuticalproducts. As the European population ages and chronic diseases
have increased, new and more expensive treatments have become
necessary. Expanding primary health care ensures that care is deliveredin the community and at an early stage, helping to provide affordable,
comprehensive and continuous care to all individuals throughout theirlives, from prevention and treatment to rehabilitation and palliative care.97

3.1.2 Accessibility
The geographic isolation of many regions and the spatial and housing
segregation affecting some groups, including the Roma population, canundermine the accessibility of physical and mental health care services.
For persons with reduced mobility, health centres and hospitals must havefunctioning elevators or ramps to allow for equal access.
In meeting their obligations under the CRPD, Council of Europe member
states must take steps to ensure that people with disabilities have accessto a full range of community support services.98 Across Europe, too manystates continue to rely on long-term residential care institutions to housepersons with disabilities. The lack of access to a range of appropriate care
options, including care in the community, is unacceptable and a longstanding violation of human rights and international law as enshrined in
Article 19 of the CRPD, including the obligation to provide for “the equal
right of all persons with disabilities to live in the community, with choices
equal to others.”
Page 30 - Protecting the right to health

The COVID-19 pandemic has exposed and magnified the existing biases
that act as health care access barriers for persons with disabilities who areplaced in institutions. 99 For example, persons with disabilities in Romania
who contracted COVID-19 in institutional settings were quarantined
instead of being hospitalised, which was not the case for those without
disabilities.100 Human rights violations like these have highlighted
the importance of ending long-term institutional care and increasing
investment in community-based services.101
Many persons with disabilities enjoy healthy lives and having a disability
does not by itself put someone at higher risk of contracting or dying fromCOVID-19. But many have specific underlying conditions that increase therisk of COVID-19 being more dangerous for them. During the COVID-19
crisis, legal, social, economic and environmental constraints haveundermined the dignity and human rights of persons with disabilities andhave prevented them from accessing high-quality preventive services andcurative care. These obstacles expose them to a greater risk of contracting
COVID-19, resulting in direct discrimination and a violation of the right tohealth and potentially the right to life.102 The COVID-19 pandemic should
be a lesson to all of us that these standards are not just aspirational ideals:
failure to implement them leads to suffering and loss of life, which could
and should have been avoided or alleviated.103
Undue waiting times for preventive health services also present barriers toaccessibility of health care and contribute to health inequity in Europe.104
COVID-19 has further exacerbated the situation of premature and increased
mortality and morbidity due to foregone, delayed or interrupted treatment
for diseases such as cancer and diabetes, as well as disruption to preventive
screening services.105
The ECSR has underlined that it is contrary to the Charter for any “legislationor practice” to deny entitlement to medical assistance to foreign nationals
within the territory of a State Party, “even if they are there illegally”.106 Nonnationals, especially if undocumented, are at greater risk of contracting
infectious diseases due to multiple intersecting risk factors, including lackof access to housing and preventive health care and poor nutrition.107
During the COVID-19 crisis some states have taken positive measures toguarantee human rights, including health rights, to all.108

3.1.3 High-quality care
A 2018 WHO review of adults with psychosocial and intellectual disabilities
living in institutions in the European region found regular deficiencies
with regard to human rights commitments at national, regional and global
levels.109 For example, the individual autonomy of residents in some
Chapter 3- Building inclusive and resilient health care systems for all - Page 31

institutions was not respected and deficiencies in other key health-systembuilding blocks, including health information, essential medicines andstaffing, also undermined the accessibility, availability and quality of healthcare.110 Residents were poorly informed of their treatment options andwere not able to challenge decisions. The study also found that essential
psychotropic medication had run out in numerous facilities and thatshortages of staff, including mental health professionals, were affecting
quality of care. A CPT report of December 2020 found that the persistentlack of adequately trained staff in psychiatric and social care institutions ina member state had led to regular ill-treatment of patients and the misuseof restraint mechanisms.111
The dangerous increase in long-term care for older persons in Europe mustalso be addressed as a priority.112 It runs counter to the quality requirementof devising health and social systems that are people-centred and lifecycle sensitive. In April 2020, WHO Europe reported on the large number ofdeaths in long-term care facilities, in particular those for older persons.113
The continued neglect of the situation and a lack of preparedness within
the long-term care sector has contributed to older persons suffering moredeaths during the COVID-19 pandemic than any other group.114
Adequate access to pain relief treatment is crucial to high-quality healthcare. Despite the existence of inexpensive and effective pain relief
medicines, tens of millions of people in the world continue to suffer frommoderate to severe pain each year without treatment owing to a varietyof reasons, including failure to set up functioning drug supply systems or
policies on pain treatment and palliative care, poor training of healthcare
workers, unnecessarily restrictive drug control regulations and practices,and the inflated cost of pain treatment.115
The COVID-19 pandemic has had a marked impact on respect for andaccess to sexual and reproductive health rights (SRHR) and services, which
are an essential component of women’s human rights and help to foster
gender equality.116 Several states have prevented women from having acompanion of their choice attend childbirth, thus denying women theirrights at this time, while other states have been able to develop new
approaches that respect women’s rights while maintaining COVID-19 safety
protocols, demonstrating that the pandemic can provide opportunities
for innovation that improve access to health services, thereby enhancing
resilience.117

Page 32 - Protecting the right to health3.2 Skilled health workforce
Council of Europe member states have committed themselves to ensuring
the availability of a well-financed skilled workforce, including health service
providers and health management and support workers in both the public
and private sector. Health workers are key to strengthening people-centred
health systems, increasing public health capacity and ensuring emergency
preparedness, surveillance and response.118
Despite these workforce-related commitments, continued underinvestment and undervaluing of the health workforce have underminedthe capacity of health service delivery, leaving some countries ill-equipped
to deal with the spike in demand for health care driven by COVID-19
because of factors including the resulting “brain-drain” of qualified staff insome Council of Europe member states and an over-reliance on migrant
workers in others. Respect for the rights of every worker to a safe andhealthy working environment applies to the public and private sector andremains a fundamental right also during a health emergency. The COVID-19
pandemic has exposed health and social workers to diverse work safety
challenges including shortages in the personal protective equipment(PPE) that is vital to prevent the virus from spreading to and from healthand social care workers. Especially during the first months of the pandemic,
people living in psychiatric institutions and their care-givers were exposed
to major shortages of PPE and masks, increasing their health risks.119 These
PPE shortages also exposed persons with disabilities and their personal
assistants to increased health risks.
Attention to and investment in salaries and training to ensure the necessary
skills-mix and supply of health workers is crucial. While there is no standard
for the optimal composition of a health workforce, employment in thehealth and care workforce has become unattractive in many Council ofEurope member states due to disproportionately low wages, long working
hours and insufficient efforts to reduce stress and improve work-life balance.
Health workforce shortages have threatened workplace safety as thenecessary quarantining of health workers exposed to COVID-19 has placedeven more pressure on qualified health staff. Responding to the extreme
demands of the COVID-19 crisis within the context of existing shortagesof staff and resources or routinely operating at maximum capacity will
exacerbate existing gaps in access to care and undermine the quality of the
response.120
The extra workload and high death toll from COVID-19 has placed anenormous strain on the physical and mental health of health and social
workers. Some states have provided emotional, financial and practicalsupport to protect health workers’ mental health and wellbeing andChapter 3- Building inclusive and resilient health care systems for all - Page 33

