Strengthening Community Health

Capabilities: A Case

Study of One Volunteer Run Social Solidarity

Clinic

04PS3.1: Inequalities, Quality of Life and Well Being

Session Chair: Jennifer Prah Ruger

Efthymia Kolokythaa, Maria Kalisperatia, Nikolaos A. Mylonasa,, Sofia Trilivaa

a University of Crete, Faculty of Social Sciences, Department of Psychology, Greece.

Presenting author: Nikolaos Mylonas

Global Financial Recession

• The Great Recession has brought to the forefront human rightsissues especially for people facing social and economicexclusion and living without access to basic health care. Greecehas been entangled in the eye of the socioeconomic maelstromand the multitude crises that have ensued have impactedpeople’ s lives gravely and with unprecedented force.

• The neoliberal adjustments (“Memorandum”) imposed by theGreek government and the troika members included theauthorization and implementation of severe cuts in healthcarespending (Kentikelenis, Karanikolos, Reeves, McKee, & Stuckler,2014).

• People’ s health has suffered gravely as they lost jobs, a largeportion of their income and many benefits (Vandoros, Hessel,Leone, & Avendano, 2013).

Health-related Consequences • the concept of “healthconomic crisis” (Williams, & Maruthappu,

2013)

• cuts in public health spending,

• cost shifting to patients

• exponential rise in the number of uninsured people

• constant change and turmoil regarding basic social and health services and “denialism” (Kentikelenis, et al., 2014) regarding rights, inequities, and capabilities.

• large increases in morbidity and mortality (Economou, Madianos, Peppou, Theleritis, Patekakis, & Stefanis, 2013 ; Vlachadis, Vrachnis, Ktenas, Vlachadi, & Kornarou, 2014 )

• the deterioration in public health has been described as a “Greek tragedy” (Bonovas & Nikolopoulos, 2012; Kentikelenis, Karanikolos, Papanicolas, Basu, McKee, & Stuckler, 2011)

Social Solidarity Clinics (SSCs)

• The humanitarian and financial crises have mobilizedpolitical action by health care professionals culminatingin the development of volunteer run solidarity schemes.

• The first volunteer run Social Solidarity Clinic (SSC) wasestablished in Rethymno, Crete, six years ago, and theprimary focus of the services rendered at that time wasthe health care of undocumented immigrants.

• The medical personnel and volunteers at these clinicsview their efforts as forms of solidarity and resistance.

• Goal: “… to develop a free, public and universal medicalsystem which will serve the community members’ healthcare needs and will act preventively and therapeuticallyas well, with no exclusions” (“Policy charter”)

Rethymno SSC

Capability Approach and Health • The type of medical care and praxis of the SSCs has brought to the

forefront issues as:

• how is social justice in health care contrived in such praxis?

• What are the epistemological underpinnings of the systems of careimplemented?

• how can volunteer capacities and resources be best put to use inbolstering both health services and social capital?

• The conceptualization of health as a universal human right and capabilityis a basic premise of the proponents of the capability approach.

• In Amartya Sen’ s own words: “health is among the most importantconditions of human life and a critically significant constituent of humancapabilities which we have reason to value” (2002b, p. 660).

• The capability approach in spite of its alleged individualism (Robeyns,2005) has emphasized the social and political determinants of capabilities.Thus it is adequate for the examination of social determinants of healthcapabilities

Social Capital and Public Health Research

• Despite the fact that Bourdieu is the most famous exponent of social capital, it is the approach of Robert Putnam that has been used as a conceptual framework of health-related research of social capital (Moore, Shiell, Hawe, & Haines, 2005).

• In our study we used the conceptualization of social capital of both Bourdieu and Putnam.

Methods• The present study focuses on the philosophical underpinnings of the

Social Solidarity Clinics that have newly founded across Greece.

• in order to develop in-depth understandings of the social justice and healthcare philosophies of the volunteers, the users of the services and the community stakeholders we focused on the first SSC which was founded in Rethymno, Crete.

• The idiographic nature of the study requires a detailed analysis of the specific context, the services provided, the use of services and the subjective understandings of service providers, users and stakeholders and how they conceptualize the clinic’s social agenda and philosophy.

