How performance targets can ingrain a culture of 'performing out': An ethnography of two Indian primary healthcare facilities.

Low- and middle-income country health systems often apply decontextualised and unrealistic performance targets to facilities. This can lead to empty compliance and 'performing out', whereby managers and providers manipulate or inflate data to create the false impression of a functional system. While this is a well-recognised pitfall of audit-style performance accountability processes, the social processes by which these practices emerge has not been well described in the literature. In this paper, with a focus on maternal and newborn care, we seek to better understand how and why the practices of 'performing out' occur, and their implications for health system functioning, organisational culture, and quality of care. We do this through a focused facility ethnography undertaken in two primary healthcare facilities in an eastern Indian state, anonymised as Esma, where practices of 'performing out' are prevalent. We draw on the understanding that health systems are complex adaptive systems encompassing both hardware and software elements, where individual behavioural practices are an outcome of the system as a whole. To unpack how the dynamic interactions between system elements and agents influence individual behaviours, we draw upon the sociological theories of practice of Bourdieu, encompassing the concepts of field, habitus, and capital. This lens helps illustrate how resource scarcity, unyielding application of unrealistic targets with punitive sanctions for non-achievement, and complex power dynamics lead system actors to manipulate data and create documentation to show the achievement of targets that were not actually met. The practices of 'performing out' are shaped by, and in turn shape, the organisational culture of the facilities, with perverse behaviour becoming part of an entrenched habitus – the 'dispositions' of agents that guide behaviour and thinking. In the longer term, the habituation of 'performing out' contributes to a systemic orientation toward sub-par performance, undermining quality of care. • Uses an ethnographic approach for health systems research. • Unpacks 'intangible software' and organisational culture in LMIC health systems. • Describes 'performing out' to create the illusion of a functional system. • Illustrates the perverse effects of target-based performance and accountability. • Applies a complex adaptive system framing and Bourdieu's theories of practice. [ABSTRACT FROM AUTHOR]