Who Are We To Care! Exploring the Relationship Between Participation, Knowledge and Power in Health Systems

Item

Title
Who Are We To Care!
Exploring the Relationship Between
Participation, Knowledge and Power
in Health Systems
extracted text
Who Are We To Care!
Exploring the Relationship Between
Participation, Knowledge and Power
in Health Systems
Barbara Kaim

Foreword
The field of International Development is a rapidly growing and challenging field. While the idea

of poverty alleviation and economic growth has for remained a central concern for economists,
concerns like income inequality, social inclusion, participation, transparency and accountability

have become increasingly common ideas in many development for a including the World Bank.

As these ideas are embraced and become integrated in practical development interventions, it

is also necessary to review and understand how these ideas emerged or were first articulated.
While some ideas came from academics and universities, many ideas and concepts became
accepted as a result of the persistent struggles of practitioners in the field. COPASAH

(Community of Practitioners on Accountability and Social Action in Health) is a collective of

practitioners who have been developing these ideas and applying these principles in the field
of health governance in different places around the world. In these Issue Papers COPASAH

members have deliberated over some of their key concerns to draw lessons for future practice.
Health care is a contested area of governance and public policy action. It is also an area of

immediate concern being featured prominently in the erstwhile MDGs and in the contemporary
SDGs. In this series of Issue Papers, COPASAH members share their insights in critical issues

especially related to the inclusion and participation of the poor and marginalised communities
and how these may be negotiated or kept centre stage within contemporary development
practice. The Issue Papers draw upon the years of practice of COPASAH members and are

practical and insightful at the same time. We are sure these will provide important pointers
for practice for any development practitioner in the field of heath governance. On behalf of

COPASAH we look forward to your feedback and suggestions to continue the discussions and
sharpen our practice.

About the Authors
Barbara Kaim is associated with Training and Research Support Centre (TARSC),

Zimbabwe. She has expertise on health equity and social justice issues; building of

people-centred health systems, community monitoring for health, health literacy and

community mobilisation , reproductive health, HIV/AIDS and gender issues, with
particular focus on participatory approaches to working with young people. She has

been a facilitator of participatory processes, development of participatory educational
materials and is a Participatory Reflection and Action (PRA) trainer and researcher with
skills in participatory monitoring and evaluation. She is an adult educator with over 20
years experience as a workshop facilitator and trainer equipped with management and

coordination skills. For more information on TARSC visitwww.tarsc.org

Who Are We To Care?

Exploring the Relationship Between Participation, Knowledge and Power
in Health Systems

This issue paper is part of a series of papers commissioned by the Community of
Practitioners on Accountability and Social Action in Health (COPASAH).

Acknowledgement >
Special thanks to Dr Rene Loewenson (TARSC Zimbabwe) for her valuable inputs and
encouragement during the conceptualisation, writing and review of this paper.

To Dr Walter Flores (CEGSS Guatemala) and RenuKhanna (SAHA) India) for their

comments during peer review. Thanks also go to Dr Andrea Cornwall (University of

Sussex, UK) for external review and to the Open Society Foundations for their overall
support to COPASAH..
Cite as: Kaim B (2013). Who are we to care? Exploring the relationship between

participation, knowledge and power in health systems. TARSC, Zimbabwe, and

COPASAH

UTIVE SUMMARY
per is dedicated to those many
i countries where health
e failing to meet the needs of the

describes the impact of neo-liberalism and

globalization on health systems, and attempts
to build alternatives.

ere people with less power
lealth care providers, individuals,
communities - have few structured

opportuni ies to express their concerns openly
lly. It is aimed at those who work as

icilitators and activists at community

evel, civfl society organizations, government
personnel and anyone else iriferested in the

dinary citizens to participate in

nd have access to the resources that
j . - > ™.. . L
w. u
*. » l. • uL
determine the way their country s health system

People, participation, knowledge
and power
Despite the World Health Organization (WHO)
definition of a health system as incorporating

“all those actions whose primary purpose is to
promote, restore or maintain health”, people

have systematically objectified in a sector that is

supposed to be about and for people. This has
r
been happening for many decades, culminating
in the rise of‘neo-liberalism’ in the 1980s,

The paper is divided into three sections:

which saw the pursuit of market policies that

undermined the role of state services, including
The first section focuses on how the interaction
between people’s participation, knowledge

and power effects the functioning of health
systems. Section two pays particular attention

to approaches we can use to build a more just
and equitable health system. The final section

concludes by asking a series of questions to
. provoke and deepen our thinking on ways we

camdvercome obstacles to achieving this goal,

at both community level and as we move from
the local to the global as a strategy for change.

Each section blends discussion on concepts
and issues with descriptions of experiences and

case studies from around the globe, especially
from countries in Latin America, Asia and East

and Southern Africa, where a wealth of material

health. The status of communities changed
drastically over this time. Health systems

became more about profit than about people.
There were, and still are exceptions. In the

1970s, especially in some of the poorest rural
communities in the world, people’s participation

in health led to improvements in health

outcomes. This helped to inspire a movement
that eventually led to the WHO Alma Ata
Declaration of 1978 that gave powerful global

recognition to primary health care (PHC).

One of the premises underlying PHC is that
people’s knowledge must be respected as a valid
c source of information when developing policies

and programmes that affect their health. Just

because the knowledge is local, however, does

not mean that it serves the interests of the

::'.a

.

.

poor. In a world where there are oppressors and

health authonti

oppressed and where knowledge, as much as

any other resource, can be used to liberate or

dialogue and de



subjugate, we need to look at how alternative

forms of participatory knowledge can be used

health

as a means to social transformation and the
betterment of people’s lives.

leoples

been
concern with persister ineq

e such

Ultimately, this boils down to the issue of

approach goei under c

m callei

power. Power can be used to maintain the

Participatory a ction re

status quo, or as a form of resistance. One way
of looking at this is through a lens that views

Literature on I >ARidentifie<

power in four ways: as ‘power over’, ‘power

traditions. On ifocuses(

to’, ‘power with’ and ‘power within’ where the

ovement is its main
improve

last three forms of power are resisting the

assumeid that problems < m be

domination of ‘power over’. Each concept of

putting pressure on eitht

power carries with it different assumptions of

institutions to ftunction better in the interests

how to bring about change and its own level of

of the wider cor

participation and relationship to knowledge.

throi
or Bl

This app.o.eb open

up spaces for di:
discussion and g!ves people
the power to act based on their growing

r,

....

.

.

,

.

..

Building knowledge and practice
toward people-centered health
systems

understanding of the injustices they face.

The second tradition puts forward a more
emancipatory approach to change. It challenges

the political domination of elites who have
A people-centred health system gives voice
and agency to the poor and most vulnerable

in communities, situated in a larger context

where national and global economic and
political forces are harnessed to support

community efforts and where resources including public provision of adequate food,

water, sanitation and housing - are equitably

‘power over’ others. It seeks to change the
unequal distribution of power and resources
through the development of a collective
consciousness, mobilization and action, moving
people to look critically at themselves (‘power
within’) and to act together (‘power with4), both

important components to social change and
transformation.

shared in the interest of all. In well-functioning,

people-centered health systems, community
actions are undertaken, in partnership with

V

ooking ahead: Who are we to
care?



How do people-oriented forms of power

relate to other forms of power, such as the
state and technical information power?

Many examples in this paper and in the literature
as a whole show where ‘health through people’s

A number of questions surface as we think about

empowerment’ has led to positive outcomes in

the importance of moving from the local to the

^dfp1fe^ealtft>.Howev.er, there is much to be

global as a strategy for change:

done and many questions remain unanswered:

/•'



What do we mean by ‘we’? Who are the ‘we’
that is challenging the status quo, redefining

our knowledge base and working toward

more democratic and inclusive forms of
participation?

