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A glossary of theories for understanding power and policy for health equity
  1. Patrick Harris1,
  2. Fran Baum2,
  3. Sharon Friel3,
  4. Tamara Mackean4,
  5. Ashley Schram2,
  6. Bel Townsend2
  1. 1Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney. Level 6 the Hub, Charles Perkins Centre D17, Sydney, NSW, Australia
  2. 2Southgate Institute for Health, Society and Equity, Flinders University, Adelaide, Australia
  3. 3REGNET, Australian National University, Canberra, Australia
  4. 4Aboriginal and Torres Strait Islander Health, College of Medicine and Public Health, Flinders University, Adelaide, Australia
  1. Correspondence to Patrick Harris, Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney. Level 6 the Hub, Charles Perkins Centre D17, Sydney, NSW 2006, Australia; patrick.harris{at}sydney.edu.au

Abstract

Progressing public policies that improve health equity requires understanding and addressing the creation, use and distribution of power. This glossary provides an overview of some of the most relevant conceptualisations of the dynamics of power in policy with implications for health equity. The aim is to provide an accessible overview of the different theories and perspectives behind power for public health focused policy researchers and advocates. The Glossary demonstrates how the broad literature on power in policy deepens understanding of the institutional dynamics that creates and maintains health inequities.

  • power
  • policy
  • health
  • equity
  • glossary
  • theory
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INTRODUCTION

Power has long been recognised as a central force within the creation and maintenance of public policies.1 2 By extension, power is core to progressing action on public policies3 to address the determinants of health (in)equities,4 shaped as they are by ‘the distribution of power, money and resources’.5 The dynamic relationship between power, policy and politics can be found across policy theory.6 However, navigating power in policy can be challenging due to its often invisible and layered forms.

Considering the interplay between power and policy for health equity directs attention to the distribution of health outcomes among difference groups in society, and why policy plays a core influential role in that distribution. Health inequities refer to the ‘differences in health which are not only unnecessary and avoidable but, in addition, are considered unfair and unjust’.7 For instance, living in deprived conditions can mean experiencing adverse environmental, living, working and social conditions that create stress and worsening health outcomes.8 Conceptions of what is unfair and unjust reflect the different power positions groups hold in society relative to others. Wealthy elites, for example, may present their status as a result of individual endeavour rather the result of policies that exploit the working class.

Articulating the architecture of power within policy institutions is an important step in understanding the policy dynamics, actions and decisions that create or maintain health inequities, and to taking action to disrupt those dynamics in the interests of health equity.

This glossary focusses on the essential characteristics of power in policy through theories that place power as the central object of analysis. We first introduce the basics of thinking about power and policy as a mix of structural forces and individual and collective agency. We then build on these essentials by introducing the way political scientists have viewed power as layered in policy across structure, agency, and ideas. Next, we navigate critical theories. First, we overview major power theorists with a policy and equity lens. Then, we introduce power through the influential Feminist perspective that critiqued the core power theorists. We end with an Indigenous view on power that articulates and adds to the core theoretical strands presented in the glossary about equity and policy.

BASICS TO THINKING ABOUT POWER

Power is sometimes visible and sometimes not, and thus observing and attributing the influence of power is more or less straightforward depending on the circumstances in which power is being exercised. Four forms of the expression of power are provided in figure 1, each of which provide a relatively straightforward differentiation of how power is expressed.9 Beneath these straightforward categories, however, lie crucial theoretical dimensions to power in policy for health equity: power as structural domination and control or individual and collective emancipation and transformation. This tension, essentially between structure and agency,10 lies across the body of theory about power detailed in this glossary, but was most clearly articulated in the feminist critique of the historical critical tradition.11

Power always exists and exerts influence in policy but may lie dormant under some circumstances or activated and visible under others.10 A useful analytic strategy is shifting attention from a static view of power to viewing it through relations between people as individuals and collectives and the systems and structures they live or work in.12 13 This mix means attending to wider conditions, positions and interests that influence policy processes and choices. Most contexts—local or global—have moral, legal, political and historical dimensions under which power can be wielded or not, for what interests and with what consequences, and against which responsibility and accountability can be held, and how power can be challenged or manipulated.13 At the same time, power is not always intrinsically good or bad, problematic, or about manipulation and coercion (‘power over’ in figure 1). Rather, power can be empowering and transformative (as in ‘power with, to and within’).

