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.