"I pray to God that greed never sets in": Community health workers' reflections on "care" during the Covid-19 pandemic.

BACKGROUND: Care provision received renewed attention during the Covid-19 pandemic as several healthcare providers vied for the coveted title of "frontline warrior" while they struggled to provide care efficiently under varying health system constraints. While several studies on the health workforce during the pandemic highlighted their difficulties, there is little reflection on what "care" or "caring" itself meant specifically for community health workers (CHWs) as they navigated different community and health systems settings. The aim of the study was to examine CHWs' care-giving experiences during the pandemic. METHODS: Twenty narrative interviews with CHWs including ASHAs (Accredited Social Health Activists) and ANMs (Auxiliary Nurse Midwives) were conducted in different states between July and December 2020. RESULTS: Our findings highlight the moral, affectual, and relational dimensions of care in the CHWs' engagement with their routine and Covid-19 related services, as well as the "technical" aspects of it. In this article, we argue that these two aspects are, in fact, enmeshed in complex ways. CHWs extend this moral understanding not just to their work, but also to their relationship with the health system and the government, as they express a deep sense of neglect and the lack of "being cared for" by the health system. CONCLUSION: CHWs' experiences demand a more nuanced understanding of the ethics of care or caring that challenges the binaries between the "technical" and moral aspects of care.

Associations, unions and everything in between: contextualising the role of representative health worker organisations in policy.

Associations, unions and other organised groups representing health workers play a significant role in the development, adoption and implementation of health policy. These representative health worker organisations (RHWOs) are a key interface between employers, governments and their members (both actual and claimed), with varying degrees of influence and authority within and across countries. Existing research in global health often assumes-rather than investigates-the roles played by RHWOs in policy processes and lacks analytical specificity regarding the definitional characteristics of RHWOs. In this article, we seek to expand and complicate conceptualisations of RHWOs as key actors in global health by unpacking the heterogeneity of RHWOs and their roles in policy processes and by situating RHWOs in context. First, we define RHWOs, present a typology of RHWO dimensions and discuss perceived legitimacy of RHWOs as policy actors. Next, we unpack the roles of RHWOs in policy processes and distinguish RHWO roles in regulation from those of regulatory agencies. The final sections situate RHWOs in political and labour relations contexts, and in sociohistorical contexts, with attention to institutional frameworks, professional hierarchies and intersectional factors such as race, gender, sexuality, class, caste and religion. We conclude by outlining research gaps in the study of RHWOs and policy, and by encouraging global health researchers and practitioners to incorporate an expanded focus on these actors. Taking this approach will generate a wider range of strategies to better engage these organisations in policy processes and will ensure stronger health workforce policies globally.

Gynaecological Cancers in India: The Less Heard Perspectives of Healthcare Providers.

There has been mounting evidence on the role of healthcare providers in chronic illnesses such as cancer. The specific complexities in their roles to enable health are less heard. Gynaecological cancers have several undercurrents beyond the obvious. Semi-structured interviews were conducted with healthcare providers in Southern India (n = 35) and the data presented in this article were collected as a part of a larger study on the role of communication in the management of gynaecological cancers in India. Thematic analysis of the qualitative data provided information on the providers' perspectives of gynaecological cancers. Patient numbers, cost, time, cultural norms, context, and institutional constraints in cancer care provision are just some of the factors impacting care provision. Healthcare providers are typically acknowledged for the criticality of their roles in the continuum of care. However, our research suggests that the psychological harm and challenges they themselves may face in providing that care are severely neglected. Through listening to healthcare provider voices, clear solutions emerge to better support the practice of those who are responsible for cancer care.

Health in Food Systems Policies in India: A Document Review.