How do we in the health movement build
alliances with other movements?

•:

How do we make sure that the knowledge
and voices of health advocates in many

global decision-making arenas are
accountable to local actors? Who speaks

How can we be sure that participatory forms

for whom, with whose knowledge and with

of knowledge creation are really giving voice

what accountability?

to the excluded?

How can we connect the range of different

How do we move from articulating a

critique of the present status quo to

voices to develop a more ‘collective

mobilizing for action at local, national and

consciousness’ that will link up with wider

global levels in ways that involve integrating

Social arid kn owl edge processes and allow

local knowledge with critical reflection and

change to take place?

learning?

If people do get a sense of the ‘power

within’ and ‘collective consciousness’ how

These pressing questions need to be addressed.

can it be sustained, especially since these so

It is up to every one of us to take up the

often get co-opted or are out maneuvered?

challenge. We all need to care.

Table of Contents
EXECUTIVE SUMMARY

iv

1.

INTRODUCTION

1

2.

PEOPLE, PARTICIPATION, KNOWLEDGE AND POWER

3

3.

2.1

Health Systems are about People

4

2.2

Valuing People’s Knowledge

6

2.3

Power Lies at the Centre of Social Relationships

8

2.4

Making the Link between Participation, Knowledge and Power

9

BUILDING KNOWLEDGE AND PRACTICE TOWARD PEOPLE-CENTERED

HEALTH SYSTEMS

13

3.1 What do we Mean by a People-centered Health System?

14

3.2 Approaches to Building Knowledge and Practice toward

15

People-centered Health Systems

4.

LOOKING AHEAD: WHO ARE WE TO CARE?

21

REFERENCES

25

LIST OF ABBREVIATIONS

28

vii

This paper is dedicated to those many people who

in the women’s, environment or civil rights

live in countries where health systems are failing

movements - this paper is specifically looking at

to meet the needs of the majority, and where

the impact it has on the health sector. The paper

people with less power - whether individuals,

is divided into three sections:

families, communities, or health care seekers,



The first focuses on how interaction between

have few structured opportunities to express their

participation, knowledge and power effects

concerns openly and critically. Those with power

the functioning of our health system/s.

have control over what knowledge is shared,

S

how resources are used, with what outcomes

to approaches we can use to build a more

and to whose benefit. Those with unexpressed or

just, equitable and people-centred health

dormant power have little influence over policies,

system, specifically approaches in systems

structures and social norms that affect their lives
and are left to claim or create spaces where their

voices can be heard.
This unequal power dynamic - at local, national

The second section pays particular attention

improvement and the emancipation tradition.


The final section concludes by postulating a
series of questions to provoke and deepen our

thinking on ways we can overcome obstacles

and global levels - is pivotal to understanding

to achieving this goal, at community level and

the constant struggles that unfold in different

as we move from the local to the global as a

places and in different times between people

strategy for change.

and between nations. Central to these struggles
is the way people, or more usually groups of

people, use their knowledge and influence to
assert their values and ideologies. This, in turn,

impacts the dynamic nature of society, and affects
how people’s lives are constructed and how they
understand and use the systems of which they are

a part.

The paper draws on published sources, case

studies, informal discussions and community
informants. It is aimed at those who work as

health facilitators and activists at community
level, civil society organizations, government

personnel and anyone else interested in the rights

of ordinary citizens to participate in decisions and
have access to resources that determine the way

While this reality is relevant within almost any

socio- economic or political struggle, for example,

2

their country’s health system functions.

For the last 20 years, the Chikukwa community

of every member of their community. We live in

in the Eastern Highlands of Zimbabwe has been

a social system where people (should) matter.

working on a range of activities from permaculture

This cannot be taken for granted, especially in

development to strengthening marginalized

this century where we have created so many

groups such as women and youth, providing

systems’ - the education system, information

support groups for people living with HIV and

system, economic system, legal system - and

AIDS and offering preschool education for

where systems are often seen as quite alienating,

vulnerable children. The community members’

connoting something distant and impersonal, not

work is united by a common understanding that

really about people but about structures that have

despite their many differences (for no community

their own internal rules and logic.

is homogeneous) and the economic, political

and ecological challenges they have faced over

The ‘health system’ is a case in point. According

the years, the fate of their community lies in

to the WHO, a health system "incorporates

their hands. It is up to them to ensure continued

all those actions whose primary purpose is to

respect for their environment, for their local

promote, restore or maintain health” (WHO,

culture, belief systems and traditions and to

2007). Such a definition sees health improvement

continue to teach sustainability and responsibility.

as moving beyond the provision of health
services and the development of technical,

To this end, the Chikukweans have developed

biomedical interventions to include, for example,

a framework for dealing with conflict and to

a mother caring for a sick child at home, a farmer

improve internal communication. The framework

growing food for local consumption, other social

is called the Three Circles of Knowledge,

determinants of health such as access to water,

consisting of the circle of indigenous knowledge

housing and education, as well as efforts that

(that is collectively affirming the best of what

protect people against the financial consequences

traditional society has to offer), the circle of

of ill health. It also identifies equity, social justice

spiritual knowledge (which explores their own

and the participation of communities - especially

deep knowledge and innate wisdom) and the

the poorest, least organised groups who bear a

circle of analytical or transformational knowledge

disproportionate burden of health problems - as

(CELUCT, 2008). These three circles of knowledge

important factors in improving health outcomes

are interdependent and assume participation of all

(CSDH, 2005).

community members in defining and acting upon

this collective knowledge. The model recognizes

Health systems, therefore, include actions taken

that conflicts related to national resource

by women and men, old and young, in rural and

allocation, gender and the family, HIV and AIDS

urban areas, by health providers, in schools and in

and governance are often rooted in power

any other institution that works for the social and

differences in hierarchy, gender, age or ability. The

economic development of a population. People

Chikukweans, based on their own experiences

have important roles to play in all health processes

and insights, have come to understand the link

as, for example, in planning, allocating resources,

between participation, knowledge and power.

delivering services, promoting health, and
monitoring health systems. And, yet, despite these
potential roles, numerous examples abound where

2.1 Health Systems are about
People

vertical disease-focused interventions have taken

precedence over people’s active roles in defining

and taking action on their priority health needs.
The Chikukwean experience is important because
it provides a positive example of how people can

For over five decades, from the mid-1950s, some

cultivate respect for the views and experiences

dimensions of international public health have

been characterized by the proliferation of vertical’

policies reflected an ideological commitment to

programs. These programs saw implementation

unbridled market principles at a global level that,

of narrowly focused, technologically driven

through privatization and commercialization of

campaigns targeting specific diseases such as

state-owned enterprises, undermined the role of

malaria and smallpox. Despite a few notable

state services. The status of communities changed

successes, especially in the eradication of

drastically over this time - as put succinctly by

smallpox, this approach ignores the social context

Loewenson (2008) - “from citizens with public

in which people live and tends to undermine

rights and responsibilities to consumers with

the population health orientation of a health

market power, or lack of it”. Health systems

system (CSDH, 2007). Global health initiatives

became more about profit than about people.

