GHM201 - Session 6: Assessing health...

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This session was written by Karina Kielmann

GHM201 - Session 6: Assessing health systems

Session Table of Contents

1 Aims and objectives2 Planning your study3 Introduction4 ‘The view from above’ and ‘the view from below’: the clash5 Understanding ‘the view from below’6 How have health systems responded?7 Integrating activity8 Summary9 References

1 Aims and objectives

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Aims

This session goes back to the concept of health systems as social institutions, discussed earlier in the module. The session introduces the idea of how health systems are seen and experienced ‘from below’; that is, from the position of actors involved in health care encounters, service delivery and management. This perception is often very different from the intended health system design as planned at national (macro) level, ‘from the top’.

Through several practical exercises, the session will provide an opportunity to reflect on individual agency, power, and social relations among actors who make up a health system and their influence on provider and patient health care knowledge and practices.

Objectives


By the end of this session you should be able to:

Identify the limitations of a health systems model that focuses on discrete inputs and outputs as opposed to social relations within the system.

Understand how selected concepts drawn from social studies of medical systems can be used to elucidate a view of health systems from ‘below’.

Examine the tensions between global health imperatives and the realities of local health systems, and arrive at a more holistic understanding of the way health systems operate.

2 Planning your study

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In this session you should first work through the different screens and spend time on the various activities and exercises. You will also be required to read any essential reading, as indicated. This should take you about two hours.

You should then complete the integrating activity, referring to the essential reading. This should take you about three hours.

Finally, you should spend a further two hours on self-study covering the recommended reading and two or three texts from the further reading (optional).

3 Introduction

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Health systems as core social institutions

Conventional approaches to health systems and their performance tend to be fairly technical, focused on institutional inputs and outputs. Human resources for health are often described by their functional roles within the health system, a view that is oddly distanced from the actors who inhabit these roles.

These views are driven by a more normative and idealised understanding of how the system should be organised and managed, one that rarely takes into account the complexity of local social, cultural and political contexts within which health systems operate. This is partly because ‘culture’ poses such challenges for our own fundamental values about health, health-seeking, and health care delivery.

Culture is a difficult ‘variable’ to operationalise. Hence, most models of health systems are biased towards a formalised, well-resourced biomedical model of health care designed by policy-makers and planners at the national and district (macro) level. This is termed ‘the view from above’ (see Figure 9.1). Formal health systems are expected to function within a clearly defined regulatory framework. Users are expected to be less likely to experience barriers to access and to be less willing to accept inadequate access to care. At the same time, provider responses within this kind of idealised system are expected to be constrained by social norms backed up by legal sanctions.


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However, the reality of the implementation of health policies and interventions is complex and chaotic. The boundaries of health systems are by no means fixed, but fluid. Although we tend to think of a health system as the formal, publicly-funded channel of health care delivery, most health systems are pluralistic – many types of providers operate and private markets for medical goods and services have emerged in a largely unregulated manner. The boundaries between private and public health care are porous, and western biomedicine is but one tradition among many medical traditions, which deliver care in non-formalised settings. Bloom and Standing (2001) illustrate this well, showing how similar health system functions are fulfilled in the organised and unorganised health care economy, and that within the unorganised economy, there are marketised and non-marketised services (provided respectively by household members or unlicensed workers).

Yet, it is important also to remember that formal/informal, and traditional/non-traditional care boundaries are fluid (as will be discussed in Session 10). ‘Traditional’ birth attendants working within the framework of formal maternity care, rural medical practitioners trained in Ayurvedic medicine, and acupuncturists (in both high- and low-income settings) are often perceived by users and practitioners as part of the health system. This takes us back to the issues discussed in Session 1 [link], that health systems are social constructs with boundaries differing in each context. Having a comprehensive view of health systems is to go beyond what is captured by the formal ordered frameworks devised by health planners and decision-makers at the macro level.

In this session (and in the module as a whole), a health system is conceptualised as a ‘core social institution’ (Kruk and Friedman 2008). This implies a shift from a top-down and functionalist view of a health system to one from ‘below’, that is, understanding health systems from the perspectives of actors involved in health care encounters, service delivery and management (Figure 9.2).

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Figure 9.1 Health systems: the view from above

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‘The view from above’ is about health systems as planned and orderly entities designed and controlled by macro-level planners:


institutional environment: e.g. facility infrastructure, staff deployed, formal training programmes

functions and processes: regulation, clear functions of each type of facility, formal linkages, clearly distinguishable institutions, formal payments

knowledge: biomedical knowledge in specialised institutions, licensing, emphasis on evidence.

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Figure 9.2 The view from below

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‘The view from below’ is about health systems as shaped by the behaviour of the front-line participants in the care process (patients, communities, health professionals, facility managers, etc.):

institutional environment: e.g. facilities as perceived and accessed, staff retained and in place

functions and processes: regulation, unclear boundaries between institutions, informal linkages, informal payments, informal support structures

knowledge: biomedicine coexists by other traditions and customs (marketised or within families and communities),emphasis on trust and socially-generated knowledge.


4 ‘The view from above’ and ‘the view from below’: the clash

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Rhetoric and reality: understanding health systems as experienced by users

It is not sufficient to acknowledge the existence of these different realities. They are often in conflict, as planned policies and interventions fail to achieve their objectives, leading to the well-recognised discrepancy between rhetoric and reality.

As discussed in Session 1 [link], health systems are often designed with the aim of improving health and promoting fairness. The process of decision-making and system design to achieve these goals is often top-down. Thus a t national level, policy-makers typically decide on


health systems policies and design interventions to address key health problems. At district level, managers plan how the district health services will be financed and delivered, and by whom. Health systems in general are governed according to the laws of the country as postulated by legislative and statutory institutions.

However, it is increasingly recognised that these policies and interventions often fail to achieve their obj ectives, giving rise to a range of unintended consequences ( Adam and de Savigny 2012 ). Recent literature has focused on socioeconomic, political and ‘systemic’ constraints to achieving health systems goals. In this model, those who deliver services are often seen as mere implementers or conveyors of centrally (or regionally) designed policies. Users are seen as recipients of benefits who are provided with services that are designed by actors situated at macro or meso level.

[quote]

the fundamental issue of how health providers would respond to these reforms and the human resource interventions required to manage those responses was not considered. Each of the new reforms brought about changes to the motivational and incentive environment of health care workers – the predictable reaction of health professionals to these changes resulted in unintended, and sometimes perverse, effects for the reform process. McPake et al. 2006

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However, health-seeking and health care delivery are contingent not only on available resources, but on social, cultural and political considerations which in turn shape the needs and demands of local populations. It is frequently argued that if health systems are ‘core social institutions’ (Kruk and Friedman 2008), responsiveness, accountability, public participation in decision-making and user satisfaction should be key aims, beyond clinical and economic goals. Moreover, building in trust into a health systems and shared values among all participants in the care process are essential for achieving cooperation and a health system’s objectives (Gilson 2003).

