Paper short abstract:

Reflecting on fieldwork at the All India Institute of Medical Sciences (AIIMS) in Delhi, this paper demonstrates the value of anthropology for understanding India’s premier public hospital as both insulated from and permeated by the social and political context beyond its walls.

Paper long abstract:

Established through an act of parliament in 1956, with a focus on research, training, and care, AIIMS was intended above all to ensure India's self-sufficiency in medical human resources. In this paper, I reflect on recent PhD fieldwork to emphasise the indispensability of anthropological study for understanding India's premier public hospital - the institution, its patients, doctors, and students - as both insulated from and permeated by the social and political context beyond its walls.

In particular, I demonstrate how the multidimensional nature of anthropological research is essential to my troubling of narratives about a crisis of medical human resources in India. By drawing on ethnographic insight to give flesh and personal identity to these "resources" in the form of MBBS students at AIIMS, I am able to humanise them and access the influences both within and beyond the institution that inform their perceptions of healthcare in India, and their career aspirations.

I acknowledge a concern about the predominant ambition to practise super-specialised, urban medicine, despite a decline in family medicine provision, and a pressing need for primary and secondary care physicians outside the cities. However, I rely on ethnography to illuminate a textured understanding of the ways in which social norms, institutional myopia, and the historical neglect of public healthcare in India combine to preclude visions of alternative futures for many undergraduates. In doing so, I stress that any people-centred health system must humanise its human resources, and that a vital role exists for anthropology in this endeavour.

Paper short abstract:

This paper draws on ethnographic research among nomadic herders in rural Mongolia. It examines the ways in which environmental challenges, rural-to-urban migration and weak rural politics affect access to health services and impinges on national efforts to strengthen the health system.

Paper long abstract:

In the past decade, the role of national health systems and their need for strengthening has been moved onto the agenda by global health actors (Hafner & Shifman, 2012). Neoliberal efforts to create 'weak states', policies of structural adjustments and a technical bias related to processes of health systems' strengthening, are factors that have shaped the workings of public health delivery.

This paper critically examines Mongolia's health system and discusses how efforts to strengthen this 'system' have been hampered by a narrow focus on technicalities and management structures. Grounded in a longitudinal ethnographic study among nomadic herders in rural areas and of in-migration to the capital Ulaanbaatar, it is argued that a more comprehensive focus on the political and social relations that shape the health system must be taken into account in the efforts to strengthening the system. Considering the rapid changes that have taken place in Mongolia since the demise of socialism in 1990, such a comprehensive focus involves the state's political attitude to, and management of, the dynamic between the urban centre and the rural periphery. It further requires a focus on factors external to the health system that inflict on its ability to provide equitable health care. In Mongolia it is argued, these factors are grounded in weak rural politics, environmental challenges and a massive rural-to-urban migration coupled with increasing poverty and vulnerability among those most marginalized within the health system - the nomadic herders in rural areas and recent in-migrant herders to the capital Ulaanbaatar.

Paper short abstract:

This presentation introduces the concept of welfare-bricolage - the practices by which residents of superdiverse neighbourhoods combine formal and informal health services across public, private and third sectors - as well as the interdisciplinary methods used for studying these processes.

Paper long abstract:

Increasing population complexity, heterogeneity and pace of change in the context of globalisation demand a rethinking of healthcare policies and practices. How residents living in superdiverse urban neighbourhoods access healthcare according to their differing needs and resources is the focus of the Welfare-Bricolage Project UPWEB (Understanding the practice and developing the concept of welfare bricolage). We conduct comparative research in four European cities (Brimingham, Lisbon, Uppsala and Bremen) through the analytical framework of "welfare bricolage": the practice by which individuals combine formal and informal, secular and religious, local, transnational and web-based health services across public, private and third sectors.

The interdisciplinary UPWEB-project combines ethnographic methods - such as mapping, participant observation and qualitative in-depth interviews, with healthcare receivers and providers - and epidemiological quantitative approaches. Different welfare bricolage models emerging during ethnographic research will be further explored and compared cross-nationally through epidemiological surveys. An important aspect of our research is the collaboration with community researchers, who live and work in the neighbourhoods we study. The multi-methods toolkit serves to bridge existing empirical and methodological gaps between epidemiology and ethnography and to produce new knowledge of relevance to academics, policymakers and practitioners.

