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4 Case Study – Caring for the Elderly in China

4 Case Study – Caring for the Elderly in China

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6 Institutions of Health Care

by Mao Zedong’s regime such as the life-long employment policy meant that older

people, at least those living in urban areas, could be financially independent (Sheng

and Settles 2006). With privatization in the 1980s this security was lost, making

older people more dependent on family support. China introduced a population control campaign in the 1980s, often described as the one-child policy, which led to a

rapid decline in the national birth rate (Sheng and Settles 2006). As a result of the

one-child policy the relationship between generations is strained, where a single

child may need to care for two parents as well as four grandparents without siblings

to share the responsibility (Chen et al. 2015). A further complication of this picture

is that life expectancy in China has increased. At the same time, there has also been

an increase in cancer rates in this older population with cancer, a disease that can be

protracted, now the main cause of death in China (Chen et al. 2015).

With few affordable resources to care for those suffering from diseases such as

cancer, families are required to provide social and financial support for elderly

Chinese people, as well as personal and nursing care. This caring role is fostered by

the Chinese tradition of filial piety (Chen et al. 2015). But the State has had to step

in to respond to situations where the older Chinese have not been cared for by their

families, and have enacted laws like the Law of Protection of Rights and Interests of

Older People, which requires the offspring of parents older than 60 to visit their

parents frequently and make sure their financial and spiritual needs are met (Chen

et al. 2015).

In the case of older Chinese with cancer and other terminal illnesses we can see

how cultural requirements to look after parents has been made increasingly difficult.

Policy efforts to control the population size and economic restructuring has created

intergenerational tension, with the State responding with new policies requiring

Chinese to meet their cultural and familial obligations, legislating the family’s role

in Chinese institutions of health care.


The Price and Cost of Health Services

Hospitals take up a substantial proportion of the spending on health care. In many

countries within the Organisation for Economic Co-operation and Development

(OECD) between 9 and 12 % of Gross Domestic Product (GDP) is spent on health

care, with the outliers being Singapore at less than 5 % and the United States at

nearly 17 % (Mossialos et al. 2015). Health systems, including hospitals, primary

care and public health, can be funded through a mix of private and public contributions, and provision of services is also often a mix of private and public provision.

The financing of public health provision can come from general tax revenue, as

is the case of the funding of the National Health Service in England, with a relatively small proportion of the population, around 11 %, paying for better access to

services such as elective services through private hospitals (Mossialos et al. 2015).

By contrast in Canada around two thirds of the population have private health insurance to cover services not publicly provided (Mossialos et al. 2015). In the United


The Price and Cost of Health Services


States health insurance is required to access most services, with a safety net of

public provision for hospitals and clinics for those uninsured. The federal government provides tax exemptions for employer-employee health insurance programmes. It also administers a Medicare programme for those over-65 and some

other groups, and administers Medicaid and the Children’s Health Insurance programme targeted at low income groups in partnership with State governments

(Mossialos et al. 2015). The Affordable Care Act, part of what is known as

‘Obamacare’, has further extended health insurance coverage.

In most OECD countries primary care provision is in private ownership.

Payments to providers vary mainly between fee-for-service payments (as in

Australia and Germany) or a mixture of fee-for-service and capitation payments

where payments are based on the number of patients enrolled with a service (as in

the Netherlands and Italy). One consequence of the latter has been that health professionals besides doctors, such as nurses, may take on more responsibilities as a

subsidy is not dependent on the patient seeing the doctor (Barnett et al. 1998). In

some countries income is also derived from meeting particular performance criteria

such as showing evidence of interventions in chronic conditions (as occurs in


Public hospitals tend to be publicly owned (as in Denmark and Norway) or

private-not-for-profit hospitals (as in Canada and the United States) (Mossialos

et al. 2015). They are generally funded through a combination of global budgets

where a maximum amount of money is provided to the hospital and the hospital has

to work within that budget, case-based payments, where payment is made for treated

cases at a set price, and fee-for-service (Mossialos et al. 2015).

Expenditure on health care has risen consistently in OECD countries over many

decades (Chernew and May 2011). The growth in expenditure is a result of aging

populations, new medical technologies and many other factors, including the expansion of disease categories discussed in Chap. 8 on medicalization, and the powerful

influence of pharmaceutical companies discussed in Chap. 9 about pharmaceuticals.

