Women and girls' health agency: Operationalizing the "Can-Act-Resist" of the women's empowerment process.

This year marks the 25th anniversary of Bejing Declaration and Platform for Action – which committed to the improvement of human rights for women and girls, as well as the 5th anniversary of the United Nations (UN) General Assembly ratifying the Sustainable Development Goals (SDGs), including SDG5- to achieve gender equality and empower all women and girls. Unfortunately, despite advancements made in some areas of gender equality and empowerment, such as reductions in child marriage and female genital mutilation, we have seen minimal improvements in either the health indicators related to women and girls’ empowerment or expansion of these indicators to better reflect the empowerment process [1].

The empowerment process, in which disempowered individuals or groups move from critical consciousness of their choices and goals beyond the expectations and controls of other TO choice/aspiration for change TO capacity and action (i.e., agency) to enact their choices and achieve their goals TO (ideally) self/collective-determination and achievement of goals [2], [3], [4], [5], [6], [7], [8]. (See Fig. 1.) Within public health, we often measure health behaviors and assume they are indicative of agency, such as contraceptive use or institutional delivery, but we cannot presume these to be acts of agency against a given power structure. Contraceptive decision-making remains the only SDG5 indicator directly measuring women and girls’ agency as relates to a health behavior [1]. Unfortunately, accuracy of this measure as indicative of agency is unclear. The question asks whether the female partner alone, male partner alone, female and male partners jointly, or others serve as primary decision-maker(s) for contraceptive use. Is it more empowering for women to have sole or joint decision-making control? Does the woman or girl want this decision-making control, and if not, is it empowering for her to have it or not to have it? Finally, what are the consequences from other decision-makers if they do not like her decision? Is their backlash in the form of punishment and increased control (or suppression), and if so, does the woman or girl resist this control, and continue to act to achieve her goals? Newer questions are being developed to better consider these points, but are not assessed at scale [8]. The lack of information regarding choice and context relative to those with greater power in the woman and girl's environment provides little insight into agency. A similar concern is seen for the measure of early/child marriage, a known social and health risk for girls and their offspring, but a question on age at marriage offers no insight into whether the girl sought, acquiesced or was forced into the marriage [1]. Again, lack of information on choice and context impedes our ability to understand agency and child marriage in our current SDG5 indicator. If a girl under age 18 elopes consensually with a partner without her parent's knowledge, is this not an act of agency on her part, even if it is a less desirable outcome and even if it in other ways compromises other agency?

Fig. 1

The empowerment process- operating at the individual or the collective.

These examples demonstrate that acts of health agency can engage the power structure – through voice and negotiation - or can work around the power structure – through subterfuge, but may result in positive or negative health outcomes. Likely, this is the reason that measurement of agency has lagged behind emphasis on other factors relating to the empowerment process, such as assets, resources, or social norms, which we can typically agree upon as either a support or a risk. Agency in contrast requires that we accept the choices and decisions of the women and girls with whom we work, and these choices and decisions are not necessarily aligned with our desired health outcomes or even longer term agency and empowerment for women and girls. Ultimately, however, negating the choices, decisions, and acts of agency of women and girls as they relate to health or life more generally only serves to maintain disempowerment, silencing and invisibilizing women and girls. Our measurement of agency in health must include the “can-act-resist” aspects of agency, as well as the choice and consequences surrounding it by asking:

Do you want to engage in (behavior)? (choice and aspiration)

Can you engage in (behavior)? (CAN)

Have you engaged in (behavior)? This behavior can include voice/communication or organizing of a collective or the actual health behavior. (ACT)

What happened a consequence of this action? Was there backlash in the form of punishment (e.g., violence, alienation) or control (e.g., hindered mobility to prevent their further action)? Or was your desired goal achieved? (consequences)

If there was backlash, did you continue to engage in (behavior), resisting backlash in the form of attempts from others to control or stop your action? (RESIST)

We can also assess if their actions resulted in achievement of their goals

We in public health cannot lay claim to working toward SDG5 in the absence of measurement on women and girls’ health agency, respecting their aspirations and choices even if they do not align with our own. The alternative maintains health in a “power over” dynamic, in which we “experts” define the acceptable goals for patients and communities unilaterally, which will ultimately only serve to reinforce social inequalities in health [9,10]. Measurement of agency in health and empowerment must instead support women and girls’ “power to” enact change in their lives for personal autonomy, health equity, and quality of care.

Declaration of Comopeting Interest

I have no conflicts of interest to report.