Personal View: Empowering rural women's health: What's going wrong with the strategies?

Empowerment has increasingly become a popular strategy in public health since the publication of the Ottawa charter for health promotion.¹ The Ottawa charter defines empowerment as a process of capacity building which enables people to gain power that influences social and political change in favour of individuals, groups and communities seeking control². This discourse of empowerment in public health is intended to help individuals and communities gain capacity and manage decisions to improve their own health and well-being. Recently, this type of empowerment has been used to tackle poverty in developing countries. The World Bank, through its strategic framework, “Empowerment and Poverty Reduction”, has utilized this approach as a yardstick for reducing poverty and enhancing equity among rural women³. Similarly, the World Health Organization has optimized community empowerment as a concept that enhances social, economic and political stability to address health inequalities existing among rural women at the micro-level⁴. More organizations have become involved with legitimate interests in promoting health through various empowerment approaches. Nevertheless, it is increasingly interesting to observe that empowerment approaches to address the underlying causes of gender inequalities, or balance equal opportunities, rights and obligations in alignment with men is at the moment done in a controversial way, raising debates over the techniques used to enable women to gain power to act. Fawcett and colleagues note that empowerment concepts often directed at women living in conditions of poverty fail to achieve the intended goals because these models lack theoretical clarity in overcoming reciprocal constraints in the empowerment process⁵. In this paper we draw on theoretical literature on empowerment to critically explore the composite discourse of empowerment, particularly in relation to women's health in Africa. The purpose is to raise a debate on how empowerment is conceptualized and suggest practical ways to help women rediscover their voices and channel their activism to gain the power necessary to manoeuvre health inequities

Rationale for Empowering Women

Generally, women are important to our societies because of the numerous roles they play, each role having an enormous impact on the others. For example, the critical roles of women in their families as mothers, wives, sisters, aunts, nieces and grandmothers vary incredibly and range from household activities to working on the farms so that food is produced for the household. Through other activities such as small businesses or sale of agricultural produce, women generate household income that can be used to provide school fees for their children and buy medicines and clothing for their families. Traditionally in sub Saharan Africa it is the responsibility of women to look after their families and their own health and well being. Relatively recently governments in Africa, such as in Malawi and Cameroon, have recognised the role played by women in their local economies. Not only do women assist in bringing down child birth and mortality rates, but they also promote child health, nutrition, and education, all of which contributes to economic development. Women also promote the peace and stability in families and homes which is necessary for a robust and self-sustaining community.

Women work two thirds of the world working hours and produce half of the world food⁶. Despite this workload, women are found among the poorest and least well educated and they increasingly bear the heavy burden of preventable diseases. Women suffer disproportionately from the burden of extreme poverty, disease and violence. While women are uneducated and unaware of their human rights, they also remain victims of sexual assault and domestic violence in their own homes. In many ways women's circumstances prevent them as social actors from articulating their own needs, thus compromising their health and well being as well as that of their children. Women are discriminated against, abused, expected to meet unrealistic obligations, violated and denied access to appropriate and equitable services on a daily basis⁷. Women generally experience far more barriers than skirted gender issues, which discourages or puts them off pursuing their own health goals. Apart from being victims of witchcraft and murky accusations, women are subjects of male control, jealousy and promiscuity. In addition to this are the heavy physical workloads that women undertake leaving them exhausted and vulnerable to ill health.

Helping women gain power is important so they can continue to improve their health and those of their families. This has never been a simple task. Approaches and concepts of empowerment are increasingly being applied to empower women but more is still needed if women are to continue taking control over the decisions they make to influence their capabilities in choosing health. Most empowerment interventions such as those embedded in the MDGs, advocate the eradication of illiteracy and empowering women by 2015, but the methodology to capture empowerment indicators are problematic. Women can be educated, but there is no assurance within these educational systems, albeit the MDGs, that learning would be adequate to prepare these women for 21st-century job markets, or simply how these women would deal with the issues of inequality or marginalization.

