Modelling Equity in Global Health: Using Participatory Action Research to Bridge the Gap Between International Agencies and People in Southern Africa

BY SAM BRAKARSH

Introduction

Global health is a paradigm aimed at increasing equity through access to health. However, it is riddled with contradictions. It operates within a hierarchy of power where decisions are frequently made at a great distance from those upon which the interventions are enacted and so the voices of communities are lost. Participatory Action Research (PAR) critiques the flow of information and power, redefining how—and by whom—knowledge is produced. It emphasises lived experiences and focuses on the centrality of community involvement in order to incorporate local voices in policy design and implementation.  But this is not a solution. It represents a small aspect of a more complex model change to build community ‘voice’ into a countervailing power to the large global health agencies and distant policy makers. 

Outlining a Problem: An Exploration of Power Flow in Global Health

The story of the PlayPump is a favourite critique of over-romanticised global health quick fixes.1 It was a simple proposal. Constructing colourful merry go rounds in rural African villages connected to water pumps. Every time the children spun the wheel, water would gush into an elevated tank designed as a community reservoir capable of providing for up to 2,500 people. The attraction of the idea drew tens of millions of dollars’ worth of donations and the Non-Governmental Organisation (NGO) set their target at building 4,000 pumps across Africa. But we know how this story ends. Within two years, many of the PlayPumps were found abandoned and, in particularly upsetting cases, communities began forcing children to push the wheel. It became a perverse image of a device built in joyful colours being used as a symbol of oppression. The NGO did not weigh the context in which they built the pumps when conducting their analysis and they did not include communities in the implementation process nor consult them about whether a PlayPump was wanted. 

It is easy to use this narrative as a bludgeon against the “Western” condescension towards the third world; to see it as a highlight of the first world’s belief that they are able to find solutions in a matter of weeks to challenges African communities have been wrestling with for decades. I do not disagree. The critique often proceeds, ending with the notion that global organisations should learn to resist the ideas of romantic, large scale changes and instead focus on the small shifts for which they can patiently understand the contexts.1 Once again, I concur. However, the foundation of both critiques has the potential to slide into a pitfall. 

What is a valuable cautionary tale is easily—and frequently—generalised to the entirety of the global health field, reaching the conclusion that the development arena is inherently damaging and cannot work.1 The danger of such an extension is that it overlooks the fact that global health is built upon a more universal structure of abusive world power.2 It is not an isolated arena. Global health is not digging the riverbed, it is a boat flowing down on the water. As such, an argument to restructure the technologies of large-scale global health practices is ideologically sound but strategically lame. To achieve such an aim effectively is predicated on changing a far greater system. This is not to say that it is justifiable to dismiss ideology entirely in the name of strategy, but we must find a marriage between these two conceptual frames.  

In order to develop this union, it is necessary to explore the broader systems of power and information flow operating around global health practice. 

The above figure captures an interpretation of the flow of information and power between various actors in a global health network, particularly suited for a Southern African context. Interventions usually have the unique aim of improving the lived experiences of those closest to the problem: the community members. This target audience exists at the bottom of the power ladder. Within the community there is a local structure of power through the village leadership and local health centre committees, upon which point there is a bifurcation of channels of information flow.3 On one arm, the model extends into the governmental system, moving up through the various tiers of administrative health until reaching the ministry at a national level. The left arm develops into the international relationship between community, professionals, and larger agencies such as NGOs. It is noteworthy that interactions between the two branches are primarily limited to the upper echelons with one side—the left—holding the purse strings and therefore capable of determining health policy.2 

So, when viewing a hierarchy of influence, who is global health for? A key element of this interpretation of power structures are the individual agendas under which the foreign branch operates. Beginning near the top, international agencies have constructed processes where their achievement is validated based on how much work they can complete. They sit comfortably in the matrix of dominance where many agencies are competing against one another for the most weight on the global health arena.2 In turn, their impact is predicated on how much funding they are able to receive. And who are the funders? The United States is the largest funder of the World Health Organisation and companies such as Chevron and Coca-Cola are central donors to The Global Fund.4 An agency working in rural Africa is forced to mould themselves to the frameworks of those who fill their pockets. As such, the voices from above are far more pronounced than those from below.5 

