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GHM201 - Session 6: Assessing health systems
Session Table of Contents
1 Aims and objectives
2 Planning your study
3 Introduction
4 ‘The view from above’ and ‘the view from below’: the clash
5 Understanding ‘the view from below’
6 How have health systems responded?
7 Integrating activity
8 Summary
9 References
1 Aims and objectives
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Aims
This session goes back to the concept of health systems as social institutions, discussed
earlier in the module. The session introduces the idea of how health systems are seen
and experienced ‘from below’; that is, from the position of actors involved in health
care encounters, service delivery and management. This perception is often very
different from the intended health system design as planned at national (macro) level,
‘from the top’.
Through several practical exercises, the session will provide an opportunity to reflect
on individual agency, power, and social relations among actors who make up a health
system and their influence on provider and patient health care knowledge and practices.
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Objectives
By the end of this session you should be able to:
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Identify the limitations of a health systems model that focuses on discrete inputs
and outputs as opposed to social relations within the system.
Understand how selected concepts drawn from social studies of medical
systems can be used to elucidate a view of health systems from ‘below’.
Examine the tensions between global health imperatives and the realities of
local health systems, and arrive at a more holistic understanding of the way
health systems operate.
2 Planning your study
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In this session you should first work through the different screens and spend time on
the various activities and exercises. You will also be required to read any essential
reading, as indicated. This should take you about two hours.
You should then complete the integrating activity, referring to the essential reading.
This should take you about three hours.
Finally, you should spend a further two hours on self-study covering the recommended
reading and two or three texts from the further reading (optional).
3 Introduction
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Health systems as core social institutions
Conventional approaches to health systems and their performance tend to be fairly
technical, focused on institutional inputs and outputs. Human resources for health are
often described by their functional roles within the health system, a view that is oddly
distanced from the actors who inhabit these roles.
These views are driven by a more normative and idealised understanding of how the
system should be organised and managed, one that rarely takes into account the
complexity of local social, cultural and political contexts within which health systems
operate. This is partly because ‘culture’ poses such challenges for our own fundamental
values about health, health-seeking, and health care delivery.
Culture is a difficult ‘variable’ to operationalise. Hence, most models of health systems
are biased towards a formalised, well-resourced biomedical model of health care
designed by policy-makers and planners at the national and district (macro) level. This
is termed ‘the view from above’ (see Figure 9.1). Formal health systems are expected
to function within a clearly defined regulatory framework. Users are expected to be less
likely to experience barriers to access and to be less willing to accept inadequate access
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to care. At the same time, provider responses within this kind of idealised system are
expected to be constrained by social norms backed up by legal sanctions.
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However, the reality of the implementation of health policies and interventions is
complex and chaotic. The boundaries of health systems are by no means fixed, but
fluid. Although we tend to think of a health system as the formal, publicly-funded
channel of health care delivery, most health systems are pluralistic – many types of
providers operate and private markets for medical goods and services have emerged in
a largely unregulated manner. The boundaries between private and public health care
are porous, and western biomedicine is but one tradition among many medical
traditions, which deliver care in non-formalised settings. Bloom and Standing (2001)
illustrate this well, showing how similar health system functions are fulfilled in the
organised and unorganised health care economy, and that within the unorganised
economy, there are marketised and non-marketised services (provided respectively by
household members or unlicensed workers).
Yet, it is important also to remember that formal/informal, and traditional/nontraditional care boundaries are fluid (as will be discussed in Session 10). ‘Traditional’
birth attendants working within the framework of formal maternity care, rural medical
practitioners trained in Ayurvedic medicine, and acupuncturists (in both high- and lowincome settings) are often perceived by users and practitioners as part of the health
system. This takes us back to the issues discussed in Session 1 [link], that health
systems are social constructs with boundaries differing in each context. Having a
comprehensive view of health systems is to go beyond what is captured by the formal
ordered frameworks devised by health planners and decision-makers at the macro level.
In this session (and in the module as a whole), a health system is conceptualised as a
‘core social institution’ (Kruk and Friedman 2008). This implies a shift from a topdown and functionalist view of a health system to one from ‘below’, that is,
understanding health systems from the perspectives of actors involved in health care
encounters, service delivery and management (Figure 9.2).
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[click and reveal interaction – on clicking of the figures, text is revealed]
Figure 9.1 Health systems: the view from above
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‘The view from above’ is about health systems as planned and orderly entities designed
and controlled by macro-level planners:
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institutional environment: e.g. facility infrastructure, staff deployed, formal
training programmes
functions and processes: regulation, clear functions of each type of facility,
formal linkages, clearly distinguishable institutions, formal payments
knowledge: biomedical knowledge in specialised institutions, licensing,
emphasis on evidence.
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Figure 9.2 The view from below
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‘The view from below’ is about health systems as shaped by the behaviour of the frontline participants in the care process (patients, communities, health professionals,
facility managers, etc.):
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institutional environment: e.g. facilities as perceived and accessed, staff
retained and in place
functions and processes: regulation, unclear boundaries between institutions,
informal linkages, informal payments, informal support structures
knowledge: biomedicine coexists by other traditions and customs (marketised
or within families and communities),emphasis on trust and socially-generated
knowledge.
[/end hidden content]
4 ‘The view from above’ and ‘the view from below’: the
clash
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Rhetoric and reality: understanding health systems as experienced by users
It is not sufficient to acknowledge the existence of these different realities. They are
often in conflict, as planned policies and interventions fail to achieve their objectives,
leading to the well-recognised discrepancy between rhetoric and reality.
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As discussed in Session 1 [link], health systems are often designed with the aim of
improving health and promoting fairness. The process of decision-making and system
design to achieve these goals is often top-down. Thus a t national level, policy-makers
typically decide on health systems policies and design interventions to address key
health problems. At district level, managers plan how the district health services will be
financed and delivered, and by whom. Health systems in general are governed
according to the laws of the country as postulated by legislative and statutory
institutions.
However, it is increasingly recognised that these policies and interventions often fail to
achieve their obj ectives, giving rise to a range of unintended consequences ( Adam
and de Savigny 2012 ). Recent literature has focused on socioeconomic, political and
‘systemic’ constraints to achieving health systems goals. In this model, those who
deliver services are often seen as mere implementers or conveyors of centrally (or
regionally) designed policies. Users are seen as recipients of benefits who are provided
with services that are designed by actors situated at macro or meso level.
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the fundamental issue of how health providers would respond to these reforms and
the human resource interventions required to manage those responses was not
considered. Each of the new reforms brought about changes to the motivational
and incentive environment of health care workers – the predictable reaction of
health professionals to these changes resulted in unintended, and sometimes
perverse, effects for the reform process.
McPake et al. 2006
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However, health-seeking and health care delivery are contingent not only on available
resources, but on social, cultural and political considerations which in turn shape the
needs and demands of local populations. It is frequently argued that if health systems
are ‘core social institutions’ (Kruk and Friedman 2008), responsiveness, accountability,
public participation in decision-making and user satisfaction should be key aims,
beyond clinical and economic goals. Moreover, building in trust into a health systems
and shared values among all participants in the care process are essential for achieving
cooperation and a health system’s objectives (Gilson 2003).
A view of the health system ‘from below’ emphasises that the system is enabled and
brought to life by human actors including patients, providers, administrators and
managers (McPake et al. 2006) . This perspective recognises that actors on the ground
and at the front line interact in dynamic ways and shape the ways in which institutional
protocols, guidelines and codes of conduct are locally put into practice. Far too often,
health systems interventions are introduced without recognising this crucial point: the
controlled experimental settings in which particular interventions – for example, new
diagnostic and treatment modalities – are tested rarely take into account the human
factor.
