Explanatory notes:
Indicators on right-to-health features of a health system
21 November 2008
Contents
Contents
Introduction
Annotated Glossary
Abbreviations
Indicators (1-72)
1
Introduction
This document provides detailed definitions; rationale; method of computation; periodicity, disaggregation; comments; and limitations for each of the 72 indicators identified in the report.
Although not comprehensive, these explanatory notes highlight some of the issues relevant to the indicators and data collection.
These notes have been updated and revised at various stages of the project. For instance, although much of this document was written prior to the data collection process (August 2007 – August 2008), it was revised and updated in the light of data collection. The same notes were used for both the global and national data collection but the periodicity and sources identified here only reflect the global data collection. National level sources and periodicity are available in the extended data table available in the web appendix.
We limit comments to those specific to this project and acknowledge that the data sources used for each indicator hold a wealth of other information.
Annotated Glossary
AAAQ: all health services, goods and facilities shall be available, accessible, acceptable and of good quality (AAAQ).[1] The precise nature of these elements will depend on the conditions prevailing in a particular State
Available: functioning public health and health-care facilities, goods and services, as well as programmes, have to be available in sufficient quantity within the State party. The precise nature will vary depending on numerous factors, including the State party’s development level.
Accessible: health facilities, goods and services have to be accessible to everyone without discrimination, within the jurisdiction of the State party. It includes: non-discrimination; physical accessibility; affordability and information accessibility.
Acceptable: all health facilities, goods and services must be respectful of medical ethics and culturally appropriate as well as being designed to respect confidentiality and improve the health status of those concerned.
Good quality: health facilities must be scientifically and medically appropriate and of good quality. This requires skilled medical personnel, scientifically approved and unexpired drugs and hospital equipment, safe and potable, and adequate sanitation.
Accountability: the right to health brings with it the crucial requirement of accessible, transparent and effective mechanisms of monitoring and accountability. Those with right-to-health responsibilities must be held to account in relation to the discharge of their duties, with a view to identifying successes and difficulties; so far as necessary, policy and other adjustments can then be made. Examples of accountability mechanisms are:
1.Judicial, e.g. judicial review of executive acts and omissions
2.Quasi-judicial, e.g. NHRIs (see below), human rights treaty-bodies
3.Administrative, e.g. human rights impact assessment
4.Political, e.g. parliamentary committees
5.Social, e.g. civil society movements
The accountability mechanism should exist at the national, regional (if available) and international levels. Rights-holders are also entitled to effective remedies when duty-bearers have failed to discharge their right to health obligations. These remedies may take the form of restitution, rehabilitation, compensation, satisfaction or guarantees of non-repetition.[2]
Comprehensive national health plan: based on qualitative and quantitative research evidence to reflect and be responsive to national and local health priorities, (health encompasses both physical and mental health care and the underlying determinants of health) of the whole population including the indigenous population. The plan should be developed in a participatory manner. It extends to the public and private sectors as well as to traditional, indigenous and alternative preventive strategies, health practices and medicines. It must have objectives; a clear indication of who is responsible for each objective; timeframes; benchmarks and indicators; reporting procedures; and an evaluation mechanism. Indicators and benchmarks are essential to demonstrate in a transparent manner how the State is planning to progressively take steps to realize an effective and integrated health system, which is accessible to all.
We do not insist on the word ‘plan’. A State might use a different word e.g. strategy or policy (e.g. General Comment No. 14, paragraph 43, uses a different wording; it refers to “a national health policy with detailed plan”). The plan could be a set of separate documents - provided they form one reasonably cohesive package.
Disaggregation: typically data are reported for whole populations or as aggregated data. Aggregated data does not always represent the true status of health of populations. Human rights require that, so far as practical, all relevant data are disaggregated on the prohibited grounds of discrimination. This helps in monitoring the situation of marginal groups, such as women living in poverty, indigenous people, and minorities and so on.
Gross Domestic Product (GDP): the total market value of all the final goods and services produced in an economy during a given time period.[3]
General Comment No. 14 on the right to the highest attainable standard of health: adopted by the Committee on Economic, Social and Cultural Rights (CESCR) in May 2000, provides an authoritative interpretation of contours and contents of the right to the highest attainable standard of health. CESCR is the body which monitors the International Covenant on Economic, Social and Cultural Rights and also publishes its interpretation of the provisions of the Covenant in the form of general comments.
Health: a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (WHO Constitution of 1946). The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, political belief, economic or social condition. The CESCR defines right to the highest attainable standard of health as the right to an effective and integrated health system, encompassing health care and the underlying determinants of health, e.g. access to education, safe water, sanitation and food, which is responsive to national and local priorities, and accessible to all. [4] Please see definition of ‘right to health.’
Health workers: a generic term to include all those developing, delivering, monitoring and evaluating preventive, curative and rehabilitative health ‘plans’ in the private and public health sector. It also includes traditional healers whether or not they have been incorporated into the health system. Pursuant to the obligation to protect, the State has an obligation to ensure that traditional healers are aware of and carry out their responsibilities regarding the right to health.
