Act global, but think local: accountability at the frontlines

Abstract

There is a worrying divergence between the way that sexual and reproductive health and rights problems and solutions are framed in advocacy at the global level and the complex reality that people experience in health services on the ground. An analysis of approaches to accountability used in advocacy at these different levels highlights the different assumptions at play as to how change happens. This paper makes the case for a reinvigorated approach to accountability that begins with the dynamics of power at the frontlines, where people encounter health providers and institutions. Conventional approaches to accountability avoid grappling with these dynamics, and as a result, many accountability efforts do not lead to transformative change. Implementation science and systems science are promising sources for fresh approaches, beginning with the understanding of health systems as complex adaptive systems embedded in the broader political dynamics of their societies. By drawing insights from disciplines such as political economy, ethnography, and organizational change management – and applying them creatively to the experience of people in health systems – the workings of power can begin to be uncovered and tackled, sharpening accountability towards those whose health and rights are at stake and generating meaningful change.

Résumé

Il existe une divergence inquiétante entre la manière dont les problèmes et les solutions en matière de santé et droits sexuels et génésiques sont formulés dans le plaidoyer au niveau mondial, et la réalité complexe que connaissent les individus dans les services de santé sur le terrain. Une analyse des approches de l’obligation de rendre compte utilisées dans le plaidoyer à ces différents niveaux met en lumière les hypothèses en jeu sur la manière dont le changement se produit. L’article argumente en faveur d’une approche renforcée de la responsabilisation qui commence avec la dynamique du pouvoir en première ligne, là où les individus rencontrent les prestataires de soins et les institutions. Les approches conventionnelles de l’obligation de rendre compte évitent d’aborder ces dynamiques. Beaucoup d’activités de responsabilisation n’aboutissent donc pas à un changement transformateur. Les sciences de la mise en łuvre et les sciences des systèmes sont des sources prometteuses pour de nouvelles approches, à commencer par la compréhension des systèmes de santé comme structures complexes capables de s’adapter et ancrées dans la dynamique politique plus large de leur société. En empruntant des idées dans des disciplines telles que l’économie politique, l’ethnographie et la gestion du changement organisationnel, et en les appliquant avec créativité à l’expérience des individus dans les systèmes de santé, on peut commencer à mettre à jour et traiter les rouages du pouvoir, ce qui accroîtra la responsabilité face à ceux dont la santé et les droits sont en jeu, et déclenchera un véritable changement.

Resumen

Existe una preocupante divergencia entre la manera en que los problemas y las soluciones relacionados con la salud y los derechos sexuales y reproductivos son planteados en el área de promoción y defensa a nivel mundial, y la compleja realidad que las personas presencian en los servicios de salud en el terreno. Un análisis de enfoques en responsabilidad utilizados en actividades de promoción y defensa en estos diferentes niveles destaca las diferentes suposiciones en juego en cuanto a cómo suceden los cambios. Este artículo arguye a favor de un enfoque revigorizado en responsabilidad, que empieza con la dinámica de poder en primera línea, donde las personas encuentran a los prestadores de servicios y a las instituciones. Los enfoques convencionales en responsabilidad evitan abordar esta dinámica; por consiguiente, muchos esfuerzos por imputar la responsabilidad no producen cambios transformativos. La ciencia de implementación y la ciencia de sistemas son fuentes prometedoras para nuevos enfoques, comenzando por entender los sistemas de salud como sistemas adaptativos complejos arraigados en la dinámica política más amplia de la sociedad. Al adquirir conocimientos de disciplinas como la economía política, etnografía y gestión del cambio organizacional –y al aplicarlos de manera creativa a la experiencia de las personas en los sistemas de salud– se puede empezar a revelar y abordar el funcionamiento del poder y agudizar la responsabilidad hacia las personas cuya salud y cuyos derechos están en juego y generar cambios significativos.

