Power as a ‘fuzzword”: We agree that applying theories of power can be critical to understanding health policymaking and implementation, as well as the social determinants of health and population health status. However, we are concerned by references to power as a general, catch all concept that is not easily mutable.  Power as a ‘fuzzword’ may not advance knowledge or promote change, whereas thorough applications of power as a lens may help us to identify the drivers of global health injustices ranging from health disparities to implementation failure. Moreover, we are anxious to move beyond explication of power dynamics to identify actionable strategies and tools that provide avenues for change. Are there particular ways of looking at power that make this easier?

Not enough reflexivity: Some in this group expressed discomfort with researchers assessing power as an external phenomenon that affected communities in other places, but not our own work. Researcher reflexivity is one approach to naming, acknowledging and addressing/accounting for certain types of power. However, just as we may uncritically engage power as a macro concept, we may insist rhetorically on the importance of reflexivity but fail to put it into practice in a robust way.  The dynamic of the outside researcher who fails to see his/her role in the political economy of health research can be more acute in the context of the neocolonial past (and present) of global health. Northern or otherwise elite voices are often louder, and while those with louder voices may advocate for more diversity and inclusion in global health, some might be unwilling to question or concede their own privilege and prestige. Key institutions can also neglect or muzzle honest engagement with both inter- and intra-organisational power dynamics.  UNAIDS, for example, was positively appraised for its gender-related policies, but it took an outside review to identify the extent and impact of patriarchal culture that existed within the organization despite these policies.

How does power shape ‘what’s in’ in global health? Lack of reflexivity influences our own research and global health agendas.  The dynamics researchers ignore are likely to be similarly absent from the agendas of national and global policy makers. This in turn undermines our ability to understand and address the very power dynamics shaping health disparities. Of course, there is ample rigorous, empathetic, community driven research on health policy and systems. Yet, there are also issues – so-called “big invisibles” – consequential in health systems – that remain underemphasized in global health. By way of example, SHAPES members mentioned corruption, disrespect and abuse in maternity care, access to safe abortion, informal payments for health care, and hospitals detaining patients because they are unable to pay, but doubtless more exist. Germane to people’s experiences, these issues are shaped at multiple levels of the system, including national politics and policies and global health governance, and are also deeply contextual. Moreover, these dynamics and relationships of power have taken shape over time. SHAPES members emphasized that it isn’t possible to fully understand their present iteration without reference to their historical underpinnings.

How do we ‘see’? Whether or not we acknowledge them, the persistence of these invisibles in global health is evidence of power. Moreover, failure to acknowledge such issues is a further  exercise of agenda-setting power – by researchers, policy makers and programmers. SHAPES members opined that intentions are key. In this context, conscious use of theories of power is important. Are we applying these theories just to our particular research topic and site, or to the ecology of global health governance that includes ourselves? Are we thinking of power as a political scientist may, as a top down system wherein individuals have limited decision space given political and economic structures? Do we also apply an anthropological lens so that we see how people at all levels apply and subvert mechanisms of power to suit their own needs? Or, do we think of power as Foucault did, as a pervasive system that regulates our language and behavior? And, what about the postcolonial underpinnings of these power theories – essentially western in origin, but used in the context of understanding LMICs? Our choice of approach has consequences for our research and for the global health agendas we create and inform.

These issues surfaced in our discussion of power and HPSR, but there are certainly others, and we welcome a robust discussion on those topics as well. Stay tuned as we try to tackle the practical issue of identifying approaches to studying power and health systems that facilitate both rich description and subsequent action.

The authors wrote this blog on behalf of SHAPES

I recently re-read a paper presented by Prof. Mark Neocleous in 2015 in which he makes the point that security and the related concept of resilience are essentially modes of governing.  Security is a political technology and technique of power through which individuals, groups, classes and capital are reshaped and reordered.  Part of that exercise of power involves the state constantly anticipating and imagining how, where and when emergencies will happen (preparation), and how it should respond (resilience).  Neocleous argues that security and resilience as modes of governance come to shape the way people imagine the future and its possibilities, and simultaneously provide a rationale for the use of security measures and modes of organisation that often promote and defend the established order.  As he states: No political imagination except an imagination of attack and recovery; no political future except an infinite preparation for war.