The same challenges occur in global health research and academia. The predominant institutions of higher learning in the field are in the Northern hemisphere despite their research predominantly occurring in the Global South.4 When universities make partnerships in the South it is often as a business strategy to brandish their own name just as much as it is to build local capacity.4 Furthermore—and all too frequently—academics based in the developed world will neglect to include partners, place the names of those involved in research on their publications, or ensure that the findings are shared and used by those being researched. It is important to recognise the multitude of counterexamples to each one of these critical claims, but that does not negate what they reveal.6 Researchers are judged with the same emphasis on output that exists for development agencies.2 This relationship has an echo that rings dangerously close to colonialism. It is a form of resource extraction except the resource is now information and academic clout. This is one of the great ironies of global health: using an inequitable process in an attempt to achieve equity.

The value of critiquing the top-heavy dominance in this argument is not to demand that it be flattened; but instead to realise the depth at which its “scientific, programmatic, and policy imperialism” is ingrained not only within itself but within the global system in which it sits.4,7 It is not fruitless to continue this radical pressure in an attempt to limit this dominance, but there is an alternate approach. It is liberating to take the centralisation of abusive power as a given and look to methods of strengthening global health from the bottom up. Building participatory channels of action and communication, beginning at the community level, provides a new lens through which to bridge the gap between policy makers and people. 

The Participatory Action Research (PAR) Framework

PAR is a methodology designed to carry out health intervention and research from the community level up with an emphasis on local agency and context. Its central component is to directly involve those who are affected by the conditions that the intervention aims at alleviating, placing equal emphasis on the dual metrics of science and practice.8  However, the term “participatory” is often hazily defined. It necessitates an exploration of the subject-object distinction in research as well as an understanding of the roots of parallel systems of knowledge production and transfer.6,9

“Participation” is increasingly accepted by large funding bodies, but they treat it loosely. They take the term to mean any form of involvement with a group other than the professional researchers.8 Although this is a valuable first step, it is a tamed version of PAR and leaves significant room to play into the same forms of control. PAR differs from other research paradigms in its critical examination of the subject-object distinction. Even amidst participation, many research practices assume an objective measurement of society while they themselves are separate from the web of interaction.6 Communities are not a homogenous entity that can be treated as an object of study. In fact, the very term “community” can act as a smokescreen for the multitude of various identities and struggles that exist within; drawn along the lines of wealth, gender, sex, race, religion, and age to name a few. As such, recognising the heterogeneity of context means that research cannot avoid how its own social context fits into the web and frames the manner in which they angle their questions. Through PAR, participation goes beyond engaging with local actors, and recognises that they are not objects of examination. They become researchers in their own right, making explicit their subjectivity as part of the social web. 

One of the challenges with this approach is that, although it is desired in practical contexts, participatory research is often dismissed in academia as an illegitimate scientific method.8 This is not an entirely unfounded claim. By nature of PAR embracing subjective participation, traditional researchers believe that it loses the scientific distance that is required for academic credibility. However, it is also true that the dominant forms of knowledge are resistant to participatory methods because it challenges the status quo of how ideas are produced and communicated.9 

Knowledge Production and Participatory Action Research

 Looking back to the graphic above, the diagram equates the flow of power to that of information. Although these are not identical concepts, they are connected since power is involved in deciding what information and knowledge is deemed valuable. This, in turn, affects how information is used to impact the lived experiences of communities. However, not all arrows represent the same form of relationship. There is no single matrix through which all knowledge is produced. Different cultures and levels on the diagram have separate channels of information presentation. The challenge occurs when those in positions of global influence—the funders, international agencies, researchers, and policy makers in this case—deem one form of knowledge transfer as valid while dismissing alternatives. 

