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.