We all want our health systems to be prepared for, and able to adapt to, environmental, disease and conflict-related shocks.  But what if health system strengthening – in a deep and comprehensive sense – requires a reimagining of the established order?  The now accepted vision for Universal Health Coverage, for example, challenges us to confront a range of socially embedded inequities in low and high income countries, and the ways in which current health systems may actually mirror and deepen those inequities.

With this in mind, Neocleous’ critique helped me crystallize a nascent concern.  That is, if we pursue health system strengthening via a resilience agenda, the necessary focus that this brings on anticipating, preparing for and responding to emergencies may stymy our capacity or willingness to be bold in our vision for better health systems.  Some commentators have urged us to view resilience in broader and deeper terms (e.g Haldane et al; Gilson et al).  But in reality, the concept is still commonly defined and understood as the capacity to absorb shocks and sustain gains.  By focusing on this preparedness and response to ‘shock’ events, our attention is thus drawn away from the hard grind of responding to problems or dysfunctions that do not manifest as an acute emergency.  Despite its conceptual alignment with systems thinking, a resilience focus may paradoxically increase the risk of ignoring the way in which the current alignment of interconnected actors and structures underpin dysfunctional health systems.

I recognise that this argument risks setting up a straw man.  Resilience is of course a desirable quality in a health system; and building resilience, especially in fragile systems such as in post-conflict settings is important.  But the global health fraternity has also made it clear that we have other, high-level aspirations for health systems that go beyond resilience.  We want health systems to be equitable; to deliver high quality care; and to provide financial protection.   In order not be (silently) subsumed by the resilience agenda, which may have specific appeal to certain (often powerful) actors, therefore, health system strengthening advocates must make a conscious decision to promote the qualities of resilience, but to frame the reform and strengthening agenda in far more holistic terms.  We must, as always, be conscious of the power of discourse to influence the way we articulate and act on our priorities.

Some early notes and reflections:

Accountability goes in multiple directions: In order to understand CHWs as agents to improve the accountability of the health system to communities, we needed to discuss the accountability of CHW to their communities and to the health system. While CHWs are often intended to be accountable to their communities, many ultimately serve as the nurse’s helper, promoting reproductive control and immunization but unable to work on issues beyond a narrow biomedical lens. Some even serve private healthcare providers, taking commissions from private hospitals to bring patients. And what about the health system’s accountability to CHWs? Many CHWs lack employment rights, have minimal career progression opportunities, and experience stress and physical danger while going about their work.

He who pays the piper: Remuneration of CHWs remains contested. The participants were not afraid to re-examine this debate from the perspective of social accountability. If CHWs are paid by the government, how can they hold it to account? Isn’t it the case that he who pays the piper calls the tune? But insisting that CHWs work as volunteers brings out questions of exploitation, particularly since most CHWs are women. Moreover, voluntarism can also undermine the capacity to work towards social accountability: unpaid CHWs may lack time to devote to monitoring and planning and may lack the status required to raise their voices. Several participants emphasized that CHWs must be empowered themselves in order to empower communities. How does not being paid for one’s work affect empowerment? Do CHWs gain moral currency as volunteers or lose community respect?

Social accountability is a collective process. There are hundreds of thousands of CHWs in a number of countries represented at the meeting. If these CHWs are health system employees delivering quality health care, then they are indisputably advancing the right to health in the communities served. However, improved provision of services may not have a visible social impact. Social accountability is defined by Joshi and Houtzager (2012) as the “ongoing engagement of collective actors in civil society to hold the state to account for failures to provide public goods.” In the context of CHWs, this would require CHWs working together with their communities or with other CHWs. What programmatic components and contextual conditions enable collective identities and agendas to be developed among CHWs themselves and between CHWs and their communities? We discussed CHW labor rights organizing, their engagement with civil society, and their involvement in Village Health Committees as possible routes. Of course, CHW ability to participate in these processes depends on their interest and relative power in the health system and larger political context. Which brings us to our next point.