enable them to do their job during the crisis.121 For example, Armenia,
Latvia and North Macedonia have paid bonuses to health care workers
and many countries have expanded child care options. The recognition of
their vital role highlights the need for ongoing respect for their important
contribution through commensurate pay and continued investment toensure robust staffing levels. The issue of labour segregation and the overrepresentation of women in low-paid care jobs must also be addressed.122
The challenges posed by COVID-19 provide an opportunity for innovationand the transformation of medical, health and social care curricula.
Improvements and reforms should be pursued in consultation with abroad range of health workforce representatives. An increase in the use ofinnovative digital or telehealth solutions could help to address some of thehealth systems’ capacity issues, such as workforce shortages, which haveaffected the availability of quality primary and preventive care, including
antenatal care. Germany and Italy have adjusted their maternal healthcare provision, including scaling up the use of telehealth where possible,
and increasing the quantity and scope of co-ordination meetings to share
information.123
Across Europe, persons belonging to minority groups, including LGBTI
persons, persons with disabilities, Roma, migrants and sex workers
have reported discriminatory, negative attitudes when accessing healthservices, resulting in significantly diminished health outcomes.124 This may
be due to social stigma based on bias and prejudice among health care
workers and is often due to insufficient training and knowledge among
health staff. Human rights and non-discrimination education should be
included in medical and health care curricula, as should discussion of LGBTI
issues. Such material should be developed in consultation with workforce
representatives and those from concerned groups. Changes to medical
curricula and health workforce training and awareness raising can help
health workers to be sensitive to and respectful of difference. It is essentialthat LGBTI identities are not pathologised or their bodies medicalised bymembers of the health workforce.125

3.3 Health financing
Without proper and accountable fund allocation, health systems will notmeet individual and collective health needs. Council of Europe member
states finance and organise their public health care systems in different
ways. No matter the system, all states have committed to advancing UHC
through a health financing system that funds quality health care for all.126
This commitment requires that sufficient public funding, drawn fromgeneral taxation and/or compulsory health insurance contributions, isPage 34 - Protecting the right to healthallocated to the health system to meet the health needs of the population.
The right to health applies regardless as to whether a health care system
is publicly or privately financed.127 Most states have a mix of publicly
funded statutory health insurance schemes and private health insurance.
Yet, private provision of health services does not change the state’srole as the ultimate guarantor of the right to health for all. While private
health insurance schemes play a different role in each country’s systemand have been shown to expand individual choice, they have also
been shown to contribute to unequal access and fail to contain costs orincrease efficiency.128 States must adopt solid regulatory frameworks andeffective monitoring of private insurance schemes to detect and eliminate
exclusionary practices such as only enrolling wealthy, low-risk individuals,
which may lead to health equality gaps. To protect the right to health, states
must ensure through appropriate regulatory and enforcement measuresthat both private and public health care and insurance providers facilitate
access to quality health care on a non-discriminatory basis.
Following the 2008 financial crisis, many European states enacted austerity
measures, reducing public health financing, which contributed to gaps inhealth service coverage.129 Clear evidence exists that budget reductions inprimary care and public health spending adversely affect health outcomes,
including life expectancy.130
Austerity-related measures, like the introduction of user payments for basic
services, have undermined primary health care in many member states,
and weakened the foundations of health care systems.131 In Spain, forinstance, austerity measures which had been widely opposed by healthprofessionals were reported to have led to increases in malnutrition andmental health issues, and in a perceived deterioration in the quality ofcare and outcomes.132 Austerity strongly affects inclusivity, hitting themarginalised and vulnerable hardest, with those on lower or fixed incomes,
including older persons, children and persons with disabilities, suffering themost. In Sweden, austerity measures, including reductions in government
services and tax cuts, are associated with the high percentage (45%) of
COVID-19 related deaths of older persons in residential facilities and thelack of intensive care units during the first half of 2020.133 Short-term costsavings such as reducing the number of staff or stock of medicines and PPE
may have important long-term consequences on health systems’ resilience.
Sustained and long-term public investment in the various components of
the health system, including the work force, is crucial for health systems’
inclusivity.134
Collecting disaggregated data on the impact of health financing will allow
countries to identify how and where funding and investment decisions
Chapter 3- Building inclusive and resilient health care systems for all - Page 35

can be used to lessen gaps in health service accessibility. Health ministries
need to work with health economists to identify the investment needs forinclusive, efficient and effective health systems to close health equity gaps
and increase the resilience of health care systems in the mid- to long-term.
In the aftermath of the pandemic we should not repeat the mistakes of theprevious economic crisis by reducing health system capacity.

3.4 Access to essential medicines and vaccines
Providing access to essential medicines for all is a core obligation under
the right to health and should form part of national UHC packages. The
pharmaceutical industry has played an indisputable role in this context byinvesting massively in research and development for new medicines. While
it remains a key player in the health field, concerns have been expressed inrecent years as to the significant upsurge in the price of medicines, resulting
in particularly exorbitant prices for cancer and hepatitis C treatments.135
As a result, public health systems are faced with constant cost increases inthis area, jeopardising their ability to fulfil their role. In order to ensure theviability of health systems and the accessibility of affordable and innovative
medicines in the long term, member states should strengthen their cooperation with and support for WHO in its efforts to increase transparency
in terms of the real costs of pharmaceutical research and development, andto put forward alternatives to the patent-based pharmaceutical innovationand production models.
To provide access to quality medicines for all, medical research should also
be gender inclusive. In the past, women were excluded from most clinicalpharmaceutical trials because of the perception of potential risks related
to childbearing. Consequently, most drugs currently in use were approved
based on clinical trials conducted on men.136 The European Institute for
Gender Equality is pushing for greater investment in medical researchand health services that address the impact of both sex and gender on
differences in the health of women and men.137 Some member states still
set a minimum age for entitlement to certain medicines, including hormone
therapy for transgender people.138
The COVID-19 crisis has revealed the importance of protecting supply
chains for essential medical goods, including medicines and equipment.
In the early months of the pandemic, shortages of key health supplies,
including diagnostic tests and ventilators, contributed to unnecessary
deaths in many countries. As viral pandemics take hold in a population,
variants occur as part of the virus’ evolution creating further strain on thehealth system. Stopping transmission, through testing and vaccines, blocks
the opportunity for viral mutation.139 Disruptions in supply chains have
Page 36 - Protecting the right to healthalso resulted in shortages of other essential medicines and treatments andprevented women from accessing sexual and reproductive health rights,
including emergency contraception.140 Interruptions in healthcare fortransgender and intersex people have also been reported.141
The roll-out of the COVID-19 vaccine across Europe raises ethical andlogistical issues that will test the inclusivity and resilience of health systems.
Ethical discussions about which groups of people are prioritised for thevaccine must be transparent and inclusive.142 Strategies should be put inplace to avoid inequalities in access due to logistical and administrative
barriers, such as fees for vaccinations and risks of manipulations of thesystem. These strategies should further be adapted to the needs of persons
who are systematically disadvantaged in accessing healthcare. Effective
distribution planning also requires engagement with numerous non-healthsector partners and cross-border co-operation to ensure fair and equitablevaccine distribution at global level, which is an essential prerequisite forrecovery. Reports of "vaccine nationalism", in which wealthier states secure
the available vaccine stock, leaving others unable to vaccinate even theirmost vulnerable populations, are deeply alarming.143 Initiatives aimed at
the creation of global risk-sharing mechanisms for pooled procurement andequitable distribution of COVID-19 vaccines should be supported as they
ensure fair access for all countries, rich or poor, to effective immunisation.144

