Montel, LM; (2024) Assessing the implementation of the right to health through indicators: an interdisciplinary effort applied to breast cancer. PhD thesis, London School of Hygiene & Tropical Medicine. DOI: https://doi.org/10.17037/PUBS.04674819
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Abstract
This thesis explores whether implementation of the right to health in breast cancer care and management is correlated with survival for breast cancer. It comprises seven chapters, of which three are research papers. The right to health is enshrined in international human rights law treaties. It is estimated that today, all countries have signed at least one treaty recognising the right to health. Implementation of a human rights-based approach to health may improve health outcomes and remedy health inequalities. Population-based survival for breast cancer is a key measure of the overall effectiveness of a health system in managing breast cancer. The third cycle of the CONCORD programme on the global surveillance of cancer survival included individual patient records for 37 million patients diagnosed during 2000-2014 with one of 18 common cancers in adults, including 6.4 million women diagnosed with breast cancer. The five-year net survival for these women revealed wide inequalities, both within and between countries. In the first research paper, a scoping review was conducted in public health databases to assess previous attempts to measure implementation of the right to health. This review was complemented by a search of the law literature. These reviews identified some key principles of the right to health that may be translated into measurable indicators: Availability, Accessibility, Acceptability and Quality (AAAQ) of health facilities, services and medicines; the participation of affected groups in health policies and programmes; the accountability of the state and its actors; and non-discrimination between groups of the population. These principles and the indicators retrieved through both reviews informed a preliminary list of 151 indicators of the implementation of the right to health in breast cancer care and management. The second research paper shows the process and results of a Delphi survey in which 13 experts selected indicators of the right to health. Of the 151 indicators gathered in the literature reviews, 54 were selected to assess implementation of the right to health in breast cancer care and management. The selected indicators highlighted key right-to-health aspects of the health system: the formal recognition of the right to health in breast cancer strategies; the implementation of cost-efficient health systems with a population-based screening programme, prompt diagnosis, strong referral systems and limited waiting times; the provision of palliative, survivorship and end-of-life care; the AAAQ of breast cancer services and medicines; the adoption of a people-centred approach; the provision of a system of accountability; and the collection of anonymised individual data that can be used to identify patterns of discrimination. In the third research paper, information was collected for 17 right-to-health indicators in up to 58 countries, in five continents. The time-lag between enactment and implementation of laws, policies and programmes was taken into account when correlating these indicators with survival estimates. Higher survival was found in countries that had enough radiotherapy machines available according to international standards. Survival was also higher in countries where the health workforce was available in higher numbers and where palliative care was available, and financially accessible. The higher the proportion of eligible women screened for breast cancer, the higher survival was. Survival was lower in countries where there was a large proportion of women diagnosed at late stage, and where there was a large proportion of out-of-pocket payments out of the total national expenditure on health. Survival was also lower in countries where the right to health was recognised in national law, showing the limits of the right to health when legal recognition is not followed by implementation. Overall, the results show that some key right-to-health components of health systems are correlated with survival for breast cancer, suggesting that these components are crucial in implementing a human rights-based approach to breast cancer care and management. To my knowledge, this is the first research project to examine correlations between right-tohealth indicators and survival for breast cancer, or any type of cancer. The study design, literature and methods borrow from both the public health and human rights law domains. This thesis also translated complex legal concepts of the right to health into indicators to improve survival for breast cancer in a manner that should be equitable between populations and within groups of a population. I believe that this research contributes to bridging the gap between public health and human rights. By borrowing literature, methods and language from both disciplines, it makes a strong contribution to both fields that have a common aim: to improve human wellbeing. Ultimately, the results of my research tend to confirm the argument that “health and human rights are complementary approaches to the central problem of defining and advancing human well-being.” (Jonathan Mann, 1994)
Item Type | Thesis |
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Thesis Type | Doctoral |
Thesis Name | PhD |
Contributors | Allemani, C; Coleman, M and Lougarre, C |
Faculty and Department | Faculty of Epidemiology and Population Health > Dept of Non-Communicable Disease Epidemiology |
Research Centre | Cancer Survival Group |
Copyright Holders | Lisa Montel |
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Embargo Date: 21 November 2025
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Filename: 2024_EPH_PhD_Montel_L.pdf
Licence: Creative Commons: Attribution-Noncommercial-No Derivative Works 4.0