It’s a man’s world, but a woman’s decision? Power dynamics between stakeholders in communities
POLIO
In developing an understanding of power, we identified that gendered power relations shaped the use of space and ownership over decision-making linked to child health.There was a lack of consensus about who held the most power in relation to child health. Women’s groups identified women as having more power, and men identified men as having more power. Our work identified the existence of a decision-making pathway, where women and men’s power worked in parallel ways, through different forms of power, to achieve particular ends. For example, men’s influence was associated to their economic power, as they have primary decision-making in households as is common in patriarchal societies. [[The] mother is responsible for taking care of the child, to the extent of doing things that even the father cannot do for him (child), even if the father does not have money, she has to find means of taking care of him, it is only when she does not have that the father will provide – she (the mother) takes care of the child more than the father. – Participant from Young women’s sub-group Other stakeholder groups such as neighbours and other blood relations (such as grandparents and siblings) were described as alternative sources of financial resources — highlighting that the community is built on important webs of financial capital that could potentially shape how people access information and make decisions. For example, in one ward, participants indicated that ‘their doctors’ (how community members described any health staff at local clinics) were not as powerful in terms of child health as neighbours — because in a health crisis, they would go to them first for information and support.Neighbours form important kin networks, provide support, advice and access to resources that a family member may not have, or if a husband is away, then they could also provide. These networks are key for the mobilisation of various forms of resources and become opportunities to overcome products of structural forms of power (such as the organisation of state structures and their management).Discussions about the role and presence of external groups and agencies illuminated that despite an acceptance of the important things that organisations like UNICEF, Save the Children International and USAID do for child health, they couldn’t make specific reference to the actions they contributed, or the motivations for their engagement. As noted by a participant from the men’s group “…they [UNICEF] do things we don’t know how to do – [but] We can’t say where this organisation came from.” This is particularly interesting, as there is a recognition of power and capacities of these external actors, which does not automatically translate to an understanding of motivations or purpose behind their involvement. This raises concerns about how trust can be established between community members and external actors, as evidence from other settings suggests that in research among marginalised groups, trust can be limited when groups have little to no understanding of service aims and priorities 41). In some wards, participants acknowledged the failings of political power and process — noting explicit reasons for not including political figures as key players in determining well-being. In two wards, there were discussions of the inability for politicians, specifically at the local government level to be trusted. As highlighted in the below excerpt from conversations in one ward:
I: can you tell me the reason they [politicians] are not important?
MG participant: because as a politician, you can never get what you want from him at that time – whenever you are in need, he will keep promising you… anything that has to do with health needs instant help.
OWG participant: … they don’t help their fellow men, even on child health. It’s even rare of we the females to go to them for help when we are taking our child to the hospital.
YWG participant: …why we say they are important is they [set] programmes, like polio vaccination, and in some areas the health workers listen to directives from the politicians.
MG participant: …. But to be honest, we have not seen in any way that they are important to improving child health because the only [ones] that have a say in our community are community leaders (heads) or village heads – politicians only know how to deceive…
MG participant: … if you want people to come together a politician will never bring [them] together for you… but the village head or the community leader will organise people for you because we all respect them and work with their instruction. Relationships between actors involved both vertical and horizontal communication and flows of power, which hindered our ability to clearly map flows of information. For example, participant accounts indicate that the district head and ward/community heads largely disseminate information down towards communities. While this cannot be orchestrated without the approval of the Emir, a local leader who is responsible for large geographical locations, it reflects that power can also be linked to expertise, and as a result in some contexts, the King’s power can be deferred to Ward and community heads. For example, an Emir may not be involved in everyday decisions that are community specific. District Heads have the liberty to make certain decisions, but with limitations. In other instances, village/community or ward heads who make local decisions may defer to someone younger or who has more expertise in certain areas. For example, in one of the concept testing wards, when our research team organised a meeting to explain the project aims, a community head identified himself as ‘too old to understand’ and referred the team to a younger community head to organize the actions of the team. Furthermore, not all wards reported the presence of a ward head — though community heads were unanimously referenced by all groups. In most cases, dissemination of information/innovation begins with the district head and moves downward throughout the community. Everyday citizens seemed to have the least opportunity to generate information, with women the least likely to be seen as a source of knowledge outside of child-related dynamics.Given evidence which suggests that an underappreciation of power relationships can negatively impact community health interventions [