Abstract
BackgroundThere 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.MethodsWe 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.ResultsWe 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.ConclusionsThis 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.
Highlights
There are increasing calls for developing robust processes of community-based accountability as key components of health system strengthening
In this paper we explore the institutional processes involved in the implementation of community-based accountability of the public health system, in the state of Tamilnadu, India
The Advisory Group on Community Action (AGCA) included a number of representatives of civil society organizations who had experience in rights-based approaches to community health and were associated with the Jan Swasthya Abhiyan (JSA—the Indian chapter of the People’s Health Movement)
Summary
There are increasing calls for developing robust processes of community-based accountability as key components of health system strengthening. Implementation of these processes have shown mixed results over time and geography. There have been a number of initiatives in the past decades that attempted to implement programs to strengthen health system accountability at scale [7, 8]. This is against a backdrop of increasing calls for community participation in the achievement of universal health coverage at the international level [4, 9]. Interventions calling for increasing accountability to communities may be considered as innovations that need to be adopted, integrated, and sustained in the various building blocks of these health systems [10]
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