Training and Research Support Centre, Zimbabwe

"People have a central role to play in achieving better health," according to World Health Organization (WHO) Commission on the Social Determinants of Health (CSDH). This article presents two examples, one from Zimbabwe, showing disempowerment of the individual, and one from South Africa, showing empowerment of a community in making sustainable gains in health. The article analyses the need for effective allocation of resources for health based upon people's power to decide on actions and direct resources for health and to challenge those contexts, interests, and processes that block this.  In addition, it proposes interventions that strengthen empowerment.

In the first example, a woman in Zimbabwe loses a child, whose illness is exacerbated by lack of adequate nutrition and clean water, in a situation where a clinic cannot provide help. The second example, from South Africa, is about a community that approached civil authorities to clean up an illegal dump and now organises itself to monitor the site to prevent further dumping. The author suggests that underpinning the high levels of disease disproportionately affecting economically poor communities is "often the powerlessness of socially marginalised groups, including women, certain ethnic and indigenous groups, people with disabilities, people of different sexual orientation, the elderly, and young people outside stable long-term partnerships. While disempowerment is a product of deeply rooted economic, social, cultural, legal and political features in society, there is latitude in health to act differently."

For health systems to confront inequalities, rather than reflect them, health systems and ministries will be required to provide "the resources, capacity investments, mechanisms, laws, and orientation of health workers, to take these commitments from paper to practice." Good practices cited here include: information exchange between health services and community health committees; improvements to health and treatment literacy; and enhancing social capacities to take health actions. "They are found within the organisation of services and resources to overcome the barriers that disadvantaged communities face in accessing and using resources for health, such as in guaranteeing basic ‘free’ levels of water in urban areas, or providing for community health workers to bridge communities and services as a central part of health systems. [Footnotes removed by editor.] They recognise and invest in the resources that exist within communities, such as in client and social networks to support women’s access to health services. They exist from local to global level, connecting the realities of lives and struggles at local level over water, treatment, primary health care, food and other resources for health, to global commitments and decisions."

The interventions that strengthen empowerment are cited as including the following:

• Promoting better health through individual empowerment outcomes and action on the structural determinants of health, and encouraging greater health care use;
• Addressing health inequity by generating preferential gains for socially disadvantaged groups, either by impacting on structural factors or by being implemented within these groups; and
• Having, for women specifically, results of greater psychological empowerment and autonomy, and affecting a range of health outcomes through integration with the economic, education, and/or political sectors.

New networking and communication opportunities and technologies, as stated here, can support the growing social movements around health that want to enhance the voice of communities in decisions affecting their health. "At the same time market reforms of state-driven welfare systems have weakened principles of solidarity and universality, transforming citizens with rights and responsibilities into consumers with market power", resulting in a mix of opportunity and disempowerment, and the lack of consistent application of proven processes for empowerment in health systems.

Health Exchange enewsletter Summer 2009.