The right to health as a lens on development

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Chapter 3 Methods

Introduction

The previous chapter outlined the history of aid for health over the past 60 years and concluded that the health needs of people in developing countries have been poorly served. It was argued that when aid donors view health as a development project, the resulting programmes reflect the donors’ political and economic agendas. These agendas do not necessarily reflect the needs of developing countries to meet health rights obligations.
History also revealed changes in global health over the past decade that have resulted in NGOs and GHIs becoming major donors and implementing agencies of health programmes. However, they operate in the absence of appropriate governance structures to coordinate, guide, and monitor their activities. These non-state agencies favour disease-specific aid interventions that threaten to further weaken fragile health systems.
It was proposed that the right to health offers a means of addressing these major issues in global health: namely, resolving the threats imposed by disease specific programmes; introducing transparent accountability for non-state actors and prioritising the health needs of people in developing countries.
In this chapter, I describe the methodology adopted in the thesis. To provide context to the approach taken, I begin with a brief section in which I reflect on the process through which I arrived at the thesis topic and the approach I have used.
I then describe the research methodology. The process was an iterative, step-wise one: first, my reading of the literature informed the development of a rights-based framework. Next, I developed tools to operationalise the framework and then tested these tools for relevance and robustness against case studies set in PNG. After case study testing, the tools were refined into their final state. Table 3.1 shows this process in summary form.

Reflections

I began this research with what could perhaps be described as the intent of finding a holy grail: a tool that could guide international partners through the messy realities and complexities of developing country health systems to design effective and sustainable health programmes. It was, of course, a somewhat ambitious undertaking.
The idea for the research came to me as I observed a workshop in Dili, Timor-Leste, in my capacity as an employee of a health NGO. About 30 health workers from around the country had gathered to discuss and debate (at length) plans for a national eye health strategy. The meeting was inspirational. It was conducted in the local lingua franca, Tetum, of which I do not understand a word. Nonetheless, I was moved by the engagement, enthusiasm, seriousness and verbosity of all who were there. This meeting was in sharp contrast to ones I had attended the previous week in another country, PNG, which were characterised by poor attendance and deafening silences. I was intrigued by these differences, pondered whether they were a reflection of different cultures, or the product of different processes in the development of a health programme in their respective countries.
This experience planted the seed of the idea for this research: why do similar strategies for health programmes have completely different responses and results in different contexts? I wondered whether there were key elements that were essential for any programme to become successful. If so, could a tool be developed which could ‘walk’ programme planners through a process that would ensure those essential steps were not skipped over?
I was guided in this research by the conviction that good health is fundamental to an individual’s enjoyment of life, and his or her capacity to flourish. A child needs to have good health to gain an education; adults need good health to participate in their communities, be that earning a living, working on the land, or bearing and raising children. Health is, therefore, deeply connected to individual, community and state wellbeing. The poor health of the poor, and the marked health inequities within and between countries, are not a natural phenomenon, but are caused by “a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics” (World Health Organization, 2008a, p.35).
Inequalities around access to health care in our world are deeply unjust. But in the face of so much inequality and unfairness, why should health be singled out for special attention? Amartya Sen argued that health is central to our being alive and happy. “But it cannot possibly be all that there is to say in addressing the question. There are further issues that link the opportunities of having good health to some of the basic freedoms of human life” (Sen, 2010, p.viii).
The research that guided this thesis is grounded in the view that health is a basic human right, and it is linked, as Sen suggests, to basic freedoms. It seemed pertinent therefore to explore aid-funded health initiatives from within a human rights context, and to examine the role of aid and development programmes in achieving the right to health.

Literature review
History of aid

I undertook a qualitative literature review to document the history of aid for health throughout the 60-year development era. I tracked the various phases where different approaches to development were adopted. The literature search included New Zealand and Australian government publications on official development assistance, PNG official documentation on aid flows and expenditures, database searches on the history of development, and using the references within all the literature to identify further material (forward and backward searches). OECD and international financial institution statistics and historical data were available from 1975, and these were also used.

