Application of “Actor Interface Analysis” to Examine Practices of Power in Health Policy Implementation: An Interpretive Synthesis and Guiding Steps

Document Type: Review Article

Authors

1 School of Health System Studies, Tata Institute of Social Sciences, Mumbai, India

2 Oxford Policy Management Limited, New Delhi, India

3 School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa

4 Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK

Abstract

Background
The difference between ‘policy as promised’ and ‘policy as practiced’ can be attributed to implementation gaps. Actor relationships and power struggles are central to these gaps but have been studied using only a handful of theoretical and analytical frameworks. Actor interface analysis provides a methodological entry point to examine policy implementation and practices of power. As this approach has rarely been used in health policy analysis, this article aims, first, to synthesise knowledge about use of actor interface analysis in health policy implementation and, second, to provide guiding steps to conduct actor interface analysis.
 
Methods
We conducted an interpretive synthesis of literature using a set of 6 papers, selected using purposeful searches and focusing on actor dynamics and practices of power in policy experiences. Drawing upon the framework synthesis approach and using a guiding framework, the synthesis focused on 4 questions – the type of actor interfaces formed, the power practices observed, the effect of such power practices on implementation and the underpinning factors for the power practices.
 
Results
Multiple interface encounters and power practices were identified which included domination, control, contestation, collaborations, resistance, and negotiations. The lifeworlds of actors that underpinned the power practices, were rooted in social-organisational power relationships, personal experiences and interests, and social-ideological standpoints like values and beliefs of actors. The power practices influenced implementation both positively and negatively.
 
Conclusion
Based on the learnings from synthesis, this paper provides guiding steps for conducting actor interface analysis. Additionally, it presents 2 useful tools for power analysis: (1) ‘actor lifeworlds,’ to understand underpinning factors for power practices and (2) relationships of lifeworlds, interface encounters and power practices with their effect on policy implementation. We suggest that interface analysis should be applied in more empirical settings and across varied health policy experiences to nuance the method better.

