Philosophical Problems with Social Research on Health Inequalities

This paper offers a realist critique of socialresearch on health inequalities. A conspectus of thefield of health inequalities research identifies twomain research approaches: the positivist quantitativesurvey and the interpretivist qualitative `casestudy'. We argue that both approaches suffer fromserious philosophical limitations. We suggest that aturn to realism offers a productive `third way' bothfor the development of health inequality research inparticular and for the social scientific understandingof the complexities of the social world in general.     

Bringing critical realism to nursing practice: Roy Bhaskar's contribution

In the context of modern nursing practice that is embedded within complex social situations, critical discussions about the contribution of major philosophers are relevant and important. Whilst nurse theorists have advanced and shaped nursing as a discipline, other major philosophers can offer much to advance nursing enquiry. In this paper, we focus on philosopher Roy Bhaskar who, amongst others, developed critical realism, a philosophy for social science which connects with how many of us think about the world. Bhaskar's work focuses our attention on the interplay between structure and agency and on the search for the causative or generative mechanisms that explain the social world. Bhaskar was interested in human emancipation, and we suggest his work is of great importance to advance understanding of complex social situations. Critical realism has already been endorsed by a range of disciplines, especially in research which focuses on real problems and acknowledges the complexities of the social world. In recent evidence from healthcare literature, there has been a surge in research using realist methodology (realist evaluation and realist synthesis), which is underpinned by the philosophy of critical realism and which offers a different perspective to understanding nursing and healthcare problems through the realist lens. However, we suggest that sufficient attention is not always paid to the philosophical roots of this methodology. In this paper, we provide insight into Bhaskar's work and demonstrate how research positioned within critical realism and realist methodology can advance nursing and healthcare‐related knowledge. Through shining a light on Bhaskar, we illustrate how critical realism philosophy is a natural fit with human and health science enquiry, including nursing.     

Critical realism in nursing: an emerging approach

Critical realism, a philosophical framework originally developed by Roy Bhaskar in the 1970s, represents a relatively new approach to research generally and to nursing research in particular. This article explores the ontological and epistemological tenets of critical realism and examines the application of critical realist principles to nursing research and practice through a review of the literature. It is evident that few published nursing research studies have, as of yet, utilized critical realism as their paradigm of choice. Both the strengths and limitations of the presentation and use of critical realism in these studies are discussed in this article. Given the varying degrees of success of the authors in explicating critical realism as a philosophical framework, the value of critical realism to the research study, and the ways in which usage of the critical realist framework influenced development of the study and interpretation of findings, it is evident that the quality of future publications espousing the use of critical realism must continue to be strengthened significantly.     

Managerialism in the Australian public health sector: towards the hyper-rationalisation of professional bureaucracies

This paper draws on qualitative case-study research to discuss the impact of managerialism on the work organisation of public sector health professionals in Australia. The case studies included 71 semi-structured interviews with a broad range of public sector health professionals (predominantly nursing and allied health professionals, with some doctors and managers). The data are used to examine the implications of managerialism for the organisation of professional (public) bureaucracies. The findings show that while health professionals were able to exert their agency to influence managerial processes, the incorporation of managerial strategies into professional practice placed constraints upon professional autonomy. The impact of managerialism on professional bureaucracies is examined using the neo-Weberian framework of hyper-rationality, an ideal type derived from a combination of four forms of rationality identified in Weber's work: practical, formal, substantive and theoretical rationality. Applied to the social organisation of health-care work, this paper critically examines the utility of the hyper-rationality ideal type, noting its limitations and the insights it provides in conceptualising the impact of managerialism on professional (public) bureaucracies.     

Managers,teachers, researchers: sharing experience in health care

The author observes that academic training is an asset for any managerial position in the health sector. As with medicine and nursing, health care management should be more evidence-based. The author argues that top managers in health care generally lack adequate internal support to rigorously evaluate strategic interventions or consultant recommendations and to learn from industrywide best practices.     