The still tentative opening of global policy spaces to civil society has offered opportunities to test the potential of advocacy in these arenas to contribute to change on the ground. From the high point of the ICPD paradigm shift in 1994, through the low point of exclusion of sexual and reproductive health and rights (SRHR) from the original Millennium Development Goals (MDGs) in 2001, to the revival of some aspects of SRH with the Family Planning 2020 initiative in 2012, we are now on the brink of a new era of global activity as the post-2015 Sustainable Development Goals are formulated and launched. Even as new technology makes new kinds of participation possible, the proliferation of global-level forums, institutions and initiatives means that advocates need to be increasingly expert to navigate these spaces effectively -- and dedicate massive time and energy to do so.

This raises challenging questions about how, and even whether, a social movement should mobilize to influence global processes.^* Questions include how to structure participation, compete for and direct funding, engage media, prioritize goals, enter negotiations, and strike alliances. Perhaps most importantly, advocates face internal contestation over the narrative that shapes the demand for change and the strategies that follow from it.

As health and human rights activists working from a university setting in New York City, we have been privileged to have easy access to the global arena while devoting most of our own effort to initiatives focused on strengthening health services on the ground, particularly in countries where maternal mortality is high. From this dual perspective, we see a worrying divergence between the way problems and solutions are framed at the global level and the reality on the ground. Of course, each advocacy setting must be addressed strategically in the terms that will work there. But a coherent strategy across settings requires a shared understanding of how change happens. The power and glamor that courses though global meetings can be seductive: too often it lures advocates into believing that change at the top, at the pinnacle of inter-governmental and state-civil society relations where global goals are forged, will foster change at the grassroots, where people actually experience the hand of the state in their daily lives through the operation of the health system and other institutions.

In this paper, we argue for an elemental shift in our understanding of where and how real change in sexual and reproductive health and rights happens, and in the techniques we use to study it, advocate for it, and create it. We use the idea of accountability as an organizing principle that can be a leading wedge for a broader transformation of public health and human rights practice. Accountability is not the whole answer. But it can spark a set of other processes and transformations that are necessary for the coming phase of global development.

We limit our analysis to that slice of sexual and reproductive health and rights concerned with health services. Although sexual and reproductive health and rights certainly covers a far broader set of conditions that influence women’s lives, it is not the case that health services present only a narrow set of essentially technical issues. Indeed, one fundamental premise of our argument is that health services, while they always have a technical dimension, are also always deeply political. They function as core social institutions: people’s interactions with the hierarchies of power that shape such institutions often create or reinforce the very exclusion and disempowerment that are at the heart of sexual and reproductive health and rights violations. Conversely, as a reflection of state presence – and, increasingly, of the state’s alliance with private sector actors as well – the health system can be a venue in which entitlements are articulated, asserted and vindicated.

Accountability is certainly not a new idea in global development practice. But the way it has typically been conceived and operationalized globally is profoundly disconnected from the reality of women’s interactions with the forces that shape their lives on the ground. We make the case for a reinvigorated approach to accountability that begins with the dynamics of power on the frontline of the health system, deeply embedded in the broader social and political dynamics of local life. We argue that this reality needs to infuse and define the ways that global development strategies proceed, forcing a re-think on the engine of change in sexual and reproductive health and rights. In short, in taking a stance on the future Sustainable Development Goals and the direction of ICPD beyond 2014, sexual and reproductive health and rights activists still need to act globally, but their actions on the global stage need to be differently informed by local realities.

Defining accountability

How accountability is defined shapes the way it is operationalized, and ultimately, the change it fosters. We define accountability as “constraints on the exercise of power by external means or internal norms”.¹ This definition is more expansive than some of the more prevalent approaches that refer to mechanisms of accountability, e.g. to systems of answerability, enforcement and sanctions between two parties.²

Defining accountability as we propose advances concepts that are indispensable to thinking about change in sexual and reproductive health and rights. First, it puts power center stage, which makes the difference between superficial demonstrations of accountability and potentially transformative ones.