Right to health documents

The next stage of the review was undertaken to document the history and significance of the right to health as a human right, in legal terms, in practice, and as a theory of social justice. The right to health is documented in various UN treaties and declarations, in particular the ICESCR, and General Comment 14 (United Nations, 2000b).
The history of the use of the right to health, and its translation into policy and practice was investigated through database searches, and UN and WHO reports. Reports from the UN Special Rapporteur were most instructive. Again forward and backward searches of the references in the literature were the main methods employed.

Right to health as a theory

The literature was searched via Medline and ScienceDirect databases with key words (‘health rights’; ‘theory of health rights’; ‘social justice and health’; ‘ethics and health rights’; ‘international duty and health rights’), followed by backward and forward searches through the references. This process identified leading commentators on health rights as a theory, and on health aid as social justice and ethical duty.

Right to health in practice

The final stage of the literature review aimed to identify research and reports on the practicalities of incorporating right-to-health approaches in development programmes or policies. Keyword searches were used in Medline and ScienceDirect databases, including: ‘health rights’; ‘international health’; ‘health and human rights’; ‘rights-based approach’; ‘health system’; ‘public health’; ‘development’; ‘health programmes’ and ‘programme design’. Relevant references in the resulting articles were also used. UN and WHO reports, academic reports and grey literature were included in the searches, and were major sources of information on the topic.
There were over 200,000 articles that made reference to the right for health, of which about 20,000 related to international health. Special attention was paid to ‘Health and Human Rights: overview’ (S Gruskin & Tarantola, 2008, p.4), and ‘Human Rights Approach to Public Health Policy’ (Tarantola & Gruskin, 2008), and in particular to the journal Health and Human Rights. These publications were instructive as they placed an emphasis on research that had adopted a rights-based approach rather than manuscripts that refer to health rights in an advocacy context, or a secondary issue in the provision of health care. As before, I undertook further searches using the references in these articles.

Developing a rights-based framework

All aspects of the literature review informed the overall right-to-health framework and the subsequent tools to guide the design of an aid-funded health programme. The framework needed to provide a logical and thorough process, utilising three key steps in developing a health programme to ensure as far as possible it was: 1) appropriate for the context, 2) designed using crucial rights concepts to ensure the resulting services were available, accessible, acceptable and of quality (AAAQ), and 3) amenable to assessment of its impact on the health system. This process is described in more detail in the section following. It is also presented schematically in Box 3-1.
The framework provides a sequential process through the three steps. Each step informs the next: the in-depth understanding of context developed in Step One feeds into the design of programme activities in Step Two; then Step Three assesses the impact of those activities on the health system, of which a thorough understanding has also been developed in Step One.

Tool for Step One: understanding context

The methods used to design the tool for Step One in the framework were again literature searches constructed around an understanding that the health and well-being of people is dependent on many factors. These determinants of health are illustrated as layers of influence (Figure 3-1), which, especially in a globalised world, extend beyond State borders. The layers conceptualised for this framework were:
International – including rights treaties and international contracts that would have an impact on the State’s capacity to realise the right to health
National – State policies and practices, economy, capacity and commitment to health and human rights
Health system – including each of the six building blocks of the health system (Figure 3-3).
The literature was searched in detail within each of these categories to identify the key elements necessary to include in tools to develop a full understanding of that layer’s influence on the right to health.
The purpose of the first tool is to gather data to fully understand the local context in which a programme will be operating. The tool therefore needed to have three questionnaires. Each questionnaire corresponded to one layer of influence on context: international, national and health systems. Each needed a list of indicators to guide the collection of the necessary contextual information.
A review of literature assessing health system performance had been recently published (Kruk & Freedman, 2008). These authors identified and reviewed 118 papers on health system effectiveness, 90 on equity, and 97 dealing with efficiency. They identified indicator groups under the headings effectiveness, equity and efficiency.
I conducted a narrower literature search, specifically for indicator-based assessments of local health contexts that would gather data relevant for each of the three layers in the tool. Database searches using key words ‘health systems’ ‘health rights’ ‘indicators’ ‘developing countries’ were conducted on Medline and PubMed, International Encyclopedia of Public Health, referencing forward and backward.
There was only one publication that assessed health systems (not programmes) from a rights perspective (Backman et al., 2008). One other publication was also instructive as an indicator-based health system assessment, so it was also selected for use although it was not designed from a rights perspective (Islam, 2007). The indicators from these two publications were compared to the overall indicator groups identified by Kruk and Freedman. This revealed that the Backman and Islam papers had included indicators covering the range in the comprehensive review paper. On this basis, it was decided to use the combined indicators from Backman and Islam to populate the three questionnaires in the first tool.

