[MUSIC] We've talked about different models and frameworks for understanding community level change. In this lecture, we will look at the political economy framework. The political economy framework has some similarities to the ecological model, and it also borrows on the power coercive approach to planned change. The political economy has three levels. We look at individuals in the context of organizations and institutions to which they belong, or from which they seek services, or influence by. And then, at the third level, the broad political economy which could be similar in the ecological model to the policy making and broader community levels. The political economy model assumes that resources are allocated not on the bases of efficiency or merit, but according to power. The behavior and dynamics of visible and invisible actors within the healthcare sector, in our case. therefore, can be understood in terms of their power, class reli, position and relationship within the larger health system. The issues of where health services are located, issues that are current in the news in terms of who has access to appropriate up to date HIV/AIDS treatment. This model can look not just within a country, but look at the relationship between countries. Poor people within places like South Africa, Nigeria, have very little access to medications. Why is this? Who does have access? In terms of political economy analysis, the important role of the current status of the economy should be considered in that analysis. Whether the economy is improving. Expanding or whether it's contracting, this may help explain the access to and seeking of health services. It may also help explain how health and social problems arise. In 1986, in Nigeria, government bowed to pressure by the International Monetary Fund to start a structural adjustment program. In fact, the government did not take a loan from IMF, but they did institute many of the austerity" measures". In the process, they wanted to reissue the currency and there was a space of time of several months when the new currency was being introduced very slowly, and there was not money available for people. At the small clinic that our university runs, we could see increase in cases of childhood anemia. Colleagues that we've worked with at the Loyola University in Chicago have been monitoring adult morbidity and mortality in both urban and rural Nigerian communities for several years. And they noted that compared to their baseline measures, that over a three year period, body mass index among adults was decreasing. People were getting thinner. People were suffering nutritionally as the economy was contracting, inflation increasing. So, there are less resources, less access, and health and social problems increase under those circumstances. Several issues of interest in terms of power access include class, ethnicity. These are issues because communities themselves are not homogeneous. Class maybe determined the different communities by a different historical factors, maybe related to land ownership, maybe related to family history in terms of power. Who has position in terms of chiefs of communities, who has historically had a family member in Congress in this country for generations. Class may be determined by money, it may be determined by occupation. Many of the existing systems to determine social class place people in various professions at a higher level, and unskilled people at a lower level. Basically, class, however it's determined, is related to people's ability to access resources. And those of what would be termed higher classes in a community, would have more political and social influence and more ability to access resources. Here again, when we're talking about the power-coercive model and the need to redistribute resources, we recall Rothman's model of community action. Where those people, particularly the disadvantaged people in, in what would be a lower class would be pressuring those in power to share resources. These dynamics are going on in communities and influence, as we said, not only people's health, because, but, because of their access to resources but also their health related behaviors. More stress resulting in inability to feed your family, more diseases. Again, because communities are not homogeneous, ethnicity is another concern. Different ethnic groups exist together in communities. They may be aware of each other but they're also aware of their relative position of power to each other. Power relations, exploit, prejudices the people have against each other, and influence access to services. We find it even in many of the local governments or counties in Nigeria, for example, there are maybe two or three different ethnic groups. The location of a district headquarters in one of the south central states in Nigeria caused major interethnic clashes because the location of this headquarters was in a town belonging to one tribe. It had been shifted from a town that belonged to another tribe. And the location of a headquarters means location of access to government money by the people who are in the local government. Even in the western part of Nigeria where I worked with the majority, vast majority of people belonged to the Yoruba ethnic group, we find minorities living there. In particular, one group that stands out, even though it's only a few percent of the population, are the Nomadic Fulani people who are cattle herders. Their minority status results in them being overlooked by the health services. Their immunization coverage for children was only two or 3% for children under, under two years old compared to 40, 50% for the indigenous population. We found that in terms of the guinea worm eradication program, the local staff were not reporting cases that were occurring in the Fulani settlements. They were not seen. And the Fulani themselves were cautious about seeking health care. They, they felt that they were not treated fairly by local government health workers. They would usually seek care in more expensive private clinics. Another important issue of interest in terms of the political economy analysis. Looking at, again, the variety of different types of people in communities are gender issues. One needs to look at gender roles, power, distribution, economic access, decision making. We find different norms, different community customs in different parts of Nigeria, for example, about land ownership. In the western part, southwestern part of Nigeria, women can claim land in their father's family compound. So, you will find that women will build houses, even if they're married and their husband is living in another town. If they raise money through their business, they will build a house back home or they will claim farm land. They may not do much of the farming themselves but they will hire laborers. So, in that case, they have access to economic power. Although, in terms of decision making, they have less of a role. But, in some communities in the eastern part of Nigeria, women are not allowed to own land at all. The only way they can have access to land to make any money from it, for farming, is if they have born sons, and if they have sons that are nice and let them