Table 1 Laminated human rights environment with examples from Vermont Case Study

Psychology of the individual

Internalised norms, values, beliefs, interests, desires, sense of self, reflexive thought, habits. Rights exist within our understanding and knowledge of them [40].

On a personal level many decision makers were supportive of the idea of Universal Health Care.

“I saw people die, young people die of preventable diseases, and it all resulted from them not having health insurance. So for me, it was because I look at this as a human right.”

Individual material circumstances

The individual or biographical level, experiences, skills, income, education, occupation, level of human rights/SDOH knowledge, health literacy, experience of human rights fulfilment or absence, individual lifestyle factors. The embodied nature of human rights exercise or violation of rights.

In Vermont approximately 66,000 people (11%) have no health insurance at all; this includes more than 11,000 children.

“.. . the committees heard so many horror stories about. .. the way our current health care system treats people kind of like they’re meat and people driving up huge health care bills, going into bankruptcy because of. .. nothing to do with it, maybe just genetics or an accident. So those were incredibly compelling stories.”

Human face to face interaction

Interpersonal rights involve respecting the others personal space, time and integrity.

Exercise of power - creative, emancipatory and transformative vs destructive, coercive and oppressive [36].

Individuals or small group interactions with stakeholders, decision makers and, communities, interested actors.

The campaign utilised personal stories about how the current health system impacts on lives.

“the ‘Health Care is a Human Right’ campaign really did a great job of getting out and neighbor to neighbor talking to people about health care … And that kind of peer-to-peer outreach I think was helpful in getting kind of the grassroots support.”

Structures and culture

Human rights culture, structural relations, social class, institutions (rules, conventions, norms, values and customs), ideas (human rights, neo-liberalism, social determinants of health, the value of different types of evidence), policy-making frameworks, decision-making processes.

Vermont is a progressive state with a record of being a leader on human rights issues.

Vermont is a relatively small state with a very open and accessible legislature.

Legislators became aware of community members demands for UHC- leading to UHC developing increased political importance.

“there’s sort of a direct line from international law and how the right to health has been interpreted down to the Vermont Workers’ Centre framework, down to the law, to the statute in Act 48.”

“We Vermonters believe that we should take care of our poor and our sick. It doesn’t make financial sense for an insurance company to skim off, you know the easy people to cover and leave the poorest and the sickest for us to cover as a community.”

Society as a whole

Level of enjoyment/fulfilment of human rights/SDOH, the economy, governance, policies, inequalities, politics, laws, level of development, physical environment and resources, access to services, resources.

There were multiple activities beyond the campaign that were supportive of UHC.

Health care policy discourse was influenced by the economic recession.

“One interesting thing that human rights also does is it allows us to become close allies with people who are interested in other human rights issues, whether its unions or migrants rights issues or whatever and it enhances our people power incredibly.”

Geo-historical trajectories

Traditions, colonisation history, past decisions, morphogenic mechanisms, experiences of actors involved, history of activism and resistance.

Rights exist in social structures and history such as colonisation histories [36].

Historical repertoires of power [41]

Vermont has a long history of action around UHC.

“Vermont has been a leader around establishing what some of us called civil rights for same sex couples, legal recognition, and so I think Vermont has been a fertile ground for the concept of health care as a human right also because Vermont has been a leader in establishing and raising the expectations around other types of important issues such as legal recognition.”

Global trends

Global patterns of inequality, transnational organisations, international human rights agreements and rules, climate change, migration, resource distribution, international social actors, international organisations, International civil society organisations

Health care costs is recognised as a serious and increasing problem.

“I consulted around the world on health care for children. And that was Ireland, Northern Ireland, England, Scotland, Norway, France Israel, Australia, Chile. So I really got a chance to see, in all those countries that every one of them had universal health care and in every one of them, the price tag was considerably short. And in almost every one of them the quality of their health care was quite remarkable. “