Conventions, Declarations, resolutions and comments set out the minimum standards that states agree to be bound by. By participating in the international human rights framework, states agree to undertake that constitutions, laws, policies, and budgets reflect these legal obligations and policies are applied towards achieving these minimum standards . However, financing remains within state control.
The World Health Organisation (WHO) states that the right to health  requires governments to generate conditions where everyone is as healthy as possible. This right is found in the Convention on the Rights of the Child, ICESCR, and the Convention on the Elimination of All Forms of Discrimination against Women. It encompasses, provision of medical care and underlying determinants of health .
At the global level, there is a difference between countries’ health financing needs and their current health spending . This can be seen from the differences in the financing gap between high-income countries, middle-income countries and low-income countries. Low-income countries carry 90 % of the world’s health burden, yet only 12 % of global health spending occurs in these countries . In addition, low-income countries account for 12 % of global GDP. There has been little commitment towards bridging the financing gap between the high income and low income countries. Conventional options at the global level reflect the domestic level financing options such as taxation, user fees and insurance, with limited innovation. A set of principles guiding global health financing is overdue.
This section delves into concepts to guide global health financing. Within health this includes: firstly, stating that resources are necessary in order to achieve rights; and secondly, unpacking international co-operation and assistance. Within the financing domain, there is a need to firstly, delineate fiscal legitimacy within the context of health; and secondly, discuss the principles and canons of taxation that could be used to fill in the gap in the global and regional health financing architecture.
Rights Require Resources
In theory, when a state signs an international covenant like the ICESCR that contains the right to health, it takes on the duty to protect, promote and respect the right . This duty has been set out in the commencing clause of the UN Charter , the Tehran Declaration , the Vienna Declaration  and most recently in 2004 by a General Assembly Resolution  through General Comment 31 where it stated at paragraph 5 that the obligations of the Covenant and article 2 are binding on every State Party as a whole and all its branches of government . There was however, no further step taken to concretize its fiscal implications. All declarations avoided mention of finance or resources and instead used immediate or progressive realization. This resulted in states like those in Africa prioritizing rights that fall under immediate realization.
Reference to the issue of resources, especially domestic resources like tax revenue and its allocation was avoided on the grounds of the sovereignty of nations and to allow states to pursue independent domestic economic policies. General Assembly resolutions reaffirmed that states should not interfere in the domestic policies of other countries [39, 41]. It was not until the declaration on the Right to Development that there was finally crystallization of the principle that there was a need for resources and that ideals were no longer enough . This declaration was spearheaded by developing countries including many African states as they recognized the lacuna.
From a fiscal perspective, the absence of a directive on the need for resources meant that ministries of finance ignored it in budgets. However rights that impose duties, responsibilities and obligations on a state by necessity require resources. International treaties could only become more than mere declarations if they would confer fiscal power on bodies whose decisions are legally binding. People, not living in a state having effective government policies supporting rights, would have no remedies and in reality have no legally, fiscally enforceable rights. In finance, legal rights exist in reality when and if they have budgetary support. If the state claims to grant the right to free health for example, this will only take place on the ground if there are adequate resources to build clinics near communities. This conceptual lacuna in the human rights principles that stopped short of stating resources were required has impeded national realization of the right to health as it relies solely on political will.
Unpacking International Assistance and Co-operation
The ICESR went a step further than the ICCPR and stated at article 2(1):
Each state party to the present covenant undertakes to take steps, individually and through international co-operation especially economic and technical, to the maximum of its available resources, with a view to achieving progressively the full realization of the rights recognized in the present Covenant by all appropriate means, including particularly the adoption of legislative measures .
Analysis of the specific term in the article: international assistance and co-operation leads to terms like ‘limitation to resources’ or resource ‘constraints’. These terms are used repeatedly while espousing ‘progressive realization’ of human rights ‘obligations’ . These terms are used by states to delimit and exclude themselves from domestic level human rights obligations, limit and avoid international obligations for assistance and co-operation. For example ODA states have internationally committed to giving 0.7 % of GDP per state, in reality not all states contribute ODA and only four states periodically reached that figure .