3.5 Health research, information and communication
A well-functioning health research and information system is vital toensuring that health authorities and other stakeholders have up-todate information with which to assess their policies and improve theperformance of the health care system. Systems for monitoring andcollection of disaggregated data on health should be designed to be
forward-looking and help identify emerging gaps or relevant shifts indemography. The impact of ageing on demand and access to health careservices, for instance, will be an increasingly important challenge acrossEurope requiring excellent, inter-disciplinary health research and data.145
Monitoring the availability of different health services is also vital where
it comes to identifying access and coverage problems. It should cover
data such as the percentage of the population facing limits on access tohealth care due to distance and transportation issues or the availability ofeducation materials in culturally diverse and accessible formats. It should
also include tracking of waiting times for preventive, promotive or curative
services.146 States should collect data, in line with European data protection
safeguards, relating to multiple stratifiers, including age, gender, sexual
orientation, gender identity and sex characteristics, disability, geographic
Chapter 3- Building inclusive and resilient health care systems for all - Page 37

location and socio-economic background, and conduct qualitative surveys
to understand coverage gaps and health workforce shortages. Healthresearch and information systems also play a vital role in emergency
preparedness planning. Sustained investments in health research andinformation should help to ensure that Council of Europe member states are
better prepared for future health emergencies. It is also necessary to widely
share the benefits of scientific research to ensure that emerging treatment
options to non-communicable diseases become globally accessible.
COVID-19 has highlighted the importance of building trust in scientificresearch and public policy through well-conceived, adaptable healthcommunication policies that ensure that new scientific knowledge
is communicated rapidly, transparently and accurately in accessible
formats.147 Especially in crisis situations, when public outreach is vital,
restrictions on free access to information or a tendency to dwell on past
mistakes or remaining uncertainties or issue broad and unsubstantiatedwarnings instead of allaying public concerns are more likely to erode
trust and solidarity, thus undermining the efficiency of crisis-response
measures. The COVID-19 “infodemic” has demonstrated that transparent
communication is crucial for the public to understand the situation, makeinformed decisions, recognise disinformation and limit rumours. In a jointstatement, UN institutions have called on "member states to engage andlisten to their communities" as they develop their national action plans andto "empower communities to" develop solutions and resilience against misand disinformation.148
In the same vein, the impact of preventive public health programmessuch as mass cancer screening or childhood vaccination campaigns isundermined if health communication and education are not prioritised.149
Teaching health literacy in schools, through accessible and age-appropriate
formats, also helps to raise public awareness about the importance of healthpromotion activities, leading to empowerment in health decision making
from an early age on.
Accessing life-saving information on COVID-19 has been a challenge forsome persons with disabilities.150 States need to ensure that information
is developed rapidly for all, including in sign language, braille and easyto-read versions. Countries should also ensure that health information ismade readily available in regional and minority languages so that the entire
population is informed promptly and helped to adopt the appropriate
promotive and preventive measures.151

Page 38 - Protecting the right to health3.6 Leadership and good governance
The COVID-19 pandemic has demonstrated powerfully the importance ofeffective governance. In their analysis of the most important lessons to belearnt for health system resilience from the pandemic, experts have pointed
out that leadership and good governance are central.152 Local and regional
authorities in particular have been on the front line in containing the spreadof COVID-19 and mitigating the impact of the pandemic on society.
Good governance and leadership are integral to all the other building blocksof health systems, including the wide-ranging processes by which statesdeliver on their legal and policy commitments. While the strategic use ofhealth information and research is a core element of the leadership andgovernance function, effective governance also involves engagement withand regulation of private sector stakeholders, both profit and non-profit.
In most countries, the Ministry of Health has the regulatory and leadershiprole for health sector governance, which may be shared with other national
ministries and local government at decentralised levels.
An inclusive and resilient health care system, which builds on universal
coverage and reaches disadvantaged people, is ready to respond effectively
to public health emergencies. Emergency preparedness requires inbuilt
governance mechanisms that support a continuous process of planning,
implementing, monitoring and revising national and sub-national
pandemic preparedness and response plans. Systems that are preparedcan cope better with sudden upsurges in demand, thus saving lives andpotentially lessening the collateral impact on society.153
Strong leadership is also required to withstand the pressure to cut
emergency preparedness funding during economic crises. In the 2019 UHC
Declaration, political leaders undertook to “enhance emergency healthpreparedness and response systems, as well as strengthen capacities atnational, regional and international levels, including to mitigate the impactsof climate change and natural disasters on health”.154
Solidarity and co-operation are key features of good governance. Global
solidarity has been driving research efforts for a COVID-19 vaccine and it
will be especially important to ensure continued funding and distribution
throughout the world. The support of Council of Europe member states for
efforts to manufacture, purchase and distribute vaccines globally will be agood indicator of European commitment towards global solidarity and arecognition of the fact that the vaccine must be available everywhere foreveryone to be safe.155
Lastly, good governance requires a “Health in All Polices” approach to public
policy, grounded in holistic, rights-based approaches. While restrictive
Chapter 3- Building inclusive and resilient health care systems for all - Page 39

measures have affected everyone’s enjoyment of human rights, the rights
of some groups of people, including persons with disabilities, older persons,children and migrants, have proven to be much more vulnerable to theimpact of COVID-19-related lock-down measures.156 The accumulation of
the social, economic and health consequences of lockdown measures havecompelled governments to think carefully about more targeted responses,
through which some restrictions can be relaxed without allowing infections
to grow exponentially. The prolonged closure of schools, for instance, hasbeen shown to lead to undue social and economic costs in the short-, midand long-term.157 In addition to learning from the past, good governancerequires us to look forward and do more to address the currently known
health risks. This includes identifying and fighting climate change as adriver of emerging health threats, enhancing international co-ordination atregional and international level in support of a “One Health” approach, andstrengthening multilateral leadership.158

Page 40 - Protecting the right to healthChapter 4

The essential social
determinants of healthIn addition to the presence of inclusive and resilient health care systems,
extensive research has identified four social determinants that are
essential for creating and sustaining suitable conditions for the rightto health for all: income security and social protection; adequate living
conditions; education; and decent labour and employment conditions.
These underlying conditions are interdependent and must be addressed
comprehensively to contribute to inclusive and resilient health caresystems and good individual and population-level health outcomes. The
social determinants discussed below are often exacerbated by existing
stigmatisation and discrimination, making certain groups particularly
vulnerable, including Roma, LGBTI people, older persons, migrants andothers.