It is one thing to outline this proposal for the engagement with alternative means of dialogue in global health but, when left as a theoretical lens, the critique remains lame. A valuable example grounded in the Southern African context is the use of oral traditions and art as a means of sharing and understanding knowledge production.9 Historically, oral poetry and art served as a medium for political accountability and communication. Under the rule of Mzilikazi—the famed 19th century southern African King and founder of the Ndebele tribe—oral poetry was very prevalent. It was the only channel through which criticism of his leadership and rule was tolerated. The oral poets acted as the spokesmen—and, unfortunately they were indeed predominantly men—of the people and they used the medium to voice their concerns up the chain of power.10 Since this form of production is not written nor argument based in a manner that is accepted in the current global health framework, it is often forgotten.

A present-day manifestation of this method of communication and how it can be incorporated in global health discourse arises in a Malawian famine.11 Hunger as a technical issue differs from hunger as an experience. The experiences provide a lens into social dynamics that are often missed by conventional quantitative research. In order to synthesize the two components, researchers looked at the songs sung by Malawian women during the crisis. They revealed the particularity of their suffering as they sang about men travelling far distances to find food and then settling with other women in areas where it was more abundant, leaving their wives and children behind.11 The researchers engaged with a secondary, culturally bound form of knowledge and, in this way, developed an understanding of context and complexity that would otherwise be lost. 

This incorporation of existing modes of articulation is a first step. It falls in the realm of well-constructed ethnography that effectively transposes these artistic, experiential forms of expression into the language of the dominant. However, the element of participation is not fully pronounced. A prominent artistic example of using similar foundations in a participatory framework is Theatre of The Oppressed developed by Augusto Boal in the Brazilian barrios.12 The approach uses theatre as a means of dialogue, using community members as both actors and audience. It breaks down the performer/spectator barrier by presenting problems without solutions and leaving the gathering to “discuss” the solutions by stepping into the arena and developing various possibilities through performance. In the Southern African context, this is being used in chief meetings to strengthen systems of accountability and channels of communication.6 This is one of many approaches to research and action that is participatory, providing full respect to the community member as both researcher and actor, using local channels of knowledge production and experience. 

In this manner, PAR emboldens the arrows at the base of the power/information flow graphic. It provides mechanisms for community members to metaphorically—and literally—speak. Strengthening this link is a necessary but not sufficient step in improving the equity in voice across the global health landscape. It acts as a subtle countervailing power to the aims of the larger, more removed actors in the system for those who chose to listen.

It is at this point where PAR begins to falter when in conversation with larger structures. People at the community level are aware of what they need for their own health but they are less aware of how their personal health fits into the larger structures of power and accountability.13 Therefore, they are unsure of how to communicate the information that is beneficial to policy makers.6 As a result, people higher up the chain of command—in both the national and international branch—need to listen. However, in this process, policy-makers and researchers need to be sensitized to a different perception of communities: they are not merely the bearers of problems that demand responses, but are stores of knowledge in their own right.14 

It is important to recognise that these “sensitised” people exist. The critique on global health programs and institutions is necessary only insofar as it finds the cracks and chasms to fill while recognising that there is still firm soil around them. There are many conscientious global health projects, leaders, and institutions in positions to listen to the expressions of communities who act as a check for large-scale practice. It is the role of PAR to channel local voices in these directions. 

Limitations of Participatory Action Research

It is naïve to assume that PAR can eliminate a longstanding trend of power abuse. It strengthens the community’s ability to mobilise but, in many regards, they will still be at the whim of policy makers and large agencies. Looking to the graphic, civil society mobilisation, political accountability and democracy among many others on the right prong are vital. And, on the left, reduction in funding and research agendas associated with a global system of output obsession are equally necessary. Focusing on PAR does not permit anyone to forget the relevance of all other agents.13 

A second key limitation is that PAR acts in opposition to prevailing discourse in both policy work and academia and so will continue to be dismissed on a larger scale. Such a research approach is significantly more time-intensive and is less likely to reveal silver bullets in pursuit of which some agencies have built their bureaucracies. Additionally, the outputs are—intentionally—entrenched in a particular context meaning that research is challenging to generalise. This is complicated further by the fact that it is difficult to assess the rigor of PAR projects and so the scientific community is prone to dismissal.8

PAR has noteworthy success on small scales, bringing communities and even district councils together to address collective problems in an empowering space.6 However, this is where the reach of PAR traditionally stops. There are few examples of PAR being enacted on a broader landscape, let alone as a mechanism to change a global paradigm from the bottom up. As a result, this is not its predominant intention. It is a means of community engagement that provides a substitute to the prevailing channels of intervention.

