Re-imaging the Perspective of Health Systems Research and My Reflections on an Anthropological Lens to Understand Health Systems

This session emphasised two main points. Firstly, health system researchers should be conscious of the perspective from which we approach this field. Ultimately, the essential findings and evidence-based outcomes from health systems research should serve to improve health systems rather than a capitalistic or elitist narrative that seeks economic advantages. Previous management research was focused on system changes that can improve the profitability of health systems for shareholders and organizations by utilizing resources more efficiently. If the perspective we hold regarding the health system is about how we can maximise profit, the research that we are going to conduct (and any subsequent interventions or recommendations) will be focused on that. This example demonstrates that health systems science is at the intersection of economics, management science, sociology, anthropology, political science, public health, and epidemiology. We need to be mindful of how these narratives and their associated power dynamics can shape health systems decision-making, often to the detriment of the health system and patient outcomes. Closser et al. (2022) recall how the Structural Adjustment Programs designed by the World Bank as prerequisites for loan repayment assistance in low-income countries resulted in detrimental health outcomes for these countries. This shows how political and economic narratives can adversely shape health systems.

Not only do we need to reimagine the research that we conduct, but we should be mindful of how we conduct it. Health systems research should recognise the intersectional nature of health systems and the influence of power dynamics. We should conscientize the narrative in current research and our own research, the source of the narratives and which voices are being represented. It is also important that we can identify and understand the challenges, problems and questions around the existing culture, processes, procedures, and systems that shape the health system. This would need to guide the problems we identify that need to be researched, and how we go about researching this.

the article by Closser et al. (2022) has enabled me to reprise my Anthropology background as an entrance to utilise a systems thinking approach to health systems research and being able to center my research from the perspective of patients or healthcare professionals. Critical to an Anthropological approach is the in-depth focus and observation of people and their cultures, which enables a rich appreciation of interactions, behaviours, and practices of social systems, and in this case, health systems. Anthropology does not have a strict definition of health systems, however, health systems are understood as social systems “made up of” agents in relationships with each other. These relationships are shaped by power, politics and history. Systems are locally situated and shaped by local ecological, political, economic and social determinants. This suggests that an Anthropological approach enables a detailed understanding of how health systems operate beyond just the surface level, leading to nuanced views of challenges and necessary improvements in health systems.

Katerini Storeng and Arima Mishra (2014) argue that ethnographic research can challenge simplistic and mechanistic views of health systems prevalent in global health discourse. Mechanistic conceptions often oversimplify complex systems by focusing solely on processes and structures, neglecting the historical, political, and social contexts that shape these systems. By emphasising the importance of understanding health systems in historical, political, and social perspectives, ethnographic work adds depth and context to the analysis. This approach allows researchers to uncover the underlying power dynamics, societal influences, and historical legacies that impact the functioning of health systems.

Kielmann (2012) highlights the significance of Anthropological analysis in uncovering the tangled relationships between power dynamics, knowledge production, and healthcare practices within health systems. Anthropologists have used their unique analytical lens to delve into how power structures influence decision-making processes, disseminate health-related knowledge, shape healthcare policies, and impact the delivery of services within health systems (Closser et al., 2022).

Closser et al. (2022) demonstrate how international health interventions have historically (and to a large degree presently) perceived their beneficiaries as subjects to be changed. An Anthropological lens forces us to understand the end user more holistically, with desires, perceptions, values etc. Anthropological contributions to specific disease control programs such as smallpox and malaria eradication and immunization demonstrated the increased effectiveness of these programs when local perspectives were taken into account. Likewise, Paul's (1955) statement that "If you wish to help a community improve its health, you must learn to think like the people of that community" emphasised that challenges related to compliance, adherence and retention do not solely lie with patients and solutions to these challenges lie understanding health systems from their perspective.

The global primary health care (PHC) model introduced In the 1978 Alma Alta Declaration was a remarkable change in direction from single disease control programs to community-based integrated health systems that were to be “affordable, acceptable, appropriate, and accessible” (White, 2015). From an Anthropological lens, I can understand the PHC models as an integration of health services and nodes of connection that meet the health needs of local communities and imbue a sense of ownership.

This has also made me reflect on Eric Wolf's 'Europe and People without History' with a more local application. Eric Wolf's analysis of global historical anthropology informs us that because communities and societies are connected through relations of power, politics, communication and trade, their cultures are no more bounded to distinct communities than their corresponding social relations. By tracing the web of interactions through history, Wolf argues that there is no such thing as isolated communities. He emphasises internal diversity, fuzzy boundaries and historical transformations.

"The centrifugal forces of modernity are continuously countered by the centripetal forces of community; the human need to make sense of the world together ensures a certain degree of cohesion".

Wolf’s analysis of societies provides a unique interpretation of health systems as being made up of infinite moving components that are constantly interacting with one another and co-evolving. It also enables us to appreciate that health systems can not be closed systems. They are influenced and influence by other systems (financial, political, industrial systems etc.) and their coherance only makes sense when looking at their wider context.