Alicia Stolkiner and research team PT48 UBACyT
Research and Health Policies: including the social actors in research
Institution: Secretariat of Science and Technology of the Buenos Aires University
Address: Conde 665 (cp1426) Buenos Aires, Argentina.
Phone / Fax: (54-11) 4555-7365
I am grateful for this opportunity to participate in this meeting with you. The question that brings us together � is there any possibility of developing and supporting public health care in a neo-liberal environment? — is central to any research in the field of health and is the heart of any study dealing with the Reform of the sector.
The objective of this presentation is to share with you some thoughts about problems that are inherent to research in the area of health. To do this I will focus on three main questions: the delimitation of the field of research in health, the inclusion of the actors in the investigation process and the reflexivity exercised upon the practice of research in this area.
This proposal arises from a work carried out during six years by an interdisciplinary research team, of which I was the director and which was formed through an agreement between an academic unit (the University of Buenos Aires, Argentina) and a health care service provider (the SAMIC-Eldorado Hospital, in the Province of Misiones). The team included staff members of both institutions .
The group analyzed the impact of the transformation of health care services in the health-disease process in a small border town. The purpose was to assess the unique effects of the reform on small units, without the usual dissociation between a macrosocial and microsocial analysis. The study also included health care workers in order to identify the tools that would facilitate their development as social actors in the transformations in course.
Different levels of analysis were used: firstly, the transformation of the State and the Reform of the Health Care Sector in Argentina to set the contextual framework, then, the particular manner in which the Reform was implemented in the Province of Misiones and finally, a specific assessment of the effects of the transformation in a small border town Municipality. Our aim was to shape and to express the discourse and characteristics of the two key potential actors: workers and users of Health Care Centers.
The methodology combined quantitative and qualitative data production techniques. It included surveys, documentation and interviews. Following research tendencies in health systems and services, the study aims to relate the academic activity to political decisions about sectorial policies. But the core of the methodology was the participation of the health workers included in the research team. The participation of these health workers in the research process favored their empowerment as actors that produced political effects at local level.
The partial results of the research were presented at the last IAHP- Europe meeting in Barcelona ( Stolkiner y otros, 1999) and they show tendencies confirmed in the final field research.
Final results show deep transformations in the uses of the services by poor users and in the performance of the sector workers. These transformations imply changes in practices and social representations. There is a great gap between the statements of the reform, and what happens in the daily lives of the poor. When accessibility barriers increase, poor users develop alternative care strategies, but tend to abandon previously acquired service user habits and in some cases even accept death without medical assistance as the natural destiny of their lives. (Barcala y Stolkiner, 2000). Besides, the practices and ways of participation of the sector workers are also modified ( Contreras A. y Radunski P, 2000).The small unit that was studied shows the effects of an extreme use of mercantile logic in an area that is irrelevant as a market. The attempt to have a financially self-sufficient Hospital and to eliminate Government funding, dismantled all types of primary care, the most necessary one given the population profile in the area.
The last ten years of State reform in Argentina seem to indicate that the development of public health, even just the conservation of public health appears to be impossible within this context. But our experience does not necessarily have to be yours. Inspite of this it is good to remember that , as I said in Barcelona, our experience can be a paradigmatic example for you.
An example of what happens when the forces of civil society are weak and democracy can not limit the voracity of financial power and the national economic power groups related with it. The major interest of the most powerful actors in the Argentine health system reform is not the people�s health. The fundamental principles of the adopted reform are foreign to the health-disease process of the population. It should be noted that some of the main motivators behind all this are based on the needs of the economic model: to ensure an equilibrium in government accounts, making them independent of health care costs, to reduce labour costs and to generate investment opportunities for international investors (Gonzalez García, G. and Tobar F.; 1997).
