Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine
ß The Author 2010; all rights reserved. Advance Access publication 29 June 2010
Health Policy and Planning 2011;26:83–92
doi:10.1093/heapol/czq023
Disempowered doctors? A relational view
of public health policy implementation in
urban India
Kabir Sheikh1* and John D H Porter2
1
Public Health Foundation of India, New Delhi, India and 2Departments of Public Health & Policy and Infectious & Tropical Diseases,
London School of Hygiene & Tropical Medicine, UK
*Corresponding author. 121 Sundar Nagar, New Delhi 110003, India. Tel: þ91 9911987670. E-mail: [email protected],
[email protected]
Accepted
1 March 2010
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.
Keywords
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.
Medical practitioners, power, policy analysis, implementation, discourse, public
health guidelines, HIV testing, India
83
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HEALTH POLICY AND PLANNING
KEY MESSAGES
Indian medical practitioners are widely successful in resisting the attempts of authorities to enforce public health
guidelines. At the same time however, practitioners are unable to contribute systematically to ideational processes in
policy development for public health.
This paradoxical balance of power is emblematic of Indian practitioners’ troubled relationship with public health systems,
which calls for a sensitive combination of policy strategies balancing stronger regulations with attention to intellectual
inclusion and nurturance.
Introduction: practitioners and power
This article explores equations of power between medical
practitioners and public health systems and policy actors in
India. Power is a complex and multi-dimensional concept, and
a central theme in the study of policy and policy process (Walt
1994). In policy contexts, power is typically conceived of in a
relational sense, i.e. particular policy actors are understood to
exercise their ‘power over’ others (Buse et al. 2005, p21). Actors
may exercise political power by bringing authority (which may
be legally or traditionally determined) to bear, or by resisting
the authority of others (Buse et al. 2005; Erasmus and Gilson
2008). The conventional instruments of institutional power
range from coercion to inducement, depending on the choices
and political resources available to authorities. Policy actors
may also demonstrate power by influencing key policy decisions
and/or by limiting the scope of other actors’ activities (Parsons
1995). Apart from the direct exercise of power by one (group
of) actor(s) over another, policy theorists have also highlighted
the role of more diffused forms of power, such as that of elite
groups to shape thoughts and ideas on a large scale, and the
hegemonic potential of ideas themselves (Lukes 1974). More
recently, post-positivist theorists such as Yanow (2000) and
Fischer (2003) have drawn on the writings of political philosophers such as Jürgen Habermas to emphasize positive and
productive aspects of ‘communicative’ power, of organizing
action through discourse.
Medical practitioners have widely been seen as exponents of
different types of power. Freidson’s foundational theories
located doctors’ power in the manner of organization of the
medical profession, notably of strong controls over entry into
the profession, and over the production and utilization of
health knowledge (Friedson 1970). Ivan Illich drew attention to
doctors’ power over discourse about the nature of illness (Illich
1977), contending that the medical profession used this power
to perpetuate its interests. These influential early formulations
of medical professional power arose from empirical work in
northern countries, and have been succeeded by a significant
corpus of literature on the subject in Europe and North
America. However, power as exercised by medical practitioners,
particularly in relation to other policy and systems actors,
remains a poorly explored subject in most low- and
middle-income country (LMIC) contexts (Erasmus and Gilson
2008; Gilson and Raphaely 2008). From India, there are very
few examples of policy analyses on this subject, and a limited
body of empirical research from related disciplines (anthropology, sociology, public administration).
Widely prevailing concerns around problems of regulating
medical behaviour in India are reflected in several recent essays
(Yesudian 2001; Muraleedharan and Nandraj 2003; Peters 2003;
Das and Hammer 2004; Peters and Muraleedharan 2008).
While none of these actively investigate themes of power, they
draw on the hypothesis that doctors are able to, and frequently
do, defy conventional institutional authority, notably that of
public institutions. This is also borne out by copious literature
on the infringement of public health guidelines by private and
government practitioners (Mertens et al. 1998; Uplekar et al.
1998; Chakraborty and Frick 2002; Sheikh et al. 2005).
