Table 2

Select theorists and theories useful for research on power in health policy and systems

Theories useful for power analysis Key constructs/brief description Core texts and examples of application
KEY THEORISTS and THEORIES
Three faces and dimensions of power, Stephen LukesInfluenced by Marx and Durkheim, Lukes claims power is exercised in three ways: (1) the power to decide, (2) the power not to decide (ie, to set the agenda and circumscribe the limits of debate), (3) the power to influence people’s wishes and thoughts.Lukes 200465
Buse and Hawkes 2014120
Reynolds 2019121
Three sources of authority, Max WeberWeber described political authority as legitimate domination, distinct from concepts of coercion and force. He defined three sources of political authority: traditional (derived from established customs and social structures), charismatic (derived from the individual leader’s characteristics) and rational-legal authority (derived from the formal rules and laws of the state).Weber 194847
Sriram et al 2018122
‘Fields,’ Pierre BourdieuBourdieu proposed the concepts of fields – social domains characterised by specific logics and norms, and peopled by actors with varying levels of power. Actors in fields use forms of capital (economic, cultural, social or symbolic) to advance their self-interest and preferences.Bourdieu 199059
Shiffman 2015123
Behague et al 2008124
Hanefeld and Walt 2015125
Biopower, Michel FoucaultFoucault’s influential concept of ‘power/knowledge’ holds that rather than being an instrument of power, knowledge is constitutive and inseparable from it. In ‘Discipline and Punish’, Foucault discusses how modern institutions and techniques of control created systems of disciplinary power. He also contrasted older forms of ‘sovereign’ power, founded on violence, with modern ‘biopower’, which influences life by administration, optimisation and regulation.Foucault 1978126
Dalglish et al 2017127
Sen et al 202014
Scott et al 2017128
Taxonomy of power, Michael Barnett and Raymond DuvallBarnett and Duvall’s framework seeks to understand how states negotiate policy processes in the international sphere. They differentiate between direct forms of power (compulsory power between actors, and structural relationships) and more diffuse forms (institutional power that favours some actors, and productive power over possession and distribution of resources).Barnett and Duval 200460
Marten 2019129
Moon 201922
PowerCube, John GaventaGaventa’s PowerCube presents an operational model for the analysis of power. It depicts a dynamic relationship among three aspects of power – forms of power (based on Lukes’ three faces of power) – visible, invisible and hidden power; spaces where power is exercised and claimed; and, levels of power – global, national or local.Gaventa et al 201146
Nisbett et al 2014130
McCollum et al 2018131
Expressions of power, Lisa VeneKlasen et al The four categories of power in this framework include power over (authority over others), power to (individual powers to act on something), power with (to act with others or collaborations) and power within (the ability of a person to recognise their self-knowledge, abilities or a sense of self-worth).Veneklasen and Miller 200264
McCollum et al 2018131
Cultural hegemony, Antonio GramsciGramsci focuses on the concept of cultural hegemony, by which the state and the ruling classes use ideology, rather than violence, force, or economic modalities, to control and maintain capitalist power.Gramsci 199961;
Worth 2002132
THEORETICAL CONTRUCTS RELEVENT TO HPSR
Feminist theories/dominationAlthough there are differences among various theories, feminist-informed theories broadly elevate important and previously underaddressed issues, most notably: the ways in which gender hierarchies shape health policies; what care is available; and the relationships among and between health sector employees and patients. In addition to exposing structures and manifestations of domination, feminist theories may be used as part of an approach that seeks to identify and foster empowerment and solidarity, both through research processes and results.Young 201462
Morgan et al 2016133
Theobald et al 2017134
Parikh 2012135
Critical race theoryCritical race theory originated in US law schools in the 1980s as a way to understand how the law has been used to maintain white supremacy. Concepts and methods from critical race theory, including race conscious orientation, which require specific attention be paid to racism and its interpersonal and structural drivers, have been used to explore racial inequity in the context of health and health systems.Borrell 2018136
Hardeman et al 2020137
NecropoliticsNecropolitics builds on Foucault’s idea of biopower as the state’s ability to control and shape life, in contrast to the more traditional power of life and death over citizens. Necropolitics is the use of social and political power to control (differentially) how citizens live and die, with some (subjugated) bodies suspended between life and death, and has been used to understand inequities in health and the shortcomings of current global health governance and the pluralistic (ie, market infused or market dominated) sphere of public health.Mbembe 201953
Lee 2020138
Sandset 202157
Subaltern studies/postcolonialism/decolonisationSubaltern people are those who are subordinated for reasons of class, caste, gender, race, language and culture; subaltern studies centres these people and the structures of subordination. Postcolonialism was initially developed in literary theory; it is concerned with narrative and representation and how this perpetuates hegemonic forms of knowledge and power. Decolonisation refers to the social science study of the process of decolonisation, as well as to a newer movement to ‘decolonize global health’ (and likely other fields and disciplines).Spivak and Said 1988139
Guha 1997140
Caxaj 2015141
Kingori and Gerrets142

McPhail-Bell et al 2013143 144
OPERATIONAL PUBLIC POLICY THEORIES
Models of decision making in public policyVarious models of public policy decision making incorporate power in different ways. Buse et al, for example, list rational and incremental models of decision making, a mixed-scanning approach to decision making and the punctuated equilibrium model. Cairney et al developed a framework to study policy stability and change to explain differences among countries in tobacco control policy, as well as why policy did not reflect the public health evidence base. These approaches can be combined with other frameworks that interrogate power.Etzioni 1967145
Buse et al 2012146 147
Dalglish et al 2019147
Cairney et al 2011148
Political-economic determinantsPolitical-economic determinants of health highlight the power imbalances that emerge from the interplay between macroeconomic structures, ideas and policy.Rushton and Williams 2012149
Battams and Townsend 2019150
Kentikelenis and Rochford 2019151
Bump and Reich 2013152
Health and human rightsThe right to an adequate standard of living and to medical services were included in the 1948 Universal Declaration of Human Rights; the right to health was included in the 1966 International Covenant on Economic Social and Cultural Rights. From the late 1980s, the field of ‘health and human rights’ coalesced as a way of understanding the human rights drivers and impacts of the HIV pandemic. Human rights provides a diagnostic or descriptive framework for research on the right to health, as well as solutions for how health and other government sectors should react to that research.Mann 1996153
Gruskin 2004154
Freedman 2007155
Yamin and Norheim 2014156
Forman 2009157
Street-level bureaucracyInitially developed by political scientist Michael Lipsky, the theory of street-level bureaucracy is concerned with state employees who interact with citizens in the everyday conduct of their tasks, such as police officers, local government officials and health providers. These bureaucrats have some degree of discretion in their interpretation and implementation of policies. From the perspective of community members, decisions and actions taken by street-level bureaucrats constitute government policy.Lipsky 198058
Erasmus 2014158
Walker and Gilson 2004159
  • HPSR, health policy and systems research.