Some power theorists, like Haugaard,14 have argued for a careful separation between analytical questions about how power works and normative questions about whether particular power dynamics are legitimate. Others, like Lukes,13 contend that power analysis is not value free—to make power dynamics clearer or visible requires having an initial view or position about the circumstance under which power is being exercised, even if these views are simple or formative propositions. In a point that is crucial for addressing health inequity through policy, accepting power analysis as value laden and therefore open to challenge, Lukes argues, creates the possibility for changing power relations. In the field of public health, for instance, these types of value positions around agency versus structure form the basis of the debate about individual responsibility of the impact of structural factors.15

POLITICAL SCIENCE: STRUCTURE AND AGENCY (AND IDEAS)

Political science focusses on the essentials of power which emphasises a balance, more or less, between structure and agency.16–19 Ideas also play a central role through discourse and as the rules and mandates through which structures influence agency and vice versa.20 21

Agentic or actor centred theories of policy and power are broadly conceived as ‘instrumentalist’22 or ‘rational choice’.23 24 ‘Actors’ are stakeholders and collectives: industry, government and regulators, civil society groups, and local communities. Different actors bring ‘frames’ about specific issues that provide boundaries with which actors value and position their interests. Instrumentalist approaches emphasise individual action and influence of an actor over another actor.22 Collectives such as coalitions16 and ‘hegemonies’25 form among actors who share resources and interpretations of a policy discourse, identify (more or less) similar policy goals and engage in policy processes to achieve those goals.16 Hegemonies are both political practices—emphasising actors’ values and interests that capture the making and breaking of coalitions—and ways of winning over consent or securing compliance via negotiation and bargaining to either reproduce or challenge established structures and discourses.25

Structuralist approaches emphasise ‘Structures as the rules and mandates that influence lines of command, divisions of labour, resources, responsibility and channels of communication.22 Structuralist approaches emphasise overt or implicit (often unrecognised) social and institutional, macrosocietal, conditions that influence policy decisions and choices.16 Structural power in the form of socially or societally created rules and mandates, predetermines, guides and constrains policymakers' behaviours as ‘Rules of the game’ in terms of expectations about how the game should be played and who has power in the game.16

Ideas are the focus of discursive approaches where power covers a mix of norms, ideas and societal institutions as reflected in discourse, communicative practices and cultural values.22 Discourse is thus the term used to capture the substantive content of ideas—‘core beliefs’26—as well as the practices and processes through which ideas are conveyed and communicated (or not communicated) in institutions and by actors.20 Discourse is the point in policy in which political contests become most visible and values and interests made clearest,18 for example, ‘nanny state’ versus libertarian policy frames.

CRITICAL THEORISTS 1: MAJOR POWER THEORISTS

Marxist theories of power

Marxist theories concern the exercise of political power by the ruling class over the working class. Marx argued that power was grounded in the material world—who owns the means of production generates surpluses, accumulates capital and wields control through the State to exerts power over the working class.27 Gramsci added the concept of hegemony to Marxist theories to illustrate how the ruling class uses cultural institutions and ideologies to legitimise their power over the working class without the use of violence.28 For example, by framing capitalism as ‘common sense’, it becomes the dominant ideology within society and the status quo.

Foucault

Foucault challenged the idea that power is wielded by people or groups by acts of domination or coercion. Instead, Foucault argued that power is dispersed and pervasive as a ‘regime of truth’ that pervades society and is in constant flux and negotiation.29

‘Power/knowledge’ was the concept Foucault30 used to signify that power is constituted through accepted forms of knowledge, scientific understanding and ‘truth’ in society. Power/knowledge dynamics are the result of scientific discourse and institutions, reinforced constantly through the education system, the media, and political and economic ideologies. Thus, power is productive—it produces what is known to be true and visible.12

Disciplinary power, Foucault observed by studying institutions, refers to the ways that visibility and the threat of surveillance disciplines society into behaving according to certain rules and norms without violence or the threat of coercion.

Foucault also coined ‘biopower’ to refer to the use of technological power by governments to regulate and control human populations, such as over women’s reproductive rights, or requiring welfare recipients to submit to drug testing.

Bourdieu

Bourdieu,31 working in the Marxist tradition, similarly saw power as socially constructed. Unlike Foucault, he argued that power is constantly in flux through the interplay between structure and agency. Bourdieu developed of the notion of ‘habitus’ to explain the way that socialised norms and preferences become embedded in society. Bourdieu also developed the concept of ‘cultural capital’ (alongside economic and social capital) to refer to the ways that access to cultural resources by powerful groups, and their generational transfer, and inform societal power relations by privileging some groups over others.

