Submission ID 130216
| Issue/Objective | Ensuring high quality of care is a crucial step towards achieving universal health coverage. Paramount to high quality care provision is the creation and maintenance of a culture of quality care. Individualistic responses to negative working conditions such as burnout, moral injury, and disengagement fail to illuminate how the chronic, systemic challenges fundamentally reshape the collective, institutional dynamics of care delivery. The present study addresses this gap in knowledge by investigating how the many challenges in rural Malawian district hospitals generate not only individual distress but also a broader transformation of the work environment that ultimately impacts the quality of care. |
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| Methodology/Approach | An institutional ethnographic approach was employed in two rural district hospitals in Malawi. Data were collected over a six-week field visit through participant observation and in-depth interviews with healthcare workers. Analysis focused on how everyday practices and institutional conditions shape patterns of work and care delivery. |
| Results | Our findings indicate that ongoing systemic challenges produced institutional-level collective behavioural responses - namely, a pattern of normalised detachment from patient care. We label this detachment as a "culture of indifference," a sedimented, organisational-level orientation that is woven into the informal norms, unwritten rules, and taken-for-granted practices as the normalised way of functioning. The culture of indifference is a self-sustaining cycle composed of three mutually reinforcing elements: a systemic lack of effort to improve working conditions, a normalization of dysfunction, and resigned passivity. Together, these dynamics reinforce disengagement and contribute to diminished quality of care. |
| Discussion/Conclusion | Findings suggest that interventions focused solely on individual resilience are insufficient in contexts of systemic constraint. Instead, efforts to improve care quality and advance global health equity must address the institutional cultures that shape frontline practice. This includes prioritizing workforce conditions, incorporating healthcare worker perspectives into policy and program design, and disrupting signals that devalue both providers and patients. Addressing these structural drivers is critical to restoring accountability and enabling meaningful, scalable improvements in care delivery within fragmented health systems. |
| Presenters and Affiliations | Imre Papp University of Alberta Imre Papp University of Alberta Zubia Mumtaz University of Alberta |
