Rajat Khosla

Health systems and the right to health: an assessment of 194 countries

60 years ago, the Universal Declaration of Human Rights laid the foundations for the right to the highest attainable standard of health. This right is central to the creation of equitable health systems. We identify some of the right-to health features of health systems, such as a comprehensive national health plan, and propose 72 indicators that reflect some of these features. We collect globally processed data on these indicators for 194 countries and national data for Ecuador, Mozambique, Peru, Romania, and Sweden. Globally processed data were not available for 18 indicators for any country, suggesting that organisations that obtain such data give insufficient attention to the right-to-health features of health systems. Where they are available, the indicators show where health systems need to be improved to better realise the right to health. We provide recommendations for governments, international bodies, civil-society organisations, and other institutions and suggest that these indicators and data, although not perfect, provide a basis for the monitoring of health systems and the progressive realisation of the right to health. Right-to-health features are not just good management, justice, or humanitarianism, they are obligations under human-rights law.

The mistreatment of women during childbirth in health facilities globally: A mixed-methods systematic review

Background Despite growing recognition of neglectful, abusive, and disrespectful treatment of women during childbirth in health facilities, there is no consensus at a global level on how these occurrences are defined and measured. This mixed-methods systematic review aims to synthesize qualitative and quantitative evidence on the mistreatment of women during childbirth in health facilities to inform the development of an evidence-based typology of the phenomenon. Methods and Findings We searched PubMed, CINAHL, and Embase databases and grey literature using a predetermined search strategy to identify qualitative, quantitative, and mixed-methods studies on the mistreatment of women during childbirth across all geographical and income-level settings. We used a thematic synthesis approach to synthesize the qualitative evidence and assessed the confidence in the qualitative review findings using the CERQual approach. In total, 65 studies were included from 34 countries. Qualitative findings were organized under seven domains: (1) physical abuse, (2) sexual abuse, (3) verbal abuse, (4) stigma and discrimination, (5) failure to meet professional standards of care, (6) poor rapport between women and providers, and (7) health system conditions and constraints. Due to high heterogeneity of the quantitative data, we were unable to conduct a meta-analysis; instead, we present descriptions of study characteristics, outcome measures, and results. Additional themes identified in the quantitative studies are integrated into the typology. Conclusions This systematic review presents a comprehensive, evidence-based typology of the mistreatment of women during childbirth in health facilities, and demonstrates that mistreatment can occur at the level of interaction between the woman and provider, as well as through systemic failures at the health facility and health system levels. We propose this typology be adopted to describe the phenomenon and be used to develop measurement tools and inform future research, programs, and interventions.

Towards a new global strategy for women's, children's and adolescents' health

We know what needs to be done, say Marleen Temmerman and colleagues, but we need to push hard now to create a world in which every women, every child, and every adolescent is able to survive, thrive, and transform

Sexual health in the International Classification of Diseases (ICD): implications for measurement and beyond*

