By Vijay Avinandan and Vikas Choudhry
Empowering women to protect and improve their health is at the core of the empowerment agenda today. Recent evidence gathered by researchers at the London School of Hygiene and Tropical Medicine (LSHTM) has established that women’s increasing power to make health decisions can lead to positive health impacts. In India, efforts are being made to increase a woman's decision-making power concerning her sexual and reproductive rights through awareness campaigns/outreach and improvements in the quality of health service.
In the year 2018, the World Health Organization (WHO) highlighted India's groundbreaking success in reducing maternal deaths between 1990 and 2016. The decline in maternal death figures was critical as it entailed multiple sub-results attached to it.
Maternal deaths often reflect existing inequalities in access to health services and highlight the gap between the rich and poor. According to WHO, women in less developed and developing nations report more pregnancies than other women, and their lifetime risk of death due to pregnancy is higher. A reduction in maternal deaths, in a macro understanding, hints towards positive health-seeking behavior among women and their families in the form of institutional deliveries and improved quality of health service at the healthcare facility.
But while the evidence provides some clarity on the macro understanding, there is very little evidence in India to establish whether women's say in their health decisions has improved on the ground. In fact, the association between women’s empowerment and positive health outcomes has received less attention in the country.
Rather, recent national-level surveys indicate a contrary viewpoint. According to the National Family Health Survey (NFHS-4), the number of literate women in India increased from 55.1% to 68.4% between 2005-06 and 2015-16.
In the same period, contraceptive usage among women has remained constant, and very few health workers (18%) were speaking to women about family planning methods and benefits in 2015-16.
Women's knowledge about the benefit of consistent condom use in reducing HIV/AIDS is still far lesser compared to men and increases the risk of illness. About 31% of women were facing spousal violence in 2015-16. The poor and vulnerable categories were at higher risk.
The NFHS-4 also found that women from the poorest households were more likely to not use a contraceptive method for family planning, had lesser say in household decision making, and were more likely to be unemployed or engaged in employment without pay. Women from the poorest households were twice as likely to experience physical violence compared to better-off households.
Ideally, an increase in the literacy rates, along with an increase in decision making at a household level, should have led women to increase their self-efficacy and make life-enhancing health decisions.
For example, educated women with a greater agency (the ability to define goals) are more likely to have fewer children, more likely to access health services, and have control over health resources and less likely to suffer domestic violence. Their children are more likely to survive, receive better childcare at home, and receive healthcare when they need it.
Healthy women are more able to participate in society and markets actively and are likely to have greater bargaining power and control over resources within the household.
However, a reduction in maternal deaths or an increase in institutional deliveries in India does NOT seem to reflect a structural change in household dynamics or social norms. Especially women in poorer households remain vulnerable to health risks, often superimposed by societal norms.
There is a lack of well-researched evidence exploring the effect of public health investments and whether it has been able to increase women's power in improving their health. The insights from NFHS-4 has three key implications for the women empowerment dialogue in India. First, the initiatives aimed at improving women's health need a more proactive approach to reach women in vulnerable and poorest households.
Second, while the initiatives rightly focus on improving agency and decision-making at an individual level, there is an equal need to work on relaxing societal norms that hinder individual decision-making and the achievement of positive health outcomes.
Third, there is an urgent need to increase research efforts towards studying the relationship between multiple domains of empowerment, i.e., economic and health empowerment, and identify enabling conditions that can lead to positive outcomes across more than one domain.
The authors work with Sambodhi Research & Communications – a multidisciplinary research organization offering data driven insights to national and global social development organisations.