Lukes

Lukes32 unpacked three ‘faces’ of power. The focus is on control and domination, or ‘power over’. The theory moves from individual domination (face one), collective mobilisation of the ‘rules of the game’ to benefit some individuals or groups over others (face two), to how domination through manipulation of power becomes normalised and routine in society (face three). Writing about this third face of power, and clearly channelling Marx, Lukes suggested that power can be exercised by influencing, shaping and determining people’s basic wants and needs. ‘The supreme and most insidious form of power’, he argued, is shaping values to prevent grievances because people accept their roles in society. ‘Thought control’, he explains, does not require observable conflict and can take more or less mundane forms, such as control of information and the mass media.

Haugaard

Haugaard14 provides a seven-step framework covering ways that power is created and exercised in policy systems—often by elites to the exclusion or disempowerment of others. The framework begins with the exercise of power through the production and acceptance of societal rules (1—power created by social order). Those rules influence what is seen as legitimate in policy making systems (2—power created by system biases). Certain actions or thoughts are either compatible or incommensurable with those system biases (3—power created by systems of thought). Actors can be empowered by becoming aware of the links between knowledge and social order (4—power created by tacit knowledge). Some forms of knowledge can be reified in systems as being more than arbitrary social constructs, such as the aforementioned focus on individual behavioural risk factors over the social determinants of health (5—power created by reification). Routines become internalised to prevent knowledge from being raised to discursive consciousness (6—power created by discipline). Actual or threats of violence can occur to maintain or change the exercise of power (7—power created by coercion).

Gaventa

Gaventa offers the power cube,33 which essentially covers how power works across spaces, levels and forms. Gaventa’s work draws heavily on Lukes’ ‘faces’, adding feminist theorists emphasis on spaces for individual collective resistance and transformation.11 The cube’s aim is to facilitate change by making visible the full dimensions of power relationships, including how strategies for change in turn alter power relations and configurations. The cube emphasises citizen engagement in institutions and policymaking as a means of taking control over the decisions that affect one’s life, which is important to health equity.

Spaces in the cube are as essentially ‘opportunities, moments and channels’ by which people can potentially act to influence policy.

Levels concern how work on public spaces for participation connects or stymies local, national or global action. Action can take place at one or more of these levels: struggles to engage in globalisation and its effects; the nation state as a mediator of and beholden to global power; and local spaces depending on the extent to which power is legitimated nationally but shared with a locality.

Forms of power is the side of the cube that most closely resembles Lukes’ three faces of power. These forms include visible power and changing overt decision-making; hidden power and strengthening organisations to build collective influence and visibility of issues on the policy agenda; invisible power targets social and political culture as well as individual consciousness to transform the way people see themselves and how they envisage future possibilities and alternatives.

CRITICAL THEORIES 2: FEMINIST LENSES

Feminist contributions to the development of theories on power can be broadly classified into two major areas: (1) advancing understanding of power as domination expressed through the oppression of women and (2) evolving alternative conceptualisations that minimise power as domination in favour of power as solidarity.11

In the case of power as domination, feminist scholars have conceptualised power as a resource that has been unequally and unjustly distributed between men and women.34 Labour force mechanisms that justify lower wages for women leave them economically and politically dependent on men.35 Phenomenological explanations show women existing only in reference to men, with men as the standard or the norm and women as the deviation or other.36 Others have drawn parallels from dyadic relations of dominance and subordination, such as the relationship between master and slave.37 ‘Intersectionist’ feminist frameworks of power connect with critical race theory to broaden the understanding of women’s subordination at the intersection of other forms of social identity, such as race, class, sexuality and other axes of oppression.38

Feminist scholars have built on the work of Foucault’s Panopticon to understand domination that does not derive from physical force, economic coercion or emotional manipulation. For example, how women self-police the societal expectation that the female body should be pleasing.39 Similarly, Foucault’s concept of biopower has been deployed to understand how women’s reproductive organs are made public and appropriated as legitimated targets of public regulation and concern.35

Alternatively, many feminist scholars reject as masculinist the emphasis on power through domination that major theorists present, and in turn reconceptualise power as a capacity or ability to empower or transform oneself and others.40 41 Hannah Arendt, for example, although not a self-identified feminist, focused on community or collective empowerment, where power is created when people act in solidarity to fight subordination,40 making possible a ‘politics of shared differences’.42

