Dialogue, Review and Reflect A spiral of co-learning and co-research to surface knowledge on the right to health In this article we explore how members of civil society organisations (CSOs) and academic researchers participate in a dialogical process of co-learning and co-research about the right to health. In particular, we are interested in knowledge that has previously been suppressed or undocumented. Our focus is on the right to the highest attainable standard of health – a human rights standard which is now widely accepted (though not without its critics, see, for example, Ferraz 2009; Preis 1996) – and serves as the intellectual base for our study. To meet the challenge of making human rights a day-to- day reality, ‘democratic space’ is required to enable people to participate in, influence and hold governments to account (Jallow 2006, p. 51). While charters and commissions are important, it is the collective action of civil society which will translate human rights into practice (London 2008): in particular, the agency of the most vulnerable and those affected by human rights violations (Heywood 2009) to monitor and hold states to account, to develop programs and policies, to take on an advocacy role and to address human rights violations (London 2008). Knowledge is instrumental to agency, yet there is a diversity of ways of knowing which reflect hierarchies of knowledge and power. To translate the right to health into practice, and to research how this is done, it is important to recognise that existing dominant knowledge may be incomplete. To effect agency, it is necessary to develop new ways of surfacing and disseminating knowledge previously suppressed or undocumented. It was for this purpose that ‘Learning by Doing and Doing by Learning: A Civil Society Network to Realize the Right to Health’ (in short, the Learning Network (LN)) was established. The LN comprises Civil Society Organisations (CSOs) from historically deprived areas, both urban and rural, around Cape Town, South Africa. The LN CSO’s vary in mandate, composition and focus. They are ‘positively’ constituted in that they work for equity and seek to operate in an accountable way in consultation with constituents and members. This article understands a CSO to be any organisation outside the state or private sector. Such a broad definition is equally inclusive Gateways: International Journal of Community Research and Engagement Vol 5 (2012): 115–34 © UTSePress and the authors ISSN 1836-3393 Maria Stuttaford University of Warwick, UK Gabriela Glattstein-Young University of Cape Town, SA Leslie London University of Cape Town, SA 116 | Gateways | Stuttaford, Glattstein-Young & London of, for example, non-government organisations with a formal constitution and board of directors and a member-led community- based organisation that is informally constituted. While knowledge in the Global North is generally dominated by individualist concepts of human rights, the LN has turned to African philosophers for a contribution towards an understanding of rights including collective entitlements. The LN challenges the dominance of knowledge from the Global North on the right to health; without rejecting this knowledge, it has sought to expand theorisation of the right to health. While using reference frames other than northern knowledge paradigms to reconceptualise human rights is closely linked to controversies about cultural relativism of human rights (Connell 2007), debate about culture is not central to this article. Rather, our focus is on epistemological authenticity and generation of new knowledge paradigms. Where relevant, we allude to cultural debates but only as illustrative of the conceptual dialogue needed to overcome the hegemony of dominant ideas about the right to health. This article concentrates on two questions: How does a co- research process enable the surfacing of previously suppressed or undocumented knowledge? And how does this process of surfacing enable the dissemination of knowledge that would not otherwise be accessed? To frame the discussion, we begin by introducing the idea of competing knowledges, and setting out the potential contribution that can be made to the field of health and human rights through surfacing new knowledge. Through a presentation of empirical findings, we argue that the co-research processes of the LN support co-learning and exchange of power and have surfaced and disseminated previously subordinated knowledge. SURFACING KNOWLEDGE To understand African philosophy, Bell (1997) argues that it is not necessary to seek written ‘scientific’ texts; instead it is important to engage in discussion with African philosophers, listen to the narratives of African people and observe the visual art, performance and practices of African people. Through dialogue across contexts, the dominance of one knowledge about the right to health can be challenged and an ‘other’, in this case African, knowledge surfaced. Self-reflection on diverse views of human rights, forms of oppression and resistance, and social practices leads to the production of a plurality of knowledge (Santos, Nuens & Meneses 2007). From this practice, we find that ‘there are neither pure nor complete knowledges; there are constellations of knowledges’ (Santos, Nuens & Meneses 2007, p. xl). Attempting to assert an ‘African philosophy’ is potentially problematic because it risks homogenising a vast and diverse geographic area and valorising one philosophy over another (Bernasconi 1997). However, it is also the case that African thought, history and philosophy have been systematically dismissed and subjugated by the European and North American 117 | Gateways | Stuttaford, Glattstein-Young & London metropolis (Bernasconi 1997). In an African context, it is appropriate to surface the voices of African peoples in research on how the right to health can be translated into practice. Ibhawoh (2000) calls for a two-way cross-fertilisation between cultural systems and universal and national human rights standards. For example, while the African Charter on Human and Peoples’ Rights (OAU 1986) substantially reflects the prevailing international human rights discourse at the time of its establishment, it also contains significant departures from the dominant discourse. Unique aspects include the use of the term ‘Peoples’ in the title, indicating divergence from the much criticised individualist UN documents to a more collective understanding of human rights, and reflecting the importance of the collective in African societies (Wohlgemuth & Sall 2006). Including both collective and individual frames on rights claims in the LN research program has enabled us to draw upon Africa-centred knowledge, such