Session report: “You want to deal with power while riding on power”: Visualising the social ecology of power in politics and policy in health systems

Earlier this month at the Seventh Global Symposium on Health Systems Research in Bogota, Colombia the ARISE consortium hosted a session on power, “You want to deal with power while riding on power”: Visualising the social ecology of power in politics and policy in health systems. In the session participants were asked to engage in active listening, noting down power aspects they identified in the different presentations, and marking them on a scale of micro, meso and macro power, in order to inform later discussions.

Global perspectives on power in participatory health research and co-production approaches – Kim Ozano

Kim Ozano presented first, starting off by explaining the social ecology of power framework. She explained that socio-ecological approaches situate individual behaviors within broader interpersonal dynamics and societal structures. The framework provides a tool to examine how power inequities filter across the different levels. Kim shared some insightful and reflective questions to help monitor power:

• Have stakeholders reflected about and shared their preconceived assumptions?
• Are the most powerful stakeholders aware of how their privileges influence processes and outcomes?
• Is there a real commitment to shared decision-making?
• Are the most powerful stakeholders ready to give up power and the privileges that come with it?

Kim noted that micro self-reflexivity brings about cultural humility and commitment to shared decision making. Her presentation included helpful examples of ARISE Hub’s community based participatory approach. She then moved to the meso level questions that help monitor power. This set of questions deal with project governance structures, reward systems, effective techniques for dialogue, structures of representation and associational landscape. Finally, macro level questions handle distribution of power and resources, democratic quality, historical and economic factors. An ARISE Hub participant in India had this to say as an illustration of power at the macro level, ‘the concept of participatory action research is … new to a lot of communities … they really struggle to understand that they actually have the power to make a difference … they’re more used to researchers just coming in and dictating what needs to be done.’

In conclusion, she pointed out that despite widespread assumptions about power sharing, adopting a participatory approach is not in itself sufficient for addressing power inequities. The ‘Social Ecology of Power’ framework is a useful tool for engaging with power inequities. While many researchers are intentional about engaging with power, actions and available tools must be used more systematically to identify and address power imbalances.

Navigating the politics of health in informal settlements in Freetown – Abu Conteh

Abu Conteh from Sierra Leone Urban Research Center gave a glimpse of how governance systems are organised within informal settlements. Governance in these settings fall under two categories: formal and informal. The formal governance system has agencies within government departments with elected representatives. Formal governance includes local service providers like community health workers. Informal governance includes community chiefs, chairpersons, youth and women organizations. The reason they are called informal is because these actors in many cases only emerge to address specific leadership gaps or service provision needs in these settlements.

In terms of roles, the people in the formal categories enforce laws, provide development services such as roads, health, education, and water infrastructure. They also represent these settlements politically, appointed via elections. In the informal category, participants don’t make laws, they mostly enforce them. Their roles also encompass leadership representation, community engagement and advocacy to enhance the provision of services.

Power dynamics in Freetown’s informal settlements, as in many other settings, are very complex. This is due to overlapping roles between the formal and informal actors, as well as overlapping powers in legal instruments. There is also the issue of contested boundaries among elected and non-elected leaders such as members of parliament, councilors, and community chiefs. Factions and political patronages impact accountability on service delivery. A lack of blueprint on recognised power structures is also a major issue.

Owing to all these challenges and how it has impacted development over time, the ARISE Hub team works to create healthy shared spaces for accountability. Some of the approaches that they have introduced and that have been beneficial include: recruitment and training of co-researchers for data collection and analysis. They have also been instrumental in identifying spatial boundaries and service barriers through GIS mapping. They were a critical component of the COVID-19 response: through developing COVID-19 messages for the community, carrying out community campaigns to increase awareness of the pandemic, and increase vaccination uptake. ARISE also facilitates reflexivity sessions to reflect on power relationships and dynamics in the research space; in order to find ways of navigating them. Abu also detailed the impact of the community based participatory research.

Social ecology of power in politics and policy in health systems – Emily Wangari

Next participants heard from Emily Wangari, who described her role as a community health volunteer. Emily is a resident of Mathare informal settlement and a member of Muungano wa Wanavijiji since 1997. Emily described how she now serves as a national federation leader and has taken part in several research studies. She works to mobilise the community and train residents on data collection. She works as a link between community stakeholders such as health departments, and supports the community in advocating for the needs and services they are entitled to such as access to health and water, and fighting against land evictions.

