Reconceptualising Health Systems: A case study of lived health systems in urban informal setting in northern Nigeria

Despite growing interest in health systems strengthening among key global health actors, there is considerable debate about how to conceptualise health systems and about what the best strategies are to strengthen them. Existing conceptualisations of health systems are usually presented as static models in which the formal provision of services is central. Yet it is increasingly apparent that these conceptualisations do not constitute a complete model of how existing health systems work, and fail to capture the complex interactions between people, families, households, health services, and the wider societal context, particularly in urban informal settings in low and middle income countries where formal (state-regulated) health systems are relatively absent. This thesis critiques existing conceptualisations of health systems and develops an alternative understanding, based on detailed empirical research and the ‘lived’ experiences and perspectives of people experiencing health problems in one particular case study of an urban informal setting – Tudun Jukun in northern Nigeria.
The thesis is underpinned by critical realism, integrates ideas and methods from a range of empirical studies about health and health seeking practices from the fields of medical anthropology and sociology, and draws on fieldwork conducted in Tudun Jukun between June-September 2012, which used a variety of qualitative methods (observations, interviews, focus groups, and document sampling). Using an innovative analytical approach, which involved developing detailed narratives about episodes of health problems, the thesis explains how people in this urban informal setting understand and experience health problems; the strategies they apply (or do not apply) in solving these problems; the factors that influence (enables/prevents) the choice of strategies and how they are negotiated; and, based on people’s ‘systems of meaning' and expectations, what strategies worked.
The thesis presents an alternative conceptualisation of health systems as a ‘landscape’, in which health systems are structured by conceptualisations of health, context, prevailing beliefs or value systems, and power dynamics among individuals in a given context, which are all themselves intimately connected and inter-dependent. The thesis argues that power dynamics and existing forms of knowledge or expertise in solving health problem are crucial in defining health systems in a given context. These knowledge and expertise are distributed among different actors and access is governed by the different kinds of relationships that exist (family ties, friendship or market transactions) and networks of resources that individuals can draw upon. Distinct processes take place as people work to access knowledge and expertise: interpretation, decision-making, enabling and provision. It is argued that units of accountability or collectivity are fundamental in shaping how all elements within a health systems landscape are organised. In Tudun Jukun, the home is the most common unit of collective action on health issues.
These findings raise questions about current policy action to strengthen health systems such as relying on (the relatively ineffective) state-led institutions and the uncritical use of existing theoretical conceptual frameworks. This study suggests alternative forms of action that are needed in order to design more context relevant health systems strengthening interventions through recognising what people value or not value and why. This can result in, for example, broadening the scope of health systems to recognise landscapes such as the home and patent medicine vendors as legitimate health systems landscapes and make them safer and more effective. It can also involve recognising and creating wider supporting networks for collective action on health issues in places where such collectivity is non-existent or too small to deal with prevailing health problems.