as work by Shivji (1989), who argues that African traditional society is based on a collectivity (community) rather than on the individual. This does not exclude the individualist elements of human rights in Africa, nor seek to romanticise African communitarianism (El-Obaid & Appiagyei-Atua 1996), but rather celebrates the contribution that different human rights perspectives and knowledges can add to debates on the practical realisation of the right to health. Given the importance of surfacing subaltern and previously suppressed knowledge of collectives, the challenge is to design research that captures this knowledge. Previous research into health and human rights has found that, when asked, people at the grassroots level have been unclear as to what is meant by the right to health (London 2008; Stuttaford 2009). A community- based, participatory research design was adopted to address this challenge. Participatory research should recognise the skills and expertise of research participants, elicited by appropriate research design and methods (Israel et al. 1998). However, at the same time, there may be gaps in knowledge, necessitating consciousness- raising and learning before action research can be applied (Freire 1996), processes which are central to participatory research approaches (Cooke & Kothari 2001). Participatory approaches identify not only what people do not know but, more importantly, what they do know and build on the resources of communities (Israel et al. 1998). Furthermore, they provide methods for the co-construction of knowledge between the traditional ‘researcher’ and the ‘researched’ (Hill et al. 2001). Through the processes of reflection and action that characterise participatory research, the emancipatory potential of social science can be harnessed (Bhaskar 1989); however, framing research as participatory and emancipatory highlights the role of power in research (Flyvbjerg 2001). By adopting a participatory research design, researchers seek to create a more equal balance of power in the research relationship than is usually found in conventional 118 | Gateways | Stuttaford, Glattstein-Young & London research (Cornwall & Jewkes 1995). Furthermore, an emancipatory social science has a specific and directive critical content, identifying what is wrong and what specifically needs to be done to make improvements (Sayer 2000). Nyamu-Musembi’s (2005) actor-orientated perspective on human rights focuses on people’s understandings of rights, informed by their actual struggles for these rights. She argues for an emphasis on action that benefits the least powerful individuals and groups in society: ‘When people ask the question “works for whom?” and translate this question into action, they change the terms of institutionalised understandings of rights and make rights real in their own context’ (Nyamu- Musembi 2005, p. 32). While Nyamu-Musembi is referring here to human rights practice, the same can be said for human rights research. By asking ‘for whom’, it is possible to shift power in the critical research process to those who have experienced human rights violations – essentially the application of a rights-based approach. Through ‘internal cultural discourse and cross-cultural dialogue’, rights can be reinterpreted and reconstructed (An-Na’im 1992, p. 3). This article argues that reflection and dialogue enable a participatory research process where multiple experiences and knowledges can be shared, discussed and used to progress the implementation of the right to health. We turn now to a discussion of the Learning Network to illuminate how co-research and co- learning processes work in practice. THE LEARNING NETWORK The Learning Network (LN) was established in 2008 with an explicit agenda to build capacity within member organisations to be agents for the realisation of communities’ rights to health and to share the lessons generated from this process with organisations beyond the LN. The LN comprises six CSOs (anonymised as OC, OF, OY, OV, OE and OM) and four universities (UOT, UOW, UOA, UOS). The principles underlying the work of the LN are that: —empowerment implies knowledge, assertiveness, critical engagement and collective action; —health is a state of wellbeing, determined by access to health care and healthy social conditions; and —networking for rights must be based on a partnership of mutual respect, benefit and equality (Report of Strategic Planning Meeting 26/02/10). In addition, four roles of the LN have been identified to support delivery of the above objectives: a a research role documenting and analyzing best practices in realizing the right to health; b an informational role to ensure communities are better informed about rights to health; 119 | Gateways | Stuttaford, Glattstein-Young & London c a capacity building role to promote access to learning opportunities for member organizations; and d an action role to use the learning gained by member organizations to support services and advocacy around health (Report of Strategic Planning Meeting 26/02/10). The LN is made up of an Executive Committee (Exco) plus the general membership. Annual Strategic Planning Meetings are held, at which all member organisations jointly set research goals based on the above principles and roles of the LN. The LN project does not engage in ‘pure’ participatory research in that members of the CSOs did not participate in the initial funding application. One of the academic institutions, UOT, took responsibility for research coordination, the budget and leading funding applications – functions still devolved to UOT by the Exco. Three or four times a year Review and Reflection Workshops are held and there are quarterly Exco meetings at which progress on research goals is updated. The university-based researchers have monthly team meetings, open to CSO members, which include operational discussions and a theoretically based seminar. Tables 1 and 2 summarise the activities undertaken by the LN from inception. The design of the LN, based on a spiral of dialogue, review and reflection (described in more detail below) means that the co-learning and co-research elements are intertwined. The representation of co-research activities (Table 1) as separate from other activities (Table 2) is therefore a representational convenience to highlight role (a), alongside roles (b) to (d), as listed above. Research activity Description Questionnaire organisational profiles Basic demographic information on all LN organisations Questionnaire knowledge and practices LN organisations at baseline and three years In-depth interviews CSO understanding of health rights and perceptions of LN activities Mixed methods exploring organisation learning for health