A view of the health system ‘from below’ emphasises that the system is enabled and brought to life by human actors including patients, providers, administrators and managers (McPake et al. 2006) . This perspective recognises that actors on the ground and at the front line interact in dynamic ways and shape the ways in which institutional protocols, guidelines and codes of conduct are locally put into practice. Far too often, health systems interventions are introduced without recognising this crucial point: the controlled experimental settings in which particular interventions – for example, new diagnostic and treatment modalities – are tested rarely take into account the human factor.

A paper by Isaakidis et al. 2013 examines the challenges facing patients co-infected with HIV and multidrug-resistant tuberculosis. These include complexities in managing co-infection, financial access to a continuum of health services, and the importance of emotional support and responsive delivery even where basic services existed. Factors beyond the health systems – such as stigma, social disadvantage and a lack of family support – were critical


barriers to patient retention. Frontline providers were often aware of these issues, yet they had limited opportunities to provide holistic and responsive care.

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Activity

Consider a country you are familiar with and reflect on particular reforms that have been implemented within that setting.

Alternatively read the following case study:

Essential reading:Mathole T, Lindmark G and Ahlberg BM (2005). Dilemmas and paradoxes in providing and changing antenatal care: a study of nurses and midwives in rural Zimbabwe. Health Policy Plan 20(6): 385–393.

Reflect on situations where there has been a mismatch between the implementation of guidelines or policies as intended and the experience of front line providers and users on the ground.

Describe briefly the policy or intervention as intended, thinking about the different health system functions described in the module (financing, delivery, governance, etc.).

Describe the experience of users and front line providers in relation to the policy intervention above; consider ways in which the reality may not match the rhetoric.

Identify any mismatch between intended and unintended consequences. Reflect on the reasons for these mismatches:

Are there operational reasons, e.g. resulting from the way policies are designed and implemented? Think about patient experience as a family or community member

Who designed the policies and interventions and for whom? What are the values underpinning the policy process?

Post your reflections on Moodle to engage in discussion.

Question feedback:

Your response could have included some of the following points:

There are issues both at the design stage (e.g. policies are designed without taking account of the problems likely to be faced by users and providers). In countries at all income levels, there may be political tensions and interests influencing delivery of care, user outcomes and experience.

Health-seeking behaviour is complex: patients may choose to use or not to use services for reasons beyond the health system (e.g. give birth at home to fit in with societal expectations).


Providers and users have agency and can make a choice about how they act, which may contradict the official rules of how people are ‘meant to’ access services.

Institutions and organisations may not have all patient needs at heart but be focused on self-preservation (e.g. they may focus on health but not responsiveness and accountability).

Professional groups provide what they are trained to provide regardless of reforms.

Interaction with other actors (providers, communities) and culture will shape behavour in any social setting and a health system is one such setting.

5 Understanding ‘the view from below’

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‘Real-life’ health systems as experienced by users and front line providers

It is important to understand in what circumstances the clash between the rhetoric of health systems as formally designed and the reality of their participants occurs. For example some of these clashes are seen in:

first access to health systems/diagnostics navigating health systems (Balabanova et al. 2009) adherence to treatment perception of what is happening in reality and its effectiveness.

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Activity: Contrasting experiences of diabetes

Diabetes is a condition with many manifestations. The underlying problem is a failure to control the level of glucose in the blood. There are two main types, type 1, which usually begins in childhood and always requires insulin, and type 2, which typically occurs in adulthood and is associated with obesity. It sometimes requires insulin but may also be treated by dietary restrictions or hypoglycaemic drugs. Some people with diabetes manage to live essentially normal lives while others have numerous complications that can render them disabled or kill them prematurely.

As diabetes can affect many different parts of the body (eyes, heart, kidneys, nerves etc.) its management often requires inputs from a wide range of different professionals and specialists, making it a very complex disease.

From a patient perspective, entry to and navigation through the system is extremely complicated. Thus in Georgia ( Balabanova et al. 2007), newly-diagnosed patients initiating treatment face difficulties because of the restrictions on the provision of prescribe insulin. Following initial diagnosis at the primary health care facility (polyclinics), patients must undertake a series of steps and must wait from several weeks to a month before they actually


obtain insulin. During this period, they must buy insulin and related supplies themselves, and their treatment is often disrupted.

[quote]

When I was told for the first time that I had diabetes I was very scared and didn’t know what to do. The endocrinologist in the policlinic sent me to the hospital in Tbilisi where I stayed for three days. After that I returned to the policlinic with a prescription from the hospital doctor. The endocrinologist at the policlinic gave me a different prescription and said to go the insurance company in Tbilisi. At the insurance company I was given a document to show it at the pharmacy. It took me about three weeks before I obtained insulin. During this period I had to buy insulin myself. It was a problem for me because insulin is expensive in Georgia Source: Balabanova et al. 2007

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The following fictional vignettes illustrate some of the diverse pathways followed by individuals with diabetes. Read them before completing the activity.

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Vignette 1

John lives in an industrialised country and developed type 1 diabetes at the age of 5. Although he initially managed his condition well, when he reached adolescence he reacted against what he perceived as restrictions to his lifestyle. He frequently disregards his diet and his diabetes is often out of control. By his early 30s he had developed diabetic eye disease; at 35 he was blind in one eye and partially sighted in the other. His kidneys failed when he was 40 but he has since had a successful renal transplant. He now has extensive coronary artery disease although the presence of autonomic neuropathy means that he does not experience angina. He knows that his life expectancy is limited.

Vignette 2

Elizabeth lives in a rural part of a low-income country. She developed type 1 diabetes at the age of 9. She began to loose weight and slowly wasted away. After several months her family raised enough money to take her to a doctor in a nearby town, where her diabetes was diagnosed. However, her family could not afford insulin and she died 18 months after the onset of her disease.

Vignette 3

Peter lives in a middle-income country. His diabetes developed when he was 7. He is able to get insulin supplies from a government health centre, but often the supplies are interrupted. He cannot get a glucometer or test strips that would allow him to monitor his condition. Although he tries to stick to his diet, it is very difficult because the right types of food are often unavailable. When he was 30 he developed an ulcer on his foot although because his diabetes had damaged his nerves he did not at first feel it. There was no one who could


provide the specialist care he needed and shortly afterwards his leg was amputated above the knee. He is now unable to work and finds it increasingly difficult to manage his diabetes.

Vignette 4

Sarah lives in an industrialised country. She developed diabetes at the age of 6. She has always stuck to her diet and been careful with her insulin dosages. Despite having diabetes she leads an active life. She attends checkups regularly and is particularly careful to ensure that her eyes are checked every year. She has now reached the age of 55 and has had no complications of her diabetes.

Vignette 5

Michael lives in the capital city of a low-income country. He was a prosperous merchant and was considerably overweight. He developed type 2 diabetes aged 45. His doctor advised him that it could be treated by drugs and weight loss. He managed well until his business failed. He then found that he could no longer afford the drugs. He has now developed renal failure but has no prospect of treatment. He expects to live for only a few more months.

Vignette 6

Jane lived in a middle income country. She developed diabetes aged 10. Although she adhered to her diet and was careful with her insulin dosage, she found her diabetes very difficult to control as the advice given from different physicians conflicted. Often she was unsure who to consult and whether she was entitled to free health care. One evening she missed a planned meal, fell into a hypoglycaemic coma and died.

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In the vignettes presented above, what factors led to the positive and negative outcomes, in your view?

