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Political forces in the frontlines of service delivery: How do they matter in India and beyond?

Political forces in the frontlines of service delivery: How do they matter in India and beyond?

By Sudha Ramani
on March 27, 2020

The 6th Global Symposium on Health Systems Research (Dubai 2020) intends to facilitate deeper engagement with the political forces that surround health systems. While politics exist everywhere and at all levels, there is a tendency to equate these forces with ‘Big Politics’, the power dynamics that play out at global and national levels. In doing so, the micro-level political forces at the frontline of service delivery, that is, the set of everyday conditions that create frontline behaviours and shape ground-level action, often get discounted. But these micro-level political forces merit careful consideration. These forces have the potential to explain why certain underlying challenges continue to persist in health systems, leading to health inequities. Indeed, many of the work by Dr. Lucy Gilson and team (for instance, see here) focus on the ‘everyday politics’ in health systems.

In this article, I talk about how and why we need to engage with the micro-level everyday politics in health systems from my experiences. As a doctoral scholar, I have had the opportunity to spend some time observing the frontline of public primary health care delivery in rural India and engaging in discussions at this level. In these settings, medical doctors have often been blamed for having disrespectful attitudes or exhibiting behaviour that amounts to negligence of patients. However, an alternate way of looking at these attitudes and behaviour is by considering these as ways through which doctors cope with the everyday situational complexities they face. Such a perspective resonates with theorists such as Lipsky (1980), who hold that frontline health providers do not exhibit ‘random acts’ of poor behaviour; instead, such acts are contextually-rooted.

When considered through the above lens, doctors appear to navigate an extremely complex world. Professionally, they face a world that touts primary care models as accessible and affordable means to health equity and yet, the actual provision of primary care is associated with little prestige. Doctors share that they often feel like invisible workers, who merely complete mandated checklists imposed on them by senior management. In these settings, helping patients beyond these select mandates is often considered risky behaviour. For instance, a professionally laudable act like attempting to do a complicated delivery of a woman who simply cannot reach referral care on time is thought of as risky since any mishaps could give government health services a bad name and the media would leave no stone unturned to blame the doctor. In the web of power relationships that doctors function within, they are expected to be the “master-spiders”, yet, they often report feeling like trapped insects. In coping with several unrealistic demands from the system, limited support to staff and a culture of risk-avoidance, most doctors appear resigned to being less-than-ideal professionals.

The above experiences show that micro-level, everyday politics in health systems matters. While ‘Big Politics’ determines broadly what policy solutions get to the table, the effect of these solutions is often shaped at the frontline.

If frontline politics matter and can shape the way policies work, what can we do about it? For instance, in this case, how can we make doctors feel secure enough to take necessary professional risks?  How can we create a culture where doctors can voice their concerns rather than remain silent about impractical or unrealistic expectations? There are no ready-made answers to such questions.

But one does see scattered positive indications that such answers are worth looking for. Once, I met an exceptionally committed doctor, who had painstakingly created an innovative kitchen garden in his health facility for the use of families with malnourished children. To me, such doctors signal that despite organizational constraints and other conditions that limit them, doctors can do more than what they do now, when they think of themselves as leaders and change agents.  Thus, interventions that provide space for frontline participation, reflection and leadership can bring about culture change and make deep contributions to improving health systems.

But in the Indian setting, health systems strengthening has, conventionally, mostly been about structural interventions (the procurement of drugs and equipment, recruiting human resources and technical training). In fact, the Indian government has recently committed to a large-scale structural program to strengthen primary-level services (see here). While there is no denying that such initiatives are critical, our field experiences signal that even if they are properly resourced, they may not be adequate to overcome all frontline hurdles. There is also a need to work with the ‘software’, that is, the ideas, beliefs and values within health systems. Health system reform frameworks in India need to acknowledge the myriad interactions between the structural inputs and the system ‘software’. For instance, in this case, the uptake of structural interventions like technical training in the frontline may not be optimal if the primary care doctors are not motivated to act; but at the same time, one cannot realistically motivate all doctors to perform under stark conditions of insufficient resources. Hence, structural inputs need to be combined with culture change interventions for the system to really improve. One set of interventions is handicapped without the other in place.

Having said this, I must also point out that culture change interventions in the Indian setting are definitely not easy to design. Prior experiences warn us that the ‘letter’ of such interventions can get enacted even while their ‘spirit’ gets sacrificed. There is no denying that it is a challenge to design and implement interventions that remain true to the spirit of culture change, particularly in top-down hierarchies wherein frontline thinking and power have been historically supressed. But if we really consider health systems as Complex Adaptive Systems, it is evident that we need to move into these less familiar intervention arenas.

To conclude, globally, we have recognised that engaging with frontline political forces is essential for bringing about lasting positive changes in health systems. As we move forward, however, there is much more to think about. What combination of interventions is feasible? What sort of time frames do culture change interventions need? How can we truly embed such interventions? These are some questions to deliberate on in the upcoming symposium (fingers crossed that it materializes!) and beyond.

The author would like to acknowledge Dr. Kerry Scott, Dr. Stephanie Topp and Kristof Decoster for their inputs.

About the SHAPES article series

Welcome to the SHAPES article series, hosted by IHP. SHAPES is a thematic working group within Health Systems Global, which facilitates discussion, debate and collaboration around social science approaches for research and engagement in health policy & systems. In the months leading up to the 6th Global Symposium on Health Systems Research in Dubai (Nov 2020) SHAPES members will be blogging about the Symposium's theme of "re-imagining health systems for better health and social justice" through a social science lens.

View entire SHAPES series

About Sudha Ramani

Doctoral Scholar, Tata Institute of Social Sciences, Mumbai Fellow, Health Policy Analysis Program
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