Second, it applies to anyone wielding power, not just to those in government. Some non-governmental actors, such as private foundations and religious institutions, play determinative roles in shaping the sexual and reproductive health and rights landscape within the halls of the UN and at country level. For some reproductive health services, such as abortion, there may be no public sector choice to start with. For other services, the sorry state of the public sector often drives women into the unregulated, sometimes dangerous private sector. Finally, the increasing focus within global health on public–private partnerships, and in particular, the reliance on franchises to deliver reproductive health care, makes the inclusion of non-state actors in an accountability framework for sexual and reproductive health and rights crucial.³

Third, the definition of accountability we use acknowledges the salience of norms that are internal to individuals and to institutions – whether they are supported by policy or not – as a way that power is expressed and maintained. For example, abusive behavior by health providers may persist not because of a lack of laws or professional standards that prescribe otherwise, but because such behavior is normalized in the system, becoming routine, accepted and expected, and even naturalized.⁴ Understanding and acknowledging the influence of such norms is thus central to discovering the forces that shape women’s experiences of the health system itself.

Finally, it is important to recognize that our definition does not say what those who wield power must be accountable for. Indeed, in this sense, accountability (or lack thereof) can be a feature of any organization, whether or not it is rights-sensitive. Take, for example, the mafia or a corrupt police department. All “soldiers” in the system know, accept and often internalize the rules of the criminal enterprise from which they benefit and those rules are enforced consistently, often brutally. Accountability is in place. But the efficient organization that results is the diametric opposite of a rights-based organization.

Our point is this: The content of accountability is not inherent in the mechanism of accountability; content needs to be supplied through a political process in which a vision of a properly functioning system is negotiated and agreed. This is where the well-developed vision of sexual and reproductive health and rights remains central to accountability.⁵ Two aspects of the paradigm shift embodied in the ICPD Programme of Action are especially relevant here: (1) the primacy of women’s lived experience, namely the understanding that the content of sexual and reproductive health and rights should be defined by women’s experiences of the health system, gender relations and other social, political, and economic dynamics; and (2) a conception of rights that goes beyond a listing of “freedom from” and “freedom to” in order to challenge prevailing fundamental social meanings about gender and reproduction. In brief, it is a conception that goes beyond legal taxonomy to describe what rights realization looks like. Political, social, economic, and gender relations of power are inevitably at issue.

A conception of accountability that accommodates and leverages the paradigm shift in the Programme of Action will bring us closer to realizing it. Change will happen when we go beyond conventional analysis of the policy-to-practice gap and deeply interrogate what shapes women’s actual experiences of health services, i.e. when we “repoliticise sexual and reproductive health and rights”.⁶ In essence, it means bringing a critical analysis of the workings of power back to the heart of what we do in both public health and human rights. When a power analysis is reintroduced to the core of the sexual and reproductive health and rights endeavor, the question “how does change happen?” generates an accountability practice – and an implementation practice – that is qualitatively different from the conventional approaches that now hold sway in global health.

Conventional global-level approaches to accountability

Most conventional approaches to accountability avoid grappling with the dynamics of power that flow through a health system.

At one end of the spectrum, it has become routine, almost de rigueur, in every declaration, meeting statement, press release or speech to call for “holding [fill in the blank] accountable” with virtually no discussion of exactly for what, to whom or how. Accountability becomes little more than an “empty buzzword”.^7,8 One step up the line is accountability as efficient spending, as governmental donors and recipient countries cut expenditures and demand that health managers do more with less. A legitimate, but still rather thin use of accountability is a focus almost exclusively on corruption, with an underlying rationale that can fall anywhere from a pure efficiency argument to a more nuanced appeal to fairness. Egregious abuses may be fixed, but the essential structures of power that enable them remain unchanged.

