Governance determinants of health: exploring the structural impact of politicalization, bureaucratization and medical standardization on health inequity

Limitations

Our discussion in this article is innovative as it seeks to develop a framework that targets power dynamics inherent in GHDs to help identify and avoid GDHs that may promote unequal access to healthcare and prompt health inequity. However, this framework has limitations as the real-world, blurred and intertwined aspects of governing instruments are simplified for analytical purposes. As such, it risks overestimating the boundaries between the separate instruments and reducing the complexity of how the GDHs work in practice. Consequently, this kind of theory-driven framework does not do justice to the myriad of peoples' complex empirical practices where GDHs may overlap and intertwine with each other. Nevertheless, this framework can still help assist governing authorities in imagining a direction for the impacts of GDHs on health equity, so they can take precautionary steps to avoid adverse impacts.

Politicalization

In principle, all care and treatment provided in the primary- and specialist healthcare can be subjected to an explicit political prioritization process. Healthcare provision can become a matter of political negotiation, in which strong lobbying bodies or funders are needed to raise the concerns of distinct patient groups, interventions or diseases, for instance, HIV/AIDS and childhood vaccination in low-and middle-income countries (Khan et al., 2018), and rare types of cancers in high-income countries. Patients with conditions that are not represented by supporting lobbyists and who are not likely to voice their own needs may end up with a low priority in the system. As far as this typically applies to health issues linked to socio-economic status (e.g. obesity), the organization of ad hoc funding based on political negotiations on a case-by-case basis cannot be prioritized and thus reproduce social health inequality at the access point. Alternatively, political principles for fair distribution, instead of pushing for decisions during negotiations, can be adapted to consistently organize the prioritization process (cf. principles for priority setting in the healthcare system). In that case, negotiation will concern the principle rather than the substantial healthcare made available. The system can then avoid reproducing health inequity at the point of care only so far as the diseases and conditions that merely correlate with the socioeconomic disadvantage are captured by the politically supported principle of distribution. Moreover, the distribution of healthcare can to a large extent be expanded and differentiated by decisions made by non-healthcare professionals, e.g. policymakers deciding what shall be provided, who shall get it, where and when (transition 1 in Box 1). Then the task of medical personnel would be to identify the patients the criteria apply to and carry through the interventions. This was described in the empirical example of Burkina Faso where the policy of increasing the proposition of birth at the institutional level produced adverse effects in the local context. The impact on social inequality within such a healthcare system will depend on the substantial content of the policies. Distributional policies can be designed to level up the health of those who are worst off by prioritizing care that would benefit these groups the most, as in Burkina Faso, where policies subsidizing the out-of-pocket costs for the economically worst-off, pregnant women and young children as a group have been implemented in the last decades (Ridde, 2008; Ridde et al., 2011). The challenge then would be to avoid levelling down the health of those who are initially better off by not providing the care they would benefit from as resources are scarce.

There are good reasons to believe that non-medical, socioeconomic factors can influence people's ability to benefit from otherwise standardised treatment and should be discretionarily assessed on a case-to-case basis. The more political regulations expand into new areas of healthcare distribution (e.g. into the clinical area) or become more and more specified concerning who should get healthcare, what they should get and when they should get it, the less room there will be for individual adjustments according to individual judgment, and the more standardized the available interventions have to be (since political regulations come as policies). This would mean that input equality – equal cases get the same – is promoted rather than outcome equality. Since reaching outcome equality is a prerequisite for avoiding health inequity within the healthcare system, at some point expanding and differentiating healthcare distribution by political regulation will run the risk of reinforcing health inequity at the point of care.

Furthermore, leaving healthcare decisions, and conflict resolutions, to the field of political negotiation, may not always guarantee any protection of the needs of the socioeconomic disadvantaged. Many other concerns than the conflict in question may influence political decision-making (e.g. media attention, historical decisions, lobbying efforts, access to funding etc.), thus principled ways of determining conflict so that social health equality is promoted cannot be expected. On the other side, if we do not leave it to a political area of decision-making, what would an alternative look like? If the conflict resolution is subjected to other decisions –making agents such as experts, representatives of the pharmaceutical industry, or simply market mechanisms, basic principles of democratic decision-making processes are violated, and we lose the possibility to influence the fair distribution of healthcare according to legitimate principles subjected to democratic control. Increased political power in the distribution of healthcare (as contrasted with formal authority) may have all the adverse impacts on social health inequality already pointed out above. However, if power here refers to the capacity of the political system to influence decision-making carried out by others, political attention on social health inequality may indeed have a positive impact. Political efforts can be made outside the healthcare system to eradicate “the causes of the causes” and political work can be directed to ensure the training of healthcare personnel with a focus on their role to combat unwanted reinforcement of the social inequality within the system.