Conceptualizing the process of empowerment

Empowering voiceless and powerless women has increasingly become rhetorical in today's global climate, with little attention focused on women as the source of action. The concept of empowerment is often little understood and the empirical significance of the practical approaches of empowering women barely utilizes sociological references to properly frame the process. The past thirty years have seen a steadily rising recognition of the need to empower women and numerous strategies, concepts and approaches have emerged. However, there is dearth of coherently articulated concepts and approaches that respond to women's empowerment.

From the above context, we draw on sociology concepts from Goffman, Parson and Hobbes to argue that at the centre of women's empowerment lies a three way relationship, namely women as social actors, power relations and social systems; these three are often overlooked in women's empowerment programmes and initiatives in Africa. Empowerment can only take place if all these three core elements are conceptualised within the empowerment model.

Women's empowerment cannot take place without women as actors. Ervin Goffman's idea of “presentation of self” emphasizes the role of social actors as agents in mobilizing the best acts in order to arrive at the desired goals⁸. Actors must be able to understand themselves and be understood by others completely. Intuitive understanding of the individual as a conception of self, according to Goffman, helps to define who we are and our history enables actors and others to know what is expected of oneself and others. Informed in these ways, women as actors will know how best to act in order to bridge factors that limit their performance.

The everyday experiences of women are not only about the respective difference between the advantages and disadvantages of women and men, but about women's activity and how their social life is organised in reality. It is about their interaction with things that they have to deal with, i.e. quality of health, healthcare services, their barriers to access, and their level of literacy and schools education etc. Goffman assumes that the role of external agents such as economies and educational programmes are there to catalyze or facilitate individuals to earn power to act, but this can only take place if individuals themselves decide to take action or are receptive. It is essential to look at the mundane details of women's everyday lives, such as the social setting or space, appearance, manner of interaction and certain impressions that women can make. Through these identities it is hoped that women can remind men that they are equally important and powerful. This is the context in which women as actors is best understood.

Women's concerns and their roles don't occur singly and discretely; they are organised in social systems. An explanation of social systems by Talcott Parsons presents a clear process by which individuals are viewed⁹. Parsons claims that individuals exist in a system that consists of multiple roles and complex interactive forces and the consequences of these orient individuals to seek control and take action. Individual control can only be achieved if social systems influencing the definition of situations encountered by individuals are fully understood, so that social actors and others can act either by conveying changes, or accepting the preferred definition of social structures. Talcott Parsons attempts to illustrate how hierarchical relationships of social systems are organised to control actions or personality. For Parsons, the most strategic point to control the process and actions relating to individual acts are represented by four dynamic aspects of social systems: adaptation, goal attainment, integration and pattern-maintenance. Adaptation, according to Parsons, is simply a system in which both agents and structures need to relate appropriately or adapt to the environment and resources need to be made available to achieve these goals. The goal directedness of actions either in decision-making or political systems and structures must appropriately motivate social actors to take action. The understanding of ‘integration’ refers to the appropriate structures and mechanisms as these that must be constructed in order to maintain order. In an effort to make actors perform, Parsons suggests that actors' motivation and interactions require pattern-maintenance to influence certain values in society.

Closer to Parsons' theory of social control is Hobbes's analysis of power and obligation¹⁰. The emphasis on the significance of sovereign relationships and how these are socially constructed can be understood in the themes of power. While Hobbes does not formally comment on empowerment, his ideas suggest that power should be the central point of organizing control over causative determinants such as those responsible for health inequalities. Often men dominate over women and in Africa, men have complete control over everything. Men own resources such as land and control the household activities. If married, men control their wives' wages and even control sexual intercourse and determine the number of babies women can have. Hobbes notes that “people living in a state of nature without a common power over them to keep them in awe, are in a state of war of every person against every other”. Women are at war and are in a constant power struggle with men. Without a common power to mediate amongst men and women, nothing can be unjust. According to Hobbes, where there is no common power, there is no law; where no law, no injustice. Thus according to Hobbes, people need to obey covenants, since the rewards for doing so outweigh the risk of breaking them. Conceptualized this way, we will show that institution implementing empowerment programmes do not provide a voice to actors. Women are unable to choose what to do and are rather forced to do what the implementers prefer as a course of action. Hobbes' reasoning is thus well justified when scrutinizing conflict relationships between the needs held by men and women, and women and the social system.

