Unleashing the power of communities to confront health inequity

South Africa spends 8.3% of its Gross Domestic Product (GDP) on health care and 20% of all government expenditure is invested in health care, yet the health outcomes are deteriorating. The National Planning Commission (NPC) states that the investments being made in health care are not producing better health outcomes. Despite the fact that financial and other resources are being directed towards health care service provision, the country is faced with a quadruple burden of disease and worsening health outcomes, which can be attributed to enormous health inequities.

Health inequities in South Africa are not only a legacy of the past governmental systems’ design, but it is perceived that they continue and thrive due to the passive citizen mentality that is prevalent. The legacy of this passive culture can be attributed to the shortcomings of decades of authoritarian leadership and skewed closed party list system of voting that effectively gives decision making powers to the privileged few at the expense of the electorate. Even though South Africa is now considered to have one of the most progressive constitutions in the world (1), a majority of its citizens feel powerless and are not meaningfully participating in tackling challenges in their communities. It is believed that such anomalies are impeding the country’s aspirations of becoming a prosperous egalitarian democracy. Therefore, there is a need to develop a way of empowering citizens and helping them take on active roles in resolving the challenges faced in their communities – hence the Letsema-circle-model.

The “Letsema-circle-model”

The “Letsema-circle-model”, is a model designed to empower the community through dialogue, with the view to encourage citizen participation on health and other issues of national significance. The model recognizes the nature of woundedness that exists in society which has resulted in citizen apathy. Hence the implementation of the model incorporates sessions designed to help communities to transition from a state of woundedness to dignity and in turn this unleashes the required citizen energy. Once the energy is unleashed the community members become more meaningfully involved in solving their own challenges. In turn, this results in more desirable outcomes and sustainable change in health and other spheres of national development.

The “Letsema-circle-model" can also be perceived as a community engagement model in which communities are assisted to leverage on their existing wisdom and resources to unleash citizen energy in order to resolve their own challenges. There are four key components for unleashing citizen energy:

  1. Paradigm shift – citizens have to believe in themselves as agents of change and change their behaviours from those of “subjects” to those of “citizens”;
  2. Personal, social and organizational change;
  3. Re-enforcement of change in vital behaviour by harnessing the power of numbers and leveraging social capital; and
  4. Leadership engagement – the role of leadership is to enable the development of inter-personal skills that enhance social capital to sustain change.  

Paradigm shift – From “subject” to “citizen”

Although the South African constitution allows for freedom of expression the majority of the citizens are yet to fully embrace the liberties they are afforded by the bill of rights enshrined in the South African constitution. At present, South Africans subject themselves to those in authority instead of exercising their democratic privileges as citizens (sovereigns) of a democracy, for reasons already stated – feeling powerless due to past humiliation among other reasons. In this context, we define a “subject” to mean one who is dependent and or subordinate of a system yet a “citizen” is an independent self-governing individual in a community. For that reason, the initial process of unleashing citizen energy is a process by which individuals are encouraged to have a change of mindset from merely being “subjects” to “citizens”.

The journey from “subject” to “citizen” involves recognizing the wounded state of the subject. It also requires mutual recognition of fellow citizens in the same predicament. Since the transition to democracy in South Africa did not involve this moment of recognition beyond the Truth and Reconciliation’s laudable efforts to deal with gross violations of human rights a majority of citizens are wounded. Therefore, it is critical to help them transition from woundedness to dignity. Once the individuals begin to break free of the woundedness the transition from “subject” to “citizen” commences.

Studies state that the humiliation that results from being treated with disrespect by fellow human beings inflicts deeper social wounds and pain than physical assault which results in more violent behaviour societies (3) as such South Africa is not atypical. Having realized that people are wounded the next critical aspect is cultivating respect for others through a process to humanize them in such a manner – introduce yourself to others using your name and theirs; make and maintain eye contact; engage in getting feedback from them about what you are saying or doing so they feel that you take them seriously. Even the most disinterested person would tend to want to engage if he/she feels that you are not out to control or bully them. Through this process every member feels included and is more likely to progressively voice their concerns and contributions – a move towards being a “citizen”.

The journey from “subjects” to “citizens” also involves addressing the extreme inequalities in the society. A cornerstone in addressing inequalities in any society is education for democracy. It equips citizens with relevant knowledge of their rights, role and responsibilities in a democracy. Education is an essential part for the preparation of the journey of unleashing the human potential of all citizens. When the citizens are informed, they tend to develop self-respect and recognition of the need to work with other citizens to hold those in authority accountable to ensure a more effective and efficient state.

Personal, social and organizational change

In order to change vital behaviours in a sustainable way Kerry Patterson et. al. (2) state that motivational factors and structures that promote the change need to be identified. At a personal level one has to make the undesirable – desirable such as breaking the gang code that calls for “care only for yourself and don’t rat on anyone” or changing sexual practices from risky to safer ones. Such changes require support to surpass limits that one places on one’s own ability to change. One may harness the power of positive peer pressure. The power of numbers is essential to re-enforcing desirable behaviour.

