By Members of the EQUINET pra4equity network
When the Fourth Global Symposium on Health Systems Research (HSR 2016) gathers health systems researchers in November 2016 to explore ‘resilience’ in health systems in a context of inequality and economic, social, environmental and health challenges, what learning and insights will we bring to the table?
Between August and October this year we carried out two rounds of discussion drawing in diverse voices from over 300 people globally in our pra4equity list, hosted by the Regional Network for Equity in Health in East and Southern Africa (EQUINET). The first was to discuss our experiences in learning from action in participatory action research (PAR) and the second on what that implies for how we understand the concept of resilience.
Learning from action in PAR
The PAR process involves gathering and systematising lived experience to:
- collectively analyse and validate the underlying causes;
- set, take and reflect on actions on these causes; and
- draw knowledge from it.
In earlier meetings we realised that people are less confident on learning from action. There was a demand to discuss further the processes for building the understanding, power and self-confidence to produce and evaluate change.
In the discussions, people drew attention to various methods they used to facilitate learning from action, including through the ‘but why’ method, progress markers and wheel charts, and mapping or taking photographs of change from initial findings as a means to reflect on the change and what has enabled or blocked it. These processes and tools have not only been used to review how far we have achieved intended actions and outcomes, but also to reflect on the thinking and hypotheses on what produces change. The collaborative development of hypotheses for change by those involved in the PAR (as a form of critical theory or using PAR forecasts, like weather forecasts) was seen to be integral to learning from action. So, too, was helping people to document their ongoing learning.
Experiences of applying PAR to build learning
In our learning network we’ve also used the reflections across countries on actions on the same problem area as a form of ‘meta-analysis’, to share insights on what facilitates the implementation of change, what blocks it and why, drawing learning also from what is similar and different across countries.
The steps of action and learning often take several PAR cycles to address deeper determinants and build meaningful change. This is especially relevant when people are engaging on deeply rooted power relations or determinants that are beyond local control, such as addressing gender in South Sudan or commercial sex work in Malawi. While not always the case, some noted that this can take more than a decade of work in both high- and low-income settings, calling for sustained processes.
This raises challenges in some settings. Tracking of change may stop too early, those working in communities may lack time or resources to record and report change, and the resources and attention may not last for the time needed. Researchers or facilitators may not always be included in or able to stay with change processes that take place over years. PAR processes may also differ from the institutional cultures or priorities of organisations that represent or work with the social groups involved.
The power imbalances involved are often protected by strong interests. We reflected that before applying any method, including PAR, we need to be clearer on its strategic possibilities, given the contexts and social actors. While this may lead to choices within range of approaches and forms of activism, it was asserted that a self-determined understanding of the symbolic and material dimensions of inequalities remains a powerful starting point for any approach. Notwithstanding the difficulties, numerous examples of positive experience were shared! In Monrovia, for example, PAR implemented after the Ebola epidemic led to a shared, more comprehensive understanding of maternal health amongst the health workers and community members involved, pointing to actions to strengthen the continuity and interaction of the different services and roles needed to improve maternal health care.
In our discussions it was also suggested that the action and change in PAR should not only be seen in terms of material changes in conditions, although this is important. It can, in addition, be seen in the change in the people involved. As one participant noted in the discussion, “we pay too much attention to the actions and not enough to the actors.” For those often excluded from formal planning and decision making, it is important to appreciate how far they themselves are transformed in the process, in terms of their consciousness and self-confidence to produce change. This can start early in the PAR process, even from the first step of recognising and listening to shared experience.
Understanding ‘resilience’ using a PAR lens
Given these reflections, we had a second, equally challenging discussion on the concept of resilience from a PAR lens. In part, this was due to its adoption as a theme for the HSR 2016 and its increasing use in global discourse. Resilience has been used in environmental and physical sciences to describe the stability of a system against interference from external disturbances, but has migrated to the social sciences. The HSR 2016 website says: “Resilience: absorbing shocks and sustaining gains…. Health systems must be resilient – able to absorb the shocks and sustain the gains already made….”
As was raised in June by Topp, Flores, Sriram and Scott, our network also challenged use of a term that implies ‘absorbing shocks’ and ‘stability’ when the system is an outcome of unjust and structural inequalities that undermine health. PAR has developed in many settings as a direct confrontation with these inequities, seeing their disruption as necessary for health. It would thus not comfortably be applied in the science of ‘absorbing shocks’, when these derive from such injustice.
At the same time, some noted that there seems to be a second set of meanings to the term. Resilience has also been used in some contexts to refer to the capability to sustain a positive change or to resist negative change, to transform and move from a harmful equilibrium to new more positive one and the ability to self-organise into a healthier state. This appears to have greater resonance with the PAR process, as it draws in learning from action on a system and intends to raise the direct power and capability ofthose directly affected.
Given how different these ‘meanings’ are, we need to explicitly understand, and not assume, how people are using the term resilience, including at HSR 2016. It has often been applied in relation to shocks and emergencies, for example. However participants raised that ‘emergency’ responses commonly use command and control styles that do not strengthen the capacity of or build co-determination with the affected community. If resilience refers to the ability to move to a healthier state, then systems need to transform the conditions producing shocks to prevent them, and not merely to absorb them, and to do so in ways that are defined with – and build the capabilities, voice and power of – those directly affected.
This blog is used with permission from the EQUINET newsletter November 2016, submitted by R Loewenson, EQUINET secretariat. The exchanges on the pra4equity list are also feeding into work on PAR in the SHAPES technical working group in HSG. Please send any feedback or queries on the issues raised or interest in the pra4equity list to the EQUINET secretariat at email@example.com.