The complexity of accountability and accounting for maternal deaths in India

The human-rights approach to health may be one of the most challenging paths to a healthier world, but I believe it also may be the one with the greatest potential. Its power lies in the ability to transcend biomedical and behavioral approaches to address the structural causes and political economics of health issues by introducing the variable of accountability (Birn, 178). Birn further states, “the use of rights-based approaches to guide the formulation of government policies…establishes a framework to account for the stepwise satisfaction of government responsibilities (Birn, 179). As Birn notes and reality underscores, a human-rights approach to health is all but a dream if it is unaccompanied by social justice movements that can affect political change and use tools like litigation, advocacy, and coalition building as part of a “broad social mobilization” (180). Getting all these factors to align is rare and not often a luxury available to developing or developed nations. That said, recent developments in India provide an interesting case study on demanding accountability through a human rights-based approach to health.

Since 2008, India has “broken new ground” in securing legal accountability for maternal deaths. As part of a legal strategy, Indian lawyers, supported by organizations such as the Center for Reproductive Rights, have filed cases on behalf of the families of women who died or developed morbidities like obstetric fistulas after being denied care at government hospitals or clinics. Highlighting select cases that typify the lack of care poor mothers receive has caught the attention of the Delhi High Court and led to a landmark ruling in 2010 that for the first time in Indian jurisprudence called the denial of maternal healthcare a violation of fundamental constitutional and human rights. The judgment also emphasized that the Indian government is obligated to provide maternal health services under its constitution as well as under its international legal commitments, including the Universal Declaration of Human Rights, the Convention on the Elimination of All Forms of Discrimination Against Women, and the International Covenant on Economic, Social, and Cultural Rights.

This ruling and a few others that have followed are important and show that the Indian judiciary is responding in part to the calls to hold the government accountable in providing maternal health to its citizens. In addition to the precedent setting ruling, the high court has mandated the government pay reparations to the victims families and issued a series of orders aimed at improving several maternal health care schemes, such as the portability of benefits across state lines and access to maternal care irrespective of number of children.

However, we know that’s not enough. Only time will tell whether this is an awakening of a larger call to accountability or if it’s a powerfully worded, but ultimately powerless decree.

Any discussion of accountability raises questions about what is being accounted for and how. In this, the high court falls short. While its ruling has individual remedies and policy prescriptions, it doesn’t mandate the gathering of maternal health data such as through state governments conducting death audits for every maternal mortality.

In light of this week’s readings, this raises several questions in my mind. While it is necessary for governments and international organizations to gather national health statistics, such as MMR, isn’t it more important that this information be available at the regional, state, city, town, or village or panchayat level?

Easterly asks “Many will argue that modeled numbers (or in this case, twice-modeled numbers) are better than no numbers at all. To this we ask, better for what, and for whom?” This is a valid question. If we need the estimates to formulate policy, then doesn’t it matter more that we have better estimates for Bihar or Rajasthan or maybe even a marginalized, tribal community within Rajasthan—where the MMR might be two or three times the national estimate—than a figure for India as a whole? How useful are country estimates in the current context anyway? With India rich enough to continue its space program and ascending to a geopolitical position where it now has some resources and the incentive to plan for its own development agency, the argument can be made that it doesn’t matter as much what India’s MMR is and more what Bihar’s is. In addition, is an accurate MMR estimate equally as important in the hands of villagers protesting maternal deaths in their area or a WHO maternal health expert when it comes to affecting structural change and applying political pressure?

Furthermore, can an increased emphasis on continuous tracking at the state level help make health data a less “slippery commodity” (Byass, 1) and help improve national estimates? National health estimates are important, very important. But perhaps we should try to improve them by both employing a critical eye toward the models and assumptions used to devise estimates (as done by Easterly, Byass, Grepin) and leveraging society driven, internal demand for health care accountability.


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