This paper will assess the effects of the Skilled Health Entrepreneur (SHE) program in Sylhet District, Bangladesh, on the SHE's power in their social context. This program developed a cadre of community-based skilled birth attendants (SBAs). The SHEs offered home delivery services that met minimum clinical standards for safe delivery and received formal recognition from the health system, allowing them to refer complications to health facilities. (Hossain et al., 2020) This approach created a reliable source of Skilled Birth Attendants (SBAs) care in geographically remote, underserved areas.
Notably, the newly introduced frontline health workers in this intervention closer to social peers of clients than nurses and doctors in mainstream health facilities. The Skilled Health Entrepreneurs (SHEs) were women already residing in the communities served. The SHE model incorporated activities deliberately designed to increase the power of the SHE in their social context. The inclusion of those elements in the project design grew from the assumption that increased independence and importance could help the SHEs be more effective in serving their clients and potentially support positive norms change about women's role in the community. This analysis will examine whether the SHE program increased the social power of the community women who became SBAs.
The SHE model deliberately incorporated elements targeted explicitly at "empowering" the SHEs, in addition to skills-building and performance-focused supervision. This work seeks to clarify the understanding of the "empowerment" of the SHEs. This paper will develop the concept of social power as a framework to understand relevant power dynamics, elaborate a measurement strategy to quantify it, and assess the change in social power from the beginning to the end of the project.
Because empowerment as a concept is fraught with contradictions and ambiguities, this analysis will develop the concept of social power as an alternative. Drawing on the concept's use in psychology and other fields related to global health, social power refers to the individuals' power over decisions in the context of their social relationships. (Gülgöz & Gelman, 2017; Keltner, Van Kleef, Chen, & Kraus, 2008; Rucker & Galinsky, 2017; Scholl, Sassenberg, Ellemers, Scheepers, & de Wit, 2018) Social power has been proposed as a valuable way to understand how group status can influence individual member behavior within a group. (Scheepers, Ellemers, & Sassenberg, 2013) While no consensus exists on the precise measurement, this work can specify the concept in the global health context.
Social Power and the Elements of Social Power
The concept of social power serves as an alternative to "empowerment." Constructions of empowerment abound and lack a single, commonly accepted approach to conceptualization or measurement. (Kok et al., 2015; Richardson, 2018) Furthermore, the term "empowerment" connotes a passive process performed on the powerless by the powerful. (Kane et al., 2016) We choose to offer social power as an alternative. This analysis defines social power as the state of having the ability to exercise one's own will autonomously in one's social context.
These elements contribute to an increase in SHEs' power, a change this paper will conceptualize as increasing social power instead of using the concept of empowerment. Empowerment is an often-used, ill-defined concept, measured in many different forms from psychological to organizational and levels from individual to the community. (Cyril, Smith, & Renzaho, 2015) Empowerment can present internal contradictions, as it is often conceptualized as top-down, a characteristic conferred on those with less power by those with more power. (Closser et al., 2020) Further, empowerment can be co-opted to obscure the reality of power relations among community-based health workers, their clients, and municipal and health authorities. (Closser et al., 2019)
This work will construe social power more narrowly than most characterizations of empowerment. Social power will be constructed to refer to individuals, not communities or social systems. Agency, a central concept in empowerment and one of the most straightforward to measure directly, is central to social power. A second key element is their compensation, which increases the SHEs' independence and provides concrete evidence of the value of her service. A third element is her professional engagement, marking a transition from a less socially powerful homemaker to a more powerful health professional. (See Fig. 1.) Social power does not attempt to encompass and measure the broader enabling structures or a comprehensive assessment of the SHEs' interpersonal or psychological conditions.
Increasing the social power of the SHEs may enhance their ability to gain their clients' trust and link them to services and the clients' perception of the SHE's skills. According to a framework advanced by Afulani et al., client perceptions of need, quality, and accessibility of birthing care are critical pathways to increasing uptake of skilled birthing care. (Afulani, Diamond-Smith, Golub, & Sudhinaraset, 2017) For this paper, the authors assume that increasing the social power of SHEs also increases clients' perception of accessibility and quality while ensuring high-quality care and appropriate referral. By providing a quantitative analysis of the change in SHE social power, this analysis will partially explain the mechanisms for elevating the status and influence of FLHWs SBAs in this case). The increased status and influence may contribute to the observed increase in uptake of skilled care to some extent. (Hossain et al., 2020)
The analysis will assess the increase in the social power of the SHEs. Implemented in a Sylhet District in Bangladesh, a rural area with low coverage of SBAs and high maternal mortality relative to the rest of Bangladesh, the SHE program developed a cadre of birth attendants among women residents of rural communities. Hossain et al. (Hossain et al., 2020) the program; the SHEs received certification as SBAs and were recognized as legitimate referral sources for complications to government facilities. They received training and supervision from government health personnel but were not government employees. SHEs charged clients on a fee-for-service basis, in a context where many women choose to pay unskilled private traditional birth attendants.
This analysis will assess the three significant elements of the social power of the SHEs: compensation, agency, and professional engagement. SHEs reported their income from SHE activities, allowing for the direct measurement of compensation. The SHE's decision-making power will represent the SHEs' agency. The frequency with which they attend and present at professional meetings will represent their recognized importance in the community as legitimate allied health workers.