ACCOUNTABILITY & POWER – When accountability meets power: realizing sexual and reproductive health and rights

by Gita Sen, Aditi Iyer, Sreeparna Chattopadhyay, Rajat Khosla

International Journal for Equity in Health 8 July 2020;19(111)  (Open access)


This paper addresses a critical concern in realizing sexual and reproductive health and rights through policies and programs – the relationship between power and accountability. We examine accountability strategies for sexual and reproductive health and rights through the lens of power so that we might better understand and assess their actual working. Power often derives from deep structural inequalities, but also seeps into norms and beliefs, into what we ‘know’ as truth, and what we believe about the world and about ourselves within it. Power legitimizes hierarchy and authority, and manufactures consent. Its capillary action causes it to spread into every corner and social extremity, but also sets up the possibility of challenge and contestation.

Using illustrative examples, we show that in some contexts accountability strategies may confront and transform adverse power relationships. In other contexts, power relations may be more resistant to change, giving rise to contestation, accommodation, negotiation or even subversion of the goals of accountability strategies. This raises an important question about measurement. How is one to assess the achievements of accountability strategies, given the shifting sands on which they are implemented?

We argue that power-focused realist evaluations are needed that address four sets of questions about: i) the dimensions and sources of power that an accountability strategy confronts; ii) how power is built into the artefacts of the strategy – its objectives, rules, procedures, financing methods inter alia; iii) what incentives, disincentives and norms for behaviour are set up by the interplay of the above; and iv) their consequences for the outcomes of the accountability strategy. We illustrate this approach through examples of performance, social and legal accountability strategies.

From the Introduction

In this paper, we go deeper by examining these three types of accountability strategies (performance, legal and social) through the lens of power so that we might better understand and assess their actual working. Why power? Because, we argue, power relations shape the realization of human rights. While the normative frames for human rights may be well defined, their actual fulfilment depends on power relations that operate at many levels. The interrogation of power must, therefore, be central to understanding whether and how accountability strategies work, and how to assess them. This holds a fortiori for sexual and reproductive rights, which are deeply imbricated in power relations from the level of households to the negotiation chambers of the United Nations….

We use a set of illustrative cases to show how power may work to reinforce a status quo, weaken an accountability strategy, or transform a situation leading to realization of sexual and reproductive rights. The cases were chosen from existing literature to cover all six of the processes/outcomes described below, through a mix of both pragmatic and substantive criteria: how well they were documented in English, whether power relations were clearly illustrated, and whether together they covered a mix of major SRHR themes. The chosen illustrations cover family planning, maternal health (maternal death reviews, and disrespect/abuse), HIV/AIDS, abortion, the functioning of community health workers, and sexual violence in conflict….

The six processes/outcomes described are: reinforcing dominant power relations, accommodation, subversion, contestation, negotiation, and transformation.