Discuss the role of the health system vis-à-vis other factors (socioeconomic, political, non-health system determinants of health, etc.).

Question feedback

The text and the vignettes demonstrate the critical importance of health systems to successfully managing diabetes.

The vignettes show how the multiple determinants of health interact, enabling or obstructing treatment, and reflecting factors such as national and personal wealth, resources, support to manage diabetes (e.g. supportive family) and power (e.g. affecting the knowledge and opportunity to demand timely treatment).

Diabetes exemplifies these challenges and provides an excellent lens through which to observe them. It is a condition where the diagnosis is clear, the patient pathway potentially very complex, the outcome of failed health care is easily measurable, and successful control depends on many different components of health and social systems working together.


Even in countries with moderate levels of resources, lack of integration between skills and specialities, and internal conflicts in health systems, can lead to treatment failure

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Theoretical approaches to understanding multiple realities: ethno-medicine

A volume of empirical papers has documented the barriers experienced by users in navigating health systems to a successful outcome: financial, geographical, knowledge-related, social status-related, among others. Based on these, there are efforts to provide a theory to understand the operation of health systems, accommodating the views of the different stakeholders involved.

Anthropology seeks to explore the tensions between how a health system and providers are ideally supposed to work, and seeks to interpret actual working practices in a given context. This approach is necessarily relativist – in other words, it adopts a premise that there are always multiple ways of understanding reality based on perspective, lived experience, local context and dynamics. This contrasts with a conventional rationalist perspective that suggests there is only one ‘objective’ way of looking at things (see Session 6, Developing the field of health system research, page 1 [link]). Two influential streams of thought shed light on this more human and actor-oriented perspective of a health system.

The ethnomedical approaches perceive health systems as cultural systems, focusing on the ideas through which providers and patients organise their perceptions and experiences of illness episodes and the interventions to control these events. Thus, individuals’ cultural knowledge and beliefs influence their cognition of illness events, and how they respond to these (de-Graft Aikins 2005). The focus is on local interpretations and ‘explanatory models’ of illness and risk in order to provide insight to people’s experiences (Murguía et al. 2003). The individual is conceptualised as a health-seeking agent, and the following questions are asked:

When is experience articulated as illness? How is illness classified (e.g. perceived symptomatology, etiology, severity, etc.)? What are the thresholds of care-seeking (when do individuals deem an illness

‘worthy’ of health seeking)? How, when and where do people seek care?

This model is commonly applied in the fields of health promotion and health education, in particular in ‘behaviour change’ models that try to examine and predict individuals’ health behaviours. Although behaviour change models have undergone variation over the years, they are heavily influenced by cognitive psychology, and rely on the idea of individual agency – in other words, what people do, as directly linked to what they think (i.e. cognition).

Among the limitations of the ethnomedical approach is that it is focused on individual intent and on cultural meanings and ideas – how they shape individual behaviour in illness episodes. Studies may decontextualise ‘health beliefs’ and ‘practices’, there may be an over-emphasis on individual psychology and rational action, and in the worst case scenario there may be a ‘victim-blaming stance’ that attributes poor or ‘risky’ health behaviours to individuals’ cultural pre- and misconceptions. The critique of ethnomedical models is that


they undervalue the role of social determinants and structural factors. Other actors, such as providers, and their influence on patient behaviour and care-seeking treatment, are less commonly studied.

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Reflection point

Examine the three models of health behaviour models drawn from the literature (below).

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Model 1

Figure 9.3a Theory of planned behaviour Source: Conner & Sparks 1995

Model 2

Figure 9.3b Kroeger’s model Source: Kroeger 1983

Model 3


Figure 9.3c Good’s model Source: Good 1983

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What are the determinants of health-seeking behaviour in each of these models? How have the models evolved (e.g. what new features are included in Figures 9.3b and 9.3c)?

In a setting you are familiar with, think what makes people seek care?

Question feedback

All three models give central prominence to the individual as a rational actor, although they give varying emphasis to factors deemed to influence individuals’ ability to seek health (or change health-related behaviours). The first model focuses on self-perceived efficacy or self-control as the major enabling determinant; the second brings in considerations of enabling resources, while the third examines pathways to care.

Significantly, the third model is the only one to bring in the role of ‘significant others’. There is acknowledgement that people do not make decisions by themselves. In most settings, people make decisions and take actions with regard to health-seeking as well as their engagement with a health system in conjunction with a set of people we would call the ‘therapy management group’. It is only in the last model that we see the idea of the individual, rational health-seeking agent challenged by the inclusion of the social network within which the individual is situated.

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Theoretical approaches to understanding multiple realities: political economy of health

The political economy approach or the model of a health system understands health systems to be social and political enterprises and focuses specifically on social relations of power that exist among actors. It moves away from the individual and emphasises the importance of political and economic forces (national and global), including the exercise of power, poverty, race, gender and class, all of which shape people's experience of illness as well as affecting their access to care and their experience of a health system (Degenhardt et al. 2010, Jorgensen 2013).


The approach focuses on health care systems and their functioning at different levels: individual, micro, intermediate and macro. The following questions are commonly asked:

Who controls/deploys biomedical knowledge and technology? How is power delegated within a health system? How is power expressed through social relations in a health system? What are the contradictions and arenas of struggle within biomedicine? Who controls

the dominant models of treatment?

The approach comprises work at four levels:

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Macro level [click to reveal hidden content]

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The ways in which health policies are framed. The unit of analysis is policy, or the system, or the institution as a whole. Each therapeutic mode, whether home-based or industrial, private or public, is consistent with the economic forces and the relations of production within the society. Studies include equivalents of policy analysis with a view to analysing, for example, political dominance and political agendas (e.g. donors’ agendas in planning, implementing and directing health systems in low-income settings).


Intermediate level [link – onclick reveal hidden content]

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Examining social relations among medical providers and within institutions. For example, a hospital is seen as a key arena of social relations and it is argued that hierarchies in the administration of a hospital, as well as in the provision of health care, reflect the kinds of hierarchies seen in society based on class, gender and race. Studies on the professionalisation of midwives or clinical officers in Tanzania demonstrate how professional and power relationships affect such hierarchies and subsequently social relations within health systems.


Micro-social level [link – on click reveal hidden content]

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The relationship between patient and provider and how it is mediated by social factors that are outside the examining room. Studies focus on how communication between patients and providers can be hampered, not only by the gap in terms of professional and lay knowledge but by other pervasive hierarchies including age, sex and class.



Individual level [link – on click reveal hidden content]

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The experience of illness is constrained by broader political and economic factors. For example, the so-called ‘lifestyle diseases’ (chronic fatigue syndrome, depression, alcoholism) are often medicalised and privatised in a clinical setting, rather than politicised or collectivised. These conditions often reflect broader social and structural inequalities.

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Among the limitations of this approach is that it focuses on social relations and power, specifically power and knowledge held by the providers. There is less scope to understand the behaviour of patients, and the subjective content of suffering as lived experience can be neglected. The underlying premise of a health system is not questioned.

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Understanding real-life health systems: the way forward

Table 9.1 summarises the key characteristics of the ethnomedical and political economy approaches and their interpretation of ’real life‘ health systems and their unintended outcomes.