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A paper by Isaakidis et al. 2013 examines the challenges facing patients co-infected
with HIV and multidrug-resistant tuberculosis. These include complexities in managing
co-infection, financial access to a continuum of health services, and the importance of
emotional support and responsive delivery even where basic services existed. Factors
beyond the health systems – such as stigma, social disadvantage and a lack of family
support – were critical barriers to patient retention. Frontline providers were often
aware of these issues, yet they had limited opportunities to provide holistic and
responsive care.
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Activity
Consider a country you are familiar with and reflect on particular reforms that have
been implemented within that setting.
Alternatively read the following case study:
Essential reading:
Mathole T, Lindmark G and Ahlberg BM (2005). Dilemmas and paradoxes in
providing and changing antenatal care: a study of nurses and midwives in rural
Zimbabwe. Health Policy Plan 20(6): 385–393.
Reflect on situations where there has been a mismatch between the implementation of
guidelines or policies as intended and the experience of front line providers and users
on the ground.
Describe briefly the policy or intervention as intended, thinking about the different
health system functions described in the module (financing, delivery, governance, etc.).
Describe the experience of users and front line providers in relation to the policy
intervention above; consider ways in which the reality may not match the rhetoric.
Identify any mismatch between intended and unintended consequences. Reflect on the
reasons for these mismatches:
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Are there operational reasons, e.g. resulting from the way policies are designed
and implemented? Think about patient experience as a family or community
member
Who designed the policies and interventions and for whom?
What are the values underpinning the policy process?
Post your reflections on Moodle to engage in discussion.
Question feedback:
Your response could have included some of the following points:
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There are issues both at the design stage (e.g. policies are designed without
taking account of the problems likely to be faced by users and providers). In
countries at all income levels, there may be political tensions and interests
influencing delivery of care, user outcomes and experience.
Health-seeking behaviour is complex: patients may choose to use or not to use
services for reasons beyond the health system (e.g. give birth at home to fit in
with societal expectations).
Providers and users have agency and can make a choice about how they act,
which may contradict the official rules of how people are ‘meant to’ access
services.
Institutions and organisations may not have all patient needs at heart but be
focused on self-preservation (e.g. they may focus on health but not
responsiveness and accountability).
Professional groups provide what they are trained to provide regardless of
reforms.
Interaction with other actors (providers, communities) and culture will shape
behavour in any social setting and a health system is one such setting.
5 Understanding ‘the view from below’
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‘Real-life’ health systems as experienced by users and front line providers
It is important to understand in what circumstances the clash between the rhetoric of
health systems as formally designed and the reality of their participants occurs. For
example some of these clashes are seen in:
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first access to health systems/diagnostics
navigating health systems (Balabanova et al. 2009)
adherence to treatment
perception of what is happening in reality and its effectiveness.
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Activity: Contrasting experiences of diabetes
Diabetes is a condition with many manifestations. The underlying problem is a failure
to control the level of glucose in the blood. There are two main types, type 1, which
usually begins in childhood and always requires insulin, and type 2, which typically
occurs in adulthood and is associated with obesity. It sometimes requires insulin but
may also be treated by dietary restrictions or hypoglycaemic drugs. Some people with
diabetes manage to live essentially normal lives while others have numerous
complications that can render them disabled or kill them prematurely.
As diabetes can affect many different parts of the body (eyes, heart, kidneys, nerves
etc.) its management often requires inputs from a wide range of different professionals
and specialists, making it a very complex disease.
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From a patient perspective, entry to and navigation through the system is extremely
complicated. Thus in Georgia ( Balabanova et al. 2007), newly-diagnosed patients
initiating treatment face difficulties because of the restrictions on the provision of
prescribe insulin. Following initial diagnosis at the primary health care facility
(polyclinics), patients must undertake a series of steps and must wait from several
weeks to a month before they actually obtain insulin. During this period, they must buy
insulin and related supplies themselves, and their treatment is often disrupted.
[quote]
When I was told for the first time that I had diabetes I was very scared and didn’t
know what to do. The endocrinologist in the policlinic sent me to the hospital in
Tbilisi where I stayed for three days. After that I returned to the policlinic with a
prescription from the hospital doctor. The endocrinologist at the policlinic gave me
a different prescription and said to go the insurance company in Tbilisi. At the
insurance company I was given a document to show it at the pharmacy. It took me
about three weeks before I obtained insulin. During this period I had to buy insulin
myself. It was a problem for me because insulin is expensive in Georgia
Source: Balabanova et al. 2007
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The following fictional vignettes illustrate some of the diverse pathways followed by
individuals with diabetes. Read them before completing the activity.
[tabs interaction – 1 vignette per tab]
Vignette 1
John lives in an industrialised country and developed type 1 diabetes at the age of 5.
Although he initially managed his condition well, when he reached adolescence he
reacted against what he perceived as restrictions to his lifestyle. He frequently
disregards his diet and his diabetes is often out of control. By his early 30s he had
developed diabetic eye disease; at 35 he was blind in one eye and partially sighted in
the other. His kidneys failed when he was 40 but he has since had a successful renal
transplant. He now has extensive coronary artery disease although the presence of
autonomic neuropathy means that he does not experience angina. He knows that his life
expectancy is limited.
Vignette 2
Elizabeth lives in a rural part of a low-income country. She developed type 1 diabetes
at the age of 9. She began to loose weight and slowly wasted away. After several
months her family raised enough money to take her to a doctor in a nearby town, where
her diabetes was diagnosed. However, her family could not afford insulin and she died
18 months after the onset of her disease.
Vignette 3
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Peter lives in a middle-income country. His diabetes developed when he was 7. He is
able to get insulin supplies from a government health centre, but often the supplies are
interrupted. He cannot get a glucometer or test strips that would allow him to monitor
his condition. Although he tries to stick to his diet, it is very difficult because the right
types of food are often unavailable. When he was 30 he developed an ulcer on his foot
although because his diabetes had damaged his nerves he did not at first feel it. There
was no one who could provide the specialist care he needed and shortly afterwards his
leg was amputated above the knee. He is now unable to work and finds it increasingly
difficult to manage his diabetes.
Vignette 4
Sarah lives in an industrialised country. She developed diabetes at the age of 6. She has
always stuck to her diet and been careful with her insulin dosages. Despite having
diabetes she leads an active life. She attends checkups regularly and is particularly
careful to ensure that her eyes are checked every year. She has now reached the age of
55 and has had no complications of her diabetes.
Vignette 5
Michael lives in the capital city of a low-income country. He was a prosperous
merchant and was considerably overweight. He developed type 2 diabetes aged 45. His
doctor advised him that it could be treated by drugs and weight loss. He managed well
until his business failed. He then found that he could no longer afford the drugs. He has
now developed renal failure but has no prospect of treatment. He expects to live for
only a few more months.
Vignette 6
Jane lived in a middle income country. She developed diabetes aged 10. Although she
adhered to her diet and was careful with her insulin dosage, she found her diabetes very
difficult to control as the advice given from different physicians conflicted. Often she
was unsure who to consult and whether she was entitled to free health care. One
evening she missed a planned meal, fell into a hypoglycaemic coma and died.
[/end tabs]
In the vignettes presented above, what factors led to the positive and negative
outcomes, in your view?
Discuss the role of the health system vis-à-vis other factors (socioeconomic, political,
non-health system determinants of health, etc.).
Question feedback
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The text and the vignettes demonstrate the critical importance of health systems
to successfully managing diabetes.
