Paper short abstract:

This qualitative study analyzes the impact that “structural competency,” an emerging framework for helping clinicians navigate social processes within the health system, had on medical students’ and physicians’ understanding of societal problems affecting patient health and health system practices.

Paper long abstract:

In this study, we analyze the impact that “structural competency,” an emerging framework for helping clinicians navigate social processes within the health system, had on medical students’ and physicians’ understanding of societal problems affecting patient health. In this qualitative study conducted between August and December 2020, we analyzed 19 semi-structured interviews with 7 first-year medical students, 7 upper-level medical students, and 5 physician course facilitators who participated in a course called Introduction to Medicine and Society at an medical school in the United States affiliated with a large urban academic medical center. This paper focuses on three main findings: how medical students and faculty describe “structures” and their effects on patients and patient care; how they use or imagine using structural competency to improve patient-physician communication and work inter-professionally to address social needs; and the emotional and personal reactions that confronting societal challenges provokes. We conclude that structural competency enhances existing efforts to improve patient-physician communication and to address patients’ social needs. However, we highlight how structural competency efforts might fall short of their goal to shift physicians’ perspectives “upstream” to the determinants of health due to both critical ambiguities in the concept and inattention to the emotional and personal impacts of addressing societal problems in the clinic. These findings have practical implications for how clinicians are trained to act on societal issues from within the health system and conceptual implications for refining how existing frameworks and curricula conceive of the intersection between healthcare and broader processes.

Paper short abstract:

Ethnographies of health systems form a theoretically rich and rapidly growing area within medical anthropology. We review work in this space from the 1950s to the present, and provide thoughts on how to move this field forward.

Paper long abstract:

Ethnographies of health systems are a theoretically rich and rapidly growing area within medical anthropology. Critical ethnographic work dating back to the 1950s has taken policymakers and health staff as points of entry into the power structures that run through the global health enterprise. In the last decade, there has been a surge of ethnographic work on health systems. We conceptualize the anthropology of health systems as a field; review the history of this body of knowledge; and outline emergent literatures on policymaking, HIV, hospitals, Community Health Workers, health markets, pharmaceuticals, and metrics.

High-quality ethnographic work is an excellent way to understand the complex systems that shape health outcomes, and provides a critical vantage point for thinking about global health policy and systems. As theory in this space develops and deepens, we argue that anthropologists should look beyond the discipline to think through what their work does and why it matters.

Paper short abstract:

In this paper, we adopt a patient pathway approach to examine moments of breakdown and repair in the coordination of patient care in Sierra Leone, and argue that exploring how the responsibility for ‘making the system work’ is distributed, is essential to understanding what a health system is.

Paper long abstract:

Central to the workings of a hospital are the technical and bureaucratic systems that ensure the effective coordination of information and biological materials of patients across time and space. In this paper, which is based on ethnographic research in a public referral hospital in Freetown, Sierra Leone, conducted between October 2018 and September 2019, we adopt a patient pathway approach to examine moments of breakdown and repair in the coordination of patient care. Through the in-depth analysis of a single patient pathway through the hospital, we show how coordination work depends on frequent small acts of intervention and improvisation by multiple people across the pathway, including doctors, managers, nurses, patients and their relatives. We argue that such interventions depend on the individualisation of responsibility for ‘making the system work’ and are best conceptualised as acts of temporary repair and care for the health system itself. Examining how responsibility for the repair of the system is distributed and valued, both within the hospital and in terms of broader structures of health funding and policy, we argue, is essential to developing more sustainable systems for repair.

Paper short abstract:

This presentation reflects on the use of qualitative evidence in the WHO's guidelines for task shifting in maternal and newborn health programs. While evidence-based medicine conflicted with key aspects of qualitative research paradigms, important openings and opportunities were nonetheless present.