(GHIs), such as the Global Fund to Fight AIDS,
Tuberculosis and Malaria (GF), bring enormous

However, there were exceptions. During the

amounts of money into health systems within

1970s, some of the poorest rural populations in the

low income countries (USD$ 8.9 billion in 2006

world, in countries like Guatemala, Indonesia and

for HIV and AIDS alone. Hanefeld, 2007), but

Tanzania, were improving people’s health. While

these international agencies “rarely give explicit

these program were often small-scale projects

attention to the need to take equity seriously in

run by charismatic leaders and “an expression of

their activities; these activities may actually work

a quietly functioning and informed community”,

to exacerbate health inequity” (CSDH, 2007) and

all of them recognized that people were the most

undermine people’s action at the local level.

important resource in improving a community’s

health (Newell, 1975).
This situation has been re-enacted time and again

over the last 50 years. In the 1980s industrial

Let’s look, for example, at Jorge’s story, as described

countries, through the powerful agency of the

in 1975 by Carroll Behrhorst in the book Health

International Monetary Fund and World Bank,

bythe People (Newell, 1975). Dr. Behrhorst was a

and fuelled by corporate capital and their motive

clinical doctor working with the Cakchiquel Indians

for profit, colluded with the elite in numerous

ofGuatemala. In 1962, Jorge was a five-year old boy

countries in the south to cut back on public

who lived in a village near Dr. Behrhorst’s clinic.

financing. Social services, such as health, were

He came to the clinic suffering from malnutrition, a

badly affected. As the quality and outreach

common condition (amongst others) in that village.

of public health services were undermined by

The underlying causes of Jorge’s malnutrition lay in

underfunding, a weakened public infrastructure

the political and economic environment in which he

and competition with the private sector, health

lived, where villagers had no access to agricultural

care came to be seen as a commodity to be

land due to the dominance of large plantations

bought and sold on the market, rather than

operating for the benefit of absentee landlords. It

as a basic right to be realized by all citizens

did not take Dr. Behrhorst long to realize that his

(Loewenson, 2008).

efforts to keep Jorge and his community healthy

through treating their symptoms were fruitless Why and how did this happen? How is it that

drastic changes were needed in the village itself.

people have been so systematically objectified

Thus began a whole program that started with the

in a sector that is supposed to be about and for

clinic providing short-term loans to villagers to raise

people? As already intimated, economics and

chickens and produce eggs. Over time, villagers’

politics play a large part. The 1980s saw the rise to

banded together and bought some land from one

dominance of the economic and political model

big absentee owner, using a small fund borrowed

known as ‘neo-liberalism’, which saw the pursuit

from the clinic that they paid back conscientiously

of market policies and the opening of countries

as crops began to bring in some income.

to transnational corporations (TNCs). These

5

Thirteen years later, the village is a "reasonably

2005). Despite the repressive environment in

healthy, economically viable community” (Newell,

China at that time’ and problems associated with

1975)-

x975» Jorge was a robust teenager and

devolving primary care provision without adequate

malnutrition had all but disappeared in his village.

backup, this approach saw impressive gains in the

In addition, villagers had set up community

health of the people. In 1973, an American doctor

health committees responsible for identifying and

visited China and wrote glowingly about the

monitoring the work community health promoters,

health care system there, noting that, since 1949,

trained by the clinic to undertake basic health

"there has been a pronounced decline in infant

services. Promoters were also trained as community

mortality. Major epidemic diseases have been

catalysts, working in areas such as literacy, family

controlled.... [and] nutritional status has been

planning and agricultural extension work.

improved” (WHO, 2008).

Many lessons emerged from this program,

These experiences from different parts of

including the importance of tackling basic social

the world reinforced the notion that people’s

and economic problems to improve people’s

participation was central to the functioning

health. Related to this was the realization that

of a successful health system. They inspired a

"public health work should begin with a dialogue

movement within the WHO that, together with

with the people, encouraging them to consider

earlier struggles around social and economic

themselves and their situation and to state their

rights, eventually led to the Alma Ata International

needs. People everywhere have their own ideas

Conference on Primary Care in 1975 and the

about what should be done with their lives, health

resulting Alma Ata Declaration (WHO, 1978).

and homes” (Newell, 1975:49).

In it, almost all 134-member states of the WHO
agreed to a radically new approach to health,

While this story is inspiring in its own right, it did

in which they rejected vertical, disease-focused

not influence the Guatemalan health system,

approaches in favor of accessible, integrated

mainly because of political developments

health care. Known as primary health care (PHC),

within the country. In 1976, the 35-year civil war

this approach shifted the focus from large urban

in Guatemala intensified, leading to massive

hospitals to local health providers as the first

repression and assassination of prominent activists

point of contact. Importantly, the strategy also

including the Cakchiquel Indian leaders who

embraced the role of communities and citizens,

were involved in the health program close to Dr.

including local government and civil society

Behrhorst’s clinic (personal discussions with Walter

organizations. The Alma Ata Declaration gave

Flores, CEGSS Guatemala, November 2012).

powerful global recognition to primary health care
and was lauded as one of the most important

We have to look further - to China - for an

moments in the history of people’s health.

example of a national-level program aimed to
address the health needs of the poor. In 1968,
the People’s Republic of China introduced

2.2 Valuing People’s Knowledge

the 'barefoot doctors’ program to provide
basic health services at low cost to the rural

Throughout history, popular systems of knowledge

population. Barefoot doctors lived in the

transmission and knowledge production have

community they served, usually in agricultural

been ignored by the dominant system more set

communes and collective brigades, providing

basic preventative and curative health services

through a combination of western and traditional
medicines. They also provided other services such
as immunization and improved sanitation (Hakley

1

The barefoot doctor program was implemented
during the Cultural Revolution in China when
millions of people were persecuted and displaced.
It is, therefore, questionable to what extent these
barefoot doctors empowered communities beyond
basic health provision.

on maintaining the status quo. Nevertheless,

policy makers, state officials and others within

local knowledge, passed on from one generation

the region who aims to promote and realize

to the next through imitation, oral storytelling,

shared values of equity and social justice in health.

art, music and other forms, has been embedded

They have implemented work in various areas of

in community relations, practices and decision­

health, including mental health, maternal health

making for centuries. It suffuses not only people’s

services, HIV and AIDS care, environmental

way of thinking, but also the way they feel and

health, and more broadly on strengthening

experience their environment.

mechanisms for community involvement in health

planning (Mbwili- Muleya et al., 2008; University
Paulo Freire (1921-1997), arguably one of the

of Namibia, 2008; HEPS Uganda, 2008). Their

most influential educationalists of the twentieth

work has shown the wider EQUINET family

century, understood the importance of drawing

how participatory approaches can strengthen

on community wisdom. He was born in Brazil and

communication between health personnel and

worked with the marginalized poor in slum areas

communities, enhance mutual respect and joint

for many years, until the military coup in 1964

analysis, leading to a greater understanding of the

when he was forced into exile. After that, he spent

barriers to health and strategies for overcoming

some time in Chile and the United States, and

them. In turn, other work within EQUINET,

later in Switzerland, until he was able to return to

for example in the use of sentinel surveillances

Brazil in the early 1990s. Throughout his life, Freire

on monitoring health equity and the debates

argued against a ‘banking system’ of education,

around human resources for health, has helped

in which people are treated as empty vessels into

PRA practitioners understand the value of

which knowledge can be deposited (like deposits

using multiple sources of knowledge to deepen

in a bank). Rather, he claimed, the purpose of

community actions in health.

education is human liberation where people are

the subjects of their own learning and where their

Access to communities’ or people’s knowledge is

culture, values, experiences and relationships are

not a simple panacea to the challenges we face

central to how they interpret and create their own

in making our health systems more equitable

world (Freire, 1970).