Bhat and Maheshwari (2005), Das Gupta et al. (2003) and
Muraleedharan and Nandraj (2003), among others, have
reported on the ineffectiveness of Indian government health
departments in executing their administrative and regulatory
roles. The failings of autonomous medical councils in performing their professional regulatory functions, including dereliction
of disciplinary duties and corruption, have been extensively
documented and are an important context for the apparent
freedom with which doctors flout regulations (Nandraj 1994;
Gonsalves 1997; Singhi 1997; Tavaria 1997; Sharma 2001;
Pandya and Nundy 2002). The assumption of Indian doctors’
ability to resist the influences of public regulatory institutions is
also implicit in recent plans and propositions for harnessing
market strategies to influence medical behaviour (Hammer and
Jack 2001; Peters et al. 2002; Peters 2003; Peters and
Muraleedharan 2008).
Another documented variant of medical power in India is that
of medical professional groups’ influence over the development
of key government health policies. Maru’s historical analysis of
national health workforce policy development chronicles the
collective actions of medical associations and councils in
opposing reforms which would ostensibly have led to attenuation of doctors’ control over health markets (Maru 1985). The
role of medical professional bodies in political lobbying to
preserve professional inviolability and private pecuniary interests have also been documented by Jeffery (1988), Baru (1998)
and Duggal (2005) in subsequent separate commentaries.
On the obverse, explorations of Indian doctors’ vulnerabilities
in policy contexts are also rare. Baru (2005) has commented on
how increasing commercialization and the growth of the private
sector have precipitated a trend of demoralization of government practitioners, faced with growing institutional and financial insecurity and loss of social prestige. Kamat (2001) and
Kielmann et al. (2005) have reported on uncertainties experienced by medical practitioners in contexts of multiple conflicting policy directives and increasing patient agency. In an earlier
article, Jeffery has highlighted vulnerabilities of Indian doctors,
particularly private doctors, as a result of their isolation from
DISEMPOWERED DOCTORS IN INDIA
colleagues and susceptibility to control by patients, and the
vulnerability of the medical profession at large as a result of
political intrusions in medical policy-making (Jeffery 1977).
There are a small number of examples of empirical research
on the nature of doctors’ interactions with contiguous institutional and programme actors, which would permit an appreciation of power in real-life workplace contexts. These include
Bhat and Maheshwari’s (2005) study of district health services
in Chhattisgarh state, which delineates how rigid government
health management systems favoured a convention of mechanistic and centralized decision-making, and discouraged doctors from attempting field-level innovations to improve service
delivery. Uplekar et al. (1998), Vyas et al. (2003) and De Costa
et al. (2008) have separately commented on the role of mutual
distrust between private practitioners and government health
officials as a factor affecting private doctors’ uptake of public
health guidelines.
Summarizing, the scantiness of the literature and dearth of
analytical detail in this area do not permit the formulation of
strong hypotheses around medical power in India. The only
theme that emerges from the literature with some clarity is of a
generalized political dominance of medical professionals over
other social groups and within health systems, even as their
individual and collective vulnerabilities have also been highlighted by some authors. The treatment of ideas and discourse
as a currency of power is particularly deficient in the Indian
literature.
based on bottom-up theory helps in locating power—otherwise
an ephemeral concept—in the real-life events and processes in
which policy actors participate; an epistemic approach which
has not been adequately utilized in LMIC health policy contexts
(Erasmus and Gilson 2008). Scrutinizing policy processes in
‘in-vivo’ workplace contexts also permits a concurrent engagement with retrospective and prospective research objectives, i.e.
(1) understanding the nature of practitioners’ power relationships with health systems and policy actors, and (2) deliberating on the viability of different policy strategies in the context
of these relationships (Ritchie and Spencer 1994; Erasmus and
Gilson 2008).
National HIV testing guidelines were used as a case study for
public health regulations in general, and helped to focus the
research inquiry on specific acts and events. Those guidelines
that apply to the behaviour of doctors include the requirement
of taking specific written informed consent before prescribing
the test, prohibition of ‘mandatory’ tests and maintenance of
strict confidentiality around test results (NACO 2003; NACO
2007). The national guidelines are derived from global UNAIDS/
WHO guidelines and are founded on an ethics perspective,
revolving around considerations of individual rights and
autonomy (UNAIDS 2004).
