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Divergences, dissonances and disconnects: implementation of community-based accountability in India’s national rural health mission
Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
2020 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Accountability of health systems to the individuals and communities they serve is increasingly recognized as a key aspect in efforts at health system strengthening. This has led to a greater focus on efforts to evolve systems that enable communities to hold health systems accountable. In parallel with this change, the governance of public systems has been transformed under the influence of the neo-liberal paradigm of governance. India introduced the flagship National Rural Health Mission (presently termed the National Health Mission) in 2005, to bring about an architectural correction of the health system. One of the five key components of the mission was ‘Communitization’. This component aimed to increase the ownership of the health systems by the communities they serve. As part of this a programme called Community Action for Health (CAH) was piloted in nine states and then rolled out nationally. The implementation diverged from the originally envisaged process in different states.

This PhD research aims to understand the institutional level influences that impact on the implementation of community-based accountability and governance mechanisms and the potential of integrating such processes in the public health system in India. I used qualitative methods to map out the divergences in implementation and sought to understand the reasons for these. Next, I conducted a case study of the southern state of Tamil Nadu, in which I focused on the processes within the apex administrative level of the state.

In addition to mapping two dimensions along which the policy seemed to diverge, I also documented three distinct perspectives on accountability among the key actors involved in implementing CAH. Overall there were three constructs that emerged from the research: ‘Divergences’, ‘Dissonances’ and ‘Disconnects’. Divergences refer to the way in which policies and programmes shift from the original conceptualization. Dissonances points to the presence of multiple perspectives on the same concept in the same organizational setting. Disconnects represents the lack of spaces within the organization that enable processes of collective sensemaking. The emergent understanding from the research is that the divergences in policy implementation may in fact reflect a deeper level of conflict at the level of belief and perspectives in different layers of the administration. In the absence of spaces and processes to facilitate collective sense-making, it is likely that policies, even when introduced with significant commitment from policymakers at the higher administrative layers, are likely to require systematic effort to sustain.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2020. , p. 79
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2071
Keywords [en]
Community Action for Health, Community-based Accountability, Policy Implementation, Problematization, Institutional Perspective, National Rural Health Mission / National Health Mission, Tamil Nadu, India
National Category
Public Health, Global Health, Social Medicine and Epidemiology Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Public health
Identifiers
URN: urn:nbn:se:umu:diva-167590ISBN: 978-91-7855-204-7 (print)ISBN: 978-91-7855-205-4 (electronic)OAI: oai:DiVA.org:umu-167590DiVA, id: diva2:1390255
Public defence
2020-02-28, N440, Naturvetarhuset, Umeå universitet, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2020-02-07 Created: 2020-01-31 Last updated: 2020-02-07Bibliographically approved
List of papers
1. Community Action for Health in India's National Rural Health Mission: One policy, many paths
Open this publication in new window or tab >>Community Action for Health in India's National Rural Health Mission: One policy, many paths
2017 (English)In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 188, p. 82-90Article in journal (Refereed) Published
Abstract [en]

Community participation as a strategy for health system strengthening and accountability is an almost ubiquitous policy prescription. In 2005, with the election of a new Government in India, the National Rural Health Mission was launched. This was aimed at 'architectural correction' of the health care system, and enshrined 'communitization' as one of its pillars. The mission also provided unique policy spaces and opportunity structures that enabled civil society groups to attempt to bring on to the policy agenda as well as implement a more collective action and social justice based approach to community based accountability. Despite receiving a lot of support and funding from the central ministry in the pilot phase, the subsequent roll out of the process, led in the post-pilot phase by the individual state governments, showed very varied outcomes. This paper using both documentary and interview based data is the first study to document the roll out of this ambitious process. Looking critically at what varied and why, the paper attempts to derive lessons for future implementation of such contested concepts.

Keywords
Community action for health, National Rural Health Mission India, Policy implementation, Community participation, India
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-138466 (URN)10.1016/j.socscimed.2017.06.043 (DOI)000408783400009 ()28732238 (PubMedID)
Available from: 2017-08-23 Created: 2017-08-23 Last updated: 2020-02-04Bibliographically approved
2. Accountability in the health system of Tamil Nadu, India: exploring its multiple meanings
Open this publication in new window or tab >>Accountability in the health system of Tamil Nadu, India: exploring its multiple meanings
2019 (English)In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 17, article id 44Article in journal (Refereed) Published
Abstract [en]

Background: Accountability is increasingly being demanded of public services and is a core aspect of most recent frameworks of health system strengthening. Community-based accountability is an increasingly used strategy, and wasa core aspect of India's flagship National Rural Health Mission (NRHM; 2005-2014). Research on policy implementation has called for policy analysts to go beyond the superficial articulation of a particular policy intervention to study the underlying meaning this has for policy-makers and other actors of the implementation process and to the way in which problems sought to be addressed by the policy have been identified and problematised'.

Methods: This research, focused on state level officials and health NGO leaders, explores the meanings attached to the concept of accountability among a number of key actors during the implementation of the NRHM in the south Indian state of Tamil Nadu. The overall research was guided by an interpretive approach to policy analysis and the problematisation lens. Through in-depth interviews we draw on the interviewees' perspectives on accountability.

Results: The research identifies three distinct perspectives on accountability among the key actors involved in the implementation of the NRHM. One perspective views accountability as the achievement of pre-set targets, the other as efficiency in achieving these targets, and the final one as a transformative process that equalises power differentials between communities and the public health system. We also present the ways in which these differences in perspectives are associated with different programme designs.

Conclusions: This research underlines the importance of going beyond the statements of policy to exploring the underlying beliefs and perspectives in order to more comprehensively understand the dynamics of policy implementation; it further points to the impacts of these perspectives on the design of initiatives in response to the policy.

Place, publisher, year, edition, pages
BMC, 2019
Keywords
Accountability, Community-based accountability, National Rural Health Mission, Belief structures, problematisation, Policy implementation
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-159067 (URN)10.1186/s12961-019-0448-8 (DOI)000466190800001 ()31029173 (PubMedID)
Available from: 2019-05-21 Created: 2019-05-21 Last updated: 2020-03-26Bibliographically approved
3. Dissonances and disconnects: the life and times of community-bsaed accountability in the National Rural Health Mission in Tamil Nadu, India
Open this publication in new window or tab >>Dissonances and disconnects: the life and times of community-bsaed accountability in the National Rural Health Mission in Tamil Nadu, India
2020 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 20, article id 89Article in journal (Refereed) Published
Abstract [en]

Background: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

Place, publisher, year, edition, pages
BioMed Central, 2020
Keywords
Policy implementation, Problematization, Community-based accountability, National Health Mission India, Institutional perspective, Diffusion of innovations, India
National Category
Public Health, Global Health, Social Medicine and Epidemiology Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-167589 (URN)10.1186/s12913-020-4917-0 (DOI)000513675800002 ()32024516 (PubMedID)
Available from: 2020-01-31 Created: 2020-01-31 Last updated: 2020-03-12Bibliographically approved

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