Paper long abstract:

Systematic reviews of qualitative evidence—or ‘qualitative evidence syntheses’ (QES)—have become an important form of knowledge production within ‘evidence-based medicine’ (EBM) and ‘evidence-informed policymaking’. QES proponents argue these reviews promote ‘health systems thinking’ and better understanding of local process and context in global health policy- and decision-making. EBM’s detailed technical procedures, however, do not fit well with conventional qualitative research paradigms. There are concerns that subjecting qualitative research to EBM’s logics and practices might fatally compromise its epistemological integrity and political impact. This presentation addresses these concerns via a case study of the WHO’s OptimizeMNH guidelines for task shifting in maternal and newborn health programs. When I joined the team developing these health systems-oriented guidelines, I wondered whether including qualitative research would broaden of the forms of reason, experience and judgment informing global health policy, or instead, be another disheartening example of how modern bureaucratic systems coopt, standardize, and complexity-reduce alternative logics. While the integration of qualitative evidence did come at some cost to the depth and critical insights of the evidence we were reviewing, there were also important ways in which the technical procedures of evidence-based medicine were open to adaptation and transformation. The formal inclusion of qualitative evidence syntheses in these global guidelines did not represent—or produce—a dramatic about-turn in global health policy’s hegemonic discourses and practices. It did reveal, however, that powerful systems of health governance like the WHO and evidence-based medicine are not inevitably closed, but in fact open to change, in often unpredictable ways.

Paper short abstract:

Discourses around health systems take for granted the concept of the ‘system’. Based on ethnographic research, I argue that the biomedical terrain in Bangladesh defies such representations, as unregulated private health services mushroom to shape the ‘system’, materially, spatially and temporally.

Paper long abstract:

With growing consensus regarding the weaknesses and limitations of siloed, disease-specific health research and programming, the global pendulum swing towards health systems research is a welcome development. However, while well-intentioned, such discourses assume a priori a ‘health system’ that is decipherable and governable. In Bangladesh, an expansive sub-national public health system fits neatly into representation through mapping and organigrammes. However, such representation fails to capture the reality and complexity of the biomedical ‘system’ people reckon with today. Indeed, ethnographic investigation muddles the imaginary of an organised ‘system’ amenable to homogenised intervention. Based on ethnographic data carried out in Kushtia district in peri-urban and rural settings focusing on maternal health care delivery, I argue that ethnographic inquiry is critical to understand the nuanced ways the health ‘system’ is constituted, materially, spatially and temporally. Political, economic, and development forces have combined over recent decades to give rise to a flourishing market of little-regulated private health care services, which operate almost entirely outside of ‘system’ imaginaries. These private health services have grown like vines around the scaffolding of the public health system yet fall almost entirely outside the purview of facile categorisations evoked in health systems discourses in the county. Today, private biomedical services dwarf the circumscribed public health system. While technically distinct from the public health system, they overlap, as the same workforce often animate both. Private health services also work symbiotically with the public health system as they strategically serve to fill (and commoditise) gaps of an unreliable public health system.

Paper short abstract:

The use of 'therapeutic itineraries' revealed that models of care based on mere access and availability of clinical interventions fail to reflect the complexity of people’s understanding and lived experiences of hypertension and are thus ultimately unhelpful in improving its control.

Paper long abstract:

This paper characterizes the ‘therapeutic itineraries’ of people with hypertension from poor communities in rural and urban settings in the Philippines. We employ longitudinal qualitative methodology comprised of repeat interviews and digital diaries using mobile phones from 40 recruited participants in 12 months. Our findings demonstrate that therapeutic itineraries, rather than being organized according to categories that stem from the structure of the health system (i.e., diagnosis, treatment, follow-up, adherence), diverge from clinical pathways. Therapeutic itineraries begin at a stage we label as ‘pre-diagnosis’ (PD). Following this, itineraries diverge according to two possible entry points into the healthcare system: via incidental diagnosis (ID) whereby participants were diagnosed with hypertension without deliberately seeking care for hypertension-related symptoms and symptom-driven diagnosis (SD) whereby their diagnosis was obtained during a clinical encounter specifically prompted by hypertension-related symptoms. Participants whose itineraries follow the SD route typically oscillated between periods of regular and intermittent medical treatment, while participants who were diagnosed incidentally (ID) typically opted for self-care. As we follow our participants’ therapeutic itineraries, we explore the confluence of factors informing their care journey, namely, their conceptions of hypertension, their social relationships, as well the choices and trade-offs they make. We conclude with policy implications from our findings, chief of which is our proposition that models of care based on mere access and availability of clinical interventions fail to reflect the complexity of people’s lay understanding and their lived experiences of hypertension and are thus ultimately unhelpful in improving its control.

Paper short abstract:

In many countries, when health systems are examined from the bottom up medicine sellers appear as critical actors. In this paper, we ask ‘what happens to the conceptualisations of a health system when medicine sellers and their practices are foregrounded in research?’

