Governance and participation in health

Each year at least 300 million cases of malaria result in more than a million deaths worldwide. Ninety percent of these deaths are in sub-Saharan Africa and most are children under five years old. Preventing and treating malaria are now firmly on the international public health and global poverty agendas. However, despite a considerable increase in funds over recent years the malaria burden in much of sub-Saharan Africa shows little sign of decreasing. Over recent years there has been emphasis on the idea that improving knowledge about malaria in communities will lead to better use of interventions. Research on managing malaria in communities has been largely concerned either with individual perceptions about the causes and symptoms of the disease or with the implementation of specific interventions. It fails to provide essential information on the context in which communities and households cope with their day-to-day problems, including malaria.

The research presented in this paper responds to years of academic speculation and subsequent policy concerns about the possible collapse of Africa’s democratic project under the complex waves of impacts introduced by the HIV/AIDS pandemic. It is the result of three years of exploratory studies in seven countries: Botswana, Namibia, Malawi, Tanzania, South Africa, Senegal and Zambia. Anecdotes of Lesotho and Zimbabwe have also been highlighted.

When faced with a complex public health problem there is a natural urge to find solutions. People hire consultants, gather data, test hypotheses and examine P-values to identify risk factors: data-driven technological fixes get implemented every day. In the right situation, there is nothing wrong with solutionism – the belief that all difficulties have technical solutions. Solutionism works well for circumscribed problems involving a small number of motivated individuals, where every element of the prescribed solution can be implemented as planned. However, complex problems in public health usually have elements that defy planning, because health involves people, and people are unpredictable. Recent research has shown that integrating community participation in the planning and implementation of health reforms is a key factor in supporting health improvements. The approach has been applied in a variety of areas including: the control of infectious disease; reducing maternal deaths and improved birth outcomes; enabling better health seeking behaviours; improving quality of life by promoting healthy environments through improvements to housing, reducing crime and building social cohesion. Critical factors for achieving trust include allowing participants to see their common concerns and building strong relationships within health committees or participatory groups. There must be a commitment to sustain long-lasting relationships between the community, local health workers and managers. Technical solutions for health problems are still needed. The authors argues there is still need the familiar P-value because biological evidence is necessary, but public health practice also needs to recognize the value of people. Regardless of the political environment, the power of the state to alter health decisions inside the home has limits. Only an approach that values, honours and engages people can alter how they make decisions about their health.

In the last several years, a democratic boom has given way to a democratic recession. Between 1985 and 1995, scores of countries made the transition to democracy, bringing widespread euphoria about democracy's future, but more recently, democracy has retreated in some. These developments, along with the growing power of China and Russia, have led many observers to argue that democracy has reached its high-water mark and is no longer on the rise. The authors argue that that conclusion is mistaken and that the underlying conditions of societies around the world point to a more complicated reality. They note that it is unrealistic to assume that democratic institutions can be set up easily, almost anywhere, at any time. The conditions conducive to democracy, it is argued, can and do emerge – and the process of ‘modernisation’ advances them. Once set in motion, it tends to penetrate all aspects of life, creating a self-reinforcing process that transforms social life and political institutions, bringing rising mass participation in politics and – in the long run – making the establishment of democratic political institutions increasingly likely.