READ  DATA COLLECTION INSTRUMENTS

Tool One: indicator selection

Every indicator presented in the Backman and Islam assessments was considered for allocation to one of the three questionnaires in Tool One. If the indicator sought additional information regarding the State capacity, commitment, and progress towards fulfilling the right to health, it was allocated to one of the three questionnaires. Care was taken that there was no duplication of indicators so if both papers had the same indicator, it was only entered into the tool once. The goal of the questionnaires was to have the least number of indicators possible to produce a comprehensive understanding of the context.
The Backman paper had 72 indicators for assessing right-to-health features of health systems. These were divided into 15 groups covering, inter alia, health system building blocks, underlying determinants of health, human rights concepts and national health plans. The Islam manual contained a core module of 17 indicators to build a picture of the population socioeconomic dynamics. Then there are another 174 assessment indicators for each of the six building blocks: 40 indicators to assess governance, 18 for finance, 31 for health service delivery, 20 for human resources, 39 for pharmaceuticals and 26 for information systems. In total, Islam had 191 health system indicators. There were then, between the two papers, 263 indicators.
They were allocated to one of the three questionnaires using a process of 1) division into categories of international, national and health system building blocks,no duplication, 3) only including indicators that provided additional information regarding the State capacity, commitment, and progress towards fulfilling the right to health.
Questionnaire 1 (international layer) was allocated 13 indicators (Table 6-1). These addressed recognition and record of human rights and other international agreements and commitments. Questionnaire 2 (national layer) had 27 indicators, addressing local demographics and State politics (Table 7-1). Questionnaire 3 (health system assessment) had 70 indicators to examine core obligations measures and capacity of each of the six building blocks of the health system (Table 8-1). Therefore, in total, the first tool, prior to testing it against the case studies, had 112 indicators.
When tested in this research against a case study (Chapters 6-8), the data collection process to populate these three questionnaires is conducted over two time periods, five years apart. This enables trends to be identified to gauge whether the right to health is being progressively realised. As retrogressive measures in relation to the right to health are not permissible, and if taken, the “State party has the burden of proving that they have been introduced after the most careful consideration of all alternatives” (United Nations, 2000b, para 32), it is important that declining health indicators are documented.
The questionnaire that assesses the health system examines each of the six building blocks to assess its capacity to fulfil the right to health (Figure 3-3). The same approach was used in the USAID health system assessment (Islam, 2007). This view of the health system is maintained throughout the thesis, and is used again in the health system impact assessment.
Tool One, with its three questionnaires, is tested against a case study from PNG following which refinements to the questionnaires were made. These refinements included deletion of indicators if they were shown to be unnecessary; amendments to make them more appropriate; or the addition of new indicators where the case study showed existing indicators had failed to identify an important element of context. This process is explained more fully in section 3.5.