Abstract This paper examines different dimensions of sexual health as related to the measurement of sexual health indicators and the proposed changes in the International Classification of Diseases to address issues related to sexuality and sexual health with an aim of informing health policy-making and programming. The lack of mechanisms for monitoring and evaluating sexual health outcomes has impeded the development of policies and programmes that support sexual health. The potential impact of changes to the ICD-11 is major and far-reaching given that the ICD is used by countries to define eligibility and access to health services and to formulate relevant policies and laws, and is used by health professionals as a basis for conceptualizing health conditions, treatments and outcomes. Improving the measurement of sexual health-related indicators builds the evidence base on scientific knowledge of sex, sexuality, sexual health and rights. As we stand on the cusp of the post-2015 era and the development agenda transitions to the Sustainable Development Goals, a unique opportunity presents itself to further consider how sexual health is defined, conceptualized, and monitored. Résumé Cet article examine différentes dimensions de la santé sexuelle par rapport à la mesure des indicateurs de santé sexuelle et aux changements proposés dans la Classification internationale des maladies (CIM) pour aborder les questions relatives à la sexualité et la santé sexuelle, dans le but de documenter les décisions et la programmation de santé. Le manque de moyens de suivi et d’évaluation de l’état de santé sexuelle a empêché d’élaborer des politiques et des programmes de soutien dans ce domaine. Les changements de la CIM-11 ont un impact potentiel majeur et de grande envergure puisque les pays utilisent la CIM pour définir le droit et l’accès aux services de santé et pour formuler des politiques et législations pertinentes, alors que les professionnels de la santé s’en servent comme base pour conceptualiser les pathologies, les traitements et les résultats. Améliorer la mesure des indicateurs relatifs à la santé sexuelle consolide la base de données sur les connaissances scientifiques en matière de rapports sexuels, sexualité, santé et droits sexuels. Au seuil de l’ère de l’après-2015 et de la transition de l’ordre du jour du développement en faveur des objectifs de développement durable, une occasion unique se présente d’examiner de façon plus détaillée comment la santé sexuelle est définie, conceptualisée et surveillée. Resumen Este artículo examina diferentes dimensiones de la salud sexual con relación a la medición de los indicadores de salud sexual y los cambios propuestos en la Clasificación Internacional de Enfermedades para tratar asuntos relacionados con la sexualidad y salud sexual, con la finalidad de informar la formulación de políticas y programas de salud. La falta de maneras de monitorear y evaluar los resultados en salud sexual ha impedido la formulación de políticas y programas que apoyen la salud sexual. El posible impacto de los cambios a la CIE-11 es importante y de gran alcance, dado que la CIE es utilizada por los países para definir la elegibilidad y el acceso a los servicios de salud y para formular políticas y leyes pertinentes, y es utilizada por profesionales de la salud como base para conceptualizar condiciones, tratamientos y resultados en salud. Al mejorar la medición de los indicadores relacionados con la salud sexual, se crea la base de evidencia sobre conocimientos científicos de sexo, sexualidad, salud y derechos sexuales. Ahora que estamos en la cúspide de la era post 2015 y la agenda de desarrollo pasa a ser los Objetivos de Desarrollo Sostenible, se presenta una oportunidad única para considerar más a fondo cómo definir, conceptualizar y monitorear la salud sexual.

Acesso a medicamentos como um direito humano

Este articulo analiza el componente del derecho al disfrute del mas alto nivel posible de salud que se relaciona con el acceso a los medicamentos, incluyendo los medicamentos esenciales. Utilizando el marco analitico del derecho a la salud que ha sido desarrollado en los anos recientes, la primera seccion se concentra en las responsabilidades de los Estados. La segunda seccion provee una breve introduccion a las responsabilidades de las companias farmaceuticas.This article considers the component of the right to the highest standard of health that relates to medicines, including essential medicines. Using the right-to-health analytical framework that has been developed in recent years, the first section focuses on the responsibilities of States. The second section provides a brief introduction to the responsibilities of pharmaceutical companies.

Evidence and knowledge gaps on the disease burden in sexual and gender minorities: a review of systematic reviews.

Sexual and gender minorities (SGM) include individuals with a wide range of sexual orientations, physical characteristics, and gender identities and expressions. Data suggest that people in this group face a significant and poorly understood set of additional health risks and bear a higher burden of some diseases compared to the general population. A large amount of data is available on HIV/AIDS, but far less on other health problems. In this review we aimed to synthesize the knowledge on the burden of communicable and non-communicable diseases, mental health conditions and violence experienced by SGM, based on available systematic reviews. We conducted a global review of systematic reviews, including searching the Cochrane and the Campbell Collaboration libraries, as well as PubMed, using a range of search terms describing the populations of interest, without time or language restrictions. Google Scholar was also scanned for unpublished literature, and references of all selected reviews were checked to identify further relevant articles. We found 30 systematic reviews, all originally written in English. Nine reviews provided data on HIV, 12 on other sexually transmitted infections (STIs), 4 on cancer, 4 on violence and 3 on mental health and substance use. A quantitative meta-analysis was not possible. The findings are presented in a narrative format. Our review primarily showed that there is a high burden of disease for certain subpopulations of SGM in HIV, STIs, STI-related cancers and mental health conditions, and that they also face high rates of violence. Secondly, our review revealed many knowledge gaps. Those gaps partly stem from a lack of original research, but there is an equally urgent need to conduct systematic and literature reviews to assess what we already know on the disease burden in SGM. Additional reviews are needed on the non-biological factors that could contribute to the higher disease burden. In addition, to provide universal access to health-care for all, more information is needed on the barriers that SGM face in accessing health services, including the attitudes of health-care providers. Understanding these barriers and the additional health risks they impose is crucial to improving the health status of SGM.

