As financial crises 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 shows how interventions that empower communities in health lead to better health, but explains that we still have a way to go.
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. This is not 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 stated more clearly is this: 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 or ability to decide what action to take and where to direct resources for health and to challenge any situations, interests and processes that block this. Two stories from southern Africa, presented below, show the differences in empowerment in health:
The first tells of the helplessness of an individual. A woman watches 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.
The second tells a story of collective organisation, 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.
There is little question of the difference in both social power and health outcomes in these two situations. The second leads to a positive, wider, and more sustainable gain for people’s health.
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Yet there is still little investment in the processes that build collective organisation for health. The alienation of the first story is played out again and again in millions of people’s lives. Social and economic differences are behind high levels of AIDS-related mortality, malnutrition, water borne disease and other major disease burdens that disproportionately affect poor communities. 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, in the case of health there is a reason to act differently. Health systems often reflect the inequalities in power and wealth in society, but they can also confront them.
There are examples of good practice to draw from. They include:
- Information exchange between health services and communities, for example in neighbourhood and health centre committees in Uganda, Zambia, Zimbabwe and South Africa.
- Improvements to health and treatment literacy, such as civil society work with communities in Brazil, Zimbabwe, Botswana, Malawi or Thailand.
- Enhancing social capacities to take health actions: supporting disadvantaged communities to access and use resources for health, such as 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.
- Recognising and investing in the resources that exist within communities, such as in client and social networks to support women and other vulnerable groups’ access to health services.
There is evidence that these strategies make a difference. Studies, including in low income settings, show that interventions that empower communities in health can improve health equity outcomes by enhancing the flow of health resources to socially disadvantaged groups, or encouraging use of health services.
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, supported by new networking and communication opportunities and technologies, as communities try to get their voices heard in decisions affecting their health. At the same time, market reforms of state-driven welfare systems have weakened principles of solidarity and universality. Making health care a commodity transforms people from citizens with rights and responsibilities into consumers with market power, or as shown in the first story of the mother and daughter struggling to get care, without market power. This mix of opportunity and disempowerment, and the lack of consistent application of proven processes for empowerment within 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.
Click here for a longer version of this article with full references.
Rene Loewenson, Training and Research Support Centre, Zimbabwe
Filed under: social determinants of health