The vignettes show how the multiple determinants of health interact, enabling
or obstructing treatment, and reflecting factors such as national and personal
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wealth, resources, support to manage diabetes (e.g. supportive family) and
power (e.g. affecting the knowledge and opportunity to demand timely
treatment).
Diabetes exemplifies these challenges and provides an excellent lens through
which to observe them. It is a condition where the diagnosis is clear, the patient
pathway potentially very complex, the outcome of failed health care is easily
measurable, and successful control depends on many different components of
health and social systems working together.
Even in countries with moderate levels of resources, lack of integration between
skills and specialities, and internal conflicts in health systems, can lead to
treatment failure
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Theoretical approaches to understanding multiple realities: ethno-medicine
A volume of empirical papers has documented the barriers experienced by users in
navigating health systems to a successful outcome: financial, geographical, knowledgerelated, social status-related, among others. Based on these, there are efforts to provide
a theory to understand the operation of health systems, accommodating the views of the
different stakeholders involved.
Anthropology seeks to explore the tensions between how a health system and
providers are ideally supposed to work, and seeks to interpret actual working practices
in a given context. This approach is necessarily relativist – in other words, it adopts a
premise that there are always multiple ways of understanding reality based on
perspective, lived experience, local context and dynamics. This contrasts with a
conventional rationalist perspective that suggests there is only one ‘objective’ way of
looking at things (see Session 6, Developing the field of health system research, page 1
[link]). Two influential streams of thought shed light on this more human and actororiented perspective of a health system.
The ethnomedical approaches perceive health systems as cultural systems, focusing on
the ideas through which providers and patients organise their perceptions and
experiences of illness episodes and the interventions to control these events. Thus,
individuals’ cultural knowledge and beliefs influence their cognition of illness events,
and how they respond to these (de-Graft Aikins 2005). The focus is on local
interpretations and ‘explanatory models’ of illness and risk in order to provide insight
to people’s experiences (Murguía et al. 2003). The individual is conceptualised as a
health-seeking agent, and the following questions are asked:
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When is experience articulated as illness?
How is illness classified (e.g. perceived symptomatology, etiology, severity,
etc.)?
What are the thresholds of care-seeking (when do individuals deem an illness
‘worthy’ of health seeking)?
How, when and where do people seek care?
This model is commonly applied in the fields of health promotion and health education,
in particular in ‘behaviour change’ models that try to examine and predict individuals’
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health behaviours. Although behaviour change models have undergone variation over
the years, they are heavily influenced by cognitive psychology, and rely on the idea of
individual agency – in other words, what people do, as directly linked to what they
think (i.e. cognition).
Among the limitations of the ethnomedical approach is that it is focused on individual
intent and on cultural meanings and ideas – how they shape individual behaviour in
illness episodes. Studies may decontextualise ‘health beliefs’ and ‘practices’, there may
be an over-emphasis on individual psychology and rational action, and in the worst
case scenario there may be a ‘victim-blaming stance’ that attributes poor or ‘risky’
health behaviours to individuals’ cultural pre- and misconceptions. The critique of
ethnomedical models is that they undervalue the role of social determinants and
structural factors. Other actors, such as providers, and their influence on patient
behaviour and care-seeking treatment, are less commonly studied.
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Reflection point
Examine the three models of health behaviour models drawn from the literature
(below).
[tabs interaction – 1 model per tab]
Model 1
Figure 9.3a Theory of planned behaviour
Source: Conner & Sparks 1995
Model 2
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Figure 9.3b Kroeger’s model
Source: Kroeger 1983
Model 3
Figure 9.3c Good’s model
Source: Good 1983
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What are the determinants of health-seeking behaviour in each of these models? How
have the models evolved (e.g. what new features are included in Figures 9.3b and
9.3c)?
In a setting you are familiar with, think what makes people seek care?
Question feedback
All three models give central prominence to the individual as a rational actor, although
they give varying emphasis to factors deemed to influence individuals’ ability to seek
health (or change health-related behaviours). The first model focuses on self-perceived
efficacy or self-control as the major enabling determinant; the second brings in
considerations of enabling resources, while the third examines pathways to care.
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Significantly, the third model is the only one to bring in the role of ‘significant others’.
There is acknowledgement that people do not make decisions by themselves. In most
settings, people make decisions and take actions with regard to health-seeking as well
as their engagement with a health system in conjunction with a set of people we would
call the ‘therapy management group’. It is only in the last model that we see the idea of
the individual, rational health-seeking agent challenged by the inclusion of the social
network within which the individual is situated.
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Theoretical approaches to understanding multiple realities: political economy of
health
The political economy approach or the model of a health system understands health
systems to be social and political enterprises and focuses specifically on social relations
of power that exist among actors. It moves away from the individual and emphasises
the importance of political and economic forces (national and global), including the
exercise of power, poverty, race, gender and class, all of which shape people's
experience of illness as well as affecting their access to care and their experience of a
health system (Degenhardt et al. 2010, Jorgensen 2013).
The approach focuses on health care systems and their functioning at different levels:
individual, micro, intermediate and macro. The following questions are commonly
asked:
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Who controls/deploys biomedical knowledge and technology?
How is power delegated within a health system?
How is power expressed through social relations in a health system?
What are the contradictions and arenas of struggle within biomedicine? Who
controls the dominant models of treatment?
The approach comprises work at four levels:
[click and reveal interaction]
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Macro level [click to reveal hidden content]
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The ways in which health policies are framed. The unit of analysis is policy, or
the system, or the institution as a whole. Each therapeutic mode, whether homebased or industrial, private or public, is consistent with the economic forces and
the relations of production within the society. Studies include equivalents of
policy analysis with a view to analysing, for example, political dominance and
political agendas (e.g. donors’ agendas in planning, implementing and directing
health systems in low-income settings).
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Intermediate level [link – onclick reveal hidden content]
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Examining social relations among medical providers and within institutions.
For example, a hospital is seen as a key arena of social relations and it is argued
that hierarchies in the administration of a hospital, as well as in the provision of
health care, reflect the kinds of hierarchies seen in society based on class,
gender and race. Studies on the professionalisation of midwives or clinical
officers in Tanzania demonstrate how professional and power relationships
affect such hierarchies and subsequently social relations within health systems.
[/end hidden content]
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Micro-social level [link – on click reveal hidden content]
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The relationship between patient and provider and how it is mediated by social
factors that are outside the examining room. Studies focus on how
communication between patients and providers can be hampered, not only by
the gap in terms of professional and lay knowledge but by other pervasive
hierarchies including age, sex and class.
[/end hidden content]
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Individual level [link – on click reveal hidden content]
[hidden content]
The experience of illness is constrained by broader political and economic
factors. For example, the so-called ‘lifestyle diseases’ (chronic fatigue
syndrome, depression, alcoholism) are often medicalised and privatised in a
clinical setting, rather than politicised or collectivised. These conditions often
reflect broader social and structural inequalities.
[/hidden content]
Among the limitations of this approach is that it focuses on social relations and power,
specifically power and knowledge held by the providers. There is less scope to
understand the behaviour of patients, and the subjective content of suffering as lived
experience can be neglected. The underlying premise of a health system is not
questioned.
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Understanding real-life health systems: the way forward
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Table 9.1 summarises the key characteristics of the ethnomedical and political
economy approaches and their interpretation of ’real life‘ health systems and their
unintended outcomes.
Health system as...