and human rights Impact of LN participation amongst member organisations Photovoice CSO members taking photos about health and human rights, which are used as a basis for focus groups and in-depth interviews Case studies In-depth interviews regarding health violations; used for training and advocacy Table 1: Co-research activities undertaken within the LN (adapted from London et al. 2012) 120 | Gateways | Stuttaford, Glattstein-Young & London Research activity Description Toolkit on the right to health Development and piloting of a toolkit as a training and advocacy tool; monitoring and evaluation of roll-out; adapting for use in Southern and East Africa Mixed methods evaluation: Community Participation through Health Committees Health Committees as vehicles for community participation in advancing the right to health Audit of Health Committees Study of the capacity-building needs of Health Committees and barriers to participation Documentation of Health Team development Following the development of a Health Team in a rural farming region Language as a component of the right to health How language acts as a barrier to realising the right to health, based on data from experiences of deaf persons using sign language and Xhosa-speaking patients Qualitative evaluation of LN pamphlets Assessment of coverage and effectiveness Document review and key informant interviews Policy study analysis of the provincial draft policy on participation and Health Committees Qualitative study on disability and human rights Understanding of human rights by people with disabilities Qualitative reflection on the process of co-learning and knowledge creation Reflecting on how the LN undertakes research Literature review exploring the contribution of African philosophy to conceptualising the right to health An annotated bibliography; theoretical analysis of the traditional value of ‘Ubuntu’ as expressed in the rights concept of dignity; rights explored as collective entitlements Ethnographic study of women’s development within the LN Experiences and development of women participants in the LN 121 | Gateways | Stuttaford, Glattstein-Young & London Research activity Description Mixed methods research to explore the process of knowledge generation through rights-based research processes Power and trust in the context of University- CSO engagement Development and evaluation of modules for in-service training on the right to health for health- care providers Health-care provider training Training area Focus No. of activities The right to health General information on what is meant by the right to health and how to hold government accountable 14 Piloting of toolkit on the right to health 8 Training of trainers on the toolkit 2 Disability and the right to health 3 Rights advocacy 1 Community participation as key to the right to health 2 Engaging state services Accessing basic services – advocacy with provincial and municipal authorities 3 Community development tools Participatory community mapping as an action research method 1 Alternative methods for community decision-making in social structures 1 Leadership training 1 Re-theorising the right to health based on our experience What do African theories and philosophies say about human rights, individual and collective rights, and the right to health? 2 Culture as obstacle and opportunity 1 Writing skills Building capacity of LN members 2 Table 2: Co-learning activities undertaken within the LN (adapted from London et al. 2012) 122 | Gateways | Stuttaford, Glattstein-Young & London METHODS FOR RESEARCHING CO-LEARNING AND CO-RESEARCH In order to examine the two questions at the heart of this article – how does a co-research process enable the surfacing of previously suppressed or undocumented knowledge and how does this process enable the dissemination of that knowledge – the authors explored how co-research has shaped the internal evolution and development of the LN. We asked whether the use of co-research has enabled the LN to fulfil the roles established by its Exco. Reflective email and face-to-face interviews were conducted with 11 LN participants between October and December 2010 by one author (GGY). The questions developed for the reflective email interviews were based on feedback from participants at previous Review and Reflection Workshops on how they perceived the LN to be functioning. Areas explored related to the knowledge people had of the right to health and of each other’s organisation before joining the LN; the role of trust, power and the Exco in establishing and developing the LN; how and where power has been exchanged in the LN; and how the goals of the LN have changed over time (see Appendix 1). These interviews, as well as data collected as part of the wider LN research project, including Learning Network Exco Minutes, Review and Reflection Workshop notes and Strategic Planning Meeting notes, were managed using the qualitative data analysis software, Nvivo. Data were analysed by two of the authors of this article and coded according to themes probed by the research questions. Further themes were identified when reading and re-reading data and in discussion between authors. These additional themes included: what participants value about the LN; how and where participants contribute to the LN; the extent to which knowledge is surfaced and how such knowledge strengthens agency; and accounts of examples of work being undertaken by organisations based on what they had learnt through LN activities. While being action-orientated, the LN was established from an academic base with research processes that expect academic writing for journals (such as, for example, this article), which can be interpreted as subjugation of CSO voices by the norms of the academy. For this reason, an outline of this article was circulated and presented to both academic peers and CSO members at a workshop in Cape Town in October 2010. A draft article was circulated and then presented at further workshops with academic peers and CSO members in February 2011. On the basis of comments received, the article was revised into its current format. Ethical approval for the research was obtained from the University of Cape Town’s Faculty of Health Sciences Research Ethics Committee. Data presented in this article have been anonymised using organisational identifiers and individuals have been allocated a unique number. 