Background: the implementation
ecosystem
A plethora of different agencies, groups and organizations are
involved, actually and putatively, in processes of implementation of public health policy guidelines in India. The National
HIV/AIDS prevention and Control Programme (NACP) launched
its third phase in 2006. It is coordinated by a nodal body—the
National AIDS Control Organization (NACO)—at the national
level, and by State AIDS Control Societies (SACS) at state level.
The programme and its constituent organizations are the
official source of national policies and guidelines for various
aspects of HIV care including HIV testing. The system of
medical professional self-regulation in India consists of medical
councils at national and state levels. While the Medical Council
of India confers the right to practise medicine, state medical
councils are charged with regulation of medical practices and
The implementation metaphor
In this study we apply the metaphor of policy implementation
analysis to examine themes of medical power ‘in-vivo’: in
workplace and organizational settings (hospitals, government
programmes and departments, regulatory bodies, nongovernmental organizations). We conceptualize the implementation process in terms of interactions and negotiations
between involved groups of actors (see Figure 1), corresponding
to ‘action-centred’ frameworks suggested by Barrett and Fudge
(1981) and Hjern and Hull (1982). Our approach is also
bottom-up, in that the behaviour of frontline service providers
(medical practitioners) represents the focal point of research
inquiry (Lipsky 1980; Elmore 1982). Implementation analysis
DESIGNATED POLICY IMPLEMENTERS
Govt Health
Departments
Public Health
(HIV/AIDS)
Programme
OTHER ACTORS
Donor
Agencies
Professional
Regulators
Professional
Associations
HOSPITALS
Hospital
Administrators
85
Medical
Practitioners
Civil Society
Organizations
Figure 1 The implementation process: interactions and negotiations between involved groups of actors
86
HEALTH POLICY AND PLANNING
the conduct of practitioners. Government Departments of
Health Services (DHS) have little direct contact with practitioners and tend to have devolved specific supervisory and
regulatory functions to hospital authorities. Hospital authorities
are ultimately responsible for the behaviour of their doctors.
Hospitals are typically organized into administrative levels
represented by officers such as Medical Superintendents,
Heads of Department and unit or team heads. Larger hospitals
have nodal officers to address HIV-specific issues. Other groups
such as donors, voluntary professional associations and civil
society organizations play important (if not officially mandated)
roles. See Figure 1 for an indicative map of actor groupings and
their interlinkages.
Methods
Nine urban hospitals were purposefully selected (Patton 2002)
with representation from the government (4), and private (5)
sectors. They were located in five cities, one each from the
North, West, South, East and Central zones of the country.
Within the hospitals, individual participants were selected
ensuring maximum variation across four criteria: extent of
experience, designation, sex and departmental affiliation
(Silverman 2004). The selection included hospital authorities
such as Superintendents and Heads of Department, who were
also medically qualified. A list of public and private organizations and bureaux involved in the implementation of public
health policies was prepared following consultations with key
informants, and supplemented by information emerging from
the study (Hjern and Porter 1981). Representatives of these
organizations and bureaux were interviewed. Fieldwork was
concluded when representatives of all the groups identified as
being involved had been interviewed, and no ‘new’ names of
Table 1 Study participants
Group
Results
We report on two key thematic areas relating to the core
question of power relations between medical practitioners
and health systems actors that emerged from the analysis:
(1) practitioners’ relationships with authority in the context of
implementation; and (2) their positions in terms of influencing
the policy discourse around HIV testing.
Relationships with authority
No. of
participants
Practitioners
In government hospitals
18
In private hospitals
14
Hospital authorities
In government hospitals
4
In private hospitals
3
Representing other organizations, groups and agencies
HIV/AIDS programme
3
Professional regulatory council
1
Government Health Department
1
Public health educationists
4
Donor agencies
4
NGOs involved in policy advocacy
3
NGOs involved in care provision
3
Medical association
1
Accreditation boards
2
TOTAL
organizations were being identified (Hjern and Porter 1981;
Yanow 2000). See Table 1 for a grouped listing of study
participants. Nine key informants were also interviewed (Patton
2002) and included specialist academicians, civil servants and
other experts.