Sexual and reproductive health and rights: a global development, health, and human rights priority

In May, 2014, at the 67th Session of the World Health Assembly, member states reviewed the progress made in the implementation of resolution WHA57.12, the WHO Reproductive Health Strategy. The progress report noted that although a range of regulations and strategies to strengthen sexual and reproductive health and related rights have been implemented, certain areas required further attention, which include unmet need for contraception, comprehensive sexual and reproductive health services for adolescents and young people, as well as prevention and management of the consequences of unsafe abortion, gender equality, violence against women and girls, and cancers related to reproduction. Importantly, in the progress report WHO reaffi rmed its commitment to making sexual and reproductive health a priority in the post-2015 development agenda. This reaffi rmation underscores the importance of sexual and reproductive health and rights and WHO’s commitment on these issues. Sexual and reproductive health and rights are fundamental to individuals, couples, and families, and to the social and economic development of communities and nations. However, 20 years after the International Conference on Population and Development and the UN Fourth World Conference on Women, universal access to sexual and reproductive health remains an unfi nished agenda. Much remains to be done to achieve Millennium Development Goal (MDG) 5 (reducing maternal deaths MDG 5a and achieving universal access to reproductive health MDG 5b). Furthermore, as highlighted in the UN Secretary-General’s report, inequalities between and within countries, and persistent disparities between women and men, and between social and ethnic groups, continue to inhibit progress. At the Rio+20 Summit governments reaffi rmed the need to achieve sustainable development. To achieve these objectives governments must create greater health equity, ensure gender equality, and promote and protect human rights. Promotion and protection of sexual and reproductive health and rights lies at the very core of this approach. Sexual and reproductive health and rights encompass eff orts to eliminate preventable maternal and neonatal mortality and morbidity, to ensure quality sexual and reproductive health services, including contraceptive services, and to address sexually transmitted infections (STI) and cervical cancer, violence against women and girls, and sexual and reproductive health needs of adolescents. Universal access to sexual and reproductive health is essential not only to achieve sustainable development but also to ensure that this new framework speaks to the needs and aspirations of people around the world and leads to realisation of their health and human rights. Better control of women’s fertility allows girls to remain in education longer, accumulate more skills, and eventually earn higher wages. According to the World Bank, female participation in the labour force decreases with each additional child: by about 10–15 percentage points among women aged 25–39 years, and about 5–10 percentage points among women aged 40–49 years. Universal access to sexual and reproductive health is therefore not only an essential human rights priority to ensure women’s empowerment and gender equality, it is also a key international development priority. Over the past 2 years, through the ICPD Beyond 2014 Global Review and the post-2015 development agenda Published Online July 16, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61190-9

