The analysis is arranged by the EPF and LPF to illustrate power dynamics, how community power built and was sustained within and between cycles, and overall. The results are illustrated by verbatim quotes, visual data, and reflections from community, and health systems stakeholders and researchers.
Cycle 1: Establishing collective capabilities and spaces with mutuality, and collaboration
In Cycle 1, community stakeholders identified alcohol and other drug (AOD) abuse and lack of safe water as priority health concerns. Youth and women of reproductive age were nominated as people affected by and whose voices were excluded from attention to the issues respectively. Including these perspectives was important, however some youth participants were initially disruptive, aggressive, uncooperative, and despondent about the possibility of change. Sensitive and assertive facilitation was required to reiterate principles of respectful conduct and representation, and expectations for change were managed honestly and consistently.
Engagement gradually improved as core principles were transmitted, discussed, revisited, owned, and taken up. Ownership was supported as participants assumed control of the process: identifying priority health concerns, directing expansion of the participant base, and controlling practical aspects such as, dates, times, and venues of workshops. Collective capabilities, ‘power within’, developed as participants’ familiarity built with public speaking, analysis methods (including with causal maps and in selecting, appraising, and captioning visual data), consensus-building, and in co-facilitation and recording of meetings (Fig. 4). Regular revisiting of PAR principles moreover supported shared vision and purpose. More coherent, respectful exchanges emerged as a result, with quieter participants speaking up and more dominant participants giving space for others to talk:
“…we should talk about one actor at a time because others talk about the pastor while some talk about police and it is confusing” (Woman of reproductive age, Cycle 1).
“...I want to say that in the past we were laughing to each other when someone talks but now there is a change. We are united, we listen to each other” (Community stakeholder, Cycle 1)
Figure 4
Initially, each village represented themselves but over the course of the workshops, groups realised they had common issues and worked together. As a weekly workshop rhythm was established, groups collectively deliberated over causes and impacts of AOD abuse and lack of water, mapped key stakeholders and agencies, and developed and appraised local action agendas. ‘Power within’ developed further; community stakeholders reported becoming more informed about local issues, processes, and structures, and collectively learned ways to address shared concerns.
“…we gain knowledge, we learned about caring for ourselves and to work together with other people” (Community stakeholder, Cycle 1)
Unemployment, poverty, and proliferating taverns were identified as key drivers of AOD abuse, which was conveyed as destructive of communities, and disproportionately affecting children and young people (57) (59). On water, repeated and prolonged periods without piped water documented, as were unreliable and unavailable infrastructure, inadequate service delivery, unregulated sources, empty reservoirs, and poor supply exacerbated by droughts (58). We supplemented community intelligence with statistical data on the extent of the burden and its social and circumstantial drivers (61)(62).
Credible, actionable information, and collective capabilities were the foundations upon which we engaged with the authorities. Reflecting the community-nominated priorities, we engaged widely with different levels and sections in Departments of: Health; Water and Sanitation; Basic Education; Cooperative Governance and Traditional Affairs; Social Development; Home Affairs; Culture, Sports, and Recreation; the Local Drugs Action Campaign; Water Catchment Management Agency; with non-government stakeholders such as the South African National Council on Alcoholism and Drug Dependence (SANCA) and the Africa Foundation.
There were new and varied power dynamics in these workshops and some discussions were dominated by powerful local officials. Again, we revisited PAR principles regularly, and with sensitive/assertive facilitation, constructive and respectful dialogue was supported. ‘Power with’ emerged; health officials came to see and welcome a view of community stakeholders as active change agents, rather than passive beneficiaries, and criticism of the authorities from communities gave way to a collective awareness that working in isolation would not support solutions. Community power deepened as tangible commitments for local action were developed with representatives of the authorities (Fig. 5):
“There have been a lot of service delivery protests in communities, but they did not accomplish much – everyone realised that it is time to shift our ways of thinking and initiate dialogue, unite and collaborate and create sustainable partnerships to solve community problems” (Community stakeholder, Cycle 1)
Figure 5
‘Power with’ developed as stakeholders developed and collectively implemented local action plans. There was mixed success with the action plans (some actions were achieved, some partially, and some did not progress). As the researchers monitored action through follow-up visits, entrenched systems challenges became evident (69). In response, we framed the monitoring process as a learning opportunity: prioritising psychologically safe spaces for reflection in a no-blame, appreciative approach.
This supported acceptability. In the final reflection element of Cycle 1, the authorities embraced the process as a platform to safely engage with communities without having to defend themselves, and for multisectoral dialogue. Health officials proposed adaptions to deepen links between researchers, communities, and health system: integrating the process as a standing item in district health management team (DHMT) meetings and with local health officials joining the PAR community workshops (63). This deepened opportunities and spaces for collective action and conferred a new legitimacy to the process, enabling ‘power to’.
