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Health Commons: A New Paradigm

Talking Points, James B. Quilligan, 23 October 2012, Indian YMCA , London                                


In the present economic system, the market creates value by enclosing a common area, whether material (land, natural/mineral resources) or immaterial (culture, ideas, digital space). Through the process of enclosure, the division of labor between producers and consumers creates a top-down, hierarchical structure in the flow of private and public goods This is said to increase economic efficiency, productivity and quality, while lowering the costs of goods and services. But current business models based on the division of labor are becoming less and less useful

Evolutionary forms of technology and culture are altering the nature of resource exchange systems, creating new ways of interacting and coordinating social and economic life. We are in the midst of a transition from hierarchical governance and institutional forms to ones which are based upon decentralization and peer-to-peer interaction. Innovative models and tools are emerging that now enable us to organize and coordinate our activity in new ways, transforming the nature of community and social institutions

New norms and rules are being developed to oversee collective resources sustainably, involving peer-to-peer management and open source models. Such innovative systems often include free software, open hardware groups, open media and educational models, open collaborative research in commerce and science, and horizontal decision-making by communities. For example, the Linux operating system and Wikipedia are non-hierarchical models which don’t depend on centralized quality control but the collective goodwill of the community

What’s unique is that the greater good is achieved by individuals working collectively on a voluntary basis, out of conscious choice, not out of dependency or coercion generated by a central authority

Thanks to this growing evolutionary impulse toward peer-to-peer systems, a new production and governance logic of learning-by-doing is becoming possible

When resource users become co-producers, their motivations, knowledge and skills become part of the production praxis, leading to new ways of coordinating social and economic life and the development of innovative property management structures. This expands the distribution of the means of production and decision-making far more widely than through top-down systems. When consumers become co-producers of the goods and services that they receive and organize, their mutual activity transcends privatization, centralization and the idea that institutional change can come only through a traditional command structure or social hierarchy

With the proliferation of innovative platforms and models that are more and more collaborative, communities are engaging around projects in a deeper and more powerful way. This technology is emerging at the same time that government provisioning of public services under the 20th century social welfare model is rapidly breaking down. Not only are people demanding greater choice and quality in public services, they are seeking to provide the services themselves where possible. The commons movement is demonstrating how technology, culture and evolutionary forces are driving resources users to become the producers of their own resources.

The emerging commons society points the way toward new political accountability structures which reflect less command-and-control delivery of public services and more subsidiarity, pluralism and polycentricity in the provisioning of people's needs


Health Commons

We have now begun to understand how commons principles apply to healthcare, shifting the discourse and practice of cure and disease to human behavior and well-being..How do we make this shift towards a more meaningful healthcare system? In health care, as in other social modalities, where people cannot always provide their own technical, specialized services, the goal is to close the gap between resource users and resource providers.  In the present hierarchy of the health care system, the emphasis is on prolonging life -- but not on improving quality of life and relationships.

In the emerging health care systems, private and public purchasers, health care organizations, clinicians, and patients will be working together to redesign health care processes through new relationships, accountability, participation and empowerment. New Means of Participation and Empowerment. The closing of the division of labor begins with personal awareness. This means recognizing that the way we view the world has an enormous influence on our health.

Our worldview determines our health, how we see ourselves and the world around us. If we see ourselves merely as consumers of healthcare, we cannot create sustainable healthcare. But it becomes easier for people to engage in a new approach when they understand that it is already part of what they do. We begin by helping people understand that they are already part of their own health commons. Simply recognizing that we are co-producers of our own health changes the way we view the healthcare system. This can only be done through personal relationships and accountability.

Relationships are built and developed through generative conversations. People need to discuss why they are dissatisfied with how health is practiced and doesn't transform peoples lives. They also need to discuss what is working, identifying relationships that create social value, engagement and health. This includes relationships in our communities, as well as organisational and inter-professional relationships.

The new health dialogue enables people to know and to utilize the wider resources of the community. What makes relationships successful is accountability: what am I responsible for and what can others count on me to contribute as my gift to community health? When we create commitments and rules, we are really generating the means of accountability. Awareness, relationship and accountability lead to fully embodied participation in the health commons. When people become health advocates, they take their knowledge and practice into the workplace and neighborhoods, engaging and inspiring others in sustainable health practices. Through participation, individuals experience a degree of control and become better able to define and analyze their concerns and find joint solutions to act on their own issues. People can be equipped with the knowledge, confidence and skills to make a difference in their communities.

