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.