This paper focuses on the conventional ways that accountability is used in global forums by those who genuinely seek to promote sexual and reproductive health and rights. Activism through the UN conferences of the 1990s was organized around the negotiation of the content of inter-governmental agreements, with precious little attention to their implementation. The accountability practice that has grown up around the conference declarations from within the global institutions that monitor them is a kind of refined expose-and-denounce approach, exemplified by the ICPD +5, +10, +15, and +20 processes and by NGO shadow reporting. These global efforts to track and publicize progress against the declarations’ goals are based on the assumption that embarrassment and peer pressure will generate policy change, and that this policy change will in turn translate into changes in health and rights outcomes.

In 2000, governments adopted the Millennium Declaration, which spawned the MDGs. The design and content of these goals – with narrow, problem-specific quantitative targets – made progress easier to measure, but did little in their own terms to point the way to transformative change. The international community’s efforts to put some teeth into governments’ commitments have been premised on a faith that the vision of bold aims, combined with political will and adequate financial resources, will yield progress.

To be fair, an approach that sets targets and tries to align incentives, but leaves the actual decisions about how to get to the target up to the countries, represents a step forward from a colonialist approach that believes all answers lie in the North and that the imposition of Northern technical assistance will bring along the backward states of the South.^* But the accountability techniques the MDGs spawned and the underlying assumptions about how change happens are feeble weapons in the struggle for the changes being sought.

First, there is the massive investment in drumming up political will – which now usually boils down to stage-managing political leaders through a public profession of commitment replete with celebrity photo ops. These are combined with good faith efforts to create accountability too. The Secretary General’s Every Woman, Every Child campaign established the Commission on Information and Accountability. The very name hints at the faith that animates this initiative. If political will is combined with tracking and publicizing progress, accountability will result. The Commission’s accountability formula of “monitor, review, remedy” is about results, not process – a markedly more anemic formula than alternatives such as “responsibility, answerability, enforceability” promoted by human rights advocates.

“Countdown to 2015”, the initiative tracking progress on MDGs 4 and 5, picked up the Secretary General’s charge with aplomb, very quickly adapting its methodology to include specific information recommended by the Commission. The Countdown is the prototype for the accountability approach, much favored in public health, centered on the development of quantitative indicators and investment in the collection of data necessary to measure them. While good public health practice should make good use of the data and indicators that have resulted, the faith in statistics themselves to generate the cascade of actions needed to create change at all – much less in a rights-based way – is unwarranted. This approach to accountability assumes that exposure and tracking – this time better, closer tracking with hard, quantitative evidence – will do the trick.

Of course, Countdown advocates know that change requires more than an understanding of the quantitative scope of the problem; it also requires a strategy to fix it. The MDGs inspired multiple global efforts to identify effective strategies, including the UN Millennium Project, the Partnership for Maternal, Newborn and Child Health’s Knowledge Portal and, in a sense, the multiple Lancet series on reproductive, maternal, newborn and child health. Taken together, these initiatives have made an extraordinary contribution in organizing and analyzing the evidence on clinical interventions, in particular. But they all use largely a “best practices” approach to implementation – one in which earning the label of “best” (or even “good”) requires evidence generated through studies with experimental designs that, almost by definition, require the nullification of exactly the power dynamics so central to understanding sexual and reproductive health and rights. Indeed, the workings of power that shape sexual and reproductive health and rights on the ground are intentionally “controlled for” or otherwise cancelled out in experimental approaches.

Meanwhile, on the ground, the energy, money and glamor produced (curated) by these global-level accountability efforts leave only the faintest whiff. Discrimination and exclusion continue largely unabated. Many services mandated in policy documents are missing in communities and facilities. Where services do exist, quality of care is often dismal, with disrespect and abuse rampant. Forms of “quiet corruption” such as absenteeism, lackluster performance, and pilfering of commodities erode users’ trust and depress utilization.⁹ And big-time corruption rears its head as well.¹⁰

Conventional local-level approaches to accountability

The literature analyzing the way accountability is currently practiced within public services reveals some of the same problems that plague accountability exercises at the global level: when program planners and implementers start with a limited concept of accountability, the resulting approaches to it foster weak implementation; even if they operate according to plan, the “mechanisms” do not necessarily generate change.

