Health Exchange

As financial crisis and shortfalls in health workers draw global attention, there is a possibility that we lose sight of a key resource for achieving our aspirations and rights in health – people! Rene Loewenson of the Training and Research Support Centre, Zimbabwe tells us more.

The Commission on the Social Determinants of Health has echoed at global level the point made in many prior reports – people have a central role to play in achieving better health (WHO CSDH 2008). This isn’t a new perspective. ‘Community involvement in health’ (CIH) has been recognised as a critical dimension of health systems for many decades. The 1976 Alma Ata declaration made participation a central feature of primary health care. The 1987 World Health Organization (WHO) Harare declaration proposed reorientation of political and health systems to support such participation. Perhaps what is now being more clearly stated is that making sustainable gains in health and in the effective allocation of resources for health is as much about power as about method. One aspect of this is peoples’ power to decide on actions and direct resources for health and to challenge those contexts, interests and processes that block this.  Nina Wallerstein (1992) describes this social empowerment as ‘people’s ability to act through collective participation by strengthening their organisational capacities, challenging power inequities and achieving outcomes on many reciprocal levels in different domains: including psychological empowerment, household relations,… transformed institutions, greater access to resources, open governance and increasingly equitable community conditions’ .

Two stories from in southern Africa, presented below, exemplify differences in empowerment in health:
The first tells a story of the helplessness of an individual, with a woman watching her child die from a preventable disease, unable to create a healthy environment and unable to obtain the support she needs from health care services:
“We get water maybe twice a week. My five-year-old daughter had fever and diarrhoea.  I took her back to the clinic three times, but every time they said I should give her food and lots of water – that there was nothing they could do because they had no drugs. I thought about taking her to the central hospital, but it costs so much money. I just hoped… but my daughter died.”
Resident of a high density area Harare, Zimbabwe  McGreal, C (2008)

The second tells a story of collective organisation around a health problem, where communities are engaged with authorities to keep their community healthy:
“We approached the Municipality about the illegal dumping. They agreed to clean the dump site.  Now it’s us, the community members who are monitoring that site.  We are very determined that no-one should dump there again.”
Community Health Committee, E Cape, South Africa in Boulle et al (2008)

There is little question of the difference in both social power and health outcomes in these two situations, with the second achieving a positive, wider, and more sustainable gain for people’s health. Yet there is still little investment in the processes that build collective organisation for health, and the alienation of the first story is played out again and again in millions of people’s lives. Behind high levels of AIDS-related mortality, malnutrition, water borne disease and other major disease burdens disproportionately affecting poor communities are social and economic differences. Underpinning these is often the powerlessness of socially marginalised groups, including women, certain ethnic and indigenous groups, people with disabilities, people of different sexual orientation, the elderly, and young people outside stable long-term partnerships.

While disempowerment is a product of deeply rooted economic, social, cultural, legal and political features in society, there is latitude in health to act differently. Health systems often reflect the inequalities in power and wealth in society, but they can also confront them.  So it is not surprising to find commitments such as those made by the Kenya Ministry of Health 2005 on taking the Essential Package for Health to the Community. “It is to be realized that households have the deepest interest of their own health at heart and are always trying their best even when what they do appears unreasonable. Yet the providers do not listen enough to hear what the consumers are expressing in their own terms and context, because providers tend to be rooted from their socio-cultural contexts. This leads to loss of trust as local efforts and initiatives are ignored or displaced by temporary actions that fizzle away”. What is needed perhaps are the resources, capacity investments, mechanisms, laws, and orientation of health workers, to take these commitments from paper to practice.

There are examples of good practice to draw from. They include elements of information exchange between health services and communities, as community health committees are doing in examples from Uganda to South Africa (Loewenson et al 2004; Muhinda etc al 2008; Mbwili et al 2009); of improvements to health and treatment literacy, as is happening in some areas of civil society work with communities from Brazil to Zimbabwe to Thailand; and of enhancing social capacities to take health actions. They are found within the organisation of services and resources to overcome the barriers that disadvantaged communities face in accessing and using resources for health, such as in guaranteeing basic ‘free’ levels of water in urban areas, or providing for community health workers to bridge communities and services as a central part of health systems  (EQUINET SC 2007; Loewenson 2007; Boulle et al  2008; Baez and Barron 2006).  They recognise and invest in the resources that exist within communities, such as in client and social networks to support women’s access to health services (Ongala et al 2008; Hofne et al 2009). They exist from local to global level, connecting the realities of lives and struggles at local level over water, treatment, primary health care, food and other resources for health, to global commitments and decisions (EQUINET SC 2007; Loewenson 2007).

