Public Health Framework for Empowerment. Draft 1.

Feb 7, 2010
Kausar S Khan, Aga Khan University, Community Health Sciences, Karachi. Pakistan
(kausar.skhan@aku.edu)

Issues of methods and conceptual framework

for women’s empowerment.
Kausar S Khan

When there is a murder, it is considered a crime and judicial processes are initiated.
Procedures are available to apprehend the culprit, and who needs to do what is given.
Why a maternal death is not considered a crime? The question was posed to a human
rights activist, who after a thoughtful moment said: Yes, there is a case here; but who is
to be charged? This was a tricky question, it is not necessarily the husband, or the
mother in law who is solely responsible for a maternal death, and be charged of
homicide. Analysis of verbal autopsies of the Lady Health Workers progamme in
Pakistan 1 show the third delay as the major cause of death as opposed to the first or
second delay. With this evidence, who is to charged for this murder as violating
woman’s right to life? Another human rights lawyer, approached with the same query,
to declare maternal death as a crime, warned that this matter should not be allowed to
become an academic exercise. The Supreme Court may not hesitate in declaring
maternal death to be a crime, but go beyond it and say how it is to be prevented.
Herein lies the most somber challenge for a country that can on the one hand acquire
nuclear power, but fails to save women’s lives ! A country where laws against murder
exist, but women continue to be killed in the name of honour and the killers are not
apprehended. A legitimacy of killing women stalks the country and parallel judicial
systems justify extra-judicial deaths. The most gruesome incident was the killing of a
pregnant mother by her father in law – he hauled her out in the open and shot her to
death in front of her father. This happened in 2008, when an elected civil government
was in place.

What could be a viable public health framework for countries like Pakistan where
parallel judicial systems prevail, the State grossly under-funds the social sector,
women’s movement is too entangled in issues around discriminatory laws and
institutionalization of violence against women through parallel systems, where in some
areas women’s simple right to vote is denied collectively by the political parties
contesting the election, where health profession is dominated by clinical approaches to
health, public health professionals have not emerged as a robust public health lobby,
and non-government organization working on women’s health, and where the absence
of rule of law is the most formidable challenge to any human rights group.

In the grim context represented by conditions in Pakistan (and this is a case of many
developing countries) a public health framework for women’s empowerment evolved
out of a participatory action research designed to meet the objectives of women’s
empowerment, with ‘empowerment’ envisaged as ability to challenge local gender
systems.2

1
 Public Health Framework for Empowerment. Draft 1. Feb 7, 2010
Kausar S Khan, Aga Khan University, Community Health Sciences, Karachi. Pakistan
(kausar.skhan@aku.edu)

The framework has two critical elements—the cluster of concepts used in the
framework, and the methodology proposed as an imperative given the nature of
conditions that prevail in countries like Pakistan. Titled, Public Health Framework for
Women’s Empowerment,3 it includes understanding of women’s empowerment as
understood by women themselves, identification of factors that impede and support
women’s empowerment, and what constitutes women’s agency for overcoming the
barriers. Another conceptual framework embedded within this

Figure 1

Supporting Factors

Women’s Empowerment,
as defined by women

Impeding Factors

This triad constitutes the core of the proposed Public Health Framework for Women’s
Empowerment. This triad is to be seen in the nature of the context where they are to be
invoked for empowering women for better health through influencing their conditions
of health at three distinct levels – the micro, meso, and the macro.

Figure 2

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 Public Health Framework for Empowerment. Draft 1. Feb 7, 2010
Kausar S Khan, Aga Khan University, Community Health Sciences, Karachi. Pakistan
(kausar.skhan@aku.edu)
The three levels, micro meso and macro, constitute a mini- framework of analysis for
assessing the outcomes of interventions and strategies for changes in heath outcomes.
Barriers to accessing resources for women’s health are to be found at all three levels,
and to overcome them is not to be seen as an individual struggle, but to gauge how
women could take collective action for bringing changes in their conditions of life which
are influences by meso-level powers which can often be stronger than the macro level
policy makers’ power to intervene. The case of Naseema Solangi, who was pregnant and
shot to death by her husband, can be analysed as representing the non-reaction of the
health professionals as well as non-government organizations working in health sector.
How meso level interferes in the implementation of pro-women policies, when they
exist, is a matter to be inducted in the analysis of the contexts where health
interventions are planned.