Cultural system
(ethnomedical approach)
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Approach emerging from study of
health and illness in non-Western
settings
Focus on cultural meanings, ideas
and how they shape individual
behaviour in illness episodes
Emphasis on ‘patients’
Reification of ‘culture’ at the
expense of structural context
Social/political system
(Political economy approach)
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Approach emerging from study of
Western medicine
Focus on social relations, access to
power and knowledge at different
levels of health system
Emphasis on ‘providers’
Subjective content of suffering as
lived experience neglected
Underlying premises of medical
system not questioned
Table 9.1. Comparison of ethnomedical and political economy approaches in explaining
outcomes
Both models assume that patients to be ‘recipients’ with very limited agency, power or
knowledge. Their behaviour is shaped within a culture (the ethnomedical model) or
within macro-level forces. There is little attention to how high culture or political
economy translates in a local context nor to how broader ideas and structures actually
help people, how people adapt to them or how they resist them in practice.
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Understanding real-life health systems: the way forward (cont.)
How do we begin to account for the dynamism that we experience both as providers as
well as patients within health systems, or within and across medical systems and
sectors of a health system? An alternative approach encompasses the following
dimensions.
The basis of authoritative knowledge
How and what do people know? How do patients and practitioners know what they
know? Who owns or safeguards the knowledge? What kind and categories of
information do they find persuasive? How do they know when a judgement is wrong or
right? What do wrong and right mean to the different sectors that make up a health
system? Essentially, health systems as knowledge economies, where there are multiple
brokers owning information, and access to expert knowledge and expertise are
embodied in both people and products, are embedded in multiple types of power
relations ( Bloom et al. 2008) . Understanding medical conditions, as well as how to
deal with them, is constantly evolving.
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This approach recognises that providers and users have creative agency that allows, for
example, a pharmacist in India to wield a certain amount of power over his or her
clients, who at the same time are patients who are seeking a particular type of
information. So the pharmacist becomes a crucial actor within the health system
because of the very high percentage of people who may seek care from that person first
before seeking any other form of care.
What people actually do (praxis)
In other words, how people translate ideas into action and behaviour. This area is
becoming increasingly a focus for health systems research drawing on different
disciplines – anthropology, sociology, psychology (Gilson 2012). People who navigate
their way through a health system accumulate practical knowledge and learn ‘how to
work the system’, i.e., how to talk to a practitioner successfully in order to get a
successful treatment outcome and experience. These strategies will differ in different
settings. Therefore, health systems are complex and adaptive, and actors within them
demonstrate complex behaviour. There is a tension between the normative, evidencebased standards and the unique predicament of particular patients and providers.
McPake et al. (2006) suggest the need to examine the dynamic de facto responses of
patients and providers which are informal and mediated through informal relationships
and behaviours and which often lead to unintended consequences that impact on
quality, affordability and availability of care (see Session 2 [link]). Analysing these
may provide a clue to why health systems do not function as intended and how they
can be improved. It has also been argued that the engagement of patients with a health
system cannot be understood as a one-off event but rather as long-term engagement
with services.
Social relations within a health system
This refers to the analysis of social relations not just in terms of power and hierarchy
within health systems, but also in terms of the content of the relationship itself – for
example, issues around trust, faith and conflict. What are the social relations within a
system that shape and structure local discourses and praxis, beyond the individual
actors? Bloom and Standing (2001) suggest that social arrangements for organising
access to expert knowledge can be understood as social contracts between actors. This
shifts the discourse away from individuals’ intent to groups and communities,
perceiving individuals within groups and drawing on a social capital.
The concept of ‘symbolic capital’ means that patient behaviour will have a different
meaning in different settings. As noted by Mogensen (2007) : some people are better
than others and finding the right person to ask about where to go and presenting the
sickness in the right time frame and presenting themselves respectfully. Gilson (2003)
argues that the level of trust is fundamental determinant to how participants in the care
process ‘comply’ with the health system arrangements and relate to each other.
The relationships of power in a clinic or any health care setting may be shaped by
professional codes of conduct, by funding arrangements or by relationships between
the network of organisations that comprise a health system, but they can be negotiated
via informal processes. George (2009) examines how disciplinary and organisational
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measures taken by health care managers in relation to their health workers and primary
health care systems, intended to reinforce accountability, are constantly negotiated and
resisted.
Implications
The role of the three dimensions described above becomes really visible when
introducing a new health system policy or intervention into an existing context.
Introducing new ideas or new resources in a context where there is already a complex
set of social relationships and structures may disable the intended mechanisms of
change and lead to worse outcomes. Any health system evaluation seeking to establish
how well a health intervention – specifically a systems intervention – has worked or
will/will not work has to take account of the social organisation of implementation.
Back to Table of Contents
6 How have health systems responded?
Page 16 (GHM201_s09_060_010.html)
There have been a range of strategies and individual and collective solutions to
reconcile the top-down with bottom up approaches. Some of these are illustrated
below, with respective readings.
Read on two of these examples before proceeding with the Integrating activity.

Inclusion of ‘responsiveness’ as a principal health system goal alongside health
attainment, in the World Health Report 2000 (WHO 2000)
Reference link:
World Health Organization (2000). Chapter 2. How Well do Health Systems
Perform ? In The World Health Report 2000. [online] Geneva: WHO. Available
at:
www.who.int/whr/2000/en/whr00_ch2_en.pdf (accessed November 2013)

Individual patient empowerment (‘exit’)
Reference link:
Small N, Bower P, Chew-Graham CA, Whalley D & Protheroe J (2013).
Patient empowerment in long-term conditions: development and preliminary
testing of a new measure. BMC Health Serv Res. 13:263.

Promoting self-care in management of complex chronic disease, the ‘Expert
Patients Programme’ in the UK
Reference link:
Taylor D & Bury M (2007). Chronic illness, expert patients and care transition.
Sociol Health Illn. 29(1): 27-45.
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‘Personalisation’ of services as a means of increasing choice and empowerment
(e.g. individual budgets)
Reference link:
Needham C (2013). Personalized commissioning, public spaces: the limits of
the market in English social care services. BMC Health Serv Res. 13 Suppl
1:S5. doi: 10.1186/1472-6963-13-S1-S5.

Collective patient empowerment (‘voice’): health facility boards as a means of
increasing patient representation and community buy-in
Reference link:
Goodman C, Opwora A, Kabare M, Molyneux S (2011). Health facility
committees and facility management - exploring the nature and depth of their
roles in Coast Province, Kenya. BMC Health Serv Res 11: 229

Shared decision-making: the role of patient advocates/champions to promote
better treatment outcomes
Reference links:
Schwartz L (2002). Is there an advocate in the house? The role of health care
professionals in patient advocacy. J Med Ethics 28(1): 37-40.
Soo S, Berta W & Baker GR (2009). Role of champions in the implementation
of patient safety practice change. Healthc Q 12 Spec No Patient: 123-8.

The key role of cultural acceptability in promoting uptake of effective services
Reference link:
Payne CM, Debbink MP, Steele EA, Buck CT, Martin LA, Hassinger JA &
Harris LH (2013). Why women are dying from unsafe abortion: narratives of
Ghanaian abortion providers. Afr J Reprod Health 17(2): 118-28.
7 Integrating activity
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Health systems from the viewpoint of the participants in the care process: an
analytical exercise
Choose Option 1, suitable for countries at high income or Option 2, for middle-/lowincome settings.
[tabs interaction – one option per tab]
Option 1: Collaboration and conflict in health care relations (high-income
countries)
Maximising interprofessional collaboration in health care settings is deemed an
important means to improve patient care and create satisfying work roles. However,
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collaboration is a complex process that requires intentional knowledge sharing across
professional cadres that traditionally do not ‘share’ knowledge and joint responsibility
for patient care where traditional roles may be quite rigidly defined. It may occur
within long-term relationships that evolve over time between health professionals,
however, it may also involve fleeting encounters in patient arenas where new networks
of care, delegation, substitution and task-shifting are taking place.