BACKGROUND: Food systems affect nutritional and other health outcomes. Recent literature from India has described policy aspects addressing nutritional implications of specific foods (eg, fruits, vegetables, and trans-fats), and identified opportunities to tackle the double burden of malnutrition. This paper attempts to deepen the understanding on how health concerns and the role of the health sector are addressed across food systems policies in India. METHODS: This qualitative study used two approaches; namely (i) the framework method and (ii) manifest content analysis, to investigate national-level policy documents from relevant sectors (ie, food security, agriculture, biodiversity, food processing, trade, and waste management, besides health and nutrition). The documents were selected purposively. The textual data were coded and compared, from which themes were identified, described, and interpreted. Additionally, mentions of various health concerns and of the health ministry in the included documents were recorded and collated. RESULTS: A total of 35 policy documents were included in the analysis. A variety of health concerns spanning nutritional, communicable and non-communicable diseases (NCDs) were mentioned. Undernutrition received specific attention even beyond nutrition policies. Only few policies mentioned NCDs, infectious diseases, and injuries. Governing and advisory bodies were instituted by 17 of the analysed policies (eg, food safety, agriculture, and food processing), and often included representation from the health ministry (9 of the 17 identified inter-ministerial bodies). CONCLUSION: We found some evidence of concern for health, and inclusion of health ministry in food policy documents in India. The ongoing and planned intersectoral coordination to tackle undernutrition could inform actions to address other relevant but currently underappreciated concerns such as NCDs. Our study demonstrated a method for analysis of health consideration and intersectoral coordination in food policy documents, which could be applied to studies in other settings and policy domains.

Power analysis in health policy and systems research: a guide to research conceptualisation.

Power is a growing area of study for researchers and practitioners working in the field of health policy and systems research (HPSR). Theoretical development and empirical research on power are crucial for providing deeper, more nuanced understandings of the mechanisms and structures leading to social inequities and health disparities; placing contemporary policy concerns in a wider historical, political and social context; and for contributing to the (re)design or reform of health systems to drive progress towards improved health outcomes. Nonetheless, explicit analyses of power in HPSR remain relatively infrequent, and there are no comprehensive resources that serve as theoretical and methodological starting points. This paper aims to fill this gap by providing a consolidated guide to researchers wishing to consider, design and conduct power analyses of health policies or systems. This practice article presents a synthesis of theoretical and conceptual understandings of power; describes methodologies and approaches for conducting power analyses; discusses how they might be appropriately combined; and throughout reflects on the importance of engaging with positionality through reflexive praxis. Expanding research on power in health policy and systems will generate key insights needed to address underlying drivers of health disparities and strengthen health systems for all.

A Draconian Law: Examining the Navigation of Coalition Politics and Policy Reform by Health Provider Associations in Karnataka, India.

A comprehensive picture of provider coalitions in health policy making remains incomplete because of the lack of empirically driven insights from low- and middle-income countries. The authors examined the politics of provider coalitions in the health sector in Karnataka, India, by investigating policy processes between 2016 and 2018 for developing amendments to the Karnataka Private Medical Establishments Act. Through this case, they explore how provider associations function, coalesce, and compete and the implications of their actions on policy outcomes. They conducted in-depth interviews, document analysis, and nonparticipant observations of two conferences organized by associations. They found that provider associations played a major role in drafting the amendments and negotiating competing interests within and between doctors and hospital associations. Despite the fragmentation, the associations came together to reinterpret the intentions of the amendments as being against the interests of the profession, culminating in a statewide protest and strike. Despite this show of strength, provider associations only secured modest modifications. This case demonstrates the complex and unpredictable influence of provider associations in health policy processes in India. The authors' analysis highlights the importance of further empirical study on the influence of professional and trade associations across a range of health policy cases in low- and middle-income countries.

Perceived Health Impacts of Watershed Development Projects in Southern India: A Qualitative Study.

