Suffering and powerlessness: the significance of promoting participation in rights-based approaches to health.

In a rights framework, participation is inextricably related to power. Through effective participation, we can challenge political and other forms of exclusion that prevent people from having power over the decisions and processes that affect their lives and health. Yet concepts of power are as contested as notions of participation. Thus, I argue here that, far from there being a formula for what participation means in a rights-based approach to health, the way in which we conceptualize the role of participation is closely linked to how we understand power and, in turn, the purpose and meaning of human rights themselves. I outline three ways of thinking about domination and participation-as-empowerment. In a liberal understanding of how power operates, there is an overarching concern for ensuring processes of participation that enable competing groups to express their voices on the proverbial level playing field, so that no one group may impose its will on the others. Critics of this approach assert that it ignores the power relations in which participatory processes are embedded, which determine which of the issues that affect health get decided--and which issues are never brought to the table because they are systematically blocked. If a second dimension of power entails deciding what gets decided, participatory approaches need to challenge the definition of what is "up for contention," or they risk merely legitimating social control. A third dimension of power entails securing compliance from oppressed groups by shaping their perceptions of their own interests. A human rights-based approach concerned with the effects of this form of domination on people's health calls for developing critical consciousness before there can be any truly "empowering" participation. I conclude by arguing that much is at stake in defining participation in a human rights framework to health, because in defining what we are calling for, we will determine how relevant human rights are to the daily struggles of people around the world for well-being.