Operationalizing the Right to Health through Governance-Based Health Systems Evaluation: A Dynamic Performance Management Approach

This doctoral thesis proposal integrates the findings of four scientific articles focused on the right to health, human rights-based approaches, and health systems performance, with particular emphasis on the Colombian case and the contemporary challenges of governance, equity, and effective access to healthcare services. The studies combine methodologies including integrative review, realist synthesis, dynamic governance analysis, and grounded theory, enabling a multidimensional approach to understanding the right to health as a normative principle, a governance mechanism, and a lived social experience.The first thematic axis corresponds to the integrative review on the right to health, human rights-based approaches (HRBA), and health systems performance. This study argues that a historical gap persists between the normative obligations derived from international human rights law and the performance evaluation systems commonly used in public health. Drawing from academic literature and international normative sources, the review proposes an integrated framework linking principles such as equity, participation, transparency, accountability, and non-discrimination with operational indicators of health system performance. The study identifies strong convergences between the AAAQ framework (Availability, Accessibility, Acceptability, and Quality) and contemporary models of universal health coverage, primary health care, and participatory governance. As its main contribution, the article develops a conceptual and operational architecture capable of translating legal right-to-health obligations into measurable dimensions for monitoring, evaluation, and public policy development. The second article advances the construction of a hybrid synthesis model for rights-based health systems. Through an integrative-realist review of 129 international studies, the research demonstrates that human rights-based approaches are consistently associated with improvements in equity, healthcare access, quality of care, community participation, and institutional responsiveness. The review identifies equity, non-discrimination, social participation, accountability, and adaptive governance as core principles. Furthermore, it incorporates analyses from Dynamic Performance Management and Dynamic Public Governance, showing that many health systems already utilize implicit mechanisms of monitoring, feedback, and institutional learning, although these are rarely conceptualized formally as dynamic governance systems. This study provides a theoretical bridge between normative human rights frameworks and the adaptive capacities of modern health systems, suggesting that the effective realization of the right to health depends on the interaction between legal recognition, accountability mechanisms, citizen participation, and flexible governance structures. The third thematic axis corresponds to the grounded theory study exploring citizens’ experiences regarding the right to health in Colombia. Through focus groups conducted across seven urban, rural, and peripheral territories, the research examines how citizens interpret and negotiate the realization of the right to health in everyday life. Findings demonstrate that although health is widely understood as a constitutional right closely linked to dignity and citizenship, persistent structural barriers related to accessibility, availability, quality, and acceptability continue to limit effective healthcare access. Participants described prolonged waiting times, administrative authorizations, institutional fragmentation, specialist shortages, and territorial inequities as recurrent obstacles to healthcare access. Particularly in peripheral regions such as Tumaco and Inírida, barriers related to infrastructure, transportation, and service availability deepen historical inequities. One of the central findings of this study was the identification of the phenomenon conceptualized as the “Rights-Rhetoric versus Systemic-Reality Gap,” describing the contradiction between constitutional recognition of the right to health and its incomplete realization in everyday practice. Participants reported that healthcare access frequently depends on adaptive strategies such as tutela actions, bureaucratic learning, and persistent institutional negotiation, revealing that effective realization of healthcare rights remains conditioned by citizens’ capacity to navigate complex administrative systems. The study concludes that citizens are not passive recipients of healthcare services, but rather active interpreters, negotiators, and defenders of healthcare rights within fragmented institutional structures. Across all four articles, a shared conclusion emerges: the right to health must be understood as a dynamic and multidimensional process shaped by legal, institutional, social, and territorial factors. The studies demonstrate that expanding insurance coverage or achieving constitutional recognition alone is insufficient when administrative fragmentation, territorial inequities, and weak institutional responsiveness persist. They further highlight that community participation, accountability, and rights-based monitoring systems are essential for transforming human rights principles into tangible improvements in health system performance.Collectively, this doctoral thesis proposes an integrative understanding of the right to health as a normative framework, a governance model, and a lived social experience. Its principal contribution lies in articulating human rights theory with health systems evaluation and citizens’ lived experiences, thereby generating an analytical model useful for examining the tensions between legal recognition and effective realization of the right to health in Colombia and other Latin American contexts. The research further argues that health systems only acquire social legitimacy when they successfully translate constitutional guarantees into concrete experiences of timely access, dignified treatment, territorial equity, and institutional responsiveness.