By Veena Sriram
In February 2014, in order to alleviate India’s seemingly intractable human resource shortage in rural areas, the Medical Council of India decided to extend the duration of the MBBS program by a year to 7.5 years, so as to include one year of mandatory rural posting for all students. Aided by social media platforms, medical students and junior doctors across India erupted in protest and went on strike, paralyzing hospitals in large cities such as New Delhi and gaining widespread media attention. The Union Minister of Health ultimately intervened in favor of the protesters, and the policy was quashed.
This example illustrates the ability for large, dispersed groups, such as consumer groups and student unions, to use their collective power and make their voices heard regarding health policy. In doing so, these groups are exercising a form of social power, through pressure and protest, to facilitate or block major health sector reform. In the Indian example above, the power that these protesters coalesced and expressed was used to shift a series of policy decisions made at the highest levels of government, within a matter of weeks. Such demonstrations of social power show just how potent such groups can be in derailing new policy or reform under the right circumstances, and highlight this area as one worthy of much more consideration in health systems research.
Expressions of ‘grassroots’ policy resistance in low- and middle-income settings are not new. What is new is the ways citizen and interest groups in these settings are increasingly able to access and leverage modern tools to both organize themselves and galvanize others to their cause. Social media platforms, such as Facebook, YouTube and Twitter have revolutionized how we communicate, with important consequences for power dynamics. Going back to the earlier example from India, the Facebook group ‘Protest against 7.5 year MBBS rule by MCI’ had over 15,000 likes, with a regularly updated feed of organizing information and updates. Although not specific to health policy, the use of social media during the Arab Spring also highlighted just how social media can further the reach and hasten the spread of such public campaigns. More recently, ‘hashtag activism’ as seen in this year’s #bringbackourgirls and the ALS Ice Bucket Challenge campaigns, has successfully raised the profile of a number of issues (although the truly skeptical might argue that gains made by such campaigns can be superficial).
From a public health perspective, one of the critical features of these mechanisms of social power is the way they have allowed groups to tap into their power base at breakneck speed. Such innovations are likely to have consequences for how organized interests engage with health policy in the coming years. It has never been easier to rally a base, and one can imagine that given the right confluence of factors, examples such as the Indian one will become increasingly common. And it will be interesting to observe whether policymakers begin to use these tools themselves to further engage with communities and constituencies impacted by policies, and therefore, begin to do a better job of bringing in a variety of voices and opinions early in the policy development process. Another question is whether such collective expressions of power only take place in opposition to a policy? Or can such power be tapped into prior to policies being formed, and therefore, in a more persuasive manner?
The intersection of power, social networks and technology in LMICs presents an exciting new direction for health policy and systems research. As such phenomena become more common, investigating these stories will be critically important to enriching our understanding of policy development and implementation.
Veena Sriram (@veena_sriram)is a health systems researcher, currently pursuing a PhD in International Health (Health Systems) from the Johns Hopkins Bloomberg School of Public Health. She has a Master’s of Public Health degree from the Mailman School of Public Health at Columbia University.