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
i®
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
REFERENCES
Abrego, D et al (undated) The Experience of
deKoning K and M Martin (eds) (1996) Participatory
Primary Health Care in El Salvador. Initiative
Research in health: Issues and experiences. ZED
of Global Health Research http://www.
Books: London.
globalhealthequity.ca/electronic%2olibrary/EI%2O
Salvador%2oPoster%2oEnglish.pdf
deVos P et al (2009) 'Health through people’s
empowerment: A rights-based approach to
CELUCT (2008) ‘The three circles of knowledge:
participation’, Health andHuman Rights Journal
How to build constructive community relations
nd).
by understanding conflicts in rural African
communities’, CELUCT: Zimbabwe.
Fals-Borda O and M Rahman (1991) Action and
knowledge: Breaking the monopoly with PAR.
Chambers R (1992) ‘Rural appraisal: Rapid, relaxed
IntermediateTechnology Publications: London.
and participatory’, Discussion paper No. 311.
Institute of Development Studies: Brighton, UK.
Fals-Bardo O (2001/2006) “Participatory (action)
research in social theory: origins and challenges’
Chomsky N (2007) What we say goes:
in Reason P and H Bradbury (eds) Handbook of
Conversations on US Power in a changing world.
action research: Participatory inquiry and practice.
Interviews with DavidBarsamian.Penguin Books:
Sage Publications: London
London
Foucault M (1977) Discipline and punishment.
Cooke B and U Kathari (eds) (2001) Participation:
Allen Lane Press: London.
The new tyranny? Zed Books: London
Freire P (1970) Pedagogy of the oppressed. Seabury
Cornwall A and A Shankland (2008) ‘Engaging
Press: New York.
citizens: Lessons from building Brazil’s national
health system’ SocialScience and Medicine 66:
Gaventa J (1980) Power and powerlessness:
2173-2184.
Quiescence and rebellion in an Appalachian Valley.
University of Illinois Press: Urbana; and Oxford:
CSDH (2005) ‘Action on the social determinants
Clarendon Press: Oxford.
of health: Learning from previous experiences’
background paper prepared for the Commission
Gaventa J (2006) ‘Finding the spaces for change: A
on Social Determinants of Health, WHO: Geneva
power analysis’, IDS Bulletin 37(6) November.
(March).
Gaventa J and A Cornwall (2008) ‘Power and
CSDH (2007) ‘Final report. Knowledge network
knowledge’ in Reason P and H Bradbury (eds) Sage
on health systems’ Commission on the Social
handbook ofaction research: Participative inquiry
Determinants ofHealth, WHO: Geneva (February).
and practice (2nded.). Sage Publications: New
York.
Danielsen L and I Scheel (2012). ‘Deep diplomacy:
The role of the People’s Health Movement in
GHW2 (2008) Global health watch 2: An
global health’, in Health Diplomacy Monitor 3(5).
alternative world health report. People’s health
25
movement.Medact Global Equity Gauge Alliance,
Loewenson R, A Laurell, C Hogstedt (1994)
Zed Books: London.
‘Participatory approaches in occupational health
research’, ArbeteochHalsa 38.
GHW3 (2012 Global health watch 3: An alternative
world health report. People’s health movement.
Loewenson R, B Kaim, F Chikomo (TARSC), S
Medact, Health Action International, Medico
Mbuyita, A Makemba (IFAKARA) (2006) ‘Organising
International, Third World Network, Zed Books:
people's power for health: Participatory methods
London.
for a people-centred health system’, TARSC/
IFAKARA (February).
Hall B (1981) ‘Participatory research, popular
knowledge and power: A personal reflection’,
Convergence 14 (3):6-iy.
Loewenson R, B Kaim, F Machingura (TARSC), I
Rusike, T Chagariro, L Mashingaidze, A Makone
(CWGH) (2007) ‘Health literacy manual for peopleHaklev S (2005) ‘Chinese barefoot doctors, a viable
centred health systems’, TARSC: Harare.
model today?’IDSCHn: Issues in International
Health.
Loewenson R (2008) ‘What does people’s power
have to do with health?’ Unpublished TARSC:
Hanefeld J, N Spicer, G Walt (2007) ‘How have
Harare
global health initiatives impacted on health equity?’
A literature review commissioned by the Health
Lukes S (1974) Power: A radical view. Macmillan:
Systems Knowledge Network, WHO: Geneva.
London
Harvey D (2005) A brief history of neoliberalism.
Mbwili-Muleya C, M Lungu, I Kabuba, I Zulu
Oxford University Press: Oxford.
Lishandu, R Loewenson, Lusaka District Health
Team, Equity Gauge Zambia (2008) ‘PRA Report
Hayward CR (2000) De-facing power. Cambridge
10: Consolidating processes for community health
University Press: Cambridge.
centre partnership and accountability in Zambia’,
EQUINET: Harare.
HEPS-Uganda (2008) ‘EQUINET PRA report:
Community empowerment and participation in
Minkler M and N Wallerstein (eds) (2008)
maternal health in Kamwenge District, Uganda’,
Community-based participatory research for
EQUINET: Harare.
health: From process tooutcomes. John Wiley and
Sons: Hoboken, NJ.
Herman E and N Chomsky (1988) Manufacturing
consent: The political economy of the mass media.
Morriss P (2002) Power: A philosophical analysis
Pantheon Books: New York.
(2nded.) Manchester University Press: Manchester.
Hickey S and G Mohan (eds) (2004) Participation:
Newell K (ed) (1975) Health by the people. WHO:
From tyranny to transformation - Exploring new
Geneva.
approaches toparticipation in development. ZED
Books:London
Newman K and H Beardon (2011) ‘How wide
are the ripples? From local participation to
Laverack G (2004) Health promotion practice. Sage
international organizational learning’, Participatory
Publications: New York.
learning and action PLA Notes 63, 11 ED.
Lebowitz M (2004) ‘The rich human being: Marx
OSF-AMHI (2011) ‘Practitioners convening on
and the concept of real human development’,.
community monitoring for accountability in health:
Paper for presentation at Marx Conference,
Convening Minutes’, 18-20 July 2011. Johannesburg,
Havana, Cuba (4-8 May 2004).
26
South Africa. (www.copasah.net/practitioners-
Tandon R (1988) ‘Social transformation and
convening-at-johannesburg.htm).
participatory research’, Convergence 21 (2-3):518. University of Namibia (2008) ’PRA report:
Reason P and H Bradbury (eds) (2008) Sage
Community action for health in Ontevrede
handbook of action research: participative inquiry
community’, EQUINET: Harare.
and practice (znded.). Sage Publications: New York.
WHO (1978a) ‘Declaration of Alma Ata’ WHO:
Rifkin S (1986) Lessons from community
Geneva. http://www.paho.org/English/DD/PIN/
participation in health programmes. Health Policy
alma-ata_declaration.htm.
and Planning i(3):24O-249
WHO (1978b) ’Primary health care, the Chinese
Rodney W (1973) How Europe underdeveloped
experience’, Report of an inter-regional seminar,
Africa.Bogle-L’Ouverture Publications: London; and
WHO: Geneva.
Tanzanian Publishing House: Dar-Es-Salaam.
WHO (2007) ‘Everybody’s business: Strengthening
SATHI (2012) ‘People are reclaiming the public
health systems to improve health outcomes’, WHO
health service: Qualitative report on community
framework for action. WHO: Geneva.
based monitoring and planning of health services in
Maharashtra’, Supported by NRHM, India
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
- Media
15571.pdf
Position: 139 (48 views)