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  • 1.
    Gaitonde, Rakhal
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Divergences, dissonances and disconnects: implementation of community-based accountability in India’s national rural health mission2020Doctoral 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.

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  • 2.
    Gaitonde, Rakhal
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Humanities and Social Sciences, Indian Institute of Technology Madras, Chennai, India.
    Muraleedharan, V. R.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Accountability in the health system of Tamil Nadu, India: exploring its multiple meanings2019In: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 17, article id 44Article in journal (Refereed)
    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.

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  • 3.
    Gaitonde, Rakhal
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Indian Institute of Technology – Madras, Centre of Technology and Policy, Chennai, India.
    Oxman, Andrew D
    Okebukola, Peter O
    Rada, Gabriel
    Interventions to reduce corruption in the health sector2016In: Cochrane Database of Systematic Reviews, ISSN 1469-493X, E-ISSN 1469-493X, no 8, article id CD008856Article, review/survey (Refereed)
    Abstract [en]

    Background: Corruption is the abuse or complicity in abuse, of public or private position, power or authority to benefit oneself, a group, an organisation or others close to oneself; where the benefits may be financial, material or non-material. It is wide-spread in the health sector and represents a major problem.

    Objectives: Our primary objective was to systematically summarise empirical evidence of the effects of strategies to reduce corruption in the health sector. Our secondary objective was to describe the range of strategies that have been tried and to guide future evaluations of promising strategies for which there is insufficient evidence.

    Search methods: We searched 14 electronic databases up to January 2014, including: CENTRAL; MEDLINE; EMBASE; sociological, economic, political and other health databases; Human Resources Abstracts up to November 2010; Euroethics up to August 2015; and PubMed alerts from January 2014 to June 2016. We searched another 23 websites and online databases for grey literature up to August 2015, including the World Bank, the International Monetary Fund, the U4 Anti-Corruption Resource Centre, Transparency International, healthcare anti-fraud association websites and trial registries. We conducted citation searches in Science Citation Index and Google Scholar, and searched PubMed for related articles up to August 2015. We contacted corruption researchers in December 2015, and screened reference lists of articles up to May 2016.

    Selection criteria: For the primary analysis, we included randomised trials, non-randomised trials, interrupted time series studies and controlled before-after studies that evaluated the effects of an intervention to reduce corruption in the health sector. For the secondary analysis, we included case studies that clearly described an intervention to reduce corruption in the health sector, addressed either our primary or secondary objective, and stated the methods that the study authors used to collect and analyse data.

    Data collection and analysis: One review author extracted data from the included studies and a second review author checked the extracted data against the reports of the included studies. We undertook a structured synthesis of the findings. We constructed a results table and 'Summaries of findings' tables. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence.

    Main results: No studies met the inclusion criteria of the primary analysis. We included nine studies that met the inclusion criteria for the secondary analysis. One study found that a package of interventions coordinated by the US Department of Health and Human Services and Department of Justice recovered a large amount of money and resulted in hundreds of new cases and convictions each year (high certainty of the evidence). Another study from the USA found that establishment of an independent agency to investigate and enforce efforts against overbilling might lead to a small reduction in overbilling, but the certainty of this evidence was very low. A third study from India suggested that the impacts of coordinated efforts to reduce corruption through increased detection and enforcement are dependent on continued political support and that they can be limited by a dysfunctional judicial system (very low certainty of the evidence). One study in South Korea and two in the USA evaluated increased efforts to investigate and punish corruption in clinics and hospitals without establishing an independent agency to coordinate these efforts. It is unclear whether these were effective because the evidence is of very low certainty. One study from Kyrgyzstan suggested that increased transparency and accountability for co-payments together with reduction of incentives for demanding informal payments may reduce informal payments (low certainty of the evidence). One study from Germany suggested that guidelines that prohibit hospital doctors from accepting any form of benefits from the pharmaceutical industry may improve doctors' attitudes about the influence of pharmaceutical companies on their choice of medicines (low certainty of the evidence). A study in the USA, evaluated the effects of introducing a law that required pharmaceutical companies to report the gifts they gave to healthcare workers. Another study in the USA evaluated the effects of a variety of internal control mechanisms used by community health centres to stop corruption. The effects of these strategies is unclear because the evidence was of very low certainty.

    Authors' conclusions: There is a paucity of evidence regarding how best to reduce corruption. Promising interventions include improvements in the detection and punishment of corruption, especially efforts that are coordinated by an independent agency. Other promising interventions include guidelines that prohibit doctors from accepting benefits from the pharmaceutical industry, internal control practices in community health centres, and increased transparency and accountability for co-payments combined with reduced incentives for informal payments. The extent to which increased transparency alone reduces corruption is uncertain. There is a need to monitor and evaluate the impacts of all interventions to reduce corruption, including their potential adverse effects.

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  • 4.
    Gaitonde, Rakhal
    et al.
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute of Medical Sciences & Technology, Thiruvananthapuram, Kerala, India.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Dissonances and disconnects: the life and times of community-bsaed accountability in the National Rural Health Mission in Tamil Nadu, India2020In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 20, article id 89Article in journal (Refereed)
    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.

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  • 5.
    Gaitonde, Rakhal
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    San Sebastian, Miguel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Muraleedharan, V R
    Hurtig, Anna-Karin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Community Action for Health in India's National Rural Health Mission: One policy, many paths2017In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 188, p. 82-90Article in journal (Refereed)
    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.

  • 6. Rangamani, Sukanya
    et al.
    Obalesha, Kannamedi Bheemappa
    Gaitonde, Rakhal
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Health issues of sanitation workers in a town in Karnataka: Findings from a lay health-monitoring study2015In: National Medical Journal of India, ISSN 0970-258X, Vol. 28, no 2, p. 70-73Article in journal (Refereed)
    Abstract [en]

    Background. Official estimates are not available for mortality or morbidity among sanitation workers (including manual scavengers) in India. Little is known about their health issues and health-seeking behaviour in the context of their occupational hazards (work practices and exposures). We attempted to understand the nature of health problems of sanitation workers using a lay epidemiological process. Methods. A community-based organization working in Chitradurga town in Karnataka for the development of sanitation workers recorded the health problems of workers and their treatment-seeking practices every month using a health-monitoring tool. We used a lay epidemiological approach to identify occupational health problems and deficiencies in healthcare access through the narrative of workers' perceptions of their illness. Descriptive analysis was done to map the occupational health status, healthcare-seeking practices and the social support mechanisms in place. Results. Injuries and chest pain were the most commonly reported illnesses. Most workers continued to work without appropriate treatment as they ignored their illness, and did not want to miss their wages or lose their job. Self-medication was common. Intake of alcohol was prevalent to cope with the inhuman task of cleaning filthy sewage, and as a modality to forget their health problems. The pattern of illnesses reported during monthly monitoring was also reported as long-standing illnesses. Health and safety mechanisms at workplace did not exist and were not mandated by regulatory bodies. Conclusion. Health and safety of sanitation workers has been inadequately addressed in public health research. Sanitation work lacks specific protective regulatory guidelines to address health hazards unlike other hazardous occupations. The government needs to institute an adequate health-monitoring and healthcare system for sanitation workers.

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