National Health Policy Review

Theoretical Aspects in India's Public Health Discourse

The provided sources reveal several theoretical underpinnings and conceptual frameworks that shape the understanding and critique of India's public health system and policies:

• Colonial Influence and Global Policy Paradigms: India's public health trajectory is deeply influenced by colonial legacies and global trends, often at the expense of local realities. The Bhore Committee Report (1946), for example, institutionalized centralized health planning, mirroring colonial governance logic rather than indigenous self-determination. Subsequent National Health Policies (NHPs) have continued to echo dominant international health agendas, such as "Health for All" (1977, influenced by Alma-Ata Declaration), privatization and insurance-led frameworks (2002, influenced by Washington Consensus), and Universal Health Coverage (UHC) (2017, championed by WHO and World Bank). These often adopt a "one-size-fits-all" approach, disregarding India's vast regional diversities.

• Indigenization: This concept emphasizes the adaptation of health policy to local contexts, which the sources argue has been a missed opportunity in India's policymaking. It calls for incorporating local knowledge systems, cultural practices, and regional administrative structures. True indigenization would involve policy co-creation with states, deeper integration of traditional medicine (AYUSH), state-specific digital governance, and district-level planning rooted in community participation.

• Decentralization vs. Centralization: A persistent tension highlighted is the disconnect between centralized policymaking and decentralized governance structures. Despite health being a state subject under the Indian Constitution, NHPs are often centrally designed, leading to mismatches in funding, accountability, and service delivery. The National Digital Health Mission (NDHM), though aiming for a federated system, is centrally governed by the National Health Authority (NHA), raising concerns about federal overreach and local adaptability.

• Rights-Based Approach (RBA): The sources advocate for a Rights-Based Approach to public health to institutionalize equity and justice. India's health policy is not anchored in enforceable constitutional rights; rather, Article 47 places public health under the Directive Principles of State Policy, making it aspirational rather than justiciable. This is contrasted with countries like Finland, Thailand, and Brazil, which have codified health as a state-guaranteed right with legal enforceability and participatory mechanisms.

• Theoretical Underpinnings of Digital Health (NDHM): The National Digital Health Mission (NDHM) is framed within several modern governance and data theories:

◦ Datafication: The process of converting aspects of human life, social practices, and services into quantifiable digital data points for collection, analysis, and decision-making. In public health, this involves extracting health-related behaviors and records for surveillance, service optimization, and governance.

◦ Technocratic Rationality: A governance style where complex social problems are treated as technical challenges solvable through expert knowledge, data, and system optimization, prioritizing metrics and algorithmic governance over local knowledge and participatory dialogue.

◦ New Public Management (NPM): Introduced private sector principles like performance measurement and cost-efficiency into public administration, shifting focus from citizen rights to quantifiable outcomes. In the health sector, this translates to insurance-based provisioning, target-driven programming, and outsourcing.

◦ Platform State: A recent conceptual development where the government acts as a digital infrastructure provider, facilitating interactions between citizens, services, and data through modular technological systems. This model emphasizes interoperability and scalability but can recentralize state control, obscure accountability, and reduce public services to transactional interfaces.

◦ Function Creep: The gradual and often opaque expansion of a digital system's use beyond its original, stated purpose. This raises concerns that health data initially gathered for clinical care or public health monitoring could be repurposed for commercial profiling, insurance risk assessments, or law enforcement surveillance, especially without strong legal safeguards.

Frequently Asked Questions (FAQ)

Q1: What is the primary aim of the National Health Policy, 2017 (NHP 2017)? 

A1: The primary aim of the National Health Policy, 2017, is to inform, clarify, strengthen and prioritize the role of the Government in shaping health systems in all its dimensions. This includes investments in health, organization of healthcare services, prevention of diseases and promotion of good health through cross-sectoral actions, access to technologies, developing human resources, encouraging medical pluralism, building a knowledge base, developing better financial protection strategies, strengthening regulation, and health assurance.

Q2: How has India's public health policy been influenced by its colonial past and global trends? 

A2: India's public health trajectory is deeply influenced by colonial legacies and global trends, which continue to shape contemporary policy frameworks, often marginalizing local realities. The Bhore Committee Report (1946), commissioned under British India, set the first comprehensive blueprint for public health and institutionalized centralized health planning, reflecting colonial governance logic rather than indigenous self-determination. Post-independence, India's National Health Policies (NHP 1977, NHP 2002, and NHP 2017) have continued to echo dominant international health agendas, such as "Health for All," privatization frameworks, and Universal Health Coverage, adopting one-size-fits-all approaches that often disregard India's regional diversities.

Q3: What are the key ideological differences among India's National Health Policies (NHP) of 1977, 2002, and 2017? 

A3: Each NHP reflects a distinct ideological orientation:

• NHP 1977: Emphasized a welfare-state model with "Health for All by 2000 AD" as its vision, focusing on public provisioning and strong state responsibility. It prioritized preventive and community health with a three-tier rural health infrastructure.