In all, 61 face-to-face in-depth interviews (Grbich 1999; Yin
2003) were conducted by the first author of this article, in five
Indian cities over a period of 18 months in the years 2005 and
2006. Interview topic guides focused on understanding respondents’ interactions with other groups of policy actors in the
context of implementing public health guidelines. Respondents
were encouraged to discuss the topics at length, and interviews
were guided by probes (Britten 2000). All interviews were
preceded by informed verbal consent and electronically recorded. Recordings were transcribed verbatim and entered in
the qualitative data analysis program Atlas/Ti 4.2. Data were
analysed with an interpretivist approach (Yanow 2000),
focusing on understanding respondents’ perspectives of the
policy process, by accessing the explanations and underlying
meanings they ascribed to events and phenomena. For
organizing the textual data from transcripts of interviews, the
‘framework’ approach for applied policy analysis was used
(Ritchie and Spencer 1994). Details of all respondents and
institutions that might lead to their identification have been
withheld.
61
In government hospitals, there was little recognition by
practitioners of a role of hospital administrators or superintendents in propagating or enforcing the HIV testing policies.
On the contrary, hospital administrators were associated mainly
with a refereeing role to adjudicate disputes and, in some
instances, even in a protective role for practitioners against
complaints from patients and pressure groups. In private
hospitals too, digressive practices were common and administrators displayed considerable leniency in implementing guidelines, often preferring persuasion over enforcement, and
accommodating wayward practices. Heads of Department
were also not regarded as enforcers of policies and in many
instances encouraged practitioner discretion rather than compliance with policies. Frequently doctors colluded with supervisors and colleagues to circumvent policies while maintaining
the outward appearance of compliance. For instance, hospital
pathologists sometimes bent the rules to accommodate HIV
testing of pre-surgical patients (a violation of the guidelines) by
their surgeon colleagues.
‘‘Every patient from [a particular surgical department] used to
come along with a requisition for HIV test . . . [The head of a
DISEMPOWERED DOCTORS IN INDIA
87
surgical department] is my classmate from college. So I thought of
a way. [I told him] . . . don’t record HIV test in the requisition. Just
give me a call, and I will do the test, and you can do your
operation. I am guilty of doing this process for many years.’’
(Senior Microbiologist, government hospital)
‘‘People [practitioners] may not take it that sportingly if we are
trying to be someone who is enforcing, and trying to police them.
We would prefer it to be as it is . . . more of advocacy than
enforcement.’’
(Senior official, State AIDS Control Society)
The authority and role of infection control departments in
government hospitals, and even their presence, was poorly
acknowledged by many practitioners. The Infection Control
Officer in one government hospital confirmed that doctors often
did not follow the policies in spirit, even though all supporting
paperwork and procedures were usually ensured. His efforts to
enforce policies were often met dismissively by practitioners.
Little mention was made of medical councils as being influential among doctors working in any sector of hospitals, and there
was a consensus among respondents (including officials from a
state medical council) that their role in the implementation of
public health policies was small. An official of a prominent
association emphasized that, being voluntary bodies, medical
associations do not have a specific mandate to implement
national policies. On the contrary, the association was active in
lobbying and exerting political influence to counter policies
favouring stronger medical regulation, including Clinical
Establishment Acts for regulating standards in medical establishments and government initiatives to curtail the autonomy of
medical councils.
Civil society organizations on their part may have had a
qualified role in limiting flagrant violations of policy guidelines
by doctors. Doctors in government hospitals faced a certain
amount of pressure to change their practices, from increasingly
aware and assertive HIV-positive patients, backed by supporters
from non-governmental organization (NGOs) and HIV-positive
people’s networks. Other types of organization did not have a
significant role in controlling or regulating practitioner behaviour. Accreditation boards have a limited reach, and donor
agencies and state government health departments tended to
have little functional authority over practitioner behaviour at
field level. Doctors also did not perceive a significant threat of
patient litigation around aberrant practices, particularly in the
case of practices not associated with grievous consequences.
