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Table 4 Limiting power framework: power limiting factors and forces observed during Cycles 1–3

From: Realising radical potential: building community power in primary health care through Participatory Action Research

 

Compulsory power ‘direct and visible’:

Direct and visible exercised by/through, e.g., police, local and national legislation

Institutional power ‘less visible’:

Exercised through organizational rules, procedures, and norms, e.g., controlling information put into the public sphere, who is involved in decision-making

Structural power ‘invisible’:

Invisible, systematic biases embedded in social institutions, generating/sustaining social hierarchies of class, gender, ethnicity and resources, opportunities, social status

Productive power ‘operates through practices’:

Invisible, operates through diffuse social discourses and practices to legitimate some forms of knowledge, while marginalizing others. Shapes meanings of different social identities

Power limiting dynamics

- Community voice typically expressed through violent service delivery protests

- Alcohol and drug abuse criminalised and stigmatised, less of public health response. Leads shift away from public health approach with collective action

- Legislation shifting the system to COVID responses limited attention to other critical public health priorities

- Top-down governance. Pronounced ‘compliance culture’ in district health system. Limited spaces for learning, little recognition of resilience, ingenuity that exist at operational levels of the system – marginalises experiential knowledge

- Poorly functional participatory governance. Limited, initial, recognition of community members as active change agents

- Discussions open to capture by dominant or powerful actors

- Parallel community governance systems and tensions. CDF varied roles within – limits potential. Traditional authorities and former tribal areas dominating democratic spaces, limits community voice

- Local politics seen in some discussions dominated by local politicians

- Little recognition of expertise from the margins, little recognition of alternative forms of data and evidence (e.g., visual data) (academic institutions)

- CHWs experience multiple challenges: lack of financial, logistic and health system support and training, lack of role clarity, insecure employment, low and no pay, poor safety, and low status

- Deeply embedded social inequalities (ethnicity, gender, class, occupation), combines with institutional biases to marginalise some voices and privilege others

- Rural village contexts – former homelands direct/visible implications around inadequate infrastructure/ racial segregation endures. Economic inequalities—generational impact

- HIV stigma endures. Systems structuring reinforces stigma in how services organised HIV/AIDs and TB remain deeply stigmatised

- Legitimizing certain forms of knowledge and knowing over others – creates stigmatising identities for people experiencing hardship

Forms of resistance/Areas that need attention

- ‘Safe spaces’ for dialogue between communities and authorities

- Reframing of AOD abuse as public health priority

- Process grounded in community needs and realities highlighted attention to HIV/TB treatment continuity, as services shifted to COVDI-19 responses

- Process claimed and protected spaces for new forms of ‘everyday leadership’ rooted in community voice, service response and data and evidence provision

- Process strategically positioned to increase visibility and legitimacy—building alliances with and influencing formal structures and actors e.g., DHMT (district level), training resources (sub-district) OTLs and OMs (Clinic and community level)

- More attention needed to enable and recognise significant resilience, capability, and ingenuity at operational levels of the system

- Consistent presence, navigating many different worlds to challenge established narratives around voice and power

- Cooperative, appreciate approach to sensitive conversations, building of alliances, relationships, and trust

- Working to strengthen platform to build collective power in different worlds: community, health system, academic spaces

- Sensitive and assertive facilitation, working to avoid imposing additional burdens in an already overburdened system

- Dominant and stigmatising narratives challenged through consistent, predictable, transparent presence. ‘Neutrality’ conferred by virtue of connection to research/data centre

- Use of different forms of media e.g., radio, podcasts to create positive narratives about community action and community health (narrative resilience)