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Desperate actor tensions in health systems (DEATHS): A deep-fried framework to study health policy and systems (till you drop dead)

By Rakesh Parashar
on October 28, 2020

Warning: dark satire

Someone, who was recently side chatting during a virtual meeting showered me with her frustration that the global health discussions are way too “healthy” these days. We should really get some unhealthy stuff mixed into these, she said, as humans have done for forever, for entertainment. I agreed with her, especially as lockdowns have added to the craving of getting out and doing some *really* unhealthy stuff. Recovering from my PhD marathon, I was still riding the momentum, dreaming of and conceiving ever more new frameworks. And I confess, just after my PhD life was over, I already came up with a brand new framework – at the very time when I was supposed to either celebrate or relax. I promised this colleague that I would add a deep-fried framework to the flood of super healthy, longevity increasing stuff. And what is a better opportunity to tell the world about it,  as we gear up for the greatest Kumbh Mela of the health policy and systems folks- the HSR2020 ? This year, virtual, as you know – so shaping up to be a very healthy event, indeed!

While I reflected on the actor interface analysis which I had applied for my research, I couldn’t resist adding the morbid flavour of the DEATHS framework – “DEsperate Actor Tensions in Health Systems” to our discussions. Let me tell you why the DEATHS framework is the essence of an actor centric analysis of a health policy, and why the HSG community should thus embrace it as its ‘Ohm’ mantra.

I sort of had an epiphany on DEATHS, at last deeply understanding how the health policy process works. I know, the folks who come up with the fancy structures, context, processes etc. at the top might not agree and could write many books to counter DEATHS. Worse, they could, in fact, even come up with a LIVES framework (a hint for contesters to develop this!). But rest assured, every time it is opposed, the DEATHS framework will emerge again, as it has been systemically derived and empirically tested.

Walt and Gilson, in 1994, had kept actors at the centre of the health policy triangle. Many other scholars before and after them have put actors and their power struggles (read tensions) at the centre of everything that unfolds in health systems and in the health policy process, in different ways. But if we must make use of all these serious scholarly efforts, we should recognize that the DEATHS framework adds a touch of magic to this triangle.

Why is the DEATHS framework an absolute “must-use” among the numerous (I almost said ‘endless’) foundational health policy and systems concepts and frameworks, and key to understand the health practice if we really must “reimagine the health systems”, as this symposium theme urges us to do?  (by the way, whoever came up with this theme, should get fired, as it feels like an open invitation to researchers to come up with even more fancy conceptual frameworks than usual. Asking researchers to ‘re-imagine’ something? Duh  )

Well, there is no aspect of the health policy process that does not have to face actor tensions and where actor interfaces are not formed. DEATHS is thus a framework of micropolitics, individual interests, territories, need for recognition, validation, and ambitions. Of course, it is all about the power which no actor wants to let-go, and wants to keep accumulating. Some do so with a benevolent interest and others with not so generous interests. But they engage, avoid and contest. Sometimes these actors are too humble, not wanting to hold on to any powers and personal interests. The humble ones only want their names on the publications or in the media, but of course for the benefit of others! But when they meet the former category, they are sucked into “desperate tensions”. Moreover, since one has to face DEATHS at all stages and aspects of policy, I argue that DEATHS is not a just micro policy analysis framework. It is diffused everywhere: in global politics, global health governance (Dr. Tedros is gently nodding now) the national systems, the local systems, at the frontlines of service delivery and choice and choice-lessness of the intended policy beneficiaries. And dare I say, it’s also right there at the global HSG symposium as well! (though I haven’t really gotten my head around what virtual DEATHS would imply)

On a more philosophical level, DEATHS just cannot be afforded to be ignored by researchers and practitioners. We must discuss actors more and more, especially desperate actors engaged in desperate tensions, I would argue, and so it is vital to examine the DEATHS. We need to think of actors as people. Social justice is for people and for communities. The health systems and the policies are for the people and for the communities. The research and the practice are done by people and are meant for people. These people form actors. And actors are immersed in desperate tensions on all these aspects. It is these tensions that determine what is done, ignored, facilitated, manipulated, facilitated, or resisted. The agendas, context, priorities, processes, the ideas, the framing, the need for and the use of power etc. are eventually processed by the actors within their lived realities or their lifeworlds, and it is their assembling and reassembling of these surrounding realities and their relational dynamics with other actors, that determine the way policy takes shape.  Huh. Hope with this complex explanation I didn’t cause your “DEATH” now : )

But think about it. We can deconstruct all types of politics in policy processes using DEATHS. For example, in  Covid-19 control; HCQS, remdesivir, tocilizumab- DEATHS; Sinking economy; Managing pollution; Tobacco control; Non-communication diseases and commercial determinants of health. I dare you, name one health policy issue that is not about DEATHS. And how about unending Teams Meetings and Zoom- DEATHS??  Exactly.

After this short explanation, HPSR and HPA folks should be able to use DEATHS on a massive scale, as a conceptual weapon of mass enlightenment. In fact, after the November symposium, it should become the highest ever cited framework in 2020, ànd being used in all your future grant writing. Bet quite a few funders will love it!

Acknowledgements: Many thanks to Sharmishtha Nanda and Arpana Kullu for their continuous inspiration to take DEATHS to the world out there! And thanks to Kristof Decoster and Radhika Arora for their peer review of DEATHS!

About Rakesh Parashar

Rakesh Parashar is a physician, a public health specialist and is in convalescence of his PhD in health systems and policy. He is a health policy analysis fellow from the 2017 cohort and is working with Oxford Policy Management Limited. Rakesh has a love-hate relationship with frameworks.
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