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

Some early notes and reflections:

Accountability goes in multiple directions: In order to understand CHWs as agents to improve the accountability of the health system to communities, we needed to discuss the accountability of CHW to their communities and to the health system. While CHWs are often intended to be accountable to their communities, many ultimately serve as the nurse’s helper, promoting reproductive control and immunization but unable to work on issues beyond a narrow biomedical lens. Some even serve private healthcare providers, taking commissions from private hospitals to bring patients. And what about the health system’s accountability to CHWs? Many CHWs lack employment rights, have minimal career progression opportunities, and experience stress and physical danger while going about their work.

He who pays the piper: Remuneration of CHWs remains contested. The participants were not afraid to re-examine this debate from the perspective of social accountability. If CHWs are paid by the government, how can they hold it to account? Isn’t it the case that he who pays the piper calls the tune? But insisting that CHWs work as volunteers brings out questions of exploitation, particularly since most CHWs are women. Moreover, voluntarism can also undermine the capacity to work towards social accountability: unpaid CHWs may lack time to devote to monitoring and planning and may lack the status required to raise their voices. Several participants emphasized that CHWs must be empowered themselves in order to empower communities. How does not being paid for one’s work affect empowerment? Do CHWs gain moral currency as volunteers or lose community respect?

Social accountability is a collective process. There are hundreds of thousands of CHWs in a number of countries represented at the meeting. If these CHWs are health system employees delivering quality health care, then they are indisputably advancing the right to health in the communities served. However, improved provision of services may not have a visible social impact. Social accountability is defined by Joshi and Houtzager (2012) as the “ongoing engagement of collective actors in civil society to hold the state to account for failures to provide public goods.” In the context of CHWs, this would require CHWs working together with their communities or with other CHWs. What programmatic components and contextual conditions enable collective identities and agendas to be developed among CHWs themselves and between CHWs and their communities? We discussed CHW labor rights organizing, their engagement with civil society, and their involvement in Village Health Committees as possible routes. Of course, CHW ability to participate in these processes depends on their interest and relative power in the health system and larger political context. Which brings us to our next point.

CHWs as people: Community health workers are not saints, liberators, or lackeys. They are people, often women, doing their best within weak health systems, difficult social hierarchies, and systems of deep economic inequity. Accountability is ultimately about power, and regardless of what CHW policy dictates, CHWs do feel accountable to someone. Demanding accountability from the state involves challenging systems that benefit the powerful. How much can and should be expected of CHWs, in terms of taking on the risks associated with accountability functions? In what conditions can CHWs make these demands?

It is remarkable that against all odds, we heard many examples of CHWs finding mechanisms to try to improve the responsiveness of government systems and engage in collective activism: CHWs fighting against government-sanctioned deforestation; CHWs striking and marching to demand better employment conditions and the resources necessary to provide health care in their communities; CHWs helping individuals to overcome systematic social exclusion; CHWs who could not directly protest health system failures using their insider knowledge to tip off community monitoring groups. CHWs are diverse and capable. Researchers, policymakers, and activists should listen to CHWs to identify when and how to support CHWs to engage in the larger, collective project of claiming their own rights and those of their fellow community members.

“We don’t want anything. We don’t need a single rupee or tea but only do something on water and give us drinking water”.

– Hiren(a pseudonym), male, village health, sanitation and nutrition committee members, rural northern India

While conducting an implementation research study in a marginalized area of northern India, on the implementation of guidelines to support village health, sanitation and nutrition committees (2013),  day after day, interview after interview, people explained to us how desperate they were for an adequate supply of clean drinking water. Yet, day after day, interview after interview, we kept exploring and focusing on other issues.

Yes, we took note of the urgent need for water. But as we had “a job to do” as researchers,  we moved on to other topics. Our study had to cover a lot of ground. As mentioned, we were there to learn about village health, sanitation, and nutrition committees, which were primarily set up to take collective local health action (such as organizing village health education or cleaning events) and monitor the services offered by government pre-schools and clinics.

We weren’t expecting to find such severe water shortages and terrible drinking water quality. Much of the water in this region of north India was either too salty or too high in fluoride content to be consumed. Women explained that it ruined the tea when mixed with milk. The shortage and change in water quality also affected crop cultivation and changed the pattern of production. People could only access potable water through a few deep bore wells, and the bore wells could only be used when the irregular electricity became available.

Insufficient water and poor water quality were the single most pressing issues for all the villages we visited. Yet the health committee intervention was not designed to engage in the large-scale infrastructure projects required to address this problem. Buying reverse osmosis filters, digging new bore wells, installing new motors, building new tanks, and setting up piped water systems were all (often) beyond the capacity of the health committee. Many village committees tried to address their water issues by writing request letters to the authorities. However without access to sufficient funding, and without the ability to apply political pressure, few committees made headway—at least during our one-and-a-half year research period.