Cycle 2: Expanding spaces for local decision-making
Grounded in and accepted by the district health system, a pronounced ‘localisation’ emerged during the second cycle. Community stakeholders engaged more deeply as co-researchers. They identified and recommended new stakeholders to join including leaders from the traditional authorities and the Community Development Forum (CDF). In the development of action agendas, fewer actions were developed, and they were more locally focussed and achievable. Community stakeholders committed to act locally and to build partnership with the local governance in villages. Community stakeholders, moreover, worked with the PAR tools quickly as they understood them, taking ownership of discussions, leading, and facilitating the deliberations (Fig. 6). This deepened ‘power within’ and extended ‘power with’: identifying key actors affirmed stakeholders using their voice and courage to reach out and connect. Creating partnerships and capacity and building new connections in local services and across sectors further enabled identification of, and engagement with, those with the power to act.
Figure 6
Regular interaction with a range of stakeholders revealed few spaces for departments to engage, and the process was again seen as valuable among representatives of the authorities. Participants co-designed time-bound action plans enabling accountability from different departments with more focus on local stakeholders. Community stakeholders tailored demands while fostering strategic relationships. While some dissatisfaction with the authorities remained, constructive mind-sets were also evident with deeper understanding and appreciation of structures, opportunities, and responsibilities for collective action:
“…we really understand…. that they won’t fix the water problem overnight… what matters is that we have already taken the step of approaching people who we know are dealing with water. This is us taking responsibilities for our problems.” (Youth participant, Cycle 2)
“We can use the methods to solve community issues, for example when there is no water or electricity people may decide to strike where they usually destroy infrastructure but now that there are people like us who have been exposed to these methods we can opt and encourage everyone to use this approach since it is peaceful and attracts attention.” (Community stakeholder, Cycle 2)
As COVID took hold in early 2020, the second cycle was interrupted and redesigned to be of practical support in rural communities and the district. Through remote and in-person consultations during lockdown, rural communities and service providers expressed concerns over lack of understanding of preventative measures to reduce transmission, and about access to non-COVID care. There was a shared realisation that CHWs were the first line response to connect people and services, especially vulnerable people, but lacked support. The collective re-design revealed an urgent need to formalise dialogue spaces for collective action. Both community stakeholders and service providers realised the gap/disconnection between them, and collectively agreed to fill the gap with the learning platform (Table 2) (64)(65). This extended ‘power to’ in terms of establishing new structures, processes and opportunities cooperative learning and action.
Table 2
Cycle 3: Connecting and sustaining structures and opportunities for action
The third cycle was reconfigured to include a training programme to support CHWs to develop community mobilisation competencies by connecting, raising, and responding to local health concerns, using rapid PAR tools and techniques, and facilitating action in communities, the health systems, and public services. While CHWs had relationships within communities, processes to convene to discuss issues faced by the community were not optimised and often disrupted (44). Training CHWs in PAR methods and principles for bottom-up learning and action, and embedding platform in community health system, was seen as worthwhile in this space.
In the third cycle, CHWs led a collective decision to focus on attitudes, interactions, and behaviours between communities and services, specifically focussing on people lost to follow up with HIV/TB treatment as a critical and potentially overlooked area as services shifted to COVID. Issues were problematised and local action plans collectively developed, implemented, and monitored. Action plans were again focussed and local: to improve access to information, support, treatment, and care including through support groups addressing stigma and related priorities such as food security and access to social workers.
‘Power within’ was again built as community mentors supported CHWs during the training, building capabilities improving public speaking and application of PAR tools. Community mentors also supported CHWs managing dominant participants, listening to, and respecting everyone regardless of status or power. CHWs and community mentors also took it upon themselves to arrange venues for workshops, remind community stakeholders about workshop logistics, and in facilitating and recording activities during action plan implementation. Collective rather than researcher-led monitoring further strengthened CHW and community ownership and control.
‘Power with’ was seen in terms of commitments to the process throughout community and clinic levels of the system: clinic Operational Managers (OMs) and outreach nurses (OTLs) were highly supportive throughout, regularly attending meetings to demonstrate support ‘voting with their feet’ (66). This fostered ‘power within’: CHWs reported that the process made them feel recognised by clinic staff, and programme managers and other officials, and that they felt respected and valued. Furthermore, they indicated that their presentation and reporting skills improved significantly and that they were more determined to be involved in the communities (66). Through the PAR training, quality relationships between CHWs were also seen as both a positive experience and strategic benefit (Fig. 7).
“The VAPAR training was good…I learned a lot about respect, communication and how to use all the tools that we learnt during the training. Most importantly, I learnt the power of working together as CHWs, communities and traditional authorities. If the communities can master this approach of working together, we can solve a lot of issues that our communities come across every day.” (CHW participant, Cycle 3)
“The training taught me ways of identifying challenges and addressing them, I understand challenges better than I used to. I'm confident that now I know even how to identify people who can assist us in dealing with various issues.” (CHW participant, Cycle 3)
“I can use the skills I learnt during the training to work with community members and other CHWs to identify the challenges we have and work together to solve them.” (CHW participant, Cycle 3)
Figure 7
‘Power with’ was further built, following completion of the CHW training, as the process progressed to engaging with higher levels of the system to analyse, interpret, act on, and learn from the data and evidence generated. Again, departments realised that each have policies that address common problems, but that these are disconnected. The learning platform provided a process for stakeholders to convene, discuss and collectively find new ways to address issues faced by communities e.g., via clinic committees supporting CHWs with guidance on where and how action can be implemented. Clinic OMs and higher-level managers became integral to the process, supporting CHWs and participating.