Finally, if people increasingly tend to think of themselves and their conditions in terms of being an issue for political negotiation (transition 4 in Box 1) on increased legal framing

Then the rhetoric of illness and health care needs must be expected to become increasingly important as well as well-developed argumentation skills. Again, to be able to master political regulation of healthcare distribution in this sense would likely benefit from having education, a merit people who are socio-economically disadvantaged typically lack. Consequently, the healthcare needs of the socioeconomically worst-off may pass unnoticed and social health inequality is reinforced by the healthcare system itself.

Bureaucratization

While political regulation denotes political decision-making by elected politicians or designated political bodies about technological and medical treatments to offer within a healthcare system, bureaucratization refers to a rationalization process emphasizing specialization, division of labour and impartial procedures. The process requires calculability and predictability and embraces society in general and not only state administration (Calhoun, 2002). The logic of bureaucracy is the capacity to make predictable and fair decisions based on population needs (Weber, 1978). Equity is thus a fundamental underlying value of bureaucracy. In this way, bureaucracy is essential for a “good government” that is not based on shifting political interests and employees' subjective judgements that may violate citizens' rights.

Bureaucratic rules can be established to channel patients to the right services (either from outside and into the system or in between services within the system). If it is cumbersome or difficult to get in touch with healthcare personnel in the first place, people who enjoy social contact with health professionals will have the opportunity to filter out when and where one really should make the needed efforts to establish contact and when one does not. If bureaucratic barriers increase people's aversion to seeking healthcare assistance, this may imply socially related, unequal access for serious conditions. Our Burkina Faso example illustrates a potential bureaucratic barrier when women will have to present their antenatal care card to access a facility birth. In the absence of such a card, they could be denied access to the facility, or be charged an extra fee (fine). Consequently, a lack of bureaucratic understanding of the system may result in unequal access to health care typically affecting patients who are socio-economically disadvantaged.

Another scenario is an increased recording and documenting of medical decisions that produce more paperwork for the individual health worker as part of an expansion and differentiation of bureaucratic regulations and procedures of accountability (transition 2 in Box 1). Increased focus on accountability in healthcare performances leads to less time for healthcare personnel to focus on patients' life conditions and non-medical circumstances but also on carrying out medical care and procedures. In areas with health worker shortages, like Burkina Faso, increased bureaucratization has the visible cost of coming at the direct expense of clinical care able to improve patients' immediate health outcomes. Subsequently, more demands on being accountable redirect health personnel's attention towards bureaucratic rather than patient-oriented, clinical practices. One could also expect that more weight put on the conditions of formal procedures in conflict situations may benefit those with skills to take advantage of the system. Persons with the skills to understand the underlying rationales for the procedures and with the capacity to make counterarguments to the very same conditions or the substantial discussion would be more likely to benefit from such a system than those who lack such capacities.

Bureaucratic reforms and managerialism may have a considerable impact on medical practice as it is likely to reduce medical professional power. Managerial strategies attempt to systematically control medical work along with the development of new methods of financing and emphasis on performance indicator systems represent changes to the role and boundaries of medical professionals' jurisdiction. The focus on improving the average induced by quantifiable indicators can lead to a focus on the easy-to-reach, at the expense of the worst-off. The latter demands more time and resources when providing the same services. It would be easier and more cost-efficient to vaccinate people with permanent residence than nomadic groups, for example. Managerial and bureaucratic intrusion may represent a rationalization of medical reason and practice determining “what to do when in what way and with what means” (Andri and Kyriakidou, 2014, p. 636). Undermining professional autonomy through extending managerial jurisdiction over the content and context of work may also imply that the experiential knowledge of clinicians is detached from frontline practice and the competencies required for adequate patient treatment (Waring and Currie, 2009). The empirical case describes how healthcare workers tried to fulfil national and local policies for a more institutional birth practice with bureaucratic means. This goal of increasing the number of women giving birth in a health facility and the instruments employed to achieve led women into experiences of pressure to use facility care and of sanctions when not complying with the practice. Consequently, this bureaucratization of healthcare practices masks problems in service provision and fails to address the realities experienced by frontline health workers and their often-disadvantaged patients. Furthermore, it marginalizes women with already poor access to facility care and contributes to worsened health outcomes and health equality. Finally, a lack of professional discretion to consider needs according to non-medical circumstances may lead to less beneficial, individualized care for the socioeconomic worst-offs. At a general level, framing in terms of bureaucratization can be expected to foremost benefit those who have the understanding and skills of how to cope with bureaucratic regulations and procedures and thus recognize their opportunities within a bureaucratic discourse. Choosing (within one's range of opportunities) the best health facility for treatment requires knowledge of how to access information about the availability and quality of the treatment in question at different healthcare institutions. Bureaucratic regulations and managerial accountability may lead to the development of indicators or activities that are poorly patient-oriented, as our Burkina Faso example discloses. However, the conceptualization of increased conflict resolution regarding the law is not easily translated into a justified structure that concerns other regulation areas because of the overriding, normative status of legal norms relative to other regulations within constitutional states. In the lack of substantial legal regulations that would settle the issue, it is imaginable that established committees, bureaucratic discretion, or medical expertise could increasingly be called upon to solve conflicts within healthcare, a process comprehensively described by Rose (2002).