‘‘It is very difficult to make people understand, especially the
medical community . . . if you don’t belong to that community, it is
impossible. If you go to a doctor, [they say] kal ka bachcha [you
spring chicken], where have you come from? You have come to me
– will you tell me what to do? . . . [administrative jobs] are all
thankless jobs . . . there is no culture of this.’’
(Infection Control Officer, government hospital)
Several doctors’ narratives also revealed a generalized indifference to administrative and coordinative tasks.
‘‘Is there no difference? Administrators, all these people: different
pedestal; and surgeons who are actively handling [patients]:
different pedestal. Their requirement is different.’’
(Senior Surgeon, government hospital)
Hospitals were sometimes inspected by HIV/AIDS programme
officials to ensure compliance to policy guidelines. One past
Head of Department recounted two such inspections, highlighting acts of complicity with local programme officials to
conceal digressions from the external inspectors and ‘present a
good face’ of the programme.
‘‘I told [the local HIV/AIDS programme officials] that if you are
sending somebody, you should let me know one day in advance or
at least give me two hours time. Of course, [the programme
officials] would only show them the suitable boys. We would have
to present a very good face.’’
(Past Head of Department, government hospital)
Outside the settings of testing and treatment centres, the
National HIV/AIDS programme and its constituent organizations (NACO and the SACS) were viewed by doctors as external
donors, facilitators and collaborators, with little actual role in
monitoring their practices. In private hospitals too, there was
little recognition of the HIV/AIDS programme’s authority. On
their part, the attitudes of HIV/AIDS programme officials
towards changing medical practitioners’ behaviour were ambivalent, and focused more on supportive and educational
interventions than on regulation. One official opposed the
institution of laws around HIV testing, in contradiction of the
official position. Others emphasized the unfeasibility of
regulating practices in the vast private medical sector. A
senior SACS official reflected on the problematic position of
combining advocacy and policing roles.
Influencing policy discourse
An HIV/AIDS programme official reported that international
agencies such as the World Health Organization and the US
Centers for Disease Control were influential in determining the
content of national HIV testing policies. However, the
rights-oriented value considerations underlying the policies,
such as for specific informed consent, were not always favoured
or well comprehended by actors at national and local level. It
was remarkable that some programme officials (privately, in
these interviews) supported practitioners’ positions contradicting the national policies that they (the officials) were themselves involved in propagating.
‘‘Their [practitioners’] doubts [about HIV testing policies] are
absolutely valid, and whatever [divergent] practices they are doing
– they have a reason, it is not unnecessary.’’
(Official, HIV/AIDS programme)
There were also significant gaps in the programme’s ability to
communicate policy ideas to practitioners at street-level. Even
as the HIV/AIDS programme perpetuated the symbolic expressions and terminology of the policies—such as ‘consent’,
‘confidentiality’ and ‘counselling’—the ethos of free choice
and autonomy that these terms signify was widely lacking at
the point of care.
88
HEALTH POLICY AND PLANNING
Box 1 Some ‘alternative’ ideas of medical practitioners
Value of discretion over standardized approaches, given the differing needs of patients.
Importance of according patients equal status in hospitals, as opposed to the ‘exceptional’ treatment of patients having/
suspected to have HIV/AIDS.
Arguments in favour of mandatory pre-surgical HIV screening, given the risks to health workers.
The need to adapt counselling and HIV-related information to be more congruent with patients’ world views and
attitudes.
Virtues of paternalism as being closer to many patients’ expectations, perplexity at the paradox of taking consent for
providing a service (HIV diagnosis).
Importance of flexibility in interpretation, regarding policies as ideals to strive for (rather than as norms), in the face of
situational constraints.
Practitioners, on their part, expressed a number of concerns and reservations around the application of the policy
guidelines in practice. However, even if they privately
disagreed, on most occasions doctors publicly deferred to the
HIV/AIDS programme’s authority to define the ideational
frameworks for their action, and did not proffer active
challenge to the policy guidelines that they privately opposed.
Many practitioners reported complying superficially with
policies, without integral engagement with the principles of
the recommended procedure.
‘‘We have always taken informed consent. How much information
the clients have understood is a separate issue. How do we validate
or verify that? Humne to bata diya [We did what was required].
Now how much they have ingested, understood, we can’t say that,
we can’t guarantee that.’’
