Applying Amartya Sen’s capability approach to understanding reproductive health in India: A Policy Process

Saxena, Swati (2016). 'Applying Amartya Sen’s capability approach to understanding reproductive health in India: A Policy Process' Paper presented at the annual conference of the HDCA, Tokyo 2016.

abstract Through this paper I explore how Capability Approach can be used for health policy formulation and take the case of Adolescent Reproductive and Sexual Health (ARSH) in India as my case. This is an area which is poorly understood and worst served and neither research not services research has focussed on adolescents and their unique health and information needs. This neglect assumes tremendous health consequences considering adolescents aged 10-19 represent over one fifth of the population. Also the few policies to tackle this issue concern themselves more about awareness rather than access and affordability of services and cater largely to male population when adolescent girls are more vulnerable to health problems, particularly when they are the child bearers and are more prone to nutritional deficiencies than their male counterparts. There is evidence that poor nutritional status for Indian females delays the onset of menarche delaying the biological onset of adolescence. However early marriage and the consequent sexual activity and child bearing thrust females early into adulthood even before physical maturity is attained or even regular menstruation is established. More than half the women in India are married before the legal age of 18 and the use of contraception is dismal. Early marriage and pregnancy affect the girl’s education and economic wellbeing apart from her health.   Capability Approach with its focus on multidimensionality of wellbeing can serve as a very good framework for designing policies and for the evaluation and assessment of individual wellbeing and social arrangements. The major constituents of the CA are functionings and capabilities. Functionings are the actual “beings and doings” of a person, whereas a person’s capability is the various combinations of functionings that a person could potentially achieve. In this case the functioning will loosely be the reproductive health services and contraceptives accessed by female population and capabilities will be the freedom and opportunities they have to do so. I will discuss several policies already addressing this issue to illustrate the gaps in current discourse and the need for rectification.   CA is an approach that can be advantageous in several respects. Firstly, by recognising the heterogeneity of the adolescent population and thus being able to cater to the specificities of their needs. Secondly, by ensuring that capabilities to achieve functionings are not denied, by providing access to health care. Thirdly, recognising the importance of choice, the opportunity and freedom to make that choice and the social conditioning that goes behind making that particular choice (and not other). This is especially significant for female adolescent population whose reproductive and sexual choices are a result of many social and economic factors. A policy based on CA will take into cognizance women’s empowerment, their bargaining position within the family and their knowledge so that they can make an informed and an effective choice and have the freedom to make it. Existing policies do not address the operation of the larger social determinants which feed into early marriage/pregnancy issue. Even when these issues are addressed at policy/legal level (example- laws against dowry and minimum age at marriage), there is seldom convergence between these and the health policies. What is needed is a comprehensive and an inclusive policy which not only addresses reproductive/ sexual needs but also takes into cognisance the factors that make early pregnancy situation likely.   The capability approach does not only advocate an evaluation of people’s capability sets, but insists also that we need to scrutinize the context in which economic production and social interactions take place, and whether the circumstances in which people choose from their opportunity sets are enabling and just. Thus several gaps in the current policies can be addressed through the capability approach. For example a large number of these polices tend to treat adolescents as a homogeneous groups, often offering services only to married adolescents. However CA recognises people’s heterogeneity and diversity and thus will be useful in a country where women have to be married and/or pregnant to get reproductive health advice. Also most of these policies focus on sexual health awareness but neglect the need for sexual health services. In other words opportunities (or capabilities) to get health (functioning) are denied. The CA based policy will ensure that clinics, health centres, doctors, gynaecologists, sex specialists, psychologists, medicines, contraceptives, relevant literature etc. are available and affordable (free). Similarly with its focus on the importance of individual, CA also has the potential to address the need for confidentiality and privacy which is extremely important in sexual and reproductive health. However CA suffers from several problems especially when it comes to the operationalisation of the policy. Measurements of capabilities (or choices that people had) are difficult to observe and thus very often the only empirical data available for policy appraisal maybe just be the functionings (that are achieved). Also the idea of social choice arrived through a democratic, deliberative process is problematic in a country where democracy is not always as fair and representative as the ideal, and in most instances is influenced by market forces which can insidiously distort the preference patters of the population. Thus it is important that the problematic insights be taken cognizance of, before CA can become a good framework for policy formulation and application.  

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