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Closser S, Mendenhall E, Brown P, Neill R, Justice J. The anthropology of health systems: A history and review. Soc Sci Med 2021; 300:114314. [PMID: 34400012 DOI: 10.1016/j.socscimed.2021.114314] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 08/04/2021] [Accepted: 08/11/2021] [Indexed: 12/17/2022]
Abstract
Ethnographies of health systems are a theoretically rich and rapidly growing area within medical anthropology. Critical ethnographic work dating back to the 1950s has taken policymakers and health staff as points of entry into the power structures that run through the global health enterprise. In the last decade, there has been a surge of ethnographic work on health systems. We conceptualize the anthropology of health systems as a field; review the history of this body of knowledge; and outline emergent literatures on policymaking, HIV, hospitals, Community Health Workers, health markets, pharmaceuticals, and metrics. High-quality ethnographic work is an excellent way to understand the complex systems that shape health outcomes, and provides a critical vantage point for thinking about global health policy and systems. As theory in this space develops and deepens, we argue that anthropologists should look beyond the discipline to think through what their work does and why it matters.
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Affiliation(s)
- Svea Closser
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Rm E5545, Baltimore, MD, 21205, USA.
| | - Emily Mendenhall
- Science, Technology and International Affairs Program, Edmund A. Walsh School of Foreign Service, Georgetown University, USA
| | - Peter Brown
- Department of Anthropology, Emory University, USA
| | - Rachel Neill
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, USA
| | - Judith Justice
- Institute for Health and Aging, School of Nursing, University of California, San Francisco, USA
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Neel AH, Closser S, Villanueva C, Majumdar P, Gupta SD, Krugman D, Akinyemi OO, Deressa W, Kalbarczyk A, Alonge O. 30 years of polio campaigns in Ethiopia, India and Nigeria: the impacts of campaign design on vaccine hesitancy and health worker motivation. BMJ Glob Health 2021; 6:bmjgh-2021-006002. [PMID: 34344665 PMCID: PMC8336205 DOI: 10.1136/bmjgh-2021-006002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/11/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction The debate over the impact of vertical programmes, including mass vaccination, on health systems is long-standing and often polarised. Studies have assessed the effects of a given vertical health programme on a health system separately from the goals of the vertical programme itself. Further, these health system effects are often categorised as either positive or negative. Yet health systems are in fact complex, dynamic and tightly linked. Relationships between elements of the system determine programme and system-level outcomes over time. Methods We constructed a causal loop diagram of the interactions between mass polio vaccination campaigns and government health systems in Ethiopia, India and Nigeria, working inductively from two qualitative datasets. The first dataset was 175 interviews conducted with policymakers, officials and frontline staff in these countries in 2011–2012. The second was 101 interviews conducted with similar groups in 2019, focusing on lessons learnt from polio eradication. Results Pursuing high coverage in polio campaigns, without considering the dynamic impacts of campaigns on health systems, cost campaign coverage gains over time in weaker health systems with many campaigns. Over time, the systems effects of frequent campaigns, delivered through parallel structures, led to a loss of frontline worker motivation, and an increase in vaccine hesitancy in recipient populations. Co-delivery of interventions helped to mitigate these negative effects. In stronger health systems with fewer campaigns, these issues did not arise. Conclusion It benefits vertical programmes to reduce the construction of parallel systems and pursue co-delivery of interventions where possible, and to consider the workflow of frontline staff. Ultimately, for health campaign designs to be effective, they must make sense for those delivering and receiving campaign interventions, and must take into account the complex, adaptive nature of the health systems in which they operate.
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Affiliation(s)
- Abigail H Neel
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Svea Closser
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Catherine Villanueva
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Piyusha Majumdar
- SDG School of Public Health, Indian Institute of Health Management Research, Jaipur, Rajasthan, India
| | - S D Gupta
- SDG School of Public Health, Indian Institute of Health Management Research, Jaipur, Rajasthan, India
| | - Daniel Krugman
- Anthropology, Middlebury College, Middlebury, Vermont, USA
| | | | - Wakgari Deressa
- Preventive Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Anna Kalbarczyk
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Olakunle Alonge
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Rodriguez DC, Neel AH, Mahendradhata Y, Deressa W, Owoaje E, Akinyemi O, Sarker M, Mafuta E, Gupta SD, Salehi AS, Jain A, Alonge O. The effects of polio eradication efforts on health systems: a cross-country analysis using the Develop-Distort Dilemma. Health Policy Plan 2021; 36:707-719. [PMID: 33882118 PMCID: PMC8173659 DOI: 10.1093/heapol/czab044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 01/12/2021] [Accepted: 03/23/2021] [Indexed: 12/12/2022] Open
Abstract
Vertical disease control programmes have enormous potential to benefit or weaken health systems, and it is critical to understand how programmes' design and implementation impact the health systems and communities in which they operate. We use the Develop-Distort Dilemma (DDD) framework to understand how the Global Polio Eradication Initiative (GPEI) distorted or developed local health systems. We include document review and 176 interviews with respondents at the global level and across seven focus countries (Afghanistan, Bangladesh, Democratic Republic of Congo, Ethiopia, India, Indonesia and Nigeria). We use DDD domains, contextual factors and transition planning to analyse interactions between the broader context, local health systems and the GPEI to identify changes. Our analysis confirms earlier research including improved health worker, laboratory and surveillance capacity, monitoring and accountability, and efforts to reach vulnerable populations, whereas distortions include shifting attention from routine health services and distorting local payment and incentives structures. New findings highlight how global-level governance structures evolved and affected national actors; issues of country ownership, including for data systems, where the polio programme is not indigenously financed; how expectations of success have affected implementation at programme and community level; and unresolved tensions around transition planning. The decoupling of polio eradication from routine immunization, in particular, plays an outsize role in these issues as it removed attention from system strengthening. In addition to drawing lessons from the GPEI experience for other efforts, we also reflect on the use of the DDD framework for assessing programmes and their system-level impacts. Future eradication efforts should be approached carefully, and new initiatives of any kind should leverage the existing health system while considering equity, inclusion and transition from the start.
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Affiliation(s)
- Daniela C Rodriguez
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, 8th Floor, Baltimore, MD 21205, USA
| | - Abigail H Neel
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, 8th Floor, Baltimore, MD 21205, USA
| | - Yodi Mahendradhata
- Center for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Sekip Utara, Yogyakarta 55281, Indonesia
| | - Wakgari Deressa
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, P. O. Box 9086, Addis Ababa, Ethiopia
| | - Eme Owoaje
- College of Medicine, University of Ibadan, AddL P.M.B 3017 G.P.O Ibadan, Nigeria
| | - Oluwaseun Akinyemi
- College of Medicine, University of Ibadan, AddL P.M.B 3017 G.P.O Ibadan, Nigeria
| | - Malabika Sarker
- BRAC James P Grant School of Public Health, BRAC University, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka-1212, Bangladesh.,Heidelberg Institute of Global Health, Heidelberg University, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - Eric Mafuta
- Kinshasa School of Public Health, University of Kinshasa School of Public Health, Kinshasa, The Democratic Republic of Congo
| | - Shiv D Gupta
- Indian Institute of Health Management Research, 1 Prabhu Dayal Marg, Near Sanganer Airport Terminal 1, Jaipur 302029, India
| | | | - Anika Jain
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, 8th Floor, Baltimore, MD 21205, USA
| | - Olakunle Alonge
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, 8th Floor, Baltimore, MD 21205, USA
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