Participation thus leads to empowerment. Empowerment is about allowing people to take control of the decisions that influence their lives and health. Empowerment cannot be given to people, but comes from individuals and communities empowering themselves. This means groups of people investing energy, enriching their lives, acquiring skills and advocating for their own change. Community empowerment involves power relations and intervention strategies which ultimately focus on challenging social injustice through political and social processes.

Much research indicates that personal empowerment also has a great impact on the health and well-being of individuals and communities. This all starts with personal awareness and grows through the  cohesion of small mutual groups; then through community organizations and partnerships; and finally through groups of people taking political and social action to create social change through the redistribution of resources and power.

Accountability Structures

New means of participation and empowerment will lead to the creation of new accountability structures in society, where producers and users of health resources are not separated but are the same people.

Rather than outsourcing responsibility for public services to government or to corporations, which creates a top-down service delivery structure, new accountability structures allow communities to guarantee and manage health care for their members.

Communities can form their own health trusts, which ensure that resource users are driving the common health process, not resource providers or managers. This means that communities are going to have to organize in new ways. Creating new political accountability structures through social charters and health trusts will enable communities to obtain quality health care services on their own terms.

This would lead to improved equity of services and the reduction of institutional barriers of governments, enhancing participation in local government, strengthening civil society associations and creating healthy public policies which lead to improved health. New Networks for Information and Education.

To build this new health community with broad-based popular support, we can create a commons network, catalyzing a bottom up commons movement for sustainable health and making health projects more visible to the community through information and education.

This could include:

•  a clearing house of practices worth replicating

•  education for individuals and organizations on commons friendly practices, including workshops and seminars

•  information on health literacy, health as a common good, how to develop commons friendly practices

•  information on obesity, heart disease, diabetes, and depression -- which are often linked to food

•  information on healthy eating, physical fitness activity, mental health, health inequalities

•  connections with groups which foster sustainable therapies like self-care, exercise, yoga, plants, herbs, diet, breathing and living medicines like plants and herbs and the maintenance of community medicinal gardens

•  patient-generated information, shared knowledge and free flow of information, giving patients access to their own medical information and clinical knowledge

•  evidence-based decision making, based on the best available scientific knowledge

•  social networks for patient data and peer-to-peer disease management

•  patient-doctor medicinal pacts for continuous, responsive healing relationships over the Internet, by telephone, and by other means in addition to face-to-face visits with health professionals

•  new groups of health care organizations to increase quality, including civil society, the commons, local health boards and city agencies

New Identity for Sustainable Health

The health commons must be created and sustained for the benefit of everyone in society.  To make this conversation sustainable and maintain peoples’ interest and motivation, a new story is needed. Mainstream medicine is now defining the meaning of health for the public. We need a story of health that is told by the people, a story which transcends barriers and connects us together. Creating a platform for the relationships between people through the health commons will create a new identity for common health.

This new view of health -- health as a self-regulating system and personal health as a commons – will shift our understanding by helping people understand how life works through them. Like the commons, health is a spontaneous, self-organizing system that can balance and manage itself without centralized control.

In this view, the body is seen as a self-healing, self-regulating system that grows in resilience by adapting to change. This inspires people to trust their own bodies. In turn, our bodies are also teaching us how to remodel society.

When we consider the wisdom of the body or any living system, it becomes apparent that what makes a living system healthy is the functional relationships between all of its parts. In effect, this means that we need to make visible the parts of the existing health movement, rather than create a new movement. In the same way that our bodies already co-produce health, society can co-produce health services. The very cycles that make a success of our health care will be reflected in a new understanding of the human being. Our bodies are an essential part of the biosphere, which should be providing a model for our economic and systems. And this involves the role of citizens and governance in society.

To change the current paradigm -- where individuals are forced to be consumers of health care -- we must enable individuals to be partners in health care and to take control of the decisions that influence their lives and health. Evolution is teaching us to be the users of this knowledge and also the producers for the benefit of the whole -- information which is open source and free for the benefit of all. 

This organizational principles -- that resource users must become the producers of their own resources -- isn’t really new. It’s the ancient but much-neglected foundation of self-organizing communities, consensus decision-making and the common responsibility of people to protect and sustain their common resources

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