What do you – researchers – do when the community’s expressed priority does not perfectly align with your public health program? In many cases, including ours, a public health intervention seeks to address important local challenges but often has little to contribute towards solving the most pressing ones, such as water shortages or unemployment.

Ideally, community-oriented public health will support communities in identifying and solving local problems. But reality is rarely like this. Many projects have a pre-determined focus. Many funders want to use evidence-based public health approaches to generate a measurable reduction in mortality and morbidity, within a fixed timeframe and fixed budget. A hand washing promotion intervention is a feasible way to achieve this goal. Conversely, an expensive, intensive and multi-sectorial attempt to bring potable water to a drought ridden fluoride belt is usually not what they have in mind.

The reason that so many public health interventions focus on valuable but secondary issues in people’s lives is that we lack the political clout or consensus to solve the bigger social problems: rampant financial inequality and unfair distribution of scarce resources. These huge, seemingly intractable, issues are the primary social determinants of health. We need to emphasize cross-sector collaboration and long-term funding for initiatives that create health-enabling environments—rather than short-term disease-specific or behaviour change oriented interventions.

The United Nation’s Sustainable Development Goals (SDGs) may help create such a push. These goals present an opportunity to renew our vision for development. Countries must set agendas, allocate finances, partner across ministries and implement development projects that are oriented around the “causes of the causes” of ill health. Just this week, for example, it was reported that  at least two-thirds of the global population, over 4 billion people, live with severe water scarcity for at least one month every year.

It’s uncomfortable to learn that a remote village is desperate for water, and then try to convince community members to get excited about joining a health committee that is not equipped to solve their water problems. Perhaps this discomfort should be a reminder to refocus on the big stuff. There will always be a tension between specific, short-term interventions (encouraging hand washing behaviour, improving health worker training and support) and broad, long term interventions (water infrastructure development, labour rights advocacy, increasing the money available for public services). Ideally we can integrate these approaches, for example through helping village health committees in India gain the power to better advocate for their water needs.

Let’s remember that our greatest work lies in addressing the broad social determinants of health. Short and medium term interventions matter too—but we need to ensure that public health remains oriented around the true priorities, even though they are the most difficult.

They are so for a reason.

I’m not talking about the recommendations we make in our reports on the social determinants and how to address healthcare inequality. I’m talking about how we live our lives.

Our work is full of accounts of injustice. While there are success stories, policy victories and research breakthroughs, our work is often sad and infuriating. We read of and speak to marginalized people denied healthcare, financially ruined by illness, disrespected in health care facilities, and struggling to access the food, employment, housing, water and sanitation needed to live well.  And when we’re not working, injustice remains ubiquitous. It is particularly visible in low and middle income countries where many of us live or visit.  I’m sure we’ve all experienced the anguish of a child begging us for change, or the dissonance of passing a slum on the way to a secure and comfortable home. The disparities in high income countries may be less stark but are nonetheless visible. Moreover, the international dealings of high income countries often support deepening global disparity.  Whether we see it or not, disparity is there.

We work in public health; being confronted with injustice is a part and parcel of our jobs. We want to develop strategies and critiques that contribute to better health systems for all and ultimately achieve health for all.

But beyond our official capacity, how do we reconcile our broader lives with our professional ethics? And what about that grey-zone in between: our offices, salaries and official travel?

How lavish should our conferences be? What kinds of hotels should we book for our visitors and ourselves? For that matter how expensive should our own homes be? Our clothes and gadgets? What kind of healthcare should we secure for our loved ones?

Some find it easy to sneer at the “Development Set”, satirizing those who “discuss malnutrition over steaks” and live in posh homes decorated with ethic knick-knacks picked up from field visits.  Then there are passionate activists who live with only the most basic belongings and give away all their money.

Others suggest there is no inherent conflict between tackling social issues and earning like your friends in banking or similarly lucrative professions. Why shouldn’t travel for work be comfortable and why can’t one seek financial stability? Impoverishment is not a pre-requisite to do good research on the social determinants of health. In fact, attracting more bright minds to socially oriented work and motivating them with payments and perks may go a lot further to change the world than expecting a few selfless saints to move mountains on their own.