New technologies can lead to a rapid escalation in costs, so for example, the cost of

new diagnostic technologies for screening purposes is supplemented with extra cost

of treatments for the conditions detected by the technology (Chernew and May

2011). The cost of health care can increase with changes to practices around preventive care and defensive medicine. Preventive care targets, such as ensuring that all

patients over 50 have cholesterol tests, drive the cost of laboratory testing services

up. Defensive medicine, where doctors are concerned about possible patient complaints or scrutiny from practitioner organizations, may increase demand for more

diagnostic tests, and so it goes on.

Dominant discourses in contemporary health policy are those of priority setting

and rationing (Joyce 2001). Rationing has of course always occurred. For example,

nineteenth century hospitals rationed by such means as only admitting patients with

certain conditions (not incurable or syphilitics), only admitting those deemed worthy of receiving treatment and only admitting those for whom beds were available

(Rosenberg 1987). Local or state government involvement in the funding of health

services has always involved rationing. To ration out health services means criteria


6 Institutions of Health Care

are developed so that some people have access and some do not. The criteria we

choose varies over time, and are based on our values and also the organization and

politics of health service delivery.

Many governments have agencies that undertake cost effectiveness assessments

of technologies and pharmaceuticals, such as the National Institute for Health and

Care Excellence (NICE) in England and the Canadian Agency for Drugs and

Technologies in Health (CADTH) in Canada. Canada also has a Patented Medicine

Prices Review Board that regulates the prices of new patented drugs (Allin and

Rudoler 2015). Agencies such as these can make recommendations or provide

guidelines or can, as is the case of PHARMAC, the pharmaceutical management

agency in New Zealand, determine which pharmaceuticals will be subsidised by the

government. These agencies place pressure on pharmaceutical companies to price

their products to meet the cost effectiveness thresholds if they want their drugs

widely available to the public. Patient co-payments for pharmaceuticals are also

commonly used to contain costs, as in Australia.

Assessing the cost effectiveness of a service requires some means of assessing

the clinical effectiveness of a service. The development of evidence-based medicine

(EBM) has been a central element in the determination of clinical effectiveness.


Evidence-Based Medicine and Protocols

The rise of EBM can be seen as a consequence of a number of goals. One is to provide credibility to the medical profession by claiming that interventions are backed

up by the best science. Another is that evidence can lead to guidelines or recommendations being developed so that variation in clinical practice can be reduced. As

noted, evidence can also feed into calculations about what services are cost-effective

and so whether they should be provided in a public system or not.

EBM promotes a hierarchy of authority. EBM developed in an effort to orient

medicine towards what was perceived as the existing science and knowledge base.

It became increasingly important in the 1990s, although Lohr and colleagues (1998)

suggest that a landmark treatise was Archie Cochrane’s 1972 text Effectiveness and

Efficacy. At the top of the EBM hierarchy of evidence for interventions is the randomised controlled trial (RCT) while the bottom level is where guidelines are based

on the consensus of experts. Although advocates of EBM argue that decisions

should be based on the most appropriate evidence, therefore potentially extending

beyond RCTs in the context of interventions, RCTs still dominate systematic

reviews aimed at influencing treatment decision-making (Green 2000).

Linking EBM to forms of professional accountability restricts the art of medicine and the autonomy of the practitioner. Drawing on Weber, it has been argued

that evidence-based practice undermines traditional clinical expertise as clinicians

are increasingly required to point to an external evidentiary authority in order to

provide justification for their decisions as opposed to relying on their own experience (Lipman 2000). In what has been termed scientific-bureaucratic medicine,


Rationing Debates


bureaucracies oversee and control the implementation of evidence-based practice

further undermining the clinical autonomy of practitioners (Checkland et al. 2008;

Lipman 2000).

Codes of conduct and professional standards, including guidelines, protocols and

practice policies, are some of the bureaucratic means of gaining conformity to

evidence-based findings. These bureaucratic means are “instructions telling medical

personnel to do a certain thing in a certain situation” (Berg 1997: 2). Medical practice can then be more standardized and defined as the logical and sequential application of science.

It should not be assumed that attempts to standardise medical practices through

such means as requiring the use of protocols will have the intended outcome. Indeed,

as has been demonstrated by detailed analysis of interactions between patients and

clinicians, there are a range of means by which clinicians can ignore, undermine or

utilize protocols and standardized procedures (Dew et al. 2005, 2010).


