The Politics of Measurement

Pritpal S Tamber

June 5, 2019

How eliciting social definitions of value may make emerging partnerships between health care and CBOs more effective

“That’s interesting. So, what do you measure?” 

I have found the above phrase to be powerful in seeing what really matters to health care leaders doing ‘community health’ work. All too often I have heard kind words about starting from where communities are, responding to what they’re actually saying, understanding the challenges from their perspectives – but, at the end of the day, what matters most is what’s measured. 

And that’s almost always bio-medical. 

Of course, there’s nothing wrong with measuring bio-medical values. We work in health care, after all. But what if the bio-medical is downstream from more fundamental things, like emotions and relationships. Would it make sense to also understand those and their connection to the bio-medical values that health care professionals seek?

Last week I published a conversation with Andrew Harrison, a consultant who’s spent the last 30 years helping systems to see themselves differently in order to change. Andrew contends that people in systems, including health care, often hide what they value in their work. That’s because what we value is what motivates us and hence is entwined with our identities. Talking about what we value, then, becomes deeply personal – more personal than we tend to be at work.

This ‘hidden’ value never makes it into status reports and performance dashboards. As Andrew says, we insist on “cognitive frames” to describe what we’re doing and what we’ve achieved. By rejecting – or perhaps avoiding– the emotional parts of our work we create a limited, and perhaps even false, understanding of the value we’re creating.

In response, Andrew and his colleague, Andrew Darnton, created Revaluation. They describe it as a ‘social process’, one in which people within systems can surface the value that they feel in their work alongside the usual metrics. Not only can the process create a more complete picture of value but, as Andrew says, it’s also “surprisingly developmental” – it has helped make value visible to those creating it. 

The challenge, of course, remains what one does with such insights when one’s paymaster is only interested in bio-medical outcomes.

That issue is front and centre for entities exploring new ways to use health care money to address social needs as a way to improve health and reduce the demand for care. Many health care organisations see community-based organisations (CBOs) as vehicles for the provision of social services and so partnerships are beginning to develop. But many CBO leaders know that what they do is much deeper than ‘service provision’. Such provision is only possible through the relationships they have with communities. And so, the core of what they do is relate

The currency of relating is trust. Will trust be eroded if a CBO becomes too focussed on the bio-medical demands of their new partners in health care? My gut tells me it’s a distinct possibility, especially given some of the strange practices within health care, such as in the US where physicians are paid a cut of a drug’s cost to incentivise prescribing. What CBOs trade is not only their ability to deliver services but also their credibility with communities. So, how does ‘credibility’ get remunerated when the funding is solely based on bio-medical outcomes?

All this ruminating takes me to bioethics. If we assume a definition of ‘the moral principles of medical practice’, the question becomes what are the principles that underpin these new relationships between health care and CBOs? Are they to be derived from health care’s metrics? It’s their money, after all. Or is the fact that health care cannot handle the challenges facing health alone enough to make us look for a different set of principles to influence the work? 

If the above paragraph hasn’t made your head hurt, it’s worth finding 19 minutes to listen to this fascinating monologue by Dr Michel Accad on how bioethicists have framed health care through a utilitarian lens – the idea that resources should be directed to where they might have the greatest use to society. The question becomes who gets to decide what’s useful? In other words, who gets to decide what’s to be valued? 

Andrew Harrison believes defining value should be a group activity. We need to be able to tell stories about what we value in our work. And we need to be able to make sense of those stories collectively if we’re really going to design the health promoting, protecting and caring systems of tomorrow. 

So, if you’re in a community health meeting this week, ask yourself whether you’ve really debated the principles that underpin any new relationships being put into place between health care and CBOs. Look at your colleagues around the table (or image them over the conference line) and consider whether you really understand the value they feel in their work. And if you haven’t had the chance to do either, ask yourself whether your community health work has any chance of success beyond some immediate fire-fighting around social needs. 

I realise that raising these issues with your colleagues will mean being more personal – and perhaps vulnerable – than you usually are at work. But if you don’t raise them, who will? 

Dr Pritpal S Tamber MBChB 

Further Reading

  • My conversation with the always-fascinating Andrew Harrison is here
  • You can learn more about Revaluation here
  • The 19-minute monologue from Dr Michel Accad is here(it’s part of the often-thought-provoking podcast, The Accad and Koka Report)
  • If the utilitarian thing has caught your interest, consider this 60-minute discussion with Tom Koch (although I have to admit his manner got in the way of his message) 
  • Learn more about Community & Health here, including signing up 
  • And if the abuse of measurement is something that interests you, have a read of this excellent critique of how The Global Fund is misrepresenting its impact 

The photo behind the title is by Nik MacMillan on Unsplash.

Pritpal S Tamber

Independent Writer, Researcher & Consultant | pritpal@pstamber.com

I'm an independent writer, researcher and consultant focussing on community health and medical information. I'm a former physician, medical editor and medical publisher, and also the former Physician Editor of TEDMED. I began my career at The BMJ. For more information, see the About page.

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