123 | Gateways | Stuttaford, Glattstein-Young & London FINDINGS AND DISCUSSION This article seeks to address two key issues: co-research enabling the surfacing of previously suppressed or undocumented knowledge and co-research enabling the dissemination of this knowledge. Given the spiral design of reflection and action (Bhaskar 1989), these two issues are interlinked. The first sub-section below focuses on how co-research processes fundamental to the LN facilitate a dialogical process in which no one knowledge is valorised (Bernasconi 1997) and in which co-learning contributes to a constellation of knowledges (Santos, Nuens & Meneses 2007). The second sub-section focuses on how the co-research processes facilitate the dissemination of surfaced knowledge and inform efforts to realise the right to health. Process for Surfacing Suppressed Knowledge Rather than a lengthy chronological description of how the LN has evolved, we focus here on the development of Review and Reflection Workshops and the Exco – two key processes that illustrate the iterative spiral of co-learning and co-research within the LN and have informed both the Network’s development and its responses to the challenges faced over time in establishing a dialogical process. Review and Reflection Workshops were found to be central to creating a space for surfacing knowledge and enabling co- learning. These meetings are held three to four times a year and are open to all members. At the workshops, and also at Exco meetings, agendas are mutually agreed, chairing roles are shared, presentations are given by all partners, activities are reported on, and new research and advocacy activities identified. Workshops are held at a mutually agreed location, with refreshments served on arrival and a ‘cafe style’ room layout allowing people from different organisations to mingle and chat before the workshop begins. Presentations range in content and are followed by discussion. In the past, for example, there has been a presentation (jointly by CSO members and a university-based researcher) on findings from using photovoice (Fick et al. 2010), an update on research with Community Health Committees (by a university- based researcher) and a presentation of a practice-based tool for promoting disability and human rights (by a CSO). Other activities during the day have included small group exercises such as piloting the health rights toolkit. This illustrates how a research network of ‘researcher’ and ‘researched’ can support agency to establish a dialogue between active social agents as human rights defenders (P de Vries 1992). As co-researchers, participants came together to explore themes through narratives and images (collected, for example, during interviews and photovoice) which were rooted in everyday experiences (Reason 2001). This sharing of social experiences began a reflexive process, which Hervik (1994) frames as facilitating the sharing of understanding and knowledge, and which also allows for the identification of tensions within the co-research relationship and provides flexibility in responding to each other (Read & Maslin-Prothero 2011). LN participants 124 | Gateways | Stuttaford, Glattstein-Young & London visualised shifts in power and knowledge as a spiral between co- researchers (Figure 1). Power within research cannot be simply conferred on others. In the network of co-researchers, power was experienced as fluid and crossing boundaries between participants. As one participant commented: ‘[The workshop] made me feel empowered and gave me confidence’ (Review and Reflection Workshop 25/08/09). In responding to questions about learning, trust and power, one CSO member argued that ‘Learning by doing is the first thing that comes to mind and I do believe that trust was built through actions, sharing and communication … The exchange of power has influenced learning’ (OC1). Another CSO participant confirmed how learning was based on a process of review and reflection: ‘The trust was built through engagement, dialogue, review and reflect, um, because you moved forward but you also look back at where have we made mistakes’ (OM1). This notion of co-learning in cyclic iterations is reinforced by the project’s ongoing meetings. For example, at a Review and Reflection Workshop, participants reported that ‘The spiral model allows us to review and reflect so that challenges and solutions are shared; we are able to shape and change direction as we go. This was an organic process and we have been evolving/changing to meet needs of member organizations’ (Report of Review and Reflection Workshop 29/06/10). These findings illustrate the LN intent of fostering an emancipatory spiral of co-learning (Bhaskar 1989) in which there is an iterative process of sharing information (Ruger 2006) and learning (Kolb 1984). De Vries (1992) has highlighted how civil society needs to create space for its own projects and programs. As public space becomes increasingly regulated, CSOs have had to transform spaces into ‘sites for health rights’ where the right to health can Figure 1: ‘Information moves in a circular process of learning, action and reflection’ (illustration of the Learning Network drawn by CSOs at Review and Reflection Workshop 29/06/10) 125 | Gateways | Stuttaford, Glattstein-Young & London be advocated for and realised (Stuttaford, Hundt & Vostanis 2009). Creating this type of space in which co-research and co- learning activities can occur has been an important part of the LN’s approach. One CSO participant explained ‘… there’s a space, um, to dialogue and there’s also a space for us to reflect on what it is that we want, as an organization, so that is an advantage’ (OM1). Furthermore, asserting ownership of the physical spaces for supporting learning has been important: ‘We hosted two meetings, we took control … the power was in our hands … um … and I think that is what an organization needs to do, if you are the host you’re the person with the power for the day’ (OM1). One of the clearest examples of CSOs and university-based researchers sharing power while engaged in a dialogical process of co-learning was when CSOs led an intervention to improve the governance of the LN. The Exco, established in the first year of the research in response to CSOs wanting to have more decision- making power, was not functioning effectively due to low turn-out at meetings and inconsistent attendance, indicating a perceived lack of ownership and limiting the ongoing development of the LN. This was a critical point for the LN. Members were keen to shift the LN’s focus from training and information dissemination to being more participative and engaging in deeper co-learning, as originally intended. One of the CSOs (OC) volunteered to lead an Exco meeting convened specifically to address poor attendance and participation and to introduce members of the network to REFLECT (Regenerated Freirean Literacy through Empowering Community Techniques), a method commonly used by OC. This method not only identified the reasons for poor turn-out and