Through the lens of theories by Elvin Goffman, Talcott Parsons and Thomas Hobbes, women's problems such as increased health care costs, reallocation of health services and poverty can be overcome if various dimensions of empowerment focus on women as active subjects of empowerment while paying attention to the four dynamic social system and the power relations within which women interact in everyday life. Empowerment models will be lacking if they are not associated with the individual, their needs, culture and history. In such models, it is difficult to glean clues that enable individuals to act. Clues can be uncovered if women's empowerment approaches assess women's participation or situation correctly and ordinarily so that the empowering process is allowed to navigate corners and negotiate all aspects under which women experience their concerns. The only way to command women's social space at the front stage according to Parsons is to create a social system that works for everybody. In reality, a social system such as the state, markets, globalization and norms are not straightforward and as such it exposes men and women to power imbalance. According to Hobbes, we need to create an environment where common power is mutually agreed through contracts such as transferring rights of self-preservation to a common authority.

Empowering women - a practical approach

Helping women to act and gain power often begins with a normative approach. The theoretical concepts narrated by Goffman, Hobbes and Parsons can facilitate the capacity to act only if they are interpreted within the context of specific social interactions, social actions and power relations taking place in social institutions, groups, cultures and norms. While this provides an overview of how the process of empowerment should be organised, the vexing issue tends to be when and how to balance these power relations against social structures, politics, economics and social actions.

To illustrate the conceptual framework developed earlier we use example programmes and activities on empowerment in two African countries, Cameroon and Malawi. The Integrated Management of Childhood Illness (PCIME) illustrates how empowerment is framed in the context of community participation to help fight malaria in Cameroon through a combination of a broad public health and specific fast track medical intervention measures^11,12. It was first launched by the WHO and UNICEF in partnership with the Pan-American Health Association in 1990 to reduce infant mortality in developing countries through the WHO/UNICEF-led Primary Health Care model. Since the late 1990s PCIME has created several Women Associations and Children Forums to help implement malaria control activities in three provinces.

The way in which PCIME was set up and implemented means that it focused more on enabling self with little done to reconcile the balance of social structures to enable women to acquire power. What we see more clearly within the PCIME programme is how women are being enabled to directly participate in improving their health and the health of their children. This is related to the notion by Goffman of enabling ones self. It can also be argued that PCIME provided some form of social structure to help women to actively participate. First of all, women can meet in their associations with fellow community members to formulate and implement malaria control programmes in relation to their community-specific needs. In addition, financial resouces are provided by international donors while technical advice is provided by the National Malaria Control Programme through Provincial Malaria Control Coordinators.

However, the power structures within which Women's Associations operate seem to be problematic. For example, the clinical and institutional aspects of PCIME are ignored as the programme hardly uses public health structures such as hospitals and health units under the Ministry of Public Health. Similarly, capacity building that is meant to link these civil society associations with the public health system, bypasses the public hospitals and pharmacies exclusively. Consequently, questions are being raised over the extent to which these Women's Associations possess the skills needed to implement malaria control programmes beyond distribution of insecticide treated bednets. In the PCIME, most of these women operate as volunteers with limited attention given to the need for them to be integrated into the public payroll system (espacially as most of these women are unemployed subsistence farmers). This highlights the situation where women's associations operate as NGOs and community associations within a social system that do not recognise women's representations and do not listen to women's serious grievances such as gender sterotypes and discrimination. Under representation in positions of power in PCIME in terms of unemployment levels and salaries means that women are vastly unequal to men.