CHWs as people: Community health workers are not saints, liberators, or lackeys. They are people, often women, doing their best within weak health systems, difficult social hierarchies, and systems of deep economic inequity. Accountability is ultimately about power, and regardless of what CHW policy dictates, CHWs do feel accountable to someone. Demanding accountability from the state involves challenging systems that benefit the powerful. How much can and should be expected of CHWs, in terms of taking on the risks associated with accountability functions? In what conditions can CHWs make these demands?

It is remarkable that against all odds, we heard many examples of CHWs finding mechanisms to try to improve the responsiveness of government systems and engage in collective activism: CHWs fighting against government-sanctioned deforestation; CHWs striking and marching to demand better employment conditions and the resources necessary to provide health care in their communities; CHWs helping individuals to overcome systematic social exclusion; CHWs who could not directly protest health system failures using their insider knowledge to tip off community monitoring groups. CHWs are diverse and capable. Researchers, policymakers, and activists should listen to CHWs to identify when and how to support CHWs to engage in the larger, collective project of claiming their own rights and those of their fellow community members.

The HQSS Commission seeks to respond to what it calls the lack of “agreed upon single definition of a high-quality health system” and the attendant lack of consensus metrics with which to measure this.  One the Commission’s four specific aims is thus to propose tractable measures of quality.  But phrases like ‘single definition’ and ‘measurable indicators’ in the context of an exercise seeking to strengthen quality (in highly variable LMIC) health systems, should raise red flags.

Several years back, the World Health Organization convened a Task Force on Developing Health Systems Guidance, to provide evidence-informed decisions about health system interventions.  A series of processes and tools were proposed (see here and here and here), many adapted from guidelines used in clinical evidence-based medicine, such as the GRADE criteria.  But a subsequent and insightful commentary noted that the Taskforce’s focus on an evidence-based list of ‘what works’ seemed to overshadow more pressing questions that policy makers at the country level needed answering, such as: “what can work in our (non-research) environment?”, “how can we make an intervention work well?” and “how can we overcome obstacles to implementation in our situation?” The critical need for any guidance to acknowledge contextual – including deeply embedded socio-political and cultural – differences at the national and sub-national level was central to this critique.

Reflecting on that exercise made me wonder whether a ‘single definition’ of health system quality and associated metrics will assist LMIC policy makers in answering similar questions they may have about how to improve quality, or overcome known implementation obstacles to quality-improvement programmes? Two specific issues come to mind: how (and by default what) we measure; and how these measures are subsequently used.

First, regarding how (and what) we measure.  Empirical research (not to mention expert opinion) increasingly draws attention to the way quality in health systems is shaped by relational mechanisms and social experiences, including accountability, trust and importantly, perceptions of responsiveness and respect (see for example: here, here and here).  Indeed, Margaret Kruk, chair of the HQSS noted some of these issues at the Commission’s launch.  Measurement or capture of these relational aspects of health system quality thus become indispensable to the project of understanding health system quality sufficiently well to improve it (as argued in this excellent article).  At least at first blush, however, such an approach does not not marry with the Commission’s stated goal of needing a single definition.  Moreover, since many of these relational mechanisms and social experiences are contextually contingent it is questionable whether a universal definition or a generalizable set of metrics can adequately inform ‘actionable solutions’ across multiple settings.

A second question arising from the Commission’s goals, is to what use these metrics should or could be put?  According to the Commission, there is a need to “galvanize research and action” on quality of care in LMIC health systems to produce “science-led, multidisciplinary, actionable work with wide-reaching goals and measurable indicators”.  But in seeking to produce such set of highly visible, (and likely highly respected) metrics with the aim of supporting ‘actionable work’, the Commission has an obligation to consider the ways in which such indicators may be put to use.  I am thinking, in particular, about the broken promises of New Public Management (NPM) and its indicator-dependent performance targets (read quality metrics in another setting).  A now self-evident truth of NPM is that when introduced into organizations with traditional bureaucratic cultures (LMIC health systems anyone?) it often fails to make a difference.  Why? Because without addressing root causes of the work culture in which individuals are operating (including the governance structure, work norms and power dynamics) the targets become at best meaningless and at worse perverse incentives to game the system.