4.1 Income security and social protection
Income security and social protection gaps are the main problem most
associated with health equity gaps in the WHO EURO region. 35-46% of
self-reported health inequities in health, mental health and life satisfaction
relate back to them.159 The correlation between low income levels andpoor health has been long established, with evidence making it clear thatconcerted efforts in the social security sphere are required to improve healthoutcomes for all.160 The 1990 revised European Code of Social Security
commits states to making progress in many aspects of social protection,
including pensions, unemployment and invalidity benefits.161
Insecurity and lack of control over income have powerful effects on health.
The lower people are in the social hierarchy of industrialised nations, themore common are continued anxiety and stress, which can lead to poor
health and premature death.162 While average life expectancy across the
WHO European region of 52 countries has increased overall, significant
health inequities remain between social groups, with women’s life
Page 41expectancy reduced by 7 years and men’s by up to 15 years if they findthemselves among the most socio-economically disadvantaged groups. It
is also deeply worrying that health gaps between socio-economic groups
increase with age.163 Alarmingly, the COVID-19 pandemic has demonstrated
a direct link between poverty and increased mortality as a result of theinfection.164
Over the past two decades, many workers have seen their employment
conditions deteriorate, often with insufficient social protection guarantees.
The increase in insecure contracts, such as zero hour contracts, andemployment policies that encourage the replacement of employee
contracts with bogus self-employment contracts are two developmentsthat have increased economic insecurity, contrary to the objectives of theEuropean Social Charter and the European Code of Social Security.165 The
COVID-19 crisis has highlighted the consequences of these measures inmany countries and serves as a wake-up call for Council of Europe member
states to ratify European instruments in the fields of social rights and social
security, such as the revised Charter, its collective complaints procedureand the European Code of Social Security.
It is also vital to understand and address the gendered dimension ofincome security and social protection to improve health outcomes for
all, throughout people’s lives. Both the gender pay-gap and the factthat women are more likely to work part-time and in less-economicallyvalued sectors like primary education and care professions, contributeto a gender pension gap and income insecurity and poverty in later life.
The ECSR has found violations of the right to equal pay and the right toequal opportunities in the workplace in 14 out of 15 countries applying theEuropean Social Charter’s collective complaints procedure, demonstrating
the potential of this mechanism where it comes to promoting social rights,
including the right to health.166

4.2 Living conditions
Living conditions, which include housing provision, fuel deprivation,
environmental conditions, such as water and air quality or access to green
spaces, and unsafe neighbourhoods, are associated with between 22 and
30% of health inequities identified in self-reported health, mental healthand life satisfaction data.167 The Commissioner for Human Rights has
highlighted the importance of housing, including the need for long-term
solutions for homeless people, as a key means of promoting the right tohealth.168

Page 42 - Protecting the right to healthResearch shows that poor housing and indoor environments cause orcontribute to many preventable diseases and injuries, such as respiratory,
nervous system and cardiovascular diseases and cancer. A degraded urban
environment, with air and noise pollution and lack of mobility options, also
poses health risks. A French study showed that disproportionately highcoronavirus infection rates in certain neighbourhoods were mainly the
result of crowded and substandard housing situations, where it is often
impossible to implement sanitary measures properly due to a lack of cleanwater and sanitation.169 The impact of the COVID-19 crisis on incomes has
further exacerbated the affordable housing problem in many countries,
thus highlighting the need for fresh thinking in this area and further efforts
to honour commitments under Article 31 of the European Social Charter
guaranteeing the right to housing, which is integral to delivering the rightto health. WHO’s health equity status report of 2019 argued that the mostcost-effective means of closing the health divide is increased investment inhousing and community amenities.170
Across Europe, feeling unsafe in one’s neighbourhood and fear of crime orviolence contribute to mental health problems, especially among women.171
There is also growing evidence that hazardous environments have a direct
detrimental effect on human health, with some estimates finding that theenvironment accounts for almost 20% of all deaths in the WHO European
Region.172 More than 9 out of 10 people worldwide breathe polluted air,which contributes to a third of all deaths by stroke, cardiovascular andrespiratory diseases. The European Environment Agency estimates thatpolluted air causes almost half a million premature deaths each year in theEuropean Union alone, and WHO says it decreases every European’s life
expectancy by almost an entire year.173
Human health is therefore intimately linked to the state of the naturalenvironment. The sustainable and urgent protection of the ecosystems
which underpin human, animal and environmental health is a key worldwide
challenge, which Europe should play a leading role in addressing, throughsteps including support for UN efforts to advance formal recognitionof the human right to a healthy environment,174 participation in the UN
Framework Convention on Climate Change process, and ratification of
the Aarhus Convention on Access to Information, Public Participation in
Decision-Making and Access to Justice in Environmental Matters, whichis the first international treaty to recognise “the right of every person ofpresent and future generations to live in an environment adequate to his
or her health and being”. Within Europe and beyond, the human rights
and health rights of the marginalised are disproportionately affected byenvironmental degradation and the climate emergency. Addressing these
problems requires European and global co-operation.
Chapter 4 - The essential social determinants of health - Page 43

4.3 Education
Even in places where health care is guaranteed, people with limited
education tend to be sicker. Higher education is more likely to lead tohealth-promoting benefits such as higher wages, paid leave and early
retirement options, while people with less education are more likely towork in high-risk occupations with fewer benefits. This means that building
genuinely inclusive education systems to guarantee the right of all children
to education without discrimination is also an important health-enhancing
measure. The Commissioner for Human Rights has called for urgent steps
to end school segregation in all its forms, which continues to particularly
affect Roma children, children with disabilities, children with a migrantbackground and other children encountering problems because of theirsocial or personal circumstances (such as children living in institutions andchildren in the juvenile justice system).175
Research shows that building social and human capital through education,social cohesion and trust empowers individuals and communities toincrease control over life and health.176 Education in particular has beenshown to offer positive lifelong health effects, not only through increased
employment opportunities and income but also through better living
conditions, confidence levels and literacy, including health literacy.177 Lifelong learning is also of great value, with research showing that adult learning
can have positive effects on life satisfaction, mental health and changes inhealth-supporting behaviour such as giving up smoking, adopting active
lifestyles and healthy eating. The Commissioner for Human Rights has
highlighted the importance of comprehensive sexuality education for all
children, especially girls.178
A health-related programme in Greece focusing on the improvement ofRoma social inclusion offers an example of how otherwise marginalisedcommunities can be empowered by using education as an innovative
approach to improving health.179 It included Roma mediators who had
expert knowledge of Romani language and culture and who worked
closely with Roma communities, alerting them to the significance of healthpromotion, preventive care and vaccination.
Recent research suggests that the COVID-19 pandemic is having particularly
adverse implications for the mental health of children and adolescents, due
chiefly to the experience of disruption from their daily routine and social
support structures as a result of school closures.180

Page 44 - Protecting the right to health4.4 Employment and working conditions
Employment has clear social, psychological and financial benefits which
improve health. Beyond the material and status-related rewards, paid
work also influences individuals’ social integration, prestige and senseof meaning. For men, long-term unemployment is a predictor of more
frequent heavy drinking. This gendered impact of unemployment also
contributes to men having an increased risk of cardio-vascular disease andengaging in behaviours which contribute to health risks, such as accidents,
crime, and violence. Overall, persons with disabilities have much lower
levels of employment than the general population across Europe owing
to multiple obstacles to participation in the labour market, including lackof accessibility, prejudice regarding their competence, discrimination andthe unwillingness of employers to make reasonable accommodation in theworkplace.181
An important issue from the health perspective is not only whether a person
is employed or unemployed and what their contractual circumstances are,but also the working conditions themselves. Workers may be exposed topotentially health-harming physical and psychosocial stressors, including
exploitative or dangerous conditions, the key factor being excessive
working hours.182 These can cause occupational diseases or exacerbate
other health problems.
Health and social care workers, cleaners, agricultural workers, those
employed in food production factories and many others have been
providing essential services during the COVID-19 pandemic and been
exposed to significant risks to themselves and their families. Implementing
adequate health and safety measures in these sectors and promoting
supportive working environments is key to ensuring the health and wellbeing of workers and to helping them cope in these challenging times.
Sex workers face significant risks of physical and sexual violence andcrime along with extortion and coercive police measures. Despite theirincreased health care needs, they are confronted with important obstacles
to securing their right to health due to stigma and marginalisation.183
Protecting workers is particularly challenging with respect to non-standard
forms of employment and in the informal economy, where adequate
labour and social protection are often missing. In addition, many of theseprecarious workers are young or come from groups facing multiple layersof discrimination and stigma at work and in society, such as migrants.184
The COVID-19 crisis has disproportionately affected women’s employment
and working conditions. Not only do women make up the majority ofhealth and social care professionals and vendors, but women and girls have
Chapter 4 - The essential social determinants of health - Page 45

also taken on extra, unpaid work at home, including care for school-age
children and older and sick family members. It is vitally important that thepossible longer-term effects of the pandemic on women’s working lives isaddressed in post-COVID-19 planning.