An in-depth study was conducted on inter-professional collaboration in medical wards
of a large UK teaching hospital. The data extract below illustrates a scenario of
interprofessional communication on a UK teaching hospital ward.
Read the extract from interviews given below.
What is your initial reaction to these? Do you find any of this surprising in any way?
Identify two to three specific key themes relating to communication that run through
the extracts. What common themes around collaboration and conflict in medical
workplaces emerge in the two settings?
Click here to read the extract from the interviews [link – onclick reveal hidden content]
[hidden content]
Extract from interviews
These data are drawn from a qualitative study that aimed to explore interprofessional
collaboration on general medical wards in a large teaching hospital in England. The
study used ethnographic methods, including individual and group interviews with
health and social care staff (i.e. doctors, nurses, therapists, social workers) and
participant observation of ward-based work. (see Reeves and Lewin 2005, Lewin and
Reeves 2011)
Physiotherapist: Communications are really poor. Quite often it can end up we are
seeing a patient everyday and it can go on for two weeks and it will suddenly say on
the medical notes, cancel physio please and we think well, we have been seeing them
everyday.
Interviewer: Is that a common experience for people?
Pharmacist1: Yes, yes.
Interviewer: That sort of delay?
Pharmacist2: Sometimes it is the next day unless we write it up and get them to come
and initial it. That is not strictly speaking quick.
Pharmacist1: Plus you write on the notes to point out that there is some drugs that the
patients do continue taking - erm -you write on the notes – the next day you go back
and have a look at the drug chart and it is not be added on – to the chart – even though
you have written on the medical notes.
Pharmacist2: Whereas if you were there on the wards you could just take the chart over
and say would you mind writing this up and they could do it right then and there.
Pharmacist3: … Also – you know – what to do if something – you know – if your
advice isn’t taken and – you know – or if you can’t get hold of the doctor then you go
to the medical notes and you document what, what your query is, or whatever. That is
quite difficult because of implications – you know – it is a lot more formalised, there
are a lot more things like, this is wrong. It just like increases the severity of something
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– that you saying this is it – a big problem to write it in the medical notes. Certainly
Trusts I have worked for before, pharmacists very rarely wrote in the medical notes
whereas it is quite run of the mill here to just communicate through the notes which is
quite – you know we would have only ever written in the notes if it was something
really, really serious, whereas now it is a lot more, sort of – you know – lots of people
write in them
Interviewer: That is just because you can’t get hold of them physically you have to do
it like that?
Pharmacist2: Yes.
Pharmacist3: Or – you know – when we have put a note on the drug chart – they still
are going to change it so therefore we have to note it on the notes just for our own
safeguard. So to just have a record that we have actually advised something and they
haven’t followed it up.
Pharmacist1: Sometimes the [medical] plan not always fully documented on the notes,
that is what’s needed to be done. So they [the nurses] will have to bleep after [the
doctors] and ask them to come. Wasting time and hassling a house officer who is not
very happy because they will be the first one… on the team… to answer all sorts of
questions.
*************
Nurse 2: Half the time you have to read the notes to find out what the doctor has
actually said on the rounds.
Nurse 1: There is no communication. Doctors write in their notes expecting nurses to
be psychic… they go off and tomorrow morning they come back and the patient in bed
one has ‘nil by mouth’ for some tests, nobody knows anything about it.
Nurse 2: Most of the time we cannot find enough time to read the notes and look
through…[so] we are just obliged, forced to chase them because we don’t know what is
happening and it is unfair to the patient because the treatment has been delayed and
everything has been delayed so.
Nurse 3: Quite often you will go to meetings and you will inform house officers of
what is happening and they will like – yes, yes, we fully understand, and they
understand but when then pass the information on – you know – the regular consultant
is coming round to discharge them and they are trying to pass information on and it is
second hand, it is not being listened to and the person gets discharged and that’s – it is
just second hand information, and if they are not on that ward, or if that house officer is
not on that ward round at that time, then that information is being missed, so – but you
can also understand their pressure as well because they have got everything else to do
and why should all of them have to attend meetings.
***********
Therapist: A lot of it goes sort of second hand through the nurses and it was recognised
that was quite dangerous really in the sense that having messages passed back and forth
because they were the people there all the time. Just silly things like not having enough
bleeps so not everyone can have a bleep.
Interviewer: Right… so you seem to be saying that the communication with the
medical teams might be happening through the nursing staff rather than perhaps
directly with other members of the multidisciplinary team.
Therapist: Yes… I mean we do bleep and communicate with them as well but a lot of it
does happen, sort of third hand, through the nursing staff (LG)
***********
Doctor1: Because there are loads of things the nurses could tell us and do tell us, but
we often get it very piecemeal because the sister has told somebody who is on her
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break and we have left the ward, and then - then there is a bleep and then can’t go
home today – you know – practical issues. There must be a better way
Interviewer: And I see you are saying that collaboration is happening both formally
through multi-disciplinary team meetings and informally in the corridor.
Doctor 1: Yes we bleep each other and L bleeps us when she wants to ask something,
so on the way round – it works very well actually.
Doctor 2: Really collaboration is mainly done by L, we feed back to her and then she
feeds onto others. Vice versa they feed back to her and she passes it on to us with the
care co-ordinator in the middle kind of – the collaboration is very good.
Interviewer: So she kind of acts as a routing between nurses and so on?
Doctor 2: Yes, yes.
Interviewer: What about the other professional groups? What about the physios, O.T.’s
and so on that you work with?
Doctor 3: I think probably we have even less direct contact with physios and O.T.’s.
The physios, you don’t see that often. They often aren’t on the wards when you are
going round and probably they have more direct contact with the house officers who
are on the wards more than we are.
Doctor 2: A lot of the referrals to the physios and O.T’s go through the nursing staff
and through care co-ordinators and so we don’t actually as registrars spend that much
time directly communicating with them.
Doctor 1: Our main contact with them is at the MDT meeting or if they approach you
or you - or you happen to see them on the ward. Otherwise the way that I have done it
is to say to either the care co-ordinator or the house officers or the nursing staff – they
will communicate the message, because they often don’t carry a bleep, the physios and
the O.T.’s so we can’t get in contact with them if they are not there. I think that – it is
slightly less important for us to have a direct face-to-face contact unless you really
have a specific issue to discuss. It tends to be – it is more important that you have a
direct contact with the nursing staff.
*************
Interviewer: How you see your collaboration, is it good – indifferent - are there issues
around that?
Registrar: It is very important and it is very patchy at this stage I think. It is not bad but
it is patchy, very patchy, but –
Interviewer: In what sense?
Registrar: It’s – I mean you rarely get a chance to speak directly to them – you usually
write in the notes and you take it from there. I prefer it when you can sit down and talk
about things but there is no time for that. But it is not bad, it is happening but – you
know – in the sort of paper level.
Interviewer: So you are saying that most of the communications happens through your
notes rather than face to face discussions?
Registrar: Yes, yes but it is happening to a certain degree.
Interviewer: And what would you say are the limitations on those face to face
discussions? Is it because you have a lot of other commitments and can’t spend time on
the wards?
Registrar: Yes, exactly, yes. You have got a lot of patients lying around different wards
and you have to chase up and different – er you are probably covering different wards
and really you can never see the physio on each and every ward so it is difficult.
[/end hidden content]
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Read the following and then re-read the extract.
