Power dynamics significantly influence global health initiatives, yet their role is often understudied. This research, part of the STRIPE project, focuses on the Global Polio Eradication Initiative (GPEI) in India to understand how power shaped its implementation. The study aims to analyze the various forms of power employed by different stakeholders—from governmental agencies and international organizations to community leaders and frontline workers—and how these power dynamics impacted the program's success and challenges. The significance of this study lies in its contribution to understanding how power influences health policy and systems research (HPSR) and implementation research (IR), highlighting the need to incorporate power analysis into existing frameworks like the Consolidated Framework for Implementation Research (CFIR) to improve the effectiveness of future health interventions. The Indian context is particularly relevant due to its diverse population and complex social structures, making the understanding of power dynamics crucial for effective program implementation.

The paper reviews existing literature on power in global health, noting its various conceptualizations as coercion, capital, and control. It highlights the scarcity of research on power in health policy and systems research (HPSR), particularly in low-and middle-income countries (LMICs). The authors reference Sriram's six sources of power (technical expertise, political power, bureaucratic power, financial power, networks and access, and personal attributes) and their mapping to Walt and Gilson's Policy Triangle. The study notes that while frameworks like CFIR explain implementation success, they lack an explicit dimension of power. The review also touches upon anthropological and decolonization discourse in global health, emphasizing the role of power and privilege in shaping health partnerships and calling for transformational change.

This mixed-methods study utilized data from the STRIPE project in India. Quantitative data was gathered through a survey administered to 517 participants (352 online, 165 offline) from the polio universe, encompassing individuals involved in GPEI activities at various levels. Purposive sampling was employed to recruit key informants for qualitative data collection. Twenty-five in-depth, semi-structured interviews were conducted with national (n=11), sub-national (n=10), and frontline (n=4) change agents. The research tools were developed based on CFIR and the Socio-Ecological Model (SEM). Moon's expanded typology of power served as the analytic framework, categorizing power into eight types: physical, economic, structural, institutional, moral, expert, discursive, and network. Data analysis involved examining survey responses, interview transcripts, and applying Moon's taxonomy to understand how different actors exercised power to address implementation challenges.

The quantitative survey documented various implementation barriers categorized within the CFIR framework, including challenges related to intervention characteristics, inner and outer settings, individual characteristics, and implementation processes. Significant challenges included community resistance to vaccination (linked to myths and misinformation), vaccine hesitancy, program fatigue, workforce shortages, and the GPEI's impact on other health programs. Qualitative data revealed the diverse ways stakeholders wielded power. Structural power, exercised through the government's position and monitoring mechanisms, enhanced accountability. Moral power played a significant role, with religious leaders influencing vaccine acceptance in hesitant communities. Expert power was leveraged by medical professionals and researchers, while community influencers and female vaccinators exercised network power, particularly in gaining access to traditionally inaccessible populations. The study highlighted the role of discursive power in shaping public perception and communication strategies, exemplified by public service announcements featuring prominent figures. A framework illustrating the interplay of various power relations in the polio eradication program in India was developed, linking these power dynamics to strategies for improving social learning and health outcomes. The hidden power of seemingly powerless actors like children bringing mothers to polio booths was also highlighted.

The findings demonstrate the intricate relationship between power and implementation challenges in the GPEI. The multi-pronged strategy of the GPEI, relying on securing buy-in from key actors and leveraging their power dynamics to influence decision-making, proved effective. The study showed how different types of power—technical expertise, political and bureaucratic positions, and cultural capital—were used to both overcome barriers and create new challenges (e.g., neglecting other health programs due to the dominance of GPEI). The study also found that power is not a static entity, it can be transformed and wielded in various interconnected ways. The participation of female community mobilizers highlighted how less powerful actors can leverage opportunities within complex systems to exert influence. The study emphasizes the need to account for power dynamics in health systems, acknowledging epistemic injustice and promoting inclusive practices in implementation research.

This study underscores the critical role of power in implementation research and suggests integrating power as a key variable in existing IR models. Understanding power dynamics improves the comprehension of power distribution and its impact on equity in health policy and systems. Future research should focus on expanding understanding of power dynamics in LMICs, particularly among marginalized groups, to design more effective and equitable global health programs. The study's findings are crucial for improving implementation strategies and enhancing the overall success of global health interventions.

One limitation of the study was the lack of explicit questioning on 'power' in the initial key informant interview guide, potentially leading to missed nuances in the analysis. The study focuses on the Indian context of GPEI implementation, and generalizability to other settings might require further research. The analysis relies on self-reported data which can be subject to bias.