The Commission’s focus on quality health systems is much needed; more work is obviously required to clarify the pathways by which LMICs’ health system quality can be improved.  But the way in which the HQSS Commission defines ‘measurement’; how its efforts to produce quantifiable indicators take account of health system complexities; and to what use these indicators are subsequently put, should continue to be scrutinised.  For this observer, at least, absent a broader effort to contextualise such measures, there are distinct risks in the current framing of the HQSS Commission’s aims.

Why have I returned to this issue? In part to draw attention (again) to the need for deep engagement by global health advocates, practitioners, researchers, and policy makers (i.e. us), with the complexity of designing and making operational HRH and CHW policies.  I look at the extraordinarily high level and the sustained nature of engagement by international and national policy makers on the issue of national health insurance design & implementation, and I find it curious that the same level debate has not emerged in relation to enhancing HRH or scaling-up CHWs schemes.  These health workers, will, after all, be the mainstay of actually delivering services that any national health insurance scheme pays for.  And the service coverage and quality components of UHC will be directly associated with the sophistication and contextual fit of the HRH policies in play.

Perhaps we need a Lancet Commission with Horton-style advocacy to make this issue sexier and drive the sort of ‘glamour-engagement’ that ensures a spot on the mainstream (rather than semi-peripheral) global health agenda.

I wanted to take a moment to draw out the comparison between the ‘dialogue’ on national health financing versus HRH and CHWs, spurred in part by Michael Reich and colleagues’ analysis of 11 countries’ progress towards UHC.  In re-reading this article, it struck me how across a raft of countries, progress towards UHC-oriented national insurance schemes was typically achieved via incremental steps in a kind of a ‘work-with-what we’ve-got’ approach.  That is, national health insurance schemes evolved (either via expansion, or consolidation of more targeted schemes) from existing, less comprehensive health insurance policies.  The article also neatly summarises the deep and broad analysis (predominantly domestically-led) that has underpinned this progress –  as countries grapple with the questions of who should be covered, where the money will come from, how it will be collected and re-distributed and the implications that different combinations of each of these have for the goal of UHC.

Sounds sensible?  It is.  This process also speaks to a key feature of policy design in complex systems – namely the need to understand, and work with, historical decisions and processes while accounting for various dynamic interactions between current political, social and economic features that influence the efficacy of any given reform.  Moreover, in the cut-and-thrust of such analysis and debate we see facilitation between potentially conflicting interest groups and the adjustment and reform of appropriate governance mechanisms to boot.

We in global health need to up our game when it comes to the chronic emergency of HRH.  And while far from flawless, the simultaneously high-level and broad and deep nature of the UHC-inspired national health financing dialogue does provide one example.  It is no longer sufficient or even helpful to consider HRH policies in terms of their ‘recruitment’ or ‘retention’ siloes.  Nor, as the health financing example shows us, does it seem particularly useful to rely on well-meaning but ultimately high-flown global strategies  in the absence of more robust and contextualized domestic debates that will account for the reality on the ground.  We do need a broad-ranging conversation – and one with sustained high-level sponsorship such as that provided by Global Health Workforce Alliance – but that conversation must welcome, not avoid, the messy and heterogeneous reality of existing policies, structures, institutions and norms that frame different countries’ approach to health worker recruitment and retention, organizational culture and quality improvement, and formal and informal regulatory and incentive mechanisms.  Like the health financing dialogue, moreover, these elements must be considered concurrently in order to design (country-by-country) HRH policies that not only work with what we’ve got but that also make the best of it.

