Power is a critical concept to understand and transform health policy and systems. Power manifests implicitly or explicitly at multiple levels-local, national and global-and is present at each actor interface, therefore shaping all actions, processes and outcomes. Analysing and engaging with power has important potential for improving our understanding of the underlying causes of inequity, and our ability to promote transparency, accountability and fairness. However, the study and analysis of the role of power in health policy and systems, particularly in the context of low- and middle-income countries, has been lacking. In order to facilitate greater engagement with the concept of power among researchers and practitioners in the health systems and policy realm, we share a broad overview of the concept of power, and list 10 excellent resources on power in health policy and systems in low- and middle-income countries, covering exemplary frameworks, commentaries and empirical work. We undertook a two-stage process to identify these resources. First, we conducted a collaborative exercise involving crowdsourcing and participatory validation, resulting in 24 proposed articles. Second, we conducted a structured literature review in four phases, resulting in 38 articles reviewed. We present the 10 selected resources in the following categories to bring out key facets of the literature on power and health policy and systems-(1) Resources that provide an overarching conceptual exploration into how power shapes health policy and systems, and how to investigate it; and (2) examples of strong empirical work on power and health policy and systems research representing various levels of analyses, geographic regions and conceptual understandings of power. We conclude with a brief discussion of key gaps in the literature, and suggestions for additional methodological approaches to study power.

Power is a growing area of study for researchers and practitioners working in the field of health policy and systems research (HPSR). Theoretical development and empirical research on power are crucial for providing deeper, more nuanced understandings of the mechanisms and structures leading to social inequities and health disparities; placing contemporary policy concerns in a wider historical, political and social context; and for contributing to the (re)design or reform of health systems to drive progress towards improved health outcomes. Nonetheless, explicit analyses of power in HPSR remain relatively infrequent, and there are no comprehensive resources that serve as theoretical and methodological starting points. This paper aims to fill this gap by providing a consolidated guide to researchers wishing to consider, design and conduct power analyses of health policies or systems. This practice article presents a synthesis of theoretical and conceptual understandings of power; describes methodologies and approaches for conducting power analyses; discusses how they might be appropriately combined; and throughout reflects on the importance of engaging with positionality through reflexive praxis. Expanding research on power in health policy and systems will generate key insights needed to address underlying drivers of health disparities and strengthen health systems for all.

The debate on how India's health system should move towards universal health coverage was (meant to be) put to rest by the recent National Health Policy 2017. However, the new policy is silent about tackling bottlenecks mentioned in the said policy proposal. It aims to provide universal access to free primary care by strengthening the public system, and to secondary and tertiary care through strategic purchasing from the private sector, to overcome deficiencies in public provisioning in the short run. Yet, in doing so, it ignores critical factors needed to replicate successful models of public healthcare delivery from certain states that it hopes to emulate. The policy also overestimates the capacity of the public sector and downplays the challenges observed in purchasing secondary care. Drawing from literature in policy design, we emphasize that primary, secondary and tertiary care have distinct characteristics, and their provision requires separate approaches or policy tools depending on the context. Public provisioning, contract purchasing and insurance mechanisms are different policy tools that have to be matched with the context and characteristics of the policy arena. Given the current challenges of India's health system, we argue that tertiary care services are most suitable for insurance-based purchasing, while the public sector should concentrate on building the required capacities to dominate the provisioning of secondary care and fill gaps in primary care delivery, for India to achieve its universal coverage ambitions.

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The NITI Aayog is working to develop and conduct pilot public–private partnership (PPP) projects to improve the delivery of healthcare services. The last two decades saw a rise in discussions and debates on the varied PPP models, as an opportunity to harness the private sector efficiencies and to supplement the public resources. However, the enthusiasm for experimenting with the PPP models fall short of the learnings from it. The limited but growing evidence based on PPPs in healthcare suggests that even the basic tenets of design and implementation of the PPP model have not been met, such as selection of qualified providers\contractors, designing contracts that align incentives, appropriately allocate risks and managing contracts using appropriate performance management tools. In general, the PPP models involve considerable risks and more so in healthcare given its unique characteristics, therefore if not designed and implemented with care, PPP’s in healthcare would prove to be wasteful and burdensome on the public exchequer.

Background: The state government

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