This presentation introduces the concept of welfare bricolage - the process by which residents in superdiverse urban neighbourhoods mix wide ranging and diverse forms of provision, support and knowledge - and the interdisciplinary and collaborative methods used for studying these processes. A main focus will be the interplay of anthropological and epidemiological research methods within an interdisciplinary team.

Paper short abstract:

Through an ethnography of a private São Paulo hospital’s philanthropic healthcare project, this paper explores ideas among wealthy Brazilian elites on social responsibility, the relationship between philanthropic and state provision of healthcare and the ‘right’ of the poor to health philanthropy.

Paper long abstract:

What role should local philanthropy play in the provision of health services in Brazil, a country characterised by extreme socio-economic inequality and a critically underfunded national health service? This question will be addressed through an ethnographic study of a philanthropic healthcare project, run by São Paulo's most prestigious private hospital, which provides healthcare services, medicines and vaccination to 10,000 children in the hospital's neighbouring shanty town. Rooted in the religious and cultural-political traditions of philanthropy among Brazil's financial elite, this project has evolved in line with changing ideas about the role of the third sector and (corporate and family) philanthropy after the fall of the military dictatorship in the mid-1980s. The advent of neoliberal politics and the drawing back of the state at this time saw increased state outsourcing of social services, and encouraged the growth of philanthropy and CSR. This paper will explore how the question of responsibility for the provision of healthcare to the poor within this context is viewed by different actors, drawing on ethnographic fieldwork among the project's leaders, elite volunteers and shanty town beneficiaries, and analysis of the institutional discourse of the private hospital which funds it. Do private hospitals and wealthy volunteers have a social responsibility to practice philanthropy in Brazil? Does such philanthropy replace state provision of healthcare services, and if so, what are the implications for beneficiaries? And finally, if philanthropy is a responsibility of the rich in countries of great socio-economic inequality, is it also a right of the poor?

Paper short abstract:

Analyzing the “on the ground” manifestations of global health policies in an ART clinic in rural Malawi, the paper challenges notions of normalization of ART in resource-limited settings, and points to the discrepancies between rhetoric and reality as experienced by healthcare providers.

Paper long abstract:

Recent decades had seen unprecedented changes in global health policy and a massive rollout of new health services in resource limited settings. One such example is the push towards the provision of antiretroviral therapy in many areas of sub-Saharan Africa. In Malawi, a national policy shift towards universal access, operating under circumstances of scarce resources, brought new sets of healthcare delivery challenges to bear on both patients and healthcare professionals. Drawing from ethnographic fieldwork in an antiretroviral clinic in rural Malawi, and expanding the scope of anthropological inquiry into the impact of new global health policies to include ART providers, this paper discusses the difficulties stemming from the provision of what is known to be sub-standard care, necessitated by substandard resources, that confront healthcare providers with complex practical and ethical dilemmas on a daily basis. By challenging common notions of normalization of ART in resource-limited settings, this paper broadens the discussion on new global health policies to address their "on the ground" manifestations, and the discrepancies between rhetoric and reality as experienced by healthcare providers.

Paper short abstract:

This paper describes a comparative ethnography of 8 districts across Sub-Saharan Africa and South Asia tracing the effects of global health policy on local health systems. This paper explores the health systems effects of per diems provided by the Global Polio Eradication Initiative.

Paper long abstract:

In 2012, a group of anthropologists, sociologists, and health systems researchers carried out a comparative ethnography of the impact of the Global Polio Eradication Initiative on health systems. We conducted research at 8 research sites in 7 countries (Nepal, India, Pakistan, Ethiopia, Nigeria, Rwanda, and Angola). At each site, we conducted a thorough document review; about 40 interviews with district level officials, ground level workers, and those served by the health system; and participant observation in the activities of the health system, with a particular focus on immunization. Our goal was to create a systematically comparable, ethnographically rich analysis of the effects of global policy on health systems.

This paper focuses on a phenomenon that emerged as salient in nearly all of our case studies, the impacts of per diems. The Global Polio Eradication Initiative provides low per diems (around $1-$2 per day in most places) to ground-level health staff like Community Health Workers for their work on polio campaigns. Across our case studies, these per diems had largely negative effects on worker motivation and performance. They were sufficient to ensure that workers focused on polio eradication rather than other tasks; but because they were so low and frequently arrived late, they were the common subject of bitter complaints. The very low rate of pay per diems represented was in many cases experienced by workers as a slight. Comparative ethnography has the power to illuminate when and how low per diems were especially damaging, and to provide possible ways forward.

