A critique of the policy discourse on primary health care under the Aardram mission of Kerala

Abstract

In 2017, the State of Kerala in India, launched the ‘Aardram’ mission for health. One of the aims of the mission was to enhance the primary health care (PHC) provisioning in the state through the family health centre (FHC) initiative. This was envisaged through a comprehensive PHC approach that prioritized preventive, promotive, curative, rehabilitative and palliative services, and social determinants of health. Given this backdrop, the study aimed to examine the renewed policy commitment towards comprehensive PHC and the extent to which it remains true to the globally accepted ideals of PHC. This was undertaken using a critical discourse analysis (CDA) of the policy discourse on PHC. This included examining the policy documents related to FHC and Aardram as well as the narratives of policy-level actors on PHC and innovations for them. Through CDA we examined the discursive representation of PHC and innovations for improving it at the level of local governments in the state. Though the mission envisaged a shift from the influence of market-driven ideas of health, analysis of the current policy discourse on PHC suggested otherwise. The discourse continues to carry a curative care bias within its ideas of PHC. The disproportionate emphasis on strategies for early detection, treatment and infrastructural improvements meant limited space for preventive, protective and promotive dimensions, thus digressing from the gatekeeping role of PHC. The reduced emphasis on preventive and promotive dimensions and depoliticization of social determinants of health within the PHC discourse indicates that, in the long run, the mission puts at risk its stated goals of social justice and health equity envisioned in the FHC initiative.

Background

The year 2023 marks the 45th year of the Declaration of Alma Ata, signed by the 134 member states of the World Health Organization (WHO) in 1978. The declaration endorsed its commitment towards a primary health care (PHC) approach rooted in human rights, equity and inclusion of communities and social groups, through its clarion call of ‘Health for all by 2000’ (Beard and Redmond, 1979). Through PHC, the declaration aimed to achieve the objectives of equity, universal access, community partnership and unequivocal dismissal of factors that shaped unequal and inadequate access to health care among societies. This was a momentous occasion, given the rare global consensus on the recognition of the basic health needs, especially of marginalized communities (Walraven, 2019). Nevertheless, the rollout of PHC initiatives encountered multiple challenges including powerful countervailing political–economic forces like market-driven ideas of health and limited fiscal capacities of states amongst a host of others (Rifkin, 2018). The support garnered by Selective PHC, a much-diluted version of PHC introduced soon after Alma Ata (Cueto, 2004), as well as the emergence of global philanthropies further muddied the PHC discourse with their emphasis on bio-medicalized and vertically driven health care policies (Rifkin, 2018).

The Astana Declaration on PHC, 2018 came in the backdrop of this failed promise of PHC. The declaration began with the recognition of widening health disparities and newly emerging global health challenges (UNICEF, 2018). It acknowledged the failure of health systems across the globe in tackling the rising burden of non-communicable diseases (NCDs), more so within lower- and middle-income countries (Nandan et al., 2011). Astana, therefore, reaffirmed its conviction in the principles of Alma Ata and comprehensive PHC approaches with emphasis across the spectrum of preventive, promotive, curative, rehabilitative and palliative care. Rooted in the idea of health as a fundamental human right, Astana declared the existing health inequities and differential health outcomes within communities as unacceptable (Walraven, 2019). Unlike previous attempts, Astana closed on a positive note and with a perceptible enthusiasm that the efforts to revive PHC were more likely to succeed this time around (Rasanathan and Evans, 2020). India was one of the signatories to the Declaration of Astana and committed to strengthen its efforts to improve PHC and thereby achieve the goal of universal health care (Kaur, 2018). Drawing inspiration from these global and national calls to PHC, the current study aims to critically examine the recent PHC reforms in the State of Kerala called the family health centre (FHC) initiative under mission ‘Aardram’.

