Understanding the role of power and its relationship to the implementation of the polio eradication initiative in India

Background: Power is exercised everywhere in global health and is central to understanding and transforming health policy and systems. This paper conducts a power analysis as mobilized by actors involved in implementing the polio program in India, reflecting how different power categories were exerted and embedded in strategies to address implementation challenges during the Global Polio Eradication Initiative (GPEI). Methods: Quantitative and qualitative data were collected from stakeholders in the polio universe as part of the STRIPE project. Key informants were actors at national and sub-national levels. Research tools explored challenges, strategies, and unintended consequences in implementation. Moon’s expanded typology of power in global governance was used to analyze implementation. Results: A total of 517 survey responses and 25 key informant interviews were collected. Stakeholders exerted multiple forms of power—structural, institutional, moral (e.g., religious leaders), expert (e.g., physicians), discursive (e.g., media messaging), and network power (e.g., community influencers). Hidden power was also demonstrated by seemingly powerless actors such as children who brought mothers to vaccination booths. Conclusion: Power is not finite; it can be used, shared, or created by stakeholders and networks in multiple ways. Those who appear powerless can wield invisible power that influences decisions. Power categories are interconnected and transformable, and power relations play an important role in decision-making at individual and community levels. Mid-range implementation science theories (e.g., PARIHAS and CFIR) should incorporate power as a construct necessary for successful implementation of health programs.