Health system as...

Cultural system (ethnomedical approach)

Social/political system (Political economy approach)

Approach emerging from study of health and illness in non-Western settings

Focus on cultural meanings, ideas and how they shape individual behaviour in illness episodes

Emphasis on ‘patients’ Reification of ‘culture’ at the expense

of structural context

Approach emerging from study of Western medicine

Focus on social relations, access to power and knowledge at different levels of health system

Emphasis on ‘providers’ Subjective content of suffering as

lived experience neglected Underlying premises of medical

system not questioned

Table 9.1. Comparison of ethnomedical and political economy approaches in explaining outcomes

Both models assume that patients to be ‘recipients’ with very limited agency, power or knowledge. Their behaviour is shaped within a culture (the ethnomedical model) or within macro-level forces. There is little attention to how high culture or political economy


translates in a local context nor to how broader ideas and structures actually help people, how people adapt to them or how they resist them in practice.

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Understanding real-life health systems: the way forward (cont.)

How do we begin to account for the dynamism that we experience both as providers as well as patients within health systems, or within and across medical systems and sectors of a health system? An alternative approach encompasses the following dimensions.

The basis of authoritative knowledge

How and what do people know? How do patients and practitioners know what they know? Who owns or safeguards the knowledge? What kind and categories of information do they find persuasive? How do they know when a judgement is wrong or right? What do wrong and right mean to the different sectors that make up a health system? Essentially, health systems as knowledge economies, where there are multiple brokers owning information, and access to expert knowledge and expertise are embodied in both people and products, are embedded in multiple types of power relations ( Bloom et al. 2008) . Understanding medical conditions, as well as how to deal with them, is constantly evolving.

This approach recognises that providers and users have creative agency that allows, for example, a pharmacist in India to wield a certain amount of power over his or her clients, who at the same time are patients who are seeking a particular type of information. So the pharmacist becomes a crucial actor within the health system because of the very high percentage of people who may seek care from that person first before seeking any other form of care.

What people actually do (praxis)

In other words, how people translate ideas into action and behaviour. This area is becoming increasingly a focus for health systems research drawing on different disciplines – anthropology, sociology, psychology (Gilson 2012). People who navigate their way through a health system accumulate practical knowledge and learn ‘how to work the system’, i.e., how to talk to a practitioner successfully in order to get a successful treatment outcome and experience. These strategies will differ in different settings. Therefore, health systems are complex and adaptive, and actors within them demonstrate complex behaviour. There is a tension between the normative, evidence-based standards and the unique predicament of particular patients and providers.

McPake et al. (2006) suggest the need to examine the dynamic de facto responses of patients and providers which are informal and mediated through informal relationships and behaviours and which often lead to unintended consequences that impact on quality, affordability and availability of care (see Session 2 [link]). Analysing these may provide a clue to why health systems do not function as intended and how they can be improved. It has also been argued that the engagement of patients with a health system cannot be understood as a one-off event but rather as long-term engagement with services.

Social relations within a health system


This refers to the analysis of social relations not just in terms of power and hierarchy within health systems, but also in terms of the content of the relationship itself – for example, issues around trust, faith and conflict. What are the social relations within a system that shape and structure local discourses and praxis, beyond the individual actors? Bloom and Standing (2001) suggest that social arrangements for organising access to expert knowledge can be understood as social contracts between actors. This shifts the discourse away from individuals’ intent to groups and communities, perceiving individuals within groups and drawing on a social capital.

The concept of ‘symbolic capital’ means that patient behaviour will have a different meaning in different settings. As noted by Mogensen (2007) : some people are better than others and finding the right person to ask about where to go and presenting the sickness in the right time frame and presenting themselves respectfully. Gilson (2003) argues that the level of trust is fundamental determinant to how participants in the care process ‘comply’ with the health system arrangements and relate to each other.

The relationships of power in a clinic or any health care setting may be shaped by professional codes of conduct, by funding arrangements or by relationships between the network of organisations that comprise a health system, but they can be negotiated via informal processes. George (2009) examines how disciplinary and organisational measures taken by health care managers in relation to their health workers and primary health care systems, intended to reinforce accountability, are constantly negotiated and resisted.

Implications

The role of the three dimensions described above becomes really visible when introducing a new health system policy or intervention into an existing context. Introducing new ideas or new resources in a context where there is already a complex set of social relationships and structures may disable the intended mechanisms of change and lead to worse outcomes. Any health system evaluation seeking to establish how well a health intervention – specifically a systems intervention – has worked or will/will not work has to take account of the social organisation of implementation.

Back to Table of Contents

6 How have health systems responded?

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There have been a range of strategies and individual and collective solutions to reconcile the top-down with bottom up approaches. Some of these are illustrated below, with respective readings.

Read on two of these examples before proceeding with the Integrating activity.

Inclusion of ‘responsiveness’ as a principal health system goal alongside health attainment, in the World Health Report 2000 (WHO 2000)


Reference link:World Health Organization (2000). Chapter 2. How Well do Health Systems Perform ? In The World Health Report 2000. [online] Geneva: WHO. Available at:www.who.int/whr/2000/en/whr00_ch2_en.pdf (accessed November 2013)

Individual patient empowerment (‘exit’)

Reference link:Small N, Bower P, Chew-Graham CA, Whalley D & Protheroe J (2013). Patient empowerment in long-term conditions: development and preliminary testing of a new measure. BMC Health Serv Res. 13:263.

Promoting self-care in management of complex chronic disease, the ‘Expert Patients Programme’ in the UK

Reference link:Taylor D & Bury M (2007). Chronic illness, expert patients and care transition. Sociol Health Illn. 29(1): 27-45.

‘Personalisation’ of services as a means of increasing choice and empowerment (e.g. individual budgets)

Reference link:Needham C (2013). Personalized commissioning, public spaces: the limits of the market in English social care services. BMC Health Serv Res. 13 Suppl 1:S5. doi: 10.1186/1472-6963-13-S1-S5.

Collective patient empowerment (‘voice’): health facility boards as a means of increasing patient representation and community buy-in

Reference link:Goodman C, Opwora A, Kabare M, Molyneux S (2011). Health facility committees and facility management - exploring the nature and depth of their roles in Coast Province, Kenya. BMC Health Serv Res 11: 229

Shared decision-making: the role of patient advocates/champions to promote better treatment outcomes

Reference links:Schwartz L (2002). Is there an advocate in the house? The role of health care professionals in patient advocacy. J Med Ethics 28(1): 37-40.

Soo S, Berta W & Baker GR (2009). Role of champions in the implementation of patient safety practice change. Healthc Q 12 Spec No Patient: 123-8.

The key role of cultural acceptability in promoting uptake of effective services

Reference link:Payne CM, Debbink MP, Steele EA, Buck CT, Martin LA, Hassinger JA & Harris LH


(2013). Why women are dying from unsafe abortion: narratives of Ghanaian abortion providers. Afr J Reprod Health 17(2): 118-28.

7 Integrating activity

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Health systems from the viewpoint of the participants in the care process: an analytical exercise

Choose Option 1, suitable for countries at high income or Option 2, for middle-/low-income settings.

