1. An Invitation to Participation
Countervailing power in Health Committee participation
Hanne Jensen Haricharan, University of Cape Town
I have changed my focus and title to more narrowly focusing on A concept called Countervailing power when I learned that the Length of the presentation was 5 minutes.

2. Overview
Topic: Health Committees. In South Africa statutory bodies at PHC level composed of facility manager, local government councillor, community members. This is according to the national health act.
Research Questions:
1. How do different forms of power impact on health committee participation.
2. Is invited participation a viable option? And this is seen in the context of proliferation of other forms of engagement between citizen/state such as through protest and social mobilisation. E.g. TAC
Background: Limited research on power despite acknowledgement of its central role.
Methods: Multiple qualitative case study with rural and urban committees.
The broader context: creation, promulgation and implementation of new health committee legislation. Fieldwork took place within creation/promulgation and implementation.
Data analysis approach: both inductive and deductive, using different theories and understandings of power.

3. Health committees as Invited spaces
Conceptual Frameworks: (from Gaventa/The Power Cube)
Explain what an invited space is: a space where the state or its institutions invite lay-people or citizens to participate. In contrast with closed spaces, which is traditional political or police spaces or claimed spaces, where the citizens engage with the state through other means.
Participatory democracy, human rights and primary health care approaches:
Participation is about influence in decision-making in priority setting, planning, implementation, policy, health governance at PHC level.
Closed spaces
Invited spaces
collaborative
Claimed spaces
adversarial

4. COUNTERVAILING POWER IN COLLABORATIVE PARTICiPATION
Fung and Wright (2003): Deepening Democracy. Empowered Participatory Governance
Their main conclusion is that Participation without power likely to fail.
Conversely that participatory structures need a form of power they call countervailing power, which the define as follows.
Limited knowledge on countervailing power in collaborative structures. Power in adversarial engagement. They are then looking at examples of countervailing power in collaborative and define a number of
Potential sources of collaborative countervailing power
A. Policy
B. Politicians
C. Communities
D. Transfer from adversarial structures? Which they don’t find likely because of a question of scale, different skills set and different mental frames for adversarial and collaborative. But more likely at a local level than at national.

5. Counter vailing power:
Fung and Wright: Our discussion will revolve around the concept and role of what we term countervailing power – a variety of mechanisms that reduce, and perhaps even neutralize, the power-advantages of ordinarily powerful actors. We contend that in nearly all contexts significant countervailing power is necessary for EPG [Empowered Participatory Governance] to yield the benefits for democratic governance that we have claimed for it. (ibid: 260)

6. FINDINGS: different models AND countervailing power
Appointment model
Organisational model
Self-appointed model
Election model
Where?
Envisioned in the Act
Practiced in urban committee
Practiced in rural committee
Practiced in other participatory structures envisioned in other policies
SGBs Ward committees
White Paper on Transf
Brazil Health councils
Source of countervailing power
The Act
Community mandate
Community mandate?
Problematic issues
Gives health committees a mandate, but limited by other forms of power.
Much power remains with health system.
Challenged legitimacy – poor community links .
Because of representivity
Accountability
Narrow process
Challenged legitimacy.
Stakeholder disengagement.
More legitimate?
More inclusive?

7. Findings (cont.)
Additional sources of countervailing power: (potential or actualized) Not linked to specific model.
a. Collaboration between collaborative/adversarial structures. Beginning in the urban committee
b. The existence of adversarial structures. Forced/motivated health system to take invited participation serious.
c. Rights discourse. Viewed themselves as citizens with right to participation and to health. Beliefs can be a source of positive power. Often drew on this in claiming a right to participation and a right to influence.
d. Collectivity. Challenged, but when they did they perceived their influence to improve
Limited countervailing power results in limited influence in decision-making which in turn leads to:
a. Contestation around appointment model. Current situation
a. Disengagement - clear in the rural committee. People choose not to participation
b. Exploration of claimed/alternative spaces. Situation in the urban, where they want to create a from of independent participation

8. Conclusion
Invited participation is a viable option if participatory structures have sufficient countervailing power.
Attention to source of countervailing power in design of participatory structures.
My suggestion for a form of invited space that could work (and here I also draw on some aspects of my research which I have not touched on in this presentation is)
Participatory spaces with sufficient countervailing power: rights based, legislated, election model with sufficient decision-making influence, attention to other forms of power that constraints and enables participation, sufficient support for participation.

9. Thanks
Funding and Support for the Wellcome Trust and the SASH fellowship programme is greatly appreciated.
For more information:
Salearningnetwork.uct.ac.za