How performance targets can ingrain a culture of 'performing out

An ethnography of two Indian primary healthcare facilities

Dados Bibliográficos

ID4595393
AutoresPriya Das (0000-0002-3449-7516, autor correspondente), Tom Newton-Lewis (0000-0002-8488-5226), Karima Khalil (0000-0001-5600-4682), Madhavi Rajadhyaksha, Phalasha Nagpal (0000-0001-8467-7788)
Ano2022
Volume300
Páginas114489
Data de publicação2022-05-01
Peer ReviewedSim
Open AccessSim
TipoARTICLE
PeriódicoSocial Science & Medicine (JOURNAL)
Identificadores do periódicoISSN: 0277-9536 • E-ISSN: 1873-5347
EditoraElsevier BV (PUBLISHER)
DOI10.1016/j.socscimed.2021.114489
PMID34702616
OpenAlexW3205658968
IdiomaEN
Citações recebidas8
Referências citadas35

Low- and middle-income country health systems often apply decontextualised and unrealistic performance targets to facilities. This can lead to empty compliance and 'performing out', whereby managers and providers manipulate or inflate data to create the false impression of a functional system. While this is a well-recognised pitfall of audit-style performance accountability processes, the social processes by which these practices emerge has not been well described in the literature. In this paper, with a focus on maternal and newborn care, we seek to better understand how and why the practices of 'performing out' occur, and their implications for health system functioning, organisational culture, and quality of care. We do this through a focused facility ethnography undertaken in two primary healthcare facilities in an eastern Indian state, anonymised as Esma, where practices of 'performing out' are prevalent. We draw on the understanding that health systems are complex adaptive systems encompassing both hardware and software elements, where individual behavioural practices are an outcome of the system as a whole. To unpack how the dynamic interactions between system elements and agents influence individual behaviours, we draw upon the sociological theories of practice of Bourdieu, encompassing the concepts of field, habitus, and capital. This lens helps illustrate how resource scarcity, unyielding application of unrealistic targets with punitive sanctions for non-achievement, and complex power dynamics lead system actors to manipulate data and create documentation to show the achievement of targets that were not actually met. The practices of 'performing out' are shaped by, and in turn shape, the organisational culture of the facilities, with perverse behaviour becoming part of an entrenched habitus - the 'dispositions' of agents that guide behaviour and thinking. In the longer term, the habituation of 'performing out' contributes to a systemic orientation toward sub-par performance, undermining quality of care

Accountability · Audit · Business · Economic growth · Economics · Ethnography · Habitus · Health care · Knowledge management · Political science · Public relations · Scarcity · Sociology · Computer Science · Global Maternal and Child Health · Islamic Finance and Banking Studies