The future of health care accountability: a human rights approach.

• Author: Jackman, Martha
• Position: 7th National Health Law Conference

THE PAPER ARGUES THAT there is an urgent need in Canada for a human rights approach to health care accountability. Taking as its starting point that health care decision-making must respect Canadian Charter and international human rights guarantees, the paper contends that accountability mechanisms, both in relation to the overall performance of the health care system and individual access to care, must be designed to reflect and reinforce these fundamental human rights principles, not only as a matter of domestic and international legal obligation, but in order to be effective. To make this case, the paper first provides a brief overview of the concrete steps governments have taken towards implementing the various accountability reforms that have been put forward in Canada over the past twenty years. It then considers the implications of the absence of a human rights approach to health care accountability, particularly for those whose needs are least well served within the current system. The paper goes on to suggest that what is required, moving forward, is not only the recognition that health care is a fundamental right, but the creation of institutions and mechanisms capable of enforcing that right at both the access to care and system performance levels. The paper points to the Alternative Social Charter as one possible model for achieving effective accountability within the health care system: a critical reform for the future of health and human rights in Canada.

DANS CE TEXTE, L'AUTEURE soutient qu'il est urgent que le Canada adopte une approche axee sur les droits de la personne a l'egard de la responsabilisation en matiere de soins de sante. En prenant comme point de depart que la prise de decisions en matiere de soins de sante doit respecter la Charte canadienne des droits et libertes et les garanties internationales en matiere de droits de la personne, l'auteure preconise la conception de mecanismes de responsabilisation, tant en ce qui a trait au rendement global du systeme de sante qu'a l'acces individuel aux soins, qui refletent et viennent renforcer les principes des droits humains fondamentaux, non seulement pour se conformer a nos obligations juridiques nationales et internationales, mais egalement afin d'etre efficaces. Pour etayer cette suggestion, l'auteure dresse d'abord un bref apercu des mesures concretes que les gouvernements ont prises en vue de mettre en ceuvre les diverses reformes recommandees au Canada au cours des vingt dernieres annees relativement a la responsabilisation. On examine ensuite les consequences de l'absence d'une approche fondee sur les droits de la personne a cette responsabilisation, tout particulierement pour les personnes que le systeme actuel sert le moins bien. L'article poursuit en pronant qu'il faut, dorenavant, non seulement reconnaitre que les soins de sante sont un droit fondamental, mais creer en outre des institutions et des mecanismes capables de voir a l'application de ce droit tant au niveau de l'acces aux soins de sante qu'au niveau du rendement du systeme. On souligne dans cet article comment la Charte sociale pourrait etre un modele permettant d'atteindre une responsabilisation efficace au sein du systeme de sante, soit une reforme essentielle pour l'avenir du droit a la sante et des droits de la personne au Canada.

1. Introduction II. Health Care Accountability Reform: What Progress has Been Made? A. The Implementation of Proposed Reforms 1. Accountability at the System Performance Level 2. Accountability at the Access to Care Level B. The Limits of Existing Reform Proposals: What is Left Out? 1. The Invisibility of Health as a Human Right 2. The Failings of the Current Approach: Access to Abortion 3. The Implications of the Lack of a Human Rights Framework III. A Human Rights Approach to Health Care Accountability A. Accountability from an International Human Rights Perspective B. Moving Forward: The Alternative Social Charter Model 1. The Social Charter Framework 2. The Social Charter Framework and Access to Abortion IV. Conclusion I. INTRODUCTION

   Barriers to accessing health care services, especially as they affect vulnerable and marginalized groups in Canadian society, undermine life, security of the person, and equality guarantees under the Canadian Charter of Rights and Freedoms. (1) They are also incompatible with the underlying principles of the Canada Health Act (2) and the publicly funded medicare system, (3) section (36) of the Constitution Act, 1982, (4) and Canada's international human rights obligations. (5) And, while other human rights violations, such as poverty and colonialism, are more significant determinants of health, access to health care remains the primary focus of Canadian health policy and spending. (6) Ensuring the accountability of health care decision-making affecting access to care is therefore critical from the perspective of indigenous people; people living in poverty; those with mental illnesses or addictions; people with disabilities; refugees and new immigrants; and other groups experiencing significant health-related disadvantage. (7) As United Nations Special Rapporteur on the Right to Health, Paul Hunt, affirms:

