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

The study addresses how power dynamics shape the implementation of the Global Polio Eradication Initiative in India. Power permeates health systems at local, national, and global levels, influencing policy, service delivery, community participation, access, affordability, and quality. Although central to health policy and systems research (HPSR), power has been under-studied in LMIC contexts. Power has been conceptualized as coercion, capital, and control, and manifests overtly and covertly via individuals, institutions, and structures. Sources of power include technical expertise, political and bureaucratic authority, financial resources, networks and access, and personal attributes, interfacing with actors, context, content, structures, and processes. Implementation science frameworks like CFIR explain implementation effectiveness across domains but do not explicitly recognize power. Broader social science approaches and decolonizing global health discourses highlight power and privilege in shaping partnerships and practices. Within the STRIPE project, this study analyzes how actors mobilized power to negotiate implementation challenges and how power configurations evolved across contexts in India, with implications for health equity.

The paper situates its inquiry within HPSR literature noting power’s neglect in LMIC-focused research. It references conceptualizations of power (Dahl, Bourdieu, Barnett and Duvall, Lukes), sources of power relevant to health systems, and the CFIR framework’s domains while noting the absence of an explicit power construct. It also engages literature on critical ethnography, decolonizing global health, and global health governance as complex adaptive systems, arguing for the need to integrate power analysis into implementation research frameworks.

Design: Mixed-methods study within the STRIPE project in India, using a quantitative survey and qualitative key informant interviews (KIIs). Setting and period: India, national and sub-national levels; data collected from August 2018 to January 2019. Sampling and participants: The “polio universe” encompassed ~2.4 million individuals involved in polio activities, including GPEI partners (WHO, UNICEF, CDC, BMGF, Rotary), government employees, NGOs, school staff, health workers, media, volunteers, and religious influencers. A stakeholder consultation yielded 4,957 contacts. Survey: A bilingual self-administered survey (online via Qualtrics and offline) was sent to these contacts; 517 responses were obtained (352 online, 165 offline). Respondents could report multiple roles, organizational affiliations, and goals across 1988–2019. KIIs: Purposive sampling from survey respondents identified key informants (change agents and frontline workers) at national, state, and district levels from government and partner organizations. In-depth semi-structured interviews were conducted face-to-face by a trained qualitative researcher with a bilingual note-taker; N=25 (National change agents=11; sub-national=10; frontline=4). Interviews lasted ~70–100 minutes, were audio-recorded, transcribed, and checked. Ethical procedures: Written informed consent was obtained; IRB approval by IIHMR University, Jaipur. Instruments and frameworks: Research tools were informed by CFIR and the Socio-Ecological Model to explore implementation experiences, challenges, strategies, and unintended consequences. Analytic framework: Moon’s expanded typology of power (physical, economic, structural, institutional, moral, expert, discursive, network) guided analysis to examine how actors deployed different power forms to address implementation challenges.