Re-connecting histories: modernity, managerialism and development

PURPOSE: The aim of the paper is to connect the field of health management to other related academic discourses (critical management studies and critical development studies) that can contribute to a more interdisciplinary approach to understanding health organizations and management. DESIGN/METHODOLOGY/APPROACH: The paper's design is theoretical critique that blends post-structural, critical management and critical development approaches into a focused discussion of modernity and its relevance to contemporary health management issues. FINDINGS: Modernity proliferates through a variety of rhetorical tropes that go unnoticed or remain invisible. Through a brief analysis of historical definitions of management and development, the findings suggest that health management could also be critiqued as a cultural and social construction, enriching anthropological studies as well as informing practical critiques of health projects in the development sector. RESEARCH LIMITATIONS/IMPLICATIONS: The conceptualisation of health-management as a cultural construct of modernity opens up the prospect for some rich empirical studies into what management practices support the scientific-rational claims on which it rests. PRACTICAL IMPLICATIONS: The critique informs a re-appraisal of health management practices that are often taken for granted and ritualistic parts of organizational life. Such a re-evaluation could lead to the implementation of more nuanced and appropriate health practices. ORIGINALITY/VALUE: Connecting management and development discourses in this way has not been done before and its relevance to health management remains under-researched. This paper highlights the way these discourses can enrich the study of health organizations and create a truly interdisciplinary understanding of health.     

Philanthropic hospitals and the operation of provider-owned health plans in Brazil

OBJECTIVE: To describe the management performance of philanthropic hospitals that operate their own health plans, in comparison with philanthropic hospitals as a whole in Brazil. METHODS: The managerial structures of philanthropic hospitals that operated their own health plans were compared with those seen in a representative group from the philanthropic hospital sector, in six dimensions: management and planning, economics and finance, human resources, technical services, logistics services and information technology. Data from a random sample of 69 hospitals within the philanthropic hospital sector and 94 philanthropic hospitals that operate their own health plans were evaluated. In both cases, only the hospitals with less than 599 beds were included. RESULTS: The results identified for the hospitals that operate their own health plans were more positive in all the managerial dimensions compared. In particular, the economics and finance and information technology dimensions were highlighted, for which more than 50% of the hospitals that operated their own health plans presented almost all the conditions considered. CONCLUSIONS: The philanthropic hospital sector is important in providing services to the Brazilian Health System (SUS). The challenges in maintaining and developing these hospitals impose the need to find alternatives. Stimulation of a public-private partnership in this segment, by means of operating provider-owned health plans or providing services to other health plans that work together with SUS, is a field that deserves more in-depth analysis.     

Ethics and resource allocation: an economist's view

This paper debates some of the issues involved in attempting to apply economic analysis to the health care sector when medical ethics plays such an important part in determining the allocation of resources in that sector. Two distinct ethical positions are highlighted as being fundamental to the understanding of resource allocation in this sector -- deontological and utilitarian theories of ethics. It is argued that medical ethics are often narrowly conceived in that there is a tendency for the individual, rather than society at large, to form the focal point of the production of the service "health care'. Thus medical ethics have been dominated by individualistic ethical coded which do not fully consider questions relating to resource allocation at a social level. It is further argued that the structure of the health care sector augments these "individualistic' ethics. It is also suggested that different actors in the health care sector address questions of resource allocation with respect to different time periods, and that this serves to further enhance the influence of "individualistic' ethical codes in this sector.     

Ethik versus Ökonomie in Public Health?

In the course of establishing the discourse of public health ethics in Germany, we discuss whether economic efficiency should be part of public health ethics and, if necessary, how efficiency should be conceptualized. Based on the welfare economics theory, we build a theoretical framework that demands an integration of economic rationality in public health ethics. Furthermore, we consider the possible implementation of welfare efficiency against the background of current practice in an economic evaluation of health care in Germany. The indifference of the welfare efficiency criterion with respect to distribution leads to the conclusion that efficiency must not be the only criteria of public health ethics. Therefore, an ethical approach of principles should be chosen for public health ethics. Possible conflicts between principles of such an approach are outlined.     

Family planning and sexual health organizations: management lessons for health system reform

Advocates of health system reform are calling for, among other things, decentralized, autonomous managerial and financial control, use of contracting and incentives, and a greater reliance on market mechanisms in the delivery of health services. The family planning and sexual health (FP&SH) sector already has experience of these. In this paper, we set forth three typical means of service provision within the FP&SH sector since the mid-1900s: independent not-for-profit providers, vertical government programmes and social marketing programmes. In each case, we present the context within which the service delivery mechanism evolved, the management techniques that characterize it and the lessons learned in FP&SH that are applicable to the wider debate about improving health sector management. We conclude that the FP&SH sector can provide both positive and negative lessons in the areas of autonomous management, use of incentives to providers and acceptors, balancing of centralization against decentralization, and employing private sector marketing and distribution techniques for delivering health services. This experience has not been adequately acknowledged in the debates about how to improve the quality and quantity of health services for the poor in developing countries. Health sector reform advocates and FP&SH advocates should collaborate within countries and regions to apply these management lessons.     

