The Patronage Pickle In Healthcare and Society

By Gerrit Van Wyk.

How positions are filled.

There’s a story about a university, who wanted to fill the vacant position for head of the department mathematics with someone with a track record in research and teaching. A shortlist of three candidates was drawn up after sifting through all applications. The first candidate had a PhD and published a few papers, which fitted the job description. So far so good. The second had a PhD and multiple publications, and volunteers to do humanitarian work in the community. This was even better. The third held a PhD from a prestigious university, had a track record of cutting-edge research, and was in leadership positions in several highly regarded mathematics societies. Clearly, this was their candidate. Instead, the Dean’s nephew was appointed. We all know stories of this kind.

Many years ago, the CEO of a hospital I worked at told me if I want to progress through the healthcare ranks, I had to show I was a “team player”. It means joining a patronage network in which those above you pull you up, or kick you down, depending on how much loyalty you show them.

The problem in a social patronage system in which the coinage of exchange is loyalty, and the payoff patronage, is there is no space in it for creativity and solving actual problems. On the contrary, having a different perspective from higher ups is perceived as questioning their pet interests and disloyalty, unless you can show what you propose benefits the patrons.

According to the dictionary, a patron is a powerful person who may support and protect others, and patronage the act of receiving such support or protection. In other words, patron is a role, and patronage is something we do.

I understand patronage to mean asking you to intervene on my behalf, with the implied understanding that in return, at some future date you will call in a favor, and, you arrange for what I ask with the implied understanding that if you ask me for a favor at some future date, I will act on it. An economics perspective of it is that of a social transaction involving an exchange, with, in sports terms, favors for future considerations.

Jeffrey Simpson describes the history of political patronage in Canada in Spoils of Power: The Politics of Patronage, and I take two lessons from it. Canada inherited a hidden class system and associated patronage system from Britain, designed to control and maintain privilege, and, with it, economic benefits. Secondly, historical efforts to eliminate patronage from politics only shifted around the pieces on the chess board. Technically, civil service appointments are made on merit, but there are many positions of power in higher echelons, that are vacated and occupied by new people when different political parties are elected and get their hands on the levers of power, and the patronage system. These ritual blood lettings ensure “our” people, who can be trusted, make important decisions that benefit us. That also happens to be a significant part of the healthcare playing field, both at ministries of health, and consulting and commissions of inquiry hirings.

Robert Jackall’s Moral Mazes: The World of Corporate Managers shows a similar dynamic in large corporations and bureaucracies. If you are ambitious, you must hitch your wagon to a rising star to smooth your way up the corporate ladder. In other words, patronage is widespread, not only in politics. It plays out in healthcare politics and organizations, which translates into the hiring and firing of board members, consultants, commission members, etc., who are expected to act in ways benefiting the hiring patron, or face the consequences.

Other variations of patronage are nepotism, which means hiring family and friends, and networking, or cultivating people for future favors. The common theme between patronage, nepotism, and networking is it’s not what you bring to the table that matters, it’s who you know. It eliminates creativity and innovation by reverting to what is expected, acceptable, and average, and many of the big problems confronting us today, healthcare for example, require creativity and innovation, not more of the same. Hence patronage is a brake anchoring the wagon and preventing progress.

If you think about it, the basic framework of patronage, no matter what you call it, goes far back in human social history, and for generations fulfilled the same functions. But at an even deeper level, there is the unwritten unconscious reciprocity rule, which is social code saying if someone does something for me, I feel obligated to do something in return. We are socialized in it from a very early age, and it therefore becomes a core building block of human interaction and cooperation, and of patronage. Without it, our social world will not work, but, there’s a dark side to it as well. Some, like marketers and politicians, use it to create obligations to use to their advantage. Patronage therefore can range from innocuous to toxic, depending on a context.

Being human means belonging to groups, which, like complex adaptive systems, are governed by simple social code setting out our obligations towards others within the group, including the reciprocity rule. Asking for favor also means asking to become or remain part of a group.

We unconsciously and consciously create hierarchies and rankings in groups, which creates power differences, and the underlying conditions for patronage. Inevitably, patronage points to a power difference; those who give patronage have power and control desirable resources, those who receive patronage are given an opportunity to improve their status, rank, and economic position on the ladder.

Belonging to a group requires trade-offs, compromises, and give and take. It means facing dilemmas of identity, involvement, individuality, and boundaries as part of belonging, when engaging, issues of trust and disclosure, and the problem of voice. These are all part of how authority, dependency, creativity, and courage play out, which, in turn, have links to patronage as part of group functioning.

If we bring the strings of this conversation together, one can see patronage emerges from human interrelationships and interactions and by itself is not good or bad, it depends on a context, but at the same time, it stifles creativity, innovation, and different perspectives, which are vital for solving healthcare and other complex problems. Sadly, therefore, patronage is embedded in human behavior and the human social world, and it won’t go away, and that’s a fact of life. Like a favorite uncle in jail, we know it’s there, but don’t talk about it, because it’s too uncomfortable.

I’ve been writing about the need for a different perspective and creativity to solve healthcare’s problems for many years. The depressing reality is, it’s been tilting at windmills; healthcare won’t change, because it can’t change. It is caught in a system of feudal relationships based on patronage and loyalty, with vassals working for the benefit of mandarins and no-one else. It turns out the liberty, equality, and fraternity of the 1789 French Revolution freed us from class oppression, but not the underlying yoke of the feudal class system dynamic associated with it, in which there are benefits to fealty. To change that, we’ll need another revolution.