Women’s Awareness and Knowledge of Abortion Laws: A Systematic Review

Background Incorrect knowledge of laws may affect how women enter the health system or seek services, and it likely contributes to the disconnect between official laws and practical applications of the laws that influence women’s access to safe, legal abortion services. Objective To provide a synthesis of evidence of women’s awareness and knowledge of the legal status of abortion in their country, and the accuracy of women’s knowledge on specific legal grounds and restrictions outlined in a country’s abortion law. Methods A systematic search was carried for articles published between 1980–2015. Quantitative, mixed-method data collection, and objectives related to women’s awareness or knowledge of the abortion law was included. Full texts were assessed, and data extraction done by a single reviewer. Final inclusion for analysis was assessed by two reviewers. The results were synthesised into tables, using narrative synthesis. Results Of the original 3,126 articles, and 16 hand searched citations, 24 studies were included for analysis. Women’s correct general awareness and knowledge of the legal status was less than 50% in nine studies. In six studies, knowledge of legalization/liberalisation ranged between 32.3% - 68.2%. Correct knowledge of abortion on the grounds of rape ranged from 12.8% – 98%, while in the case of incest, ranged from 9.8% - 64.5%. Abortion on the grounds of fetal impairment and gestational limits, varied widely from 7% - 94% and 0% - 89.5% respectively. Conclusion This systematic review synthesizes literature on women’s awareness and knowledge of the abortion law in their own context. The findings show that correct general awareness and knowledge of the abortion law and legal grounds and restrictions amongst women was limited, even in countries where the laws were liberal. Thus, interventions to disseminate accurate information on the legal context are necessary.

Women's health priorities and interventions

Building on the unfinished agenda, Marleen Temmerman and colleagues elaborate actions needed to improve the health and wellbeing of women and girls around the world

Sexual health, human rights, and law

www.thelancet.com Vol 386 August 22, 2015 725 Sexuality and sexual health are two closely related concepts that contribute to the overall health and wellbeing of individuals, couples, and families. Our understanding of the concept of sexual health has gone through many iterations, the fi rst one being in 1975, in which a WHO report series defi ned sexual health as “the integration of the somatic, emotional, intellectual and social aspects of sexual being, in ways that are positively enriching and that enhance personality, communication and love”. The next defi nition of the concept was in 1994 at the International Conference on Population and Development held in Cairo, Egypt, in which the Programme of Action, adopted by consensus by 179 governments, emphasised that reproductive health included sexual health and that its purpose “is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases”. However, despite these repeated affi rmations and the fundamental importance of sexuality and sexual health for the overall health and wellbeing of individuals and populations, these issues continue to be stigmatised in intergovernmental negotiations, therefore adversely aff ecting the availability and use of sexual health programmes and services. As a result, sexuality and sexual health-related mortality and morbidity, such as from HIV and other sexually transmitted infections, ill health as a result of restricted access to contraception and safe abortion, sexual violence, and female genital mutilation represent a substantial global disease burden. HIV and other sexually transmitted infections continue to have serious medical and psychological eff ects for women, adolescents, and men worldwide. Sexually transmitted infections, such as chlamydia, gonorrhoea, syphilis, and trichomoniasis, are estimated to aff ect 448 million people every year. Furthermore, 35 million people are estimated to have HIV, resulting in a huge burden related to sexual health. Studies have shown that men who have sex with men and transgender people continue to be disproportionately aff ected by HIV. Transgender people, according to some studies, have disproportionately high HIV prevalence, ranging from 8% to 68%. However, despite clear evidence of an eff ect of sexuality and sexual health on overall health and wellbeing of populations, the development of a comprehensive approach that takes into account positive notions of sexuality and sexual health has been rather limited. Studies have shown deep-rooted discrimination and inequalities related to sexuality and sexual health. Many manifestations of this discrimination and inequality exist such as marginalisation, stigmatisation, and physical and mental abuse of individuals and groups perceived as having socially unacceptable sexual behaviours (eg, men who have sex with men, sex workers, and transgender people), and the eff ect that such discrimination has on these people’s health. Worldwide jurisprudence emphasises violations of human rights, and the primacy of equality and nondiscrimination, the right to the highest attainable standard of health, and the right to privacy and confi dentiality, which shows that the realisation of sexual health is thus closely associated with the protection of human rights. This association between sexual health, human rights, and the law is the focus of a recent report by WHO (panel). The report provides an analysis based on public health evidence and legal and human rights research at international, regional, and national levels, to show how diff erent countries promote and protect sexual health through legal and other mechanisms Sexual health, human rights, and law