Kerala’s experiment on comprehensive PHC through FHCs

The PHC provisioning in the State of Kerala in India received a massive boost in the wake of a newly elected left democratic front (LDF) government in 2016 (Box 1). The left government ushered in a renewed mandate for health care across the state through the ‘Aardram’ mission in 2017 (Government of Kerala, 2017). The mission was deemed necessary given the growing influence of the for-profit private health sector and its impact on the utilization of the public health sector and health spending in the state. Kerala, once popularly known for its ‘good health at low cost’ models, stood out as one of the states with the highest out-of-pocket expenditure for health in the country (Bhatia, 2015; PHCPI, 2015). Though the state tops the list with the highest density of health care facilities in the country, a major share of these facilities and doctors belonged to the private sector. The result being a dominant private sector that catered to the curative care requirements of close to 66% of households in Kerala (Nair et al., 2017).

The Aardram mission acknowledged the detrimental effects of a strong and competitive private sector for health care provisioning in Kerala. It strongly cautioned against the growing dominance of the private health sector and selective PHC approaches. The mission within its description, therefore, states ‘with the strong emergence of the profit-oriented private healthcare sector in Kerala that seemed to have been gaining increasing popularity among all sections of society, people began to lose faith in the public healthcare system (the Primary Health Centres in this context)’ (National Health Mission, 2020). In its attempt to reverse this trend, the mission sought to strengthen the existing PHC provisioning in Kerala by adopting the principles of comprehensive PHC. (Madore et al., 2018; National Health Mission, 2020). One of the key objectives of the mission, therefore, was to upgrade the existing network of primary health centres across the state to FHCs (Vijayan, 2022). Inspired by the principles of ‘Alma Ata’, the FHC model (Box 2), openly committed to a more robust approach to PHC (National Health Mission, 2020). The new FHCs, therefore, prioritized proactive strategies for preventive, promotive, curative, rehabilitative and palliative care services, and a revised emphasis on social determinants of health (State Health Systems Resource Centre Kerala, 2019).

A critical contextual factor associated with the PHC reform under the Aardram mission is also the political landscape of decentralized local governments in Kerala. Kerala was one of the first states in India to adopt a comprehensive approach towards decentralization, which involved devolution of financial and administrative responsibilities of various departments, including that of PHC functions and functionaries, to local self-government institutions (LSGIs). The elected members of LSGIs in collaboration with the functionaries of local primary health centres, were entrusted with gauging the health needs of its community and implementing strategies to address them. These were facilitated through mechanisms like ‘gramasabhas’ (people’s forum), community-based surveys and preparation of status reports to plan strategies, termed in administrative parlance as ‘projects’, on health and health-related themes (Elamon et al., 2004). Two aspects are of crucial significance here, specifically in the context of the Aardram mission. One is the fiscal space enjoyed by the existing LSGIs and health functionaries to conceive and implement local projects for health (Nair and Naidu, 2016). The second being the administrative space available for LSGIs to try out novel strategies for improving PHC with support from primary health centre functionaries to tackle local health and related issues (Elamon et al., 2004; Varatharajan et al., 2004).

Policy discourse and its role in shaping ideas and social practices of PHC

The current FHC initiative under the Aardram mission, therefore, gathers significance owing to the conjuncture of two critical dimensions. First, the renewed political rhetoric towards comprehensive PHC through the mission. Secondly, the mission’s embeddedness within the existing political context of decentralized local governments in Kerala, as LSGIs were envisioned as the key implementing partner for the mission at the grassroots level in the state (Health and Family Welfare Department—Government of Kerala, 2017). The mission’s dependence on LSGIs to strengthen PHC provisioning thus aligns itself with the existing political and administrative autonomy for LSGIs to implement innovative PHC strategies. Therefore, the success of the Aardram mission depends heavily on the capacity of the LSGIs and primary health functionaries across the state to devise appropriate and novel strategies to tackle their local health challenges (Government of Kerala, 2021).