Rationing Debates

Debate over rationing brings to the fore a number of issues that point to some of the

tensions and contradictions within the institutions of health care. One is the claim

that medicine is based in science, and yet a great deal that is practised under the

aegis of medicine has had little scientific validation according to the precepts of

EBM. It is not easy to do a double blind controlled trial on surgery for example,

where neither the patient nor the person assessing the outcome know whether the

surgery has been performed or not. And as outlined in Chap. 9 on pharmaceuticals,

we cannot always be confident in the ‘evidence’ base of research trials.

Another issue is the tension between communal goals and individual goals. Who

should decide what services everyone should have access to? Should economists,

accountants, and managers make decisions based on explicit priorities, or should

individual practitioners make judgements on medical and ethical grounds (Tenbensel

2000)? Should decisions be made by consensus or by some particular representatives? One individual’s idea of an essential service may not coincide with the ideas

of the community. Should politicians, health professionals or patients define priorities? Is it better to spend the limited money we have on preventive measures that

may have a major impact in reducing mortality rates, such as campaigns against

smoking? Or should we make sure we have resources placed in areas such as neonatal units that are high cost but may help to save the lives of babies? Or should we

be focusing on the elderly?

In order to ration we need to have some measure of health outcomes, and there

are many of these. One commonly used measure is Quality-Adjusted Life Years

(QALYs). This is where you work out how many more ‘life years’ a particular

health care activity will produce, and the quality of life the intervention will give;

then this is set against the cost. Those activities that give the most life years at high

quality for the least cost will be prioritized (Tenbensel 2000).


6 Institutions of Health Care

Using QALYs or other measures to ration services poses a number of problems.

One is that the way you make a decision depends upon the value you assign to life.

If you price a human life as being worth $1 million then your decisions would be

very different from pricing it at $200 million (Simmons and Scott 1998). To illustrate just one difficulty, we can ask if a donated kidney infected with hepatitis C

should be used in renal transplantation. Using QALYs, it is better to use the infected

kidney than to discard it because your life years will increase. However, if you were

given an infected kidney you might not feel the same. This example illustrates how

such rational, economic decision-making can go against our own sense of ethics.

QALYs have also been criticised for failing to measure quality of life that is unrelated to health. For example, if we developed a system of rationing simply on the

basis of QALYs then people would not have access to services such as in vitro fertilization as these do not add QALYs to the individual (Devlin et al. 1999).

Another issue raised by rationing is the balance between efficiency (what works

for most people) and equity (how to ensure that the poorest have access to services).

There are always trade-offs that need to be made. An example can be drawn from

the treatment of older people and those with a disability. Older people and those

with a disability are less likely to get treatment if access to services is judged on the

number of years gained from having the treatment or the quality of those years

(Campbell 1999). Older people in general do not have as long to live as younger

people, and if you have a disability then your quality of life measured in this way is

by definition lower. A utilitarian approach, as with QALYs, prefers actions that

deliver the most happiness or pleasure and the least pain or unhappiness in society.

Utilitarian measures can mean that the lives of many are enhanced at the expense of

intolerable suffering for others.



Another way of ensuring accountability in the delivery of health services is through

gathering information about what services are delivered. New management tools

have meant that health professionals can be more easily tracked. For example, the

development of medical management information systems has meant that managers

have been able to look in more detail at how resources are being used, and so put

them in a better position to introduce guidelines and protocols (Barnett et al. 1998:

see also chapter 7).

Systems have also been put in place to track patients’ utilization of health services. This tracking of the population through the health system is an outcome of

state involvement in the provision of health services. This has been called the

administered society by Michel Foucault (1977). Wherever the state provides welfare there will be measures put in place to see that the provisions are appropriately

used. That is, welfare services should be used by those who need them, and used as

effectively as possible. These measures will involve a level of surveillance, which

means information collected about people and what people do. A possible




implication of this increasing surveillance is that we will be expected to conform to

rules laid down by the state.

In addition efforts have been made to control health practitioners to ensure quality and standards of care are met. It is not until the 1980s that we start to see efforts

being made to try to ensure that doctors remain competent to practice after receiving

their medical license (Chamberlain 2013). A number of atrocity stories related to

medical practice have facilitated this process, such as the Shipman case in the

United Kingdom. Dr Shipman was a general practitioner in the Greater Manchester

area. It was found that Shipman had murdered at least 215 elderly patients over a

period of about 25 years (Chamberlain 2013). The case is an extreme one but it supported calls for the introduction of systems of quality assurance and accountability,

such as the revalidation of practitioners to test their clinical competence on a regular

basis. As a result of the range of quality assurance programs that have been introduced, like revalidation, the professional autonomy of individual practitioners has

been limited. The development of quality assurance in medical practice does not

undermine the dominance of the medical profession in relation to other professions.

