A study of accountability and worth: making Ayurveda valuable

An accountability agenda for both governments and publicly funded healthcare providers is emerging as population health and universal equity of healthcare access for all citizens are becoming key policy objectives. As indicated in the United Nations Sustainable Development Goals 3 (SDG 3), inequalities are particularly challenging for patients in remote regions and for those with lower socioeconomic status, even in countries with well-funded and mature systems of universal health coverage. Furthermore, in Western medicine there is a heavy emphasis on reactive, disease-driven care pathways, with patients categorised and funded according to their disease 'condition'. With a focus on efficiency and volume throughput in public hospitals, there are calls for a greater emphasis on population health and integrated care with holistic outcomes, to keep people well and out of hospital. To better understand the tensions and perceptions of value in healthcare, this thesis presents an examination of the Indian public health system, in which setting Western medicine runs as a parallel/alternative offering in a dual Western (biomedicine) and traditional (heterodox) approach, through a study of Ayurveda, one of the world's oldest heterodox systems.

Boltanski and Thevenot's 'Economies of Worth' is used as the theoretical lens to examine values based on industrial, market, civic, domestic, inspired, fame and green principles. These multiple and competing values are used by actors to justify their mechanisms of accountability, providing insights into the implications this has for accountability, equality and access to healthcare.

A mixed methods approach is undertaken with survey and qualitative field insights into the valuations being undertaken in this setting. The thesis comprises four empirical papers based on: field interviews using photo-elicitation methods; and a survey measurement model and associated testing. This approach provides both theoretical insights and detailed health policy implications. This thesis covers accountability both from social and environmental perspectives as well as attending to what is perceived as valuable in Ayurvedic healthcare. The study evidences the existence of sound accountability mechanisms in Ayurvedic healthcare. Ayurveda healthcare also needs to focus on a multifaceted performance and accountability system to achieve operational efficiency and a reliable measurement system. The present study finds the existence of urban rural disparities in Ayurveda healthcare facilities, which suggests the need for greater connectivity across urban and rural healthcare settings to support rural residents. There is need to focus on policies to facilitate infrastructure connectivity across the healthcare network. This study also finds an implementation gap in SDG-related measures that draws attention to trade-offs in healthcare treatment, patient access or community programmes/social events due to funding constraints, which further impacts negatively on patients' health.