In bringing about behavior change in public health, we often focus on the individual mother, student, or farmer. We should not forget the community structure and norms constrain for encouraging individual health behaviors. This course examines the community context of the changes needed to promote the public’s health. We begin by examining the various definitions of ‘community’ and the processes by which we ‘diagnose’ or seek to understand the structure and characteristics of different types of communities. An appreciation of community similarities and differences is necessary lest we fall into the trap of designing one-size-fits-all interventions. We need to recognize that no matter that outsiders may view a community as poor or neglected, we can find strengths and capacities for improvement in each community. Identifying community capacities and resources is the first step in facilitating community change. Different practical and philosophical approaches to change and therefore, examined. Specific to the change process is our recognition of the need for communities to participate in the design, implementation and evaluation of any intervention. We examine the concept of participation in an effort to see how different levels of involvement may affect sustainability of community change efforts. Finally a case study of a community participatory approach to onchocerciasis control in Africa is presented. Community Directed Intervention has subsequently been successfully applied to providing other essential primary health care services by and in the community, such as insecticide treated bednets, malaria treatment, vitamin A distribution, deworming medicines, and pneumonia and diarrhea case management.
Lecture 5: The Political Economy Framework
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Community Change in Public Health
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Module 3
Welcome to Module 3. This week, we'll take a look at the political economy framework as well as the concepts of community participation and involvement levels. You'll also complete your first peer review assignment this week by reading a case study and using what you've learned to describe community change.
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William Brieger, DrPHProfessor, Health Systems Program of the Department of International Health
Bloomberg School of Public Health
[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.
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