(Head of Department, government hospital)
In other instances, practitioners contravened the guidelines
outright, often concealing their digressions from authorities.
Only rarely did they attempt to communicate their ideas to
higher echelons. In one instance as recounted, HIV/AIDS
programme officials were seemingly unable to give a satisfactory explanation of their own policies to this practitioner.
‘‘Everybody knew that there is this policy but nobody knew where it
has come from. And they all agreed with me – they said yes, there
is no reason for it. I visited people in NACO . . . Nobody could tell
me where this has come from. Finally [a senior HIV/AIDS
programme official] agreed – they have this, but they don’t know
where it has come from. He just said ‘it’s there’. . .’’
(Senior Physician, government hospital)
There were frequent conflicts between the requirements of HIV
testing policies, and doctors’ own values and appreciations of
situations they faced on the ground. Some of the practitioners’
‘alternative’ ideas, which explain their divergence from recommended policy guidelines are summarized in Box 1.
Privately, doctors’ propounded their ideas with conviction,
supported by accounts of real-life events. However, from all
accounts, in practice these alternative ideas were static and not
transmitted beyond limited institutional or professional boundaries or communicated to other policy actors with whom they
came into contact. An HIV/AIDS programme official reported
how practitioners’ were often unwilling to communicate their
divergent perspectives in formal fora.
‘‘You know these people [practitioners] don’t come out in front and
say these things. They come to meetings but they don’t say what
they feel. Otherwise [in private] if you talk to 100 doctors, 80 will
say that [they oppose existing guidelines].’’
(Senior official, HIV/AIDS programme)
Medical practitioners often did not have the confidence to
openly pit their own appreciations against recommended
guidelines. One government physician confided: ‘‘the general
interpretation of the personal opinion is that you are doing
something irrational’’.
Among doctors in both sectors, opportunities for academic
intercourse were widely sought after, but limited. Doctors in
smaller private practices were particularly isolated from meaningful peer interactions. Within larger private hospitals too,
there was reported to be little culture of debate around
HIV/AIDS, ethics or matters of public health, and a number
of private doctors rued the dearth of opportunities to update
their knowledge in these areas. While formative medical
education had not equipped doctors to address such contemporary issues, a limited number of in-service HIV/AIDS training
programmes existed which were regularly oversubscribed,
including a high concentration of applications from private
practitioners.
Discussion
The power paradox
Doctors in both the private and public sectors were observed to
have complex relationships with the groups and organizations
involved in implementing policies. In spite of being nominally
answerable to these actors, practitioners were widely able to
resist their authority, and protected or manipulated their
interests in different ways entailing either subversion or
simple disregard of norms. These findings are supported equally
by the accounts of practitioners and other actors. This power
dynamic manifested at every level: in the course of individual
interactions between doctors and institutional authorities; at
institutional level as government practitioners and private
hospitals contested the regulatory roles of public health
authorities; and also on a broader stage with doctors exercizing
DISEMPOWERED DOCTORS IN INDIA
political power through lobbying by professional associations.
These findings correspond broadly with perspectives of Bhat
and Maheshwari (2005), Das Gupta et al. (2003) and
Muraleedharan and Nandraj (2003) on the ineffectiveness of
governance and accountability machineries in the Indian public
health sector, and with political economy analyses documenting
exertions of influence by the medical profession to protect their
interests (Maru 1985; Jeffery 1988), and their generalized
resistance to regulatory authority (Nandraj 1994; Yesudian
2001).
Paradoxically however, the same level of autonomy and
assertiveness of practitioners did not appear to apply in the
intellectual dimension of their interactions. An exploration of
discursive processes reveals that ideas from the ‘top’, i.e.
national policy guidelines for HIV testing were clearly dominant, even though they did not effectively translate into practice.
While privately (in the course of interviews), practitioners
articulated numerous ethical and practical arguments that
contradicted or conflicted with known policies, they seldom
espoused or propagated these perspectives in public fora. They
were not active in debating aspects of the policy guidelines that
they opposed or did not comprehend, nor did their own
‘alternative’ ideas—solutions for problems—usually find expression beyond their circle of immediate peers. It would not be
inaccurate to say that doctors were largely intellectually
disempowered in the context of public health discourse, even
though they were powerful in terms of resisting administrative
and regulatory pressures.