   Because of the complexity, sensitivity and importance of many health policy issues, it is vitally important that effective, accessible and independent mechanisms of accountability are in place to ensure that reasonable balances are struck by way of fair processes that take into account all relevant considerations, including the interests of disadvantaged individuals, communities and populations. (8) At its most basic level, accountability has been defined as "the process of being called 'to account' to some authority for one's actions." (9) In her review of the accountability regimes governing federal social transfers, including the Canada Health Act, Barbara Cameron describes accountability as: "a relationship between parties whereby one party is answerable to the other for the performance of commitments or obligations that are evaluated against criteria or standards known to the parties, and sanctions are applied for failure to meet the commitments." (10) What is not lacking within the Canadian health care system--federal and provincial/territorial--are human rights based "commitments", "obligations", "criteria", or "standards". These can be found in the right to health guarantees under article 12 of the International Covenant on Economic, Social and Cultural Rights ("ICESCR"); in sections 7 and 15 of the Charteras well as in the program criteria of the Canada Health Act (12) itself. Missing in Canada are mechanisms to secure the "answerability" of health care decision-makers for the performance of, and to impose "sanctions" for failure to meet, these domestic and international human rights obligations. This core feature of accountability, "external scrutiny and sanctions" (13) as Richard Mulgan puts it, is largely non-existent within the Canadian health care system. (14) In the words of Catherine Regis:

   Deux elements sont necessaires pour que l'imputabilite depasse le stade de valeur certes louable pour en arriver a un standard susceptible d'application. II s'agit de la presence d'un devoir de justification des decideurs et l'imposition de consequences si cette justification est insatisfaisante. Ces elements definissent ce qui est necessaire pour qu'une veritable dynamique d'imputabilite se mette en place ... dans les systemes de sante au Canada. (15) The relationship between human rights and accountability is well established internationally. In particular, the ICESCR guarantees "the right of everyone to the enjoyment of the highest attainable standard of physical and mental health," (16) "without discrimination of any kind," (17) and it identifies "the prevention, treatment and control of ... diseases [and] medical service and medical attention in the event of sickness" (18) as central components of that right. The ICESCR and the UN Committee on Economic, Social and Cultural Rights' General Comment No. (14), outline Canada and other State Parties' obligations to protect and promote the right to health, including the requirement to put in place effective accountability mechanisms to ensure that health rights are respected and enforced. (19) As Paul Hunt summarizes this requirement: "[r]ights imply duties, and duties demand accountability." (20)

   In Canada, however, the prevailing view remains, as Roy Romanow expresses it, that health care "is not a legal construct, but rather, a political construct" (21) and that, in the words of Christopher Manfredi, "the question of what kind of health care system Canada should have is simply not amenable to resolution through the language of legal rights." (22) The question of how to increase accountability has been at the forefront of Canadian health reform debates over the past twenty years; however, political-based, value-based, or consensus-based frameworks have been preferred. After two decades of discussions and promises of change, as Steven Lewis puts it, "the missing piece appears to be enforceable accountability." (23)

   This paper argues that a new human rights based approach to accountability is required: one that explicitly accepts that Canadian Charter and international human rights are implicated in health care decision-making, and that ensures effective "scrutiny and sanctions" (24) where systemic or individualized decisions made by governments or their delegates -within the publicly funded system undermine, rather than reinforce, those rights. (25) will suggest that such a human rights approach to health care accountability is essential not only to bring Canada into compliance with its Charter and international obligations, but also in order to be effective, especially from the perspective of disadvantaged groups.

   To make this case, I will first provide a brief overview of the concrete steps that governments have taken towards...