Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute of Medical Sciences & Technology, Thiruvananthapuram, Kerala, 695 011, India.
Department of Epidemiology and Global Health, Umea University, Umeå, Sweden.
BMC Health Serv Res. 2020 Feb 5;20(1):89. doi: 10.1186/s12913-020-4917-0.
There are increasing calls for developing robust processes of community-based accountability as key components of health system strengthening. However, implementation of these processes have shown mixed results over time and geography. The Community Action for Health (CAH) project was introduced as part of India's National Rural Health Mission (now National Health Mission) to strengthen community-based accountability through community monitoring and planning. In this study we trace the implementation process of this project from its piloting, implementation and abrupt termination in the South Indian state of Tamil Nadu.
We framed CAH as an innovation introduced into the health system. We use the framework on integration of innovations in complex systems developed by Atun and others. We used qualitative approaches to study the implementation. We conducted interviews among a range of individuals who were directly involved in the implementation, focusing on the policy making organizational level.
We uncover what we have termed "dissonances" and "disconnects" at the state level among individuals with key responsibility of implementation. By dissonances we refer to the diversity of perspective on the concept of community-based accountability and its perceived role. By disconnects we refer to the lack of spaces and processes for "sense-making" in a largely hierarchically functioning system. These constructs we believe contributes significantly to making sense of the initial uptake and the subsequent abrupt termination of the project.
This study contributes to the overall field of policy implementation, especially the phase between the emergence on the policy agenda and its incorporation into the day to day functioning of a system. It focuses on the implementation of contested interventions like community-based accountability, in Low- and Middle-income country settings undergoing transitions in governance. It highlights the importance of "problematization" a dimension not included in most currently popular frameworks to study the uptake and spread of innovations in the health system. It points not only to the importance of diverse perspectives present among individuals at different positions in the organization, but equally importantly the need for spaces and process of collective sense-making to ensure that a contested policy intervention is integrated into a complex system.
人们越来越呼吁将基于社区的问责制作为加强卫生系统的关键组成部分来建立强有力的流程。然而，这些流程的实施在时间和地域上呈现出不同的结果。社区行动促进健康（CAH）项目是印度国家农村卫生使命（现国家卫生使命）的一部分，旨在通过社区监测和规划来加强基于社区的问责制。在这项研究中，我们追溯了该项目在印度泰米尔纳德邦从试点到实施再到突然终止的实施过程。
我们将 CAH 视为引入卫生系统的创新。我们使用了 Atun 等人开发的复杂系统中创新整合框架。我们使用定性方法研究实施情况。我们对直接参与实施的一系列人员进行了访谈，重点关注政策制定的组织层面。
我们发现，在负责实施的关键人员中，州一级存在“不和谐”和“脱节”现象。我们所说的“不和谐”是指对基于社区的问责制概念及其预期作用的看法存在多样性。我们所说的“脱节”是指在一个主要以等级制度运作的系统中缺乏“意义建构”的空间和流程。我们认为，这些构建对于理解项目最初的采用以及随后的突然终止具有重要意义。
本研究对政策实施的整体领域，特别是在政策议程出现到纳入系统日常运作之间的阶段做出了贡献。它侧重于在治理转型中的中低收入国家实施基于社区的问责制等有争议的干预措施。它强调了“问题化”的重要性，这是目前大多数研究卫生系统创新采用和传播的框架所没有包含的一个维度。它不仅指出了在组织中不同职位的个人存在多样性观点的重要性，而且同样重要的是需要有集体意义建构的空间和流程，以确保有争议的政策干预措施融入复杂的系统中。