There are other particular feminist power theorists of note for health equity and policy. Iris Marion Young critiqued liberal views of justice focus on individuals and instead emphasised the importance of recognising social groups and how institutions and policies which appear value-neutral actually favour dominant groups and embed structural inequalities in society.43 Nancy Fraser argues for greater feminist attention of how capitalism has created further wealth inequalities and eroded women’s emancipation.44 Fraser argued for a reinvigorated focus on struggle against capitalism, linking the struggle for women’s rights with workers’ emancipation. Carol Baachi’s analysis of how policy ‘problems’ are socially constructed through ideas and discourses in society enabled a framework for feminist and other policy scholars to explicitly focus on the power of ideas in policymaking. For Bacchi, unpacking how ‘problems’, such as women’s lack of reproductive rights, are defined and framed by policymakers can reveal underlying assumptions and, crucially, what is ignored and silenced.45 Baachi’s approach reveals the often unquestioned narratives that can prevent attention to health equity.46

INDIGENOUS KNOWLEDGES

Power considerations within Indigenous knowledge systems are markedly different to other power constructs. Indigenous knowledge systems are founded in deep spiritual, cultural, social, psychological and physical connections to country and all living things.47 48 These profound connections have enabled sustainable human civilisations extending back at least 60 000 and possibly 120 000 years49 through engendering deep respect and mutual care among people, animals, plants and waterways.

For Indigenous peoples, power comes from sovereignty, that is, custodianship of country as well as knowing (epistemology) being (ontology) and doing (axiology) regarding individual and collective obligations and accountabilities borne of that sovereignty.50 Governance in many Indigenous societies prior to colonisation was based less on overt expressions of power (power over) and reflected a relational expression of power in which custodial responsibilities through reciprocity, mutual benefit, communal integrity and, importantly, endurance were vital. Governance systems aimed at ensuring the continuation of all life in harmony with the natural world. Power is felt through this ecological construct of life and society in the joy and contentment of civilised permanence.51 52

This ancestral sovereign power has conflicted with colonial intent to deny sovereignty (terra nullius). The denial of sovereignty has not erased Indigenous sovereign power; however, it has imposed and exerted different constructs of power—oppression, exclusion, rejection and dispossession—that have greatly affected usual governance and knowledge systems. Colonial genocide has meant the transmission of knowledge, language, cultural practices and family attachments has been broken and tragically disrupted through the exertion of power over this system of life.53

The ongoing strength of sovereign power is realised in the fact that Indigenous peoples have not been erased. Generations of leaders and resistance fighters have made inroads into maintaining and reclaiming identity, connections to country and family, and agency within current societal governance. In this contested space of assertion of legitimacy, Indigenous peoples have developed wisdom on how to move between power structures and how to exercise power, as best as possible.54 Such manoeuvrings speak (figure 1) generating ‘power within’ through connecting to sovereign power, enabling ‘power to’ through assertion of self-determination, seeking ‘power with’ through leadership and advocacy, continually denying ‘power over’ through exerting Indigenous rights.

The distinguished Indigenous scholar Aileen Moreton-Robinson explains ‘white possessive logic’ as crucial to interrogating power within colonised societies.55 Central is scrutinising the process of dispossession to ensure disempowerment and the resulting state of hyper-invisibility of power dynamics at play in colonised nations' policymaking practices. White possessive logic engages with notions of intergenerational and collective repression, agreement making objectives and non-citizen status in exploring policy intent and the achievement of health equity.

Analysing power dynamics, using Indigenous theories such as white possessive logic and approaches such as Indigenist Research Methodologies56 and the Knowledge Interface57 alongside other theories of power, allows for full interrogation of the ideological circumstances and structural interactions of colonised First Peoples.

CONCLUDING COMMENTS

Power is fundamental to understanding how policy development and implementation influences health equity. However, power is often hidden and difficult to identify. This glossary has introduced core theories about power that help explain policy processes and institutions as sites where power influences health equity in multiple ways to include people, ideas and interests, structures, and spaces.

Acknowledgments

This glossary was developed as part of NHMRC-funded Centre for Research Excellence on the Social Determinants of Health Equity: Policy Research on the social determinants of health equity (APP1078046).

REFERENCES

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Footnotes

  • Contributors All authors contributed to the planning, design and writing of this article. PH conceived, led and oversaw the article; FB and SF commented on the whole article, TM wrote the Indigenous section and commented on the whole article, AS led the feminist section and commented on the whole article, BT wrote the main theorists section and commented on the whole article.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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