There is evidence that these strategies make a difference.  A growing range of studies, including in low- and middle-income countries (LMICs), demonstrate that interventions that  empower communities in health can generate health and health equity gains (as reviewed in Gilson et al 2007).  A systematic review of relevant empirical studies (Wallerstein 2006) concluded that interventions that strengthen empowerment:

• Promote better health through individual empowerment outcomes and action on the structural determinants of health, or by encouraging greater health care use;
• Can address health inequity by generating preferential gains for socially disadvantaged groups, either by impacting on structural factors or by being implemented with these groups, and
• Have, for women specifically, resulted in greater psychological empowerment and autonomy, and substantially affected a range of health outcomes, where most closely integrated with the economic, education and/or political sectors.

It is probably politics that matters most as to whether the strategies are implemented. Communities in low income settings recognise this political basis of empowerment in health:
“Health is a basic human right.  We need to involve people in their own health.  Clinics must be in the communities, close to the people.  Communities must own their clinics, and know that they do so”
Community member, Treatment Action Campaign, South Africa in Boulle et al (2008)

This recognition has been the basis for growing social movements around health, supported by new networking and communication opportunities and technologies, as affected communities seek to enhance their voice in decisions affecting their health. At the same time market reforms of state-driven welfare systems have weakened principles of solidarity and universality, transforming citizens with rights and responsibilities into consumers with market power, or, as in the story of the mother and daughter struggling to get care, the lack of it (EQUINET SC 2007).   This mix of opportunity and disempowerment, and the lack of consistent application of proven processes for empowerment in health systems, suggests that while we are becoming clearer about the role of social power in health, we still have a way to go to tap it for sustainable gains in health.

REFERENCES

1. Baez, C., and Barron, P. (2006). Community voice and role in district health systems in east and southern Africa: A literature review. Discussion paper 39. In Regional Network for Equity in Health in East and Southern Africa (EQUINET).
2. Blackburn, J. and Holland, J. (eds) (1998) Who changes? Institutionalising participation in development, London: Intermediate Technology Publications.
3. Boulle T, Makhamandela N, Goremucheche R, Loewenson R (2008) Promoting Partnership between Communities and Frontline Health Workers: Strengthening Community Health Committees in South Africa, EQUINET PRA paper, Community Development Unit,  Nelson Mandela University South Africa, EQUINET, Harare
4. EQUINET Steering Committee (2007) Reclaiming the Resources for Health: A Regional Analysis of Equity in Health in East and Southern Africa. EQUINET in association with Weaver Press, Zimbabwe, Fountain Publishers, Uganda, and Jacana, South Africa.
5. Gilson L, Doherty J, Loewenson R, Francis V (2007) Final report of the Knowledge Network on Health Systems WHO Commission on the Social Determinants of Health. WHO CSDH: Geneva.
6. Goetz, A.M. and Gaventa, J. (2001) ‘Bringing citizen voice and client focus into service delivery’, IDS Working Paper 138, Brighton, UK: Institute of Development Studies.
7. Loewenson, R., Rusike, I. and Zulu, M. (2004) ‘Assessing the impact of health centre committees on health system performance and health resource allocation’, EQUINET Discussion Paper 18, February 2004. Online. Available http://www.equinetafrica.org.
8. Loewenson, R. (2007). Building voice and agency in health: public action within health systems. In S. Bennett, L. Gilson and A. Mills eds., Health, Economic Development and Household Poverty. London: Routledge.
9. Mbwili-Muleya C, Lungu M, Kabuba I, Zulu Lishandu I, Loewenson R (2008) Consolidating processes for community – health centre partnership and accountability in Zambia, Lusaka District Health Team and Equity Gauge Zambia, EQUINET Participatory Research Report An EQUINET PRA project report. EQUINET: Harare
10. McGreal, C (2008) ‘The true cost of living in Zimbabwe – no food, no job and no hope’ The Guardian 10 March 2008. http://www.guardian.co.uk/world/2008/mar/10/zimbabwe.inflation (access 15 July 2008)
11. Ministry of Health Kenya (2005) ‘Taking Kenya Essential Package for Health to the Community; Strategy for the Delivery of Level One Services’ MOH: Nairobi, Kenya.
12. Muhinda A, Mutumba A, Mugarura  J (2008) Community empowerment and participation in maternal health in Kamwenge district, Uganda, EQUINET PRA paper, HEPS Uganda, EQUINET, Harare
13. Ongala J  (2008) Strengthening communication between people living with HIV and clinic health workers in Kaisipul Division, Kenya, EQUINET PRA paper, KDHSG Kenya, EQUINET, Harare
14. Wallerstein, N. (2006). What is the evidence on effectiveness of empowerment to improve health?  Copenhagen: WHO Regional Office for Europe (Health Evidence Network).
15. WHO Commission on the Social Determinants of Health (2008)  Closing the gap in a Generation, Final report, WHO CSDH Geneva.

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Filed under: social determinants of health