• A case study qualitative research design was implemented.

• Three phase study, which encompassed: 1) participatory observation and volunteering at the center; 2) quantitative demographic data analysis; and 3) interviews and analyses of the policy charter that all SSCs abide by.

Context and Services provided by Rethymno SSC

• Self-management is the political agenda in all SSCs • The volunteers of Rethymno SSC solicit support from the

wider community and frequently organize presentationsinforming the wider community about the activities at theClinic. Furthermore, they collaborate with other volunteerrun organizations and have established partnerships withthe Rethymno General Hospital, the Municipality ofRethymno and local church groups.

four medical specialties or departments:• internal medicine,• preventive gynecology,• pediatric medicine and • child dentistry

Results The thematic and quantitative data analyses yielded noteworthy conclusions

regarding:

• the impact of the financial crisis on the functioning of Rethymno SSC

• the interviewees’ conceptualization of health as universal human right.

Other interesting findings included:

• the interviewees’ conceptualizations of the Clinic’ s relationship and standing within the local community;

• the political character of the SSCs;

• the emerging amendments being made to the existing mainstream epistemological underpinnings on which the medical model is based;

• and the obstacles that the volunteers identified as barriers to the attainment of the defined goals.

These findings have intriguing ramifications regarding health care in times of crisis, social capital in health care, and the capabilities approach as it can be applied within this particular context.

Crisis Impact on the Clinic

Crisis Impact on the Clinic

The exponentially increasing numbers of unemployed, homeless, and refugee and asylum seekers gave impetus to the stakeholders to reconsider and eventually amend the Clinic’ s initial goals which were to provide free health care to undocumented immigrants and to concomitantly highlight the problems of the Greek health care system.

Conceptualization of health as a universal human right

Outcomes revealed that all participants consider health as a universal human right that needs to be protected taking into consideration that it is in unprecedented peril due to the austerity regime. It is striking that although volunteers, service users and the city council member may view the character and the goals of the Clinic from different perspectives, their perceptions are in complete alignment regarding the concept of health.

“of course we wish to achieve a health care system thatis equal, universal and accessible to everyone. We fightand will continue to fight until we achieve this”

Community Involvement and Empowerment

• The Clinic provides fertile ground for the creation and enhancement of social capital. The trust within the volunteers’ network, between volunteers and the wider community, the reciprocal exchange of services and resources as well as the collaboration of the Clinic with other voluntary organizations, are aspects of collaborative praxis and solidarity that can lead to social cohesion and consequent community development.

• Both the qualitative and quantitative data imply that Rethymno SSC offers an extremely significant service to the local community as it a) eliminates disparities in health provision;b) enhances general health; c) detects community’ s health needs; andd) provides a framework for the assessment of health care crisis‟ consequences.

Political Character of the SCC

• Participants pointed out that the SSCs are not and should not be the final solution to the health care crisis, since public health concerns should be resolved by and fall within the jurisdiction of the welfare state.

• The main goal of the SCCs is not a humanitarian, but a radical one.

• Regarding the imposed neoliberal policies in the health care sector, the Rethymno SSC has organized numerous protests to advocate for the uninsured, unemployed and disadvantaged.“ We are not, let's say, a crutch of the health care system. We are against its policies and we express verbally and actively our opposition…we encourage the public to protest against this system.”

Reconsidering the Epistemological Underpinnings of Healthcare Systems • The financial crisis brought up significant changes

in the way the medical personnel perceive their praxis.

• they try to promote medical practice in a more holistic way

• The volunteers emphatically stated that they do not only take care of the service users’ physical problems, but they must consider other secondary issues such as the transportation to and from the Clinic, financial problems and language barriers.

Challenges in Praxis

• The service users, especially the immigrants, have a total misconception of the Clinic’ s voluntary character

• service users are unwilling to actively participate and contribute in the SSC’s management

• service users’ non-politicization and their indifference to attempts to rectify the power differentials and imbalances

• patients’ inadequate knowledge base regarding health issues

Discussion• All the participants, despite differences in other aspects of the

Clinic's agenda, conceptualize health as a universal human right.This conceptualization of health is in line with the way theorists ofthe CA define health as one of the most important conditions oflife and central human capability (Nussbaum, 2000; Sen, 1993;2002b)

• Although the volunteers consider health as a universal humanright they seem to equate it with free access to a public healthcare system.

