Amanda Dorsey
This blog accompanies the Lancet Commission on Gender and Global Health seminar series. The series accompanies the development of the Commission, inviting Commissioners and Co-Chairs to discuss a key topic, question, or challenge that the Commission hopes to tackle. The series aims to involve a range of stakeholders and voices in its work and to promote discussion and debate on gender and health.
The third seminar of the Lancet Commission on Gender and Global Health series focused on the role that community mobilisation plays in combatting health inequities. The presenters were Commissioners Renu Khanna, founder of SAHAJ, and Catherine Campbell, Professor Emerita of Social Psychology at the London School of Economics. They were joined by Commission co-chair Sarah Hawkes (UCL), other Lancet Commissioners, and a YouTube live stream audience. Campbell and Khanna integrated theory and practice to discuss the successes and challenges of mobilising traditionally marginalised groups to tackle the impacts of social contexts on health. They did this in the light of the need to address structural factors and power hierarchies to achieve equitable healthcare.
Theory: Critical Approach to Community Mobilisation
Campbell began by highlighting the critical role that community mobilisation plays in addressing the broader political and structural climate around social inequalities. When implemented effectively, communities should know their rights with respect to health provision and have the knowledge to hold their health systems accountable, whilst individuals should have the means to make health-enabling behaviour changes. This approach to public health necessitates a gender lens and an intersectional approach. Otherwise, power imbalances will continue to restrict traditionally marginalised populations from making unencumbered health decisions. Campbell explained:
The solidarity and confidence that results from effective community mobilisation should serve as a launchpad for collective action by the excluded to challenge the inequalities that can’t be tackled at the local community level.
By creating local contexts where members are cognizant of their health risks and rights, public health can create what public health specialists in the tradition of Paulo Freire (1,2) deemed “health enabling communities”(3). This is not an easy feat; existing power hierarchies can seem impenetrable, but local initiatives that progress to engage in higher levels of activism hold significant potential.
Practice: SAHAJ Case Study
SAHAJ, a non-profit organisation founded 36 years ago in Gujarat, India, exemplifies this potential. Founder Renu Khanna described the work and impact of SAHAJ. The organisation utilises a gender and human rights framework and maintains an intersectional perspective to mobilise communities around key issues such as the health and wellbeing of poor and rural women. While there are existing programmes and policies in India to support women’s health, there are also structural barriers that limit implementation and uptake. SAHAJ addresses this by using the United Nations’ Sustainable Development Goals (SDG) Framework and the SDG Gender Index to track community progress. They train local organisations and disenfranchised communities to generate data, produce reports, and apply evidence in conversations with health system stakeholders. Communities are equipped with tools to hold these systems accountable. With support from SAHAJ, traditionally excluded voices express the gaps they see in local health systems.
Community report cards are one of the practical outcomes of SAHAJ’s work. Communities produce report cards which are then shared with district health officers. As well as sharing the results of their monitoring, the women’s collectives also share what they are willing to contribute towards solving the problems they’ve identified. The ongoing nature of the dialogues and co-ownership of the solutions contributes to trust-building.
While SAHAJ has made some progress against health inequities, Khanna reminded those present that we must acknowledge the challenges faced and the barriers that impede organisations from doing the same. The SDG framework may seem distant to local organisations, and governments may be inclined to fit existing programmes and schemes into this framework rather than developing something ‘fundamentally different and transformative’. Community monitoring programmes can be challenging to implement. There are also higher-order issues that the Lancet Commission is challenged to consider: grassroots efforts are competing for limited resources, organisations must carefully consider their positionality in relation to the marginalised communities they partner with, and identity politics is leading to fragmentation of social movements. Khanna then stated:
There are increasing risks in the current context, especially for the most disenfranchised who cannot afford the costs of speaking out.
For those that do take the risk, there is no guarantee that they will be heard. Dominant paradigms of what counts as evidence often exclude testimonies and narrative, even as health implementers and organisations, both local and global, talk about the importance of community voice and context. Organisations like SAHAJ are faced with these difficult challenges when their advocacy for health equity is most necessary.
Implications for the Commission
The work of the Lancet Commission on Gender and Global Health takes place at a time in which conversations about systemic inequities are at the forefront of the global collective consciousness. However multiple obstacles stand in the way of translating such conversations into practice in health policies and interventions. Whilst these can seem disheartening, Campbell reminds us that ‘optimistic social commentators have long called for a politics of hope rather than despair’ and that as long as there are individuals and groups who are willing to challenge the status quo, ‘the possibility of social change to reduce health inequalities remains alive’(4). To truly be transformative in its approach to gender and global health, the Commission will need to confront the difficult questions that grassroots organisations like SAHAJ face whilst rethinking how global public health addresses health inequities. These are rarely clear evidence-based processes, well suited to study with RCTs, nor are they as linear as public health professionals may wish. Results take time to materialise and may have only distant effects. As stated by Campbell:
[Scholars] argue that critical activists should find small cracks in the power of dominant groups and seek to widen these as much as they can rather than expecting to achieve the large-scale redistribution of wealth or power through the grand gestures of single movements.
As emulated by SAHAJ, this approach models how we should think about efforts to combat health inequities and how to tackle the many challenges facing community mobilisation. Above all, the Lancet is asked to ignite political will amongst public health researchers and practitioners to develop new frameworks for understanding and tackling the social contexts that perpetuate health inequities, recognising that this is a challenge that defies simple solutions and easy answers.
You can watch the full online seminar here.
The views expressed in this post are those of the presenters and author and may not reflect those of UNU-IIGH or the UCL Centre for Gender and Global Health.
References:
1. Freire P. Pedagogy of the oppressed. New York : Continuum; 1970. 186 p.
2. Freire P. Education for critical consciousness. New York : Continuum; 1973.
3. Tawil O, Verster A, O’Reilly KR. Enabling approaches for HIV/AIDS prevention: can we modify the environment and minimize the risk? AIDS. 1995 Dec;9(12):1299–1306.
4. Campbell C, Cornish F. Public health activism in changing times: re-locating collective agency. Critical Public Health [Internet]. 2021 Jan 15 [cited 2021 Mar 9]; Available from: https://www.tandfonline.com/toc/ccph20/current
Amanda Dorsey is an Intern at the United Nations University International Institute for Global Health.