Page 46 - Protecting the right to healthEndnotes
1.

The official name of the virus as agreed by the International Committee on Taxonomy
of Virus is severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

2.

As per the statistics provided by the Johns Hopkins Corona Research Centre.

3.

See the thematic page of the Office of the Commissioner for Human Rights, particularly
the Human Rights Comment “Learning from the pandemic to better fulfil the right tohealth”.

4.

The World Health Organisation (WHO) defines health inequities as systematic
inequalities in the health status of different population groups which can be addressed
through the right mix of government policies. See 10 Facts on Health Inequities andTheir Causes, February 2017.

5.

WHO “Healthy, Prosperous lives for all: the European Health Equity Status Report”,
2019.

6.

Abrams, E., and Szeflerhe, S. “COVID-19 and the impact of social determinants ofhealth”, May 2020.

7.

Abimbola S, Topp SM. “Adaptation with robustness: the case for clarity on the use of“resilience” in health systems and global health”, February 2018.

8.

See Commissioner for Human Rights, Statement “Lessons to be drawn from the ravagesof the COVID-19 pandemic in long-term care facilities”, May 2020.

9.

See Article 19 of the CRPD adopted by the United Nations General Assembly on
24 January, 2006.

10. See Resolution 2329 (2020) of the Parliamentary Assembly of the Council of Europe(PACE), “Lessons for the future for an effective and rights-based response to the
COVID-19 pandemic”, June 2020.
11. WHO developed the six building blocks of a health care system which serve as a usefulframework for their evaluation and assessment, January 2007.
12. Hanefeld, J., Reeves, A., Brown, C., Östlin, P. “Achieving health equity: democracy
matters”, November 2019.
13. Several Council of Europe member states submitted notifications of derogation fromthe European Convention on Human Rights.
14. The European Centre for Economic and Policy Analysis and Affairs. “The Impact of
Covid-19 on Schools in Europe”, June 2020
15. WHO Bulletin, Kutzin, J. and Sparkes, S., “Health systems strengthening, universal
health coverage, health security and resilience”, 2016.
16. See Endnote 7.
17. See Council of Europe, Statement by the Secretary General and “A Council ofcontribution to support member states in addressing health care issues in the context
of the present public health crisis and beyond”, 17 September 2020.
18. See WHO Constitution. All Council of Europe member states are members of
the WHO, 1946.
Page 47

19. See Universal Declaration of Human Rights, 1948.
20. Article 12-2(c) of the ICESCR stipulates that states should take steps necessary for “theprevention, treatment and control of epidemic, endemic, occupational and otherdiseases”.
21. UN Committee on Economic, Social and Cultural Rights, “General Comment No. 14: The
Right to the Highest Attainable Standard of Health”, August 2000.
22. WHO and Office of the United Nations High Commissioner for Human Rights (OHCHR).
Factsheet on the right to health, June 2008.
23. General Comment 14 states that “core obligations” under the right to health include
at least: 1. Ensuring non-discriminatory access to health facilities, goods and services,
especially for vulnerable or marginalised people, 2. Ensuring access to food, basic
shelter, housing, sanitation and water, 3. Providing essential drugs as defined by WHO,
4. Ensuring equitable distribution of all health facilities, goods and services, 5. Adopting
a national public health strategy and plan of action on the basis of epidemiologicalevidence addressing the health concerns of the whole population. See Endnote 21.
24. According to the General Comment, “a State party cannot, under any circumstances
whatsoever, justify its non-compliance with the core obligations”. See Endnote 21.
25. See, for instance, the Fourth Special Report on the public inquiry into the Government’s
response to the Covid-19 pandemic launched in the UK, November 2020, and the firstinvestigative COVID-19 Commission being launched in the Lombardy region of Italy,
October 2020. A Parliamentary Commission of inquiry into the coronavirus crisis was
also established in France in June 2020.
26. See Article 12 of the 1979 Convention on the Elimination of all Forms of Discrimination
against Women (CEDAW), Article 24 of the 1989 Convention on the Rights of the Child(CRC), and Articles 25, 26 and 4.3 of the 2007 Convention on the Right of Persons with
Disabilities (CRPD).
27. Global public health security is defined “as the activities required, both proactive
and reactive, to minimise the danger and impact of acute public health events that
endanger people’s health across geographical regions and international boundaries.”
See WHO, July 2007.
28. On 30 January 2020, WHO declared the novel coronavirus outbreak a public healthemergency of international concern (PHEIC), WHO’s highest level of alarm, requiring allstates to respond in eight core capacities: 1. National legislation, policy and financing.
2. Coordination and national focal point communications. 3. Surveillance. 4. Response.
5. Preparedness 6. Risk communication 7. Human resources 8. Laboratory.
29. European Court of Human Rights. Factsheet on health, October 2020.
30. Article 35 of the Charter of Fundamental Rights establishes: "Everyone has the right ofaccess to preventive health care and the right to benefit from medical treatment under
the conditions established by national laws and practices. A high level of human healthprotection shall be ensured in the definition and implementation of all Union policies
and activities".
31. See Communication establishing a European Pillar of Social Rights of 26 April 2017.
Domain 16 on health proclaims that “Everyone has the right to timely access toaffordable, preventative and curative health care of good quality”.
32. See Council of Europe European Social Charter (ETS 035) and Council of Europe
European Social Charter (Revised) (ETS 163).
33. See the Digest of Conclusions and Decisions of the ECSR, December 2018.
34. See the Statement of interpretation on the protection of the right to health in times ofpandemic, adopted by the ECSR on 22 April 2020.
Page 48 - Protecting the right to health35. See Additional Protocol to the European Social Charter Providing for a System ofCollective Complaints (ETS 158).
36. See Complaints Nos. 173/2018 (International Commission of Jurists (ICJ) and European
Council for Refugees and Exiles (ECRE) v. Greece), 185/2019 (European Roma Rights
Centre (ERRC) v. Belgium) and 195/2020 (European Roma Rights Centre (ERRC) v.
Belgium).
37. Council of Europe European Convention for the Prevention of Torture and Inhuman or
Degrading Treatment or Punishment (ETS 126).
38. The Committee for the Prevention of Torture and Inhuman or Degrading Treatment or
Punishment, Statement of Principles relating to the treatment of persons deprived of
their liberty in the context of the coronavirus disease (COVID-19) pandemic, 2020.
39. ECSR Press briefing elements conclusions 2013/xx-2 Statement of Interpretation of
Article 13, 2013.
40. See Council of Europe European Code of Social Security, ETS No. 139, 1990.
41. See Council of Europe Convention on Human Rights and Biomedicine, ETS No. 164,
1997.
42. Council of Europe, European Social Charter (Revised), ETS 163, 1996.
43. See ECSR Statement of interpretation on the right to protection of health in times ofpandemic, April 2020.
44. See Human Rights Comment “Learning from the pandemic to better fulfil the right tohealth”, 23 April 2020.
45. See European Union Agency for Fundamental Rights and the Council of Europe,
Handbook on European non-discrimination law, 2018.
46. Perceived discrimination is when respondents report that they were treated in a
way that made them feel humiliated, due to ethnicity/race, religion, gender, sexual
orientation, age or disability. See Rivenbark, J.G., Ichou, M. “Discrimination in healthcare as a barrier to care: experiences of socially disadvantaged populations in France
from a nationally representative survey”, 2020, and Wamala S, Merlo J, Boström G, et al.
“Perceived Discrimination, socioeconomic disadvantage and refraining from seeking
medical treatment in Sweden”, 2007.
47. In April 2019, the ESCR held Bulgaria responsible for Roma women’s inferior accessto reproductive healthcare in public hospitals, specifically during pregnancy andchildbirth, finding a violation of Article E in conjunction with Article 11§1 of the Charterwith regard to access to health insurance and health care for Roma women in respect ofmaternity. See also European Roma Rights Centre, 2020. Cause of Action. Reproductive
Rights of Romani Women in Hungary; and Center for Reproductive Rights, Poradňa preobčianske a ľudské práva. Vakeras Zorales – Speaking Out, Roma Women’s Experiencesin Reproductive Health Care in Slovakia, 2017.
48. European Roma Rights Centre “Hidden Health Crisis: A report by the European RomaRights Centre”, 2013.
49. See the baseline report on access to health for LGBTI people included in the European
Commission project Health4LGBTI: Reducing health inequalities experienced by LGBTI,
2018.
50. Sherriff, N, Zeeman, L, McGlynn, N, et al. “Co‐producing knowledge of lesbian, gay,bisexual, trans and intersex (LGBTI) health‐care inequalities via rapid reviews of grey
literature in 27 EU Member States”, 2019.
51. See Human Rights Council “COVID-19, systemic racism and global protests”, 2020.
Report of the Working Group of Experts on People of African Descent. See also Public
Health England “Disparities in the risk and outcomes of COVID-19”, 2020.
Endnotes - Page 49

