As part of the ongoing seminar series, this month’s conversation brought together fellows, practitioners, and policy thinkers from across resource-challenged districts of Uttar Pradesh, Jharkhand, Madhya Pradesh, and Chhattisgarh. With each seminar, the cohort engages not only in cross-learning but also in critical reflection on the development paradigms shaping health systems in India. This month’s keynote was delivered by Dr. Nirmala Murthy, Founder President of the Foundation for Research in Health Systems (FRHS), who drew upon decades of experience to challenge, contextualise, and inspire new directions for India’s public health trajectory.

Beyond Facilities: Rethinking the Architecture of Public Health

The session delved into pressing questions: What does it truly mean to reimagine public health? How can systems move beyond biomedical, hospital-centric frameworks to embrace equity, decentralisation, and prevention?

Dr. Murthy began by noting that the idea of reimagining public health is not new—India has been engaged in this task since the Bhore Committee Report of 1946. That vision—of free, state-financed healthcare rooted in community participation—continues to elude full realisation. Subsequent policies and committees diluted this vision, shifting toward selective care, with increasing reliance on private sector partnerships.

Subsequent committees—such as the Mudaliar Committee and Kartar Singh Committee—adjusted the scale and scope of that vision by promoting selective, phased approaches to primary care, often emphasising family planning and disease control as entry points.

India’s three National Health Policies—formulated in 1983, 2002, and 2017—each represented a reimagination of the public health system. One of the major shifts observed across these policies is the increasing role of the private sector. In 1983, the state positioned itself as the primary provider of public health services. By 2002, the role of private actors was acknowledged, and by 2017, the state moved toward active public-private partnerships, such as those seen in Ayushman Bharat yojana, where the private hospitals too were bought in to provide benefits of the scheme to the beneficiaries.

Dr. Murthy shared another critical insight concerning the dominant clinical orientation of public health programmes in India. While often labeled “public health,” these programmes typically emphasise curative services—diagnosis and treatment—rather than prevention and population health. But the true public health focuses on preventing disease, not merely treating it. A public health approach asks: How can we reduce the incidence of illness before people ever enter a clinic or hospital?

Through a compelling example she explained: when once a public health officer assigned to a dam construction site found himself treating 40–50 patients a day for gastrointestinal symptoms. Recognising a pattern, he ensured access to clean water by installing treated water tanks and mandating their use. Within days, cases dropped drastically, illustrating the power of preventive action over clinical intervention.

Over time, India’s health system has grown more hospital-centric, adding specialisations and focusing on tertiary care. While these are vital, an equitable public health system must also prioritise:

• Prevention and early detection;
• Affordable and accessible primary care;
• Community engagement;
• Social determinants of health;
• Digital inclusion;
• Local governance capacity.

Reimagining the public health system today requires not just technological integration but also a renewed focus on equity, decentralisation, and community-led health governance. The task is not simply to build more hospitals or provide more medicines, but to build systems that prevent illness, empower communities, and enable every citizen—especially the most marginalised—to live a healthier life.

Despite this, our health system continues to focus heavily on numbers treated—a metric that paradoxically devalues prevention. For instance, in an outcomes-driven evaluation framework, the officer who reduced illness rates might appear underperforming because fewer patients sought treatment.

Preventive health care requires a multidimension approach focusing on nutrition, sanitation, environmental health, lifestyle risks, and early interventions, yet much of the public system still emphasizes curative services delivered through facilities.

Collaboration with the Private Sector: Uneven Terrain

The discussion critically explored the public-private dynamic, Dr. Murthy shed light on the India’s multi tiered system and the existing grassroot workers.

India’s public health system is massive and multi-tiered:

ASHA workers and Anganwadi workers at the village level;

There is a sub-centre for every 5,000 people and a Primary Health Centre (PHC) for every 30,000 population. These centres typically have a doctor and support staff. In some cases, there are even two or three doctors appointed at the PHC level for a population of 30,000.

Next is the Community Health Centre (CHC) or rural hospital, which caters to a population of approximately 50,000 to 100,000. Above this is the district hospital, followed by medical colleges and speciality hospitals.

So, we essentially have a five-tiered public health system in India. In parallel, there exists an almost equally layered private sector health system. At the village level, there are Rural Medical Practitioners (RMPs) who, despite being unrecognized officially, do provide treatment to people.

There are also pharmacists who dispense medicines directly to people in rural areas, often serving as the first point of contact. Then there are single-doctor clinics, nursing homes, charity or general hospitals, and finally speciality and corporate hospitals.

AYUSH and Local Practitioners: Toward Inclusion

The integration of AYUSH and local providers into the public system has been both organic and policy-driven. Two key developments were noted:

1. Recognition of Rural Medical Practitioners (RMPs): Though unofficial, they were engaged in pilot initiatives for family planning, reporting infectious diseases, and supervised treatment of STIs—especially in hard-to-reach regions.
2. AYUSH Doctors at PHCs: Deployed in supervisory roles, AYUSH practitioners have been gradually mainstreamed, offering both legitimacy and operational relief in an otherwise overstretched system.

These efforts illustrate an attempt to rationalise a fragmented system, and acknowledge those historically excluded from formal medical structures.

Thus, people in India have a wide range of healthcare options. And that’s what makes the Indian health system unique—patients get to choose where to go and what kind of treatment to seek. No one dictates this decision. However, there is very little integration across systems—allopathy practitioners don’t understand Ayurveda, Ayurvedic practitioners aren’t trained in allopathy, and traditional practices remain unrecognized.

