Implementing and monitoring the right to health in breast cancer: selection of indicators using a Delphi process

Lisa Montel, Michel P. Coleman, Therese Murphy, Dina Balabanova, Raffaele Ciula, Dabney P. Evans, Claire Lougarre, Didier Verhoeven, Claudia Allemani

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Background: Women with breast cancer have different chances of surviving their disease, depending on where they live. Variations in survival may stem from unequal access to prompt diagnosis, treatment and care. Implementation of the right to health may help remedy such inequalities. The right to health is enshrined in international human rights law, notably Article 12 of the International Covenant on Economic, Social and Cultural Rights. A human rights-based approach to health requires a robust, just and efficient health system, with access to adequate health services and medicines on a non-discriminatory basis. However, it may prove challenging for health policymakers and cancer management specialists to implement and monitor this right in national health systems.
Method: This article presents the results of a Delphi study designed to select indicators of implementation of the right to health to inform breast cancer care and management. In a systematic process, 13 experts examined an initial list of 151 indicators.
Results: After two rounds, 54 indicators were selected by consensus, three were rejected, three were added, and 97 remained open for debate. For breast cancer, right-to-health features selected as worth implementing and monitoring included the formal recognition of the right to health in breast cancer strategies; 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 availability, accessibility, acceptability and quality (AAAQ) of breast cancer services and medicines; the provision of a system of accountability; and the collection of anonymised individual data to target patterns of discrimination.
Conclusion: We propose a set of indicators as a guide for health policy experts seeking to design national cancer plans that are based on a human rights-based approach to health, and for cancer specialists aiming to implement principles of the right to health in their practice. The 54 indicators selected may be used in High-Income Countries, or member states of the OECD who also have signed the International Covenant on Economic, Social and Cultural Rights to monitor progress towards implementation of the right to health for women with breast cancer.
Original languageEnglish
Article number142
Pages (from-to)1-20
Number of pages20
JournalInternational Journal for Equity in Health
Issue number1
Early online date29 Jul 2023
Publication statusPublished online - 29 Jul 2023

Bibliographical note

Funding Information:
We are thankful for the time and expertise of the thirteen members of the panel for this Delphi study: Prof Dina Balabanova (London School of Hygiene and Tropical Medicine, UK), Prof Sharon Batt (Dalhousie University, Canada), Dr Luciano Bottini Filho (Sheffield Hallam University, UK), Ms Judith Bueno de Mesquita (University of Essex, UK), Dr Raffaele Ciula (Sapienza University of Rome, Italy), Prof Dabney P. Evans (Emory University, USA), Prof Katherine Fierlbeck (Dalhousie University, Canada), Dr Claire Lougarre (Ulster University, UK), Prof Therese Murphy (Queen’s University Belfast, UK), Prof Sir Michael Richards (UK National Screening Committee, UK), Mr Peter Roderick (Newcastle University, UK), Ms Susan Stallabrass (University of Essex, UK) and Dr Didier Verhoeven (University of Antwerp, Belgium). We are grateful for the feedback received on an early version of this manuscript from Sharon Batt, Judith Bueno de Mesquita, and Katherine Fierlbeck. We are also thankful for the valuable guidance and resources from Prof Ellen Nolte (London School of Hygiene and Tropical Medicine, UK) and Dr Gunilla Backman (United Nations Population Fund, Thailand), as well as the endorsement of Paul Hunt (University of Essex, UK). We are grateful to three anonymous reviewers for their thorough review of an earlier version of this manuscript.

Publisher Copyright:
© 2023, The Author(s).


  • People-centred health system
  • Monitoring
  • Human rights-based approach to health
  • Breast cancer
  • Cancer control
  • Right to health


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