52. See ENAR Report “COVID-19 impacts on racialised communities”, May 2020.
53. A collective complaint is currently pending with the ECSR (Complaint No. 197/2020(Validity v. Finland)), alleging violations of Articles 11 (right to health), 14 (right tobenefit from social welfare services), 15 (right of persons with disabilities to autonomy)of the Revised Charter, in conjunction with Article E (non-discrimination) as a result of
inappropriate measures to protect the life and health of persons with disabilities during
the pandemic and the adoption of restrictive measures leading to their complete
isolation in institutions with a ban on accepting visits. See also Disability News Service.
“Coronavirus: Call for inquiry and urgent action after “shocking” disability death stats”,
June 2020.
54. See Study on the social dimension of the pandemic, Düsseldorf University, June 2020.
55. Georgantzi, N, “How Covid-19 is Compounding Inequalities against Older Persons”,
Equinet, October 2020.
56. Potts, H and Hunt, PH, “Participation and the right to the highest attainable standard ofhealth.” Human Rights Centre, Colchester, Essex, 2008.
57. See Endnote 21. Paragraph 43f of General Comment 14.
58. PACE, Resolution 2339 (2020). “Upholding human rights in times of crisis andpandemics: gender, equality and non-discrimination”.
59. Casassus, B. “Covid-19: French sidelining of patient associations is a global trend”, 2020.
60. See van Daalen KR, Bajnoczki C, Chowdhury M, et al. “Symptoms of a broken system:
the gender gaps in COVID-19 decision-making”, 2020.
61. PACE, “COVID-19 and violence against women: a holistic response based on thestandards of the Council of Europe Istanbul Convention on preventing and combating
violence against women and domestic violence”, 2020.
62. Hao Yao et al., “Patients with mental health disorders in the COVID-19 epidemic”,
The Lancet Psychiatry, April 2020.
63. Council of Europe. Recommendation CM/Rec(2014)2 of the Committee of Ministers
to member states on the promotion of human rights of older persons. Article 33 (3)of the UNCRPD provides “Civil society, in particular persons with disabilities and theirrepresentative organisations, shall be involved and participate fully in the monitoringprocess.”
64. See Endnote 21, Paragraphs 9 and 47 of General Comment 14.
65. See Endnote 43.
66. See Endnote 5.
67. PACE Resolution 2291 (2019) “Ending coercion in mental health: the need for a humanrights-based approach”. See also Commissioner for Human Rights Issue Paper on
Women’s Sexual and Reproductive Health and Rights in Europe, 2017; and European
Roma Rights Center “Coercive and Cruel”, 2016.
68. Commissioner for Human Rights “COVID-19 pandemic: urgent steps are needed toprotect the rights of prisoners in Europe”, 6 April 2020.
69. OECD (Organisation for Economic Co-operation and Development). “Tackling wastefulspending on health”, highlights. Paris, France, 2017.
70. See “Good governance practices for the protection of human rights”, OHCHR, 2007.
71. See PACE Report 13225 “Equal access to health care” of 7 June 2013.
72. See “Why fighting corruption matters in times of COVID-19”, Transparency International
Corruption Perception Index 2020, Research Analysis, 28 January 2021.
73. See GRECO guidelines, 15 April 2020.
Page 50 - Protecting the right to health74. See Endnote 8.
75. Europol. Press release “Corona crimes: suspect behind €6 million face masks and handsanitisers scam arrested thanks to international police cooperation”, 6 April 2020.
76. British Medical Journal, McKee, M. “England’s PPE procurement failures must never
happen again”, July 2020.
77. Council of Europe Gender Equality website “Women’s rights and the COVID-19
pandemic” provides extensive information about the Council of Europe institutional
response (such as official documents and statements) as well as on the initiatives byother international organisations and NGOs.
78. The Platform for Undocumented Migrants gathers statements and resources about
the COVID-19 pandemic and its impact on migrant communities, and on civil society
organisations working with migrants.
79. See Amnesty International Care Homes Report, 4 October 2020.
80. House of Commons Women and Equalities Committee, UK Impact, “Unequal impact?
Coronavirus, disability and access to services”, December 2020.
81. See the European Network of National Human Rights Institutions on COVID-19 andHuman Rights.
82. See “Protecting economic and social rights during the pandemic: How have NHRIs
responded?”. For instance, the Georgian Public Defender monitored the situation ofpeople living in social housing and their access to water, and communicated with thelocal authorities to address these issues. The French National Consultative Commission
on Human Rights analysed the impact of the nationwide “stay-at-home” order on theright to education and asked the government to guarantee that all children can accesseducation.
83. See EQUINET’s reaction to the equality challenges posed by the COVID-19 pandemic,
5 February 2021.
84. ECRI General Policy Recommendation Nr 2 on Equality Bodies to combat racism andintolerance at the national level (2018); Recommendation CM/Rec(2019)6 of theCommittee of Ministers to member states on the development of the Ombudsman
Institution. The Council of Europe Steering Committee on Human Rights (CDDH) is
preparing a new recommendation on the development and strengthening of effective,
pluralist and independent national human rights institutions.
85. See Eurobarometer, 14 July 2020.
86. See the powers of the Council of Europe Parliamentary Assembly.
87. See PACE Resolution 2114 (2016), “The handling of international public-healthemergencies”, 22 April 2016.
88. See remarks of the Director of WHO at the PACE Standing Committee, 26 June 2020.
89. UN, “Transforming Our World: The 2030 Agenda for Sustainable Development”, 2015.
90. UN General Assembly Political declaration of the high-level meeting on universal
health coverage: moving together to build a healthier world , 2019.
91. WHO, “The Tallinn Charter: health systems for health and wealth”, Copenhagen,Regional Office for Europe, 2008.
92. See Endnote 11 on the WHO six building blocks of health care systems, 2007.
93. See PACE Report 13225 “Equal access to health care” of 7 June 2013.
94. See Endnote 5.
95. WHO Regional Office for Europe, “The health and well-being of men in the WHO
European Region: better health through a gender approach”, 2018.
Endnotes - Page 51