As Mario Borini (1996) wrote, the key objective of the process is to legitimize the appropriation of the surplus that the health care funds could generate. The goal is to have less expenditure than financing as a means to legitimize the profits of the banks and insurance companies. It is the author’s opinion that the ultimate goal is an extreme financial logic (at the expense of private hospitals and mainly professional medical fees) to legitimize the appropriation phenomenon. The competition, in which all the subsectors would be involved, including state-owned hospitals would be a function of the goal to reduce costs and allow a surplus production.
In spite of this situation, at decision levels and in the academic world, the discussion tends to focus on technical and administrative issues. The adoption of innovative management and marketing techniques, quality control standards, etc., have replaced the profound analysis and a realistic assessment of the future for the health care system. Inasmuch as the goals of the transformation are external to the system, a double discourse is generated. It seems that researchers must serve this logic without being critical of it or they will be accused of being �ideologists� without any practical proposals.
We are therefore obliged as researchers to ask ourselves, first of all, what is and what should be our role in this process and the definition of this role will necessarily determine the choice of research strategies. As Alvesson and Sköldberg (2000) wrote �it is not methods but ontology and epistemology which are the determinants of good social science�.
1 The Field of Research in Health. Some Reflections on its Configuration.
As Bourdieu says the incorporation of the concept of field means thinking in relational terms. A field can be defined as a network of objective relations among positions. These positions define themselves objectively by their existence, by both the decisions they impose upon the occupants � the agents or institutions � because of their current and potential location (situs) within the distribution structure of the different kinds of power or capital, the possession of which implies access to the specific earnings that are at stake within the field and finally by their objective relations with the rest of the positions. (Bourdieu P. and Wacquant L. , 1995, pg. 64).
The field of health research appears at an intersection between the specifics of the field of health and the field of science and technology production . This point of intersection implies that its actors and institutions bring together determinations inherent to the health sector on one hand and to the domain of scientific and technological production on the other. Both areas have undergone major transformations directly related to the transformations that have taken place in the relations among State, Market and Society within the framework of the neo-liberal models.
A characteristic of this field of research is that it does not depend heavily on the traditional academic world. Industries, international agencies and organizations, governments and academic entities all participate in it.
Considered globally, the field of biomedicine and technology is the one that probably receives the largest amount of funding, being highly dependent on the interests of the industries involved . During the last decades the chemical-pharmaceutical industry�s needs to increase their competitiveness have led it to invest heavily in research and on some occasions to break ethical codes. It is estimated that laboratories must launch two o three products a year capable of generating sales of over one billion dollars just to stay in the world markets (Bouguerra, M.L. , 2001). The recent legal battles between the South African government and the important laboratories over the cost of AIDS medication is an emerging sign of the times and perhaps even a political one to be kept in mind. They clearly demonstrate the antagonism that exists between the interests in profits and the right to life.
Research into health systems and services or into health policy does not have such a direct link to the market. Its origin is more tied to health policies within the framework of the so-called Social States and to the Latin American developmentalist proposals. The fact that it is linked to states makes it vulnerable to the vicissitudes suffered by these. Although international organizations have been insisting on the need for the development and promotion of this kind of studies for the last two decades, the gap between what is investigated and the need to develop and improve the people�s health is not closing.
A document published by the Council for Health Research makes a quick situational diagnosis and states: ” No more than ten percent of global spending on Health research is devoted to solving the main health problems of the poor… even in countries with a disproportionately high burden of disease the national research effort may not be directed at pressing problems but may be driven by the profit motives of the private sector, the curiosity of researchers or the particular agendas of donor agencies” ( COHRED, 2000- p.2).
What seems to worry those in charge of developing this area is how to make research directly influence the taking of both decisions and action in health, that is to say, the policy making. The debate revolves around the question of how to develop the capacity of effective research (capacity building) and how to involve the policy makers in the results.
I will not stop to discuss this question now but rather to consider what it omits: the determinations that operate in this field of the production of knowledge and its agents. Given the struggle to obtain funding for research, the existence of hegemonic languages and methodological models in the area of health policy research determines the production of knowledge. These, in turn, determine the investigator�s position in this complex institutional world.