The financing and sustainability of a strengthened health workforce is one of, if not the key component(s) underpinning our ability to achieve universal health coverage (UHC).  But the wording of Target 3.c, with its reference to the need for recruitment and development and training and retention, hints at the complexity of an issue that must be central to global health and health systems debates in the coming months and years.  Increasingly, the human resource crises in LMIC are being recognized as not simply a crisis of numbers but also a crisis of human resource management.  Although strengthening local training capacity and increasing the output of health professionals is desirable, the experiences of various countries have demonstrated that it is not possible to ‘train’ our way out of this problem.  Even assuming they stay in the system, having more doctors, nurses or even stipendiary or volunteer community health workers available is simply no guarantee of universal access to good quality and essential health care services – as issues of distribution, motivation and retention all come into play.

While more doctors and nurses are undoubtedly needed, experiences from across different regions and countries have repeatedly demonstrated the challenges of retaining clinical health workers in service of the most vulnerable populations – including both rural and urban poor.  Meanwhile, health systems and global health programs continue to rely on lay or community health workers to deliver various primary-level services in various permutations of community- or clinic-based care.

Clearly, given the scope of the human resource short-fall and the issues of distribution in many LMICs, it is time to place community health workers (or lay health workers or auxiliary workers) at the centre of discussions around how UHC can be achieved.  And as part of that debate, the thorny – even ideological – issue of volunteerism versus formal employment of these lower cadres must be tackled.  On one side of this debate it has been argued that there is an economic imperative to maintain non-paid health workers as the only way to ensure basic service coverage in geographically remote or otherwise marginalized communities.  The potential for formal payments and/or employment to pervert intrinsic pro-social motivations among such workers has been raised along with the need for non-monetary incentives.  Problematically, however, a number of studies have also demonstrated that along with genuine ‘help-giving’ motivations, health volunteers often experience severe economic need that contributes to high levels of physical and mental stress that undermine performance and retention. Some have even suggested that our widespread reliance on volunteerism to provide health services to marginalized people is reflective of societies habituated to inequality.

Where does that leave us? As we think about how to gain traction for increased funding or negotiate complex policy reform targeting the HRH-oriented SDG target, we must move beyond the dichotomy of ‘pay vs. no pay’ in relation to community health workers.  A more helpful starting point is the desired outcome – UHC – and a better more thoughtful assessment of the way inconsistencies in recruitment, posting and retention policies impact on (both professional and community) health workers’ motivation and capacity to deliver on that outcome.  Assessment and reform of health systems to ensure congruence between the system-wide goal (UHC encompassing financial protection and service coverage) and health workers’ goals (both intrinsic and economic) is required.  This is a more nuanced lens through which to discuss the central role that CHWs will have to play if we are to achieve ‘universal’ care.  It is an approach that allows for different meanings and significance attributed to “volunteerism” in different settings. But it also moves us away from the pervasive and dangerous assumption that the most vulnerable members of our health workforce should, and are able to provide, continuous service with only minimal or no support.

 
With the upcoming Cape Town symposium generating increasing buzz, the associated 2014 class of Emerging Voices has just started their distance-learning modules. As always, in the lead up to the ‘main event’ those participating in this forum engage in a series of online discussions about relevant themes, generally chosen for their relevance to the conference. In the opening discussion held over the past fortnight, this year’s Emerging Voices discussed ‘patient centred care’ and ‘people centred health systems’ including where the differences lay between the two and what some of the common barriers and facilitators are to achieving them. In this blog we summarize some of those thoughts and invite other HS Global members to consider the relevance and applicability of these ideas to their own setting.

By and large the EVs agreed with the 5 principles of patient centred care originally outlined by Mead and Bower (2000) and echoed in various places, including this report from the International Alliance of Patient Organizations.

1. A bio-psychosocial perspective – providers viewing an illness / condition not only as a ‘clinical’ or ‘medical’ condition, but the result of interacting biological, pyschological and social factors.

2. The ‘patient as person’ – providers understanding that the patient is someone experiencing illness (and much bigger than just the illness), rather than as just a vehicle (subject) of that illness.

3. Sharing power and responsibility – an equal patient-provider relationship.

4. The therapeutic alliance – a patient and provider relationship in which decision making is shared, ensuring the relationship itself has therapeutic value since it encourages more thoughtful and appropriate decisions and treatment choices.

