Governing chronic illness through integrated care
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As rates of chronic illness have increased in recent decades there have been significant changes in national and international health systems. Emerging approaches have shifted the focus from hospital-based, acute and curative interventions to the management of chronic illness through primary health care programs in local communities. Integrated care has emerged as an increasingly prominent approach within primary health care programs that target chronically ill populations. This empirical doctoral study of an integrated care program explores how global discourses, which position the problem of chronic illness as an issue of cost to health care systems and a burden to the community, are translated from national policies to everyday lives in domestic households. Through close analysis of six chronically ill clients of a state-run primary health care program, named HealthOne Camara, this study brings to the fore the alignments, relays and connections of integrated care in ways that contrast with the dominant linear views typically generated through policy analysis and program evaluation studies. Using a governmentality perspective based on the later work of Michel Foucault and other writers on governmentality, the study identifies patterns and consistencies across policy texts and everyday practices of integrated care in HealthOne Camara. Innovatively, Foucault’s work on space and heterotopia is used in the study to identify the spaces of integrated care as heterotopias. In doing so, the focus shifts from what integrated care is to an analysis of how this care weaves through the lives of the HealthOne Camara clients. By drawing on empirical and documentary data, this study offers a unique way of rethinking chronic illness and integrated care within primary health care programs. It highlights the tensions and complexities of integrated care for chronically ill clients in a local site. The analysis of these tensions opens up new ways of thinking about HealthOne’s integrated care as an attempt to direct the self-governing abilities of people in certain ways. Examining the localised practices of care through the analytics of space and heterotopia brings to the fore the tension and resistance that emerges as practices of ‘care’ attempt to align complex lives with the often linear logic of policy. As rates of chronic illness increase, levels of health inequalities continue to rise and governments remain focused on reducing costs of care, the knowledge generated through this study argues for careful consideration of what the localised and unintended effects of programs of integrated care may be.
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