Tweaking or transforming? Dancing around power and accountability

It is a pretty ‘uncool,’ and therefore brave, thing to do these days: to organise a conference with ‘power’ in the title. In so many international meetings on health, a political economy and power are assumed, but not addressed head-on, or worse: actively evaded.

Photo: IDS’ Gerry Bloom speaking at Unpicking Power and Politics for Transformative Change: Towards Accountability for Health Equity workshop

Not so in Brighton, at the Institute of Development Studies (IDS), where this summer over 80 apassionados gathered for a workshop titled ‘Unpicking Power and Politics for Transformative Change: Towards Accountability for Health Equity‘. Stated aim: to examine critically the current practices and politics shaping accountability in health systems from the local to the global levels.

What did the workshop unpick?

With a title like this, it may not come as a surprise that the participants came from a variety of backgrounds, intellectually and geographically, involving academics, activists, policymakers and hybrids of all three.

During 3 days of generously hosted, intensive deliberation, multiple perspectives on governance, accountability and equity were opened up. A mixture of analytical and experiential research stories was shared, and distinct country, historical and cultural contexts compared. Existing governance tools, instruments, institutions were critically revisited, often in substantial detail. Throughout, the atmosphere was one of respect and mutual learning.

This was a golden opportunity, one would think, beyond the research technicalities to engage in some ‘hard talk’ on whose power, whose basic interests and whose mental and legal frameworks shape the governance configurations in global health today:

• Who is in and who is out?
• Who defines the problem?
• Who states the emergency?
• Who articulates the solutions?
• Who parades the ‘best practices’?
• Where do the current legal configurations in health benefit people, where do they fail or underperform?

Or in other words: How could we take the debates about power and accountability, and the agenda of transformative action a few big steps forward, especially now the health arena appears ever more visibly linked with a whole range of major social and economic battles and transformations?

But what about power play?

As people active in the newly founded Health Systems Governance Collaborative, it was our core interest to explore these frontiers of global health governance debates. We were keen to meet fellow governance and accountability travellers, to find out which intellectual breakthroughs were possible, and to deepen our awareness of potential entry points for transformative action.

The workshop comprised six strands:

1. Accountability politics and the local level and beyond
2. (Re) building accountability
3. Accountability responses to the spread of Health markets
4. Accountability for equity; universality and inclusion
5. New opportunities and new challenges: mutual learning for effective accountability
6. Brokering, metrics and the politics of evidence.

We enjoyed being urged to ‘shift focus’.

The question, however, which was evoked from day one as the proverbial genie-in-the-bottle, and which kept hovering over the hall throughout the conference was that of our own power involvement, and our own systems of complicity in the failures of accountability, equity, and governance that plague global health.

The dissection of power relations is an interesting enough academic pursuit, but as such may not change one iota in governance practice. Understanding different contexts or histories is certainly necessary and enriching, but the link between increased awareness and practical change is not a given.

Comparing various instrumentations of governance as part of research programmes is undoubtedly useful, but does not yield immediate adaptations, even if everybody involved agrees they would be better. Power and power plays surround us all, impacts us all, and implicates us all.

Accountability studies and practices themselves are subject to substantial power dynamics of their own, between institutions, for resources, for space under the sun. We are all actors in a reality in which the stakes are immense. Yet while we grapple with this, widening health equity gaps and accountability failures have a human face. There are millions of people who are denied basic health services or who fall into poverty because of catastrophic out of pocket payments.

Our systems of complicity

So, while we were dancing with ever greater enthusiasm around the fundamentals of accountability, transparency and governance, cherishing the complexities and enjoying the many encounters and Aha-Erlebnisse, three more fundamental calls for critical self-reflection are needed:

1. What is our own implication in creating problems and power-imbalances, rather than solutions; inequities rather than fair share in global health?
2. What needs to happen at the interface between ‘creating greater awareness’ and ‘actionable governance’ that could make a real positive difference in the lives and health of people?
3. How to create an inclusive ‘we’ in all the processes that start with: ‘We’ wish to foster better governance.

Under the Sussex sun, we seemed to be tweaking, not yet transforming. So hopefully… to be continued…

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All the authors are part of the The Health Systems Governance Collaborative. This collaborative is an open global network set up to help foster new engagement with ‘actionable governance’ at local and national levels in order to improve health systems, and linked to the UHC2030 agendas.

The Collaborative’s secretariat is hosted by WHO – email: [email protected]