improved ways of working, but placed, for the first time, a CSO in a leadership role in training others in the network, including the university-based researchers. At a technical level, the REFLECT method was able to identify ways to improve formal reporting back at Exco meetings, providing a clear way to surface, document and disseminate best practice within the LN. In reporting back at each Exco meeting, organisations share how they use a rights-based approach in their work. Increasingly, the LN is relying less on academic institutions to provide the point of contact to instigate learning opportunities, and participants are now looking across the whole of the LN for support, based on linking directly with each other or with other networks and organisations. For example, a workshop organised by one CSO (OF) on participatory mapping enabled other CSOs to learn from OF’s knowledge (Report of Exco Meeting 18/05/10). In another instance of skill exchanges between CSOs, one organisation (OV) invited a speaker from another LN CSO (OE) to lead a discussion on disability and human rights (Report of Exco Meeting 20/07/10). These developments illustrate how sharing power in the Exco has led to a deepening of the co-learning experience by bridging different contexts, actors and knowledges (de Vries 1992). The encounters between co-researchers are not simply about the 126 | Gateways | Stuttaford, Glattstein-Young & London interaction between researcher and informant, but also about the interaction between different knowledge (de Vries 1992). By having an emancipatory interest in knowledge (Bhaskar 1989), the LN has sought to redress the traditional power relationship in the research context with the explicit aim of promoting the translational potential of knowledge. The way in which the CSOs led the establishment and strengthened participation in the Exco, the subsequent increase in CSOs networking directly with each other, and the direct involvement of CSOs in undertaking research (for example, with photovoice) illustrate how CSOs are not passive recipients of information on the right to health, but rather active participants (Long 1992) as co-researchers. Further, it was not only amongst CSOs that consciousness was raised, but also amongst researchers. For example, one researcher commented: ‘I might describe our growth and movement to be like a winding tree with many knots. As opposed to one of those sterile-looking trees in urban areas that are confined by poles and wires to ensure that the tree grows in a certain direction. Instead, our tree has been much more organic – no pesticides, no wires – just growing at its own slow, meandering pace’ (UOT4). While Spivak (1988) has argued that the ‘subaltern cannot speak’ (p. 308) because ‘there is no space’ (p. 307), she has qualified this by explaining how it is possible to form an ethical and enabling relationship with the subaltern based around ‘unlearning’ and ‘learning to learn from below’ (Spivak 2002, in Kapoor 2004, p. 642). Whereas at the outset LN members felt that research remained the domain of academics, members of the LN have described how there is now sharing of experiences: ‘LN provided access to learning opportunities; access to learning, learning from each other, and also from academic institutions to learn from civil society (reciprocal process)’ (Report of Review and Reflection Workshop 29/06/10). In summary, processes for surfacing learning and knowledge have been established through a range of activities, but most notably through the establishment of iterative Review and Reflection Workshops and an Exco. Capturing and Disseminating Surfaced Knowledge Knowledge is at the heart of the LN’s stated goals. When first established, the LN aimed to explore participants’ understanding and practice of human rights and how interaction between providers and community members could generate new models for realising rights to health. However, as the spiral learning process unfolded and as the emphasis on co-learning and co-research took root in the LN, capturing and disseminating knowledge was put into practice in ways that validated all participants’ expertise. We illustrate this through three examples – the development of pamphlets and a Toolkit on the Right to Health; adapting and adopting research instruments; and embracing African philosophy in theory-based discussions about the right to health. 127 | Gateways | Stuttaford, Glattstein-Young & London In the first year of the LN, at Review and Reflection Workshops, CSOs requested specific training on the right to health and, in particular, how to address human rights violations. The development of pamphlets and a Toolkit on the Right to Health was therefore undertaken in response to self-identified learning needs of CSOs. The universities took the lead in developing these materials, but the content was created in partnership with the CSOs. The practical experiences of CSOs are captured in seven pamphlets on the right to health, published under an open access licence in the three main languages of the Western Cape (http:// salearningnetwork.weebly.com/resources.html). All LN partners have been involved in the development of the content of the pamphlets and in their translation, resulting in a strong sense of ownership of the material. For example, one CSO representative commented: ‘This milestone stands out for us as an organisation because community members were consulted and involved in the development of these pamphlets and as a result all the [members] are knowledgeable on such rights’ (OC1). The gains in knowledge evident in this quote and the effectiveness of action within LN members’ organisations has been confirmed in another study evaluating the LN pamphlets (Strecker 2011). While the LN materials have been useful for identifying and addressing health rights’ violations, LN CSOs have recognised that materials on their own are insufficient for translating the right to health into practice and should be complemented by capacity building and reflection (Report of Review and Reflection Workshop 29/06/10; Strecker 2011). Co-research has, therefore, been critical to the development of CSO-led programs. For example, one CSO has taken a LN questionnaire instrument and adapted it to the sector in which the CSO works, resulting in the development of a wider research-based work program tackling disability as a right for the organisation: ‘The network has allowed us as an organisation to relook at our human rights program more critically and as a result we have begun a research process about disability and human rights. At the end of this process we will be establishing a suitable way to incorporate the right to health and disability rights into our