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This article analyses the nature of power relationships between urban hospital practitioners and other groups of actors involved in the implementation of public health policies in India, and the effects of enacting different strategies to strengthen implementation, in the context of these balances of power. It is based on an empirical research study conducted over 18 months in five Indian cities involving 61 in-depth interviews with medical practitioners and policy actors, and an interpretivist analytical approach. An issue case study-of the implementation of national HIV testing guidelines-was used to focus the interviews on specific events and phenomena. Respondents' accounts revealed that practitioners in both private and government hospitals tended to successfully resist or subvert the attempts of regulators and administrators to enforce the guidelines. However, in spite of often possessing perspectives and convictions that differed from the nationally sanctioned guidelines, practitioners were not able to effectively communicate these ideas to other health systems actors, or introduce them into mainstream policy discourse. The metaphor of public health guideline implementation throws light on the problematical nature of the power possessed by medical practitioners in relation to public health systems in India. Even as practitioners wield 'negative' power in their ability to resist authority, they appear to lack the 'positive' power to contribute intellectually to the policy process. This mix of political obduracy and intellectual demoralization among practitioners also underpins a subtle trend in public health, of the separation of the world of ideas from the world of actions. Study findings highlight that stronger regulations and provisions for accountability in Indian health systems critically need to be balanced by measures to develop collective intellectual capital and include the voices of frontline practitioners in public health policy discourse.

Disempowered doctors? A relational view of public health policy implementation in urban India