The trajectory of advancement form individual acts of empowerment, to collective

aaction, and women getting organized, and institutionalization of women’s demands
and action constitutes another element of the public health framework for women’s
empowerment. This element constitutes a framework of analysis for planning and
assessing interventions that would facilitate this trajectory of women’s empowerment.

Figure 3

Institutionalized

Organized
Trajectory of
women’s
empowerment
The
for social Collective Action
determinants
of health, and
Individual action
influencing
polices

proposed Public Health Framework for Women’s Empowerment (PHFWE) offers a

common logic for planning and promoting any identified health issue. It requires
a) Identification of a health component (example, Reproductive Health, Mental
Health).
b) Identification of the issues of that particular health component.
c) Identification of the social determinants of the heath issues identified.
d) Identify the factors that support and impede women’s efforts to address the
social determinants. (These to be identified by the women through their
exploration of their understanding of women’s empowerment

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 Public Health Framework for Empowerment. Draft 1. Feb 7, 2010
Kausar S Khan, Aga Khan University, Community Health Sciences, Karachi. Pakistan
(kausar.skhan@aku.edu)
Figure 4 below presents the above four steps to operationalise this part of the
framework.4

Figure 4

Health Component
Supporting &
impeding
Issues (of concerned factors for
component) dealing with
issues &
determinants
Determinants of
heath

Challenging barriers

Issues of Approaches and Method/s in an Empowerment frame of Public

Health
A theoretically sound framework does not necessarily sure its effectiveness. It is the
nature of interaction between health professionals (specially the front line workers
interacting directly with women and other community members5) The issues here are
linked with the notion of empowerment as ability to challenge the barriers to use of
personal agency for access to resources at the household level (food and rest) and
access to resources outside the household ( health services), and over come the
financial and non-financial barriers to health,

If public health is to go beyond its concern with diseases and their prevalence, and
engages with the social determinants of health , and is to uphold the CSDH 6
recommendation of improving daily lives of people, it needs to work for the
empowerment of communities , specially women. Given the nature of the socio political
context , the responsibility of public health approach shall vary. The equity stratifiers 7 of
a society will pose different challenges. In a participatory approach the practioners
would need to be conscious of the dominant stratifiers and would need to have an
information system that helps them monitor reductions in inequities.

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 Public Health Framework for Empowerment. Draft 1. Feb 7, 2010
Kausar S Khan, Aga Khan University, Community Health Sciences, Karachi. Pakistan
(kausar.skhan@aku.edu)

Three learning areas need to be addressed for the use of participatory approach that
would empower communities for better health and better conditions of life
(improvement of daily life, as CSDH recommends).
a) Conceptual base for participatory approach for empowerment
b) Skill for using the participatory tools for community empowerment. 8
c) Self awareness.9

