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LSHTM Research Online Harris, Kristine; (2009) Reconciling organisational intent and local strategies an in-depth study of health workers in an urban leprosy project in India. PhD thesis, London School of Hygiene & Tropical Medicine. DOI: https://doi.org/10.17037/PUBS.00967524 Downloaded from: https://researchonline.lshtm.ac.uk/id/eprint/967524/ DOI: https://doi.org/10.17037/PUBS.00967524 Usage Guidelines: Please refer to usage guidelines at https://researchonline.lshtm.ac.uk/policies.html or alternatively contact [email protected]. Available under license. To note, 3rd party material is not necessarily covered under this li- cense: http://creativecommons.org/licenses/by-nc-nd/3.0/ honline.lshtm.ac.ukhttps://researc RECONCILING ORGANISATIONAL INTENT AND LOCAL STRATEGIES AN IN-DEPTH STUDY OF HEALTH WORKERS IN AN URBAN LEPROSY PROJECT IN INDIA BY KRISTINE HARRIS THESIS SUBMITTED IN FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY HEALTH POLICY UNIT DEPARTMENT OF PUBLIC HEALTH AND POLICY LONDON SCHOOL OF HYGIENE AND TROPICAL MEDICINE UNIVERSITY OF LONDON AUGUST 2009 For Anja, who makes everything possible. wö wýoe 5'aß ý5U For those who allowed me to walk in their shoes and see the world through their eyes. For those who dedicate their lives to social service and who work tirelessly to create the conditions in which people can be healthy. We see you. 2 1, Kristine Harris, confirm that the work presented in this thesis is my own. Where Information has been derived from other sources, I confirm that this has been indicated In the thesis. Signe Date: 14(12-101 Abstract There is growing interest in health systems research and implementation studies within public health, yet there is little in-depth research being carried out on the front-line health workers who implement interventions in the field. This study aims to add to our understanding of implementation processes through an in-depth ethnographic study conducted over a 12 month period of participant observation with field-level health workers in an urban leprosy project. The study employs a multidisciplinary approach, combining anthropological and public health methods and perspectives, and was carried out within one of India's largest leprosy organisations. The research is, in essence, a 'project ethnography' of the work and social identity of health workers, within the context of a rapidly changing policy landscape. The study argues that health workers are embedded in the structures they work within at the same time as they actively exercise agency within these structures. By understanding how health workers utilise agency within, rather than in opposition to, structure, we can come to understand health workers' social identity, as well as how they reconcile organisational intent with local strategies in the implementation process. There is a growing realisation within public health that health systems are complex social microcosms in which health workers play a pivotal role. The study argues that the application of social theory, that examines the relationship between agency and structure, will be instrumental in developing research frameworks that truly engage with the process and complexity of health systems. 4 List of Abbreviations: ANM Auxiliary Nurse Midwife - APMO Assistant Para-Medical Officer - ATP Advance Tour Programme - CBO Community Based Organisation - CHO Community Health Organiser - DCC Disability Care Clinic - DDP Drug Delivery Point - DFID Department For International Development - DLO District Leprosy Officer - DMC District Microscopy Centre - DPMR - Disability Prevention and Medical Rehabilitation FPP Frontiers Prevention Project - FSW Female Sex Worker - HAART Highly Active Anti-Retro Viral Treatment - HSD Health Systems Development Programme - IEC Information, Education Communication - ICCC Innovative Care for Chronic Conditions - ILO Indian Leprosy Organisation - ILEP - International Federation of Anti-Leprosy Associations INR Indian Rupees - IPC Inter Personal Communication - MB Multibacillary leprosy - MC Microscopy Centre - MCR Microcellular Rubber - MDT Multi-drug Therapy - MSM - Men who have sex with men NCDR New Case Detection Rate - NGO Non-governmental Organisation - 5 NHS National Health Service - NLEP National Leprosy Elimination Programme - NMA Non-Medical Assistant - OP Outpatient Clinic - PB Paucibacillary leprosy - PMP Private Medical Practitioner - PR - Prevalence rate RFT/RFC Released from treatment/control - SER - Social and Economic Rehabilitation SET Survey Education and Treatment - VCCTC Voluntary Confidential Counselling and Testing Centre - WHO World Health Organisation - UHP Urban Health Post - ULP Urban Leprosy Project - Anganwadi worker - Female community level workers of the Integrated Child Development Scheme Mahila Mandal - Local women's group Basti slum - Ayah - attender Mela fair - Chappal - sandal Table of Content Abstract 4 .................................................................................................................. List of Abbreviations: 5 ............................................................................................ Table of Content 7 ..................................................................................................... Index of Figures: 11 .................................................................................................. Index of Tables & Photos: 12 ................................................................................... Acknowledgments 13 ............................................................................................... Introduction 14 .......................................................................................................... Framing the research question 20 ................................................................ 1.1 Anthropology, Health Workers and Leprosy 21 .......................................... 1.2 Public Health, Health Workers and Health Systems 27 ............................. 1.3 Implications and Applications 31 ................................................................ 1.4 Defining a Conceptual Framework 35 ........................................................ 1.5 Refining the Conceptual Framework 37 ..................................................... 2. Me and Methodology 41 ....................................................................................... 2.1 Getting Situated 41 .................................................................................... 