Over the last 10 years, complexity theory has revolutionized health policy and systems research (HPSR). One of the implications of complexity theory for health systems is that individual behaviors are, to an extent, manifestations of underlying system dynamics. If you observe a provider behaving in an undesirable way, such as a not following clinical guidelines, it is not necessarily a problem with that individual’s knowledge or skills – rather it can be that their behavior is a ‘product’ of perversities in the underlying system.

To understand how complex system dynamics affect individual behaviors, health system researchers are increasingly turning to ethnographic research methods. The journal Social Sciences and Medicine is publishing a special issue on health system ethnography – see the overview here: The anthropology of health systems: A history and review – PubMed (nih.gov). Colleagues from my former organization and I have co-authored a paper in this issue on the results of a focused facility ethnography in India – How performance targets can ingrain a culture of ‘performing out’: An ethnography of two Indian primary healthcare facilities – ScienceDirect. The study sought to understand ‘know-do gaps’ – why providers missed or inadequately conducted routine clinical practices that they had the knowledge to do. In this post I briefly describe the methods and key findings.

Our ethnographic methods

Ethnographies rely on immersion in a context to observe behaviors and interactions up close. Behaviors are heavily influenced by ‘informal institutions’ – shared values, norms, attitudes, and expectations about how others will behave – that become internalized and ingrained into individuals through social learning, conformism, and cultural transmission. These often operate below the level of consciousness of individuals, who do not necessarily articulate them in standard qualitative interviews – hence the need for observations.

For our study, we embedded teams of researchers in two primary health care facilities for five month-long cycles, to try and uncover how these informal institutions shaped individual behavior and were, in turn, shaped by underlying system dynamics. Research teams spent six to eight hours daily at the facilities, five days a week. This ‘focused’ ethnographic approach is more time-bound and less resource intensive than a full ethnography but has been shown in the methods literature to be suitable for problem-specific healthcare research in contained settings. The research team in each study site included a female and male social scientist and a female qualified nurse researcher, to ensure medical and social understanding of clinical practices and language. Intervals between each fieldwork cycle were scheduled for debriefing, reflection, initial analysis, and planning, allowing each cycle to build on insights from preceding cycles.

Data collection was iterative, flexible, and open-ended. Respondents (approximately 35 per facility) were interviewed repeatedly, coupled with shadowing, observations of staff and staff–patient interactions, direct observation of service delivery, and post-event clarifications. To ensure standardization of approaches across these methods, 24 tools were developed. Data from labor room ledgers, case sheets, facility-wide service-related documents, rosters, attendance registers, government circulars, orders, and district-level staff interviews were triangulated to obtain in-depth insights over time. Inductive, theory-based analysis used a dynamic response model framework that sought to explain differences between how things should and did function, bringing in lenses from complex adaptive systems and sociological theories of practice, such as those of Bourdieu.

Findings

This research illustrated how individual provider behaviors, such as using a partograph during delivery or checking for retained placenta post-delivery, were influenced by ‘know-do gaps’ as a result of underlaying factors. These include lack of resources, misguided performance management systems, and perverse informal institutions – all of which interacted in complex and reinforcing ways.

Facilities chronically lacked resources, with population catchment areas disproportionately larger than intended, and deficient supplies and equipment. There were very few doctors or staff nurses, with auxiliary nurses, originally recruited to manage community preventive care, de facto managing most deliveries with limited oversight. The number of cases per nurse made following formal protocols and using partographs impossible.

Despite this lack of resources, facilities were allocated service delivery targets that were unachievable, and staff were punished (e.g., through salary deductions and other formal and informal sanctions) if they were not seen to meet them. This performance management system stemmed from a complex political economy that prioritized the right numbers over actual patient outcomes, against targets grounded in commitments to global goals rather than contextual realism.

Such unrealistic targets created the conditions for facility staff to ‘perform out’ as a coping strategy, by falsifying records (e.g., retrospectively filling in partographs), manipulating data, and creating the illusion that targets had been met. These behaviors were implicitly validated by managers and administrators. Over time, providers became habituated to a culture of performing out, which became part of their internalized behavioral dispositions, contributing to a systemic orientation towards sub-par performance and low quality of care.

Implications

It would be easy to observe poor clinical practice, assume that this was due to a lack of provider knowledge and skills, and design well-meaning interventions such as the provision of trainings and job-aids. However, in this context, poor adherence to clinical processes were a symptom of underlying systemic challenges, and these interventions would have likely had limited long-run impact unless those underlying systemic causes were also addressed, including the lack of resources and misguided performance management and reporting processes.

This research shows the value of using ethnographic methods to better understand the causes of problematic individual behavior in complex systems. In particular, the informal institutions – in this context, a culture of performing out – that shape individual behavior are more easily understood through immersion and observations. Without this understanding, there is a risk of designing well-meaning, ineffective interventions that target only the individual symptoms of underlying, systemic problems.

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