existing program’ (OE5). For another CSO, the involvement in peer research through photovoice has led to organisational action on environmental health issues as well as new knowledge about the right to health: ‘The participation of OC members in the [photovoice] research has created a different understanding in the organisation on what we perceive the right to health and health practices to be … Yes new knowledge has been created’ (OC1). The research team’s monthly meetings include a research seminar which has stimulated discussions related to theory. However, it was only when funding was received under the UCT Programme for the Enhancement of Research Capacity (PERC) (a university program aimed at promoting African knowledge) that it was possible to allocate resources to develop a strand of http://salearningnetwork.weebly.com/resources.html http://salearningnetwork.weebly.com/resources.html 128 | Gateways | Stuttaford, Glattstein-Young & London work engaging more fully in African theory. From this point, greater attention started being given to African theories relating to human rights, collective action and collective rights. Seminars organised under PERC further encouraged LN participants to explore theoretical elements: ‘The responsibility of researchers and academics is not simply to share surface information (pamphlet knowledge) but to share the theories and analyses which inform the way knowledge and information are constructed and represented’ (Smith 1999, p. 16). While the lead for PERC seminars came from academics, input from CSOs was central to dialogue which led to the incorporation of African philosophy into the theoretical underpinnings of LN activities. In particular, one of the CSO Exco members who attended the seminars and actively participated in discussions commented on the value of this engagement: ‘The PERC seminars have been good opportunities to learn from other academics, to learn and engage at a philosophical level and to find a theory to fit the practical knowledge of communities’ (OF2). The ideas emerging from the LN’s engagement with African philosophical perspectives on rights represent new insights from CSOs on the implementation of the right to health that were previously unsolicited and invisible. By way of illustration, the exploration of African philosophy in relation to rights has enabled the LN to surface new ideas about the seeming tension between public health utilitarianism advancing the collective good and human rights seemingly representing individualist rights entitlements. While framing rights as also collective in nature may partly address the shortcomings of the dominant individualist approaches to human rights, there are also serious potential shortcomings in this approach (Howard 1992). For example, collective rights may be exclusionary where they are used to alienate people, such as minority groups, who do not adhere to certain social norms. Internationally, recognising the knowledge of groups or collectives has to date focused on indigenous knowledge rights associated with natural resources in relation to ‘scientific’ knowledge (Nyamu-Musembi 2005). It seems logical to extend this recognition of bodies of knowledge to other realms, for example, the expertise of groups who have experienced violations of their right to health and how they have actively redressed such violations. It could be argued that the LN is one such collective. However, the LN makes the distinction between collective rights, meaning the rights of groups, and the right to collective health, which is more consistent with the principles of public health. Furthermore, the LN also distinguishes between the right to health conferred on groups, and collectives working to realise their right to health or to overcome violations. In other words, in keeping with the participatory design, the LN guards against becoming exclusionary by refraining from engaging with the language of 129 | Gateways | Stuttaford, Glattstein-Young & London group rights. Rather, it adopts the principles of public health in promoting the right to collective health and collective action to promote population health. Given that collective action is an important element of African approaches to human rights (Gyekye 1997), it can be argued that the protection and promotion of human rights is only as strong as the collective of human rights defenders (Abbas 2008). In the LN, CSOs are collectives taking action for the benefit of the greater public good, rather than individuals or discrete groups acting for their own exclusionary interests. Collective action in engaging the state around its human rights obligations is important within the LN. For example, a civil society submission to the South African Human Rights Commission in 2009 was based partly on LN research and led to a debate with a senior public health sector manager, who disputed the value of a participatory model for engagement with the Department of Health. Subsequent to that exchange, the Department of Health has appeared to be more receptive to participation by one of the CSOs (OM), which has since been invited to annual health service planning processes, and, on one occasion, was asked to present closing remarks to the workshop. The LN has not only researched how the right to health is implemented by CSOs, but has also been critical of the practice of the right to health and violations of this fundamental right. Following an emancipatory design has meant the LN has been involved in identifying not only what is inhibiting the realisation of the right to health but, more importantly, collective ways to address violations and promote the right to health. External impacts resulting from the LN have included improved occupational health for farm workers and improved environmental health for urban communities. However, impact can also be seen in the sharing of learning with external networks, for example, in expressions of interest in the LN Toolkit from Uganda and Angola, involvement from and with the People’s Health Movement and LN CSOs benefitting from other university-community engagement projects through environmental and education projects. While this article is partly about trust and power in co- research and co-learning, a limitation evident is that none of the CSOs partners are co-authors. This has been addressed in the LN through the establishment of writing workshops open to Exco members of the LN, and academic co-authorship is now being developed. However, we have still not engaged with a wider membership of organisations. Another challenge is that while the article is critical of dominant knowledge and explores the surfacing of previously suppressed knowledge, the LN has to date not addressed cultural relativism and the right to health. This may be an issue the LN Exco decides to explore in future seminars. 