Essential reading:
Lingard L, Espin S, Evans C and Hawryluck, L (2004). The rules of the game:
interprofessional collaboration on the intensive care unit team. Critical Care, R403–
408.
Bailey P, Jones L and Way D (2006). Family physician/nurse practitioner: stories of
collaboration. Journal of Advanced Nursing, 53(4), 381–391.
Reeves S and Lewin S (2005). Interprofessional collaboration in the hospital: strategies
and meanings. Journal of Health Services Research & Policy, 9(4), 218–225.
Lewin S and Reeves S (2011). Enacting ‘team’ and ‘teamwork’: using Goffman’s
theory of impression management to illuminate interprofessional practice on hospital
wards. Social Science and Medicine, 72(10), 1595–1602.
How do these themes relate to wider issues structuring social relations of health care
discussed in the readings which may include:




knowledge economies (ownership and control of ‘expert’ knowledge/skills)
‘time’ and ‘space’ in health units
formal and informal strategies of providing care (Fitzgerald)
trust versus risk/uncertainty.
From what you read (abstracts and paper) what are the implications for achieving the
core health system goals such as improved health, responsiveness, fairness and
efficiency (discussed throughout the module)? Think about how the emerging themes
relate to each goal.
Discuss the challenges as well as opportunities from the point of view of the different
stakeholders: planners, managers, patients, providers.
Post your reflections on Moodle to engage in discussion.
Option 2: Local health providers and praxis – knowing how to ‘work the system’.
Negotiating Autonomy and Accountability among Health Care Providers
(middle/low income countries)
Accountability is seen as an essential element in improving health systems
performance. However, forms of accountability may differ according to types
(administrative, financial, political, social) and directions (horizontal, downwards,
upwards) of accountability relations. These, in turn, imply specific configurations of
power relationships and particular roles for different actors. In practice, different forms
of accountability co-exist, and sometimes conflict with goals of professional autonomy,
collaboration, and trust among actors who make up the health system.
To understand how HIV is being managed in the private medical sector, and to discuss
the strengths and limitations of regulating health care working relations through formal
accountability mechanisms, an NGO in Pune, India carried out a series of interviews
with private practitioners (doctors, pharmacists, laboratory managers) during 2004–
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2005, just before the country began launching the free access to anti-retroviral therapy
(ART) in selected high-prevalence states. The extract illustrates the treatment strategy
employed by a private practitioner’s in managing HIV-patients. Dr. ND is a
pediatrician (MBBS) with 22 years of practice.
Read the extract from an interview given below.
What is your initial reaction to it? Do you find it surprising in any way?
What are the key themes/factors influencing this providers’ course of action in the case
of the patient described?
What are the key health system relationships referred to in this case narrative? How
would you describe their nature and content?
What key issues emerge that highlight accountability mechanisms? What are the ways
in which they reflect key dimensions of social and political relations related to HIV
care in India?
Click here to reveal the extract [link – on click reveal hidden content]
[hidden conent]
Extract from interviews
Interviewer (DD): Could you tell us about a case you’ve seen in the last 3-4 months…
ND: [big pause]… One I recently investigated. He had come for weight loss, fever. He
came for severe weight loss and loose motions. After giving him routine treatment he
did not find any change. He continued to have fever so I told him that your fever is not
going down. Let us do all the 'investigations.' He turned out to be positive. ELISA +ve.
Once it becomes positive, I usually do not give further treatment. I usually refer.
Because in our 'time limit' it is not possible for us to tell everything to the patient in
'detail' and answer all their questions. So 'usually I refer them to 'consultant' which
means I do not 'treat' HIV patients myself. (…) Then later they come back to me if they
have any problems like loose motions. I treat them for small 'ailments' but 'overall' I do
not give the 'anti retroviral treatment'. These days I feel that I should give but (laughs)
so far I have not started because the cost has reduced only in the last 2,3,4 months.
Until last year the cost was about Rs.40000 to 50000. In this area there are very few
who can afford to spend that kind of money or those who will spend that much of
money and will take that medicines 'continuously' for 5-10 years (…) now that the
treatment is more within reach I have started feeling that should I start the treatment.
That is what I feel. Let us see… But so far I have not started any 'treatment'.
DD: what was the age of the patient?
ND: his age… 25-26 years.
DD: what was his occupation?
ND: They are ‘Ghisadi’. Ghisadi means those who make instruments from iron or by
'welding'. But he himself was doing 'service' at some 'medical shop.' He himself was
not doing his traditional job. At the moment he is not doing any work.
DD: is he married?
ND: he is married. His wife is also 'positive'.
DD: did you asked him to get his wife tested?
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ND: I tested him here at my clinic. Then I referred him to a 'consultant'. Then he (the
consultant) tested his wife.
DD: and what did you tell him before testing him?
ND: I told him that you are getting 'fever' continuously. In such a case it could be HIV.
We are doing all the tests. Only this test will remain so let us do this test also. If it is
negative then it is good. But if it is positive then you can be given 'treatment'.
Otherwise we will spend money on all other investigations and you might be positive.
DD: What was this patient's reaction when you told him that let us do this HIV test?
ND: This patient’s response?…nothing. He said let’s do it. Previously 'actually' I had
done his test. At that time he had come negative. Long back……. at that time I had
suspected similarly because there was 'weight loss'. At that time also I had tested him.
That was many years ago. So I said let us do it again. And then it came positive.
Nothing … 'he accepted'. He is not that (laughs making gesture with his hand)
'intelligent'. He is a little dense (badhir).
DD: but then it must be different for you as a doctor to handle such patients. Then how
did you tell the patient that he is positive and what needs to be done in future?
ND: no, 'usually'… when the patient is diagnosed as positive I tell him that there is a
fault in your blood it is little bad (kharab) then I tell someone some elder in the
family… either an elder brother or someone from the family that he is positive.
DD: even in the case of this patient?
ND: yes, then later 'over a period of time' they come to know then after they come later
sometime I tell them gradually I do not give them a 'blow' at one time. I tell them
gradually. At first I tell them that there is a fault in the blood, you blood is bad, then I
tell some responsible person either the elder brother and then I tell the patient.
DD: but did this patient come alone or did someone accompany him?
ND: sometimes they come alone sometimes someone from the family accompanies
them.
DD: and in case of this patient?
ND: [interrupted] no, I told the elder brother of the patient because he was not that
(intelligent) so I told his brother. But many a times I also tell the patient if I find that he
is a little 'intelligent' that this is the situation because I have to tell him about
precautions that he needs to take with regard to his 'wife'. That is why I also tell
patients. 'It depends on … the patient'
DD: and what precautions did you ask this patient to take?
ND: one thing was… I told him to keep a 'regular follow up'. Take the medicines;
prescribed by the doctor I refer you to, 'regularly'. Secondly… have 'protected sex' with
your wife and 'he has no issue' so there are no problems with regard to children. Hence
'protected sex' and now 'anti retroviral' have been started.
DD: where did you refer him?
ND: Vinay Kulkarni, he is my 'classmate'. I send all my patients to him and some to
Sanjay Pujari. 'It depends' if the patients are from that side then I send to Dr. Pujari and
here… most of my patients are send to Dr. Kulkarni 'he is my close friend' now that we
know each other for 25 years… I send to him.
DD: before you referred him to that Dr. did you tell him anything as to why you were
sending him there?
ND: yes… I tell them. I do tell them. I tell most of them. Only when it is not possible I
tell them that there is a fault in your blood that doctor is an expert in that field. Go and
see him. There he does 'counseling' he has everything. And then starts 'treatment' or
then he sends the patient back to me with a note that I have started this treatment. Then
they keep coming back to me for other 'aliments' like loose motion, cough etc. then I
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give them 'symptomatic treatment' but so far I have not given any 'anti retroviral'
treatment'.
