The State and global health delivery

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Sandeep Nanwani

Sandeep Nanwani

Sandeep Nanwani is a candidate for the Masters of Medical Science in Global Health Delivery at Harvard Medical School. He works actively with street-based and marginalized populations in Yogyakarta, Indonesia.
Sandeep Nanwani

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It was a rainy afternoon. I arrived at the district social affairs office for their monthly evaluation meeting just in time for Baried, the state staffer in charge of poverty reduction, to start his presentation on the central government’s plan to “eradicate” poverty. The Indonesian government, through the department of social affairs, has issued new guidance on the management of beggars and homelessness. They have asked local governments to intensify raids in the streets and provide “rehabilitation” through “spiritual healing and hypnosis” in institutions to change beggars’ “lazy” behavior so that they can be “productive” citizens. This was followed by a psychologist who spoke about the “disease” of laziness and unproductivity plaguing Indonesia and the possibilities of religious discipline and psychological therapy to help beggars out of the cycle of poverty. The meeting ended with discussion on how the police would identify and forcefully raid squatter settlements and beggars in tourist areas where beggars can “earn” money easily and become even more lazy and unproductive. This new plan comes three months after a statement from the minister of social affairs saying the she is exploring the use of “herbal bath therapy” to rehabilitate “LGBT” and drug addicts. At this point, you may think that the Indonesian state is ridiculous and outright crazy; however, these practices are informed by a more pervasive set of ideologies and moral economies, which influence the conceptualization and management of what the state deems as “problems.”


Global health is often viewed as a collection of problems requiring a multifaceted and multidisciplinary response. Understanding how and why states conceptualize and respond to problems is thus critical to global health, especially with the prevailing rights-based discourse of the field. Social theory coupled with engaged and grounded ethnography of the state provides insights into why inequities persist and what we can do about it. Analysis of how and why deeply-rooted and historically-informed structural violence is conceptualized as an individualized and internalized pathology through the medicalization of poverty, for instance, explains how beggars are managed by the Indonesian state. Such analysis also explains why poverty, or in this case, begging, is viewed as an embodied deviance needing “rehabilitation” and “empowerment” through the improvement of “productivity” via spiritual and psychological self-governing treatment modalities.

In a field that valorizes evidence-based, rational public health practice, many global health practitioners ignore the moral and political economies that shape state practices and often blame poor health outcomes on the implementation failures and inefficiencies of lower-level state employees, which can be very misleading. Ethnographic accounts of states’ bureaucratic practices and management of citizens in the margins allow us to see the state as the perpetrator of violence and inequalities, rather than the popular notion in public health academia, which deems bureaucracy merely as a minor bottleneck to implementation.

Increasingly, global health practitioners and academics have realized the importance of strengthening public health systems to improve delivery and address health inequities. However, most analyses of health systems fail to recognize the importance of understanding moral and political dimensions of the state. Management and organizational strategies to improve efficiencies of health systems also cannot be blindly translated and applied to the state health system due its dynamic and ubiquitous nature. Analysis of the state thus becomes extremely critical to provide a more nuanced picture of the health system.

Social theories and engaged ethnographic research can fill the gaps in our understanding of the underpinnings of the state and provide global health practitioners with a more nuanced set of tool boxes and strategies to strengthen health systems in their delivery of equitable health outcomes.




  1. (2016, February 28). Mensos Punya Solusi Rehabilitasi LGBT Dengan Direbus Air Panas. Retrieved August 5, 2016, from
  2. Fassin, D., & Brown, Patrick. (2015). At the heart of the state: The moral world of institutions.
  3. Gupta, A. (2012). Red tape: Bureaucracy, structural violence, and poverty in India (John Hope Franklin Center book). Durham: Duke University Press.
  4. Kleinman, A. (2010). Four social theories for global health. The Lancet, 375(9725), 1518-1519.
  5. Lyon-Callo, V. (2004). Inequality, poverty, and neoliberal governance: Activist ethnography in the homeless sheltering industry (Broadview ethnographies & case studies. Urban series). Peterborough, Ont.; Orchard Park, N.Y.: Broadview Press.

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