96. WHO, “Can people afford to pay for health care? New evidence on financial protectionin Europe”, 2019.
97. See the Astana Declaration: “the future of primary health care?“, 20 October 2018.
98. Commissioner for Human Rights, Issue Paper, “The Right of People with Disabilities toLive Independently and be Included in the Community”, June 2012.
99. Commissioner for Human Rights statement, “Persons with disabilities must not be left
behind in the response to the COVID-19 pandemic”, 2 April 2020.
100. European Network on Independent Living, “Urgent appeal requesting access to
COVID-19 medical treatment in Romania”, June 2020.
101. The Lancet, Moreno C. et al., “How mental health care should change as a consequenceof the COVID-19 pandemic”, July 2020.
102. European Network on Independent Living, the Validity Foundation, the International
Disability Alliance et al., “COVID-19 disability rights monitor”, 2020.
103. See Commissioner for Human Rights statement “States should deliver on theircommitments to persons with disabilities”, 2 December 2020.
104. See Endnote 5.
105. See van Weert, H., “After the first wave: What effects did the COVID-19 measures haveon regular care and how can general practitioners respond to this?”, December 2020.
106. ECSR Complaint No. 14/2003, International Federation of Human Rights Leagues (FIDH)
v. France.
107. ECRI’s General Policy Recommendation No. 16 establishes the need for firewalls
between immigration enforcement and health services to ensure safe access toirregular migrants.
108. Reuters, “Portugal to treat migrants as residents during coronavirus crisis”, March 2020.
109. See WHO Assessment of the quality of institutional care for adults with psychosocial
and intellectual disabilities in the WHO European Region, pages 19-21.
110. See Commissioner for Human Rights Country Report on Slovakia, 2015.
111. See CPT Report on Bulgaria, 2 December 2020.
112. See also the Commissioner for Human Rights’ statement on the International Day ofOlder Persons, 1 October 2020.
113. See Statement to the press by the WHO Regional Director for Europe.
114. See Endnote 8.
115. See BMC Medicine, Lohman, D, Schleifer, R & Amons J, “Access to Pain Treatment as a
Human Right”, 2010.
116. Commissioner for Human Rights statement “Covid-19. Ensure women’s access to sexualand reproductive health and rights”, 7 May 2020.
117. Equinet, Konowrocka, J. “Let’s talk about sexual and reproductive health and rights:
Not fully implemented before COVID-19 & suspended during the pandemic”,
14 September 2020.
118. WHO: “Health 2020. A European policy framework and strategy for the 21st century”,
Copenhagen: WHO Regional Office for Europe, 2013.
119. See Le Monde article “De nombreux patients ne seront plus soignés : le désarroi deshôpitaux psychiatriques face au coronavirus”, 25 March 2020.
120. Thomas, S., A. Sagan, J. Larkin, J. Cylus, J. Figueras and M. Karanikolos, “Strengthening
health system resilience. Key concepts and strategies”. Policy Brief 36. Copenhagen,WHO, 2020.
Page 52 - Protecting the right to health121. See WHO Cross-country analysis, 21 May 2020.
122. Latvia, for instance, has decided to increase the lowest wages of health care workers in
inpatient and outpatient sectors, as well as family doctors and residents by 25%. Someteachers also received a one-time benefit for work performed during the COVID-19
pandemic in January 2021.
123. See WHO News of 30 June 2020.
124. European Public Health Alliance, “Health inequalities: a persistent obstacle for Romainclusion reflection paper on union of equality”, 2020.
125. McGlynn N, Browne K, Sherriff N, et al., “Health care professionals’ assumptions as
barriers to LGBTI health care”, 2020
126. UN General Assembly, Political declaration of the high-level meeting on universal
health coverage, 2019.
127. UN Committee, General Comment No. 3 (1991) “The Committee notes that theundertaking to take steps (...) by all appropriate means including particularly the
adoption of legislative measures neither requires nor precludes any particular form ofgovernment or economic system being used as the vehicle for the steps in question,
provided only that it is democratic and that all human rights are thereby respected.”
128. Wouter, O. and McKee, M., “Private Financing of Health Care in Times of Economic Crisis:a Review of the Evidence”, 2017.
129. See Endnote 5.
130. See WHO, “Review of social determinants and the health divide in the WHO European
Region”. Copenhagen: WHO Regional Office for Europe, 2014.
131. PACE Committee on Social Affairs, Health and Sustainable Development, Report 12633
on Austerity measures – a danger for democracy and social rights, May 2012.
132. See Cervero-Liceras, F., McKee, M. and Legido-Quigley, H. “The effects of the financial
crisis and austerity measures on the Spanish health care system: A qualitative
analysis of health professionals’ perceptions in the region of Valencia“, Health Policy,
January 2015.
133. In December 2020, an independent commission made up of political scientists, crisis
management experts and public health experts in Sweden published its initial report,
criticising the government’s response to the pandemic.
134. High-level Commission on Health Employment and Economic Growth. “Working for
health and growth: investing in the health workforce”. Geneva: WHO, 2016.
135. See PACE Resolution 2071(2015) “Public health and the interests of the pharmaceuticalindustry: how to guarantee the primacy of public health interests?”, September 2015.
136. Zucker, I., Prendergast, B.J., “Sex differences in pharmacokinetics predict adverse drug
reactions in women”, 2020.
137. European Institute for Gender Equality, “Covid and Gender Equality”, 2020.
138. See overview on access to hormone therapy in European Union member states,
Fundamental Rights Agency, 2018.
139. As of late December 2020, several mutations of the COVID-19 virus were detected in
the UK, South Africa and Brazil, where infection rates were particularly high and raisingconcern about the protection vaccines can offer against the variants. See Callaway E.
& Ledford H., “How to redesign COVID vaccines so they protect against variants”, inNature 590, 15-16, 2021.
140. Equinet, Konowrocka, J., “Let’s talk about sexual and reproductive health andrights: Not fully implemented before COVID-19 & suspended during the pandemic”,
14 September 2020.
Endnotes - Page 53