International Assistance and Cooperation:Health is not just a matter of domestic laws, policies and circumstances. The policies of other States, including in trade and development, as well as the policies of intergovernmental organisations such as the World Bank and the IMF, also have a profound impact on health. The control of infectious diseases, the dissemination of health research and so on has an international dimension. In practice, the realisation of the right to the highest attainable standard of health is dependent upon international assistance and cooperation. The human rights responsibility of international assistance and cooperation is reflected in important international instruments, not least the Charter of the United Nations, the Universal Declaration of Human Rights, International Covenant on Economic, Social and Cultural Rights, Convention on the Rights of the Child and the Declaration on the Right to Development. Moreover, this human rights responsibility resonates with other international commitments, such as Millennium Development Goal 8.
Medicines: active pharmaceutical ingredients, diagnostic tools, vaccines, biopharmaceuticals and other healthcare technologies.
National Human Rights Institution (NHRI): a body whose functions are specifically defined in terms of the promotion and protection of human rights. While no two institutions are exactly the same, a number of similarities can be identified. As a rule, these institutions have on-going, advisory authority in respect to human rights at the national and/or international level. These purposes are pursued either in a general way, through opinions and recommendations, or through the consideration and resolution of complaints submitted by individuals or groups. In some countries, the Constitution will provide for the establishment of a national human rights institution. More often, such institutions are created by legislation or decree. The majority of existing national institutions can be grouped together in two broad categories; "human rights commissions" and "ombudsmen". Another less common, but no less important variety is the "specialised" national institution that functions to protect the rights of a particular vulnerable group such as ethnic and linguistic minorities, indigenous populations, children, refugees or women.[5]
National Health Plan: a broad term used to describe a plan that is responsive to national and local health priorities, encompasses both physical and mental health care, some of the underlying determinants of health and extends to both public and private sectors. We do not insist on the word ‘plan’. A State might use a different word e.g. strategy or policy (e.g. General Comment No. 14, paragraph 43, uses a different wording; it refers to “a national health policy with detailed plan”). The plan could be a set of separate documents - provided they form one reasonably cohesive package.
Official Development Assistance (ODA): net disbursements of loans made on concessional terms (net of repayments of principal) and grants by official agencies of the members of the Development Assistance Committee (DAC), by multilateral institutions and by non-DAC countries to promote economic development and welfare in countries.[6]
Participation: active and informed participation of individuals and communities in decision-making that has a bearing on their health.[7]
Ratification: according to the Vienna Convention on the Law of Treaties, ratification means an international act whereby a State establishes on the international plane its consent to be bound by a treaty.[8]
‘Right to health’ and‘right to the highest attainable standard of health’ are used as convenient abbreviations for the more accurate formulations of the ‘right of everyone to the enjoyment of the highest attainable standard of physical and mental health’. The right to health is a fundamental human right, including freedoms and entitlements. It does not mean ‘a right to be healthy’; the government cannot fully ensure good health as it is influenced by factors which are in whole or in part outside the State’s control, such as individual susceptibility to ill-health and adoption of unhealthy lifestyles. However, the entitlements include the right to an effective and integrated health system, encompassing health care and the underlying determinants of health, e.g. access to education, safe water, sanitation and food, which is responsive to national and local priorities, and accessible, available, acceptable and of good quality to all. Participation by the population in all health-related decision-making at the community, national and international levels is a component of the right to health. The right to the highest attainable standard of health is codified in numerous legally binding international and regional human rights treaties. The right is also enshrined in numerous national constitutions. The right to health, as with all human rights, is linked to other rights, such as right to life and freedom from discrimination.
States have duties to respect, protect and fulfil the right to the highest attainable standard of health. These duties are equally applicable to medical care and the underlying determinants of health. The obligation to respect requires States to refrain from interfering directly or indirectly with the enjoyment of the right to health. The obligation to protect requires States to take measures that prevent third parties from interfering with the right to health. Finally, the obligation to fulfil requires States to adopt appropriate legislative, administrative, budgetary, judicial, promotional and other measures towards the full realisation of the right to health.[9]
Treaty: an international agreement concluded between States in written form and governed by international law. For the purposes of this project ‘treaties’ is used as a generic term embracing all legal instruments binding under international human rights law, regardless of their formal designation (e.g. Covenant, Convention or Optional Protocol).
The key international treaties recognising the right to health are:
International Covenant on Economic, Social and Cultural Rights (ICESCR): adopted in 1966, the Covenant contains some of the most significant international legal provisions concerning economic, social and cultural rights, including rights relating to work in just and favourable conditions, to social protection, to an adequate standard of living, and to the highest attainable standard of physical and mental health.
International Convention on the Elimination of Racial Discrimination (ICERD): adopted in 1965, the Convention provides a definition of racial discrimination in Article 1 and expands on States’ obligations to protect the inalienable human right for all to freedom from racial discrimination.
