Policymaking is an inherently political process marked, more often than not, by ambiguity, negotiations and shifting priorities. Policy actors (elected leaders, bureaucrats, technocrats, civil society activists, lobbyists, media…) play an important role in agenda setting and policy formulation – stages we will focus on in this article. Each actor brings dynamic forms of power to the policy process, based on different positions in the hierarchy, as well as diverse roles, interests and values. These power dynamics often influence policy agenda setting and formulation even more than evidence, realities on the ground or the needs of the community. Recognizing the role of power and politics in policymaking has the potential therefore to shed more light on (sometimes murky) policy processes but also understand better the underlying issues of health inequities in the health system. Recognizing these power dynamics is particularly important in low- and middle-income countries like India, with multiple concurrent health system challenges and relatively limited resources to attain Universal Health Coverage.

Since the formation of India, there has been a huge push for primary health care in the country, including a more or less realistic action plan to achieve this.In 1947, the Bhore committee (set up a few years earlier to assess India’s health condition), already clearly prescribed the need to improve India’s primary health care system. At the global level, the Alma-Ata Declaration in 1978 stressed the importance of primary health care and emphasized a paradigm shift from a medical health system model to a social model – and India was certainly paying attention. National health policies passed in 1983 and again in 2002 repeatedly emphasized the importance of primary health care. However, these (lofty) primary health care policies didn’t get much priority over the years. One of the important reasons behind this failure was that policy makers and program implementers have always conceptualized primary health care as being about selective primary care services rather than comprehensive ones. In addition, many of these actors have disproportionately focused on secondary and tertiary care, neglecting primary care. The increasing fragmentation of the Indian health system, with many players competing for power, constantly shifting priorities, and weak regulatory mechanisms to coordinate, presented another challenge.

The National Health Policy of 2017 re-emphasized India’s focus on primary health care and paved the way for the Ayushman Bharat Program, which has two main components. The first component aims to establish Health and Wellness Centers that will provide a package of 12 comprehensive primary care services and make referrals for advanced care. This involves upgrading existing Sub Health Centers (typically serving 5000 people) and Primary Health Centers (serving 30,000) by providing more health workers, infrastructure, service packages, drugs, and diagnostics. The second component of Ayushman Bharat is a health insurance scheme, called Pradhan Mantri Jan Arogya Yojana (PMJAY). The scheme aims for increased accessibility, availability and affordability of secondary- and tertiary-care health services in India.

It is interesting to observe that in spite of many years of recommendation by several committees, both at the national and global level, comprehensive primary health care appeared on the Indian political agenda only recently – and even then, still rather reluctantly.

Despite the proven cost-effectiveness of primary health care, it’s fair to say that India’s public health system is dominated by a selective, politically sanitized version of primary health care that has been reduced to a few vertical health programs, determined not by communities but by policy actors.

The aim of the first pillar of Ayushman Bharat is to establish a total of 150,000 Health and Wellness Centers across India by 2022. As of May 2020, only 40,137 Health and Wellness Centers were operational, however.In addition, there has been insufficient research so far shedding light on the actual situation on the ground. To date, it is unclear what benefits these centers have brought to ordinary citizens, the extent to which communities are using the services purported to be available at the centers and whether these centers are actually improving the India public health care delivery system through strengthening of a continuum of care model. Last but not least, resources aren’t in line with rhetoric. While the 2017 National Health Policy recommended that two-thirds of its budget had to be allocated to primary health care, Ayushman Bharat allocated only one-third (Rs. 1200 crore or $158 billion USD) to comprehensive primary health care and instead allocated two thirds (Rs. 2400 crore or $316 billion USD) to PMJAY. This flipped allocation is perhaps symptomatic for the “real” 2017 National Health Policy, showcasing far greater financial emphasis on paying for hospital-based secondary and tertiary care than on bolstering the comprehensive primary health care system.

So far, India has made reasonable progress in terms of reducing the Infant Mortality Rate, Maternal Mortality Rate, and Total Fertility Rate (major focuses of the public PHC system), but this progress is skewed across states and different social constructs such as class, caste, gender, age etc. In spite of these long standing ground realities, (as mentioned above) national level policy elites have repeatedly pushed through schemes and financial allocations that undermined the primary health care orientations of major policies, reports and calls to action – from the Bhore committee to the 2017 National Health Policy. The current epidemic of Covid-19 further exposes the (still dire) situation of the public health system in India, with chronic vacancies of health workers (e.g. more than a quarter of India’s 736 districts have no district-level epidemiologist and 11 states have no state-level epidemiologist either), a continued lack of resources in many places, a weak surveillance system etc. In short, Covid-19 is yet another wake-up call highlighting the crucial need to make the public health system resilient at all levels.

Time will tell what the real intent of the 2017 National Health Policy is, and whether it will be successful in bringing a ground-level change or instead just turn out a political gimmick. Public health priorities are set by policy elites, yet we lack evidence about how power dynamics among these actors shape India’s health policies and programs. More research should be encouraged in this respect to provide substantial evidence to enable organizations and communities to re-evaluate their existing strategies and to explore new actions for change.