The WHO’s objective is the attainment by all peoples of the highest possible level of health and it is mandated with directing and coordinating global health work . This includes partial responsibility for correcting the financial mismatch in health between states. At the global level, realization of the right to health as a membership based organisation would mandate it to make spending decisions based on a majority vote and form a large part of international co-operation and assistance. With the discussions on large-scale tax evasion and avoidance, suggestions of new taxes like the transaction tax, [14, 35] and funds like Pogge’s health impact fund [14, 35] are also being tabled. International co-operation and assistance could assist states in collecting untapped resources and newly created global taxes.
Fiscal Legitimacy in Achieving Health
Increasing resources and spending is not enough to fully realize the right to health. Application of fiscal principles in the implementation practices and policies within international co-operation and assistance is required to ensure fiscal legitimacy. Legitimacy arises out of the confidence of the ruled and fiscal legitimacy arises out of the confidence in the fiscal behaviour of the governing institution of the fiscal resources placed in its trust . Using international co-operation, at the level of states and a governing body like the UN or the WHO that act on states’ behalf there must be similar level of trust.
Firstly, citizens, both individually and as a society (and a state as a collective representative) perceive taxation or other payments as one, a necessary burden to the state (and by extension a governing interstate agency or institution) and two, as having no commensurate benefits or guarantees . The concept of ‘necessary burden’ has resulted in revenue collection disparities in countries, as the relatively large size of the economy is not reflected in the proportionately small amount of tax revenue collected. There are numerous reasons for this, including but not limited to the societal perception of tax as a burden leading to both avoidance and evasion of tax. The effects of both domestic and global policies, which allow inputs of diverse actors as well as poor governance practices, fuel this perception. Domestically all who owe taxes must pay in full and on time or pay penalties and internationally necessary burden requires that states forming the international institution must fulfill their obligations.
Secondly, the perception of poor governance fuels perceptions of the lack of accountability, transparency and responsibility of the state (or international institution) in collection and use of resources by citizens, taxpayers and society. This is commonly referred to as the tax bargain. A distinctly slow and minimal improvement of human well-being in a country, is a reflection of poor governance . High salaries in international institutions can fuel a similar perception.
Thirdly, countries constitutionally guarantee rights or powers to levy tax . The ‘no commensurate benefits’ was softened and ‘burden’ alleviated by social welfare provisions that improve living standards. This fiscal re-distribution policy has not been undertaken, adopted or achieved in many African countries thus the burden is felt strongly. Constituent documents of international institutions are not clear: article 19 of the UN Charter states failure to pay dues results in sanctions after 2 years, although what kind of sanction is implemented remains unclear . There are no limits on measures used except for reference to international standards.
Fourthly, this also affects the development of global/regional health funds and international taxes that target health concerns with a few adjustments. In order for these funds and taxes to be created and continue to exist their responsibility must rest with transparent, accountable and responsible institutions that work effectively and efficiently and make decisions that are fair and just on behalf of those that place money in their control: member states and people of the world. Since money for a health fund would be automatically earmarked for health: the only legitimate spending from this fund can be to improve global health. International fiscal legitimacy in health would allow the collection of resources from willing and compliant states and citizens satisfied with improved health outcomes.
In order to achieve health regionally and globally, it must be clear that rights require resources and health is a shared global responsibility and requires international co-operation and assistance which can only be achieved through a fiscally legitimate process. Simply reaching this point is not enough: how this legitimacy should be achieved and what the principles guiding fiscal legitimacy look like will be discussed next. Within fiscal laws and policies there are settled principles and canons that can provide a guide in collection and spending.
Applying Principles and Canons of Taxation to Health Financing
Almost every country in the world prepares its budget using principles and canons of taxation to achieve fiscal legitimacy. This is reflected in how the state decides: what tax to collect; from whom to collect; in what amount; to whom to grant exemptions; and whether it is fair or economically feasible to collect. The state budget is prepared by economists in ministries of finance who compromise one issue for another usually to collect the most from the wealthy using the overall guiding principle of progressive tax systems before being presented in parliament. There are usually political compromises depending on the strength of the lobbyists, as a result, it will always be sub-optimal . Despite the negotiations, this compromise-based budget hits certain benchmarks of tax principles, as choices must be justified at the legal, economic, social and political levels. In this real world of fiscal decision-making principles allow for the most rational compromise possible based on guiding principles.