The agencies and institutions upon which research depends are also subjected to the same transformations as those that affect the field of health. In analyzing the Brazilian scientific – technological production agencies, Mario Hamilton declares: ” The logic that precedes the realization of scientific activities is influenced by both the widest macro ” institutional context in which they are immersed and by the way the changes in this environment affect the “values” that precede the realization of such scientific activities. Among the principle stimuli affecting this process, the following factors can be highlighted:
- changes in public policies that tend to stimulate both the commercialization of the generated technologies and the practical application of knowledge that has been developed
- demands from the macro – environment requiring an adaptation in the orientation of scientific activities towards more intense competition
- the growing need for scientific institutions to search for alternative sources of research funding due to the decline from traditional public sources”.(Hamilton, M., 2000).
The collapse of the barriers separating private interests and the State, in terms of research, necessarily produces modifications in the values and representations that are the foundation of scientific activity.
For example, the elaboration of indicators and tools for evaluation and management carries an undeniable ideological and political load. A recent article by Vicente Navarro in which he analyses the WHO World Health Report is an excellent exercise in deconstruction, which criticizes suppositions and ideological values used to support the construction of the tool which was, in turn used to produce the same report that assessed the world�s health � care systems based on an overall index of performance (Navarro, 2000).
Although it may be obvious, we must remember that the researchers depend on these vicissitudes for their subsistence and for their recognition . In a recent debate about Health Systems and Services Research Susana Belmartino wrote: ��researchers must be aware that it is a scientific � technical function being exercised within the context of a strong political struggle among social organization models in conflict, and intensified by a demand for financial resources which thoroughly exceeds available supply�� (Belmartino,S., 2001). I do not agree with the definition of �scientific � technical� function for research but I do agree with the statement that �researcher must be aware�. This then, takes us into the subject of reflexivity in the research process.
Reflexivity and critical research
Given the fact that health research is strongly related to practices and their applications, it paradoxically requires a greater epistemological vigilance. This implies always being aware of the determinations and forces that act upon the process of the production of knowledge.
For Alvesson and Skoldberg (2000) a reflective approach means that…�due attention is paid to interpretive, political and rhetorical nature of empirical research. This in turn calls for an awareness among researchers of a broad range of insights : into interpretive acts, into the political, ideological and ethical issues of the social sciences and into their own construction of the �data� or empirical material� . A reflexive approximation implies recognizing oneself in the place one occupies within a specific field. This place is not neutral, is not external and does not stop producing effects.
For example, the fact that the institutional mainstay for our research was a Public University gave us some freedom in the choice of theoretical frameworks and strategies. We are aware of the fact that this freedom tends to diminish when the place of universities is questioned and attacked.
We also decided to include primary level of attention workers as team researchers because we considered that within this reform process they remained objectively linked to the health requirements of the most needy populations. There was a very strong relation between their necessities and demands and those of the population although there continue to be some differences. With their incorporation as participants and valid speakers, we counterbalanced the academic tendency and transferred tools for action into their hands. In fact, we also questioned the traditional concept of scientific objectivity.
This, in turn, was the result of an adopted ideological position; that the investigation had to place two silent actors of the reform process on the stage of events: the primary level workers and the poor users of the sector. Special consideration was also given to the organizations within civilian society that act in the area of health.
Regarding the inclusion of the users, we decided to select a particular group � the poor � and to recuperate as part of the study�s micro and psychosocial dimension their experiences, discourses and strategies. This level of analysis turned out to be indispensable for the emergence of some unexpected results.
It would seem that the weak voice of the users in the reform process is not just a local characteristic. A recent text by Richard Saltmann (2000) states that …� The reform of the Health Sector in Europe during the 90�s has made a great variety of subjects and actors appear. The institutions that provide services, the health sector professionals, the public and private payers and the public authorities, all of them have witnessed the important changes in their roles and responsibilities. The actor whose relation with the health system has least changed, as strange as it may seem, has been the patient.� He concludes by saying that patients are still more objects than subjects with respect to the health service systems.
