Practice and power: a review and interpretive synthesis focused on the exercise of discretionary power in policy implementation by front-line providers and managers

Tackling the implementation gap is a health policy concern in low- and middle-income countries (LMICs). Limited attention has so far been paid to the influence of power relations over this gap. This article presents, therefore, an interpretive synthesis of qualitative health policy articles addressing the question: how do actors at the front line of health policy implementation exercise discretionary power, with what consequences and why? The article also demonstrates the particular approach of thematic synthesis and contributes to discussion of how such work can inform future health policy research. The synthesis drew from a broader review of published research on any aspect of policy implementation in LMICs for the period 1994-2009. From an initial set of 50 articles identified as relevant to the specific review question, a sample of 16 articles were included in this review. Nine report experience around decentralization, a system-level change, and seven present experience of implementing a range of reproductive health (RH) policies (new forms of service delivery). Three reviewers were involved in a systematic process of data extraction, coding, analysis, synthesis and article writing. The review findings identify: the practices of power exercised by front-line health workers and their managers; their consequences for policy implementation and health system performance; the sources of this power and health workers' reasons for exercising power. These findings also provide the basis for an overarching synthesis of experience, highlighting the importance of actors, power relations and multiple, embedded contextual elements as dimensions of health system complexity. The significance of this synthesis lies in its insights about: the micropractices of power exercised by front-line providers; how to manage this power through local level strategies both to influence and empower providers to act in support of policy goals; and the focus and nature of future research on these issues.