I am a trained anthropologist from University of Pune-India, and hold a PhD in public health and policy from the London School of Hygiene and Tropical Medicine (LSHTM). In the year 2000, I was also ordained as a Lay Leader to serve the local Church. Although not a trained theologian, my interest in theology does sustain till date. In search of an answer for Health System Strengthening (HSS), the Holy Grail for a health systems researcher, and during the course of a Bible study, I encountered Saint Paul the Apostle in a new way. He appeared to me more as a systems researcher this time. Drawing upon Paul’s analogy of the human body, in this blog I consider the health system as a body with different parts and functions. The views expressed here are solely based on my Christian background, and I acknowledge that not everyone shares this point of view, and thus might have a (very) different interpretation of what follows below.
But some background first for readers who don’t have a Christian background. Just before Jesus Christ ascended to heaven he promised his disciples that the Holy Spirit would come on them, and would thereafter be with them as an advocate, a counsellor, a comforter and an encourager. On the day of Pentecost, as promised, all disciples were filled with the Spirit (Acts 2:2). Being filled with the Spirit is not merely a warm feeling in our hearts, but a power to go out and make a difference in the world. In his Epistle to the congregation in Corinthians (1 Cor 12:12), Paul used the metaphor of the human body to describe the relationship of human beings with each other, and how those relationships are unified by the Holy Spirit. The same Holy Spirit lives in every Christian irrespective of his/her nationality, denomination and background, and provides everybody with varying ‘spiritual gifts’ (1 Cor 12:8-10). The Holy Spirit constantly helps believers to exercise their gifts to edify Christ’s body (i.e. the Church) to maintain unity, and to produce the fruits of spirit in their lives: love, joy, peace, patience, kindness, goodness, faithfulness, gentleness, self-control (Gal 5:22-23).
Similarly, the health system is not something that is exterior to human existence, rather it is a “body” formed out of individuals (who, as we have seen above, comprise not just body (& soul), but also spirit). In recent years, scholars have recognised that in addition to the ‘hardware’ of health systems, the ‘software’ (or ‘mortar’ as some have called it recently) also underpins the relationships amongst and between system actors.
If we translate ‘software’ and ‘hardware’ according to Paul’s analogy of the body, then the ‘hardware’ would mean the physical structure of our body; the ‘software’ would be the soul – comprising of emotions, thoughts, and a determination to make decisions; the soul also involves transcendental elements (but that would lead us too far here). In addition to body & soul, there’s still the ‘spirit’ of Jesus Christ, connecting individuals (or at least Christians). There’s something very ‘resilient’ about Christians, if you watch them – and many of them would argue the Holy Spirit gives them strength.
Is there an equivalent of ‘spirit’ for health systems? And if there is, can it be capitalized upon in order to make the health system perform better and more effective, providing good quality care for all people? In addition, is the need for some sort of health system “spirit” actually felt by those working in the field of public health?
To give an example of what I mean (at least according to my world view), I am going to reflect on a small piece of information from my PhD data. This quote is extracted from an interview of a Chief Executive Officer (CEO) of an NGO. When I probed him about challenges of partnerships with Government he said:
“Government is willing to listen…but what happens is that, Government has a limitation in the sense that, top politicians, top bureaucracy, can understand what we are trying to communicate, but down the line right from the level of Directors, secretaries, and also the peripheral functionaries, that ‘spirit of partnership’, that ‘spirit of appreciation’ for the collaborative effort is not forthcoming, whatever they agree at the top level that should percolate down, in words and ‘spirit’, to the ground level, because ultimately service delivery makes all the difference”.‖
[Interview, Chief Executive Officer, NGO]
From a public health researcher’s point of view, the above quote brings the first level of understanding. The CEO highlights gaps in policy communication, policy implementation and so on. He lays in front of us the divide between the two worlds – the world of top level bureaucrats versus the world of frontline implementers. However, the discipline of public health doesn’t do (full) justice to the term ’spirit’, I feel. I find it difficult to accommodate the word ‘spirit’ within the disciplinary realm. The dominant (biomedical) public health approach often lacks the capacity to perceive the ‘subjectivity’ of individual people and to understand the context of their social relationships. There thus seems to be a need to rely on another disciplinary perspective (or at least one somewhat less dominant in public health). So now I take up the lens of an anthropologist.
Clifford Geertz (1973) states that anthropology is ‘not an experimental science in search of laws but an interpretive one in search of meaning’. The very nature of anthropology being the study of human beings in the broadest sense provides a ‘subjective’ interpretation of the quote. In the above quote, the CEO used the word ‘spirit’ thrice (thus clearly stressing its significance). From an emic perspective (insider’s point of view), he was not merely reflecting on the (content) communication of policy from top to bottom, but he also added the very core element of human existence to it – the ‘Spirit’ (at least, that is my Christian reading of this quote). The CEO acknowledged the fact that there is ‘something’ more essential to relationships beyond structures and ideas. Being an NGO executive, he had the opportunity to sit in various national level meetings, where he connected with the higher authorities and understood their intention of partnerships. However, when he went back to the field he encountered different individuals from the public sector who – clearly – did not have the same ‘spirit’ of partnership and collaboration as witnessed among and promoted by people at the top. The respondent, however, desperately wanted such a ‘spirit’ in the whole system, as it would bring coordination across levels of the public system, unite partners to make it a sustainable partnership, and induce compassion – which would in turn lead towards healthy systems.
Nowadays, secular public health researchers would perhaps use the term ‘emergent property’ (in a complex health system) for such a spirit (and discern ‘virtuous feedback loops’, while they’re at it). And perhaps people inspired by this Spirit (and the overall system) would just be called more ‘resilient’ by these researchers. That is not my view, as you understand by now.
In our daily lives we easily use the idiom, “That’s the spirit!” confirming there is ‘something’ beyond our feelings. There is a (growing?) recognition worldwide of the ‘spiritual’ aspect of our human existence, broadly or more narrowly defined. For example, in 2014, New York City hosted a conference, ‘caring for the human spirit: driving the research agenda for spiritual care in healthcare‘. Similarly, there are attempts to bring back compassion and other spiritual core values into public health. A recent article, “Spiritual Themes and Challenges in Global Health” even expresses interest in bringing spirituality to the center of the global health discourse. As we move towards Universal Health Coverage (UHC) for achieving the Sustainable Development Goals (SDGs) in the post-2015 era, the strengthening of health systems remains extremely important. In my view, in addition to the ‘hardware’ and ‘software’ needed to build resilient health systems, there is a need to also have a universal ‘Spirit’ in the health system.
So perhaps it’s time to take a pause, and ask a simple question: where is the “spirit” of a health system?