and people centered. Local knowledge is not

spread evenly throughout a community or among

This view of participatory knowledge, as liberating

communities. People may have different objectives

rather than as domesticating, has had an

and interests, and they certainly have different

important influence in the way institutions around

access to information and resources. Differences

the globe promoting primary health care have

in social status or gender or age also affect what

been working to create more equitable, people-

individuals within a community know. Therefore,

oriented health systems. Over the last 10 years, in

in defining local knowledge, we need to be clear

20 sites spanning 9 countries in east and southern

who it is that is expressing that knowledge. It is of

Africa (DR Congo, Kenya, Malawi, Namibia, South

little use only talking to a group of male leaders,

Africa, Tanzania, Uganda, Zambia and Zimbabwe),

for example, about where to place a water pump,

health organizations have been strengthening

when it is always the women who collect water.

community/health system interactions through a

process called participatory action and reflection

Furthermore, we also need to be careful that,

(PAR, also called participatory action research,

just because the knowledge is local, it serves the

see www.equinetafrica.org for all reports). These

interests of the poor. It has been argued (Gaventa

groups of health practitioners have engaged

and Cornwall, 2008; Cooke and Kuthari, 2001)

with the Regional Network on Equity and Health

that the relatively powerless may actually mirror

in Southern Africa (EQUINET) - a network

the views of a dominant, more powerful group.

consisting of professionals, civil society members,

As Noam Chomsky (American philosopher and

political activist) ironically says: “In a well-run

Nevertheless, even though mass communication,

society, you don’t say things you know. You say

such as the Internet or radio, can potentially break

things that are required for service to power”

the monopoly of powerful societal interests, we

(Chomsky, 2007). Control over knowledge

also need to be careful not to assume that greater

production, as well as how it is disseminated and

access to information means greater control over

used, is one of the main ways in which powerful

the content of that information. In a world where

societal interests are reinforced. Chomsky tells this

there are oppressors and oppressed and where

intriguing story about a pirate who was brought

knowledge, as much as any resource, can be used

before Alexander the Great (356-323 BC) who

to liberate or subjugate, we need to look at how

asked him “How dare you molest the seas with

alternative forms of participatory knowledge can

your piracy?” The pirate answered: “How dare

be used as a means to social transformation and

you molest the world? I have a small ship so they

the betterment of people’s lives. Ultimately, this

call me pirate. You have a great navy, so they call

boils down to the issue of‘power’.

you an emperor. But you are molesting the whole
world. I’m doing almost nothing by comparison”

(Chomsky, 2007:2).

2.3 Power Lies at the Centre of
Social Relationships

This is how it was, and how it continues to this

day. In the contemporary context, knowledge

Power is a complex term with multiple

control is undertaken to fulfill powerful corporate

interpretations. Supporters of a neoliberal

(for example, the tobacco or pharmaceutical

doctrine see the use of power, often referred to

industries) and state interests, using the mass

as influence, as the product of an open system of

media as one of the key ways in which society

equal competing agendas (Harvey, 2005). If certain

‘manufactures consent’ (Herman and Chomsky,

people don’t participate in the freedoms given to

1988). Through the domination of the elite,

them, it is either because they choose not to or

knowledge has become private property; and some

because of “their own apathy or inefficacy, not as

people’s knowledge has become easier to access

a process of exclusion from the political process”

than others have.

(Gaventa and Cornwall, 2008). But, as many others
- including well- known thinkers such as Stephan

This is not to say that the birth of the Internet and

Lukes, Michel Foucault and John Gaventa (Minkler

mass communication has not offered significant

and Wallerstein, 2008; Foucault, 1977; Gaventa,

new ways for people to access information, assert

1980; Gaventa and Cornwall, 2008) - have pointed

their own interests and connect with each other.

out, power affects people’s lives in much deeper

ItaiRusike (personal discussions, September 2012),

ways. Having or exercising power means some

from the Community Working Group on Health

people control and have access to information and

in Zimbabwe, tells a story about an old man in a

resources, while others do not. Any relationship -

remote rural district who approached Itai to ask

whether between individuals, groups or societies

him whether he’d met the Minister of Health

- is affected by a particular power dynamic that

before the minister went to the World Health

impacts the development of that relationship.

Assembly meeting. “No”, Itai responded. "But

8

why?” the old man asked. “Last time you were here

To explain this, Gaventa (2006), drawing on work

we told you what we wanted him to say!” The old

done earlier by Lukes (1974), developed what he

man knew about the meeting because his village

called ‘the power cube’. This cube gives a three-

had access to the Internet. In addition, note that

dimensional view of power. One set of gradients

he says ‘we’ not T, reinforcing the notion that

recognizes that power can take place at different

knowledge is - should be - collectively owned

levels - household, local, national, and global.

and used.

Another refers to where the power is acted out -

some spaces are closed to select elite who may in



Power within - where people have gained

certain situations invite others to participate but

a sense of self-identity, confidence and

within set boundaries. Then there are situations

awareness often linked to culture, religion or

where less powerful actors choose to claim a

other aspects of identity and which influences

space for themselves where they can set their

their thoughts and actions.

own agenda. Finally, there are different forms of

power - visible, hidden - where agendas are set

The last three definitions of power - ‘power

behind the scenes, or invisible, relating more to the

to, with or within’ - are all forms of power

norms, beliefs or ideology of a group (see www.

resisting the domination of ‘power over’. They

powercube.net).

are not separate entities. People, individually and

collectively, can be expressing more than one

form of power at the same time and in different

situations. The external environment - the
laws, rules, norms, customs, social identities and
standards that either constrain or enable people to

act (Hayward, 2000), affects these situations.
Linked to this is an understanding that not all uses
of power are destructive. Certainly, the abuse

of power can undermine and halt the process of

change; but Foucault (1977), in particular, argues
that the manifestation of power is not always

negative and oppressive, but can be positive
and productive - a necessary, creative source of

change.

One of the strengths of the power cube is that it
does not assume that power is always in the hands
of those who have a hold on the traditional forms

of power. Instead, it echoes work done by Foucault
(1977) in recognizing that power can also be seen

2.4 Making the Link between
Participation, Knowledge and
Power

as a form of resistance - where visible, hidden

or invisible power may be mobilized, whether
consciously or unconsciously, as strategies to

challenge or transform existing power relations.

Take a look at the pictures (Loewenson et al, 2006).
It shows four windows of two people, a nurse and

a young man, facing each other with eyes open
or blindfolded to represent the degree to mutual

This recognition of forms of‘resistance’ fits in well
with four other ways to describe power:

understanding established. Let’s call the young

man Jim and let’s say that he is an unemployed

Power over - refers to the power of the strong

youth from a remote rural area. The nurse, on the

over the weak, including the power to exclude

other hand, is from the capital city, is formally

others.

educated and has a salary income. Especially in

Power to - where individuals or groups of
people exercise agency and begin to realize

theirrights and their capacity to act.

windows 2 and 3, there is a strange dynamic being
played out between Jim and the nurse. In window
2, the nurse thinks he holds all the knowledge;

Jim is perceived to be ignorant or blind. And
Power with - which is a more collective form
of power through organization, solidarity and
jointaction to counter injustices; and finally.

Jim, in turn, is not willing to see what the nurse

has to offer. And, since the nurse perceives that
his greater status over Jim (by virtue of his age,

9

Young people ore not coming to the clinic's
health education programmes. I really don't
know what's happening.
__ -

The clinic staffs don't appreciate our
skills and how we communicate. That is

I have the information young people
need. The trouble is these young
people won't listen.

Jimmy please come to the clinic office I'd
like to discuss ideas on how to plan the next
health programme.

Source: Loewenson et al (2006)

education and position) gives him greater authority,

in which those with ‘power over’ others use that

he is also as good as blind (as reflected in window

greater power to dominate, control and exclude.