5. The doctor as person – the doctor is not just a ‘tool’ through which diagnoses / treatments are made. Rather the doctor is one half of a very important relationship and that the doctor’s own approach, his/her assumptions, work patterns will influence and reflect in the outcomes.

With a few exceptions most participants felt that patient centred care has not been achieved in their own countries to date. Among the reasons listed were chronically overcrowded clinics in which providers had little time for patients; cadres of health care workers (particularly doctors) whose training emphasized medical diagnosis but not communication or empathy; and patients whose capacity to interact with the system was undermined by a lack of information and/or confidence to be equal partners in decision making. Several participants also pointed to the way assessment of health service performance in LMIC and elsewhere remains geared towards more easily measurable indicators that may not do justice to the relational components (e.g. trust) of ‘patient centred care’.

Through a discussion of many a varied factors that currently impede patient centred care participants gradually built a more comprehensive picture of the complex interactions between certain factors that are required to achieve it. For example, EVs drew particular attention to the inter-dependence of providers, patients and the broader community in achieving people centred care, suggesting in the process that perhaps ‘patient centred’ is a misnomer, since what is most desirable is in fact closer to a partnership.

On the provider side, however, much discussion revolved around the complementary themes of capacity and the role of pre-and in-service education in providing health workers with skills beyond those of just medical diagnoses on the one hand; and patient orientation shaped by workplace and organizational culture on the other hand. Several participants drew attention to their own personal experience of how medical training may not be sufficient to enable the degree of communication and empathy necessary for patient centred care and highlighted the fact that real attitudinal change amongst professional cadres is frequently slow and difficult to change. Strong leadership (not to be confused with management which focuses more on coordination and planning) was pointed out as necessary to help promote a common vision of patient centred care (in a clinic setting, for example by mentoring juniors and modeling certain behaviours) as well as to help prevent a slide backwards in attitudes and behaviours where gains had been made.

On the patient and community side, much emphasis was placed on the need for better informed and motivated patients and family members, and the need for a community willing and capable of participating in promoting their own health. This discussion provided a neat segue for those involved in thinking about social accountability and empowerment, as a question was posed as to whether patient centred care can be achieved in the absence of an empowered client? And related, whether social accountability still needs initial stimulus and support from above?

There was some back and forth over what is understood by patient satisfaction and how this related (or not) to patient empowerment? A number of EVs pointed out that patients need a minimum level of information about the system in order to be able to engage with it meaningfully – to which we should perhaps add capabilities (as explained Amartya Sen for example) – or the skills, confidence and experience necessary to act on that information. But several participants made the valid point that patient satisfaction can also be understood as more than whether a patient’s (often low) expectations of services are met; satisfaction may in fact go to the heart of the need for respect and human treatment – a critical precondition for establishing what Mead and Bower term the ‘therapeutic alliance’.

Of relevance to the upcoming symposium, most participants agreed that a people centred health system is one that acknowledges the central role of human relationships, needs and decisions to system functionality. They suggested that a people centred health system will help and may even be a necessary prerequisite to achieving and sustaining patient centred care, for example through the way the system moulds providers’ competency (through training) and orientation (through norms established in the work culture). While acknowledging the role that resource shortages and associated incentives inevitably have on these issues, several participants also pointed to the way embedded power dynamics shape health systems at all levels. They noted that a people centred health system must be engineered in such a way as to prevent power being consolidated in the hands of just a few. It was thus suggested that a possible definition of a people centred health system could be: a system that is conscious of power dynamics and alert to the need for corrective action where power relations become skewed.

Given all this, a final question arising was whether people centred health systems that promote patient centred care are feasible in LMIC? Interestingly, the recent struggle of Western health systems to embed a patient centred approach clearly demonstrates that this issue is not exclusively linked to problems of resource availability (acknowledging that this nonetheless forms a critical backdrop). Rather – openness to reform and re-invention seem like key criteria in both developing and developed settings. While the challenges for LMIC remain substantial, therefore, localized examples of success in promoting patient-centred care and the current energy and momentum related to better understanding and strengthening people centred approaches do provide the basis for optimism.