We believe this capacity of LSGIs and primary health functionaries are contingent also on how the existing policy discourse on PHC—expressed through the Aardram mission and the narratives of policy level actors—ideologically influence and shape the social practices of PHC by the LSGIs and grassroots-level health functionaries. It is, therefore, crucial to critically examine the rearticulated vision for PHC in Kerala that came into existence through the Aardram mission, by closely examining how the current health policy discourse in the state discursively defines PHC and related innovations. In so doing, we aim to shed light on the mission’s potential to achieve its aspirations, specifically in terms of addressing health inequities and social justice through novel PHC projects by the LSGIs in Kerala.

Materials and methods

Health policy and systems research has over the years gained much in terms of its analysis of power from disciplines like social sciences and linguistics, in particular the analysis of power and its manifestation within health policies and systems across three crucial dimensions. One, power within actor relations and networks, two, diverse sources from which individuals or groups draw power, and the third, in the flow of power and how it is expressed within the context of health policy and systems The current study builds on this third dimension of power, a Foucauldian view of power which is ubiquitous and spread across various social practices and not something accessed only by individuals or groups. Power in this form lays down the conditions for a social world and the ways of talking about it, while simultaneously ruling out alternate narratives of existence and seeing (Foucault, 1977; Jorgensen and Phillips, 2002). Conceptualising power from this dimension, therefore, allows examination of how prevailing ideologies influence and shape health policies and systems, and, more crucially, the potential of such ideology-laden discourse within health policies to shape a collective understanding of what is agreed upon as normal or possible by the system and thereby engender health (in)equity (Topp et al., 2021).

Critical discourse analysis

One of the ways to discern how dominant ideologies express themselves through spoken words and texts and shape a collective idea and consequently shape social realities is by using critical discourse analysis (CDA). CDA enables one to seek beyond what is written or spoken and bring out hidden yet implicit assumptions within discourse. It allows researchers to dive deeper into the underlying assumptions and hidden meanings beneath ‘well-intentioned’ policies and associated policy narratives. (Evans-Agnew et al., 2016). Such an analysis is achieved through the examination of complex yet subtle relationships between power, dominance and control and their manifestations through language and its use to normalize oppressive structures and their role in shaping social realities (Wodak, 2013).

CDA as a methodology also allows critical examination and reveals ‘misrepresentations’ or ‘mismatches’ between the way a concept or idea is intended to operate ideally and how it exists in reality (Jorgensen and Phillips, 2002). Drawing from this, the current study attempted to highlight the alignments and misalignments between the discursive construction of PHC and innovations for it by the existing policy discourse and the globally accepted notions of PHC (World Health Organisation, 2021). By extension, such an analysis is expected to shed light on what may be missing, under-represented and/or dominant within the PHC policy discourse in the state, and is considered crucial in this case as the existing policy discourse also hold the power to shape as well as set boundaries for future PHC projects and innovations by various LSGIs and thus their ability to achieve socially (un)just and (in)equitable health outcomes for communities.

The data needed for CDA were collected from two key sources—through in-depth interviews of the health officials and available documents related to the Aardram mission and FHC. The interviewee participants were selected such that they represent the most senior staff within the department of health, Government of Kerala. These included people who hold the power to shape policies as well as set the tone of various grassroots-level PHC strategies and innovations in the state. Interviews were conducted with 14 individuals chosen from the Directorate of Health, Government of Kerala, District Medical Officers, and District Programme Managers under the National Health Mission. In addition to the interviews with policy actors, policy texts on the Aardram and FHC initiative were also included as part of the CDA. The document on the FHC initiative was sourced from the office of Kerala State Health Systems Resource Centre, Thiruvananthapuram. Documents related to the Aardram mission were sourced from the official websites of the Department of Health and National Health Mission-Kerala (Table 1).