Doctors’ disempowerment can be attributed to a range of
factors. Foremost, practitioners typically did not possess discursive skills to articulate the ethics on which their alternative
appreciations were based. Linked to this linguistic incapability
was the lack of confidence to imagine that personal experiences
could be worthy of valuation, over enshrined universal and
Western-derived principles. An unspoken value system existed,
in which concepts such as informed consent and strict
confidentiality—which are a part of formal policies—were
accorded ideal status, and the ‘practical ethics’ that characterized doctors’ own adaptive responses were generally seen as
dilutions of these high standards. Further, opportunities for the
exchange of knowledge and views between groups of actors
were often deficient, with private practitioners in particular
experiencing a phenomenon of intellectual isolation. While
other enquiries into the behaviour of Indian doctors have also
revealed complex and conflicted pictures of uncertainty, demoralization and struggles for self-actualization (Jeffery 1977;
Madan 1980; Baru 2005; Kielmann et al. 2005), none of these
analyses systematically locate doctors’ vulnerabilities in the
context of their interactions with health systems.
For public health in India, this paradoxical power equation
can be linked with a widespread and insidious phenomenon:
the separation of the formal world of public health discourse
from the informal world of actions, specifically medical practices. Doctors conceal their divergent practices, and comply
superficially with policies in spite of disagreeing with them, and
often fail to engage with the principles of the guidelines they
enact. Other implementers too report personal disengagement
from the regulatory functions and goals of their respective
organizations. Ideas for public health policies, emanating as
89
they do mainly from the national and international arenas,
represent strands of top-driven thinking, largely uninfluenced
by alternative perspectives from field-level actors. Concurrently,
at field level, cultures or subcultures of practice proliferate
among practitioners, informed by complex admixtures of
informational inputs, value systems and practical exigencies,
in which compliance with policy guidelines is but one of many
considerations (Vickers 1965). Practitioners’ own ideas are
seldom deliberated in wider fora, and their legitimacy and
persuasiveness as solutions for field problems remain untested.
Strengthening control over practitioner behaviour
The increase in control over provider behaviour, by coercion or
inducement, is typically proposed as a solution for divergent
behaviour of frontline service providers (Iyer and Jesani 1999;
Duggal 2001; Peters et al. 2002; Muraleedharan and Nandraj
2003). There were indications that programme officials and
hospital authorities were under increasing pressure to ensure
streamlining of practices in accordance with national policies.
The accordance of legal status to the HIV/AIDS policies as
envisaged in the HIV/AIDS Bill of 2005 is another instance of
an initiative for stronger regulatory control.
For doctors, increased administrative control over implementation represented a tightening of policy requirements which
they had previously ‘taken loosely’, in the words of a government obstetrician. According to Lipsky’s theories of street-level
bureaucracy, the service provider’s response to the imposition of
greater administrative control is often a greater tendency to
stereotype at the expense of regard for the needs of recipients of
services (Lipsky 1980). Analogous in this study was the
tendency of medical practitioners to follow the formal aspect
of policy without attention to the values and meaning of the
process, or in other words to separate their actions and their
beliefs, when faced with pressure or incentive to adhere to
policy guidelines.
Legal support for public health policies may have had the
effect of orienting medical practitioners away from the logic of
practice based on personally held beliefs, toward logic based on
the perpetuation of their interests. For example, the existing
guideline for written informed consent symbolized a transactional and autonomy-oriented logic for defining the patient–
provider relationship, in sharp contrast to a widely espoused
logic of beneficent paternalism that typically underpinned
provider–patient interactions. Yet, most doctors did choose to
take written consent. Their accounts reveal that this was not
because they believed in the procedure, but to benefit from the
legal safeguard it offered. It was worth noting, as one physician
pointed out, that even as doctors’ practices may have altered,
many patients’ conceptions may have remained oriented
around the logic of trust and paternalistic asymmetry.
Stronger control over implementation of unwanted policies
would also lead to more subversion, felt many respondents.