TABLE OF CONTENTS
Abstract
Acknowledgements
Abbreviations
Chapter 1 Introduction
1.1 The right to health
1.2 Global health since 2000
1.3 Human rights and international health programmes
1.4 Aims and structure of the thesis
1.5 Focus on health care programmes
1.6 Health and development discourse
PART ONE: THEORY AND FRAMEWORK
Chapter 2 Background 
2.1 Aid for health
2.2 The beginning of aid and the development era
2.3 The neo-liberal approach to aid
2.4 Fiscal austerity and its impact on health
2.5 The Millennium Development Goals
2.6 Measuring the effectiveness of health aid
2.7 Increases in aid for health
2.8 Funding increases, health systems and MDGs
2.9 Health workforce funding
2.10 Disease-specific focus in aid programmes
2.11 Reframing health aid around health rights
2.12 Shifting the paradigm from donor needs to people’s rights
2.13 A legal framework for health
2.14 Conclusions
Chapter 3 Methods
3.1 Introduction
3.2 Literature review
3.3 Developing a rights-based framework
3.4 Testing the framework and tools: preparing for case studies
3.5 Testing the framework: Tool One
3.6 Testing the framework: Tool Two
3.7 Testing the framework: Tool Three
3.8 Finalising the rights-based programme design framework.
Chapter 4 The right to health as a lens on development 
4.1 Introduction
4.2 A history of health rights
4.3 General Comment 14 clarifies right to health duties
4.4 Reframing international assistance for health as a legal duty
4.5 Rights-based approaches align with good development practice
4.6 Human rights, freedom and development
4.7 A theory of human rights and capability
4.8 Rights connect global to local
4.9 A rights framework for global health
Chapter 5 Examining the literature 
5.1 Introduction
5.2 Informing the structure of a rights-based framework
5.3 Literature guiding indicators for Tool One
5.4 Literature guiding indicators for Tool Two
5.5 Literature guiding indicators for Tool Three
PART TWO: TESTING THE FRAMEWORK
Chapter 6 Health rights and international partnerships in PNG 
6.1 Introduction
6.2 Applying the framework: the first questionnaire
6.3 PNG’s geopolitical context
6.4 UN membership and treaties
6.5 International contracts
6.6 International development assistance for health
6.7 Assessment of Questionnaire 1 on the case study
6.8 Summary of additional indicators for Questionnaire 1
6.9 Conclusions
Annex. Case Study One
Chapter 7 State capacity to meet the right to health
7.1 Introduction
7.2 Capturing national trends
7.3 Application of Questionnaire 2 to the case study
7.4 Conclusion
Chapter 8 Health system capacity to fulfil the right to health 
8.1 Introduction
8.2 Conducting a rights-based assessment of the health system in PNG
8.3 Questionnaire 3 requires qualitative and quantitative information
8.4 Applying Questionnaire 3 to the case study
8.5 Conclusion
Chapter 9 Applying a rights-based programme assessment
9.1 Introduction
9.2 Assessing rights principles in process and plans
9.3 Validating Questionnaire 4: programme assessment
9.4 Testing Questionnaire 4 on the proposed PNG activities
9.5 Assessing availability elements in Case Study Two
9.6 Accessibility: more information needed in the Plan
9.7 Assessing acceptability elements in the Plan
9.8 Assessing indicators of human rights concepts in the Plan
9.9 Revision of indicators for Tool Two
9.10 Conclusion
Annex. Case Study Two
Chapter 10 A health system impact assessment 
10.1 Introduction
10.2 Applying Questionnaire 5: could the Plan weaken the health system?
10.3 Testing Questionnaire 5 on the Plan
10.4 Validating Questionnaire 5
10.5 Conclusion
PART THREE: PRESENTING THE FRAMEWORK
Chapter 11 Tools to guide the design of an aid-funded health programme
11.1 Introduction
11.2 The three-step framework
11.3 The final tools.
Chapter 12 Discussion and conclusions
12.1 Introduction: health rights can be operationalised
12.2 The role of health systems and aid funding for health
12.3 A paradigm shift from philanthropy to rights
12.4 Strengths of this research
12.5 Research limitations
12.6 Recommendations
12.7 Concluding comments
REFERENCES
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The right to health in practice a framework to guide the design of aid-funded health programmes

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