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Final Dissertation Lauren Graham 9904542D An analysis of the dominant discourses of health in Lesotho and how they affect healthcare providers’ health perceptions. Dissertation prepared in fulfillment of the requirements for the Masters in Arts by Dissertation only by Lauren Graham 9904542D Supervisor: Mr. P Germond (Dept. of Sociology) 1 ACKNOWLEDGEMENTS There is no doubt that this work would not have been possible without the support and participation of a number of key players. First and foremost I wish to thank my supervisor, Mr. Paul Germond, who instilled in me a love of Lesotho and its people, who guided me through the theoretical maze of working in a field that is relatively under-researched, and the maze of Lesotho’s roads, and who understood my many times of writer’s block. To the African Religious Health Assets Programme (ARHAP) team for their support both financially and theoretically. Having the camaraderie of a group of people interested in the same field helped me to realize that this work is worthwhile. To Sepetla Molapo – my research partner in Lesotho who helped me to get to know some Sesotho customs, who was my interpreter and my teacher, not to mention my companion in Lesotho. To Dr and Mrs. Germond who so willingly recited their memories of Morija and of Scott Hospital to me. To all of the staff at Scott hospital who welcomed me, who shared their working lives with me and who were so willing to talk to me. Without their contribution this dissertation would never have come to fruition. 2 ABSTRACT This dissertation is a study of how Basotho healthcare providers understand health. It leads directly to a discussion of the health discourses evident in Lesotho and the way in which they impact on the perceptions of health that healthcare providers hold. The approach used was to conduct a case study of nurses, nurse assistants and technicians at Scott Hospital in Morija, Lesotho. The findings revealed that the perceptions of health that these healthcare providers hold are profoundly impacted upon by four discourses that are evident in Lesotho, these being the biomedical discourse, the Public Health discourse, the Christian discourse and the traditional discourse of health. These discourses are evident in Lesotho due to a complex interplay of history, economy, politics, development and culture amongst other factors. They play themselves out at various levels – national, local and individual – and represent the power dynamics that are at play when it comes to health in Lesotho. What is key is that each discourse, regardless of official policy, plays an integral role in the perceptions of health that the healthcare providers hold. Four elements are discussed in this dissertation. As will be shown, health, development, religion and tradition have a complex history in Lesotho that has led to the current health picture in Lesotho. As such, this dissertation, whilst being broadly a development piece of work, focuses more acutely on the interplay between health, religion and tradition, and through doing this, makes comment about development more generally. 3 CONTENTS 1.1. Situation of the dissertation in development discourse....................11 1.2. The contribution of the dissertation to health literature ....................14 1.3. Background to Morija.......................................................................17 1.3.1. A brief history of Morija and its relationship with the PEMS.....18 1.3.2. A healthy village is like Morija...................................................20 1.3.3. The current state of health in Morija..........................................22 1.4. A Background to Scott Hospital .......................................................24 1.5. Conclusion.......................................................................................30 2. METHODOLOGY ...................................................................................32 2.1. Role of this dissertation ...................................................................32 2.2. The research strategy......................................................................33 2.3. Why Lesotho?..................................................................................34 2.3.1. The ARHAP Lesotho team .......................................................35 2.4. Why Scott Hospital? ........................................................................36 2.5. Why a focus on nurses? ..................................................................40 2.6. Locating this research within the ARHAP framework ......................41 2.7. Methods used ..................................................................................43 2.7.1. Preliminary investigation...........................................................45 2.7.2. Key informant Interviews ..........................................................46 2.7.3. Interviews .................................................................................46 2.7.3.1. Semi-structured interviews ................................................47 2.7.3.2. Informal interviews ............................................................49 2.7.4. Focus Groups...........................................................................49 2.7.5. Observation ..............................................................................52 2.7.6. Questionnaire ...........................................................................52 2.8. Ethical Considerations .....................................................................54 3. DEVELOPMENT, HEALTH AND RELIGION IN LESOTHO ...................56 3.1. Contributing to development thinking...............................................56 3.2. Development discourse ...................................................................58 3.2.1. The development of development as a discourse ....................59 3.2.2. Specific Development theories and their failures......................64 3.2.2.1. Modernisation theory.........................................................65 3.2.2.2. Dependency theory ...........................................................70 3.2.2.3. Neo-liberal development model.........................................74 3.2.3. Critique of Development discourse ...............................................79 3.3. A possible way forward....................................................................83 3.3.1. The Capabilities Approach .......................................................84 3.4. Conclusion.......................................................................................87 4. HEALTH AND DEVELOPMENT .............................................................88 4.1. Health as development indicator .....................................................88 4.2. Health and inequality .......................................................................88 4.3. The political economy of health: Farmer..........................................90 4.3.1. Broad political implications for health .......................................91 4.4. Universal healthcare?......................................................................94 4.5. Access to treatment.........................................................................96 4.6. Politics and explanations of disease/dis-ease .................................97 4.7. The importance therefore of understanding health agency..............98 4.8. Healthcare in Lesotho....................................................................101 4 4.8.1. The current situation in Lesotho .............................................101 4.8.2. The Hospital ...........................................................................103 4.8.3. The Health Centres ................................................................105 4.9. Religion and development .............................................................107 4.9.1. The importance of studying religion........................................107 4.9.2. The role of religion in development.........................................109 4.9.3. Religion and health.................................................................112 4.9.4. Health, Assets and the African Religious Health Assets Programme...........................................................................................113 4.9.4.1. ARHAP – the initial theoretical framework.......................114 4.9.4.2. Thinking about assets .....................................................116 4.9.4.3. ARHAP’s Suite of Assessment Tools ..............................118 4.9.5. Other key concepts.................................................................122 4.9.5.1. Sesotho Traditional Discourse (Bongaka ba moetho) .....124 4.9.5.2. Biomedical Discourse (Bongaka ba Sekhoa) ..................124 4.9.5.3. The public health discourse.............................................125 4.9.5.4. The fourth discourse........................................................125 4.10. Conclusion .................................................................................127 5. HEALTH IN THE PERCEPTIONS OF HEALTHCARE PROVIDERS AT SCOTT HOSPITAL......................................................................................129 5.1. Understanding of the healthy person.............................................131 5.1.1. Holistic view of health .............................................................132 5.1.2. Relationality as key to health ......................................................133 5.1.3. The physical aspects of health....................................................136
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