On Power, Co-Production and Feeling Overwhelmed

Pritpal S Tamber

August 14, 2019

How co-production, self-management and health promotion all have the potential to increase social inequity, and what you can do about it

There’s a sense of overwhelm out there. Perhaps you’re feeling it too. There’s a sense that if social circumstances matter to health, what can we in health care really do about it? 

Last week I spoke with Lauren Weinstein, a self-described sociology-nerd-turned-designer who’s been searching for her ‘do’. Lauren’s journey was influenced by two insights. The first was that our responses to inequitable social systems tend to be programmes that seek to help people cope with the impact of these systems, rather than question and change them. 

The second was the inherent ingenuity of people. As she describes it: 

“In Nigeria, I saw the entrepreneurial spirit of seamstresses who carry their sewing machines around so they can work wherever they need to. In Bangkok, I saw how people balanced all sorts of things on their bikes, seemingly defying the laws of physics, to make the most of their transportation asset – a bike.”

The idea that people have the answers is getting traction in health care. There are more and more activities in which people with ‘lived experience’ are being invited into discussions about their health, the idea being to ‘co-produce’ solutions. Although it’s a step in the right direction, in its current form it may be a mis-step. Back to Lauren:

“All too often [design] teams invite one person with lived experience into a workshop and wonder why this person was quiet or only validated the ideas that the design team presented.”

So, what’s going on here? Lauren’s perspective is that the truth can be dangerous – especially to yourself. Is someone really going to criticise their rural clinic, for instance, when it’s the only health care they have access to? Is someone really going to explain that the reason why they don’t turn up for their appointments is because the receptionist is rude, knowing that they have to face that receptionist the next time they go? 

Probably not. 

So, if co-production is to have any value, the spaces in which it’s conducted need to be safe. It has to be possible for people to give the unvarnished truth and not fear the repercussions. For a space to be safe, Lauren says, people in systems, such as health care, need to be aware of their privilege – and the power that it gives them.

I suspect that all of you have privilege (I certainly do). Whether it’s the colour of your skin, your wealth, your education or the reputation of the institution you represent, you have ‘assets’ that give you power. How is it, then, that you – we – can become more aware of this power and the potential impact on work with communities? 

Lauren’s answer is a card game – Powerplay. Players are given cards to represent their power assets and asked how they’d use those assets to overcome a challenge. The idea is to start a conversation about power, to help people become aware of the privilege they have and how they have learnt to use it. Through the game and the conversations, Lauren hopes to make people with power become more aware of what life is like without it. 

Power is a tricky topic. It has surfaced through my work repeatedly and worn many clothes. Two researchers in the UK, Christine Horrocks and Sally Johnson, believe that the idea of power sits unquestioned in two movements in health care that are also gaining traction – self-management and health promotion (the process of enabling people to increase control over their health and its determinants). In their 2014 paper, they argue that these movements are designed around those with privilege and so have the potential to widen social inequity. 

Although their paper is a little dense, their argument is simple. Both self-management and health promotion require people to have power. But people experiencing social disadvantage often have little power. Indeed, the impact of that social disadvantage, including fewer opportunities for work and poorer health, reduces their power further. In the end, self-management and health promotion become the preserve of the privileged. 

We’re beginning to see programmes aimed at increasing people’s power, usually through community organising. Europe is perhaps a decade behind the US where the community organising sector includes over 300 organisations and raises about $200m annually. But recently Ariadne, a network of 550 European funders across 23 countries, partnered with the European Community Organising Network (ECON), to make the case for more support for community organising as a force for social justice. In England, Community Organisers Ltd, a charity and the home of the National Academy of Community Organising, is looking to build on its excellent work to date and create a sustainable infrastructure for community organising across the nation.

Is community organising the answer? I’ve certainly met people who think so but I suspect it’s only part of the answer. It seems to me that organising relies on the belief that change is possible. But, as Horrocks and Johnson describe, many people and communities no longer believe. Beaten down by circumstances – the same circumstances driving poor health – they’ve subconsciously internalised their marginalisation. The mainstream world is not for them. 

Are you sensing the overwhelm?

If so, know that it’s ok. We all feel it now and then (here’s me feeling it earlier this week). But ‘do’ like Lauren – find a way to talk about a difficult topic, to challenge your assumptions, to model a different way of being in the world. And if you’re in a community health meeting this week, consider whether you’ve really considered the role of privilege and power in your co-production, self-management and health promotion endeavours. 

If not, you may be making things worse. 

Further Reading 

Previous Issues of Community & Health

Recent Interviews

The photo behind the title is by Christian Erfurt on Unsplash.

This post was updated to amend two things. First, I referred to Community Organisers Ltd as Company Organisers Ltd. And second, in the penultimate sentence I said population health rather than health promotion.

Pritpal S Tamber

I’m a doctor who trained as a medical editor and publisher and now researches and consults on the link between community power and health equity. My interest in community power started when I was the Physician Editor of TEDMED and is explained in My Perspective. I also work as a freelance medical editor and publisher for organisations that want to write high-quality articles and a strategy for their publishing and promotion. Find out more on my About page.

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