Watershed development (WSD) projects-planned for over 100 million ha in semi-arid areas of India-should enhance soil and water conservation, agricultural productivity and local livelihood, and contribute to better nutrition and health. Yet, little is known about the health impacts of WSD projects, especially on nutrition, vector breeding, water quality and the distribution of impacts. We conducted a qualitative study to deepen the understanding on perceived health impacts of completed WSD projects in four villages of Kolar district, India. Field data collection comprised: (i) focus group discussions with local women (n = 2); (ii) interviews (n = 40; purposive sampling) with farmers and labourers, project employees and health workers; and (iii) transect walks. Our main findings were impacts perceived on nutrition (e.g., food security through better crop survival, higher milk consumption from livestock, alongside increased pesticide exposure with expanded agriculture), potential for mosquito larval breeding (e.g., more breeding sites) and through opportunistic activities (e.g., reduced mental stress due to improved water access). Impacts perceived varied between participant categories (e.g., better nutrition in woman-headed households from livelihood support). Some of these findings, e.g., potential negative health implications, have previously not been reported. Our observations informed a health impact assessment of a planned WSD project, and may encourage implementing agencies to incorporate health considerations to enhance positive and mitigate negative health impacts in future WSD projects.

'A light inside a pot': Sites and sources of power emerging from an ethnography of traditional healing in South India.

Medicine and healing have been critical elements of nation-building and governance in India. There is a clear hierarchy: biomedicine, followed by systems like Ayurveda which are to be 'mainstreamed,' and local health traditions, which are to be 'revitalised'. Mindful that power nonetheless resides in positions of marginality, this analysis drew from a health system ethnography on revitalisation of local health traditions in three southern Indian states. Data from multiple interviews with 51 healers, observations of meetings, healing sessions and events convened by healers, as well as a multi-stakeholder dialogue on local health traditions convened by authors were analysed using a grounded analytical process. The state was a source of power, but in an enmeshed, individualised form. Other sources of power included accomplished others who viewed healers and their practices with respect, healers' collectives that produced and reinforced power through the exercise of certain rituals, and the sacred calling to heal, which assumed stringent criteria for practice and training, while also creating a moral imperative for service orientation. Our study shows how power rests in or is derived from multiple sites and sources that inhere and interact in critical ways with the state and other systems of medicine.

On the unraveling of 'revitalization of local health traditions' in India: an ethnographic inquiry.

BACKGROUND: India has recently renewed emphasis on non-allopathic systems of medicine as a means to address the health needs of its populace. Earlier in 2002, its national health policy had sought to 'revitalize' community-based health knowledge and practices - jointly christened 'local health traditions'. Yet policy texts remain silent on the actual means by which 'revitalization of local health traditions' should take place. Our research sought to understand the policy lessons of and for revitalization of local health traditions in the three Southern Indian states through an ethnographic inquiry in 2014-2016. METHODS: Our inquiry included a narrative synthesis of policy texts tracing the history of governance processes and mechanisms pertaining to traditional medicine, including local health traditions, linking this to the activities of non-governmental organizations (NGOs) and networks involved in "revitalization". Through in-depth interviews, observations and case studies, we sought to understand the life worlds of local health tradition practitioners and what revitalization meant to them. Our method revealed that beyond a purely academic inquiry, we needed an (inter)action that would give greater voice to these perspectives and views leading to hosting an interactive dialogue among practitioners, NGO representatives, academics, and government officials. RESULTS: Our ethnographic inquiry unraveled the problematic of a litotic approach to local health traditions as those which are non- institutionalized, non-certified, non-documented; assuming the state to be the only source of power and legitimacy. Revitalization discussions were restricted (and often misled) by such an approach. Local health practitioners and others directed us to interesting possibilities of revitalization either through participatory modes of documentation of traditional health knowledge, strengthening existing collective forums for formal social recognition, and building pedagogical institutions that promote experiential learning. CONCLUSION: Were we not enabled by ethnography as a method that changes its shape apace with emerging findings, we would have not been able to comprehensively answer our questions. This is critical because not only was this already a marginalized area of inquiry, but with any other method we risked reinforcing inequities by imposing epistemological and other hierarchies on our participants- whom we would argue were partners - in arriving at our conclusions.

