Health systems and social values: the case of the South African health system

Health systems are complex social systems – driven by people and the relationships between them, characterised by feedback loops and path-dependency, and open to contextual influences. This entails that social values are an important determinant of health system change. In addition, health systems play a vital social role as generators of social value. However, the influence of social values on health systems is an under-explored field of study, and the evidence-based on the topic is weakened by conceptual confusion, a lack of theoretical models to support rigorous research, a dearth of empirical evidence, and methodological challenges attendant to the study of intangible factors such as values. In this theory-building study I explore the relationship between health systems and social values. Firstly, I use evidence mapping, interpretive synthesis and scoping review approaches to identify gaps in the existing evidence-base, develop an initial explanatory theory for the social value of health systems, and integrate insights from social sciences to establish a working definition of values, explore the social dynamics of values, and develop an account of the relationship between social systems – including health systems – and social values. Secondly, I conduct a case study of social values in the South African National Health Insurance policy process in its social and political context to gather empirical evidence on the role of social values in health system reform processes, and the mechanisms by which health systems shape social values. Lastly, I integrate the findings from the first two phases to develop a conceptual framework of the relationship between health systems and social values and offer methodological and conceptual insights intended to support further research on the topic. This study finds that social values, often borne out of social and political history, are cemented in health systems through daily practices and procedures. In this way, health systems serve to shape social values – by changing the way people think about what is just with respect to healthcare, their health rights and entitlements, and the appropriate role of the state in providing healthcare and regulating the behaviour of other health system actors

How fiction makes us better people: an analytic account of how fiction succeeds in being morally developmental

M.A. University of the Witwatersrand, Faculty of Humanities, 2012That works of fiction are morally developmental is a commonly accepted claim. However, works of fiction are epistemically dubitable. As such, any account of the morally developmental nature of fiction ought to be one on which moral development is conceived of as occurring indirectly. It is the claim of this dissertation that extant accounts of the morally developmental nature of fiction fail to do so. The positive thesis of this dissertation is that moral development can be brought about through an experience of irony. This dissertation employs Jonathan Lear’s account of irony on which an experience of irony can be occasioned by bringing the subject to recognise the disparity between a concept, understood as a social pretense, and the same concept understood as a human ideal. Subjective concepts, including the moral virtues, are such that exemplifying the ideal consists in being in a constant state of coming to exemplify the ideal. The virtue of mercy is explicated in full. It is shown that mercy involves firstly, paying attention to the particulars of a wrongdoing, secondly, the dissolution of negative affective responses to wrongdoing, and thirdly, a sense of moral humility. Fiction, by virtue of its narrative and mimetic nature, is capable of inducing these three states. Furthermore, by occasioning an experience of irony, fiction succeeds in drawing the reader into a state in which she is constantly striving to exemplify mercy as a human ideal. In doing so, fiction succeeds in making the reader merciful. It does so, without directly asserting any positive claims. The account is thus not susceptible to the epistemic dubitibility objection

Health system responsiveness: A systematic evidence mapping review of the global literature

The World Health Organisation framed responsiveness, fair financing and equity as intrinsic goals of health systems. However, of the three, responsiveness received significantly less attention. Responsiveness is essential to strengthen systems’ functioning; provide equitable and accountable services; and to protect the rights of citizens. There is an urgency to make systems more responsive, but our understanding of responsiveness is limited. We therefore sought to map existing evidence on health system responsiveness

What is Covid-19 teaching us about community health systems? A reflection from a rapid community-led mutual aid response in cape town, South Africa

The coronavirus disease 2019 (COVID-19) pandemic has exposed the wide gaps in South Africa’s formal social safety net, with the country’s high levels of inequality, unemployment and poor public infrastructure combining to produce devastating consequences for a vast majority in the country living through lockdown. In Cape Town, a movement of selforganising, neighbourhood-level community action networks (CANs) has contributed significantly to the communitybased response to COVID-19 and the ensuing epidemiological and social challenges it has wrought. This article describes and explains the organising principles that inform this community response, with the view to reflect on the possibilities and limits of such movements as they interface with the state and its top-down ways of working, often producing contradictions and complexities. This presents an opportunity for recognising and understanding the power of informal networks and collective action in community health systems in times of unprecedented crisis, and brings into focus the importance of finding ways to engage with the state and its formal health system response that do not jeopardise this potential

What is Covid-19 teaching us about community health systems? A reflection from a rapid community-led mutual aid response in Cape Town, South Africa