Paper short abstract:

This paper is concerned with how health care systems operate in times of epi/pandemic emergencies; the role of anthropology and anthropological research strategies for directing health policy guidelines; and for informed clinical practice at national and international levels.

Paper long abstract:

This paper is concerned with how health care systems operate in times of epi/pandemic emergencies; the role of anthropology and anthropological research strategies for directing health policy guidelines; and for informed clinical practice at national and international levels. Rapid up-scaling of clinical research is central to ensuring an adequate response in a crises epi/pandemic situation. A key requirement is to ensure appropriate compliance with all statutory Ethical, Administrative and Regulatory guidelines. However these as well as social and cultural factors may be seen as obstacles hindering research.

PREPARE, a European research consortium of social scientists and clinicians have highlighted multiple structural and social factors that impede effective, timely, harmonised international research.

This paper points up inconsistencies in the juxtapostion of the current regulatory mechanisms in Europe with clinical researchers' empirical experience in navigating through this system. It will reveal an important contrast between rhetoric and reality and the consequences of this.

The PREPARE research employed a raft of research techniques to identify potential barriers to epi/pandemic research.

High profile professional stakeholders (frontline physican researchers) from several Member States (MS), were interviewed via, 1) an on-line survey, 2) secondary data on clinical trial authorisation, 3) ethical approval processes in each MS and finally via a series of in depth ethnographic style interviews (face-to-face and via telephone). The paper presents a discussion of triangulated data and indicates a range of vital issues that are dogging harmonised and effective research in times of epi/pandemics.

Paper short abstract:

This paper examines how the misleading neologism “consumer directed healthcare” plays out in two U.S. settings: a dental “safety net” and an electronic insurance marketplace. Patients are obligated to act, and even feel, like consumers despite the reality that their “choices” are highly constrained.

Paper long abstract:

Consumers want choices. They want their pick of provider, to only pay for the care that they want, and to avoid being over-insured. These assumptions underwrite "consumer directed healthcare", the most recent pro-privatization, pro-competition ideology to take hold in the $2.9Tril U.S. health care industry. This misleading neologism places consumer "choices" at the center of health policy priorities, even though most innovations offered by this model result in a retraction of benefits and cost-shifting away from employers and public payers and onto consumers themselves. In this paper, we examine how "choice" plays out on-the-ground in two very different settings. In one site, low-income Appalachians' efforts to obtain dental care within a fragmented and hybridized public-private dental "safety net" are gatekept and otherwise shaped by individual providers. In the other site, uninsured residents of Rhode Island try to purchase insurance coverage on electronic insurance marketplaces, but find they need considerable help in navigating the choices they are compelled to make by new legal mandates. "Consumer-directed" health care obligates patients to act, and even feel, like consumers despite the reality that, for many, their health care "choices" are highly constrained.

Paper short abstract:

Anthropologists have grounded knowledge of total contexts. Too often their warning work is ignored by medical authorities because ‘not evidence based’. Anthropologists’ examples from Africa and the UK offer alternative possibilities achieving healthy medical impact or significant potential.

Paper long abstract:

Anthropologists have detailed, grounded knowledge of the total context of a group or people, ideally through time. Too often their work remains as warnings ignored by medical authorities because allegedly 'not evidence based'. Anthropology's holistic cultural context is not seen to be linked to 'rational' medical practices. By contrast, anthropologists' examples offer a range of possibilities: some achieving impact, others with continuing significant potential.

Louise de la Gorgendiere, completing fieldwork in Ghana, used her bureaucratic skills to facilitate the provision of a well, saving the residents from the deadly bilharzia. In recognition, the Asanti honoured her as 'Queen Mother'.

In the UK, the anthropologist challenged the unethical practice of a Medical School project. Breast-feeding African mothers were used, without their knowledge, as objects in a government funded, HIV experiment. The anthropologist's intervention ensured its cancellation.

In Zambia, Tony Simpson, after years of trust among former students, problematised heterosexual masculinity ideals and practices risking Aids. Such research retains potential beyond the locality.

Okely explored Gypsies' and Travellers' alternative pollution beliefs and mortuary rites which, in some cases, have been recognised by medical professionals. Nevertheless, these have also recently been dismissed as 'irrelevant' because 'mere culture' by an established university nursing department.

