"Unequal Playing Fields": The Exercise of Power in Strengthening Health Systems for HIV Control in Bali Province, Indonesia

Abstract

Despite the shift of strategy from emergency intervention towards strengthening health system responses over the last 15 years, the HIV epidemic in Bali Province endures, inequitable access to HIV-related services persists, and HIV incidence among key population groups has increased. The aim of this thesis was to clarify what shapes health system strengthening for HIV prevention and treatment in Bali, and in particular, to assess the ways in which these efforts may have been influenced by the differential exercise of power by the actors in the health system. Current health system frameworks reported in the literature do not elucidate the mechanisms through which the exercise of power across health actors influences the goals and outcomes of the health system. I therefore developed and applied a converging framework to guide research and practice for analysing how power influences the operations of health systems. This innovative framework provides a systematic approach for mapping different sources of power, strategic uses of power, and the observed outcomes of power in the context of health systems and policies. Adopting a place-based research approach guided by critical realist epistemology, this thesis engages with various conceptions of power to sharpen the study of power asymmetry and political analysis of health system in Indonesia. This study was conducted in five districts of Bali Province, representing diversity in wealth, health service provision and patterns of HIV. Data were collected through in-depth interviews; direct observation at community health centres, district hospitals, non-governmental organisations, coordination meetings and monitoring activities; policy document analysis; health facility-based surveys and secondary data analysis of 63 community health centres. This thesis reveals that health system actors deploy various tactics and multiple forms of capital (social, political, and epistemic) at their disposal. The exercise of power manifests not only at formal decision making and allocation of funds but also extend to political framing of the problem of HIV, service delivery and at-risk populations. Power in health systems and policy making is not only relative and relational as previously understood but is also intersectional and transformational. The perennial concern is not merely the existence of power but the asymmetrical distribution of power among health system actors which manifests at individual, organisational, institutional and structural levels, and governs the day-to-day practice of health system strengthening. Given the intersectional and transformational nature of power, this thesis contends that power asymmetries can be challenged, confronted and reversed to support equity-oriented health system strengthening. This can be achieved through shifting the overriding framing of health system strengthening from economic toward the right-to-health paradigm and systematic implementation of tailored social accountability models to promote downward accountability mechanisms. The participation of civil society becomes central to guide implementation of the right-to-health framework.