Organising through compassion: The introduction of meta‐virtue management in the NHS

This paper investigates the comprehensive compassionate care reform programme within the National Health Service (NHS) in England. Through a synoptic reading of policy documents, we show how ‘compassion’ is introduced as an overarching meta‐virtue designed to govern relationships and formal positions in health care. Invoking an ‘ethics of office’ perspective, mainly drawing on the thinking of Max Weber, we evaluate the promotion of compassion as a managerial technology and argue how seemingly humanistic and value‐based approaches to healthcare management might have unintended consequences for the quality of care and the conduct of health professionals that in some ways resemble and in some ways exceed those of the more traditional New Public Management measures, which the new compassion paradigm is expected to outdo. In the paper's final sections, we turn to the original work of the nursing icon Florence Nightingale to argue that compassion and other virtues should continuously be formulated and re‐formulated in relation to the role‐specific skills and duties of particular offices in the healthcare sector.     

Assessing healthcare digitalisation in Ghana: A critical realist's approach

BackgroundThe emergence of digital technologies within the health sector has presented opportunities for improving medical care while strengthening health systems across the globe. Despite this promise, the extent of digitalisation, especially in developing countries, somewhat remains undetermined. Such knowledge is needed to learn and shape future advances in the sector. The purpose of this study, therefore, is to explore the generative mechanisms of digitalisation in the Ghanaian health sector, in order to understand and assess the extent of digitalisation, based on the digitalisation outcomes of the respective generative mechanisms.MethodsUnderpinned by the critical realism philosophy, a single case study approach was adopted to explore the generative mechanisms of digitalisation in the Ghanaian health sector, and how the varying degrees of digitalisation are interpreted and explained in the empirical world.ResultsThe study found five generative mechanisms of digitalisation in the Ghanaian health sector. These were Standardisation, Convergence and Connectivity, Storage Systems, Financial Transparency, and Data Security. Full activation of these mechanisms revealed that the first three generative mechanisms achieved high levels of digitalisation based on the extent of organisational transformations observed after the digitalisation process, as compared to the last two generative mechanisms which were rated as average.DiscussionThis study concludes that the extent of digitalisation in Ghana's health sector is more of reality than mere perception. The demonstration of how critical realism can be used to unearth insights into the extent of healthcare digitalisation in a developing country context spells the contribution of this paper.     

What can developing economies learn from health system reforms of developed countries?

This paper outlines some general lessons developing nations can draw from the health system reform experiences of developed nations. Using the experiences of developed countries, developing countries should be better able to anticipate socio-economic changes and choose an optimal path for their health systems development to accompany those changes. Most developed countries have adopted rather common objectives and principles in their health systems because of market failure in health care; developing countries may start adopting those principles because they do not have market conditions in the first place. It is suggested that developing countries strengthen what is probably the most fundamental initial systemic asset they have: public finance. They should do so by attracting democratically, possibly through earmarked taxes, resources otherwise channelled through the private sector, competing with public finance for limited real resources. This effort can be promoted by giving consumers, mainly of high income groups and in urban areas, more say (through institutions performing the OMCC function) in the nature of care these groups have access to under auspices of public finance. Where feasible, private insurance as a major source of finance should be seen as a transitional phenomenon, giving way to the emergence of OMCC institutions which require similar financial and managerial market infrastructure. Private and competitive provision of care may be unrealistic in many developing areas because of both scarcity of real resources, mainly manpower, and health needs. The challenge of government is, as resources grow, to divest itself from the provision of care and stay involved in activities and facilities that are of 'public nature'--under specific circumstances--that foster private competitive provision. In general, the government should play an enabling role also by investing in health promotions and management skills for health systems.     

试论卫生产业的调控与经营理念

政府对产业资本的调控要通过产权结构多元化，引入市场竞争机制，提高现有资源使用和分配效率，放大有限国有资本的控制能力来管理。主管部门要以市场为导向，做到从办卫生走向管卫生，加速医疗机构的战略性调整，促进卫生产业的优化升级和提高卫生产业效益。产业发展必须服从行业发展，其目的并非是卫生资源增长，而是满足医疗服务需要。就医院经营管理而言，更应关注医疗消费的社会经济负担、公平性与资源利用效率，“以低廉的价格提供优质的服务”为改革目标，体现经营医疗服务的社会目标较其他行业更具有刚性。     

卫生经济改革对医院管理行为的影响研究

该文主要验证两项假设:卫生经济政策对医院管理行为有影响和政策决策者与医院管理者的目标有差异.资料来源于政策文件和对淄博和南通市的现场调查,分析采用以定性为主的时间序列方法.主要结论是医院管理行为对应卫生经济改革总体上时间滞后,医院经济管理将进入成熟期,卫生经济政策不能落实的原因之一是政策制定者和医院管理者的目标不一致.     