Engaging with actors in health system was challenging, and there were disruptions owing directly and indirectly to the pandemic. We sought to be flexible and sensitive to this situation and worked to avoid imposing administrative and time burdens in an already over-burdened system, explicitly identifying, and ensuring mutual benefit throughout. Crucially, as the process engaged with the authorities at higher levels, there was explicit recognition of CHW roles, value, and contribution at higher levels of the system.
“I never knew how much these people [CHWs] know…we never knew we could learn from these people” (Health system manager, Cycle 3)
“For the first time, CHWs and managers sit at one table and engage” (Researcher, Cycle 3)
“The [VAPAR CHW training] manual, from the department’s perspective, particularly at the sub-district level, inspires a great sense of pride about the realisation of the possibility of building capacity for this cadre of emerging health care workers in South Africa. The manual will go a long in providing a practical and a formal tool to guide CHWs through their day-to-day work with communities” (Health system manager, Cycle 3)
At the end of the cycle there was a collective reflection. There was agreement to work to re-establish a CHW support structure that had previously existed with clinic outreach teams, and to embed the PAR process into clinic processes. This was welcomed by OTLs who did not see the process as imposed but as one that was owned by and relevant to WBPHCOTs. The shift was formalised in a request to roll out the community mobilisation training through the sub-district with the Department of health (DoH). The third cycle thus drove ‘power within’, ‘power with’ and ‘power to’; developing a collective voice driven by CHWs, connecting with other agencies and communities, and by further embedding the platform with a focus on CHWs as key public health agents in the district health system, respectively. Analysis with the EPF revealed that power-building dynamics were non-linear; different components of the EPF progressed in different ways in each cycle, and overall (Table 3).
Table 3
Limitations on power building
We also used the LPF to document forms of power limiting community control, measures to address these and areas that need attention. Compulsory power is defined as direct and visible exercised through, e.g., legislation. Several formal and restrictive dynamics were seen, for example, community voice expressed in illegal service delivery protests, a criminalising approach to AOD, and in the strict lockdown. Compulsory power can be seen to limit community voice, and contextualises the value expressed by stakeholders for safe dialogue spaces between service providers and users, for reframing AOD abuse as a public health concern, and for driving attention to and action on community health priorities, when these were limited owing to COVID.
Institutional power is defined as less visible, exercised through organizational rules, procedures, and norms. Here, we observed top-down governance, limited learning spaces, and little recognition of the significant capability, resilience, and ingenuity at operational levels of the system (69). There was little recognition, initially, of community members as active change agents, poor functionality of participatory governance such as clinic committees, and some discussions were dominated by local actors. We also observed parallel systems and tensions between groups such as the CDF, which had varied roles, and with traditional authorities and former tribal areas dominating democratic spaces, which on some occasions limited community voice. We claimed and protected spaces for new forms of ‘everyday leadership’ rooted in community voice, cooperative learning and data and evidence. We strategically positioned the process to increase visibility and legitimacy - building alliances with and influencing formal structures and actors e.g., DHM. Nevertheless, some actors at higher levels of the system had limited power to act owing to institutional power limiting dynamics.
Structural power is defined as invisible, systematic biases embedded in social institutions, generating/sustaining social hierarchies of class, gender, ethnicity and resources, opportunities, and social status. The second and third cycles revealed the centrality of CHWs to the district health system, and especially in the face of emerging threats such as COVID-19. Building collective voice and agency with CHWs revealed that, despite this centrality, in practice CHWs experience multiple challenges: lack of financial, logistic and health system support and training, lack of role clarity, insecure employment, low and no pay, poor safety, and low status (66). We observed engrained social inequalities and hierarchies along various lines - ethnicity, gender, class, occupation (especially with CHWs) - and that these acted in combination with e.g., institutional power dynamics.
Productive power is also invisible, operating through social discourses and practices to legitimate some forms of knowledge, while marginalizing others. The wider context of the learning platform, in former homelands characterised by intergenerational structural disadvantage, economic inequalities and enduring stigmatisation of HIV/AIDS was important. During workshops, some stakeholders were dominant and disruptive, leading to others feeling intimidated to raise their opinions. In some instances, we observed local politicians using the platform to promote political parties. We dealt with this with sensitive, but assertive, facilitation reinforcing principles of democratic participation, voice, representation, and respect. The regular negotiating of these principles supported more equal participation. Finally, in some clinical and academic spaces, we observed some views of enquiry paradigms concerning knowledge for action, plurality of knowledge, and expertise from the margins as low quality/non-science. We dealt with this with a consistent presence, open and reproducible methods and engaging widely in critical debate and activity across disciplines and sectors (Table 4).
Table 4