Public Health Foundation of India, New Delhi, India.
Health Policy Plan. 2011 Jan;26(1):83-92. doi: 10.1093/heapol/czq023. Epub 2010 Jun 29.
This article analyses the nature of power relationships between urban hospital practitioners and other groups of actors involved in the implementation of public health policies in India, and the effects of enacting different strategies to strengthen implementation, in the context of these balances of power. It is based on an empirical research study conducted over 18 months in five Indian cities involving 61 in-depth interviews with medical practitioners and policy actors, and an interpretivist analytical approach. An issue case study-of the implementation of national HIV testing guidelines-was used to focus the interviews on specific events and phenomena. Respondents' accounts revealed that practitioners in both private and government hospitals tended to successfully resist or subvert the attempts of regulators and administrators to enforce the guidelines. However, in spite of often possessing perspectives and convictions that differed from the nationally sanctioned guidelines, practitioners were not able to effectively communicate these ideas to other health systems actors, or introduce them into mainstream policy discourse. The metaphor of public health guideline implementation throws light on the problematical nature of the power possessed by medical practitioners in relation to public health systems in India. Even as practitioners wield 'negative' power in their ability to resist authority, they appear to lack the 'positive' power to contribute intellectually to the policy process. This mix of political obduracy and intellectual demoralization among practitioners also underpins a subtle trend in public health, of the separation of the world of ideas from the world of actions. Study findings highlight that stronger regulations and provisions for accountability in Indian health systems critically need to be balanced by measures to develop collective intellectual capital and include the voices of frontline practitioners in public health policy discourse.
本文分析了印度城市医院从业者与其他参与实施公共卫生政策的群体之间权力关系的本质，以及在这些权力平衡背景下，实施不同策略以加强实施的效果。它基于一项在印度五个城市进行了 18 个月的实证研究，涉及对 61 名医疗从业者和政策参与者的深入访谈，以及一种解释性分析方法。采用国家艾滋病毒检测指南实施的案例研究，将访谈重点放在具体事件和现象上。受访者的叙述表明，私立医院和公立医院的从业者往往成功地抵制或颠覆监管者和管理者执行这些指南的尝试。然而，尽管从业者的观点和信念往往与国家认可的指南不同，但他们无法有效地将这些想法传达给其他卫生系统参与者，也无法将其引入主流政策话语。公共卫生指南实施的隐喻揭示了印度医疗从业者相对于公共卫生系统所拥有的权力的问题性质。即使从业者在抵制权威方面拥有“消极”权力，但他们似乎缺乏在政策过程中提供智力贡献的“积极”权力。这种从业者之间政治固执和知识士气低落的混合，也支撑了公共卫生领域的一个微妙趋势，即思想世界与行动世界的分离。研究结果强调，印度卫生系统需要在加强监管和问责制的同时，采取措施发展集体智力资本，并将一线从业者的声音纳入公共卫生政策话语。