use some of the farmland. So, these are examples of how people have access to resources. And, of course, having access to resources mean that people can use those resources to improve themselves and their children nutritionally get access to health care when they need it. And as we noted, the community action approach of Rothman is important to consider in terms of a strategy to overcome these disparities that may be due to gender, class, and ethnicity. Political participation is not something that people in every country and every culture are used to. This slide shows an example of a community coalition of community partners for health that was established by the Basics Project in Nigeria in three major cities, Lagos, Kano, and [INAUDIBLE]. We'll be talking a bit more of that in the next lecture. But the important point is that they realized that if they were expecting mothers to take action on child survival, getting immunization for their children. Ensuring that their environment was clean to prevent diarrheal diseases. Finding prompt and appropriate treatment for their children if they had malaria. But these women needed some power. Because they may not have access to services. They may not be able to get to the immunization clinic. They may not be able to find that the clinics are offered at the right time and place. And they need to speak out to ensure that these services are available for their children, and that the environment is clean to protect their children so they need a political voice. So, one of the important parts of the project was not simply teaching mothers to recognize signs and symptoms of disease or teaching mothers the six different diseases for which immunizations were available, but organizing mock parliament to teach them the participatory and political process so that they could gain the confidence and the skills to engage in the political process and make their needs known and help bring about community change. The political economy framework looks at three different types of power based on the three different levels. At the individual level, the question arises of whether the person has situational power in the given situation they're in, their class, their ethnic group, their gender. Are they able to make concrete decisions to help themselves? Are they able to chose the kind of healthcare they want when they're sick, or their child is sick? So, within the structured rules and power relationships in that community, situational power talks about the individual's ability to make these kinds of decisions and act on them. Organizational power relates to those people within various agencies who define the rules of the game. Who gets services, who is eligible. Eligibility criteria is a very common way of including and excluding people of services in this country. And then, at the third level is the systemic or structural power. We've talked about an individual being able to make choices within the context of the rules. We've talked about organizations setting the rules. People who have structural power are able to influence the basic economy, what are considered to be important and valued resources. They set the broad, ecological or environmental context of how the game is played. They define the issues, they control the resources. Several of the health problems that we've discussed so far and that are current today can be clearly seen in terms of the political economy. We have situations of conflict between haves and have nots. We have hidden communities that are low down the ladder of, of power, we have the need for community action. Guinea worm disease has been termed the disease of neglected people. You don't find legislators, governors, suffering from guinea worm. You find poor rural farmers, who live in isolated villages that are not served by decent roads. Who do not have access to wells, electricity. These are the people who suffer from getting worm and they are not even able to have situational power to make choices because resources have not even been located in their area. Aids is another important issue to look at in terms of the political economy. Marginalized groups, or even marginalized poor countries are most affected. Alcohol and drug abuse is another important political economy issue. In many inner cities in this country, one can see or has seen some changes have been made in some places. Major advertising, billboards, etc., for liquor in those poor communities. In places where people have less resources. The people who define the context to talk about alcoholism as a disease as oppose to a socially created problem. The corporations whose advertising appears on this bulletin boards distance themselves so that they don't have to take responsibility for promoting their product. And the communities where alcohol and drug misuse is highest have th, have less political influence. Nutrition is another issue. Political decisions influence what people have to eat, what choices they can make. Mention the example from Nigeria, where it's been seen that as the economy deteriorates, that body mass index reduces, people have less food to eat. One of our MHS students at Hopkins came to Nigeria to do a study. And she interviewed people who prepare food in home, primarily women, but she also had focus groups with, with men. And they discussed with her how over the years they've changed their diet. They eat less meat. They eat less often during the day because their money will not stretch far enough to feed themselves. Especially in urban areas, the contrasts are much stronger. We see in the slide, in the background, the tall skyscrapers on the Marina, in Lagos Island, where all the big corporations, government offices have banks are located. People that work there commute from housing estates and developments from the suburbs. They come in and work there and leave. In the background, you find the indigenous community densely populated. People who were the original settlers, their descendants. They may simply be selling small things in shops. They may be barbers seamstresses. Not a lot of access to, to resources and wealth, a lot of street fighting, gangs in those areas. Another political economy issue, there is a brief reference in your reading materials about adolescent pregnancy and how during Apartheid this was a structurally created disparities. Found that in the rural areas of Transkei that 11% of the women had married by the age of 19, but 43% had already had children by that age. For more than a century, their males had been recruited to work in the cities and the mines but they were not allowed by law to bring women and children with them, to stay in the various camps and boarding houses in the city. This promoted the norm of unmarried women and the norm of children born out of wedlock. And so, the community had no choice but to accept the childbearing occurred outside of marital unions without the financial and social support that, that would have provided. So again, the political economy could help us understand that people who set the context, who control the resources, have a major influence on the health of children, maternal health, the, the dangers of having children in your teenage years.
