Public health policies, like other public policies, are crucial in determining the overall health of the population and are an important contributor to a nation seeking to reap the benefits of its demographic dividend. One of the major claims of health policies in recent years has been the achievement of universal health coverage (UHC), a novel idea that seeks to ensure that every individual has access to needed health services without suffering financial hardship. Yet, populist ideas often dominate public policy despite evidence to the contrary, as seen in the case of publicly funded health insurance schemes. The changing nature of public health policy in recent years is particularly concerning, not only because it has often failed to be evidence-based, but also because of its inability to guarantee even minimal health benefits to the population.

More troubling is the failure of public health policies to improve access to health care at a time when such access is deteriorating significantly owing to rising costs in the private sector and poor quality in the public sector. Two recent government initiatives — the Ayushman Bharat Health and Wellness Centres and the Digital Health Mission — illustrate these inadequacies.

The interpretation

The Ayushman Bharat Health and Wellness Centres, introduced as a policy initiative in 2018, were intended to strengthen health infrastructure. What eventually happened, however, was that the names and identities of grassroots-level institutions — namely, the health sub-centres (SCs), primary health centres (PHCs), and community health centres (CHCs) — were altered by mandatorily adding “Health and Wellness Centre” as a prefix. The identity of these grassroots institutions and their mandates have evolved over time based on their roles within the district health system. The use of a common prefix has created considerable ambiguity among health professionals and policymakers regarding their actual mandate. Another consequence of the “health and wellness” approach has been a shift in focus from population health outcomes to individual well-being. The major challenge in using well-being as an outcome measure lies in the elusive and subjective nature of the concept itself.

A historical inquiry into the concept of wellness reveals that it was initially used to denote the absence of disease and was often contrasted with illness. It was also frequently used interchangeably with health. During the 1950s, the wellness movement popularised the idea of positive well-being by conceptualising health beyond its biological dimensions. The mental cure model similarly emphasised the psychological and spiritual aspects of healing. Influenced by these developments, the World Health Organization (WHO) defined health as not merely the absence of disease, thereby promoting the notion of positive well-being. Over time, wellness expanded beyond physiological health to include mental, spiritual, social and environmental dimensions, offering a more holistic understanding of health. In public health, however, the emphasis shifted towards health promotion — a population-based approach that recognises how social, economic and environmental conditions shape people’s ability to adopt healthy behaviours.

Another reason for preferring health promotion over wellness was the greater rigour and feasibility associated with measuring the former. There are no universally accepted measures of well-being at the population level, as the concept is inherently individualistic and deeply subjective. Unlike health promotion, the concept of wellness places the primary responsibility on individuals, assuming that they possess the capacity and opportunity to modify their health-related choices. In doing so, it often underestimates the structural and social determinants that shape health outcomes.

The individualisation of health

The shift from population health status to individual well-being is a consequence of the changing wellness narrative brought by the public health policy. The implication is that health status, which was previously assessed through unmet needs in preventive, promotive, curative and rehabilitative care — including access to basic services such as drinking water, food and nutrition, chronic disease management, emergency care, and maternal and child health services — is increasingly being replaced by the aspiration to achieve individual well-being. This shift in focus has contributed to the rise of health coaches and the proliferation of social media messages promoting individual well-being, often under the banner of public health.

When health outcomes are framed primarily in terms of individual well-being, there is a risk of failing to systematically capture a wide range of unmet health needs that remain significant for the population. The broader narrative increasingly suggests that the achievement of individual well-being is the ultimate objective of health and wellness centres. This presents a serious challenge. As the well-known principle in management states, “If you cannot measure it, you cannot improve it”. Given the inherently subjective nature of well-being, an excessive policy focus on this outcome may undermine the ability to evaluate health systems effectively and address concrete deficiencies in health care access and service delivery.

Another major public health policy initiative of recent years is the Ayushman Bharat Digital Health Mission (ABDHM), whose principal objective is to create a digital repository of health information for every individual through a unique health ID, known as the ABHA card. In addition, the mission seeks to maintain registries of health facilities, health-care professionals and information related to health insurance. However, an information portal containing health records and details of health infrastructure cannot, by itself, address the challenges posed by inadequate access to health care. Nor does it justify the annual budget of around ₹300 crore to the ABDHM in the absence of measurable outcomes.

Factors behind inadequate access to care

It is well established that inadequate access to health care in India stems from the unaffordability of care in the private sector and the lack of quality health-care facilities in the public sector. Merely creating databases of individual health records, health facilities and health-care professionals cannot improve access to health care. If the argument is that information is the first step towards strengthening the health system, there exists a substantial body of reports and datasets that provide such information.

The more pertinent question is how information contained in an individual’s health record, through an ABHA card, can guarantee access to health care when health-care infrastructure remains grossly inadequate and unaffordable for large sections of the population. Even if every individual in a district possesses an ABHA card and all health facilities and health-care professionals are digitally mapped, the delivery of health care still requires a robust institutional mechanism. Unfortunately, the ABDHM, as currently designed, has little to say about the provisioning of care. It primarily generates information on individuals, facilities and health-care professionals, all of which continue to operate largely in silos.

It is therefore difficult to identify a compelling public health rationale for this scale of data generation. What is missing from current policy initiatives are concrete measures to strengthen public health-care institutions, as envisaged under India’s three-tier health-care system. Instead, these institutions continue to weaken in many parts of the country.

For most people, access to curative care constitutes an immediate and pressing need. Only after these basic health-care requirements are met can individuals meaningfully engage with preventive and promotive health interventions. When public health policies fail to recognise people’s felt needs, they risk becoming mere vehicles for advancing the priorities of policymakers and health-care providers rather than addressing the actual concerns of the population.

Mathew George is Professor with the Department of Public Health Sciences, Central University of Kerala, Kasaragod, Kerala. The views expressed are personal