3), unwilling to listen to Jim to find out what he

Communication is impeded because those with

can offer, to understand his values, his passions, his

greater authority determine what is important or

dreams.

possible, for and by whom. Other forms of power
(‘power to’, ‘power with’ or ‘power within’) then

The two are stuck. Neither will be able to break

come into play, as groups of people begin to flex

down the barriers that separate them, until

their muscle and push the boundaries of what is

they are both able and willing to remove their

possible, demanding greater access to knowledge

blindfolds and talk with each other, with respect

and greater participation in its production, use and

and understanding. Only when they begin to

dissemination.

share their respective knowledge (window 4),
participate equally in a shared vision and, most

The question, though, is how does this interplay

important, acknowledge and attempt to change

between power, participation and knowledge play

the unequal power dynamic that exists between

itself out in relation to the development of our

them, including their unequal access to resources,

health systems?

will they slowly relearn how to interact with each

other, each from a position of strength.

These links are summarized in Table i, Interface
between Power, Knowledge and Health Systems

Take this example and broaden it outwards, placing
this dynamic in a political and economic context

The Table 1, (Interface between power, knowledge
and health systems) points to a number of issues.

10

First, the empowering processes are not linear and

more accountable. In other instances, it’s about

if marginalized groups organize themselves, they

rebuilding the health system itself or even a wider

can influence power relations and pressure the

process of seeing health rights as part of a larger

state into action (de Vos et al., 2009). However,

struggle for justice.

it is clear that each concept of power carries

with it different assumptions of how to bring

In the latter case, we are not merely talking about

about change. In some cases, it is about finding

building knowledge but about transforming

ways to work within the system, to gain access

the way people and systems interact, literally

to information usually not available to them and

to counter the monopoly of expert knowledge

then to use that knowledge to make the system

producers who exercise ‘power over’ others. When

Table 1: Interfac e between power, knowledge and health systems

Power over...

General Implications of
Health Systems

Level of participation

Relationship to Knowledge

Dominated by those

Creates a 'normative'

Public health planning and

creation shifts away from

world - in media,
education, shaping of
political beliefs-where

health systems analysis
mostly top-down. Quality

communities.

knowledge of some groups

in control. Decision­
making and knowledge

more valid than others.

and outreach of state
services weakened by
neoliberal policies and

competition with the
private sector.
Power to...

Power with...

Opens up spaces for

Introduces concept of state
accountability to meet their

ideology and begin to

discussion and debate and
expands who participates

organize; want 'a seat at

in knowledge production.

to health, for example,

the table', to be part of

Often not about creating

budget tracking.

the discussions. Usually
facilitated by civil society.

new knowledge but about

People recognize injustices
created by dominant

obligations to people's right

demanding access to
information.

Restores people's agency

Knowledge deepened

Creates the possibility for

as active participants for

through a participatory

demands at local, national

change.
Involves community
mobilization and action.

process of people acting

and international level for

together to understand

the development of a more

and change their reality.

people-centered health

Shared knowledge builds

system based on social

a sense of solidarity and

justice and equity.

collective understanding
of what the world should
look like.
Power within...

Involves capacity to

Produce own knowledge

Community participation

imagine, have hope and the

that changes awareness

in health systems is not

ability to Act and change

or world view of those

enough. Needs to be

the world (agency).

involved.

dynamically linked to

Not about wanting greater

People understand there is

access to resources and

access to what already

an alternative and become

consciousness of actions.

exists, but about wanting

strategic.

power in decision-making,

Health rights seen as part

something different. Creates

of a larger struggle for

own power base.

economic and social justice.

11

people begin to gain power it usually involves

transformative. It can just as easily be used to

greater activism and organizing. The power to

target groups to participate as beneficiaries of

act (‘power to’) and to act in concert with others

programs with the objective of improving delivery

(‘power with’) is fundamental to social change. At a

of health services. This is quite different from a

deeper level, when people begin to acquire ‘power

more empowering concept of participation that

within’ they are developing a stronger individual or

encourages people to use their own knowledge

group consciousness and a sense of identity about

and the knowledge of others to celebrate their

who they are and what change they want. This is

individual and collective strengths and agency as

when change becomes more transformative. It is

active participants for change.

not about wanting greater access to what already
exists, but about wanting something different.

Ultimately, knowledge creation needs to be

This is never quite as simple as it looks. For

“Knowledge without action is meaningless, just

example, while it is generally acknowledged

as action without reflection and understanding

linked to action, either directly or indirectly.

that community participation is one of the

is blind” (adapted from Reason and Bradbury,

determinants of positive health outcomes, i.e. for

2008:4). Although development of an equitable

health to improve, people need to be informed

health system rests solidly on our understanding

and motivated to make choices and take action

of the complexities of participation, knowledge

that promote health, it is also clear that the use of

and power relations, none can exist without its

participation as a discreet ‘magic bullet’ weakens

practical application. This directly links into the

understanding of its complex nature (Rifkin, 1986).

focus of the next section.

Participation by definition is not necessarily

12

■■

workers. (Loewenson et al, 2006:54)

So, how can we change the power relationships to

make them people centered, just and pro- poor?
How can we get to a point where participation

As we see, people-centered health systems enable

is not a form of tokenism, but connects with

people to take action to improve their health and

and builds the consciousness of communities,

the health of their community. People participate

reinforces their identity and knowledge processes,

in defining their own problems and in designing,

and leads to action?

implementing and monitoring their actions in

an empowering process. In well-functioning
As a starting point, let’s begin by exploring what

people-centered health systems, community

we mean by the term 'people centered’.

actions is undertaken in partnership with health
authorities, building a sense of trust and solidarity

3.1 What Do We Mean by a
People-centered Health
System?

and opening up new spaces in which dialogue
and development can flourish. The focus is on

strengthening comprehensive primary health care.
The role of the state in supporting these processes

At its core, a people-centered health system

is crucial, especially in providing resources to

values people’s knowledge and acknowledges

the primary level and in supporting community

the important role people play in improving their

efforts. People-centered health systems are more

health. As Loewenson et al (2006) has pointed out,

sustainable when supported by adequate health

people are important in many aspects of health

financing and progressive means of resource

systems:

mobilization. In these situations, the state can



®

People stay healthy by their understanding

become an instrument of transformation, as has

and awareness of health - parents are

been shown in countries such as Brazil where there

responsible for the health of their children,

is a political commitment to the provision of a

partners for each other’s health, and

publicly funded, rights-based health system where

communities should care for the elderly and

citizens are involved in discussions over health

poor in their communities.

policy and in mechanisms for accountability and

People share information with health services

on the conditions in their community and on
preventing and treating disease.

®



decision-making (Cornwall and Shankland, 2008)?

Community participation in health systems
can also take place in isolated pockets. During

People have local health knowledge to

the civil war against the military dictatorship

contribute to health systems, including

in El Salvador in the 1980s, one community in

information on healthy foods and local health

Guarjila came together to improve its own basic

risks.

conditions of life, constructing a potable water

People play a role in implementing health

system, houses and latrines, developing their own

actions, including outreach of health

food production system, and generally assuming

programs, caring for ill people and supporting

responsibility for their collective health. Despite

health services.

adverse conditions characterized by militarization

People set priorities and make decisions on

and institutionalized repression, health and living

how health problems should be addressed and

conditions improved dramatically, thanks to the

how resources should be allocated.

efforts of everyone in the community and under

Communities also monitor and make sure
that their services are functioning in the way

they expect. They give feedback to health

authorities and discuss issues with health

2

Ironically, we have also seen authoritarian states,
such as in Vietnam, China and Cuba, transforming
their health systems to be more people centered’,
done in a top-down manner with little focus on
participator)' or democratic processes.

the leadership of a highly organized health team

also known as participatory reflection and action

(Abrego et al, undated). Spring forward 20 years

(PRA), mutual inquiry, critical action, feminist

and the present El Salvadoran Ministry of Health

participatory research, and others. While these

is using the successes in Guarjila as a model for

different approaches may have varying goals or

the current health reform processes. “We have

perspectives (feminist research, for example, has

come to learn of this population which has strived

a much more nuanced approach to looking at the

so much to build its own health”, Ml Rodriguez,

different experiences of men and women), they all

Minister of Health, said. "We wish to support

share a common set of core principles that:

them with health that is superior and of better

®

quality.” (Quoted in Abrego et al, undated).

objects of knowledge generation.
O

3.2 Approaches to Building
Knowledge and Practice
toward People-centered
Health Systems

View people as the subjects rather than the

Include a commitment to engaging
community members and outsiders in a joint

process of learning and reflection.
Hl

Involve an empowering and power-sharing

process that attends to social inequities.