Epicenter of Figure 5
Empowerment
1
This programme employs over 60,000 young women in rural areas to deliver some basic health services
and education to women at the household level. A verbal autopsy form is filled for every maternal death.
Conceptual
This data is then analyzed to identify areas for strengthening the programme.
2
base
A four country study including two cross border studies, was developed in 2006 . It involving seven
partners representing a mix of academia and non-government organizations with a rights based approach.
Skills
The study was titled: Women’s Empowerment in Muslim Contexts, poverty, gender, and democratization
from inside out (WEMC) Funded by DFID, its focal point was City University, Hong Kong. Aga Khan
University, Karachi, Pakistan, through its department of Community Health Sciences interpreted the given
Self which included mental
research framework for the health sector, and designed a health framework
health, reproductive health, and community health (with focus on equity) as its components.
3
This was first presented at a Symposium in CityAwareness University, Hong Kong,
Feb 2009. It was then titled: Women’s Empowerment for Health a new public
health framework.
4
Examples of this framework for RH and Mental Health are available.
5
It is important to note that when discussing the approaches and methods in public health or primary
health care, the entire team needs to be well versed with the meaning and principles of participation .
The field team, or those interacting at the community level even if well equipped with the tools of
participatory approach they also need support from their supervisors both in terms of conceptual depth
and skills needed . There is a risk of upper cadre of a team becoming somewhat complacent about the
needs of maintaining and deepening the participatory approaches and the tools needed for its
sustenance. The real challenge lies in the context in which it is being used. When the power relations at
the community level are seeped in gender and class discriminations, challenges to this approach would be
greater as compared with more egalitarian communities and societies.
6
See the final eport of the WHO Commission on the Social Determinants of Health. 2009
7
See Paula Baverman and Barbara Starfield on equity stratifiers.
8
Eleven participatory tools were developed in the project Women’s Empowerment in Muslim Contexts
(2006 – 009). These tools were guided by the family of tools available in the larger field of (PLA) or PRA
(Participatory Learning & Assessment), and conceptually inspired by the writings of Paolo Freire . This is a
fairly well developed field of theory and practice, but its use in health sector is somewhat limited. Even
where it is seen to be flourishing in countries like India, it appears overwhelmed by the challenges posed
by the neo-liberal development model that has come to dominate India. Perhaps the biggest challenge
faced by the developing countries is the domination of the neo-liberal development model, and weak
democracies as democracies continue to be limited to the ballot and democratization of institutions and
the flourishing of parallel systems remain a major challenge for societies to become truly egalitarian and
uphold justice for all. Besides the ability to use the participatory tools, that would also include interviews,
focus group discussions, and in depth interviews, communication skills are also imperative for processes
to be empowering
9
In many trainings in participatory approaches Self Awareness is incorporated and given the importance it
needs. To know yourself is to know your own strengths and weaknesses so that the latter could be
overcome and the former sustained. Challenges to self can come from within (in the form of prejudices )

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 Public Health Framework for Empowerment. Draft 1. Feb 7, 2010
Kausar S Khan, Aga Khan University, Community Health Sciences, Karachi. Pakistan
(kausar.skhan@aku.edu)

Conclusion
A public health framework for empowerment is a framework for operationalizing right
to heath. It offers an approach to the contexts of political instability and/or poor
governance, where egalitarian principles at best have a verbal support but practices are
rife with unfairness.10 It is a framework that is to be guided by the epicenter of
empowerment as it would seek to facilitate and mediate between citizens and the State,
with the empowerment of communities for a better engagement with the State and
public sector service providers. It is a framework that is to operate with an
understanding of the importance of linking democracy (including democratization of
institutions 11) as the ultimate goal for sustainable health care for all. Research for this
framework would need to be participatory action research, as this research too is
empowering of communities as it takes them as its partners in research. This is probably
the only way to take forward health issues in countries as they plunge into anarchy with
rising poverty and State appearing more and more helpless as global forces like the
WTO rips open the barriers to trade. Developing countries like Pakistan are unable to
deal with the flooding of their market with cheap foreign goods, and local products
losing ground, and terrorism is not a sporadic act but has created a near state of war in
the country. Even countries that are fearing better in the world of today where poverty
political instability or weak democracies are endemic, public health would need to
become part of human rights movements but with the additional caveat of
empowerment of communities around health issues.

and from outside (in the form of discriminatory behavior that prevails as a cultural norm). Self awareness
means knowing your own helplessness, and thereby becoming conscious of it in others and how it impacts
behaviour. It requires the ability to reflect , and to be aware of the power of reflexivity.
10
See Health systems and the right to health : an assessment of 194 countries. (www.thelancet.co Volume
372 December 13, 2008. ) This is a telling tale of how being signatory to the UN Conventions and treaties
does not build equitable functional health systems. This, however, is not to call for a suspension of
efforts to lobby with governments for ratification of UN conventions. It is to be seen as a challenge to
going beyond ratification of UN conventions. Often having laws is not enough, but building a society
where rule of law prevails is equally important.
11
Erik Olin Wright, Envisioning Real Utopias (forthcoming publication, but book available in pdf) discusses
at length the viability of a truly egalitarian and emancipatory democracy for the developed countries.
However, the principles of democracy discussed in the book are also relevant for countries like Pakistan.

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 Public Health Framework for Empowerment. Draft 1. Feb 7, 2010
Kausar S Khan, Aga Khan University, Community Health Sciences, Karachi. Pakistan
(kausar.skhan@aku.edu)

Key terms: women’s empowerment; impeding and facilitating factors; contexts;

women’s agency; levels: micro, meso, macro; participation,