Telling talking: discourse and practice in context

Abstract

The paper explores the contribution that discourse analysis can make to understanding the unevenness of policy implementation. This aim is addressed through three questions regarding the relationship of discourse to actors and places: Do discourses map systematically onto identifiable constituencies of actors? Do discourses map systematically onto places in a way that has some coherency with the variation found in the performance of health care provision? Does patterning of discourse by place merely reflect local composition by constituencies of actors or is something more contextually specific at work? The study explores discourses relating to a programme of health reforms in the state of Ceará, Northeast of Brazil, a state strongly committed politically to the reform agenda. Three case studies of decentralised political units, the municipio, are selected based on different settlement type (urban, metropolitan and rural) and differently performing health systems. Mapping various forms of argumentation shows clear association with identifiable constituencies within and between local health systems. However, the presence of different forms and combinations of discourses between the three case studies implies an influence of context beyond structural interests in shaping local cultures of practice. The relational and situated nature of discourse coalitions identified in this study makes clear that discourse analysis has to be used as an approach to understanding spatial differentiation in tandem with other methods, sources of data and types of analysis. However, discourse analysis may define the questions for those other approaches by acting as a probe to tease out issues.