Emphasize collective ownership of knowledge

The reality is that most of our health systems are

and promote skills sharing and capacity

not people centered. However, this should not

building.

deter us. Our challenge is, first, to be clear about
what changes we are striving to achieve, and

then to find the means of getting there, step by

step. As I have argued in this paper, our ideal is
the creation of a health system that gives voice

and agency to the poor and most vulnerable in
communities, situated in a larger context where

national and global economic and political forces
are harnessed to support community efforts, and

where resources - including public provision of

adequate food, water, sanitation and housing - are
equitably shared in the interest of all. It is about

developing a caring environment where health
rights are seen as part of a larger struggle for

social justice. This is not an ideal that can be put
into practice immediately - many problems and
constraints are involved. The real challenge is to

look for entry points to help differing perspectives

emerge and, in doing so, to help move the social
change agenda forward.

Fortunately, multiple approaches have been
used to address people’s concern with persistent

inequalities in the distribution of power and
resources, and the linking of processes of knowing

to learning and action (de Koning and Martin,
1996). These all go under an overarching term

called participatory action research (PAR), but are

As Robert Chambers, a strong proponent of PRA

has said: “These sources and traditions have, like
flows in a braided stream, intermingled more and

more” (Chambers, 1992 and quoted in Minkler and
Wallerstein, 2008).

Methodologically, PAR is known for its emphasis
on the acquisition of qualitative information
- involving visual and tangible expressions of

analysis - for example, mapping, modeling,
diagramming and scoring through to methods
arising from oral traditions of communication

and dissemination of knowledge, such as songs,
drama and music. PAR also uses more traditional,

quantitative methods such as questionnaires,

group discussion formats and different ways of
ranking and scoring. The issue is not whether
the methods are qualitative or quantitative, but
rather how the information is used to validate
the firsthand, practical experience of the group

as an important source of knowledge. Integral
to this is an understanding that PAR allows for

different ways of producing knowledge that
is systematic and verifiable and leads to the

production of knowledge that can be used both

by the scientific community and for society
(Loewenson et al, 1994). Other forms of health

15

systems research can be done using PAR methods,

focusing more on substantive structural change.

such as sentinel surveillances or policy analysis,

While it is all too easy to see this as a one or

thus advancing new ways of accessing knowledge

the other’ dichotomy, Chomsky argues that

drawing on these approaches. It is not a situation

tinkering is, actually, preliminary to large-scale

of either-or.

change. As he says: “There can’t be large-scale
structural change unless a very substantial part

A key component of PAR is the commitment to a

of the population is deeply committed to it. Its

process of reflection and action, an ongoing cycle

going to have to come from the organized efforts

of learning that allows for a deepening analysis

of a dedicated population. That won’t happen,

of the problems people face and an increasing

and shouldn’t happen, unless people perceive

capacity to initiate action to bring about change.

that the reform efforts, the tinkering, are running

A healthy tension arises between knowledge

into barriers that cannot be overcome without

and action, between knowing and doing, where

institutional change” (Chomsky, 2007:121).

knowledge production itself may become a form

of mobilization (Gaventa and Cornwall, 2008).

With that in mind, let’s take a closer look at how

Thus, PAR moves:

these two traditions are used in the struggle for

health equity and social justice.
_______________

From

To

Objectivity

Knowledge for its own sake as less relevant than

knowledge for change

Individual interpretation

Group analysis and validation of evidence and

experience
Expressing needs for others to address

Addressing own needs and analyzing underlying

Separation between subject and object

The experience of those affected is the

causes to take actions

primary source of information

Statistical analysis provides the only scientific basis

Verification arises from collective agreement

for Verification

and from evaluating action based on information
generated

Acceptance

Critical thinking

Isolation

Creative action with and through others

People being treated as a commodity

A sense of humanity

Defensiveness, fear and exploitation

Appreciation and hope

Source: Adapted from Tandon (1988); Loewenson et al (1994).

Much of the literature on participatory action

Approaches for Systems Improvement

research (Minkler and Wallerstein, 2008; de

Vos, 2009; Tandon, 1988) identifies two distinct

16

The assumption underlying this approach is that

traditions in this approach. One focuses on

problems are solved by putting pressure on either

systems improvement as its main goal, and the

state or non-state institutions to function better in

other puts forward a more emancipator approach

the interests of the wider community. It does this

to change that challenges the political domination

through the pragmatic use of community-based

of elites and the structural inequities in which we

knowledge, through strengthening frontline health

live. To use the words of Noam Chomsky, one

worker/community dialogue and other forms of

‘tinkers’ and is engaged in undertaking cosmetic

acquiring information (such as budget monitoring

improvements, while the other ‘overhauls’,

or social audits). This approach opens up spaces

for discussion and gives people the ‘power to’

services by village health workers and midwives.

act based on their growing understanding of the
injustices they face.

Clearly, this program gave a strong message to

the government that it had to respond to the
A good example of this approach can be

needs of rural people. However, this in itself was

seen in the community-based monitoring of

not enough. In addition to the monitoring that

health services in India (see www.copasah.

was going on, communities were also part of a

net/practitioners-convening-at-johannesburg.

strong civil society movement linked to a national

html). In 2005, the new government in India

campaign platform for health rights in the form of

introduced a national rural health mission (www.

the people’s health movement. This meant that

nrhmcommunityaction.org) with a mandate to

key systemic issues were picked up by the health

improve the health system and overall health of

rights campaigners and used to strengthen wider

the Indian population. The government developed

social support and political commitment to CBM

clear delivery standards and guidelines under the

that were not adequately addressed through

Indian Public Health Standards (IPHS) that spelt

the CBM program. As noted in the Practitioners

out the range of services that should be available

Convening Report (OSF-AMHI, 2011): on the

at different levels of care. These guidelines were

one hand, civic organizers “plan to continue to

used as the basis for community monitoring of the

occupy and expand the spaces for community

public health system.

monitoring and, on the other, develop health

rights struggles and policy-related campaigns

Maharashtra was identified as one of nine pilot

for structural change. The belief is that when

states for this community-based monitoring

people’s knowledge and people’s organization

(CBM) program. Working with and through

are combined then change will start to happen.”

a number of civil society organizations, and

Even though there has been no major impact

coordinated at state level by the Support for

in policy changes in the health sector to date,

Advocacy and Training to Health Initiatives

mainly because of the unwillingness of the state

(SATHI), village health committees were trained

government to make such required changes, these

in community monitoring and undertook to

campaigns have been important in generating

work with community members in gathering

wider social mobilization and ongoing pressure for

information on the functioning of health services.

pro-people health system change (correspondence

The program used a number of methods, many of

with AbhayShukhla, SATHI, March 2013).

which were accessible to the illiterate, including
report cards at village, primary health care and