Finally, the contrast between semi nomadic Gypsies and their enforced, scattered settlement has brought isolation and extreme depression- treated in the short term by repeat medical prescriptions. By contrast, anthropological grounded knowledge could offer an alternative policy to this ever-costly NHS budget, by facilitating ethnic coexistence and renewed wellbeing.

Paper short abstract:

Nineteen months of research in communities and health facilities in Tanzania sheds light on quality of care, patient satisfaction, and trust between clients and providers by focusing on historical, social and institutional dynamics of facilities during obstetric care and crises.

Paper long abstract:

In an era of public health campaigns focused on encouraging women to give birth in biomedical health facilities with the assistance of skill attendants, little ethnography has been conducted in these settings, particularly in Tanzania where women still have a one in 44 lifetime chance of dying due to pregnancy related causes. Though many women successfully overcome barriers (e.g., poor transportation) to reach a health facility, too many still die within these settings. Nineteen months of ethnographic research in communities and biomedical health facilities in the Rukwa region of Tanzania suggests there are a number of ways in which this type of qualitative research can be particularly powerful in recommending new directions for healthcare reform that will continue to reduce maternal deaths. This research sheds light on how to improve quality of care, patient satisfaction, and trust between clients and providers by focusing on historical, social and institutional dynamics of health facilities, community interactions with biomedical providers, and the ways in which facilities work in practice versus their documentary representations. This research uncovered missing links between community members as clients and healthcare providers and administrators and, rooted in the mediating power of ethnography, suggests ways to improve patient satisfaction, communication, leadership, trust, and ultimately quality of care in a system perpetually lacking financial and human resources. Many health sector reforms are constructed far from implementation sites, often producing interventions not well grounded in the reality of those seeking healthcare services or those meant to dispense them; anthropology provides another option.

Paper short abstract:

This paper counters top down approaches to health by bringing out the patient's voice and knowledge around tuberculosis and illness management in East London.

Paper long abstract:

This paper ethnographically explores the tuberculosis (TB) situation among migrant communities in East London. East London is currently the TB capital of Western Europe, predominantly due to large numbers of migrants coming from countries with a high burden of TB, who continue to face health inequalities once arrived.

Das argues that most global health strategies insufficiently address the regional variation of where and how people live, and that the experience of illness is directly related to these practical conditions. To redress this, she argues for a focus on 'what is happening on the ground in relation to the health of the poor' (Das, 2015: 185). Further, current NHS policies advocate that the voices of those who are 'experts by experience' (NHS, 2014: 12) can actively contribute to and control the direction and provision of their care.

In light of these theoretical and policy driven directives, this paper addresses the following questions:

• What knowledge bases and resources do migrant communities have for illness management, care and recovery?

• What barriers impede TB recognition, diagnosis, and compliance with treatment amongst migrant communities in East London?

• What is an acceptable way for public health practitioners to reach out to and engage with migrant communities regarding their health?

Through the experiences and voices of those bearing the disease and of those caring for TB sufferers, whether formally or informally, this paper elaborates on how migrant knowledge bases can better shape the priorities for health-care delivery systems.

Paper short abstract:

This paper focuses on Andean households’ strategies in terms of medical pluralism. Despite their existing access to biomedical care, my informants may choose other options linked with traditional medicine.

Paper long abstract:

This paper presents ethnographic research carried out in the city of El Alto, Bolivia. Well-being in El Alto and in the surrounding countryside is defined in relation to harmonious social relations with both people as well as spiritual forces. If a member of the household is ill, the rest of the household are believed to be affected, indicating many inter-connections between concepts of health and the spiritual and religious spheres. The causes of various pathologies reveal unsolved tensions or conflicts among household or neighbourhood members. Difficult relations with spiritual forces can cause someone to be unwell. Illness and bad luck, however, can be affected through a complex process which may involve rituals performed by a yatiri -local shaman, or other means, such as participating and dancing in a religious celebration in honour of a patron saint or engaging in regular acts of faith. Informants interviewed in this study expressed that health and luck can be controlled and changed by treating the spirits better. This paper focuses on encounters with local shamans, but also looks at Andean households' strategies in terms of 'medical pluralism' as defined by Chrisman and Kleinman (1983). Despite their existing access to biomedical care, my informants may choose other options, providing complex insights into a political economy of care and 'resource gap'. This is particularly interesting at this historical moment, when Morales government has proposed to include traditional medicine in the healthcare system.