Re-enforcement of change in vital behaviour by harnessing the power of numbers and leveraging social capital

The Letsema-circle-model, leverages traditional dialogue methods that have all the above elements built into them. Many rural communities like to be perceived as attentive to tradition, thus by harnessing familiar idioms one makes community dialogues about health and well-being desirable. The structure of the circle creates a social level playing field that promotes an egalitarian platform that affirms everyone. Status and hierarchy that undermine the spirit of community and empathy have no place in these healing circles. Individuals are affirmed through eye contact and personal introductions that link people as fellow human beings – the “I am because you are” – is played out as common problems and solutions are discussed. These discussions lead to short and long term plans being agreed on for collective action.

The impact of this approach has been noted in the four sun-districts where we work in (Intsika Yethu, Mqanduli, Buffalo City – Duncan Village and Uitenhage). Mobilizing human and social capital makes change in behaviour possible. Social capital mobilized in this way represents the profound enabling power of networks of relationships that unleashes the energy of individuals who would have felt too vulnerable to stand up and be counted.

Leadership role for change

Sustaining change from subjects to citizens who are active in changing their own and other people’s lives requires leadership that is alive to the need to develop the skills for inter-dependence. People living under stress from poverty, over-work or on the edge of survival need to be assisted to re-discover the power of working with, instead of against, others. They need a reminder that “it takes a village” which is what calling an “Ilima” is about. (Ilima is a Xhosa term for collective action which traditional agrarian communities used to build social capital and tackle common challenges.)

Letsema Circle has over the last 18 months recognized how fragile these networks can become without local re-enforcement. Establishing core teams in each sub-district and extended core teams in each village is essential to creating the inter-personal skills needed to sustaining trust and collaboration. It takes time and resources to sustain these networks and core teams which in turn hold the energy unleashed to drive desirable personal and community behaviour.

Major change also needs to happen at the personal and institutional levels amongst public officials to see themselves as proud citizens serving the public. The greater the social distance between public servants and health professionals the harder one has to engage to close the gap. Despite the amount of work being done to unleash the energy of communities, unchanged relationships between citizens and public servants would undermine such efforts. It would be a mistake to blame the public servant who takes the cue from a system that is not geared to serve, but to promote the interests of self –“me, myself and I”. A major task of the journey from “subject” to “citizen” has to be accompanied by active education for democracy at home, at school and in communities including professional communities in both the public and private sector.

We need to call “Ilimas” at all levels of society to harness the power of the South African heritage to tackle the complex problems faced as a young democracy plagued by growing inequality. It takes a village to support the radical mindset change that is needed to make us live up to our rhetoric of being a society known for its “Ubuntu” (humanity). The greater the social distance between public servants and health professionals the harder it will be to sustain whatever energy is unleashed in poor communities.

Story of a school in the Eastern Cape

An informal “Ilima” conducted by a health facility manager at one of the high schools in her district revealed the high risk approach by many of the young people. She encouraged young people sitting in a circle of healing to introduce themselves and indicate what grade they were in and what their future career plans were. The students were highly ambitious many wanting to be engineers, doctors, lawyers, teachers, etc. When asked about their lifestyles it became clear that their aspirations were at variance with the conduct of their personal lives with respect to life choices: risky sexual behaviour and drugs; lack of application to the business of learning and preparing for the future.

When it was pointed out to them that their lifestyles were exactly those that fuelled HIV/AIDS epidemic, panic set in. The nursing sister explained the documented link between multiple sexual partners and the spread of the HIV. The “Ilima” ended with encouragement of young people to get counselling, testing and change in lifestyles.

The fight against HIV/AIDS cannot be successfully fought without tackling the social determinants of risky sexual practices. Failure to comply with treatment and healthy lifestyles, absent fathers (only 37% of children in South Africa grow up with both parents), poor role modelling by teachers and other adults, and poor quality education and high unemployment create a poisonous mix that make young people not feel it is worth protecting themselves and preparing for a future. Through coming together and having open conversations like “Ilima”, the social ills, enablers and inhibitors in the fight against HIV/AIDS may be identified.

What is clear is that high risk behaviours which are common in young people due to the belief that “it won’t happen to me” needs to be tackled systematically to change the behaviours and to mobilize the schools, health clinics and parents to work together to support peer group support systems for positive deviant behaviours. It takes a village to change behaviours in a sustainable way.

“The big idea is that what matters in determining mortality and health in a society is less the overall wealth of that society and more, how evenly wealth is distributed. The more equally wealth is distributed, the better the health of that society. –Wilkinson & Pickett (3)”

South Africa has to tap into its heritage, seize the advantages of its social justice constitutional dispensation and work together to become the country of its dreams. Poverty and growing inequality are symptoms of a society that has yet to learn to collaborate to enable each one to become an engine of a prosperous community. Together we can do so much better but it all starts with each of us taking individual responsibility.

Note that the views expressed in this article are those of the author(s) and do not necessarily represent the views of PHASA.

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