[tabs interaction – one option per tab]

Option 1: Collaboration and conflict in health care relations (high-income countries)

Maximising interprofessional collaboration in health care settings is deemed an important means to improve patient care and create satisfying work roles. However, collaboration is a complex process that requires intentional knowledge sharing across professional cadres that traditionally do not ‘share’ knowledge and joint responsibility for patient care where traditional roles may be quite rigidly defined. It may occur within long-term relationships that evolve over time between health professionals, however, it may also involve fleeting encounters in patient arenas where new networks of care, delegation, substitution and task-shifting are taking place.

An in-depth study was conducted on inter-professional collaboration in medical wards of a large UK teaching hospital. The data extract below illustrates a scenario of interprofessional communication on a UK teaching hospital ward.

Read the extract from interviews given below.

What is your initial reaction to these? Do you find any of this surprising in any way?

Identify two to three specific key themes relating to communication that run through the extracts. What common themes around collaboration and conflict in medical workplaces emerge in the two settings?

Click here to read the extract from the interviews [link – onclick reveal hidden content]

[hidden content]

Extract from interviews These data are drawn from a qualitative study that aimed to explore interprofessional collaboration on general medical wards in a large teaching hospital in England. The study used ethnographic methods, including individual and group interviews with health and social care staff (i.e. doctors, nurses, therapists, social workers) and participant observation of ward-based work. (see Reeves and Lewin 2005, Lewin and Reeves 2011)


Physiotherapist: Communications are really poor. Quite often it can end up we are seeing a patient everyday and it can go on for two weeks and it will suddenly say on the medical notes, cancel physio please and we think well, we have been seeing them everyday. Interviewer: Is that a common experience for people?Pharmacist1: Yes, yes.Interviewer: That sort of delay?Pharmacist2: Sometimes it is the next day unless we write it up and get them to come and initial it. That is not strictly speaking quick.Pharmacist1: Plus you write on the notes to point out that there is some drugs that the patients do continue taking - erm -you write on the notes – the next day you go back and have a look at the drug chart and it is not be added on – to the chart – even though you have written on the medical notes.Pharmacist2: Whereas if you were there on the wards you could just take the chart over and say would you mind writing this up and they could do it right then and there. Pharmacist3: … Also – you know – what to do if something – you know – if your advice isn’t taken and – you know – or if you can’t get hold of the doctor then you go to the medical notes and you document what, what your query is, or whatever. That is quite difficult because of implications – you know – it is a lot more formalised, there are a lot more things like, this is wrong. It just like increases the severity of something – that you saying this is it – a big problem to write it in the medical notes. Certainly Trusts I have worked for before, pharmacists very rarely wrote in the medical notes whereas it is quite run of the mill here to just communicate through the notes which is quite – you know we would have only ever written in the notes if it was something really, really serious, whereas now it is a lot more, sort of – you know – lots of people write in themInterviewer: That is just because you can’t get hold of them physically you have to do it like that?Pharmacist2: Yes.Pharmacist3: Or – you know – when we have put a note on the drug chart – they still are going to change it so therefore we have to note it on the notes just for our own safeguard. So to just have a record that we have actually advised something and they haven’t followed it up. Pharmacist1: Sometimes the [medical] plan not always fully documented on the notes, that is what’s needed to be done. So they [the nurses] will have to bleep after [the doctors] and ask them to come. Wasting time and hassling a house officer who is not very happy because they will be the first one… on the team… to answer all sorts of questions.*************Nurse 2: Half the time you have to read the notes to find out what the doctor has actually said on the rounds.Nurse 1: There is no communication. Doctors write in their notes expecting nurses to be psychic… they go off and tomorrow morning they come back and the patient in bed one has ‘nil by mouth’ for some tests, nobody knows anything about it.Nurse 2: Most of the time we cannot find enough time to read the notes and look through…[so] we are just obliged, forced to chase them because we don’t know what is happening and it is unfair to the patient because the treatment has been delayed and everything has been delayed so.Nurse 3: Quite often you will go to meetings and you will inform house officers of what is happening and they will like – yes, yes, we fully understand, and they understand but when then pass the information on – you know – the regular consultant is coming round to discharge them and they are trying to pass information on and it is second hand, it is not being listened to and the person gets discharged and that’s – it is just second hand information, and if they are not on that ward, or if that house officer is not on that ward round


at that time, then that information is being missed, so – but you can also understand their pressure as well because they have got everything else to do and why should all of them have to attend meetings.***********Therapist: A lot of it goes sort of second hand through the nurses and it was recognised that was quite dangerous really in the sense that having messages passed back and forth because they were the people there all the time. Just silly things like not having enough bleeps so not everyone can have a bleep. Interviewer: Right… so you seem to be saying that the communication with the medical teams might be happening through the nursing staff rather than perhaps directly with other members of the multidisciplinary team.Therapist: Yes… I mean we do bleep and communicate with them as well but a lot of it does happen, sort of third hand, through the nursing staff (LG)***********Doctor1: Because there are loads of things the nurses could tell us and do tell us, but we often get it very piecemeal because the sister has told somebody who is on her break and we have left the ward, and then - then there is a bleep and then can’t go home today – you know – practical issues. There must be a better wayInterviewer: And I see you are saying that collaboration is happening both formally through multi-disciplinary team meetings and informally in the corridor.Doctor 1: Yes we bleep each other and L bleeps us when she wants to ask something, so on the way round – it works very well actually.Doctor 2: Really collaboration is mainly done by L, we feed back to her and then she feeds onto others. Vice versa they feed back to her and she passes it on to us with the care co-ordinator in the middle kind of – the collaboration is very good.Interviewer: So she kind of acts as a routing between nurses and so on?Doctor 2: Yes, yes. Interviewer: What about the other professional groups? What about the physios, O.T.’s and so on that you work with?Doctor 3: I think probably we have even less direct contact with physios and O.T.’s. The physios, you don’t see that often. They often aren’t on the wards when you are going round and probably they have more direct contact with the house officers who are on the wards more than we are.Doctor 2: A lot of the referrals to the physios and O.T’s go through the nursing staff and through care co-ordinators and so we don’t actually as registrars spend that much time directly communicating with them.Doctor 1: Our main contact with them is at the MDT meeting or if they approach you or you - or you happen to see them on the ward. Otherwise the way that I have done it is to say to either the care co-ordinator or the house officers or the nursing staff – they will communicate the message, because they often don’t carry a bleep, the physios and the O.T.’s so we can’t get in contact with them if they are not there. I think that – it is slightly less important for us to have a direct face-to-face contact unless you really have a specific issue to discuss. It tends to be – it is more important that you have a direct contact with the nursing staff. *************Interviewer: How you see your collaboration, is it good – indifferent - are there issues around that?Registrar: It is very important and it is very patchy at this stage I think. It is not bad but it is patchy, very patchy, but –Interviewer: In what sense?


