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.