130 | Gateways | Stuttaford, Glattstein-Young & London CONCLUSIONS From the empirical findings, the LN emerges as a research process for surfacing knowledge that contributes to a constellation of knowledges. Two aspects of the LN have been highlighted. First, the role of sharing power in establishing the processes of co-learning and co-research, illustrated in the establishment of the Exco for sharing decision-making between academic and CSO members on the management and strategic direction of the LN, and in the implementation of regular Review and Reflection Workshops for sharing practice and research findings. Second, how co-learning and co-research has surfaced previously silenced knowledge that has been added to a constellation of knowledges being disseminated and used in a new way. In this article we have demonstrated how research processes can enable subordinated collectives and their knowledge to be given prominence. By challenging and redefining power in the research process, spaces for co-learning have been created in which knowledges from different contexts have been shared through a dialogical spiral of co-learning and co-research. As researchers, policy-makers and CSOs increasingly grapple with the implementation of the right to health, a research design such as that of the LN provides an example of how a dialogue of co-research and co-learning may surface knowledge on its implementation. ACKNOWLEDGEMENTS This article draws on the experiences and knowledge of colleagues at the Cape Metropolitan Health Care Forum, Epilepsy South Africa Western Cape, Ikamva Labantu, Ikhaya Labantu, The Women’s Circle, University of Cape Town, University of Maastricht, University of Warwick, University of Western Cape and Women on Farms Project. We thank fellow participants in workshops of the Programme for the Enhancement of Research Capacity (PERC) at the University of Cape Town (UCT) and participants at two writing workshops. The British Academy/Association of Commonwealth Universities funded the two writing workshops. At the time of undertaking the research drawn on here, the Learning Network was funded by PERC, the South Africa Netherlands Research Programme on Alternatives in Development (SANPAD), the Open Society Foundation of South Africa (OSF), the South African National Research Foundation and Oxfam. REFERENCES Abbas, H 2008, ‘Africa’s long road to rights’, in H Abbas (ed.), Africa’s long road to rights: Reflections on the 20th anniversary of the African Commission on Human and Peoples’ Rights, Fahamu, Nairobi, Kenya, pp. 1–12. An-Na’im, A 1992, Human rights in cross-cultural perspectives: A quest for consensus, University of Pennsylvania Press, Philadelphia, PA. Bell, R 1997, ‘Understanding African philosophy from a non-African point of view: An exercise in cross-cultural philosophy’, in E Eze (ed.), 131 | Gateways | Stuttaford, Glattstein-Young & London Postcolonial African philosophy: A critical reader, Blackwell, Malden, MA, pp. 197–220. Bernasconi, R 1997, ‘African philosophy’s challenge to continental philosophy’, in E Eze (ed.), Postcolonial African philosophy: A critical reader, Blackwell, Malden, MA, pp. 183–96. Bhaskar, R 1989, Reclaiming reality: A critical introduction to contemporary philosophy, Verso, London. Connell, R 2007, Southern theory: Social science and the global dynamics of knowledge, Polity Press, Cambridge. Cooke, B & Kothari, U 2001, Participation: The new tyranny?, Zed Books, London. Cornwall, A & Jewkes, R 1995, ‘What is participatory research?’, Social Science and Medicine, vol. 41, no. 12, pp. 1667–76. El-Obaid, A & Appiagyei-Atua, K 1996, ‘Human rights in Africa: A new perspective on linking the past to the present’, McGill Law Journal, vol. 41, pp. 819–54. Ferraz, O 2009, ‘The right to health in the courts of Brazil: Worsening health inequities?’, Health and Human Rights: An International Journal, vol. 11, no. 2, pp. 33–45. Fick, N, Stuttaford, M, Jaantjie, S, Asvoel, M & London, L, 2010, ‘Using photovoice as a participatory method to explore community perceptions of health’, paper presented at PHASA conference, Healthy Environments, Healthy People and Public Health Advocacy, East London, South Africa, 29 November – 1 December. Flyvbjerg, B 2001, Making social science matter: Why social inquiry fails and how it can succeed again, Cambridge University Press, Cambridge, UK. Freire, P 1996, Pedagogy of the oppressed, rev. edn, Penguin Books, London. Gyekye, K 1997, Tradition and modernity: Philosophical reflections on the African experience, Oxford University Press, Oxford, UK. Hervik, P 1994, ‘Shared reasoning in the field: Reflexivity beyond the author’, in K Hastrup & P Hervik (eds), Social experience and anthropological knowledge, Routledge, London, pp. 78–100. Heywood, M 2009, ‘South Africa’s Treatment Action Campaign: Combining law and social mobilization to realize the right to health’, Journal of Human Rights Practice, vol. 1, no. 1, pp. 14–36. Hill, T, Motteux, N, Nel, E & Paploizou, G 2001, ‘Integrating rural community and expert knowledge through applied participatory rural appraisal in the Kat River Valley, South Africa’, South African Geographical Journal, vol. 83, no. 1, pp. 1–7. Howard, R 1992, ‘Dignity, community, and human rights’, in A An- Na’Im (ed.), Human rights in cross-cultural perspectives: A quest for consensus, University of Pennsylvania Press, Philadelphia, PA, pp. 81–102. Ibhawoh, B 2000, ‘Between culture and constitution: Evaluating the cultural legitimacy of human rights in the African state’, Human Rights Quarterly, vol. 22, pp. 838–60. Israel, B, Schulz, A, Parker, E & Becker, A 1998, ‘Review of community- based research: Assessing partnership approaches to improve public health’, Annual Review of Public Health, vol. 19, pp. 173–202. 