Management of Healthcare

Rosemary Stewart

• Publisher: Routledge
• Year: 2019
• Print ISBN:
  9781138325760
• eBook ISBN:
  9780429833090
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

Published in 1998, this collection of essays on the management of healthcare look at topics such as: income, distribution and life expectancy; internal market reform of the National Health Service; the changing nature of the medical profession; and doctors as managers.

Part I
Context for Management

[1]


CONCEPTS AND A MODEL FOR THE COMPARISON OF MEDICAL SYSTEMS AS CULTURAL SYSTEMS*

ARTHUR KLEINMAN

Division of Social and Cross-Cultural Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98195

Abstract—A model and related concepts are present for ethnographic and comparative research on medical systems as cultural systems. The major structural and functional aspects of the health care system model are briefly sketched. Clinical realities, explanatory model (EM) transactions in health care relationships, a distinction between disease/illness, cultural healing and cultural iatrogenesis, and the core adaptive taks of health care systems are concepts based on this model which have practical clinical and public health, as well as research, implications. A number of hypotheses are outlined which can be used to focus medical ethnographies and to construct comparative cross-cultural studies of health care systems. The model. concepts. and hypotheses attempt to exploit medical anthropology’s. fundamental tension between medical and anthropological interests; and thereby to contribute to the development of theory that is original to this discipline.

INTRODUCTION

The task assigned to me was to examine theories and concepts that can be used to compare medical systems as cultural systems. Review of the relevant medical anthropology literature, in preparation for writing this paper, revealed, with a few notable exceptions [1], a paucity of well-developed theoretical positions on this subject which could be neatly summarized, compared, and contrasted. Instead, most of the literature is taken up with empirical studies that usually do not specify the theoretical frameworks they employ, that unsystematically import concepts from social science or biomedicine, and that, as a result, are fragmented and difficult to relate. We possess a large array of empirical descriptions, but few cross-cultural comparisons, and hardly any attempts to test specific hypotheses. Here is evidence of the lack of a theoretical base, which is the reason for holding this Conference. Rather than try to integrate and critique the few theoretical straws in the wind, frail things that they are, I shall, at the risk of appearing egocentric, present a model that I have been working with for the past 5 years. That model is itself an outgrowth of my own field research and my reading of what relevant theory there is, as well as empirical studies [2]. The model is an attempt to understand health, illness, and healing in society as a cultural system, and to compare such systems cross-culturally. A theoretical model of medicine as a cultural system, if it is to be useful, should specify what that system is and how it functions. It should provide a method for describing individual systems and for making cross-cultural comparisons between different medical systems. It also should produce a more systematic analysis of the impact of culture on sickness and healing than is possible without such a framework.

Furthermore, a model of medicine as a cultural system will be valuable if it can (1) operationalize the concept of culture in the health domain in more precise and potentially quantifiable ways; (2) relate directly to clinical questions: (3) specify hypotheses which could be falsified against existing data or confirmed in prospective field studies; (4) provide systematic interdisciplinary translation between anthropology and the health sciences: and (5) provide a terminology that is not limited to biomedicine. but through which biomedicine can be related to other professional, as well as popular and folk, healing traditions within a broader comparative cross-cultural science of sickness and health care, My interest here is not to convince you that this is the solution-framework for our field. but rather to place before you one type of problem-framework that we can react to, criticize, and hopefully move beyond. Provisional though it be, this model does suggest at least a few of the advantages to be gained by developing a theory of medicine as a cultural system. It doubtless will also illuminate limitations, but these relate to the specific characteristics of the model, not to models for this field generically. Thus, this presentation is intended to provoke participants at the Con-ference and readers of the proceedings to take this model apart in order to build others that will perhaps eventually provide us with a unified framework. Even if it simply provides a common set of terms useful for talking about medicine in different societies that would be an advance over the chaotic situation that now’ prevails. The model has been found helpful in the study of medicine in Chinese cultures and in making comparisons with medicine in the U.S. [3, 4]. A word of caution is indicated. No matter how they are construed, medical systems are both social and cultural systems. That is, they are not simply systems of meaning and behavioral norms, but those meanings and norms are attached to particular social relationships and institutional settings. To divorce the cultural system from the social system aspects of health care in society is clearly untenable. The title of this paper merely reflects an emphasis on the cultural dimension. I am sure that other participants at the Conference will make the alternate emphasis. The model described below, which has been construed in other papers as an ecological model relating “external” (social, political, economic, historical, epidemiological demiological and technological) factors to “internal” (psychophysiological, behavioral and communicative) processes, grounds medical beliefs and activities in socio-political structures and in particular local environmental vironmental settings. Again, for reasons of emphasis, I shall not focus on this aspect of the model, only note that it is consistent with the view of medical systems as cultural systems. Our concern will be to understand how culture, here defined as a system of symbolic meanings that shapes both social reality and personal experience, mediates between the “external” and “internal” parameters of medical systems, and thereby is a major determinant of their content. effects. and the changes they undergo.

HEALTH, ILLNESS, AND CARE AS A CULTURAL SYSTEM

Health, illness, and health care-related aspects of societies are articulated as cultural systems. Much field research supports this thesis, which marks a divide between the older and the newer approaches to medical ‘anthropology [3, 5, 6]. Such cultural systems, which I shall call health care systems [7], are, like other cultural systems. e.g. kinship and religious systems, symbolic systems built out of meanings, values, behavioral norms, and the like. The health care system articulates illness as a cultural idiom, linking beliefs about disease causation, the experience of symptoms, specific patterns of illness behavior, decisions concerning treatment alternatives, actual therapeutic practices, and evaluations of therapeutic outcomes. Thus, it establishes systematic relationships between these components.

Because they are part of a cultural system, health, illness, and health care need to be understood in relation to each other. Health beliefs and behavior, illness beliefs and behavior, and health care activities are governed by the same set of socially sanctioned rules.

To examine one in isolation from the others distorts our knowledge of the nature of each and how they function in the context of specific health care systems; it also leads to errors in cross-cultural comparisons. Semantic network analysis [8] is one method of demonstrating these linkages and their important implications for health care. Symbolic analyses have also disclosed the organization of the health care aspects of society as a cultural system [9–14]. However, it is to be expected that full appreciation of the structure and functions of this cultural system will only follow upon ethnographic studies that test specific hypotheses generated by theoretical models of the system, and that use those models to focus their phenomenological descriptions [15]. We can already see this happening in field studies of medicine in Chinese culture [3], which have become more sophisticated, in part, in response to better medical anthropological and cross-cultural medical models. Cross-cultural comparisons either must wait for the emergence of this new kind of medical ethnography, or incorporate that approach simultaneously in several different field settings. Studies of change in health beliefs and practices must examine changes in health care systems.

THE STRUCTURE OF HEALTH CARE SYSTEMS

Most health care systems contain three social arenas within which sickness is experienced and reacted to (see Fig. 1). These are the popular: professional; and folk arenas. The popular arena comprises principally the family context of sickness and care, but also includes social network and community activities. In both Western and non-Western societies somewhere between 70 and 90% of sickness is managed solely within this domain [4, 16, 17]. More-over, most decisions regarding when to seek aid in the other arenas, whom to consult, and whether to comply, along with most lay evaluations of the efficacy of treatment, are made in the popular domain. Until very recently, medical anthropology tended to deemphasize studies of this domain, while at the same time it overemphasized studies of the folk arena. The latter consists of non-professional healing specialists. s...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• Series Preface
• Introduction
• Part I Context for Management
• Part II Health Care Reforms
• Part III Service Management
• Part IV Performance Indicators
• Part V Management of Professionals
• Name Index