Sample and roles: Among 517 survey respondents, levels of involvement included sub-district 51.5% (292), district 25.4% (144), state 12.7% (72), national 7.94% (45), global 2.47% (14). Organizational representation: government/implementing agencies 64.2% (418), GPEI partners 22.5% (220), research organizations 5.4% (51), global NGOs 2.5% (27), others 3.3% (31). Program goals/activities: vaccination 51.2% (266); surveillance 24.5% (127); community engagement 22.4% (116); monitoring and evaluation 22.4% (116); strengthening delivery system 12.5% (65); strategy development 9.4% (49); partnership development 4.0% (24); resource mobilization 3.4% (18). Implementation barriers (CFIR domains): • Process of implementation (n=151): major challenges in executing (33.7%), engaging stakeholders (27.1%), reflecting & evaluating (23.1%), and planning (14.5%). • Outer setting (n=126): social resistance and vaccine hesitancy were prominent (73.0%), including myths (e.g., anti-fertility, pig-derived vaccine), community fatigue from repeated campaigns, and inequities; economic constraints 11.9%; political challenges 6.35%; technological 0.79%; geographic/migration challenges 7.94%. • Intervention characteristics (n=74): adaptability limitations (20.2%), complexity and logistical challenges (16.2%), relative advantage concerns including program run parallel to routine immunization (17.5%), intervention source perceived as external with distrust of Western interventions (13.5%), cost challenges including financing post-donor support (6.7%). • Inner setting (n=69): culture/priorities (24.6%), implementation climate (23.1%), network/communication gaps (20.2%), structural challenges including shifting roles and understaffing (11.5%), implementation readiness issues including chronic underfunding (17.39%). • Characteristics of individuals (n=44): knowledge and beliefs gaps (43.1%), stage of change and fatigue (22.7%), perception of organization (22.7%), self-efficacy challenges (11.3%). Qualitative insights: • Early resistance included child hiding, stone throwing, and safety risks for vaccinators; repeated SIAs led to fatigue; opportunity costs affected other health programs; workforce shortages tied to low honoraria and long hours. • Strategies contributing to success: 41.8% cited process factors (planning, execution, reflection, adaptation); externally, changing the social environment (68.7%) was most frequently cited. Power dynamics observed: • Structural power: Political ownership and accountability were strengthened through district task forces led by district magistrates, regular monitoring and reviews by chief ministers and administrators, and clearer roles, responsibilities, and transparency. • Moral and institutional power: Religious leaders (e.g., Imams) and religious/secular institutions (e.g., Dargahs; universities like Aligarh Muslim University, Jamia Hamdard, Jamia Islamia) advocated for vaccine acceptance, countering misinformation and legitimizing vaccination through faith-based and institutional endorsements. • Expert power: Medical associations and health professionals influenced public opinion through speeches, research, and advocacy; their authority helped debunk myths. • Gendered and local influencer power: Female vaccinators increased household access and acceptance; local volunteers enhanced trust and engagement. • Discursive power: Strategic mass communication (e.g., celebrity endorsements by Amitabh Bachchan, ubiquitous slogans on consumer goods and railway tickets) reframed vaccination as a social norm and duty. • Network power: Social Mobilization Network (SM.Net) leveraged community influencers and peer mobilizers (including children’s “Bulawa tolies”) to build trust and motivate participation. • Hidden power: Children and other seemingly powerless actors influenced caregivers’ decisions, demonstrating covert yet impactful agency. Overall, multiple power forms were mobilized, often in combination, to overcome vaccine hesitancy, improve accountability, and enhance program reach and effectiveness.

Findings demonstrate that power is integral to implementation processes across CFIR domains, shaping both barriers and strategies. External social resistance and misinformation interacted with internal programmatic constraints and workforce dynamics, where actors wielded varying forms of power—structural, moral, institutional, expert, discursive, network, and hidden—to influence vaccination decisions and system behaviors. The GPEI’s large footprint generated positive health system changes (e.g., accountability mechanisms) while also contributing to campaign fatigue and deprioritization of other programs. Power in complex adaptive systems is distributed and dynamic; less powerful actors (e.g., female mobilizers, children) can exert substantial influence under certain conditions. Intersections among power types matter: moral authority often operated through discursive strategies and institutional alliances; expert authority was amplified by networks and communication; structural arrangements enabled accountability. Gendered power relations were pivotal for household access and acceptance, yet female mobilizers faced safety and support gaps, underscoring equity considerations. Stakeholder analyses and IR practices themselves are sites of power, risking epistemic injustices if marginalized perspectives are undervalued. Incorporating power explicitly into IR frameworks can improve transparency, equity, and effectiveness in program design, stakeholder engagement, and adaptation.

The study elucidates how diverse power forms are mobilized by individuals, organizations, and networks to address implementation challenges in India’s polio eradication efforts. It argues for incorporating power as an explicit construct within implementation science frameworks (e.g., CFIR, PARIHAS) to better explain and guide effective strategies, accountability mechanisms, and equitable stakeholder engagement. Policymakers should design programs with attention to health systems dynamics, path dependency, interconnectedness, and the distribution and interplay of power. Further research, particularly involving LMIC stakeholders and marginalized groups, is needed to refine theory and practice regarding power-informed implementation strategies for global health programs.

Power was not explicitly addressed in the original key informant interview guide, which may have limited the depth and nuance of power-related insights in the analysis.