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Inaugural KEYSTONE Course on Health Policy and Systems Research 2015

Health Systems Ethnography

Ethnography Health Systems

Ethnographic approach

• Is well suited to bring in to the open a social and political perspective to the study of politics and practices of diverse health systems

• But, has largely stayed of the radar of Public health research community – considered not rigorous enough to inform public policy and practice

• Ethnographic work is mainly published in specialist disciplinary journals

Classical ethnographies• Quite rare in applied health research – constraints on time

and practical feasibility & do not resonate with most health related study design (positivist)

• ‘traditional’ ethnography – medical anthropologists and sociologists do offer important insights for understanding HPS

• Those that have followed the life, or lives, of individuals and groups affected by a particular health condition – have developed our understanding of how and why people are enabled/hindered in their efforts to make effective use of services & manage their conditions (especial in chronic health illness)

– Example: ethnographic work that has examined how people living with a condition draw on a collective ‘biosocial’ identity to formulate claims to treatment, compensation, and other social resources. In relation to HIV, some have argued that this form of ‘therapeutic citizenship’ has directly affected policies around access to treatment and delivery of care (Nguyen, 2008)

• Ethnographies have explicitly focused on practitioners and their professional socialisation within health systems – these provide an insight into the feasibility of health system interventions that assume or introduce shifts in professional hierarchies or working arrangements. – One area of focus is to examine how working environments & dynamics shape

provider identities and inter-professional collaboration– Complex working relationships between nurses and clinicians (Fitzgerald,

2008)– Working ‘cultures’ of less visible cadres of health staff, such as ‘peons’ (Justice,

1986)

• Ethnographies that have focused on organizations – they aim to examine how work activities shape and maintain the institution, analyses of ideological procedures that make these processes accountable.

• They also explore how these work practices are intricately connected to other social processes.

• Allows for a nuanced analysis of organizational culture and dynamics, a means of identifying for example: How “… the organization’s formal structure (rules and decision making hierarchies) are influenced by an informal system created by individuals or groups within organizations (Savage, 2000:1402)– Examples include: hospital ethnographies, project ethnographies that

examine contexts within which policies are formulated at a national & international level play out in the context of local institutional codes of practice

• Ethnographies have also focused on controversies and debates – mainly to bring to light the tensions between rhetoric and practice in health system relationships– Taylor (1977) – was one of the first to undertake an ethnography of a

health system – he used a controversy over resource allocation in a Scottish archipelago to make visible ways in which – different groups in the system formulate and pursue their interests both within and outside of the formal structure of the local health care system

• But there are very few extensive ethnographies of biomedical practice and health systems in LMIC settings. – Khare, (1996) – realm of ‘traditional healing’ as opposed to everyday ‘practised

medicine’– Allen (2002) – Historical and structural bases of Western medical policies and

systems and health care organizations in LMIC settings can be gleaned from ethnographies of colonial medical systems

– Judith Justice (1986)- ethnography on international health bureaucracy in Nepal examined the context of policy making and implementation of the integrated community health program

Politics and practices of global health

• One of the areas where there has been rich work – Kleinman, Das, Nichter, Farmer among others

• Agenda setting (at least around debates)• Interactions and effects of global health policies/programmes

with weak health systems – shaping access and ill health experiences

• local consequences of structural adjustment programmes – push for privatization of care and its consequences

• Health systems role in reproducing ‘structural violence’ (how social arrangements put people and populations in harm’s way)

Why ethnographies of HPS?• The ethnographic approach offers a unique research space

to better understand context (political, social, institutional, historical) of health policies and policy formulation; and how these policies are translated and come alive in health systems.

• This approach lends itself well for a nuanced analysis of the relationships between power, knowledge and practice in health systems.

• A bouquet of characteristics’ (humanistic, holistic, interpretive, iterative and reflexive) and types of ethnographies’ (total, single sited, multiple sited, institutional, classical etc.) can be mined to use this approach towards understanding of health systems.

Mainly drawn from

• Gilson L, ed. (2012). Health Policy and Systems Research: A methodology reader (empirical paper 4 by Karina Kielmann)

• James Pfeiffer and Mark Nichter for the Critical Medical Anthropology for Global Health Special Interest Group. What can critical medical anthropology contribute to global health: a health systems perspective. Medical Anthropology Quarterly 22(4): 410–415, 2008.

• Politics and practices of global health: critical ethnographies of health systems in context. Storeng, K. T. & Mishra, A. Global Public Health, 2014;

References• Allen DR (2002). Managing motherhood, managing risk: fertility and danger in West Central

Tanzania. Ann Arbor, University of Michigan Press. • Fitzgerald R (2008). Rural Nurse Specialists: Clinical Practice and the Politics of Care. Medical

Anthropology: Cross-Cultural Studies in Health and Illness, 27(3):257– 282. • Justice J (1986). Policies, plans, and people: culture and health development in Nepal. Berkeley,

University of California Press. • Khare RS (1996). Dava, Daktar, and Dua: anthropology of practiced medicine in India. Social

Science & Medicine 43(5):837–848. • Kielmann , K. Empirical paper 4 in Health Policy and Systems Research: A methodology reader

(ed) Gilson L, (2012)• Nguyen V-K (2008). Antiretroviral Globalism, Biopolitics, and Therapeutic Citizenship. In: Ong A,

Collier SJ, eds. Global assemblages: technology, governmentality, ethics. Oxford, Blackwell Publishing.

• Pfeiffer, J., & Nichter, M. (2008). What can critical medical anthropology contribute to global health?. Medical anthropology quarterly, 22(4), 410-415.

• Savage J (2000). Ethnography and health care. British Medical Journal, 321(7273):1400–1402. • Storeng, K. T., & Mishra, A. (2014). Politics and practices of global health: Critical ethnographies

of health systems. Global public health, 9(8), 858-864.• Taylor R (1977). The local health system: An ethnography of interest-groups and decision-

making. Social Science & Medicine, 11(11-13):583–592.

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