The principles/canons in this section discuss the three main economists that developed them: Khaldun, [30, 31] Smith  and Ricardo [30, 31]. This sub-section will set them out to assess how international fiscal health legitimacy could be achieved when reflecting on: existing resources, new forms of tax, global taxes as well as the global and regional health institutions and funds that are being considered for health.
The first canon: justice. No one likes to pay taxes and based on this assumption, Ibn Khaldun argued for low tax rates in order that the incentive to work is not killed and taxes are paid willingly . At the regional and global level this would include small amounts of membership dues to international organisations. For example, global taxes like the carbon tax should have low rates of tax of a small fixed amount. This principle of justice was later supported by David Ricardo and reiterated by Stiglitz  and has since been referred to as the canon of justice. It is an overall principle that ideally should guide all fiscal decision-making.
The second canon: ability to pay. Ibn Khaldun, in discussing taxpayers’ ability to pay, argued that when government is honest and people-friendly, “taxation yields a large revenue from small assessment.”  Smith [30, 31] supported it. It could be separated into the third canon: economy, which recommends that the cost of collecting tax should be the minimum possible for both the government and the taxpayer. This links the physical limits of both the taxpayer to the tax administrative costs of the collector. When referring to examples of new funds like the health impact fund or even the Ebola emergency fund it is important that these funds do not cost more to administer than they receive.
The fourth canon: equality or equity. Smith [30, 31] called it economic justice. At the WHO level it implies that all member countries should be allowed to vote on the projects for financing and that the process cannot and should not be driven by the decisions of the large contributors. This canon would also support the ability to pay argument that more wealthy states should pay more money into communal funds while spending gives states an equal voice. However this limited justice to only issues of economy and equality and not other areas of justice as set out by ibn Khaldun which include social justice as well.
The fifth canon: certainty. Smith argued that taxpayers should not be subjects to the arbitrariness and discretion of the tax officials, which could breed corruption [30, 31]. In the context of WHO financing it would mean that assisting low income countries in meeting their financial needs precludes arbitrary conditionalities. Global and regional health financing would require that membership dues are known in advance, fixed, clear and stable. Domestically revisions are made bianually but global processes take longer to negotiate and inserting formulas in clauses allowing for upward movement by a small percentage after a fixed period or a downward movement based on the growth of the economy may be more reliable.
The sixth canon: convenience  The mode and timing of tax payment should be convenient to the taxpayers. In this case the taxpayer would be member states and the collector would be the fund being set up or health institution being mandated to carry out certain work. The system in place would again reflect collections reflective of state circumstances.
The seventh canon: productivity [30, 31] The tax system should be able to gain enough revenue to avoid deficit financing. Most international institutions and states today work under deficit financing and the use of deficits has resulted in the differences in the debt burden of children.
The eighth canon: flexibility, requires that funds be re-directed when necessary. In case of health emergencies this should be within certain parameters with minimum delay. The ninth canon: simplicity requires that a system should not be complicated, be easy to understand, administer and interpret. To this Stiglitz adds the system should respond easily to changes in economic conditions .
The tenth canon: diversity argued by Stiglitz requires that there should be diverse sources of state income such as government engagement in business and tax. At regional and international level this would be reflective of the current health structure where revenues include memberships that are traditionally sources from the nations (most likely from tax) as well as private donations, which could be in cash or kind without undermining those allowed to make spending decisions .
Stiglitz also adds economic efficiency: the tax should allow for efficient allocation of resources. In the context of health financing in Africa for example, efficiency could mean allocating 15 % of the state budget to health. Coupled with transparency this could result in a tax burden easily ascertainable and politically tailored to what society considers desirable .
Today these principles are balanced off with each other and compromised in the fiscal and political processes leading up to tax decisions at domestic level [5, 28, 46]. In conclusion, this section discussed the absence of resource allocation and fiscal principles in allocations of resources to health globally. It looked into how one could begin to conceptualize international co-operation and development from both a health and a fiscal perspective to obtain and allocate resources to global health. It has then set out the domestic principle of fiscal legitimacy and its constituent tax principles to provide guidance on how one would collect and allocate resources. The next section will discuss health financing policy and practice in place and/or being discussed at the global and African level through the lens of the principles of taxation.