Despite increasing attention paid to the apparent integration of human rights into public health policies and programs, it is difficult to find concrete examples of the benefits that have been derived from linking human rights norms and standards to public health imperatives. There is a need to identify existing approaches that link human rights and health concerns and then to determine the best ways to assess their impact on the effectiveness and outcomes of health policies and programs. As basic as it sounds, this approach requires clarity, not only in defining human rights, but also in recognizing what incorporation of identified norms and standards should look like in practice.
In the interests of validity and comparability, from a public health perspective, assessment requires appropriate quantitative indicators. Implicit in the use of such indicators is a sense that they are both impartial and objective. Yet a human rights perspective suggests querying the assumed neutrality of an indicator: we should think about who uses it, for what purposes and in what ways. What occurs before, during and after the measurement process itself is equally important as what is being measured. Thus, the purpose of this paper is to begin to disentangle the diversity of approaches to health and human rights indicators and to suggest issues to consider in determining the value of existing approaches.
Human Rights and Public Health Practice
Human rights bring into focus the relationship between the government, which is the first-line provider and protector of human rights, and individuals (who hold these rights as human beings).1 Every country in the world is party to at least one human rights treaty and all have made rights-related commitments relevant to health.2 While for many years it was unclear what the incorporation of human rights principles meant for public health practice, certain actions are increasingly considered part of a human rights-based approach to health (Box 13.1).
Although generally not incorporated so systematically, many of the interventions implied by the actions named in Box 1 are familiar to people involved in public health. Those that are not so familiar, such as ensuring transparency for how decisions are made, are unique contributions that the human rights field offers to public health. A difficulty lies in determining whether, by drawing attention to the human rights aspects of those actions traditionally in the domain of public health, the nature of the indicator appropriate for their measurement should remain the same or change. Additionally, the fact that institutions may engage differently with the same concepts and even the same indicators has implications for assessing the ways in which monitoring and evaluation are done across the fields of health and human rights.
A wide range of actors use indicators to capture human rights concerns relating to health including international and national human rights mechanisms, governments, health and development organizations and civil society.
In general terms, an indicator is “a variable with characteristics of quality, quantity and time used to measure, directly or indirectly, changes in a situation and to appreciate the progress made in addressing it.”4 Table 13.1 lays out definitions and examples of the two types of indicators used to capture health and human rights concerns.
A health indicator has been defined as a “variable that helps to measure changes in a health situation directly or indirectly and to assess the extent to the objectives and targets which of a program are being attained.”5
The number of maternal deaths is a raw statistic that takes on greater meaning when converted into an indicator of number of maternal deaths/live births/year, which can be tracked over time alongside programmatic activities. Other examples include: the percentage of the population that has sustained access to improved drinking water sources, the percentage of children aged less than 5 who sleep under insecticide-treated bed-nets, and total expenditure on health as a percentage of gross domestic product.
Human rights indicator
A human rights indicator has been defined as a measure that provides information on the extent to which human rights norms and standards are addressed in a given situation.6
Indicators of fulfilment of human rights would include, for example, the extent to which international human rights obligations are incorporated into national laws and policies relevant to maternal health. Human rights indicators also include indicators of violations such as quantitative summaries of human rights violations, legal audits and determination as to the existence and use of mechanisms for challenge and redress if violations are alleged to occur.7
It is immediately apparent that many of the human rights indicators constitute measures that fall outside the traditional definition of a health indicator. To assess the degree to which human rights are respected, protected and fulfilled in the area of health is to expand the notion of what constitutes an indicator in this field. Inevitably this brings with it complications, some of which are explored in this paper.
Human Rights Indicators to Measure Health
For those involved in monitoring the human rights compliance of States, indicators are primarily used to enhance the practice of accountability for health-related rights issues. In this context, interest in health arises primarily from its relevance to a range of rights, in particular when nonfulfilment of health-related rights is thought to impede fulfilment of a range of human rights. For example, human rights organizations may quantify violations in specific areas to highlight governmental failure to protect human rights relevant to health, e.g., sexual violence in conflict situations.8 Further, some treaty monitoring bodies ask governments to show the kind of legislation that exists to protect population groups from discrimination in their access to health care,9 while others ask for such information as disaggregation by ethnicity of the reported number of births attended by skilled health personnel.10
Box 13.1 Actions Suggested to Constitute a Rights-Based Approach to Health
- Considering the legal and policy context within which interventions occur.
- Supporting the participation of affected groups, especially vulnerable groups, in all efforts that concern them.
- Working to ensure discrimination does not occur in the delivery of services nor in the health outcomes experienced among different population groups.
- Using human rights standards to deliver services in particular with respect to ensuring their availability, accessibility, acceptability and quality.
- Ensuring transparency and accountability both for how relevant decisions are made and their ultimate impact.3
Attention to the use of such human rights indicators by actors in the health arena is rapidly increasing. To ensure a shared understanding of why and how they are being used, as well as transparency, it is important to make explicit the justification for the assumption that these indicators are grounded in international human rights law and they are linked to the field of health. Highlighting the legal bases from which such indicators are derived can also help to minimize bias in how they are used.
Health Indicators to Measure Human Rights
Within the human rights field, compliance with human rights norms and standards and assessment of government accountability is often done through use of “traditional” health indicators. An example is infant mortality rates, which are used as a measure of State Party compliance with their obligation to respect the child’s right to life, survival and development, even though they were created as an indicator of population health.10
For those involved in health, the fact that health indicators draw attention to rights issues is generally a by-product of efforts to determine the appropriateness and effectiveness of policies and programs. As one example, disaggregation of data on the basis of sex and age may be used to gauge usage of available health services,11 but may also draw attention to larger underlying concerns related to inequities in access. In other instances, attention to human rights may be driven by a genuine, but nebulous, desire to “do good” and thus give insufficient attention to why a particular health indicator, or set of indicators, is assumed to measure human rights.
Even as indicators are frequently used for purposes beyond those for which they were originally intended, it is useful to consider whether health indicators ostensibly used to measure human rights would have been constructed differently if human rights considerations had formed part of their design, and also to consider the criteria that are or should be used to determine how health indicators are linked to specific human rights for valid inferences to be made.
Indicators of Health and Human Rights
With regard to the capture of information at the intersection of health and human rights, increasingly a third category of indicators exists—those created in the health field to capture information specifically relating to human rights issues in the design and delivery of health policies and programs.12–15
This can most plainly be seen in relation to the components noted previously as key aspects of a human rights approach. Some examples follow.
Assessment of laws that may present obstacles to effective HIV prevention and care for vulnerable populations provide a useful example of an indicator that brings to light issues equally of interest to both fields.16