The rights-based approach to health and health care has been the subject of much discourse since the 1948 Universal Declaration of Human Rights (UDHR). Article 25 of the UDHR bestows on everyone “the right to a standard of living adequate for them to enjoy good health and well-being including food, clothing, housing, medical care, social services and the right to security in the event of circumstances beyond their control such as unemployment, disability, sickness, widowhood, old age or any other lack of livelihood” . However, there has been considerable emphasis on the rights-based approach by scholars and practitioners alike post 2015 MDGs, especially in relation to maternal health care . This is due to the sub-optimal progress gained in reducing maternal mortality in the past few decades, particularly in developing countries. In the light of the sustainable development goals (SDGs) number 3 calling for a reduction in maternal mortality ratio (MMR) of less than 70 per 100,000 live births, it is reasonable that the rights-based approach is on the centre stage of research and practice.
Generally, it is argued that access and utilization of maternal health care services such as antenatal care, skilled birth attendance and emergency obstetric care for all, are essential in the prevention of maternal and child mortality . Often the insufficient progress in maternal health care and utilization of health services in general is attributed to weak and underdeveloped health systems and lack of political commitment to improving women’s health due to their secondary status in society [2,4,5]. This points to issues of public policy and politics rather than medical science per se, as the main source of inadequacies in the prevention of maternal mortality. This is because it is within the realm of politics and public policy that national resources are distributed across the population, including health and health care expenditure. The human rights framework is important in this regard as it creates the political and social benchmarks to assess the process and outcomes of development and to underscore the power hierarchies that may lead to injustices in the social, economic and health sector .
Furthermore, the rights-based approach provides the powerful normative role of human rights in establishing accountability for protections and freedoms of the people, especially the vulnerable . It also ensures active agency by those vulnerable to human rights violations. Since national governments tend to designate deserving and undeserving claimants of rights, it is plausible to assume that this distinction depends on the extent to which governments are accountable to the population . Accountability is possible only with a vigorous and well organised civil society, which is also only possible in a society that respects civil and political rights .
Agency is a critical element in the rights-based approach because the right to health and health care, for example, cannot be left to governments alone to address. The government is not the only entity capable of inflicting suffering on vulnerable populations, individuals and the social system also can. A human rights approach seeks to give voice to those who are vulnerable and enable them to change their conditions for better outcomes. In this framework, rights are not only universal standards that should be followed by states, but a medium through which the suffering of people by the state, individuals acting in response to the social structure or the social structure itself, is ameliorated. Thus, individuals, groups, and communities whose rights have been or are likely to be violated should have choices and capabilities enabling them to claim their rights to better conditions [7,9–11]. Thus, the rights-based approach is or should be complemented by the capability approach as highlighted by many proponents of both the rights-based and the capability approach [12–15].
The capability and the human rights approach have a common motivation of fostering the dignity and freedoms of the individual. The capability approach highlights the critical importance of substantive freedoms and opportunities of individuals and groups while the human rights approach highlights the importance of values such as freedom, dignity and respect, equality and none discrimination, participation and autonomy and the arrangements that are needed to protect and promote these . In practical terms, what people can positively achieve including good maternal health outcomes, is influenced by economic opportunities, political liberties, social power and the enabling conditions of good health, basic education and encouragement and cultivation of initiatives.
It can be argued that disparities in maternal health care utilization in SSA are a manifestation of limited freedoms in the sense that societal gender division of labour assigns responsibilities of pregnancy and childbirth to women, whom at the same time occupy subordinate positions and have limited access to resources in society. Beyond this, it is also established that women die during childbirth because of specific organisational failures . It is important for the rights and freedom approaches to maternal health care to form core strategies and tools to address root causes of maternal morbidity and mortality (MMM) within and beyond health systems as well as the other violations of women’s sexual and reproductive health and rights across their lives including formative gender inequalities and structural violence against women .
The implication of the rights-based and capability approaches is that women who are empowered by capability functionings and live in countries that respect human rights and are accountable to the population, may be better able to utilize maternal healthcare services. However, there are still debates in literature whether in fact civil liberties contribute to attainment of socioeconomic entitlements such as health and health care . Additionally, we have seen that the social system though community agency, as well as individual agency is important in ameliorating the suffering of individual persons. Reviewed literature indicates that there are no studies which considers these issues especially in low resource societies like sub-Saharan Africa and many researchers call for further studies linking civil and political rights to specific outcomes . The current study fills the gap in literature by examining the extent to which the rights-based and capability approaches can contribute to maternal healthcare utilisation. We apply multilevel models on country, community and individual level variables representing freedom and capability functionings to not only delineate the effects of country and community level factors but also to control for individual level characteristics.