• Although, the achievement of this goal should not beunderestimated, we believe in accordance with the CA that a highlevel of health does not depend solely on access to health care.Other important social determinants of health such as nutrition,lifestyle, education and the extent to which inequalities determinesocial opportunities in a society (Sen, 2008) clearly impact health.It seems facile to assume that to improve health all that needs tobe in place is the provision of ample and good quality health care(Ruger, 2004)

Health Capability Approach (Ruger, 2010)

• This approach attempts to reconcile a view which considers health a result of the complex interaction between an individual and his or her social context, with one that sees health as the outcome of purely individual choices in the course of their life (Weaver, Lemonde, Payman, & Goodman, 2014).

• Of central concern in the CA is the incorporation of health in a wider theoretical rubric of social justice (Sen, 2002b, 2009).

Social Capital & Capability Approach

• Individuals who possess social capital are able to achieve particular capabilities which allow them to improve their socio-economic position. In addition, one aspect of social capital is social connections which, according to Nussbaum (2000), can be understood as capabilities. Hence, social capital can be regarded “as a sort of hybrid concept within the theory of capability approach as it includes both capabilities and functionings” (Migheli, 2011, p. 138).

• The importance of the connection between social capital and CA lies in the potential to develop the concept of collective capabilities. Ballet, Dubois, and Mahieu, (2007) argue that social capital is a crucial component for the development of a collective capability.

CBPR as a Way of Rectifying the Challenges in Praxis

• Community-Based Participatory Research (CBPR) is an action research paradigm widely used in community health intervention projects.

• This empirical intervention paradigm has potential for reinforcing individual, community, and professional (in this case medical practice) capabilities.

• A major advantage of enhancing the individual and collective capabilities of the community of Rethymno through CBPR would be the positive outcomes regarding social capital.

• An increase of social capital leads to strengthening of human capabilities. According to Migheli (2011) “social capital participates in the dynamics between capabilities and functionings as a catalyzer for the process. During the process social capital increases and reproduces opening the way for another cycle for the process” (p.138). Hence, the expansion of social capital leads to a faster transformation from capabilities to functionings.

Selected References

Comim, F., & Carey, F. (2001). Social capital and the capability approach: Are Putnam and Sen incompatible bedfellows?. In EAEPE Conference, Siena.

Ibrahim, S. S. (2006). From individual to collective capabilities: The capability approach as a conceptual framework for self‐help. Journal of Human Development, 7(3), 397-416.

Israel, B. A., Schulz, A. J., Parker, E. A., & Becker, A. B. (1998). Review of community-based research: assessing partnership approaches to improve public health. Annual Review of Public Health, 19(1), 173-202.

Kentikelenis, A., Karanikolos, M., Papanikolas, I., Basu, S., McKee, M., Stuckler, D. (2011). Health effects on financial crisis : Omens of a Greek tragedy. The Lancet, 378(9801), 1457-1458.

Migheli, M. (2011). Capabilities and functionings: The role of social capital for accessing new capabilities. Review of Political Economy, 23(1), 133-142.

Putnam, R. D. (2000). Bowling alone: The collapse and revival of American community. New York: Simon and Schuster.

Selected References

Ruger, J. P. (2004). Ethics of the social determinants of health. Lancet, 364(9439), 1092.

Ruger, J. P. (2010). Health capability: Conceptualization and operationalization. American Journal of Public Health, 100(1), 41-49.

Sen, A. (2002b). Why health equity?. Health economics, 11(8), 659-666.

Sen, A. (2008). Why and how is health a human right?. The Lancet, 372(9655), 2010.

Venkatapuram, S. (2012). Health justice: An argument from the capabilities approach. Cambridge: Polity.

Williams, C., & Maruthappu, M. (2013). “Healthconomic crises”: Public health and neoliberal economic crises. American Journal of Public Health, 103(1), 7-9.

Thank You