My Perspective – July 2019

Health care must develop deeper relationships with the people and communities it purports to serve if it’s to have any chance of being effective and sustainable


My perspective changes as I learn from my work. This perspective was written in July 2019. My current perspective is available here.

I began my work on the observation that clinical science and practice fail to appreciate how working class people and communities define their health.

This failure stems from its inability to appreciate health as more than ‘the absence of disease’, and has fuelled medicalisation, health care inflation, and the rise of non-communicable chronic conditions – all of which have made health care unsustainable.

Through my writing and research, I have explored what it takes for the health sector in high-income countries to better understand low-income communities.

I have discerned 12 practice-based principles for how to build a bridge between the health sector and communities. Collectively, they describe an inclusive and participatory process.

From the health sector’s perspective, the principles offer a framework for authentic community engagement. From a community’s perspective, the principles create the conditions for its members to influence the health sector.

More fundamentally, the principles have the potential to change both sides of the bridge.

For the health sector, the principles encourage its leaders to acknowledge people’s social contexts, something that is known to be responsible for up to 80% of health. For communities, the principles have the potential to foster their agency – their ability to influence their circumstances. This is considered to be fundamental to health.

Ultimately, what the principles reveal is the profound imbalance that exists between the health sector and communities. A solely technical understanding of health – ie ‘the absence of disease’ – prioritises the knowledge of the technician over the non-technician, effectively allowing clinical science and practice to exert power over people and communities.

The 12 Principles

  1. Include in a community’s collective effort those who live there, those who work there, and those who deliver or support services provided there
  2. Spend time understanding differences in context, goals and power
  3. Appreciate the arc of local history as part of the story of a place
  4. Elicit, value and respond to what matters to community residents
  5. Facilitate and support the sharing of power, including building the capacity to use it and acknowledging existing imbalances
  6. Operate at five levels at the same time: individual, family, community, institutional and policy
  7. Accept that this is long-term, iterative work
  8. Embrace uncertainty, tension and missteps as sources of success
  9. Measure what matters, including the process and experience of the work
  10. Build a vehicle buffered from the constraints of existing systems and able to respond to what happens, as it happens
  11. Build a team capable of working in a collaborative, iterative way, including being able to navigate the tensions inherent in this work
  12. Pursue sustainability creatively; it’s as much about narrative, process and relationships as it is about resources

I have developed this perspective, including the 12 principles, through my projects, writing and reports, and with the assistance of seven advisors: Jeff Cohen, Lauren A Taylor, Leigh Carroll, Mark Wieland, Ollie Smith, S Leonard Syme and Scott Liebman.

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