DD: this patient had fever and weight loss initially (ND: yes) can you tell us about the
diseases progression after weight loss? What other problems did he have?
ND: no, 'usually' what happens is that when these people come to me in the very 'early
stage' they have only one complaint… only 'stomatitis, or continuous mouth ulcers' or
only cold. They come with such complaints. Then that continue for many days. After
that 'recurrent cough' starts, then 'usually' they develop Koch (TB). They start taking
anti-Koch and they realize that they may have HIV. Then after that the 'anti Koch
treatment' continues and then sometimes he comes down with 'herpes zoster' or
'candidial infection'. In between some days are ok…and then again he starts getting
'recurrent cough, fever, loose motions'. This continues after 7-8 years …
DD: in case of this patient what are the other infections that you see?
ND: Not much now… 'he is in a quiet phase'. At present, he is taking only 'anti Koch',
other than that he does not have any 'immediate problem'. The patient that I just spoke
of (DD: yes) he is only on 'Anti Koch' and 'Anti retroviral drugs…2 drugs
Lamuruvidine plus something else. Those two drugs and Anti Koch. 'At present he is
ok'.
DD: Ok, and do you give him Anti Koch treatment?
ND: No, I don't give. I give other patients but in the case of this patient he was taking
'Anti Koch' and the other treatment from the doctor I referred him to. Now if they say
that it is not possible for us to take the (ARV) then there is no use of doing the 'viral
load' or 'CD4' otherwise if they say that we don't have that much of money then we
start with only the Anti Koch treatment and tell them that once you have arranged for
the money, tell us. Then I refer them there (to consultant) because then all these things
have to be done.
And in the end you cannot decide when to take 'Anti retroviral treatment' unless you do
the 'CD4count' and 'viral load'. Then we give these patients whatever treatment is
necessary and tell them to have 'protected sex' and we give them whatever 'routine'
treatment needs to be given. Later if they are able to arrange for the money and they
'develop' something we 'refer' them because even viral load and CD4 count costs about
Rs. 2- 2500/DD: Is he taking anti Koch treatment from Dr. Vinay Kulkarni?
ND: Yes, many a times. Sometimes I also give Anti-Koch… to so many patients… but
I don't give 'Anti retrovirals'.
DD: You have told the elder brother (ND: in this case, yes) so how is the response of
the family towards the patient?
ND: …[pause]…family response means his wife is illiterate. That is why she doesn't
understand much of this. He himself is not that…only one of his elder brothers is
comparatively intelligent. I told him. Parents are insensible (badhir). They don't have
anything against him. 'At least' in front of me they show that they are not very…only
that brother is quite ok. He also drives 'rickshaw'. But he takes care of the medicines
etc.
DD: means in the family…any…?
ND: No. Not yet. So far the 'family is intact'. Everyone is looking after him. So at least
as of now it is a joint family. So far they have not throw him or his wife out of the
house. So far, 'they are staying together'. In our situation it rarely happens that…only
those who are chronic and 'alcoholic' are probably thrown out of home. But in case of
'most of the patients' their parents look after them…it's a good thing.
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[/end hidden content]
Read the following readings and then re-read the extract.
Essential reading
Fochsen G, Deshpande K, Ringsberg K and Thorson A (2009). Conflicting
accountabilities: doctor’s dilemma in TB control in rural India. Health Policy 89 : 160–
167. George A (2009). ‘By papers and pens, you can only do so much’: views about
accountability and human resource management from Indian government health
administrators and workers. International Journal of Health Planning and
Management , 24, 205–224. De Costa A, Johansson E and Diwan VK (2008). Barriers
of mistrust: public and private health sectors’ perceptions of each other in Madhya
Pradesh, India. Qualitative Health Research , 18 (6), 756–766.
How do these themes relate to wider issues structuring social relations of health care
discussed in the readings which may include:






knowledge economies (ownership and control of ‘expert’ knowledge/skills)
theory versus ‘praxis’ of health care systems
‘time’ and ‘space’ in health units
formal and informal strategies of providing care
trust versus risk/uncertainty
accountability channels.
From what you read (abstracts and paper) what are the implications for achieving the
core health system goals such as improved health, responsiveness, fairness and
accountability (discussed throughout the module)? Think about how the emerging
themes relate to each goal.
Discuss the challenges as well as opportunities from the point of view of the different
stakeholders: planners, managers, patients, providers.
Post your reflections on Moodle to engage in discussion.
8 Summary
Page 18 (GHM201_s09_080_010.html)
Much of the current debate is driven by a normative view of health systems as clearly
organised institutions owning technical knowledge and expertise, effectively raising
and managing resources and providing services to improve health outcomes that are
beneficial to all. This is how health systems are designed and viewed from ‘from
above’.
However, this paradigm often differs from the way health systems are experienced by
front-line participants in the care process, and viewed ‘from below’. Health systems are
core social institutions involving multifaceted social relationships between actors. They
are situated within complex social, cultural and political contexts, and actor behaviour
is influenced by culture, customs and beliefs.
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Explanations for these multiple realities are provided by the ethnomedical approach
which is concerned with individuals and their practical knowledge, and by the political
economy approach which emphasises the importance of political and economic forces
(power, poverty, race, gender) shaping people’s experience of a health system. Other
approaches recognise the significant agency that health systems actors have within the
local context of health services and communities. Health systems can be seen as
knowledge economies embedded in power relations, where there are many ways
(formal and informal) to access expert knowledge and obtain care. Users can thus
become skilled at learning ‘how to work the system’.
There are often tensions between these two perspectives. Macro-level health
imperatives often do not reflect the realities of health systems actors. Reforms and
policy implementation may fail to achieve their envisaged outcomes due to unintended
consequences. These arise first, as a result of front line interactions among actors and
the way they adapt formal rules, and second, the failure to take account of social,
cultural and political factors influencing actor behaviour. Achieving effective and
responsive health systems requires reconciling these two views, and a holistic
understanding of how health systems operate in reality. It is important to understand
different actors’ strategies, when designing health systems interventions.
Recognising that health systems are social institutions entails that they are not there
just to produce health, but they are expected to be responsive, accountable, and
empower the participants in the care process. Thus, building trust and shared values
among all actors can be essential for meeting health systems’ objectives.
Back to Table of Contents
9 References
Page 19 (GHM201_s09_090_010.html)
Essential reading (session)
George A (2009). †˜By papers and pens, you can only do so much†™: views about
accountability and human resource management from Indian government health
administrators and workers. Int J Health Plann Manage 24: 205-224.
Gilson L (2003) Trust and the development of health care as a social institution. Social
Science and Medicine 56(7): 1453-1468.
Fochsen G, Deshpande K, Ringsberg K & Thorson A (2009). Conflicting
accountabilities: doctor†™s dilemma in TB control in rural India. Health Policy 89,
160†“167.
Lewin S & Green J (2009). Ritual and the organization of care in primary care clinics
in Cape Town, South Africa. Social Science & Medicine 68: 1464†“1471.
Essential reading (activities)
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[Type text]
Bailey P, Jones L and Way D (2006). Family physician/nurse practitioner: stories of
collaboration. Journal of Advanced Nursing, 53(4), 381†“391.
Lewin S and Reeves S (2011). Enacting †˜team†™ and †˜teamwork†™: using
Goffman†™s theory of impression management to illuminate interprofessional
practice on hospital wards. Social Science and Medicine, 72(10), 1595†“1602.