Registrar: It’s – I mean you rarely get a chance to speak directly to them – you usually write in the notes and you take it from there. I prefer it when you can sit down and talk about things but there is no time for that. But it is not bad, it is happening but – you know – in the sort of paper level.Interviewer: So you are saying that most of the communications happens through your notes rather than face to face discussions?Registrar: Yes, yes but it is happening to a certain degree.Interviewer: And what would you say are the limitations on those face to face discussions? Is it because you have a lot of other commitments and can’t spend time on the wards?Registrar: Yes, exactly, yes. You have got a lot of patients lying around different wards and you have to chase up and different – er you are probably covering different wards and really you can never see the physio on each and every ward so it is difficult.


Read the following and then re-read the extract.

Essential reading:Lingard L, Espin S, Evans C and Hawryluck, L (2004). The rules of the game: interprofessional collaboration on the intensive care unit team. Critical Care, R403–408.

Bailey P, Jones L and Way D (2006). Family physician/nurse practitioner: stories of collaboration. Journal of Advanced Nursing, 53(4), 381–391.

Reeves S and Lewin S (2005). Interprofessional collaboration in the hospital: strategies and meanings. Journal of Health Services Research & Policy, 9(4), 218–225.

Lewin S and Reeves S (2011). Enacting ‘team’ and ‘teamwork’: using Goffman’s theory of impression management to illuminate interprofessional practice on hospital wards. Social Science and Medicine, 72(10), 1595–1602.

How do these themes relate to wider issues structuring social relations of health care discussed in the readings which may include:

knowledge economies (ownership and control of ‘expert’ knowledge/skills) ‘time’ and ‘space’ in health units formal and informal strategies of providing care (Fitzgerald) trust versus risk/uncertainty.

From what you read (abstracts and paper) what are the implications for achieving the core health system goals such as improved health, responsiveness, fairness and efficiency (discussed throughout the module)? Think about how the emerging themes relate to each goal.

Discuss the challenges as well as opportunities from the point of view of the different stakeholders: planners, managers, patients, providers.



Option 2: Local health providers and praxis – knowing how to ‘work the system’. Negotiating Autonomy and Accountability among Health Care Providers (middle/low income countries)

Accountability is seen as an essential element in improving health systems performance. However, forms of accountability may differ according to types (administrative, financial, political, social) and directions (horizontal, downwards, upwards) of accountability relations. These, in turn, imply specific configurations of power relationships and particular roles for different actors. In practice, different forms of accountability co-exist, and sometimes conflict with goals of professional autonomy, collaboration, and trust among actors who make up the health system.

To understand how HIV is being managed in the private medical sector, and to discuss the strengths and limitations of regulating health care working relations through formal accountability mechanisms, an NGO in Pune, India carried out a series of interviews with private practitioners (doctors, pharmacists, laboratory managers) during 2004–2005, just before the country began launching the free access to anti-retroviral therapy (ART) in selected high-prevalence states. The extract illustrates the treatment strategy employed by a private practitioner’s in managing HIV-patients. Dr. ND is a pediatrician (MBBS) with 22 years of practice.

Read the extract from an interview given below.

What is your initial reaction to it? Do you find it surprising in any way?

What are the key themes/factors influencing this providers’ course of action in the case of the patient described?

What are the key health system relationships referred to in this case narrative? How would you describe their nature and content?

What key issues emerge that highlight accountability mechanisms? What are the ways in which they reflect key dimensions of social and political relations related to HIV care in India?

Click here to reveal the extract [link – on click reveal hidden content]

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Extract from interviews Interviewer (DD): Could you tell us about a case you’ve seen in the last 3-4 months… ND: [big pause]… One I recently investigated. He had come for weight loss, fever. He came for severe weight loss and loose motions. After giving him routine treatment he did not find any change. He continued to have fever so I told him that your fever is not going down. Let us do all the 'investigations.' He turned out to be positive. ELISA +ve. Once it becomes positive, I usually do not give further treatment. I usually refer. Because in our 'time limit' it is not possible for us to tell everything to the patient in 'detail' and answer all their questions. So 'usually I refer them to 'consultant' which means I do not 'treat' HIV patients myself. (…) Then later they come back to me if they have any problems like loose motions. I treat them for small 'ailments' but 'overall' I do not give the 'anti retroviral treatment'. These days I feel


that I should give but (laughs) so far I have not started because the cost has reduced only in the last 2,3,4 months. Until last year the cost was about Rs.40000 to 50000. In this area there are very few who can afford to spend that kind of money or those who will spend that much of money and will take that medicines 'continuously' for 5-10 years (…) now that the treatment is more within reach I have started feeling that should I start the treatment. That is what I feel. Let us see… But so far I have not started any 'treatment'. DD: what was the age of the patient? ND: his age… 25-26 years. DD: what was his occupation? ND: They are ‘Ghisadi’. Ghisadi means those who make instruments from iron or by 'welding'. But he himself was doing 'service' at some 'medical shop.' He himself was not doing his traditional job. At the moment he is not doing any work. DD: is he married? ND: he is married. His wife is also 'positive'. DD: did you asked him to get his wife tested? ND: I tested him here at my clinic. Then I referred him to a 'consultant'. Then he (the consultant) tested his wife. DD: and what did you tell him before testing him? ND: I told him that you are getting 'fever' continuously. In such a case it could be HIV. We are doing all the tests. Only this test will remain so let us do this test also. If it is negative then it is good. But if it is positive then you can be given 'treatment'. Otherwise we will spend money on all other investigations and you might be positive. DD: What was this patient's reaction when you told him that let us do this HIV test? ND: This patient’s response?…nothing. He said let’s do it. Previously 'actually' I had done his test. At that time he had come negative. Long back……. at that time I had suspected similarly because there was 'weight loss'. At that time also I had tested him. That was many years ago. So I said let us do it again. And then it came positive. Nothing … 'he accepted'. He is not that (laughs making gesture with his hand) 'intelligent'. He is a little dense (badhir). DD: but then it must be different for you as a doctor to handle such patients. Then how did you tell the patient that he is positive and what needs to be done in future? ND: no, 'usually'… when the patient is diagnosed as positive I tell him that there is a fault in your blood it is little bad (kharab) then I tell someone some elder in the family… either an elder brother or someone from the family that he is positive. DD: even in the case of this patient? ND: yes, then later 'over a period of time' they come to know then after they come later sometime I tell them gradually I do not give them a 'blow' at one time. I tell them gradually. At first I tell them that there is a fault in the blood, you blood is bad, then I tell some responsible person either the elder brother and then I tell the patient. DD: but did this patient come alone or did someone accompany him? ND: sometimes they come alone sometimes someone from the family accompanies them. DD: and in case of this patient? ND: [interrupted] no, I told the elder brother of the patient because he was not that (intelligent) so I told his brother. But many a times I also tell the patient if I find that he is a little 'intelligent' that this is the situation because I have to tell him about precautions that he needs to take with regard to his 'wife'. That is why I also tell patients. 'It depends on … the patient' DD: and what precautions did you ask this patient to take? ND: one thing was… I told him to keep a 'regular follow up'. Take the medicines; prescribed by the doctor I refer you to, 'regularly'. Secondly… have 'protected sex' with your wife and


