Differences in interpretation affect the implementation of health programs

 

ImageLena Mustonen

One of the key components of the programs and policies to strengthen access to and the functioning of health systems of Low- and Middle-Income Countries has been to increase the involvement of the people whom the health system serves. These efforts include getting people involved in priority setting, monitoring whether the services that are supposed to be provided are indeed being provided and giving feed back to the health system on the ways they feel the system can improve. Among these the process whereby the community seeks to hold the health system responsible for the commitments they make is termed as community-based accountability. Increasing community involvement and community-based accountability have been further reiterated during the recent Global Conference on Primary Health Care at Astana arranged by the World Health Organization and by the internationally accepted Social Development Goals of the United Nations.

Despite the global and local support for community involvement the actual implementation of policies to enable this has been disappointing at the country level. The author of this research was involved in such an effort to implement a progressive model of community monitoring and health planning in India. Despite positive experiences the program was not continued after the first two years. Through this research he sought to understand the reasons why a policy regarding community involvement which focused on increasing the ownership of the health system by the community it serves through strengthening systems of accountability failed to get incorporated into the day-to-day functioning of the health system.

The research aims to understand the processes involved in the way different components of a particular policy are understood and further how actions to implement these components are designed by the responsible officials in the Department of Health. For this the research focused on the implementation of a policy to increase community involvement that was introduced in the National Rural Health Mission (now referred to as the National Health Mission) in India. The research was conducted in the south Indian state of Tamil Nadu.

The research sought to understand the implementation process through the study of relevant documents as well as interviews with those who were involved in the process of implementation. The research discovered that different officers understood the concept of community involvement, and how it could contribute to health system strengthening differently. These differences, the research suggested, were possibly due to different assumptions with regards to the reasons for the problems and gaps in the health services in the first place. Further not recognizing these differences and not making attempts to engage with these differences in order to come up with a shared understanding could lead to the policy not being implemented in the way it was originally intended.

The research calls for more attention to the different ways in which key decision makers understand different problems. It also calls for the strengthening of systems to engage with these differences as organizations evolve shared understandings with regards to the problems they are attempting to solve. While focusing on the situation in the south Indian state of Tamil Nadu, the research does have relevance for a broad range of Low- and Middle-Income country contexts as well as possibly for the High-Income countries as well.

Read the doctoral thesis