Paper long abstract:

In many countries, when health systems are examined from the bottom up medicine sellers emerge as critical

actors providing care and access to commodities. Despite this, these actors are for the most part excluded from

health systems and policy research. In this paper, we ask ‘what happens to the conceptualisations of a health

system when medicine sellers and their practices are foregrounded in research?’ We respond by arguing that

these sellers sit uncomfortably in the mechanical logic in which health systems are imagined as bounded institutions, tightly integrated and made up of intertwined and interconnected spaces, through which policies,

ideas, capital and commodities flow. They challenge the functionalist holism that runs through the complex

adaptive systems (CAS) approach. We propose that health systems are better understood as social fields in which

unequally positioned social agents (the health worker, managers, patients, carers, citizens, politicians) compete

and cooperate over the same limited resources. We draw on ethnographic research from Uganda (2018–2019) to

analyse the responses of different actors to a new policy that sought to rationalise the medicines retail sector and

exclude drug shops from urban centres. We examine the emergence of new lobby groups who contested the

policy and secured the rights of ‘drug shop vendors’ to trade on the basis that these shops are increasingly

populated by trained nurses and clinical officers, who are surplus to the capacity of the formal health system and

so look to markets to make a living. The paper adds to the growing anthropological literature on health systems

that allows for a focus on social change and a form of holism that enables phenomena to be connected to diverse

elements of the context in which they emerge.

Paper short abstract:

We critique instrumental approaches to 'patient pathways' as a way of understanding how people achieve or thwart health systems goals. We present a relational approach that explores infrastructural and social aspects of clinics as they bear upon TB care interactions that diverge from a set pathway.

Paper long abstract:

Patient 'care pathways' often refer to the ways health care interventions are optimised within specific temporal and spatial frames. In structuring an ideal trajectory, they are imbued with values and assumptions around individual and system performance and often used to set targets against which progress is evaluated. The pathway metaphor instantiates an instrumental approach to care-seeking as a ‘fixed plan’. In contrast, a relational approach allows for a ‘mental map’ of the multiple, interrelated dimensions of care-seeking. Using the lens of tuberculosis (TB) care, we outline features of a relational approach through comparative analysis of qualitative interviews with health care providers (HCPs) and people receiving care for TB in South Africa, Latvia, and the United Kingdom. First, TB care pathways are path-dependent, that is, they cannot be seen independently of the historical trajectories of health systems; second, systems infrastructure delimits the material, spatial, and temporal aspects of TB care pathways as experienced by both health care providers and patients; third, social relations within the clinic and outside of it define what it means to become a TB patient, and consequently how care events and interactions are experienced. A relational framework can open the space for bringing the perspectives of people with TB and their experiential knowledge more fully to bear in learning health systems. Enabling person-centred care requires HCPs and the health system to recognise that lags, interruptions, and diversions in care-seeking are not so much steps ‘off the pathway’ as dissonances experienced in the relational aspects of care.

Paper short abstract:

Drawing on ethnographic data from two primary health care facilities in India, we seek to better understand how and why the imposition of unrealistic performance targets lead to ‘performing out' with implications for health system functioning, organisational culture, and quality of care.

Paper long abstract:

Low- and middle-income country health systems often apply decontextualised and unrealistic performance targets to facilities. This can lead to empty compliance and ‘performing out’, whereby managers and providers manipulate or inflate data to create the false impression of a functional system. While this is a well-recognised pitfall of audit-style performance accountability processes, the social processes by which these practices emerge has not been well described in the literature.

In this paper, with a focus on maternal and newborn care, we seek to better understand how and why the practices of ‘performing out’ occur, and their implications for health system functioning, organisational culture, and quality of care. We do this through a focused facility ethnography undertaken in two primary healthcare facilities in an eastern Indian state, anonymised as Esma, where practices of ‘performing out’ are prevalent.

We draw on the understanding that health systems are complex adaptive systems encompassing both hardware and software elements, where individual behavioural practices are an outcome of the system. To unpack how the dynamic interactions between system elements and agents influence individual behaviours, we draw upon the sociological theories of the practice of Bourdieu, encompassing the concepts of field, habitus, and capital.

This lens helps to illustrate how practices of ‘performing out’ become part of an entrenched habitus – the ‘dispositions’ of agents that guide behaviour and thinking. In the longer term, the habituation of ‘performing out’ contributes to a systemic orientation toward sub-par performance, undermining the quality of care.