The coronavirus disease 2019 (COVID-19) pandemic has exposed the wide gaps in South Africa’s formal social safety net, with the country’s high levels of inequality, unemployment and poor public infrastructure combining to produce devastating consequences for a vast majority in the country living through lockdown. In Cape Town, a movement of selforganising, neighbourhood-level community action networks (CANs) has contributed significantly to the communitybased response to COVID-19 and the ensuing epidemiological and social challenges it has wrought. This article describes and explains the organising principles that inform this community response, with the view to reflect on the possibilities and limits of such movements as they interface with the state and its top-down ways of working, often producing contradictions and complexities. This presents an opportunity for recognising and understanding the power of informal networks and collective action in community health systems in times of unprecedented crisis, and brings into focus the importance of finding ways to engage with the state and its formal health system response that do not jeopardise this potential

How does power shape district health management team responsiveness to public feedback in low- and middle-income countries: an interpretive synthesis

Responsiveness is a core element of World Health Organization's health system framework, considered important for ensuring inclusive and accountable health systems. System-wide responsiveness requires system-wide action, and district health management teams (DHMTs) play critical governance roles in many health systems. However, there is little evidence on how DHMTs enhance health system responsiveness. We conducted this interpretive literature review to understand how DHMTs receive and respond to public feedback and how power influences these processes. A better understanding of power dynamics could strengthen responsiveness and improve health system performance. Our interpretive synthesis drew on English language articles published between 2000 and 2021. Our search in PubMed, Google Scholar and Scopus combined terms related to responsiveness (feedback and accountability) and DHMTs (district health manager) yielding 703 articles. We retained 21 articles after screening. We applied Gaventa's power cube and Long's actor interface frameworks to synthesize insights about power. Our analysis identified complex power practices across a range of interfaces involving the public, health system and political actors. Power dynamics were rooted in social and organizational power relationships, personal characteristics (interests, attitudes and previous experiences) and world-views (values and beliefs). DHMTs' exercise of 'visible power' sometimes supported responsiveness; however, they were undermined by the 'invisible power' of public sector bureaucracy that shaped generation of responses. Invisible power, manifesting in the subconscious influence of historical marginalization, patriarchal norms and poverty, hindered vulnerable groups from providing feedback. We also identified 'hidden power' as influencing what feedback DHMTs received and from whom. Our work highlights the influence of social norms, structures and discrimination on power distribution among actors interacting with, and within, the DHMT. Responsiveness can be strengthened by recognising and building on actors' life-worlds (lived experiences) while paying attention to the broader context in which these life-worlds are embedded

Strengthening research and practice in community health systems: A research agenda and manifesto

While there have been increased calls for strengthening community health systems (CHSs), key priorities for this field have not been fully articulated. This paper seeks to fill this gap, presenting a collaboratively defined research agenda, accompanied by a ‘manifesto’ on strengthening research and practice in the CHS. The CHS research agenda domains were developed through a modified concept mapping process with a team of 33 experts on the CHS including policy-makers, implementers and researchers from institutions in six countries: Uganda, Guatemala, South Africa, Sweden, Tanzania and Zambia. The process began remotely with brainstorming research priorities and concluded in a one-week workshop that was held in Zambia where priorities for strengthening CHS were discussed, grouped into domains, interpreted, and drafted into a collective declaration. Eight domains of research priorities for CHSs were identified: clarifying the purpose and values of the CHS, ensure inclusivity; design, implementation and monitoring of strategies to strengthen the CHS; social, political and historical contexts of CHS; community health workers (CHWs); social accountability; the interface between the CHS and the broader health system; governance and stewardship; and finally, the ethical methodologies for researching the CHS. By harnessing a set of diverse and rich experiences and perspectives on CHS through a structured process, a multifaceted research agenda and manifesto that transcend context, disciplines and time were developed. We posit this as an entry into greater debate and diversity in the field as we continue to find ways to strengthen research and practice in the CHS

The multiple lenses on the community health system: Implications for policy, practice and research

Community health systems (CHSs) have historically been approached from multiple perspectives, with different purposes and methodological and disciplinary orientations. The terrain is, on the one hand, vast and diverse. On the other hand, under the banner of universal health coverage (UHC) and the Sustainable Development Goals (SDGs), a streamlined version of ‘community health’ is increasingly being consolidated in global health and donor communities. With the view to informing debate and practice, this paper seeks to synthesise approaches to the CHS into a set of ‘lenses,’ drawing on the collective and multi-disciplinary knowledge (both formal and experiential) of the authors, a collaborative network of 23 researchers from seven institutions across six countries (spanning low, middle and high income). With a common view of the CHS as a complex adaptive system, we propose four key lenses, referred to as programmatic, relational, collective action and critical lenses. The lenses represent different positionalities in community health, encompassing macro-level policy-maker, front-line and community vantage points, and purposes ranging from social justice to instrumental goals. We define and describe the main elements of each lens and their implications for thinking about policy, practice and research. Distilling a set of key lenses offers a way to make sense of a complex terrain, but also counters what may emerge as a dominant, single narrative on the CHS in global health. By making explicit and bringing together different lenses on the CHS, the limits and possibilities of each may be better appreciated, while promoting integrative, systems thinking in policy, practice and research