'he has no issue' so there are no problems with regard to children. Hence 'protected sex' and now 'anti retroviral' have been started. DD: where did you refer him? ND: Vinay Kulkarni, he is my 'classmate'. I send all my patients to him and some to Sanjay Pujari. 'It depends' if the patients are from that side then I send to Dr. Pujari and here… most of my patients are send to Dr. Kulkarni 'he is my close friend' now that we know each other for 25 years… I send to him. DD: before you referred him to that Dr. did you tell him anything as to why you were sending him there? ND: yes… I tell them. I do tell them. I tell most of them. Only when it is not possible I tell them that there is a fault in your blood that doctor is an expert in that field. Go and see him. There he does 'counseling' he has everything. And then starts 'treatment' or then he sends the patient back to me with a note that I have started this treatment. Then they keep coming back to me for other 'aliments' like loose motion, cough etc. then I give them 'symptomatic treatment' but so far I have not given any 'anti retroviral' treatment'. DD: this patient had fever and weight loss initially (ND: yes) can you tell us about the diseases progression after weight loss? What other problems did he have? ND: no, 'usually' what happens is that when these people come to me in the very 'early stage' they have only one complaint… only 'stomatitis, or continuous mouth ulcers' or only cold. They come with such complaints. Then that continue for many days. After that 'recurrent cough' starts, then 'usually' they develop Koch (TB). They start taking anti-Koch and they realize that they may have HIV. Then after that the 'anti Koch treatment' continues and then sometimes he comes down with 'herpes zoster' or 'candidial infection'. In between some days are ok…and then again he starts getting 'recurrent cough, fever, loose motions'. This continues after 7-8 years … DD: in case of this patient what are the other infections that you see? ND: Not much now… 'he is in a quiet phase'. At present, he is taking only 'anti Koch', other than that he does not have any 'immediate problem'. The patient that I just spoke of (DD: yes) he is only on 'Anti Koch' and 'Anti retroviral drugs…2 drugs Lamuruvidine plus something else. Those two drugs and Anti Koch. 'At present he is ok'. DD: Ok, and do you give him Anti Koch treatment? ND: No, I don't give. I give other patients but in the case of this patient he was taking 'Anti Koch' and the other treatment from the doctor I referred him to. Now if they say that it is not possible for us to take the (ARV) then there is no use of doing the 'viral load' or 'CD4' otherwise if they say that we don't have that much of money then we start with only the Anti Koch treatment and tell them that once you have arranged for the money, tell us. Then I refer them there (to consultant) because then all these things have to be done. And in the end you cannot decide when to take 'Anti retroviral treatment' unless you do the 'CD4count' and 'viral load'. Then we give these patients whatever treatment is necessary and tell them to have 'protected sex' and we give them whatever 'routine' treatment needs to be given. Later if they are able to arrange for the money and they 'develop' something we 'refer' them because even viral load and CD4 count costs about Rs. 2- 2500/- DD: Is he taking anti Koch treatment from Dr. Vinay Kulkarni? ND: Yes, many a times. Sometimes I also give Anti-Koch… to so many patients… but I don't give 'Anti retrovirals'. DD: You have told the elder brother (ND: in this case, yes) so how is the response of the family towards the patient? ND: …[pause]…family response means his wife is illiterate. That is why she doesn't understand much of this. He himself is not that…only one of his elder brothers is comparatively intelligent. I told him. Parents are insensible (badhir). They don't have


anything against him. 'At least' in front of me they show that they are not very…only that brother is quite ok. He also drives 'rickshaw'. But he takes care of the medicines etc. DD: means in the family…any…? ND: No. Not yet. So far the 'family is intact'. Everyone is looking after him. So at least as of now it is a joint family. So far they have not throw him or his wife out of the house. So far, 'they are staying together'. In our situation it rarely happens that…only those who are chronic and 'alcoholic' are probably thrown out of home. But in case of 'most of the patients' their parents look after them…it's a good thing.


Read the following readings and then re-read the extract.

Essential readingFochsen G, Deshpande K, Ringsberg K and Thorson A (2009). Conflicting accountabilities: doctor’s dilemma in TB control in rural India. Health Policy 89 : 160–167. George A (2009). ‘By papers and pens, you can only do so much’: views about accountability and human resource management from Indian government health administrators and workers. International Journal of Health Planning and Management , 24, 205–224. De Costa A, Johansson E and Diwan VK (2008). Barriers of mistrust: public and private health sectors’ perceptions of each other in Madhya Pradesh, India. Qualitative Health Research , 18 (6), 756–766.

How do these themes relate to wider issues structuring social relations of health care discussed in the readings which may include:

knowledge economies (ownership and control of ‘expert’ knowledge/skills) theory versus ‘praxis’ of health care systems ‘time’ and ‘space’ in health units formal and informal strategies of providing care trust versus risk/uncertainty accountability channels.

From what you read (abstracts and paper) what are the implications for achieving the core health system goals such as improved health, responsiveness, fairness and accountability (discussed throughout the module)? Think about how the emerging themes relate to each goal.

Discuss the challenges as well as opportunities from the point of view of the different stakeholders: planners, managers, patients, providers.


8 Summary

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Much of the current debate is driven by a normative view of health systems as clearly organised institutions owning technical knowledge and expertise, effectively raising and


managing resources and providing services to improve health outcomes that are beneficial to all. This is how health systems are designed and viewed from ‘from above’.

However, this paradigm often differs from the way health systems are experienced by front-line participants in the care process, and viewed ‘from below’. Health systems are core social institutions involving multifaceted social relationships between actors. They are situated within complex social, cultural and political contexts, and actor behaviour is influenced by culture, customs and beliefs.

Explanations for these multiple realities are provided by the ethnomedical approach which is concerned with individuals and their practical knowledge, and by the political economy approach which emphasises the importance of political and economic forces (power, poverty, race, gender) shaping people’s experience of a health system. Other approaches recognise the significant agency that health systems actors have within the local context of health services and communities. Health systems can be seen as knowledge economies embedded in power relations, where there are many ways (formal and informal) to access expert knowledge and obtain care. Users can thus become skilled at learning ‘how to work the system’.

There are often tensions between these two perspectives. Macro-level health imperatives often do not reflect the realities of health systems actors. Reforms and policy implementation may fail to achieve their envisaged outcomes due to unintended consequences. These arise first, as a result of front line interactions among actors and the way they adapt formal rules, and second, the failure to take account of social, cultural and political factors influencing actor behaviour. Achieving effective and responsive health systems requires reconciling these two views, and a holistic understanding of how health systems operate in reality. It is important to understand different actors’ strategies, when designing health systems interventions.

Recognising that health systems are social institutions entails that they are not there just to produce health, but they are expected to be responsive, accountable, and empower the participants in the care process. Thus, building trust and shared values among all actors can be essential for meeting health systems’ objectives.

Back to Table of Contents

9 References

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Essential reading (session)

George A (2009). â˜By papers and pens, you can only do so muchâ� ™� : views about accountability and human resource management from Indian government health administrators and workers. Int J Health Plann Manage 24: 205-224.

Gilson L (2003) Trust and the development of health care as a social institution. Social Science and Medicine 56(7): 1453-1468.

