The number one cause of ill health is poverty, and power is the underlying dynamic determining why the poor are poor, and – let us not forget – why the rich are rich. That’s how I see things, and that’s why I’m interested in understanding power as a distal but pervasive determinant of health, notably at the level of health policy. However while analyses of health policymaking in low- and middle-income countries frequently evoke power and power dynamics, these concepts are rarely explicitly defined or explored.

Niger is a low-income West African country that recorded precipitous drops in child mortality (1998-2009) thanks in part to a policy called integrated Community Case Management (iCCM) providing care for pneumonia, malaria and diarrhea to large numbers of poor children. To understand why a pro-poor child survival policy succeeded in Niger, we relied on a political economy outlook to operationalize the concept of power and identify three relevant dimensions: 1) political authority, 2) financial resources and 3) technical expertise.

The policy analysis showed that manifestations of power during iCCM policymaking were multiform, combining Nigerien forms of political authority (Niger is a neo-patrimonial, multi-party democracy) with hard cash from various sources and smart policies appropriate for local health infrastructure. The Nigerien President at the time, Mamadou Tandja, laid the groundwork for iCCM starting in 2001 by launching a campaign to build over 2,500 “health huts” using funds from the Heavily Indebted Poor Countries initiative (HIPC), simultaneously building up his rural constituencies and supporting client networks charged with construction. Community health workers staffing the “health huts” were undertrained, however, until the advent in 2007 of a nationwide iCCM training campaign paid for by funds from Unicef and the Canadian development agency under the Catalytic Initiative, alongside support for supply of essential medicines. The demand-side piece fell into place around the same time when the World Bank strong-armed the Tandja administration into declaring fee exemptions for health services for children under five (without consulting health officials), leading to a well-documented jump in care-seeking.

Power dynamics were perhaps best understood as an ongoing dialogue between actors, who used the leverage available to them while for various reasons maintaining the interests of the poor at heart.  President Tandja’s pro-poor outlook emerged from his political ambitions; he would later cite his rural development works (and even the fee exemptions) in his 2009-2010 campaign to revise the constitution to extend his rule (known as Tazartché, continuation).  For World Bank negotiators in Washington, the conditionality on fee exemptions was motivated by adherence to recent statements and evidence on abolishing user fees, in a turnaround for the organization following on the backlash to structural adjustment in the 1990s and early 2000s.  For technical experts at national and international levels, the emphasis on the poor was based on prioritization of equity, access and perhaps above all impact.

The Nigerien case sheds light on dimensions of power in health policymaking, particularly in neo-patrimonial African regimes, and provides insights on how external actors can work within these contexts to promote pro-poor policies. With national elections in Niger last weekend, and the machine of international health and development grinding on, keeping the attention of the powerful focused on the poor is both an ethical imperative and a programmatic one, if the goal is to meet the greatest need.  While a growing body of work examines how power shapes health policy processes in low- and middle-income countries, more research and practical guidance is needed on how to apply such a profound, multi-faceted and contested theoretical concept. Our article presents one attempt at operationalizing the concept of power in policy-making that we hope will spark conversation on this critical topic.

Full article: “Power and pro-poor policies: the case of iCCM in Niger,” Health Policy & Planning (2015)