Through controlling the work of individual medical practitioners, quality assurance

preserves the power of the medical profession as a whole (Coburn et al. 1997).



How we organize the delivery of health services is based on our social values and

which values prevail have varied across countries and over time. In some countries

services may be made available to everyone at no cost to patients at the point of

contact and so taxpayers share the cost of providing those services. In other countries the state may provide services to the most needy only, and let others carry the

cost of their own health provision. For many countries there is a complex mixed

economy in the funding and provision of health services, which at various times has

swung between universal principles and targeted provision.

This chapter has only covered a fraction of the issues in the development of our

institutions of health care. Physiotherapists, nurses, dentists, pharmacists, alternative therapists, and many others have played roles in the shaping of health provision.

Powerful groupings within the health field have shaped the way services are delivered to protect their privileges. Attempts to re-organize services to ensure greater

efficiency or a more equitable distribution of services meet resistance. Attempts to

develop objective criteria on which to base the allocation of health resources are

overwhelmingly influenced by social values. New organizational forms appear in

the face of changes in the health system.

Although changes to the institutions of health care may not be a rational and

linear process, it can be seen as demonstrating the process of rationalisation in the

sociological sense. That is, increasing control is exerted over what practitioners can

do and how they do it, what the patients can receive, and what is known about them.

The rationalism of economics as applied to health services is one attempt to control


6 Institutions of Health Care

expenditure, and at the same time make more transparent the assumptions and reasons for the decisions we make. The other side of the coin is that there are quite

unethical aspects to this from a humanitarian perspective, and sometimes the consequences deeply offend our sense of moral justice.


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Chapter 7

Health Care Work and Everyday Health Work

Abstract Health work takes place in multifaceted environments, with interactions

between a range of professions, people and technologies and a complex division of

labor. This chapter addresses the historical development and professionalization of

the medical profession. It then explores the gendered division in health work, particularly between doctors and nurses, while also noting the increased blurring of

professional jurisdictions in some contexts. The chapter draws on a case study of

maternity work to highlight the impact of attitudes towards gender on health care

work. The chapter concludes with a section on the everyday health work undertaken

by non-professionals in daily life.

Keywords Medical dominance • Professionalization • Gender and healthcare •

Diagnosis • Maternity care • Chile • Household healthcare



The delivery of health care and the work of health takes places in multifaceted environments, with interactions between a range of professions, people and technologies and a complex division of labour (Allen and Pilnick 2005). Early sociological

attention to health work focused on the health care professions dominated by medicine. However, the way in which health professionals work together blurs the distinction over who has control of, and responsibility for, health care work. Blurring

occurs on many fronts explored here with particular reference to nursing. This chapter outlines major sociological positions on health professional work and draws on

the case study of midwifery to examine the broader political and policy influences

on health work. Throughout the chapter it will be seen that health care practices

have a gendered nature, a consequence of broader social and cultural trends.

However, the way that gender influences the work of health care and its delivery

plays out differently over time and in different settings. Finally the chapter notes

that a great deal of health work is not undertaken by health professions at all, but is

an unexceptional aspect of everyday life.

© Springer International Publishing Switzerland 2016

K. Dew et al., Social, Political and Cultural Dimensions of Health,

DOI 10.1007/978-3-319-31508-9_7





Health Care Work and Everyday Health Work

Medical Dominance and Professionalization

As noted in Chap. 5, historically states have conferred great authority on the medical profession, establishing it as an autonomous profession with powers to selfregulate and to exert control over other health care occupations (Larkin 1983).

Sociological theorizing around professions and their work has gone through a number of phases. Early efforts influenced by functionalist orientations attempted to

understand the role of professions in society and what distinguished a profession

from other occupations. From this functionalist perspective professions played a

role in stabilizing society and supporting the status quo. The medical profession was

seen in altruistic terms, where medical practitioners were not motivated primarily

by financial gain but their patients’ needs came first (Chamberlain 2013). Traits that

could help define whether an occupational grouping was a profession or not included

a long period of training, a research culture, a high degree of autonomy over their

practice, and a code of ethics to be followed that is overseen by professional associations (Chamberlain 2013). Furthermore, professions are able to “set the very

terms of thinking about problems which fall in their domain” (Dingwall 2008: 4).

