Gilson Lucy, Schneider Helen, Orgill Marsha
Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Rondebosch, South Africa, Department for Global Health and Development, London School of Hygiene and Tropical Medicine, School of Public Health, University of the Western Cape, Cape Town, South Africa and Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Rondebosch, South Africa, Department for Global Health and Development, London School of Hygiene and Tropical Medicine, School of Public Health, University of the Western Cape, Cape Town, South Africa and Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town
Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Rondebosch, South Africa, Department for Global Health and Development, London School of Hygiene and Tropical Medicine, School of Public Health, University of the Western Cape, Cape Town, South Africa and Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town.
Health Policy Plan. 2014 Dec;29 Suppl 3:iii51-69. doi: 10.1093/heapol/czu098.
Tackling the implementation gap is a health policy concern in low- and middle-income countries (LMICs). Limited attention has so far been paid to the influence of power relations over this gap. This article presents, therefore, an interpretive synthesis of qualitative health policy articles addressing the question: how do actors at the front line of health policy implementation exercise discretionary power, with what consequences and why? The article also demonstrates the particular approach of thematic synthesis and contributes to discussion of how such work can inform future health policy research. The synthesis drew from a broader review of published research on any aspect of policy implementation in LMICs for the period 1994-2009. From an initial set of 50 articles identified as relevant to the specific review question, a sample of 16 articles were included in this review. Nine report experience around decentralization, a system-level change, and seven present experience of implementing a range of reproductive health (RH) policies (new forms of service delivery). Three reviewers were involved in a systematic process of data extraction, coding, analysis, synthesis and article writing. The review findings identify: the practices of power exercised by front-line health workers and their managers; their consequences for policy implementation and health system performance; the sources of this power and health workers' reasons for exercising power. These findings also provide the basis for an overarching synthesis of experience, highlighting the importance of actors, power relations and multiple, embedded contextual elements as dimensions of health system complexity. The significance of this synthesis lies in its insights about: the micropractices of power exercised by front-line providers; how to manage this power through local level strategies both to influence and empower providers to act in support of policy goals; and the focus and nature of future research on these issues.
解决实施差距是低收入和中等收入国家（LMICs）卫生政策关注的问题。到目前为止，人们对权力关系对这一差距的影响关注有限。因此，本文对定性卫生政策文章进行了解释性综合分析，探讨以下问题：卫生政策实施一线的行为者如何行使自由裁量权，会产生什么后果，原因是什么？本文还展示了主题综合的具体方法，并有助于讨论此类工作如何为未来的卫生政策研究提供信息。该综合分析借鉴了对1994年至2009年期间低收入和中等收入国家政策实施任何方面已发表研究的更广泛综述。从最初确定与特定综述问题相关的50篇文章中，选取了16篇文章纳入本综述。9篇报告了围绕权力下放（一种系统层面的变革）的经验，7篇介绍了实施一系列生殖健康（RH）政策（新的服务提供形式）的经验。三位评审员参与了数据提取、编码、分析、综合和文章撰写的系统过程。综述结果确定了：一线卫生工作者及其管理人员行使权力的做法；这些做法对政策实施和卫生系统绩效的影响；这种权力的来源以及卫生工作者行使权力的原因。这些结果还为经验的总体综合提供了基础，强调了行为者、权力关系以及多个相互关联的背景因素作为卫生系统复杂性维度的重要性。这一综合分析的意义在于其对以下方面的见解：一线提供者行使权力的微观实践；如何通过地方层面的策略管理这种权力，以影响并赋予提供者权力，使其支持政策目标；以及未来关于这些问题研究的重点和性质。