Conclusion: Modelling Equity

Global health strategies are not devoid of abuse. In the last few decades there has been an outburst of valuable self-reflection on how its potential for harm stands on near equal footing with its potential for significant world benefit as a force for equity. PAR acts as an alternate conception of community based global health in a manner that redefines the production and framing of knowledge.15 

Equity is not limited to resource allocation. Treating all people and communities with respect and ensuring local agency is a health intervention in and of itself.16 As global health practitioners continue to reflect on their role in a larger system, the recognition that equity in process and not merely an objective is imperative. Global health must model equity with the same fervour that it claims to fight for it. Perhaps with this paradigm shift, PlayPumps would not have gained so much traction. The direct needs of the communities would have been voiced and heard, and processes of participatory change would have begun. The needed shift is not necessarily that large agencies should dream small, as Hobbs concludes,1 but that communities and policy makers should dream together. 

Sam Brakarsh is a Senior from Zimbabwe. He is majoring in social psychology and is in
the special program in global health. He can be contacted at sam.brakarsh@yale.edu

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References

  1. Hobbs M, (2019). Stop trying to save the word: Big ideas are destroying international development. In Foundations of Global Health: An Interdisciplinary Reader (ed. PJ Brown and Closser S), pp. 470-479 
  2. Deaton A, (2015). The great escape: Health, wealth, and the origins of inequality. Princeton: Princeton University Press.
  3. EQUINET, (2014). Health Centre committees as a Vehicle for social participation in Health Systems in East and Southern Africa. EQUINET.
  4. Horton R, (2014). Offline: The case against global health. The Lancet 383: 1705
  5. Biehl J and Petryna A (2013). Critical Global Health. In Biehl J and Petryna (Eds) When People Come First: Critical Studies in Global Health, pp.1-20. 
  6. Loewenson R, Laurell AC, Hogstedt C, D’Ambruoso L, & Shroff Z, (2014). Participatory Action Research in Health Systems: A methods reader. Harare, Zimbabwe: EQUINET.
  7. Milanović B, (2016). Global inequality: A new approach for the age of globalization. Cambridge (Mass.): The Belknap Press of Harvard University Press.
  8. Bergold J, and Thomas S, (2012). Participatory Research Methods: A Methodological Approach in Motion. Forum: Qualitative Social Research.
  9. Tandon R, (1988). Social Transformation and Participatory Research. Society for Participatory Research in Asia.
  10. Vail L, & White L, (1991). Power and the praise poem: Southern African voices in history. University Press of Virginia Currey.
  11. Martin M, (1996). Issues of power in the participatory research process. Participatory Research in Health, Zed Books, London.
  12. Boal, A. (1985). Theatre of the Oppressed (C. A. McBride, Trans.). New York: Theatre Communications Group.
  13. EQUINET, (2007). Reclaiming the resources for health: A regional analysis of equity in health in east and southern Africa. Kampala, Uganda: Fountain.
  14. Minkler M, et al., (2012). Community Based Participatory Research: a strategy for building healthy communities and promoting health through policy change. Policy Link, Oakland, CA.
  15. Loewenson R, Laurell AC, Hogstedt C, (1994). Participatory Approaches in Occupational Health Research. Arbette Och Halsa, Goteborg (working paper 38).
  16. Wilkinson RG, & Pickett K, (2011). The spirit level: Why greater equality makes societies stronger. New York; London; New Delhi; Sydney: Bloomsbury Press.    

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