HIV testing in urban Indian hospitals a study of policy-practice relationships in the formal medical sector

HIV testing is an example of the separation between public health policy guidelines and practices of medical providers in urban Indian hospitals. An action-centred policy framework and interpretivist analytical approach was adopted to investigate problems of policy-practice gaps and identify strategies to resolve them. I conducted depth interviews with 61 respondents representing different groups of involved actors, including medical practitioners from public and private hospitals in five Indian cities, administrators, public health officials, regulators, educators, representatives of civil society organizations and international agencies, and with key informants. Respondents' perspectives on their participation in implementing the policies and on interactive processes between different groups were explored. There was a concentration on four aspects of HIV testing - selectivity in testing, pre-surgical testing, infonned consent, and confidentiality. I found that the actions of medical practitioners and other actors, and their respective interactions with each other, frequently diverged from expected nonns . of policy implementation. Explanations for divergences in actions included ambiguities around roles, conflicting valueorientations and practical considerations such as workplace relationships and systemic inadequacies. The nature of existing interrelationships between groups of actors was often inconsistent with a 'rational' top-down process of implementation. Irregularities in conveying meanings of policies also contributed to problems in their implementation. Different groups of actors are observed to inhabit discrete 'systems of meaning' and be guided by differing senses of purpose in their actions. This raises questions of the sufficiency and appropriateness, in isolation, of conventional prescriptions of strengthening regulations towards aligning implementers' practices with policymakers' intentions. In India's complex health policy ecosystem, the need for greater attention to the quality of interactive processes is identified. A renewed understanding of 'rationality' in the implementation of public health policies, based on good communicative practices and inclusion of different fonns of knowledge, is suggested as a standard for change