Medical standardization

Medical standardization refers to any action taken to shape clinical practice according to an evidence-based standard, such as medical practice guidelines for primary care issued by health authorities and protocols for treatment procedures in hospitals. Standardization based on evidence could mean less room for judgment based on practice experiences and the “art of medicine”. When health personnel work in line with a more “evidence-based” medicine and are required to account for their activities in terms of medical guidelines it becomes harder to use practices that are difficult to standardize and evaluate. Also, with standardization, the opportunity for patient lobbying is reduced. How this would affect social health inequality depends on several factors. One factor would be the degree to which the evidence/medical guidelines is/are individualized. While a low degree of individualization of evidence and guidelines would lead to equality of access to services but not necessarily an equal outcome, a high degree of individualization could imply unequal access but an equal outcome in terms of health. Whether increased standardization would enhance the level of health of disadvantaged patients, depends on at least two distinct matters: whether health workers practising discretion distribute services by compensating for “less knowledgeable” patients' increased need for services to benefit as much as other patients or whether they today are lured by “knowledgeable” patients to admit them the most or best services.

It is difficult to increase standardization for specific patient groups, such as patients with psychiatric disorders or a high degree of comorbidity, (which often applies to older patients) because the evidence of the effect and efficiency of different treatments is lacking. If treatment is standardized despite lacking evidence of medical effects and the feasibility of the intervention for some patient groups, one would expect that treatment becomes less effective (and efficient) for these groups, increasing social health inequality. The Burkina Faso case shows that when guidelines refer all women under the age of 18 to the district hospital from the local health centre to give birth, social health inequality increased rather than decreased as women with limited financial assets reduced their opportunity to access health centres. However, if standardized guidelines can replace inadequate judgment, people with low socioeconomic status living in deprived areas with poor access to highly qualified healthcare personnel may benefit more than people in prosperous areas from receiving standardized care. In many low-income countries, standardization of tasks and task-shifting from medical doctors and nurses to lower-level health workers has increased access for disadvantaged groups living far from health facilities (see for example Bereket et al., 2017 on sepsis treatment by Health Extension Workers in Ethiopia). In this sense, standardization may imply less inequality across socioeconomic groups. One could also expect less disagreement between patients and healthcare personnel when treatment is based on standardization and authoritative knowledge of more experts than the doctor in front of the patient. This could again lead to less scope for resourceful patients to argue for a disproportionate part and therefore ultimately lead to less social inequality of health (potentially at the unfortunate price of levelling down the health of the better-offs).

Nevertheless, increased power to evidence or expert advice implies less power to the individual health worker and less request for her professional assessment and experiences, as health care workers in Burkina Faso reported. While the subjective experiences of patient groups are sometimes included in evidence-based medical guidelines as “experienced-based knowledge”, this would still imply less room for individual patient preferences and personal experiences. Hence, increased power to expert advice would presumably decrease the scope for patients' arguing their case during the consultation, typically those patients who are ‘not fitting into standardized treatments. If the consequence is that individual needs shaped by socioeconomic factors in unique ways are not adequately comprehended and acted upon, this could mean that social health inequalities would increase.

Another challenge concerns professional judgement, which decreases in parallel with increased political regulation of the distribution (Bærøe and Bringedal, 2014). Medical personnel can assess and implement treatment according to the condition and circumstances of the individuals (Bærøe and Bringedal, 2011). This competence is crucial to ensure that the treatment provided within a healthcare system can be adjusted to circumvent social and material barriers to benefit to produce the most effective results. Structurally, this is how the healthcare system can produce outcome equality in health, i.e. making sure that people are benefitting from the treatment and obtain an equal level of health across different socioeconomic groups. If lacking room for such discretionary manoeuvring, the result of equal treatment for similar conditions can be outcome inequalities, e.g. postponing the diagnosis and reducing the opportunity to focus on recovery. Along this line of reasoning, a further consequence would be that the less discretion left for healthcare personnel to identify and act upon barriers for patients to fully take advantage of interventions, the less the possibility that patients who are socio-economically disadvantaged obtain the same health outcome that patients with the same conditions, but no socioeconomic barriers can gain (see Spangler, 2011 describing this from Tanzania). At the same time, being left with more directions is no guarantee it is used to circumvent barriers for the disadvantaged.

Framing in terms of standardized biomedicine would entail that patients are identified by their biomedical diagnosis or condition. If people who are socio-economically disadvantaged are suffering from “clusters of related health problems”, a biomedical focus on distinct diagnoses and treatment could lead to inequality in health. This is because this type of co-morbidity requires a holistic approach in terms of complex and integrated treatment and the biomedical model may be too specific/narrow to promote full effect. At the same time, if a lack of compliance with the regulations is met with sanctions the development of these regulations can also be seen to control the clinical performance of healthcare personnel.