Many fall somewhere in the middle. It’s not feasible to give away everything and live like Mother Theresa—and probably not that useful either if we end up burnt out. We may tell ourselves that we are trying to change policies and systems that will have broad positive implications, not toss around charity that eases our discomfort. We may note that our motivation to solve issues of disparity is grounded in a belief that everyone should have access to the good quality healthcare and broader opportunities and safety that we enjoy. We may each rationalize our comforts by saying we’re trying to bring the quality of life for the poor up, not drag the quality of life for everyone else down to an unacceptably low level.

But. But.

It still feels wrong to interview a woman in rural poverty about her daily struggle to survive and then eat a meal that costs more than she earns in a week.

It still feels wrong to discuss the poorest of the poor surrounded by opulence at international conferences.

The poem “The Development Set” certainly still stings.

Can everyone really live like us? Are we really going to win a war on poverty without fighting a war on wealth? How much does our own expenditure and resource consumption, at home and at work, have to go down to sustain a fairer standard of living for all?

Perhaps we need to set a common maximum in our field, to match the common minimums we seek for the poor. Place a cap on aspects of expenditure and compensation that allows for a good life without contributing to widening the gulf between the haves and have-nots.  However the logistics of doing such an exercise—of essentially defining “enough”—are complex, difficult and subjective.  But I think it’s a conversation we need to have.

In the short term, in our own lives, what do we do?

Burn out?

Indulge?

Give up?

Live simply?

Donate?

Compartmentalize?

Ultimately, I guess we all need to make peace with this messed up world in our own way.

The course focused on health policy and systems research (HPSR) as fundamentally  a question-driven field. The research interest, generally distilled into a specific question, is the starting point; decisions around the appropriate research approach are made based on how best to answer the question. HPSR approaches (such as realist evaluation, policy analysis and implementation research) were presented in single or half-day “capsules” (as the organizers called them) in order to introduce participants to a range of ways to study health policy and systems issues. In addition to the research approaches, the course emphasized fundamental principles that apply to all HPSR research, including understanding HPSR frameworks, ethics, social justice and gender, as well as complexity and knowledge translation.

Most participants entered the KEYSTONE course with a clear sense of an issue they wanted to study, often something that had been intriguing and bothering them for years. One participant spoke of a marginalized woman giving birth in an autorickshaw just meters from a hospital in the city of Bangalore. This injustice led her to explore how fragmentation of urban maternal health services shape user experiences. Another participant spoke of the challenges faced by policymakers in moving key decisions and approvals through system bottlenecks. He sought to explore the structural and procedural issues that constrain decision making in his state’s health department.

The questions took up issues of governance, from village-level health committees engaged in planning, managing and financing in Nagaland to the decision-making space and authority held by various Indian states within the central government’s flagship scheme, the National Health Mission. Others sought to analyze the formation and implementation of policies, such as Maharashtra’s new drug procurement and disbursement policy, and to understand the political economy of health systems, such as the process of accepting development aid, or the place for nutrition within conceptualizations of health systems.

The course coordinators, after sighing with relief for having pulled the whole thing off, are beginning to reflect on the participant feedback and think about the course’s achievements and learnings. The participants’ commitment and engagement in the material far exceeded expectations, as did the energy of the group to manage readings, quizzes, planning a research project and developing presentations for the final day’s program.  While the course was organized with a focus on teaching and classroom content, the evening cultural program put on by participants emerged as one of the most memorable aspects of the course. Time spent joking and singing together contributed to community-building in vital and unanticipated ways. Maybe next year should include an “HPSR’s Got Talent” competition? We already mentioned in another blog post that Bollywood also found its way into the regular course program.

Including participants from a range of backgrounds and regions also emerged as an important asset. Participants came from academic institutions, government health departments and NGO research organizations, as well as some outliers in clinical practice and technical advisory groups. They also came from many states across the country (although there were large Delhi and Maharashtran contingents). This diversity ensured that many tightly held opinions were challenged inside and outside the classroom, which is an important pedagogical consideration for HPSR teaching and learning.

KEYSTONE seeks to strengthen the capacity of health policy and systems researchers in India and support the development of robust national and international networks. The participants have continued to engage with one another through the Moodle online platform, sharing articles and reminiscing (and noting the after-effects of all that rich hotel food). They have also been enrolled in the SHAPES google group within Health Systems Global, to further connect with the international HSPR community.

Each KEYSTONE fellow returned home with their own finely tuned research question and preliminary research plan, which focused and clarified their interest in an Indian HPSR issue. The wide range of questions illuminate the complexity and diversity of issues requiring examination within the Indian health system. In addition, the long debates and discussions illuminate the passion and urgency felt by the group to better understand these HPSR issues and help build stronger and more just health systems. It will be exciting to watch as the KEYSTONE fellows take their research forward.