• NHP 2002: Represented a market-based reform approach, shifting towards private sector engagement and health insurance models. It focused on efficiency and expanded reach through private investment.

• NHP 2017: Signaled a return to universalism with an emphasis on Universal Health Coverage (UHC) and a technocratic digital state approach, focusing on digital health as a transformative strategy and wellness centers. It frames health as a strategic goal, combining technology, efficiency, and preventive care.

Q4: Is health legally recognized as a fundamental right in India's National Health Policies? 

A4: While the National Health Policy, 2017, symbolically acknowledges health as a right, it stops short of enshrining it legally or making it justiciable. The Indian Constitution places public health under the Directive Principles of State Policy (Article 47), making it aspirational rather than justiciable. However, the Supreme Court has interpreted the right to health as an essential part of the fundamental right to life under Article 21, giving it some legal weight. This "pseudo-legality" has led to calls for explicit, justiciable fundamental rights and a National Public Health Act.

Q5: What are the primary objectives of the National Digital Health Mission (NDHM), now known as Ayushman Bharat Digital Mission (ABDM)? 

A5: The NDHM, rebranded as ABDM, is a major initiative to digitize India's healthcare ecosystem. Its primary aims include connecting public and private stakeholders, improving health data management, and supporting universal health coverage through digital technologies. Specifically, it seeks to unify health records, improve care continuity, empower citizens with digital control over their health data, increase efficiency, integrate systems, and enable data-driven governance.

Q6: What are the main challenges and criticisms associated with the National Digital Health Mission (NDHM)? 

A6: The NDHM faces several significant challenges and criticisms:

• Centralized Control and Federal Tensions: It is a centrally governed initiative, raising concerns about federal overreach and limited state-level adaptability, despite health being a state subject.

• Weak Legal and Privacy Protections: It lacks a strong legal basis for health data management, with no dedicated health data protection law specific to health and an over-reliance on Aadhaar-based authentication. Traditional informed consent mechanisms are insufficient in a digital context.

• Risks of Datafication: There's a risk of "function creep", where health data could be repurposed for commercial profiling, insurance risk assessments, or surveillance beyond its original purpose. This raises concerns about data commodification and exploitation.

• Digital Divide and Equity Concerns: The mission assumes infrastructure readiness, potentially exacerbating rural and marginalized exclusion due to uneven digital infrastructure and literacy barriers based on gender, class, and caste.

• Impact on Health Outcomes: Overemphasis on data collection ("dataveillance") might shift focus from patient-centered care to monitoring, potentially risking a loss of empathy in clinical interactions. Without parallel investment in frontline services and digital literacy, improved data alone may not guarantee better health outcomes.

Q7: How does NHP 2017 plan to address human resource and skill gaps in the health sector? 

A7: The NHP 2017 outlines several strategies to address human resource and skill gaps:

• Increasing Doctors and Specialists: It recommends strengthening existing medical colleges and converting district hospitals into new medical colleges.

• Improving Medical Education: It advocates for a common entrance exam (like NEET) and a common national-level Licentiate/exit exam for medical and nursing graduates.

• Attracting and Retaining Doctors in Remote Areas: Policy proposes financial and non-financial incentives, creating medical colleges in rural areas, offering preference to students from under-serviced areas, and mandatory rural postings.

• Developing Mid-Level Service Providers: It supports the development of a cadre of mid-level care providers through courses like B.Sc. in community health or bridge courses for AYUSH doctors, nurses, pharmacists, and GNMs.

• Nursing and Paramedical Skills: The policy recognizes the need to improve regulation and quality management of nursing education and develop specialized nursing training courses. It also aims to develop training for super-specialty paramedical care.

Q8: What is the target for public health expenditure as a percentage of GDP in NHP 2017? 

A8: The National Health Policy, 2017, proposes a potentially achievable target of raising public health expenditure by the Government as a percentage of GDP from the existing 1.15% to 2.5% by 2025.

Q9: How does NHP 2017 envision collaboration with the non-government/private sector? 

A9: The NHP 2017 advocates for a positive and proactive engagement with the private sector for critical gap filling towards achieving national goals. Key aspects include:

• Strategic Purchasing: The government would act as a single payer, strategically purchasing secondary and tertiary care services as a short-term measure, with preference for public sector, then not-for-profit private sector, and finally commercial private sector in underserved areas.

• Capacity Building and Skill Development: Outsourcing training programs and coordinating with private hospitals for skill development.

• Corporate Social Responsibility (CSR): Leveraging CSR funds to fill health infrastructure gaps and promote awareness campaigns on various health issues.

• Specific Service Collaboration: Engaging the private sector in mental healthcare, disaster management (medical relief, post-trauma counseling), and managing rare diseases.

• Enhancing Accessibility: Encouraging private hospitals to volunteer for referrals from public facilities and provide increased designated free/subsidized beds for the poor.

• System Integration: Recognizing the private sector's role in immunization, disease surveillance (data sharing from laboratories), tissue and organ transplantations, and contributing to a seamless health information system