10 best resources on power in health policy and systems in low- and middle-income countries.

Power is a critical concept to understand and transform health policy and systems. Power manifests implicitly or explicitly at multiple levels-local, national and global-and is present at each actor interface, therefore shaping all actions, processes and outcomes. Analysing and engaging with power has important potential for improving our understanding of the underlying causes of inequity, and our ability to promote transparency, accountability and fairness. However, the study and analysis of the role of power in health policy and systems, particularly in the context of low- and middle-income countries, has been lacking. In order to facilitate greater engagement with the concept of power among researchers and practitioners in the health systems and policy realm, we share a broad overview of the concept of power, and list 10 excellent resources on power in health policy and systems in low- and middle-income countries, covering exemplary frameworks, commentaries and empirical work. We undertook a two-stage process to identify these resources. First, we conducted a collaborative exercise involving crowdsourcing and participatory validation, resulting in 24 proposed articles. Second, we conducted a structured literature review in four phases, resulting in 38 articles reviewed. We present the 10 selected resources in the following categories to bring out key facets of the literature on power and health policy and systems-(1) Resources that provide an overarching conceptual exploration into how power shapes health policy and systems, and how to investigate it; and (2) examples of strong empirical work on power and health policy and systems research representing various levels of analyses, geographic regions and conceptual understandings of power. We conclude with a brief discussion of key gaps in the literature, and suggestions for additional methodological approaches to study power.

'Safe', yet violent? Women's experiences with obstetric violence during hospital births in rural Northeast India.

The majority of maternal health interventions in India focus on increasing institutional deliveries to reduce maternal mortality, typically by incentivising village health workers to register births and making conditional cash transfers to mothers for hospital births. Based on over 15 months of ethnographically informed fieldwork conducted between 2015 and 2017 in rural Assam, the Indian state with the highest recorded rate of maternal deaths, we find that while there has been an expansion in institutional deliveries, the experience of childbirth in government facilities is characterised by obstetric violence. Poor and indigenous women who disproportionately use state facilities report both tangible and symbolic violence including iatrogenic procedures such as episiotomies, in some instances done without anaesthesia, improper pelvic examinations, beating and verbal abuse during labour, with sometimes the shouting directed at accompanying relatives. While the expansion of institutional deliveries and access to emergency obstetric care is likely to reduce maternal mortality, in the absence of humane care during labour, institutional deliveries will continue to be characterised by the paradox of "safe" births (defined as simply reducing maternal deaths) and the deployment of violent practices during labour, underscoring the unequal and complex relationship between the bodies of the poor and reproductive governance.

Health system challenges in organizing quality diabetes care for urban poor in South India.

BACKGROUND: Weak health systems in low- and middle-income countries are recognized as the major constraint in responding to the rising burden of chronic conditions. Despite recognition by global actors for the need for research on health systems, little attention has been given to the role played by local health systems. We aim to analyze a mixed local health system to identify the main challenges in delivering quality care for diabetes mellitus type 2. METHODS: We used the health system dynamics framework to analyze a health system in KG Halli, a poor urban neighborhood in South India. We conducted semi-structured interviews with healthcare providers located in and around the neighborhood who provide care to diabetes patients: three specialist and 13 non-specialist doctors, two pharmacists, and one laboratory technician. Observations at the health facilities were recorded in a field diary. Data were analyzed through thematic analysis. RESULT: There is a lack of functional referral systems and a considerable overlap in provision of outpatient care for diabetes across the different levels of healthcare services in KG Halli. Inadequate use of patients' medical records and lack of standard treatment protocols affect clinical decision-making. The poor regulation of the private sector, poor systemic coordination across healthcare providers and healthcare delivery platforms, widespread practice of bribery and absence of formal grievance redress platforms affect effective leadership and governance. There appears to be a trust deficit among patients and healthcare providers. The private sector, with a majority of healthcare providers lacking adequate training, operates to maximize profit, and healthcare for the poor is at best seen as charity. CONCLUSIONS: Systemic impediments in local health systems hinder the delivery of quality diabetes care to the urban poor. There is an urgent need to address these weaknesses in order to improve care for diabetes and other chronic conditions.

