Social
Science and Health Research
Contributions
to Academia and Social Policy
CONCEPT
NOTE
Over
the last decade, health care and health care systems have been under debate all
over the world and especially in developing countries. This has prompted in
turn wide ranging efforts to understand health care systems, why some work and
some do not, what determines health status, how social and economic biases and
political factors affect access to care, and so on. Conventionally, much of the
research on health was the domain of the medical fraternity. More recently in
India, the perception that health status, health care and systems of delivery
are determined by complex linkages that are themselves determined by social,
economic and political factors has seen the involvement of social scientists in
health research. This seminar is to examine the contributions of social science
in this area and to move towards understanding issues and problems that have
challenged social scientists in the course of doing health research.
In modern times, the control over the health
care systems and services has been with the medical fraternity. Traditionally,
healthcare all over the world had a strong basis within the social milieu and
healthcare provision and providers had clear social responsibilities. Personal
healthcare was largely =handled
within the immediate community setting by well-defined set of providers who
were trained based on traditions running through family or caste lineages.
Institutional care was invariably a state supported activity or a charitable
intervention. In such a setting, information and data were an integral part of
the social milieu, and part of state records wherever state interventions were
there. In some parts of India, for instance, there was the jajmani1 system within which various healthcare
providers operated giving services on demand and were socially supported
through the system of jajmani obligations. The knowledge systems were largely
local though there is evidence of exchange of knowledge about healthcare as
material trade expanded with progress of human history.
After
the industrial revolution and the concomitant changes that it brought about in
the process and systems of production, the widening of the arena of knowledge
production, the emergence of a new scientific temperament in all spheres of
life, including healthcare were affected. At one level Public Health emerged as
an independent discipline to deal with environmental health, control epidemics
and develop preventive and promotive health strategies. At another level
medical care to cure sickness got organized on the basis of new scientific
evidence.2 Both moved in a direction of
centralized control, the former largely by the state through a public health
bureaucracy and the latter largely by civil society, but often with substantial
public (including charitable) support, through centralized medical education,
medical associations and the pharmaceutical industry. The common element in
both the streams was that medically qualified people controlled them, even
though in case of public health, civil servants may have often played a key
role. This hegemony of the germ theorists was broken by the likes of Rudolf
Virchow3 and Henri Sigerist4
from the public health side and Talcott Parsons5
from the social sciences who reiterated the social basis of illness. Parsons
redefined the sick role and this laid the foundation for health services
research outside the public health and medical systems. Parsons' work, and
later the setting up of the National Institute of Health in 1940 in the USA,
paved the way for social scientists to develop health services research
separate from the medical perspective.
Within
health service research in the US, there were clearly two schools of thought.
The first one was the functionalist approach which followed Talcott Parsons and
focused on sick role, doctor-patient relationships, culture of medicine, etc.
The second was the structuralist approach which looked at systems, access and
equity questions.6 While the former
approach was largely drawn from social anthropology, the latter focused on the
political economy foundations of health services. The structuralist approach
got consolidated on the eve of World War II. Continental Europe had already
seen the emergence of compulsory health insurance post-Bismarck, which began in
Germany/Prussia and spread to other parts of Europe. But it was in New Zealand
that the first National Health System got established as early as 1935 and
post-war in the United Kingdom.7 So both
these models of healthcare provision began to spread across Europe and the rest
of the world since then and the emergence of these health systems has spawned a
lot of research on health services. There is also the US model that continues
with the system of user-fee and/or private insurance-based healthcare
provision. While India and a number of other countries with poor health
outcomes have been following the US model largely, there is considerable debate
about the appropriateness of these models.
Thus over the last five decades health services research has
developed in the above context. The major thematic areas of research may be
divided into the following categories:
·
Health systems
·
Health Financing
·
Healthcare access and utilization patterns
·
Evaluatory and operations research
This is not an exhaustive categorisation and also a lot of
research would cut across above thematic areas as well as overlap with other
research areas like epidemiological research, behavioural research, and policy
research. Also many sub-themes have emerged over the years as independent areas
of research like reproductive health and sexuality, family planning, primary
healthcare, HIV and AIDS, urban health, etc.
In
India, research has largely ignored the structural dimensions of the health
services, focusing more on functional and operational elements. This has
largely led to a program based approach rather than comprehensive systems based
approach to healthcare services. Also, the obsession for population control
(fertility reduction) has directed all energies within the public health system
towards that goal. And this is true of health services research through
development of population research centres. Does this approach need to
change? Do we need to introduce a
rights based approach? What are the
challenges social scientists face in attempting to study such issues as uneven
access, linkages between economic status and nutrition status and its impact on
well-being, campaigning for better regulations, etc? The seminar will look at
this dimension of social sciences in health research through select examples of
research themes which should drive health policy in India in a direction of
establishing universal access to healthcare. The following themes were
presented and discussed:
1. The political economy of
health systems: A social science perspective-
Hilary Standing, Institute of Development Studies, Sussex, U.K.
2. Poverty
and Health: Reflections through nutrition studies - Neeraj Hatekar, Dept of
Economics, University of Mumbai, Mumbai
3. Restructuring
and regulating health systems - Ravi Duggal, CEHAT, Mumbai
The
seminar was held on the 22nd of December, 2004 between 10 am to 5 pm at the
ICSSR Centre, University of Mumbai (Kalina Campus), Santacruz East, Mumbai. The
tentative schedule is as follows:
PROGRAMME
AGENDA
1
The jajmani system was
a set of economic interrelations across caste groups in the local community
which had social sanction and linked to it mandatory social obligations. While
at one level it facilitated economic organisation of the local community and assured
livelihoods within both productive and service sectors, at another level it
also restricted occupational mobility because occupational assignment under
such a system was caste based, especially for service occupational categories.
Hence the jajmani system also kept intact the economic basis of the caste
system. Today it is largely destroyed but may be found in pockets in most
states, but especially the Hindi heartland.
2
It was Anton van
Leeuwenhoek, a Dutch cloth merchant and amateur lens grinder, as early as
1670s, who first made and used lenses to observe living micro-organisms. Making
these lenses and looking through them were the passions of his life. Much later
in mid-19th century Pasteur, Lister, Koch, Semmelweis made remarkable
contributions in germ theory (JG Black : Microbiology - Principles and
Applications, Prentice Hall, New Jersey, 1996)
3
In 1859 Virchow was
elected to the Berlin City Council on which he dealt mainly with such public
health matters as sewage disposal, the design of
hospitals, meat
inspection, and school hygiene. He also designed the new Berlin sewer
system.(http://www.vet.ksu.edu/depts/dmp/personnel/faculty/virchowbioe.ht
m)
4
Sigerist, a medical
doctor and an authority on history of medicine, had spent years conducting
comparative studies of ancient and modern medical cultures, and eventually
concluded that medicine must undergo an evolutionary process that ends--by
necessity--in socialized medicine. He was one of the first to publicly support
compulsory health insurance in the USA.
(http://www.jhu.edu/~jhumag/0400web/25.html)
5
Talcott Parsons: The
Social System, Free Press, Illinois, 1951
6
William Cookerham:
Medical Sociology, Prentice Hall, New Jersey, =
1978; Rene
Dubos: Man Medicine and Environment, Mentor, New York, 1969; =
Brian
Abel-Smith: An International Study of Health Expenditure, WHO, =
Geneva, 1967
7
Brian Abel-Smith: An
introduction to Health: Policy, Planning and =
Financing, Longman, London, 1994