Health policy processes in Gujarat: A case study of the Policy for Independent Nurse Practitioners in Midwifery

Abstract

Background: The policy processes of the policy on ‘Nurse practitioners in midwifery’ (NPM) are described. The policy aims to educate and create a new cadre of competent midwives in the government hospitals as an alternate human resource for maternal and newborn care for remote rural facilities. Methods: Participant observation in every day setting, in depth interviews with actors involved in policy processes and a self administered questionnaire to one batch of 37 NPMs were used. The conceptual framework of policy processes developed by Andrew et al (2011) was used for analysis. Findings: The NPM policy was delayed because of frequent change of secretaries and commissioners of health who led the policy process but did not share the vision of policy initiators, and there was less push and shared vision unlike the national programmes, being a state driven policy. The nature of the issue influenced the policy process; many were unconvinced about developing an autonomous cadre of midwives who can fill in for doctors. It was seen as competition by obstetricians. The policy processes were closed though many departments within the government and some actors outside the government were involved. There was less space for open dialogue amongst the various actors, all the discussion was through notes on the file. The main actor s to push the policy forward were less powerful within the government machinery. Overall the NPM course has been successful in developing competence for normal childbirth; some more practice is needed for complications during labour. Since majority of the candidates for the course come from cities, the objective of human resource for remote rural facilities may only be partially fulfilled. Conclusions: There is a need to develop a protocol for robust policy processes which are unaffected by changes in leadership, where there are opportunities for dialogue, to bring in and examine evidence, to improve policy processes.