Theorizing about professions took a more critical turn when the question shifted

from what defines a profession to how its occupational control is achieved, with the

focus now on professionalizing strategies (Chamberlain 2013). Rather than basing

an analysis on the altruism of professions the idea of professional self-interest featured strongly. The medical profession was understood as an occupational grouping

that was able to secure a monopoly over its scope of practice and secure high status

through processes of political lobbying (Larkin 1983). This form of analysis drew

on the sociology of Max Weber. For Weber, legally recognized closure is one of the

most powerful means of exclusion exercised by an occupation. As noted in Chap. 5,

the medical profession gained the legal means to determine who could have the title

of medical doctor, the determination of which has been based on educational and

practice requirements. If someone did not have the appropriate medical degree then

they could not claim the title of doctor. Larkin, in his book Occupational Monopoly

and Modern Medicine (1983) uses the concept of occupational imperialism to illuminate the behavior of medical and para-medical occupations. By this Larkin is

referring to attempts by occupations to mould the division of labour to their own

advantage and the struggle to “establish ‘natural’ or ‘legitimate’ claims to segments

of the medical division of labour” (Larkin 1983: 15). This approach to professions

has been labelled the social closure model (Chamberlain 2013).

According to Willis (1983) medical dominance in the health division of labour is

sustained over three areas. One is dominance over its own work, therefore the medical profession is autonomous from other health professionals. Another is dominance

over the work of others, therefore it has authority over other health occupations and

their claims to legitimacy. Thirdly, the medical profession is dominant in the wider

health sphere, where doctors are institutionalized experts on matters relating to

health (Willis 1983: 2). Regarding dominance over its own work, Abbott (1988: 40)

argues jurisdictional claims over work content has three parts: claims to classify a

7.2 Medical Dominance and Professionalization


problem (diagnosis); claims to reason about it; claims to take action on it


Sociologists have argued that an important aspect of the jurisdiction over diagnosis and treatment is that this power does not simply lie in the application of medical

science but is also based firmly in clinical experience or acumen (Chamberlain

2013). Clinical experience involves aspects of the art of medicine, a view that can

be associated with the notion of indeterminate knowledge. Here indeterminate

knowledge refers to claims that there are aspects of medical practice that cannot be

codified or made technical (Jamous and Peloille 1970). This form of knowledge

may be a product of experience. Atkinson argues on the basis of his ethnographic

research on medical training that:

[T]he clinician who appeals to his [sic] personal knowledge does so not by reference to his

uncertainty, nor the uncertainty of his colleagues. Rather, he bases his actions and decisions

on what is taken as a bedrock – the certainty – of direct experience. (Atkinson 1997: 188)

Such a claim to clinical expertise can act as a form of resistance against external

efforts to control the work of medical practitioners as only those ‘in the club’ of

medicine can pass judgment about the competence or otherwise of club members

(Chamberlain 2013).

Chapter 5 notes a number of challenges to the autonomy of the medical professions. Challenges can be to the autonomy of the individual practitioners, such as

increasing requirements to align with evidence-based medicine, with the medical

profession itself having the authority to determine the adequacy of the practices of

the individual doctor. Other challenges can come from outside of the medical profession. An important challenge is the outcome of managerialism where new management tools are deployed to gather information on the delivery and outcomes of

health care interventions and require demonstrations of competency, quality and

efficiency. Deprofessionalization is a concept that has been used to describe this

challenge to medical autonomy that results in attempts to standardize medical practice (Chamberlain 2013). This process of standardization is compounded by other

developments such as the challenge to medical authority from an increasingly

informed patient population, the growth in self-help groups and the challenge to

medicine from unorthodox healing professions (explored in Chap. 2 on health consumers and the clinical encounter).

In this chapter we explore a range of phenomena that complicate a picture of the

medical profession as an autonomous health care occupation and the only domain

in which the health work of diagnosis, reasoning and treatment is legitimately conducted. The activities of the medical profession are far more widely dispersed. But

first we attend to another aspect of health work and occupations: the gendered

nature of health work.

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4 Case Study – Caring for the Elderly in China

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