Fochsen G, Deshpande K, Ringsberg K & Thorson A (2009). Conflicting accountabilities:


doctorâ™s dilemma in TB control in rural India. � Health Policy 89, 160â“167. �

Lewin S & Green J (2009). Ritual and the organization of care in primary care clinics in Cape Town, South Africa. Social Science & Medicine 68: 1464â“1471. �

Essential reading (activities)

Bailey P, Jones L and Way D (2006). Family physician/nurse practitioner: stories of collaboration. Journal of Advanced Nursing, 53(4), 381â“391.�

Lewin S and Reeves S (2011). Enacting â˜teamâ� ™� and â˜� teamworkâ™� : using Goffmanâ™s �theory of impression management to illuminate interprofessional practice on hospital wards. Social Science and Medicine, 72(10), 1595â“1602. �

Lingard L, Espin S, Evans C and Hawryluck, L (2004). The rules of the game: interprofessional collaboration on the intensive care unit team. Critical Care, R403â“408. �

Mathole T, Lindmark G and Ahlberg BM (2005). Dilemmas and paradoxes in providing and changing antenatal care: a study of nurses and midwives in rural Zimbabwe. Health Policy Plan 20(6): 385â“393.�

Reeves S and Lewin S (2005). Interprofessional collaboration in the hospital: strategies and meanings. Journal of Health Services Research & Policy, 9(4), 218â“225.�

Any two of the following:

Goodman C, Opwora A, Kabare M, Molyneux S (2011). Health facility committees and facility management - exploring the nature and depth of their roles in Coast Province, Kenya. BMC Health Serv Res 11: 229

Needham C (2013). Personalized commissioning, public spaces: the limits of the market in English social care services. BMC Health Serv Res. 13 Suppl 1:S5. doi: 10.1186/1472-6963-13-S1-S5.

Payne CM, Debbink MP, Steele EA, Buck CT, Martin LA, Hassinger JA & Harris LH (2013). Why women are dying from unsafe abortion: narratives of Ghanaian abortion providers. Afr J Reprod Health 17(2): 118-28.

Schwartz L (2002). Is there an advocate in the house? The role of health care professionals in patient advocacy. J Med Ethics 28(1): 37-40.

Small N, Bower P, Chew-Graham CA, Whalley D & Protheroe J (2013). Patient empowerment in long-term conditions: development and preliminary testing of a new measure. BMC Health Serv Res. 13:263.

Soo S, Berta W & Baker GR (2009). Role of champions in the implementation of patient safety practice change. Healthc Q 12 Spec No Patient: 123-8.

Taylor D & Bury M (2007). Chronic illness, expert patients and care transition. Sociol Health Illn. 29(1): 27-45.


World Health Organization (2000). Chapter 2. How Well do Health Systems Perform ? In The World Health Report 2000. [online] Geneva: WHO. Available at:www.who.int/whr/2000/en/whr00_ch2_en.pdf (accessed November 2013)

Recommended reading

The Recommended reading includes materials to draw upon when undertaking your assignment or in self study, according to your interests (this may be 2-3 readings typically).

Atkinson S, Medeiros RLR, Oliveira PHL & de Almeida RD (2000). Going down to the local: incorporating social organization and political culture into assessments of decentralized health care. Social Science & Medicine 51: 619-636.

Kielmann K, Deshmukh D, Deshpande S et al. (2005). Managing uncertainty around HIV/AIDS in an urban setting: private medical providers and their patients in Pune, India. Social Science and Medicine 61(7): 1540-1550

Lewin S & Reeves S (2011). Enacting ‘team’ and ‘teamwork’: using Goffman’s theory of impression management to illuminate interprofessional practice on hospital wards. Social Science and Medicine 72(10): 1595–1602.

Mogensen, HO (2007) Finding a path through the health unit: practical experience of Ugandan patients. Medical Anthropology 26(1): 7-52.

Sheikh K & Porter JD (2011). Disempowered doctors? A relational view of public health policy implementation in urban India. Health Policy Plan 26(1): 83-92.

Standing H & Chowdury AMR (2008). Producing effective knowledge agents in a pluralistic environment: What future for community health workers? Social Science Medicine 66: 2096-2107.

Cited references and sources

Adam T & de Savigny D (2012). Systems thinking for strengthening health systems in LMICs: need for a paradigm shift. Health Policy Plan 27(Suppl. 4): iv1–iv3.

Bailey P, Jones L & Way D (2006). Family physician/nurse practitioner: stories of collaboration. Journal of Advanced Nursing 53(4): 381–391.

Balabanova D, McKee M, Koroleva N, Chikovani I, Goguadze K, Kobaladze T, Adeyi O & Robles S (2009). Navigating the health system: diabetes care in Georgia. Health Policy Plan 24: 46–54.

Balabanova D, McKee M & Koroleva N (2007). Georgia: diabetes and systemic constraints. Appendix 3: challenges of design and implementation. In Adeyi O, Smith O & Robles S eds. (2007). Public Policy and the Challenge of Chronic Noncommunicable Diseases. Washington, DC: World Bank Publications.


Bloom G & Standing H (2001). Pluralism and Marketisation in The Health Sector: Meeting Health Needs in Contexts of Social Change in Low- and Middle-Income Countries. IDS Working Paper No. 136. Brighton: Institute of Development Studies.

Bloom G, Standing H & Lloyd R (2008). Markets, information asymmetry and health care: towards new social contracts. Soc Sci Med 66 (10): 2076-87.

De Costa A, Johansson E & Diwan VK (2008). Barriers of mistrust: public and private health sectors’ perceptions of each other in Madhya Pradesh, India. Qualitative Health Research, 18(6): 756–766.

Degenhardt L, Mathers B, Vickerman P, Rhodes T, Latkin C & Hickman M (2010). Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed. Lancet 376(9737): 285-301.

de-Graft Aikins A (2005). Healer shopping in Africa : new evidence from rural-urban qualitative study of Ghanaian diabetes experiences . BMJ 331(7519):737.

Fochsen G, Deshpande K, Ringsberg K & Thorson A (2009). Conflicting accountabilities: doctor’s dilemma in TB control in rural India. Health Policy 89: 160–167.

George A (2009). ‘By papers and pens, you can only do so much’: views about accountability and human resource management from Indian government health administrators and workers. International Journal of Health Planning and Management 24: 205–224.

Gilson L (2003). Trust and the development of health care as a social institution. Social Science & Medicine 56(7): 1453–1468.

Gilson L (ed.) (2012). Health Policy and Systems Research: A Methodology Reader [online] Geneva: WHO. Available at: www.who.int/alliance-hpsr/resources/alliancehpsr_reader.pdf (accessed October 2013)

Isaakidis P, Rangan S, Pradhan A, Ladomirska J, Reid T & Kielmann K (2013). 'I cry every day': experiences of patients co-infected with HIV and multidrug-resistant tuberculosis. Trop Med Int Health 18(9): 1128-33.

Jorgensen PD (2013). Pharmaceuticals, political money, and public policy: a theoretical and empirical agenda. J Law Med Ethics 41 (3): 561-70.

Kruk ME & Freedman LP (2008). Assessing health system performance in developing countries: a review of the literature. Health Policy 85: 263–276.

Lewin S & Reeves S (2011). Enacting ‘team’ and ‘teamwork’: using Goffman’s theory of impression management to illuminate interprofessional practice on hospital wards. Social Science and Medicine 72(10): 1595–1602.

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