Understanding power relations is key to scaling change for healthy communities

Levelling three elements of power creates the preconditions to achieve scale for health interventions say Scott Berns and Sebabatso Manoeli. This article is part of our Building Healthy Communities collection.

Expanding the reach of interventions that have been proven to promote health and wellbeing in communities, especially for the most vulnerable, remains a challenge. For example, why are there still challenges and disparities in scaling-up access to clean water globally, even in the United States?1,2 What makes it so difficult to scale up health interventions?

We recently met with nine other leaders in healthcare, nonprofit, academia, public health, community and private philanthropic sectors from across four continents at the Salzburg Global Seminar to share our experiences in scaling health interventions. One of the striking findings of our discussions was that while there are many guidelines for scaling up interventions,3,4 there is a dearth of work on the preconditions needed to successfully scale them.

The few resources that define the preconditions needed to successfully scale up health interventions focus on: the evidence to support scaling an intervention, identifying and engaging stakeholders to generate demand for the intervention, mobilizing resources to pay for the intervention, and creating coordinated implementation and sustainability plans.5 

These insights are commonly agnostic about the explicit importance of power relations, particularly as they relate to equity, as a key precondition for scaling health interventions. We believe that a deep consideration of power relations is at the heart of creating an optimal environment for scaling community-level health and wellbeing interventions. Every subsection of a community—governments, funders, academia, community-based organisations, healthcare professionals, health systems and families—collectively represents a social power system within which, structures, processes, relationships and roles of control emerge to ideally stabilise a complex environment.

In order to create the right conditions to scale health interventions for sustained impact, the sites of power within communities and the relations therein need to be understood by implementers. This process begins with no longer framing power as a confined commodity to certain groups of people or a zero-sum game. And, it is essential to understand power as a resource that can—and should—be shared equitably among people.

If we are to reimagine an equitable redistribution of power, we need to level mountains and fill valleys. But what elements are our mountains made of, and with what should we fill our valleys? Within the complexities of power relations there are three essential elements that are the components for scaling change for healthy communities: people, knowledge and resources.

Power expresses itself in different ways in each element and in each community but is often concentrated in ways that privilege certain groups of people, forms of knowledge and types of resources at the expense of others. Across these elements of power, we maintain that power ought to be deployed through them in the service of gaining trust, with equity as the central and driving ethos that levels and realigns the three elements of power to create the optimal conditions for change and achieving scale.

The Healthy Start initiative in the US has equity as its central ethos and illustrates the importance of realigning power relations to achieve its goal of tackling disparities in communities with higher than average rates of infant mortality. Healthy Start is funded by the US Department of Health and Human Services and initially started in 15 urban and rural communities in 1991 and has grown to 101 in 2019. Healthy Start communities are marked by poverty, lack of resources, and a need to address a constellation of social determinants of health, including housing, education, economic inequality, transportation, food insecurity, high crime, and racial bias that contribute to poor maternal and infant health outcomes.6,7

At the core of the initiative is the belief that the community itself, guided by a multi-sector consortium of individuals and organisations—including community residents, medical providers, social service agencies, and the business community—can best design and implement evidence-based4 services tailored to the needs of all populations they serve, ensuring that the entire community is committed to fighting to reduce infant mortality.7-9

These consortia—or community action networks—are a required component of Healthy Start and demonstrate that it is vital to equitably consider the key elements of power—people, knowledge, and resources – in processes of scaling change. For example, community action networks have been instrumental in sharing power by training community members to be peer-outreach workers, educating fathers about infant mortality, and assisting Healthy Start clients start new local businesses.

In summary, to engineer the optimal conditions for scaling interventions that promote healthy communities, we must level mountains and fill valleys, holding equity as the pivotal central ethos. If this is not explicitly done, then efforts to implement proven health interventions at scale will be jeopardized. Ultimately, an active awareness of the shape of power relations across the key elements of people, knowledge and resources is crucial for building the trust and commitment that will last in communities. 

Scott D. Berns, MD, MPH, FAAP is President and CEO at the National Institute for Children’s Health Quality (NICHQ) in the US where he has extensive experience working to improve the health of children and families across academic, clinical, nonprofit and public health settings. Berns is also a Clinical Professor of Pediatrics and Clinical Professor of Health Services, Policy and Practice at Brown University.



Sebabatso C. Manoeli, PhD is Director of Strategic Programmes at Atlantic Fellows for Racial Equity based at Columbia University and the Nelson Mandela Foundation. She has expertise as a public benefit strategist and as an executive in private philanthropy. Manoeli is author of Sudan’s “Southern Problem”: Race, Rhetoric and International Relations, and she also is a Research Associate at the University of Johannesburg.


Competing Interests: None 

Provenance: In December 2018, more than 50 people from 15 countries attended a Robert Wood Johnson Foundation funded Salzburg Global Seminar to consider the topic of “Healthy Children/Healthy Weight”. The authors would like to thank our colleagues for their thoughts, ideas and expertise: Sarah Brown, Helen Crisp, Jemima Gilbert, Mary Glasgow, Bernadette Moffat, Michelle Palmer, Seri Renkin, Susanne Ring and Adam Smith.


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  6. Escarne JG, Atrash HK, de la Cruz DS, et al. (2017). Introduction to the Special Issue on Healthy Start. Matern Child Health J 2017;21(Suppl 1):1-3. 
  7. United States Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Healthy Start. Retrieved from: https://mchb.hrsa.gov/maternal-child-health-initiatives/healthy-start
  8. Kotelchuk M. Evaluating the Healthy Start Program: A Life Course Perspective. Matern Child Health J 2010;14:649–653.
  9. Parasuraman SR, de la Cruz DS. Evaluation of the Implementation of the Healthy Start Program: Findings from the 2016 National Healthy Start Program Survey. Matern Child Health J 2019;23:220–227.