49. Atkinson S. R., L. R. Medeiros, P. H. L. Oliveira and R. D. De Almeida (2000), ‘Going Down to the Local: Incorporating Social Organization and Political Culture into Assessments of Decentralized Health Care’, Social Science and Medicine, 51: 619-636.

The social organization and political culture of the society in which an organization is embedded can have major effects on the way in which organizational policy is implemented and on how that organization functions. Research on health sector reforms has paid scant attention to this aspect. If the claims made for decentralized management in the health sector are to be evaluated seriously, it is critical to develop concepts and methods to evaluate not only the formal organization and the outputs of the health system, but also the aspects of local social organization and political culture within which that local health system is embedded that may mediate their relationship.  The paper explores three cases of district health systems in Northeast Brazil in order to identify aspects of local social organization and political culture that appear to influence the implementation of the reforms and thereby potentially impact upon the quality of the care provided. The results of the study indicate the importance that aspects of local social organization and political culture may exert on the operations of a decentralized health system. Key aspects identified are: the space for autonomy; the space for local voice in political life; personalized and institutionalized influences on autonomy and local voice; differences of involvement of health staff with the district; different spaces of acceptable practice and accountability.  These factors are seen to moderate the intent of the health reforms at all stages in their implementation. Three possibilities are discussed for the nature of the interaction in terms of cause and effect between the formal organization of the health system and its local context. Seeing this relationship as one of a dialogue offers some cautious optimism for the potential of the reform agenda. The paper closes with suggestions on how to take this line of research forward.