Surgeons pointed to numerous practical ways of circumventing
regulations by exploiting their dominant positions vis à vis both
authorities and patients. It is evident that stronger regulations
are of restricted value in improving the quality of interactions
between practitioner and patient, unless accompanied by
concurrent attention to existing power dynamics between
90
HEALTH POLICY AND PLANNING
field-level actors, and also, critically, to the importance of
nurturing ideas and discourse.
Nurturing intellectual capital
If public health systems and programmes are to become more
meaningful at the level of service delivery, it is necessary that
they take account of and process knowledge which evolves
from the experiences and values of field-level actors. This
requires the institution of channels for listening, for ideas to
feed ‘upwards’, and for the HIV/AIDS programme and policymakers to learn from the perspectives of implementers and
adapt policies accordingly. Practitioners’ appreciations, like
other forms of local knowledge, are seldom well structured or
articulated (Yanow 2000), and do not conform to widely
recognizable frameworks (such as the individual rights and
autonomy frames around which HIV testing policies are
founded). In the first place, an approach towards inclusion of
local knowledge requires a conceptual widening of the scope of
what constitutes valid knowledge as a basis for planning action.
Healey, paraphrasing Habermas, has suggested that this
includes such knowledge forms as practical sense, lived
experiences and accumulated moral and cultural knowledge
(Healey 1993).
A second area of strategic focus is the development of the
discursive skills of practitioners, to help them articulate their
perspectives and enable their inclusion in public health policy
discourse. Planned reforms to redress inadequacies of basic
medical education in India in aspects of ethics and public
health unfortunately remain neglected, in spite of the recommendations of numerous national committees and taskforces
(Ramachandran 2006; Ravindran 2008). Among the respondents of this study, in-service training programmes were widely
cited as significant platforms for expression and interchange of
ideas, and for improving discursive skills and confidence.
Research projects and collaborations that facilitated human
interaction and exchange between practitioners and other
policy actors (civil society groups, public health programmes)
engendered new forms of discourse, it emerged, and these also
represent a critical avenue of intellectual nurturance.
Conclusion
A relational perspective on policy implementation provides
distinct and complementary insights into what is gained by
examining group behaviour in isolation. In the Indian context,
this analytical approach is poorly utilized, which is surprising
given the multitude of actors who are involved in different
ways in health policy implementation processes, and the
fundamentally relational nature of health care activity. In this
study, the relational analysis undertaken allows insight into the
complex nature of Indian medical practitioners’ positionality vis
à vis public health systems. While hypotheses of their intransigence against authority remain intact, an examination of
discursive processes demonstrates poorly understood aspects
of their vulnerability and the challenges they face in pursuing
meaningful roles in public health. India’s medical practitioners
ostensibly represent an intellectual elite engaged in a critical
developmental activity. Yet they appear to lack the ‘positive
power’ to ideate effectively, to convey ideas to public health
policy-makers, and use them to organize action (Fischer 2003).
Public health planners and donors can play a specific role in
building practitioners’ capacities for deliberating on relevant
subjects, and encouraging more equitable intellectual participation of different groups in policy-relevant discourse. In order for
this to happen it is necessary for planners to embrace broader
conceptions of the success of public health programmes,
incorporating long-term goals of learning, emancipation and
nourishment of existing intellectual resources (Connelly and
Emmel 2003), not just short-term targets predicated on mechanistic conformance on the part of constituent actors with
policy-makers’ intentions. Even as control over aberrant practices
remains a vital concern in developing systems such as India’s, the
unqualified imposition of regulatory measures carries with it the
risk of devaluation of practices; of increasing the gap between
ideas and actions with potentially deleterious consequence for
the quality of patient–practitioner interactions. It is equally
important to enfranchise practitioners’ voices and to help
them develop the capacity to deliberate appropriate courses of
action on the basis of their values and lived experiences. Along
with other frontline health providers, medical practitioners are
ultimately responsible for delivering health services, and it is
crucial that they are given opportunities to believe in what
they practice.
Funding
The authors are grateful for the financial support received from
the Aga Khan Foundation’s International Scholarship
Programme, the DFID TARGETS Consortium at the LSHTM,
and the University of London’s Central Research Fund, towards
conducting this research.
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