132 | Gateways | Stuttaford, Glattstein-Young & London Jallow, H 2006, ‘New challenges and opportunities for human rights promotion and protection in Africa’, in L Wohlgemuth & E Sall (eds), Human rights, regionalism and the dilemmas of democracy in Africa, CODESRIA, Dakar, pp. 41–56. Kolb, D 1984, Experiential learning: Experience as a source of learning and development, Prentice Hall, Upper Saddle River, NJ. London, L 2008, ‘What is a human-rights based approach to health and does it matter?’, Health and Human Rights, vol. 10, no. 1, p. 65–80. London, L, Fick, N, Hoan Tram, K & Stuttaford, M 2012, ‘Filling the gap: A learning network for health and human rights in the Western Cape, South Africa’, Health and Human Rights, Special Issue, vol. 14, no. 1. pp. 1–18. Long, N 1992, ‘From paradigm lost to paradigm regained?’, in N Long & A Long (eds), Battlefields of knowledge: The interlocking of theory and practice in social research and development, Routledge, London, pp. 16–43. Nyamu-Musembi, C 2005, ‘Towards an actor-oriented perspective on human rights’, in N Kabeer (ed.), Inclusive citizenship: Meanings and expressions, Zed Books, London, pp. 31–49. OAU 1986, African Charter on Human and Peoples’ Rights, OAU Doc. CAB/ LEG/67/3 rev. 5, 21 I.L.M. 58 (1982), viewed 6 August 2012, http://www. africa-union.org/official_documents/treaties_%20conventions_%20 protocols/banjul%20charter.pdf. Preis, A 1996, ‘Human rights as cultural practice: An anthropological critique’, Human Rights Quarterly, vol. 18, no. 2, pp. 286–315. Read, S & Maslin-Prothero, S 2011, ‘The involvement of users and carers in health and social research: The realities of inclusion and engagement’, Qualitative Health Research, vol. 21, no. 5, pp. 704–13. Reason, P 2001, ‘Learning and change through action research’, in J Henny (ed.), Creative management, Sage, London, pp. 182–93. Ruger, J 2006, ‘Toward a theory of a right to health: Capability and incompletely theorized agreements’, Yale Journal of Law & the Humanities, vol. 18, pp. 273–326. Santos, B de S, Nuens, J & Meneses, M 2007, ‘Introduction: Opening up the canon of knowledge and recognition of difference’, in B de Sousa Santos (ed.), Another knowledge is possible: Beyond northern epistemologies, Verso, London, pp. ix–lxii. Sayer, A 2000, Realism and social science, Sage, London. Shivji, I 1989, The concept of human rights in Africa, CODESRIA, Dakar. Smith, L 1999, Decolonizing methodologies: Research and indigenous peoples, Zed Books, London. Spivak, G 1988, ‘Can the subaltern speak?’, in C Nelson & L Grossberg (eds), Marxism and interpretation of culture, University of Illinois Press, Chicago, IL, pp. 271–313. Spivak, G 2002, ‘Righting wrongs’, unpublished paper available at www. law.columbia.edu/law culture/Spivak%20Paper.doc, viewed 12 October 2002. In Kapoor, I 2004, ‘Hyper-self-reflexive development? Spivak on representing the Third World “Other”’, Third World Quarterly, vol. 25, no. 4, pp. 627–47. Strecker, M 2011, ‘Realizing the right to health through the use of health print materials in the Western Cape, South Africa’, submitted in partial OAU Doc. CAB/LEG/67/3 rev. 5, 21 I.L.M. 58 (1982), available from http://www.africa-union.org/official_documents/treaties_%20conventions_%20protocols/banjul%20charter.pdf (last accessed 6 August 2012). OAU Doc. CAB/LEG/67/3 rev. 5, 21 I.L.M. 58 (1982), available from http://www.africa-union.org/official_documents/treaties_%20conventions_%20protocols/banjul%20charter.pdf (last accessed 6 August 2012). OAU Doc. CAB/LEG/67/3 rev. 5, 21 I.L.M. 58 (1982), available from http://www.africa-union.org/official_documents/treaties_%20conventions_%20protocols/banjul%20charter.pdf (last accessed 6 August 2012). www.law.columbia.edu/law culture/Spivak%20Paper.doc www.law.columbia.edu/law culture/Spivak%20Paper.doc 133 | Gateways | Stuttaford, Glattstein-Young & London fulfilment of the requirements for the degree of Masters in Public Health, University of Cape Town, Cape Town, SA. Stuttaford, M 2009, ‘Methods in health and human rights research: Towards a spiral of co-learning’, in F Coomans, M Kamminga & F Grunfled (eds), Methods of human rights research, Intersentia, Antwerp, Belgium, pp. 135–57. Stuttaford, M, Hundt, G & Vostanis, P 2009, ‘Sites for health rights: The experience of homeless families in England’, Journal of Human Rights Practice, vol. 1, no. 2, pp. 257–76. de Vries, P 1992, ‘A research journey: On actors, concepts and the text’, in N Long & A Long (eds), Battlefields of knowledge: The interlocking of theory and practice in social research and development, Routledge, London, pp. 47–84. Wohlgemuth, L & Sall E 2006, Human rights, regionalism and the dilemmas of democracy in Africa, CODESRIA, Dakar. AppENDIx 1: EMAIL AND FACE-TO-FACE INTERvIEW SCHEDULE A Learning Network for the Right to Health: Co-learning and knowledge production Please find six questions below that we would like you to consider. You can take up to one week to complete these questions, allowing yourself time to reflect on the responses you will provide and then returning to the questions. Please provide your response under each of the questions, giving examples where you think this will be helpful. All Learning Network members, academics and CSOs, are answering the same questions. CSO respondents QUESTIONS: 1. Thinking back three years to the start of the Learning Networks, can you remember if you made any assumptions about the knowledge that already existed with you as a person, in your organisation, or with other organisations joining the networks (both CSOs and academic institutions)? (For example, were there any assumptions you made about the level of knowledge in your organisation about what the right to health means?) 2. What knowledge did CSOs and academic institutions have of each other at the outset of the Learning Network? 3. Previously when asked about lessons learnt in the LN, respondents identified trust as being an important forerunner of co-learning. How was trust, or mistrust, built through the Learning Network over time? Please give examples where possible. 4. Previously when asked about lessons learnt (June 29 Review & Reflection), respondents said that the establishment of the Executive Committee was an important milestone in the development of the Learning Network. We would like you to reflect on how the exchange of power in the LN has or has not influenced co-learning. a. How was power exchanged in the Learning Network and how did this influence co-learning? b. Where was power exchanged and did where people meet and interact influence co-learning? 134 | Gateways | Stuttaford, Glattstein-Young & London 5. Do you think the direction of the Learning Network has changed since the outset? If yes, please explain the way in which the direction has changed. 6. When asked before about lessons learnt, respondents said that members of organisations have gained new knowledge about the right to health. It would appear that there has been co-learning and knowledge has been transferred between organisations. a. Would you say that new knowledge has been created? That through the LN we have created new knowledge about the right to health? b. If yes, how have you and your organisation understood, participated in and contributed to the process of knowledge generation? If no, then please explain. c. If yes, how do you think the academic institutions have understood, participated in and contributed to the process of knowledge generation? d. How has ‘new’ knowledge been translated into practice? Can you give concrete examples of this?