Several recent prominent global health events – the Health Systems Research Symposium in Liverpool, and the Women Leaders in Global Health event in London among them – demonstrated interest in the role of power in health systems and in health systems research. A group of interested researchers and practitioners affiliated with SHAPES (Social Science Approaches for Research and Engagement in Health Policy and Systems) and Emerging Voices for Global Health, both thematic working groups of Health Systems Global, have had follow up conversations on power and health systems. This blog represents a summary of some of our musings on these developments.
Power as a ‘fuzzword”: We agree that applying theories of power can be critical to understanding health policymaking and implementation, as well as the social determinants of health and population health status. However, we are concerned by references to power as a general, catch all concept that is not easily mutable. Power as a ‘fuzzword’ may not advance knowledge or promote change, whereas thorough applications of power as a lens may help us to identify the drivers of global health injustices ranging from health disparities to implementation failure. Moreover, we are anxious to move beyond explication of power dynamics to identify actionable strategies and tools that provide avenues for change. Are there particular ways of looking at power that make this easier?
Not enough reflexivity: Some in this group expressed discomfort with researchers assessing power as an external phenomenon that affected communities in other places, but not our own work. Researcher reflexivity is one approach to naming, acknowledging and addressing/accounting for certain types of power. However, just as we may uncritically engage power as a macro concept, we may insist rhetorically on the importance of reflexivity but fail to put it into practice in a robust way. The dynamic of the outside researcher who fails to see his/her role in the political economy of health research can be more acute in the context of the neocolonial past (and present) of global health. Northern or otherwise elite voices are often louder, and while those with louder voices may advocate for more diversity and inclusion in global health, some might be unwilling to question or concede their own privilege and prestige. Key institutions can also neglect or muzzle honest engagement with both inter- and intra-organisational power dynamics. UNAIDS, for example, was positively appraised for its gender-related policies, but it took an outside review to identify the extent and impact of patriarchal culture that existed within the organization despite these policies.
How does power shape ‘what’s in’ in global health? Lack of reflexivity influences our own research and global health agendas. The dynamics researchers ignore are likely to be similarly absent from the agendas of national and global policy makers. This in turn undermines our ability to understand and address the very power dynamics shaping health disparities. Of course, there is ample rigorous, empathetic, community driven research on health policy and systems. Yet, there are also issues – so-called “big invisibles” – consequential in health systems – that remain underemphasized in global health. By way of example, SHAPES members mentioned corruption, disrespect and abuse in maternity care, access to safe abortion, informal payments for health care, and hospitals detaining patients because they are unable to pay, but doubtless more exist. Germane to people’s experiences, these issues are shaped at multiple levels of the system, including national politics and policies and global health governance, and are also deeply contextual. Moreover, these dynamics and relationships of power have taken shape over time. SHAPES members emphasized that it isn’t possible to fully understand their present iteration without reference to their historical underpinnings.
How do we ‘see’? Whether or not we acknowledge them, the persistence of these invisibles in global health is evidence of power. Moreover, failure to acknowledge such issues is a further exercise of agenda-setting power – by researchers, policy makers and programmers. SHAPES members opined that intentions are key. In this context, conscious use of theories of power is important. Are we applying these theories just to our particular research topic and site, or to the ecology of global health governance that includes ourselves? Are we thinking of power as a political scientist may, as a top down system wherein individuals have limited decision space given political and economic structures? Do we also apply an anthropological lens so that we see how people at all levels apply and subvert mechanisms of power to suit their own needs? Or, do we think of power as Foucault did, as a pervasive system that regulates our language and behavior? And, what about the postcolonial underpinnings of these power theories – essentially western in origin, but used in the context of understanding LMICs? Our choice of approach has consequences for our research and for the global health agendas we create and inform.
These issues surfaced in our discussion of power and HPSR, but there are certainly others, and we welcome a robust discussion on those topics as well. Stay tuned as we try to tackle the practical issue of identifying approaches to studying power and health systems that facilitate both rich description and subsequent action.
The authors wrote this blog on behalf of SHAPES