Convention on the Elimination of Discrimination Against Women (CEDAW): adopted in 1979, the Convention provides a definition of discrimination against women in Article 1 and expands on States’ obligations to protect women against discrimination by public authorities or agents of the State. Importantly, the Convention also holds States responsible for discriminatory acts committed by private individuals or organisations where a State fails to offer protection against such violations or to bring to justice the perpetrators.
Convention on the Rights of the Child (CRC): adopted in 1989, the Convention sets minimum entitlements and freedoms for children that States have the duty to respect, protect and fulfil. These include the right to survival; to develop to the fullest; to protection from harmful influences, abuses and exploitation; and to participate fully in family, cultural and social life. The Convention also sets standards in relation to health care.
Disability Convention (DC): adopted in 2006 but not yet in force, the Convention aims to ensure that persons with disabilities enjoy human rights on an equal basis with others.
Other relevant international treaties, which do not explicitly recognise the right to health, but contain health-related rights and duties are:
International Covenant on Civil and Political Rights (ICCPR): adopted in 1966, the Covenant contains some of the most significant international legal provisions establishing civil and political rights, including the inherent right to life, right to liberty and security of person, rights to freedom of association and expression, and the right to information.
International Labour Organisation Convention 169 on Indigenous and Tribal Peoples (ILO 169): adopted in 1989, the Convention is the foremost international legal policy document on indigenous and tribal peoples; covering the areas of human rights, culture, land, development, education and health.
Treaty-bodies: committees of independent experts that monitor implementation of the core international human rights treaties. They are created in accordance with the provisions of the treaty that they monitor. Treaty-bodies consider State parties’ reports and publish general comments or recommendations interpreting the treaties. Two treaty-bodies regularly referred to in this commentary are the:
Human Rights Committee (HRC): monitors implementation of the ICCPR 1966 and its optional protocols.
Committee on Economic, Social and Cultural Rights (CESCR): monitors implementation of ICESCR 1966.
Underlying Determinants of Health: include access to safe and potable water and adequate sanitation, an adequate supply of safe food, nutrition and housing, healthy occupational and environmental conditions, and access to health-related education and information, including on sexual and reproductive health.Other determinants of health includegender, poverty and social exclusion.
Abbreviations
ACHPR – African Charter on Human and Peoples’ Rights
ACHR – American Convention on Human Rights
ACHPRW - Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa
AIS - Tanzania HIV/Aids Indicator Survey
ARWC – African Charter on the Rights and Welfare of the Child
CCS - Country Cooperation Strategy
CEDAW – Covenant on the Elimination of Discrimination against Women
CEN - Census / Census of Population and Housing
CO2 - Carbon dioxide
CRC – Covenant on the Rights of the Child
CRI - Country Report on Indicator for the Goals
CWD - Cyprus Water Development Department
CWIQ - Core Welfare Indicator Questionnaire Surveys
DC - Convention on the Rights of Persons with Disabilities
DHS - Demographic and Health Survey
DWK - Report on monitoring of drinking water quality 2004, quoted in “Global Water Supply and Sanitation Assessment, European region, WHO 2005”.
EDIAIS -Enterprise Development Impact Assessment Information Service
EMIP - Mauritanie Enquète sur la Mortalite Infantile et le Paludisme
ENE-CEF - Enquete Nationale d’Evaluation des Conditions de vie de l’enfant et de la Femme
ENSM - Encuesta Nacional de Salud Masculina
EPH - Encuesta Permanente de Hogares
EPI - Expanded Programme on Immunisation (cluster survey)
EPSF - l’Enquète sur la Population et la Santè Familiale
ESC – European Social Charter
ESCR - Economic, Social and Cultural Rights
EURO - EUROSTAT (Statistical Office of the European Communities)
FESAL - Encuesta Nacional de salud familiar
FHS - Family Health Survey
DFID - Department for International Development
DTP3 - Diphtheria, Tetanus, Pertussis 3 vaccine
GDP - Gross Domestic Product
GLIN - Global Legal Information Network
HIA - Health Impact Assessment
ICCPR- International Covenant on Civil and Political Rights
ICERD - International Covenant on the Elimination of Racial Discrimination ICESCR - International Covenant on Economic, Social and Cultural Rights
ICPS - Inter-Censal Population Survey
IDA - International Development Association
ILO - International Labour Organisation
JMP - Joint Monitoring Programme
JWWA - Japan Water Works Association
LMCHS - Arab Libyan Maternal and Child Health Survey
LSMS - Living Standards Measurement Study Survey
LSS - Living Standards Survey
MCV - Measles Containing Vaccine
MDG - Millennium Development Goals
MICS - Multiple Indicator Cluster Survey
NBD - National Burden of Disease
NHRI - National Human Rights Institution
OHCHR –Office of the High Commissioner for Human Rights