The Emancipation Tradition

rural hospital levels, public hearings, media

coverage and state level conventions.
Over nearly six years, SATHI has developed

community monitoring in collaboration with

partner organizations in over 600 villages in

13 districts around the state (SATHI 2012).
And, in the process, SATHI documented some
impressive improvements in rural health services,

including a reduction in prescription of medicines
to be privately purchased, putting an end to

illegal charging by some medical officers, an

improvement in health service delivery such
as immunization and an increase in extension

The emancipation tradition came into being
around the 1970s. It arose out of the struggles

against the structural crisis of underdevelopment

in Latin America, Asia and Africa and the impact
of globalization (Minkler and Wallerstein, 2008).
Influenced by such thinkers as Paulo Freire
(1970) and Walter Rodney (1973) and later by
people such as John Gaventa (2006) and Fals
-Borda (2001/2006), this tradition challenges

the hegemonic dominance of certain groups

who have ‘power over’ others. It seeks to

change the unequal distribution of power and
resources through development of a collective

17

consciousness, mobilization and action. It moves

and theory, thinking and doing. To facilitate

people to look critically at themselves (‘power

this praxis, he proposes an alternative method

within’) and to act together (‘power with’), both

of education called ‘problem posing’ which

seen as important components to social change.

concentrates on showing people that they have

the right to ask questions and to find out about
At this stage, it is useful to explore Brazilian

causes and influences in their lives. The focus is on

educator Paulo Freire’s views on emancipation.

creating a dialogue around a specific ‘generative

As mentioned earlier in this paper, Freire

theme’ that poses a problem (not a solution,which

opposed what he named the ‘banking concept’

is the more usual way of transferring knowledge)

of education that prevents the oppressed from

resonating with the reality of people’s lives.

‘restless, impatient, continuing and hopeful

Through dialoguing around this theme, people

inquiry” (Freire, 1970). He argues that the banking

develop a critical awareness of the problem that,

system teaches fatalism: the world is a given

in turn, will motivate them to act.

and “one can but submit to it”. The system of
dominant social relations, says Freire, creates a

It is not difficult to see how Freire’s work has

culture of silence that instills a negative, silenced

influenced the approaches used in participatory

and suppressed self-image into the oppressed.

action research, and particularly in participatory

To overcome this, the oppressed need to regain

reflection and action (PRA). Freire’s generative

their sense of humanity and develop a ‘critical

themes have been used in multiple ways over

consciousness’ - that is, an ability to look at

the decades - through, for example, drama

a problem, not as individually created, but as

('theatre of the oppressed’) and the use of

rooted in the socio-economic contradictions and

picture codes, as shown in the diagram above

structural problems of society.

(Loewenson et al 2006), and in a range of sectors
from health literacy, AIDS program, health

and safety, sanitation and the environment
(see present and back issues of PLA Notes
www.planotes.org).

The challenge is to move from the local to
the global. Newman and Beardon (2011) use

a beautiful image to describe the challenges

related to this process: of a pebble that has been
thrown into the water which has an immediate
visible impact - the splash - and then ripples

outwards, getting weaker and less defined as it

loses momentum. They continue: “In the same
way, a good quality participatory grassroots
process can have a strong local impact... but the
influence and impact naturally dissipates the
Source: MashetNdhlovu in Loewenson, et al (2006)

further away from the original context you get.”

The challenge is how to bring the knowledge

18

Here, it is logical to ask the question: “So, what

and information generated at community level to

can be done to let people speak for themselves

bear on international processes, especially with

so they can liberate themselves and others from

regard to decision-making and action. Progressive

domination?” According to Freire, change can only

international non-government organizations who

come about through ‘praxis’, by which he means

support the value of local knowledge and capacity,

the integration of reflection and action, practice

and who understand the unequal power dynamic

at play, have a complex role in this. On the one

and international levels. It maintains its grassroots,

hand, participatory processes are time consuming

community focus by consciously supporting the

and require a long-term commitment to building

creation of structures - called country circles

principles of equity, respect and collective action.

- and planned activities in about 70 mostly low-

On the other hand, policy advocacy involves

and middle-income countries. Its focus is on

timely inputs into complex advocacy initiatives,

opposing the weakening of public health systems,

using dense, technical language (Newman and

making health systems accountable and effective,

Beardon, 2011). It is not easy to marry these two

countering commercialization of health care, and

processes, especially when issues of downward

in ensuring access to health care for all within

accountability and attempts to turn the 'subjects’

a broader 'right to health’ framework (www.

of development into equal partners are necessary

phmovement.org, GHW 2, 2008).

ingredients to international solidarity.
There certainly are obstacles, not only within the

Social movements that have a south-to-south

larger political and economic world order, but also

perspective probably have more space in which

in relation to struggles to combine local activism

to do this. The People’s Health Movement

with horizontal global networking and advocacy

(PHM) is one such organization. Formed

(Danielsen and Scheel, 2012). The PHM has

in 2000 in Bangladesh at a People’s Health

managed to relate directly to global bodies, such

Assembly attended by nearly 1500 people from

as the World Health Organization (WHO), and has

92 countries, the PHM is a global network of

successfully initiated a People’s Health University

health activists, civil society organizations and

where hundreds of young people from many parts

academic institutions from around the world who

of the south have participated in short courses

are seeking to revive the core messages of Alma

on ‘The Struggle for Health’. Nevertheless, there

Ata. The movement has a strong critique of neo­

are still challenges to keeping the country circles

liberalism and the negative forces of globalization

active and integrated into the larger movement.

that prevent equitable distribution of resources

The motivators behind PHM continue to explore

necessary for people’s health, particularly to the

creative ways of ensuring the diversity of people

poor. The People’s Charter for Health, endorsed

involved in PHM remain the drivers of the change

by participants at thefirst People’s Health

they so clearly demand.

Assembly, calls for action at grassroots, national

19

♦Hit

It is 34 years since the signing of the

Kingdom (Cornwall and Shankland, 2008; de

Alma Ata Declaration. While there has been

Vos, 2009; GHW3, 2011) where “health through

progress in global health since that time,

people’s empowerment” (do Vos, 2009) has led

especially in life expectancy, we have also seen

to positive outcomes in people’s health.

a massive widening of inequalities between and

within countries. Despite the initial commitment

These examples show how a range of strategies

to primary health care, the conservative climate

has led to increased spaces for dialogue

of the 1980s and subsequent economic crises led

between different actors in the health system

to a global reluctance to tackle inequalities and

and an increased level of organizing at all

the underlying causes of ill health. While Alma

levels. Groups of people have confronted

Ata pointed to the importance of community-

exclusion through networking and the building

oriented comprehensive primary health care for

of social movements for change. Many are also

all, some argued that the basic concepts of this

demanding state action and accountability.

approach were unattainable because of the costs

While some of these actions are taken with the

and numbers of trained personnel required. This

support of public health structures, civil society

argument also suited the dominant neoliberal

organizations (CSOs) have played a pivotal role,

economic and political consensus of the time

especially those that have connections with local

that focused on privatization, deregulation and

communities (Loewenson, unpublished) or have

a shrinking role of the state. Instead, a selective,

managed to act as pressure groups at national or

disease-oriented approach gained dominance

global level.

and, with it, a whittling down of the earlier

commitments to equitable social and economic
development, inter-sectoral collaboration and

community participation (GHW3, 2011).
Nevertheless, despite this sustained hegemony

of the rich and powerful, this paper has shown
that it is possible to build alternatives. The
villagers in Chikukwa District, Zimbabwe,

continue to share and respect each other’s
knowledge and to build a more collective
understanding of their right to health; Thailand

and numerous other countries have made
significant progress in implementing program

to make health coverage available to all;
Maharashtra State in India is still making strides

in publicizing health service abuses of health
rights at community level through a state­

level community monitoring program; and
the People’s Health Movement continues to

mobilize health activists from around the globe

in critiquing and taking action against neoliberal
policies that undermine the right to health for
all. These are just a few examples: the literature

draws on other case studies - for example,

from Brazil, Cuba and until recently, the United

However, even though progress has been
made, much is still to be done and many sticky

questions to be addressed.
A key question is: what do we mean by ‘we’?