In practice, many accountability mechanisms are designed for aggrieved individuals to access. Mechanisms such as complaint boxes, individual investigation and litigation, and ombuds institutions can play a key role in identifying a remedy for an injured person, but they are only part of realizing accountability. While such individual mechanisms might create an aura of a responsive system, they are often meaningless for the most disempowered, who are dissuaded by the costs and risks of expressing preferences or complaints or who lack access to services to start with.¹¹

Given ongoing frustration with efforts to reform and improve the public sector, academics and advocates increasingly point to civil society engagement^2,12,13 and the role of organized groups of citizens for promoting “social accountability” in service delivery by leveraging “political and reputational costs”.¹⁴ Frequently cited examples include citizen “report cards” of perceived service quality, social audits, and public expenditure tracking. These efforts are more successful but only in certain situations, such as when the political leadership is sensitive to shaming, providers are committed to improving their reputation, and patients are interested in improved clinical performance and rights-based service delivery.^14,15 Donors and implementers of social accountability initiatives sometimes fail to undertake the robust contextual analysis required to see if these conditions pertain, and/or they may not be in a position to plan for how to effect change with the data social accountability efforts produce. Whether assessing national or local level implementation of ICPD, “expose and denounce” tactics do not inevitably generate change. Indeed, two meta-reviews of social accountability efforts concluded that the assumed relationship between transparency, voice, empowerment, and accountable systems does not always hold.^16,17

Both individual and social accountability interventions may become ends in themselves – what Joshi and Houtzager have called “widgets”,¹⁴ meaningless formal processes that do nothing to transform an inequitable system. Indeed, at their worst, they function as Potemkin processes – maneuvers that create the superficial and misleading appearance of responsive services, and in so doing deflect challenge and keep the drivers of poor sexual and reproductive health and rights intact.

Part of the problem lies in the conception of health system functioning that underlies these initiatives. The complex interplay of the workings of power that shape reality in health systems is elided by a simplistic supply-and-demand model, in which the supply side consists of policy-makers and providers and the demand side consists of users. This model misses the diversity of interests among health policy-makers and providers as well as patients.¹⁸ These three “groups” cannot be assumed to hold unitary interests. There are critical power differentials among and between them that must be disaggregated in order to discern and explicate the multiplicity of accountability relationships that exist. Important questions then become: What are frontline health professionals and workers accountable for? Who is accountable to them? To whom are they accountable? Do accountability mechanisms privilege certain users of services?

While social accountability and individual complaint mechanisms are frequent “demand side” interventions, new laws, policies, and target compliance mechanisms are often the proposed points of entry for “supply side” interventions. Changes in these domains may promote accountability, but they should not be the sole spheres for intervention. Mountains of program evaluations and case studies trot out the well-worn lament of a gap between policy and practice, though only rarely do they bring a sufficiently political critique to the problem.

In fact, it is often norms – rather than policies and procedures – that are decisive in shaping individual behavior and organizational culture. Policy may shape norms, but it may also have no influence on deeply entrenched values and practices. Informal norms may be intransigent in part because they reflect the social, material or other needs of those tasked with providing public goods, as illustrated in the street-level bureaucrat literature. For example, a study of a community-based family planning program in Kenya found that community-level agents were motivated not only by the goals of the program but also their desire to build up prestige and respect among community members, leading to behaviors that were inconsistent with the program’s goals.¹⁹ Another example is in cases where monitoring of accountability is especially stressed, making reporting itself become the most salient norm, as when an ethnography of district health services in Nepal found that “the drive was not so much to meet targets as to provide reports on targets”.²⁰ In essence, “what counts becomes what matters, rather than, what matters counts”.²¹

Rethinking accountability: Can implementation science and systems science generate a more effective accountability practice?

A different set of conceptual frameworks is needed to understand what is really happening within health systems that make them so resistant to the kind of change required for sexual and reproductive health and rights, and to support the design and implementation of accountability mechanisms that will work. Implementation science and systems science are promising sources of fresh approaches, beginning with better understanding of health systems as complex adaptive systems embedded in the broader political dynamics of the societies they serve.