2.2 Participant Observation 42 ......................................................................... 2.3 Informal Interviews 44 ................................................................................ 2.4 Time-Series Analysis Methodological Mix-up 46 - ..................................... 2.5 The Mighty Pen Stroke, the Photo and the L-word 47 ................................ 2.6 Me, Myself & I: Ethics, Loyalty and Reflexivity 49 ...................................... 2.6.1 Participant Objectivation 50 .......................................................... 2.6.2 Who ArnIto You? 51 ................................................................... 2.6.3 Ethics beyond Consent - Elephants and Universities ............. 52 3. Stepping Into the Field 59 .................................................................................... 3.1 Leprosy in the Library with the Lead Pipe 59 ............................................. 3.2 Urban Leprosy Project - History, Organogram and Status Quo ............ 62 7 3.3 Location, Location, Location 68 .................................................................. 3.4 Urban Leprosy 71 ....................................................................................... 3.5 Hyderabad as Mega-City 73 ....................................................................... 3.6 To the Sound of the Azaan 75 .................................................................... 3.7 Health Care in the City 76 .......................................................................... 4. Health Work and the Health Worker 82 ............................................................... 4.1 All in a Day's Work 82 ................................................................................ 4.2 The Health Worker 89 ................................................................................ 4.3 "When I first started working here I had no moustache" 92 ........................ 4.4 Unity and Diversity 94 ................................................................................ 4.5 'We are family' Loyalty to the Organisation 96 - ........................................ 4.6 Assimilate, Integrate, Conform 100 ............................................................ 4.7 Walk the Line: Party Line and 'Wrong Notions' 103 ................................... S. Mapping the Dance Floor. Policy, Process and People 107 .............................. 5.1 Leprosy through the Ages in Policy and Practice 107 ................................ 5.2 Discourse, Development, Definitions and Drivers 112 ............................... 5.3 No Discourse is an Island 117 .................................................................... 5.4 Dominant Discourses 118 .......................................................................... 5.5 and Emotive Narratives 124 ... .................................................................. 6. Social Identity and Restructuring 131 ................................................................. 6.1 The Times They Are A-Changin .......................................................... 131 6.2 From 'Dr. Patches' to 'Jack of all trades' 137 ............................................. 6.3 From Pillars to Millstones 138 .................................................................... 6.4 Stigma of Leprosy Work - New Men for a New World ........................ 141 6.5 No Room in the House We Built 143 ......................................................... 6.6 The Room to Roam - The World of Health Workers ........................... 146 6.7 Social Identity and Nostalgia. 'We were warriors... ' 151 ............................ 6.8 Alternative Discourse as Technology of Seif 153 ....................................... 8 7. Judicious Agency. That Thing that They Do 156 ............................................... 7.1 Above and Beyond... Duty, Social Service and Necessity 159 .................. 7.2 Double-Edged Sword 169 .......................................................................... 7.3 Building Rapport 171 .................................................................................. 7.3.1 Tricks of the Trade 173 ................................................................. 7.3.2 The Simple Things in Life 176 ...................................................... 7.3.3 Street Cred............................................................................ 178 7.3.4 Access, Potential & Process 180 .................................................. 7.4 Qualitative Work in a Quantitative Reporting Structure ....................... 184 7.5 The Secret Ingredient 187 .......................................................................... 7.6 Off the Cuff and On the Fly 189 ................................................................. 7.7 1 See Multi-Dimensional Health Workers 191 ............................................. 8. Manipulative Agency 200 ..................................................................................... 8.1 Working to Targets, Working around Targets 200 ...................................... 8.2 28 Days Later 202 ..................................................................................... 8.3 Let the Record Show 206 .......................................................................... 8.4 Manufacturing Compliance 212 .................................................................. 8.5 IMPRO-WISE: Now, Add a Pinch of Jugaad 213 ....................................... 8.6 Beyond the Incidental 216 .......................................................................... 9. Organisational Culture Considering the Framework 218 - ................................ 9.1 Power Play Organisational Culture 6 la Geertz 220 - ................................. 9.2 Be the Change 222 .................................................................................... 9.3 Fashion Victim The Financial Imperative and Re-structuring 223 - ............ 9.4 No Open Doors in the Chain of Command 226 .......................................... 9.4.1 Shooting the Messenger 227 ........................................................ 9.4.2 Opportunity to Determine Representation 229 ............................. 9.4.3 "Not in India, no? " 231 .................................................................. 9.5 United we stand, divided we fall 234 .......................................................... 9.6 Rising to the Occasion Insight through Implementation 236 - ...................
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