Keywords


  1. Walt G, Gilson L. Reforming the health sector in developing countries: The central role of policy analysis. Health Policy Plan. 1994;9(4):353-370. doi:10.1093/heapol/9.4.353
  2. Sheikh K, Ranson MK, Gilson L. Explorations on people centredness in health systems. Health Policy Plan. 2014;29:II1-II5. doi:10.1093/heapol/czu082
  3. Erasmus E, Gilson L. How to start thinking about investigating power in the organizational settings of policy implementation. Health Policy Plan. 2008;23(5):361-368. doi:10.1093/heapol/czn021
  4. Gilson L, Raphaely N. The terrain of health policy analysis in low and middle income countries: A review of published literature 1994-2007. Health Policy Plan. 2008;23(5):294-307. doi:10.1093/heapol/czn019
  5. Lee K. Revealing power in truth Comment on “Knowledge, moral claims and the exercise of power in global health.” Int J Health Policy Manag. 2015;4(4):257-259. doi:10.15171/ijhpm.2015.42
  6. Gilson, Schneider H, Orgill M. Practice and power: A review and interpretive synthesis focused on the exercise of discretionary power in policy implementation by front-line providers and managers. Health Policy Plan. 2014;29(Suppl 3):iii51-iii69. doi:10.1093/heapol/czu098
  7. Sriram V, Topp SM, Schaaf M, et al. 10 best resources on power in health policy and systems in low- and middle-income countries. Health Policy Plan. 2018;33(4):611-621. doi:10.1093/heapol/czy008
  8. Long N. Development Sociology, Actor Perspectives. Abingdon, UK: Roultege; 2001.
  9. Lukes S. Power, Second Edition: A Radical View. Palgrave Macmillan; 2005:200.
  10. Gordon C, Marshall LEO. Power/Knowledge, Selected Interviews and Other Writings. New York: Pantheon Books; 1980.
  11. Gaventa J. Reflections on the Uses of the ‘Power Cube’ Approach for Analyzing the Spaces, Places and Dynamics of Civil Society Participation and Engagement. Inst Dev Stud. 2006;4:1-45. doi:10.1016/j.worlddev.2003.06.005
  12. VeneKlasen L, Miller V. Power and empowerment. In: A New Weave of Power, People & Politics. Oklahoma: World Neighbors; 2007:39-58. 
  13. Long N. UNESCO Paper on Interface Analysis: Norman Long. The Netherlands: Wageningen University; 1999:1-25.
  14. Gilson L, Orgill M, Shroff ZC. A Health Policy Analysis Reader: The Politics of Policy Change in Low-and Middle-Income Countries. https://www.who.int/alliance-hpsr/resources/publications/Alliance-HPA-Reader-web.pdf. Published 2018.
  15. Erasmus E, Orgill M, Schneider H, Gilson L. Mapping the existing body of health policy implementation research in lower income settings: What is covered and what are the gaps? Health Policy Plan. 2014;29(Suppl 3):iii35-iii50. doi:10.1093/heapol/czu063
  16. Lipsky M. The Client Processing Mentality. In: Street Level Bureaucracy Dilemmas of the Individual in Public Services.  New York: Russell Sage Foundation; 1980.
  17. Barrett S. Implementation Studies: Time for a Rivival? Personal Reflections on 20 Years of Implementation Studies. Public Adm. 2004;82(2):249-262. doi:10.1111/j.0033-3298.2004.00393.x
  18. Gilson L. Qualitative research synthesis for health policy analysis: What does it entail and what does it offer? Health Policy Plan. 2014;29:iii1-iii5. doi:10.1093/heapol/czu121
  19. Yanow D. Interpretation in policy analysis: On methods and practice. Crit Policy Stud. 2007;1(1):110-122. doi:10.1080/19460171.2007.9518511
  20. Walt G, Gilson L. Can frameworks inform knowledge about health policy processes? Reviewing health policy papers on agenda setting and testing them against a specific priority-setting framework. Health Policy Plan. 2014;29:iii6-iii22. doi:10.1093/heapol/czu081
  21. Langlois É V, Daniels K, Akl EA. Evidence Synthesis for Health Policy and Systems: A Methods Guide. http://apps.who.int/iris/bitstream/handle/10665/275367/9789241514552-eng.pdf?sequence=1&isAllowed=y. Published 2018.
  22. Barnett-Page E, Thomas J. Methods for the synthesis of qualitative research: a critical review. BMC Med Res Methodol. 2009;9:59. doi:10.1186/1471-2288-9-59
  23. Lehmann U, Gilson L. Actor interfaces and practices of power in a community health worker programme: A South African study of unintended policy outcomes. Health Policy Plan. 2013;28(4):358-366. doi:10.1093/heapol/czs066
  24. Prashanth NS, Marchal B, Devadasan N, Kegels G, Criel B. Advancing the application of systems thinking in health: A realist evaluation of a capacity building programme for district managers in Tumkur, India. Health Qual Life Outcomes. 2014;12(1). doi:10.1186/1478-4491-12-42_old
  25. Aniteye P, Mayhew SH. Shaping legal abortion provision in Ghana: Using policy theory to understand provider-related obstacles to policy implementation. Health Res Policy Syst. 2013;11(1):15-17. doi:10.1186/1478-4505-11-23
  26. Atun RA, Kyratsis I, Jelic G, Rados-Malicbegovic D, Gurol-Urganci I. Diffusion of complex health innovations - Implementation of primary health care reforms in Bosnia and Herzegovina. Health Policy Plan. 2007;22(1):28-39. doi:10.1093/heapol/czl031
  27. Barasa EW, Cleary S, English M, Molyneux S. The influence of power and actor relations on priority setting and resource allocation practices at the hospital level in Kenya: a case study. BMC Health Serv Res. 2016;16(1):536. doi:10.1186/s12913-016-1796-5
  28. Penn-Kekana L, Blaauw D, Schneider H. “It makes me want to run away to Saudi Arabia”: Management and implementation challenges for public financing reforms from a maternity ward perspective. Health Policy Plan. 2004;19 Suppl 1:i71-i77. doi:10.1093/heapol/czh047
  29. Scott JC. Weapons of the Weak. Yale University Press; 1985. http://www.jstor.org/stable/j.ctt1nq836.
  30. Tilly C. Domination, Resistance, Compliance... Discourse. Sociol Forum. 1991;6(3):593-602.
  31. Varvasovszky Z, Brugha R. How to do (or not to do) ... A stakeholder analysis. Health Policy Plan. 2000;15(3):338-345. doi:10.1093/heapol/15.3.338
  32. Chambers D, Wilson P, Thompson C, Harden M. Social network analysis in healthcare settings: A systematic scoping review. PLoS One. 2012;7(8):e41911. doi:10.1371/journal.pone.0041911
  33. Wasserman S, Faust K. Social Network Analysis: Methods and Applications. Cambridge University Press; 1994. doi:10.1017/CBO9780511815478