Implementation science focuses on how innovations – ideas, strategies, technologies newly introduced into a service delivery system – find their way into practice. This begins with a useful distinction between degrees of implementation: paper, process and performance.²² “Paper implementation” is when the innovation is codified in policy, as when a new contraceptive is added to the essential medicines list. “Process implementation” is when the systems changes needed to deliver the innovation are put into place: the contraceptive is purchased and made available, curricula are changed, providers are trained. “Performance implementation” is when the desired objective is achieved: patients are able to access the contraceptive and receive good quality counseling on its use.

Although the logic here is linear, the operationalization is not because performance implementation has its own dynamics in a complex adaptive system. Systems thinking, a strand of systems science, specifies three relevant concepts: context, policy resistance, and emergence.^23,24 Although the importance of context is obvious, it is striking how rarely and how narrowly context is typically defined. Epidemiological methods focused on measuring change attributable to an intervention – e.g. the randomized controlled trial – proceed by controlling for context rather than explicating its role. A focus on the social determinants of health brings many social and policy dynamics in, but they may still be seen as independent variables in a factorial model, rather than what shapes the functioning of the health system itself. By adapting methodologies from other disciplines, such as political economy analysis, ethnography, and organizational change management and applying them to the experience of people in health systems, it becomes possible to uncover the workings of power.^25–27

“Policy resistance” is a phenomenon widely experienced but rarely documented in health. It occurs when the system reacts to an intervention in a way that neutralizes its effect.²⁸ A study conducted by MIT’s Poverty Lab offers an excellent example. An NGO implemented a financial incentive system to improve attendance by chronically absent nurses in Rajasthan, India. The program was initially effective, but within 18 months of its initiation, the nurses had found a way to follow the rules of the system but still remain absent.²⁹ The short timelines and narrow monitoring and evaluation strategies of most public health initiatives mean that they may fail to detect the occurrence and effects of policy resistance altogether.

“Emergence” is a concept that goes against conventional public health models that seek to separate out and measure each causal factor instead of recognising that the whole system is more than the sum of its parts and cannot be broken down into constituent components.³⁰ We contend that accountability can best be achieved when it is seen as an emergent property of a system with a multiplicity of accountable relationships within an overall culture of transparency, rights, responsibility, and solidarity. It requires a perspective that captures the entirety of the policy landscape and the activities and negotiations that occur among all the stakeholders.

The inability or unwillingness to grasp and contend with the nature of these dynamics has led to patterns of “persistent implementation failure” seen over and over again in the sexual and reproductive health and rights field and elsewhere in global health.³¹ For example, the enthusiastic pursuit and promotion (or imposition) of so-called evidence-based best practices has often led to “isomorphic mimicry”: countries adopt the form of the favored practice – policy documents read right, curricula are changed, indicators are identified – but the underlying (dys)function remains unchanged.³²

In fact, the causes of the dysfunction are typically complex, including capacity gaps that have their roots in the history of colonialism, followed by modernization initiatives.³³ Despite their emphasis on achieving goals rather than counting inputs, the results-based initiatives much favored in global health today do little to fix the problems of weak capacity, particularly when the results that are rewarded ignore the power dynamics used to achieve them. India’s Janani Suraksha Yojana (Safe Motherhood Scheme) is an example. It provides a cash incentive to women and to community health workers if pregnant women deliver in a health facility, with little attention to the quality of care in that facility or to the ways that the incentive could lead to abusive treatment or other “unintended” consequences.³⁴

The focus on results to the exclusion of process is also problematic from a human rights perspective. Recent developments in the maternal mortality field show how rights-based approaches can incorporate a deeper understanding of accountability. In the “Technical guidance on the application of a human rights based approach to the implementation of policies and programmes to reduce preventable maternal morbidity and mortality” by the Office of the High Commissioner for Human Rights,³⁵ rather than being cast solely as a system of compliance assurance, accountability is presented as “fundamental to each stage of the process” – from planning, to allocation of resources, to “feedback from the ground through to implementation in practice”.³⁵

The need to redirect our attention is clear. As a global community, we have poured our energy and resources into global goals without a clear idea of what is needed at the frontlines to make change happen and achieve performance implementation. Without a clear strategy for identifying and addressing those dynamics, “accountability” can become another weapon wielded by the powerful rather than a tool for transforming power relations.

