Decoding the black box of health policy implementation: A case of regulating private healthcare establishments in southern India.

Background: . Implementation of healthcare regulatory policies, especially in low- and middle-income countries where the private health sector is predominant, is challenging. Karnataka, a southern state in India, enacted the Karnataka Private Medical Establishments Act (KPMEA) with an aim to ensure quality of care in the private healthcare establishments. After more than a decade the implementation of KPMEA is suboptimal. Methods: . We used a case study design. The case was 'implementation of KPMEA'. The case study site was Bengaluru Urban district in Karnataka. Data from key informant interviews, focus group discussions held at the state, district and subdistrict levels and key policy documents, minutes of the meetings, data from the State Department of Health and Family Welfare, district level KPMEA data and litigations at the High Court of Karnataka were analysed using a framework. Results: . The policy (KPMEA) content is inadequate and requires clarity in certain provisions of the Act. There was a lack of coordination between the implementing agencies. Workforce shortages were evident. Factors that impede the enforcement of the Act include poor knowledge and lack of competency of the officials on the content and the implementation mechanics of the policy, insufficient policy oversight from the state on the districts, corruption, political interference and lack of support from the local public, especially during raids on illegal establishments. Conclusions: . A regulatory policy such as KPMEA needs a clear, comprehensive content and directions for operationalization. However, improving the content of the policy is not easy as some aspects of the policy remain contentious with the private healthcare providers/ establishments. Addressing health governance issues at all levels is key to effective enforcement.

Conflicts of interest in tobacco control in India: an exploratory study.

INTRODUCTION: The government of India introduced a tobacco control legislation in 2003 and is a party to the WHO Framework Convention on Tobacco Control. However, anecdotal evidence points to the government's conflicting interests in tobacco control and trade. This research seeks to scope instances of conflicts of interests within the government and analyse how they operate in the Indian context. METHODS: We conducted an exploratory study analysing documents over a 2-year period. We scanned media reports related to tobacco, documents of the tobacco industry, information retrieved from governments using the Right to Information Act and relevant websites. The data were analysed through thematic coding. RESULTS: 100 instances of conflicts of interest were found and classified under six categories: public support for the tobacco industry by government institutions or individuals; stakeholding or ownership of tobacco companies by government functionaries; individuals holding positions both in tobacco companies and the government; formal partnerships between the tobacco industry and public agencies; conflicting policies; and incentives available for the tobacco industry. These instances occur at all three levels of government: the individual, institutional and policy levels. CONCLUSIONS: Conflicts of interest are rampant in India and operate in many different ways. These conflicts can lead to negative consequences for tobacco control with far-reaching effects. Varied strategies using legal, administrative and legislative tools need to be adopted to manage conflicts of interest.