141. See UN Independent Expert on Sexual Orientation and Gender Identity, “Violence
and Discrimination based on Sexual Orientation and Gender Identity during thecoronavirus (COVID-19) disease pandemic”, 28 July 2020; Organisation Intersex
International Europe, “COVID-19: A report on the situation of Intersex People in Europe
and Central Asia”, December 2020.
142. See “COVID-19 and vaccines: Equitable access to vaccination must be ensured”,
Recommendations by the Council of Europe Committee on Bioethics of 22 January
2021.
143. UN Secretary General António Guterres has repeatedly called for COVID vaccines to betreated as a “global public good,” available to everyone, everywhere on the planet. Yet,by September 2020, OXFAM International reported that wealthy nations representing
just 13 percent of the world’s population were reported to have secured 51% of thepromised doses of leading COVID-19 vaccine candidates. In January 2021, the Director
General of the WHO warned of “catastrophic moral failure” because of “me-first”
approaches to COVID-19 vaccine policies that “will only prolong the pandemic, therestrictions needed to contain it, and human and economic suffering”.
144. COVAX, which was launched in April 2020, brings together governments, global healthorganisations, manufacturers, scientists, private sector, civil society and philanthropy,
with the aim of providing innovative and equitable access to COVID-19 vaccines. See
also Covid-19 vaccines: ethical, legal and practical considerations, PACE Resolution
2361 (2021) (Provisional version) of 27 January 2021.
145. See Helen Creighton, “Europe’s Ageing Demography”, 2014.
146. Danish Institute for Human Rights, AAAQ & Sexual and Reproductive Health and Rights.
International Indicators for Availability, Accessibility, Acceptability and Quality, 2017.
147. WHO has been working closely with more than 50 digital companies and social media
platforms, including Facebook, Twitter, LinkedIn, TikTok, Twitch, Snapchat, Pinterest,
Google, Viber, WhatsApp and YouTube, to ensure that science-based health messages
from the organisation or other official sources appear first when people search for
information related to COVID-19.
148. Joint statement by WHO, UN, UNICEF, UNDP, UNESCO, UNAIDS, ITU, UN Global Pulse,and IFRC, “Managing the COVID-19 infodemic: Promoting healthy behaviours andmitigating the harm from misinformation and disinformation”, 2020.
149. In January 2020, WHO reported that Romania, Bosnia and Herzegovina, and Ukraine
remain at high risk of a sustained polio outbreak partly due to insufficient vaccination
coverage. ECDC, “Update on Global Polio Situation“, 2020.
150. Commissioner for Human Rights statement “Persons with disabilities must not be left
behind in the response to the COVID-19 pandemic”, 2 April 2020.
151. Council of Europe statement: “COVID-19 crisis: vital that authorities also communicate
in regional and minority languages”, 30 March 2020.
152. See “COVID-19 and health systems resilience: lessons going forward” Policy Brief
Eurohealth 2/2020.
153. Imperial College, (2020) Report 27. “Adapting hospital capacity to meet changing
demands during the COVID-19 pandemic“
154. UN General Assembly, “Political declaration of the high-level meeting on universal
health coverage: moving together to build a healthier world”, 23 Septembr 2019.
155. Statement by UN Human Rights Experts “Universal access to vaccines is essential for
prevention and containment of COVID-19 around the world” on 9 November 2020.
156. See Council of Europe “Protecting and empowering children during the Covid-19
Page 54 - Protecting the right to healthpandemic”, 2020. See also Fundamental Rights Agency, “Coronavirus pandemic in the
EU – Fundamental rights implications: with a focus on older people”, 2020.
157. See UNESCO and Education International call on governments to consider teachersand school personnel as a priority group in COVID-19 vaccination efforts, UNESCO,
14 December 2020.
158. See also “Lessons for the future for an effective and rights-based response to the
COVID-19 pandemic”, Resolution 2329 (2020) of the Parliamentary Assembly of theCouncil of Europe (PACE) of 26 June 2020.
159. See Endnote 5)160. Forster, T., Kentikelenis, A., Bambra, C., “Health Inequalities in Europe: Setting the Stagefor Progressive Policy Action”, 2019.
161. See Endnote 40.
162. See “Social determinants of health: the solid facts”, edited by R. Wilkinson and
M. Marmot, WHO 2003.
163. See Endnote 44.
164. See WHO Webinar “Inequities in COVID-19 infection and mortality: socioeconomic risk
factors and populations at risk”, 4 November 2020.
165. Bobek, A., Pembroke, S. and Wickham, J., “Living with Uncertainty: Social Implicationsof Precarious Work”, 2018
166. See ECSR News “Right to equal pay: European Committee of Social Rights finds
violations in 14 countries”, 29 June 2020.
167. See Endnote 5.
168. See Endnote 44.
169. See Study by the French National Institute of Health and Medical Research,
9 October 2020.
170. See Endnote 5. In January 2020, the Commissioner for Human Rights highlighted
multiple challenges where it came to guaranteeing the right to affordable housing,including the high rates of housing costs in Bulgaria, Denmark, Germany and Greece.
Housing cost overburden arises when more than 40% of a person’s disposable income
is spent on housing. See Commissioner for Human Rights Comment “The right toaffordable housing: Europe’s neglected duty”, 23 January 2020.
171. Lorenc T, Petticrew M, Whitehead M, Neary D, Clayton S, Wright K, et al. “Fear of crime
and the environment: systematic review of UK qualitative evidence”, May 2013.
172. See WHO overview on “Environment and Health“, 2020.
173. See more information in the Commissioner for Human Rights Comment “Living in aclean environment: a neglected human rights concern for all of us”, 4 June 2019.
174. See “Right to a healthy and sustainable environment report, prepared jointly by
the former Special Rapporteur Mr. John Knox (2012-2018) and the current Special
Rapporteur Mr. David Boyd (2018 – present), OHCHR, July 2018.
175. See Commissioner for Human Rights Position Paper “Fighting School Segregation in
Europe through Inclusive Education”, 2017.
176. Rocco L, Suhrcke M., “Is social capital good for health? A European perspective”,
Copenhagen: WHO Regional Office for Europe, 2012.
177. WHO Regional Office for Europe, “Health 2020: Education and health through the lifecourse“, 2015.
178. See Commissioner for Human Rights, Human Rights Comment “Comprehensive
sexuality education protects children and helps build a safer, inclusive society”,
21 July 2020.
Endnotes - Page 55

179. This ROMED related project was jointly organised by the Greek Government, Council ofEurope and the European Commission.
180. National Centre for Biotechnology Information, “School closures and mental
health concerns for children and adolescents during the COVID-19 pandemic”,
4 September 2020.
181. See for an overview "For a disability-inclusive workforce", PACE Report 14665,
November 2018.
182. See statement of Group of Experts on Action against Trafficking in Human Beings(GRETA) on the special needs and exploitation risks of victims of human trafficking as aresult of COVID, 16 October 2020.
183. See Amnesty International “Research on human rights abuses against sex workers”,
May 2016.
184. See ILO Policy Brief on COVID-19, “Pillar 3: Protecting workers in the workplace”, 2020.

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The Commissioner for Human Rights is an independent and impartial
non-judicial institution established in 1999 by the Council of Europe topromote awareness of and respect for human rights in the member states.
The activities of this institution focus on three major, closely related areas :• country visits and dialogue with national authorities and civil society,• thematic studies and advice on systematic human rights work, and• awareness-raising activities.
The current Commissioner, Dunja Mijatović, took up her functions in
April 2018. She succeeded Nils Muižnieks (2012‑2018), Thomas Hammarberg(2006-2012) and Álvaro Gil-Robles (1999-2006).

www.commissioner.coe.int

ENG

www.coe.int

The Council of Europe is the continent’s leading
human rights organisation. It comprises 47 member
states, 27 of which are members of the European
Union. All Council of Europe member states havesigned up to the European Convention on Human
Rights, a treaty designed to protect human rights,
democracy and the rule of law. The European Courtof Human Rights oversees the implementationof the Convention in the member states.