Lingard L, Espin S, Evans C and Hawryluck, L (2004). The rules of the game:
interprofessional collaboration on the intensive care unit team. Critical Care,
R403†“408.
Mathole T, Lindmark G and Ahlberg BM (2005). Dilemmas and paradoxes in
providing and changing antenatal care: a study of nurses and midwives in rural
Zimbabwe. Health Policy Plan 20(6): 385†“393.
Reeves S and Lewin S (2005). Interprofessional collaboration in the hospital: strategies
and meanings. Journal of Health Services Research & Policy, 9(4), 218†“225.
Any two of the following:
Goodman C, Opwora A, Kabare M, Molyneux S (2011). Health facility committees
and facility management - exploring the nature and depth of their roles in Coast
Province, Kenya. BMC Health Serv Res 11: 229
Needham C (2013). Personalized commissioning, public spaces: the limits of the
market in English social care services. BMC Health Serv Res. 13 Suppl 1:S5. doi:
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Payne CM, Debbink MP, Steele EA, Buck CT, Martin LA, Hassinger JA & Harris LH
(2013). Why women are dying from unsafe abortion: narratives of Ghanaian abortion
providers. Afr J Reprod Health 17(2): 118-28.
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professionals in patient advocacy. J Med Ethics 28(1): 37-40.
Small N, Bower P, Chew-Graham CA, Whalley D & Protheroe J (2013). Patient
empowerment in long-term conditions: development and preliminary testing of a new
measure. BMC Health Serv Res. 13:263.
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World Health Organization (2000). Chapter 2. How Well do Health Systems Perform ?
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Recommended reading
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[Type text]
The Recommended reading includes materials to draw upon when undertaking
your assignment or in self study, according to your interests (this may be 2-3
readings typically).
Atkinson S, Medeiros RLR, Oliveira PHL & de Almeida RD (2000). Going down to
the local: incorporating social organization and political culture into assessments of
decentralized health care. Social Science & Medicine 51: 619-636.
Kielmann K, Deshmukh D, Deshpande S et al. (2005). Managing uncertainty around
HIV/AIDS in an urban setting: private medical providers and their patients in Pune,
India. Social Science and Medicine 61(7): 1540-1550
Lewin S & Reeves S (2011). Enacting ‘team’ and ‘teamwork’: using Goffman’s theory
of impression management to illuminate interprofessional practice on hospital wards.
Social Science and Medicine 72(10): 1595–1602.
Mogensen, HO (2007) Finding a path through the health unit: practical experience of
Ugandan patients. Medical Anthropology 26(1): 7-52.
Sheikh K & Porter JD (2011). Disempowered doctors? A relational view of public
health policy implementation in urban India. Health Policy Plan 26(1): 83-92.
Standing H & Chowdury AMR (2008). Producing effective knowledge agents in a
pluralistic environment: What future for community health workers? Social Science
Medicine 66: 2096-2107.
Cited references and sources
Adam T & de Savigny D (2012). Systems thinking for strengthening health systems in
LMICs: need for a paradigm shift. Health Policy Plan 27(Suppl. 4): iv1–iv3.
Bailey P, Jones L & Way D (2006). Family physician/nurse practitioner: stories of
collaboration. Journal of Advanced Nursing 53(4): 381–391.
Balabanova D, McKee M, Koroleva N, Chikovani I, Goguadze K, Kobaladze T, Adeyi
O & Robles S (2009). Navigating the health system: diabetes care in Georgia. Health
Policy Plan 24: 46–54.
Balabanova D, McKee M & Koroleva N (2007). Georgia: diabetes and systemic
constraints. Appendix 3: challenges of design and implementation. In Adeyi O, Smith
O & Robles S eds. (2007). Public Policy and the Challenge of Chronic
Noncommunicable Diseases. Washington, DC: World Bank Publications.
Bloom G & Standing H (2001). Pluralism and Marketisation in The Health Sector:
Meeting Health Needs in Contexts of Social Change in Low- and Middle-Income
Countries. IDS Working Paper No. 136. Brighton: Institute of Development Studies.
Bloom G, Standing H & Lloyd R (2008). Markets, information asymmetry and health
care: towards new social contracts. Soc Sci Med 66 (10): 2076-87.
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De Costa A, Johansson E & Diwan VK (2008). Barriers of mistrust: public and private
health sectors’ perceptions of each other in Madhya Pradesh, India. Qualitative Health
Research, 18(6): 756–766.
Degenhardt L, Mathers B, Vickerman P, Rhodes T, Latkin C & Hickman M (2010).
Prevention of HIV infection for people who inject drugs: why individual, structural,
and combination approaches are needed. Lancet 376(9737): 285-301.
de-Graft Aikins A (2005). Healer shopping in Africa : new evidence from rural-urban
qualitative study of Ghanaian diabetes experiences . BMJ 331(7519):737.
Fochsen G, Deshpande K, Ringsberg K & Thorson A (2009). Conflicting
accountabilities: doctor’s dilemma in TB control in rural India. Health Policy 89: 160–
167.
George A (2009). ‘By papers and pens, you can only do so much’: views about
accountability and human resource management from Indian government health
administrators and workers. International Journal of Health Planning and
Management 24: 205–224.
Gilson L (2003). Trust and the development of health care as a social institution. Social
Science & Medicine 56(7): 1453–1468.
Gilson L (ed.) (2012). Health Policy and Systems Research: A Methodology Reader
[online] Geneva: WHO. Available at:
www.who.int/alliance-hpsr/resources/alliancehpsr_reader.pdf (accessed October 2013)
Isaakidis P, Rangan S, Pradhan A, Ladomirska J, Reid T & Kielmann K (2013). 'I cry
every day': experiences of patients co-infected with HIV and multidrug-resistant
tuberculosis. Trop Med Int Health 18(9): 1128-33.
Jorgensen PD (2013). Pharmaceuticals, political money, and public policy: a
theoretical and empirical agenda. J Law Med Ethics 41 (3): 561-70.
Kruk ME & Freedman LP (2008). Assessing health system performance in developing
countries: a review of the literature. Health Policy 85: 263–276.
Lewin S & Reeves S (2011). Enacting ‘team’ and ‘teamwork’: using Goffman’s theory
of impression management to illuminate interprofessional practice on hospital wards.
Social Science and Medicine 72(10): 1595–1602.
Lingard L, Espin S, Evans C & Hawryluck L (2004). The rules of the game:
interprofessional collaboration on the intensive care unit team. Critical Care R403–
408.
Mathole T, Lindmark G & Ahlberg BM (2005). Dilemmas and paradoxes in providing
and changing antenatal care: a study of nurses and midwives in rural Zimbabwe.
Health Policy Plan, 20(6): 385–393.
Document1
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McPake B, Blaauw D & Sheaff R (2006). Recognising Patterns: Health Systems
Research Beyond Controlled Trials (HSD working paper HSD/WP/10/06) [online]
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www.dfid.gov.uk/r4d/PDF/Outputs/HealthSysDev_KP/recognising_patterns_web_vers
ion.pdf (accessed October 2013)
Mogensen HO (2007). Finding a path through the health unit: practical experience of
Ugandan patients. Medical Anthropology 26(1): 7-52.
Murguía A, Peterson RA & Zea MC (2003). Use and implications of ethnomedical
health care approaches among Central American immigrants. Health Soc Work
28(1):43-51.
Reeves S & Lewin S (2005). Interprofessional collaboration in the hospital: strategies
and meanings. Journal of Health Services Research & Policy 9(4): 218–225.
All contents © LSHTM 2015 except where otherwise indicated.