'Trust and teamwork matter': community health workers' experiences in integrated service delivery in India.

A comprehensive and integrated approach to strengthen primary health care has been the major thrust of the National Rural Health Mission (NRHM) that was launched in 2005 to revamp India's rural public health system. Though the logic of horizontal and integrated health care to strengthen health systems has long been acknowledged at policy level, empirical evidence on how such integration operates is rare. Based on recent (2011-2012) ethnographic fieldwork in Odisha, India, this article discusses community health workers' experiences in integrated service delivery through village-level outreach sessions within the NRHM. It shows that for health workers, the notion of integration goes well beyond a technical lens of mixing different health services. Crucially, they perceive 'teamwork' and 'building trust with the community' (beyond trust in health services) to be critical components of their practice. However, the comprehensive NRHM primary health care ideology - which the health workers espouse - is in constant tension with the exigencies of narrow indicators of health system performance. Our ethnography shows how monitoring mechanisms, the institutionalised privileging of statistical evidence over field-based knowledge and the highly hierarchical health bureaucratic structure that rests on top-down communications mitigate efforts towards sustainable health system integration.

Constraints faced by urban poor in managing diabetes care: patients' perspectives from South India.

BACKGROUND: Four out of five adults with diabetes live in low- and middle-income countries (LMIC). India has the second highest number of diabetes patients in the world. Despite a huge burden, diabetes care remains suboptimal. While patients (and families) play an important role in managing chronic conditions, there is a dearth of studies in LMIC and virtually none in India capturing perspectives and experiences of patients in regard to diabetes care. OBJECTIVE: The objective of this study was to better understand constraints faced by patients from urban slums in managing care for type 2 diabetes in India. DESIGN: We conducted in-depth interviews, using a phenomenological approach, with 16 type 2- diabetes patients from a poor urban neighbourhood in South India. These patients were selected with the help of four community health workers (CHWs) and were interviewed by two trained researchers exploring patients' experiences of living with and seeking care for diabetes. The sampling followed the principle of saturation. Data were initially coded using the NVivo software. Emerging themes were periodically discussed among the researchers and were refined over time through an iterative process using a mind-mapping tool. RESULTS: Despite an abundance of healthcare facilities in the vicinity, diabetes patients faced several constraints in accessing healthcare such as financial hardship, negative attitudes and inadequate communication by healthcare providers and a fragmented healthcare service system offering inadequate care. Strongly defined gender-based family roles disadvantaged women by restricting their mobility and autonomy to access healthcare. The prevailing nuclear family structure and inter-generational conflicts limited support and care for elderly adults. CONCLUSIONS: There is a need to strengthen primary care services with a special focus on improving the availability and integration of health services for diabetes at the community level, enhancing patient centredness and continuity in delivery of care. Our findings also point to the need to provide social services in conjunction with health services aiming at improving status of women and elderly in families and society.

Indian youth speak about tobacco: results of focus group discussions with school students.

This article discusses the findings of Focus Group Discussions (FGDs) that were conducted as a formative assessment for Project MYTRI (Mobilizing Youth for Tobacco Related Initiatives in India), a randomized, multicomponent, school-based trial to prevent and control tobacco use among youth in India. Forty-eight FGDs were conducted with students (N=435) in sixth and eighth grades in six schools in Delhi, India. Key findings include: (a) students in government schools reported as "consumers" of tobacco, whereas students in private schools reported as "commentators"; (b) parents and peers have a strong influence on youth tobacco use; (c) chewing gutkha is considered less harmful and more accessible than smoking cigarettes; (d) schools are not promoting tobacco control activities; and (e) students were enthusiastic about the role government should play in tobacco control. These findings are being used to develop a comprehensive intervention program to prevent and control tobacco use among Indian youth.