The private/public mix in health care in India

Private hospitals and private medical practitioners play a significantpart in delivering health care services in India. As the demandfor health care has increased, institutions in this sector haveexpanded widely in both urban and rural areas. The relationshipbetween patient and private practitioner considerably influencesthe perceived and actual needs about health care. This relationshipis expected to play an important role in the control of diseasepatterns and management. However, the developments in this sectorhave prompted concern about the efficiency of resources, equityand access to facilities, and the availability of financingmechanisms to support private health care. Also, the efficiencywith which the resources are used in this sector has directbearing on the cost and quality of services. The existence ofthese health care institutions therefore has profound implicationsfor the present character of the Indian health care system,and its future course. The objectives of the present study are to review the role ofthe private health care sector in India and the policy concernsit engenders. The discussion suggests that policy makers inIndia should take serious note of the growing influence of theprivate sector in providing health care in India. Policy interventionsin health should not ignore their existence and this sectorshould be explicitly involved in the health management process.It is argued that regulatory and supportive policy interventionsare inevitable to promote this sector's viable and appropriatedevelopment.     

Nightingale's realist philosophy of science

Abstract This paper examines Florence Nightingale's realist philosophy of science by comparing it to the contemporaneously dominant philosophy of positivism. It starts by adumbrating the tenets of positivism and continues by assessing the degree to which Nightingale accepted or rejected those tenets. It is argued that while she accepted much of positivism, on realist grounds she opposed its belief in phenomenalism, its rejection of speculative philosophy, its separation of fact and value, and its rejection of religion. Following an examination of how Nightingale's philosophy impinged on her approach to nursing and health care, the paper concludes with a comparison of her ideas with those of modern realism and a discussion of the contemporary salience of her ideas. It is argued that while some aspects of her approach may no longer provide an appropriate basis for modern nursing, her environmental approach, her transcendental realism, and her adherence to caring values may still be of use to contemporary nurses.     

Vertical or holistic decentralization of the health sector? Experiences from Zambia and Uganda

Many countries in Africa have embarked on health sector reforms. The design of the reforms differs considerably. A key feature of the reforms is decentralization, of which Uganda and Zambia are implementing two different models. This paper analyses the two models of health sector reform, and their implications for ultimate development goals. In Uganda, the whole government has been decentralized, with a wide range of powers and resources transferred to the districts. The health care system is part of the political set up of the country. In Zambia, only the health sector has been decentralized. Power and resources for health care have been divested to new parallel organizations. While useful lessons can be drawn from the managerial and administrative experience in the two countries, not least concerning donor coordination, it seems that neither form of decentralization has so far led to a clear and appreciable improvement of health services and, ultimately, to a clear focus on development goals, such as poverty alleviation. The conditions for this to happen are discussed in this paper.     

Analysing the hindrance to the use of information and technology for improving efficiency of health care delivery system in Tanzania

Information Technologies (IT) have been described as offering tremendous opportunity to improve health services as well as in meeting broader developmental goals which have an impact on health. Through the use of IT, healthcare sectors can potentially plan, monitor and evaluate health services as well as communicate more effectively within and across organizational hierarchies. However, a number of studies suggest several hindrances where the use of IT to bring critical change in the health sector of Tanzania has been problematic. Despite the lack of appropriate use of the existing IT resources in the health sector, donors and government have continued helping the health sector to acquire up-to-date IT resources while however placing little emphasis on long term IT training, data management and effective utilization of information resulting into wasted of such resources hence little improvement in health services delivery. This study is based on the Health Information System Programme (HISP), an action research project aimed at improving health information system in developing countries with the use of IT and information for local action. Under the project, the district health information software which is customizable, open source and freely distributed has been implemented in five pilot districts in Tanzania. The lessons learned from HISP project and other levels of the health sector in general indicate the lack of skills for data interpretation and utilisation, policy guidelines on information and human capacity building as well as a lack of flexible system.