Conclusions

More clarity is needed on how change happens, particularly for marginalized and excluded people, who will need to be a primary concern of the new Sustainable Development Goals. Experience shows that implementation and accountability are both negotiated – as is the enjoyment of sexual and reproductive health and rights.³⁶ The policies and programmes ultimately implemented are much more variegated than their articulation on paper; they are adapted, subverted, and filtered through formal and informal power hierarchies. The result is a negotiated outcome.^18,37,38 Achieving performance implementation requires anticipating, accommodating, and directly engaging this negotiation process. Similarly, attaining a system where accountability is emergent requires mediating among competing values at multiple levels and “repoliticising” the process.⁶ Competing interests cannot be engaged and negotiated if some of the most powerful ones are ignored or if the challenges are considered to be purely technical, thereby making any progress vulnerable to policy resistance.

What does this mean for the work of advocates and implementers? Accountability needs to be built from the ground up with new concepts and tools to help shape change. Our proposed re-orientation draws on some emerging trends in global health, programme evaluation, and development that focus on the expression of power and emphasize the lived experiences of the people whose health and rights are at stake.

For example, anthropological methods such as participant observation are not only valuable in themselves, but can be strategically combined with standard quantitative methods used in clinical research.³⁹ Approaches to strategy development, such as Andrews et al’s “Problem driven iterative adaptation,” move from the bottom up to systematically consider context and anticipate policy resistance, engaging a broad spectrum of stakeholders to participate in an ongoing, iterative process of programme identification, remedy and learning.⁴⁰ Realist evaluation and other theory-driven approaches bring new recognition to the importance of context, as well as to elucidating the actual mechanisms of change, rather than just detecting a statistical association between exposure to an intervention and a desired outcome.⁴¹ Disciplined use of theory of change frameworks, such as Klugman has proposed for effective social justice advocacy, ensures attention to all essential elements of a carefully constructed change process.⁴² Finally, activist trainers have developed models, such as Gaventa’s power cube or VeneKlasen’s typologies of power, to guide activists in deciding how they themselves will demand and use power constructively.^43,44

These techniques are not an answer but simply tools to guide the determined investigator, planner, implementer, or activist in the systematic application of what is ultimately a political choice: to put grappling with the workings of power back to the core of understanding how change happens – and to carry out work in public health or human rights on that basis. We do not fool ourselves into thinking that “participation” or “on the ground negotiation” can overcome frontline power differentials alone; indeed, these processes can sometimes actually engender and reproduce exclusion. But an “eyes open” use of these tools in a grounded approach that draws on the knowledge and agency of actors within the health system has potential to generate change. And the field is open: if those with influence in academia and publishing, in grant-making and development aid, and in policy and programme design embrace these fundamental points, then there will be space and support for new and creative methodologies.

This may mean creative new thinking about the key metrics to track in global monitoring of the forthcoming Sustainable Development Goals. It would also mean that global initiatives such as the Independent Expert Review Group on Information and Accountability for Women’s and Children’s Health that has called for people-centered (rather than intervention-centered) health systems⁴⁵ expand their focus beyond global and national levels to highlight the rather different dynamics that operate at the local level to prevent access and equity.

Notes

* Indeed, the very question of whether a loosely organized initiative, dominated by professional advocacy experts, can even be considered a global social movement has implications for the principles that guide it.

* “Results-based” approaches were gaining ground in development aid generally with sector-wide approaches, General Budget Support, and multilateral efforts such as the International Health Partnership.