She is responsible for one hundred households in her role as community health volunteer and collects and reports health indicators on these households. She covers thirty households every month and reports to the sub county health department. She additionally responds to emergencies from community members experiencing gender-based violence and links them to emergency services. She also keeps a record of expectant mothers, and monitors children’s development.  Emily also mobilises and trains other CHVS and is also involved in conflict resolution as part of the Nyumba Kumi intitaive. During research studies, she accompanies the co researchers to ensure that the study runs smoothly. She is also the community’s representative at the local administration level, and so provides a bridge between formal and informal power structures.

Dealing with Power in Community-based Participatory Research: ARISE Project Experience in Bangladesh – Bachera Aktar

In her presentation Bachera Aktar explained that it is important to take into account context, gatekeepers, local power dynamics, people and positionality in order to understand power dynamics. Context includes: location, history, demography, economic conditions, local culture, customs and gender norms. It is also important to identify who gatekeepers are, their categories, roles and influences and most importantly, think through strategies on how best to keep them informed and included in projects.

It is vital to understand the local power dynamics which can be understood through an analysis of the local hierarchy, the positions of different stakeholders and the influencing factors. Based on this analysis, projects and programs can then implement strategies and approaches that are a good fit. Understanding the people in the different groups that make up the community is integral for the success of any research project. There are different groups that make up a community including the marginalised, the socially excluded and the religious/ethnic minorities. They all have different characteristics and experiences, and they occupy different positions in the local hierarchy. Researchers also need to reflect on the power they possess just by virtue of being researchers and outsiders of the community. That awareness has helped many researchers balance the power imbalances.

Participation, accountability and power in neoliberal times: The waste worker context in India – Prasanna Saligram

Prasanna Saligram highlighted that social accountability has three pillars: voice, answerability, and enforceability. It involves an informed citizenry exercising voice that is transmitted to those with enforcement capabilities in order to generate answerability from authorities. Participation is seen as the voice of the poor exercising their agency to influence institutions and policies and thereby holding them accountable. It is also linked to human and ‘citizenship’ rights. Perceived failure of the welfare state and ‘inefficiencies’ led to the rise of neo-liberalism in the 1980s across the world. This rollback of the governments under neo-liberal regimes have undermined traditional forms of accountability.

In India, an estimated 1.5 million workers are engaged in waste work and a majority are in the informal sector. The waste supply chain has both an informal and formal set of workers. The formal comprise of: municipal sanitation workers and door-to-door garbage collectors. The informal sector is made up of itinerant buyers, street-side waste pickers and those that work at the dump yards. The neo-liberal governance and layers of informality manifest through how informal setups insulates the governments from accountability seeking mechanisms. Informal waste workers collect over 80% of the recyclable waste in India which results in considerable savings to the municipal bodies which are entrusted with solid waste management. The informal therefore subsidises the formal, and the neoliberal governance mechanisms push for more and more informal arrangements which results in layers and layers of informalisation. Waste pickers scouring the streets live near the dumping yard as they have no access to housing, social security or even sanitation equipment. The premise of participatory action research is to raise critical consciousness to give power to demand for accountability.  

Unfortunately during the session the panel did not have enough time to present Prasanna’s video, however we have uploaded and summarised his message for this blog post.

Table discussion and closing comments

Our facilitators, Bachera Aktar, Kim Ozano and Linet Okoth, ended the session by leading a table discussion on the themes emerging from the session. We’ve included some reflections from participants below:

• We need a grounded understanding of what is informal / what is formal
• The term ‘informal’ can be seen to be downplaying the role of communities. Informal seems less than, but communities have power.
• Which is more powerful, depends on the context – informal or formal? Formal gov structures very vulnerable to political changes, have less trust. Informal can be more powerful, efficient at getting community buy in. There can be a greater influence for informal voices.
• Researchers tend to have a deeper understanding of the micro level of power, as this is where their work is concentrated.
• In each level there are micro through to macro levels – structures within levels. It is challenging to face up to and understand this complexity. Power dynamics exist in everything, and we need to find a way to work within this

Sally Theobald closed the session by thanking participants for their active engagement, thoughtful questions and rich discussion. She spoke of how the session and discussion had really highlighted how intersecting inequities are playing out at different levels, and how blurred the boundaries between formal and informal actors can be.