This leads us to an important question: Is this truly a “system”? Due to the lack of communication between these stakeholders it is the patient who is left to navigate this complexity, often without guidance. Ideally, one might think that having options is a good thing. But in India, there is no gatekeeping or enforced referral mechanism. Patients bypass the lower levels—like sub-centres and PHCs—and go directly to specialists or hospitals. And hospitals don’t stop them. This leads to overcrowding of the tertiary centres and the primary, secondary level centres go defunct at times.

From an administrative lens, every system is expected to be structured, with clear lines of reporting, control, record-keeping, and regulation. However, our health system doesn’t align with this expectation. Efforts were made to streamline the referral chain—ensuring that patients follow a logical path from sub-centre to PHC to higher facilities. But as the Pune example shows, this top-down system design doesn’t reflect ground realities.

Listening to the People: What Marginalised Communities Expect

Drawing from field interactions, Dr. Murthy emphasized that the reimagination of public health must be rooted in lived experience, particularly that of the most marginalised. She highlighted three core demands:

1. Good Governance and Fair Systems- Communities value predictability, fairness, and competence. As Dr. Reddy has observed, people expect that systems reward effort—not connections. Citing Maharashtra’s experience, she shared how tracking performance based on selected indicators (logistics, punctuality, delivery) and reducing political interference led to enhanced efficiency and accountability.

Simple logistical changes—like scheduling Village Health and Nutrition Days (VHNDs) in distant villages—made services more accessible and timely for frontline workers and beneficiaries alike.

2. Responsiveness

A responsive system solves real problems—not just on paper, but on the ground. This means listening to staff, addressing barriers, and enabling service delivery. If an ANM or ASHA cannot reach a village on time, the system must adapt—not penalise.

3. Respect

Perhaps the most intangible, yet critical expectation is dignity. Poor patients often report humiliation or neglect in public facilities. Dr. Murthy noted that many avoid public hospitals due to perceived discrimination, while they receive better treatment in private facilities where they are seen as paying clients.

ASHAs were initially instrumental in bridging this trust gap, offering emotional support. However, as incentive-based models became more transactional, some of that trust has eroded.

The Three R’s: A Framework for Reimagining

To rebuild trust and accessibility in the system, Dr. Murthy proposed a guiding framework based on the three R’s:

• Responsiveness – Solving real-world problems with empathy and efficiency
• Reliability – Building consistent, accountable systems
• Respect – Ensuring dignity for every individual, regardless of socio-economic background

Social Disadvantage and Caste Bias

One of the more sobering insights emerged from the discussion on caste and class in healthcare access. Individuals from marginalised castes often hesitate to approach public services, fearing humiliation or poor treatment. Ironically, private providers—motivated by revenue—sometimes offer more respectful care.

As one private practitioner in Karnataka candidly remarked, “These poor patients are our bread and butter.” This exposes how economic value can override social stigma, while also raising concerns about ethics and equity.

Gaps in Accountability

While internal mechanisms exist to address workplace misconduct, no robust system currently handles grievances from patients, especially those who feel mistreated or disrespected in public settings.

Even within the system, workers face trust deficits. Sub-centres receive logistical funds, but complicated verification processes and fear of audits deter spending. ANMs and VHSNCs often underutilize allocated funds—not because of negligence, but because the system offers low autonomy and high scrutiny, without adequate support.

Resilience in Crisis, Stagnation in Routine

Despite these systemic issues, Dr. Murthy emphasised that the public health system displays exceptional resilience during emergencies—such as natural disasters or epidemics. The challenge lies in sustaining that same energy in day-to-day operations.

Strengthening the System: Moving Toward Solutions

Dr. Murthy proposed several pragmatic steps to rebuild systems from within:

• Engage CBOs and SHGs in disseminating health information
• Recognise and reward their health-related contributions
• Use video conferencing for remote training and supervision
• Embed daily problem-solving into governance structures
• Support trust-building and transparent fund utilisation

Field Voices: Reflections and Realities

The session concluded with a rich Q&A that brought diverse field insights:

• Learner Shilpa from Alirajpur raised concerns about the absence of adolescent-friendly clinics. Dr. Murthy acknowledged the challenge, noting that adolescent health remains under-prioritised. She cited early attempts in Gujarat that failed due to lack of buy-in. Youth clubs and Nehru Yuvak Kendras were suggested as local entry points.
• Learner Dipti from Prayagraj shared experiences from the Mahakumbh, where referral step-down mechanisms were tested via the RT-BARP portal but saw poor follow-through. ABHA ID systems hold potential, but uptake among doctors remains low.
• A query was raised about private hospitals built on panchayat land, such as Apollo. Dr. Murthy responded that private sector accountability cannot be enforced by health systems alone—it requires legal mechanisms, which often lag behind policy intentions.
• Learner Mahima from Mandla asked how to avoid sending high-risk maternal cases to distant cities. Dr. Murthy responded that “the system must truly want to solve the problem.” Leadership and genuine prioritisation of maternal health, she stressed, remain critical—especially since the issue is still viewed through gendered and bureaucratic lenses.

In Closing: A Call to Reimagine Through Consistent Efforts and Practice

This seminar did more than provide insights; it offered a vocabulary to think anew. The Indian public health system, with all its flaws, remains one of the most complex, vast, and socially consequential institutions in the country. But to reimagine it—means to centre the needs of the poor, respect every body, and hold systems to account. As participants signed off, dispersed across India’s most remote districts, they carried with them not just policy recommendations, but a renewed commitment to care, equity, and courage in public health.

(This lecture note was authored by Dipti Arora, a Praxis Learner from the 2024–2026 cohort, currently placed in Prayagraj, Uttar Pradesh.)