But this quality and characteristic of being an object is precisely how the patients are represented in the logic of the service providers and is many times adopted acritically by researchers in their methodologies. In the micro and psychosocial dimension of our research the users showed themselves as subjects of great vitality but having a low capacity of impact upon the decision � taking level. This poor population that had had access to free state health services and that had actively participated in a successful primary attention health program � later dismantled by the reform � developed health care strategies which are basic in all rational use of health services. They had a spontaneous tendency towards preventive practices if they were offered the adequate information, they did not practice self-medication with industrial drugs (a frequent habit among Argentine middle class sectors) and within the process of attention they especially valued the doctor�patient relationship very highly, far more than the use of devices and medication. They also established informal community health care networks. The downside of the matter is that when they were prevented from using the services they acted with resignation : the idea of social rights was not installed among them (Barcala and Stolkiner, 2001).
Just like the term `population´, the category of �user�, which is created by the service sector, is an amorphous unit that quickly breaks down into different groups and associations as soon as it is analyzed. �Macro� research tends to consider the users as a unit and passes directly from this undifferentiated collective grouping to the individuals themselves and their behavior. They are frequently omitted as possible actors except to consider their individual behaviors. The opposite of this would be to��overcome the interpretation of the user as an individual-patient-carrier requiring attention and build a new relational perspective that would link the service organization with the needs, expectations and demands of the population under its charge. This would imply incorporating the dimension of groups or social units and refers to ways of organizing demand that could incorporate a political dimension.� (Belmartino, 2001-pg40).
One of the effects that our research work had was to promote a demand for primary health action within the community and this proposal was inevitably taken up by some possibly influential actors. It also strengthened the political strategies of the health worker sector.
The first step that must be taken to assure that research has an influence on policies and decisions would be to recognize the political nature of all research processes. This implies that the investigators must firstly reflect upon their own position as actors, both in the field in which they do their research and in the field of research itself.
Within the field of research itself, it is a matter of finding collective and social ways of defending the autonomy in the production of learning and knowledge. Nowadays ,research institutions are obliged to submit to market logic as must the health sector. This determines both the possible limits for thought and the influence upon its values.
We must recognize ourselves as actors of our institutions (universities, agencies, etc.) so as to build and defend spaces for counter-hegemonic thought. In Latin America there are extreme cases of social movements made up of people excluded from the system that create or develop their own knowledge producing institutions and centers. This is the case of the Universidad de los Sin Tierra (University of the Landless Ones) in Brazil or of the recent founding of their own university by a faction of the Madres de Plaza de Mayo (The Mothers of May Square).
This is one more emerging factor in the configuration of a globalized pole of groups that defend rights � among them the right to health and to live � and that do not accept being subordinated to the needs of financial capitals. In our countries this antagonism is more evident but in essence it is universal.
Furthermore, any research done in the area of health policies and services requires adopting a position with respect to the actors in that field. We must formulate the questions and the problems from the point of view and understanding the logic of those actors whose interests are objectively bound to the health of the general populations and to the defense of the right to life. The establishment of a knowledge production alliance with these actors fortifies the research processes and simultaneously strengthens their actions. To do this, the research process must necessarily conserve their nature as subjects methodologically intact, that is to say, they must not be objectivized.
All of this does not mean forsaking technical and methodological rigor in research. It simply means abandoning the idea of research done from a neutral site because it is carried out in fields that are basically built upon antagonism and conflict. The question is to favor the redistribution of the symbolic capital, in contrast to the growing tendency towards the concentration of capital and wealth.
Meetings such as these can be part of the fulfillment of this objective.
Alvesson M.& Sköldberg (2000) : �Reflexive methodology- New Vistas for Qualitative Research� SAGE Publications, London.
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Stolkiner A. y otros (1999) : “Neoliberalism and Health Services in Argentina: a case study” Barcelona, España, Mayo de 1999. 11 INTERNATIONAL CONFERENCE – International Association of Health Policy- EUROPE