Who are the ‘we’ that is challenging the status

quo, redefining our knowledge base and working
toward more democratic and inclusive forms of

participation? The problem to date is that our
‘we’ is still fragmented ideologically, strategically

and geographically. This results in a subsequent
loss of collective identity. Take, for example, the

Occupy Movement in which the main message

of rampaging economic inequality got lost in “a

flurry of other equally important but somewhat

distracting issues” (Labonte plenary presentation

at PHA, July 2012). This ultimately undermined
their ability to organize and mobilize. In his
opening address at the third People’s Health

Assembly in South Africa this year, Ronald

Labonte, an authority on Globalization and

Health Equity,addressed this issue, lamenting
that our neoliberal ‘compatriots’ have learnt
the lesson of using short, sharp and simple

messages that tap into people’s moral outrage.

Their message - we blame the government for

22

usurping the rights of the individual’ - has won

examples in the struggle for more equitable,

support amongst a large number of people from a

people- centered health systems of citizens

broad range of social classes, even if the message

coming to the decision-making table, participating

is incorrect. What about ‘us’, those of us in search

in public hearings or stakeholder consultations,

of an alternative? What is our collective message?

engaging in community monitoring of government

He proposes, as a start, the following:

expenditure or implementing PRA processes, we

need to ask:
“Life that is secure,



Opportunities that are fair,
a planet that is livable and
governments that are just.”

How can we be sure that these processes are
really giving voice to the excluded?

B

How can we connect the range of different
voices to develop a more ‘collective
consciousness’ that will link up with wider

It is a slogan that most people would support.

social and knowledge processes and allow for

more fundamental change to take place?

This still does not answer the questions as to how

we can achieve these goals; questions that relate



If people do get a sense of that ‘power within’

to processes we need to engage in for us to get

and ‘collective consciousness’, how can it be

to this alternative world, a world where every one

sustained, especially since these so often get

of us is a ‘rich human being’ (Lebowitz 2004) in

co-opted or out maneuvered?

terms of our mental, spiritual and physical well­



being. In relation to the issues addressed in this

power relate to other forms of power,

paper on participation, knowledge and power,

I attempt to put down some of the burning
questions - to provoke us into deeper thinking

How do these people-oriented forms of

especially state and technical power?


Finally, to quote Hall (1981), “What happens

after people have spoken up, have made

and action:

alliances, and had a taste of countering the

One of the arguments that has surfaced in this

dominant forces? Is there a ‘memory’ of

paper is that participatory forms of knowledge

power which will resurface at a later time?”

creation and use can give previously marginalized
people greater access to their own power (their

‘power within’) to change and create a greater
sense of solidarity and potential for collective

action (‘power with’). As pointed out by Gaventa
and Cornwall (2008), there is a growing legitimacy

globally of different forms of knowledge and a

lessening of a dependence on the voice of the
‘expert’; they also state quite clearly, however,

that “simply creating new spaces for participation,
or new arenas for diverse knowledge to be

shared, does not in itself change social inequities
and relations of power” (Gaventa and Cornwall,
2008:184). The voiceless can still be co-opted or

A number of questions surface as we think about
the importance of moving from the local to the

global as a strategy for change. Clearly, solidarity

is essential if we want to create meaningful
change. Compared to just a few decades ago,
many more movements - environmental, labor,

trade, women - are questioning the logic of
capitalism and speaking out with a loud voice.

This suggests that ‘manufacturing consent’
as a strategy of the powerful is being slowly
undermined. Nevertheless, as we move toward a
more global civil society:


alliances with all these other movements?

manipulated, they are limited by the dominance

of the ‘old ways’ of interacting in these spaces

How do we in the health movement build



How do we make sure that the knowledge

including the language used, and often are

and voices of advocates in many global

silenced by their own internalized sense of

decision-making arenas are accountable to

powerlessness. While there are a number of

local actors (Gaventa and Cornwall, 2008)?

23

®

Who speaks for whom, with whose knowledge

These pressing questions need to be addressed. It

and with what accountability?

is up to every one of us to take up the challenge.

How do we move from articulating a critique

We all need to care.

of the present status quo to mobilizing for

action at local, national and global levels in
ways that involve integrating local knowledge

with critical reflection and learning?

24

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27

CBM

Community-based Monitoring

CEGSS

Centro de Estudiospara la Equidad y Gobernanza en los Sistemas de Salud,

Guatemala

28

CHSJ

Centre for Health and Social justice, India

CWGH

Community Working Group on Health, Zimbabwe

COPASAH

Community of Practitioners on Accountability and Social Action in Health

CSO

Civil Society Organisation

CSDH

Commission on the Social Determinants of Health

EQUINET

Regional Network on Equity and Health in Southern and East Africa

GF

Global Fund to Fight AIDS, Tuberculosis and Malaria

GHI

Global Health Initiative

IPHS

Indian Public Health Standards

NRHM

National Rural Health Mission, India

PAR

Participatory Action Research

PHC

Primary Health Care

PHM

People’s Health Movement

PRA

Participatory Reflection and Action

SAHAJ

Society for Health Alternatives, India

SATHI

Support for Advocacy and Training to Health Initiatives, India

TARSC

Training and Research Support Centre, Zimbabwe

TNC

Trans National Corporation

UNHCO

Uganda National Health Consumers Organisation

WHO

World Health Organisation

COPASAH Publications
ISSUE PAPERS

i.

Who are We to Care? Exploring the Relationship between Participation,
Knowledge and Power in Health Systems - Barbara Kaim

2.

How Do We Know We are Making a Difference? Challenges before the
Practitioner of Community - Abhijit Das

3.

Ethical Issues in Community Based Monitoring of Health Programmes:

Reflections from India - Renu Khanna
4.

Developing an Approach towards Social Accountability of Private
Healthcare Services - Anant Phadke, Abhijit More, Abhay Shukla,
Arun Gadre

CASE STUDIES

1.

Women in the Lead: Monitoring Health Services in Bangladesh Sarnia Afrin, Sarita Barpanda, Abhijit Das

2.

Accountability and Social Action in Health - A Case Study on Solid Waste
Management in Three Local Authority Areas of Zimbabwe - Training and
Research Support Centre (TARSC) with Civic Forum on Housing (CFH)

3.

Citizen Monitoring to Promote the Right to Health Care and

Accountability - Ariel Frisancho, Maria Luisa Vasquez
4.

Claiming Entitlements: The Story of Women Leaders’ Struggle for the
Right to Health in Uttar Pradesh, India - Abhijit Das, Jashodhara Dasgupta

5.

Community Based Monitoring and Planning in Maharashtra, India Abhay Shukla, Shelley Saha, Nitin Jadhav

6.

Empowering Marginalized Indigenous Communities through the
Monitoring of Public Health Care Services in Guatemala - Walter Flores,

Lorena Ruano

29

COPASAH Secretariat and Communication Hub

Centre for Health and Social Justice

Basement of Young Women’s Hostel No. 2
Near Bank of India, Avenue 21,
G Block, Saket, New Delhi-110017
+91-11-26535203, +91-11-26511425

copasahnet@gmail.com
www.copasah.net

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