If empowerment is good for health, as I argued two weeks ago, and if communities — particularly marginalized communities — can become empowered and effect change, then the question becomes: Are governments enabling empowerment, or obstructing it? Are they serving us, and helping us become more empowered, or ruling us and disempowering us?
In her book Shared Space: The Communities Agenda, the Caledon Institute’s Sherri Torjman focused on a key outcome of empowerment — building resilience in both people and communities. She defined resilience as the “ability to not only cope but also to thrive in the face of tough problems and continual change.”
She argued that building resilience requires investing in both personal capacity (“the skills, abilities and assets of individuals and households”) and community infrastructure (“the supply of amenities and resources that contribute to well-being”).
Building those capacities and that infrastructure is an important part of empowerment. But while non-governmental organizations and the private sector can assist in both these tasks, this is largely an investment that governments can and should make.
It is important to recall that those who need empowerment most are those people and communities that lack power. So while everyone needs skills and abilities, amenities and resources, government policy and programs need to preferentially invest in those who have the greatest needs.
But it goes beyond simply building capacities and providing amenities, important though that is. Governments at all levels need to find ways to share power by engaging people in the democratic process of decision-making, because empowerment is good for health. Again, this is more important in communities that lack power.
Brazil has for decades been a hothouse for the development of such approaches. Scarred by their experience under dictatorship from 1964 to 1985, Brazilians resolved not to allow that to happen again, in part by deepening democracy.
The city of Porto Alegre was the first to develop and apply the approach called participatory budgeting, in which local people have some say in how resources spent locally are applied. In a 2012 article, Brian Wampler of Boise State University reported that in both Porto Alegre and the city of Belo Horizonte — another early adopter — there was evidence that in using participatory budgeting these two cities were successful in promoting social justice. He noted that “the poorest neighbourhoods with the least amount of public or private infrastructure received the greatest amount of resources both in absolute and per capita terms.”
But just as important as that is the level of engagement achieved by participatory budgeting, which is itself empowering and health-promoting. Wampler reported that in Porto Alegre there were 479 councils, and “participatory budgeting … brought over 50,000 residents to public meetings in the 2009/2010 participatory cycle.”
One of the features of Brazilian democracy at its best is the number of local citizen councils based around schools, public health clinics and so on. I have seen this local level-democracy in action in Curitiba. There, the 120 or so local primary-care and public-health centres all have community councils. These councils are elected locally and, under the national constitution as it applies to health care, their composition is 50 per cent users, 25 per cent health-care workers and 25 per cent health-care managers.
Not only do these councils provide input into decisions about local needs and priorities, they also send delegates to the nine regional councils that provide input to the regional priorities within the city, and they in turn send delegates to the Municipal Health Council, which is chaired by the vice-mayor for health.
Every two years, they hold a conference of all these councils that sets the strategic direction for municipally managed health services for the next two years. Even if this only works half as well as it is described, this is way more participatory and democratic than anything we have in Canada’s health sector.
Finally, Belo Horizonte was also the source of another important democratic innovation: a municipal deputy secretary of democratic governance. Given the importance for health of democratic participation and empowerment, why doesn’t every city in Canada (and every province) have a senior person and/or an office with such a role? Why can’t we learn from Brazil?
Dr. Trevor Hancock is a professor and senior scholar at the University of Victoria’s school of public health and social policy.