In Malawi a non profit-making NGO called Foundation for International Community Assistance (FINCA) has initiated income generation activities (microfinance) that support women with small loans to generate their own jobs, raise household incomes and improve their standard of living¹³. Founded in 1994, FINCA- Malawi is part of the global network which helps women's associations to access the loans. It supports a group of 15–30 women and loans can be between $50–100. To ensure loans are repaid on time, FINCA accepts group repayments only and this acts as a cross-guarantee. If one person does not repay the loan, other members will meet the repayments. This system places social pressure on women's groups and indivuals to repay loans dispite any personal circumstances in order to avoid embarassment. Borrowers also pay interest rates on the loans, which usually match interest rates of local banks. As can be seen FINCA is a profit making organisation whose social system furthers its own interests than empowering poor women. At first glance, these loans can be considered important as a means to empower women, but the conditions of the credit facilities and the business environment in which women operate their businesses reminds us that women are yet to be recognized as actors, or their concerns or interests are not fully taken into account.

There is also a fundamental problem related to power relations within the groups as individual women do not have privacy or autonomy thus their interests may not be represented. FINCA avoids individual loans because group loans have historically proved to be better credit risks. In this FINCA opts for women to work an Association, however, what this does demonstrate is that women are yet to gain a position of power. While microfinance or credit can empower women, this is impossible in situations where women are not recognized as actors in empowerment programs implemented in societies where social systems don't function or are manipulated. For example, situations where women are expected to repay their loans shortly after receiving them, on a weekly basis for 16 weeks without giving them time to launch a business, only succeed in broading the gap between women and men.

Although training support is provided on how to run a successful business, the majority of these women end up in debt because these loans are sometimes used for urgent priorities, such as hospital costs or food. Failure to repay loans means women will be brutally humiliated and forced back into poverty. The financial empowerment model currently used by FINCA Malawi perpetuates women's underdevelopment and is yet to set an example of a ground-breaking project.

The same applies to political, administrative and socioeconomic empowerment where women are raised or handpicked to positions of power due to the political affiliation of the current government, but once a different government comes into power such women are casualties of disempowerment. This type of empowerment is short lived, personal and does not influence social change on a long term basis. The financial empowerment model by FINCA, for example, highlights the “war against all” for self-preservation. Women are operating in environments where there is no mutual common power agreed through contracts. There is no system where borrowers and lenders are able to transfer their rights of self-preservation to the government so as to stop lenders from competition and exploiting borrowers or vice visa. There needs to be a social system that functions so that businesses oriented to economic production not only make profits but improve women's affairs such as health.

Conclusion

In sum, through the lens of theories by Hobbes, Parsons and Goffman, we conclude that the construct of empowering women's health can only be understood and achieved within the context of complex social and cultural systems, rather than by imposing and judging what types of empowerment women should adopt as a means to enhance social, economic and political stability. To understand the complex agendas embedded in the concept of empowerment, social histories of the relation of power between women and others are very important to provide practical ways to help women rediscover their voices and channel their activism to gain the power necessary to manoeuvre health inequities.

While the connection between empowerment and the three core elements of women's empowerment (self, power and social systems) are clear in promoting personal, interpersonal and political power necessary for women to take control of their life situations, these themes may not fit every context and setting. It is necessary to ensure that each element associated with empowering women is considered within empowerment models as mutually reinforcing.

While these concepts are of western origin, they are relevant in articulating women's empowerment in Africa when little philosophical contribution to women's empowerment in the African context exists. Most African theorists concerned with gender under representation in scientific and technical education have promoted tools and means that narrow the social and economic gaps but lack a concept of the interdependence between women's identity and socioeconomics. Women's unequal status or underrepresentation is a result of political and economic power influenced by western markets, thus to address women's economic subordination requires a western solution.