To perform the CDA, we specifically extracted the areas of text that described the ideas related to PHC within formal policy documents and policy actor narratives. In addition to this, texts representing the ideas related to PHC innovations from within policy actors’ narratives were also examined. The final material for CDA was prepared through the process of transcribing and translating recorded interviews of senior health staff from Malayalam to the English language and importing them to NVivo^TM. In addition, the Aardram policy document and related documents were also imported to NVivo^TM. The compiled body of text was then analysed for: (1) the inclusion, exclusion and/or dominance attributed to the key constructs that constitute PHC (preventive, promotive, curative, rehabilitative, palliative and social determinants); and (2) how the included PHC constructs are ‘represented’ within formal policy texts and through the spoken words of policy actors.

Results

The policy discourse on PHC was critically examined for two key attributes—firstly, whether it accommodates the complete spectrum of PHC, i.e. preventive, promotive, curative, palliative and rehabilitative, and secondly, the nature of PHC strategies and innovations considered desirable at the level of LSGIs. The CDA suggests subtle yet crucial gaps between the health system’s claim of comprehensive PHC and how it is ultimately represented both within the Aardram mission and associated policy actor narratives. It was apparent that the mission aims to move away from the grips of the private health sector and its curative care bias through comprehensive PHC modalities. Yet the discursive construction of PHC within the policy fails to shrug off its tendency to prioritize curative care strategies. This discrepancy demands urgent attention and problematization as it potentially poses a challenge to the achievement of the larger goals of equity and social justice envisaged within the Aardram mission and FHC initiative. The analysis of the discourse points to three major interrelated themes that dominated within the comprehensive PHC narratives examined: (1) dominance of early detection and treatment strategies; (2) disproportionate priority attributed to infrastructural improvements; and (3) a ‘sanitised’ discourse on social determinants.

Dominance of ‘early detection’ and ‘treatment’ strategies

Reduced priority to preventive and promotive aspects of comprehensive PHC

The key strategy of the FHC initiative under the Aardram mission is ‘strengthening PHC’ through activities that are aimed at promotive, preventive, curative, rehabilitative and palliative services (Box 2). This includes activities like registration of individuals and families and their health information with the local FHC to facilitate timely and appropriate planning of preventive and promotive activities for both communicable diseases (CDs) and NCDs, as well as strengthening access to quality primary care through well-equipped sub-centres. The promotive and preventive components for ‘strengthening PHC’ include activities like preparing health status reports (HSR) of villages by the LSGIs supported by primary health functionaries. The HSR activity aims at facilitating the needs assessment under the FHC initiative and envisions the collection of crucial information in terms of specific family needs and those related to ‘social determinants’ to plan appropriate promotive and preventive activities by LSGIs (Box 3).

Expectedly, ‘need assessment’ and ‘health status report’ were also some of the key phrases that were repeatedly co-located in the narratives on PHC innovations among policy actors. However, careful examination of this ‘need assessment’ discourse of policy actors as well as what happens in the name of ‘need assessment’ points to the conflict between what is envisioned and what transpires operationally. The policy actors’ idea of ‘need assessment’ suggests an exercise limited within the boundaries of measuring disease ‘prevalence’. These include the collection of data regarding the prevalence of CDs and NCDs as well as information related to other service beneficiaries including pregnant women (Box 4). Though a critical exercise, such an idea of ‘need assessment’ among policy actors and the existing ways of undertaking it by LSGIs points to a narrower interpretation than what is envisaged in the FHC document. The needs assessment within the policy document encompasses a broader idea of capturing details beyond disease numbers, including dimensions related to social determinants. Potentially, these could have involved gathering information on more upstream factors like ‘distribution’ and ‘access’ to determinants (water, sanitation, etc.) and how they may vary between social groups. However, the policy actor’s idea of measuring diseases after their occurrence to provide curative care falls under the classical definition of ‘secondary prevention’ limited to early detection and treatment (Kisling and Das, 2022). By extension, the policy actor narratives demonstrate a significant deviation from the mission’s expectations and the ideals of comprehensive PHC and how the mission stands to be achieved through the interventions by LSGIs in the State.

PHC innovation discourse driven by the emphasis on early detection and treatment

The idea of primary health care equated to early detection of diseases and provision of good quality curative care was also reflected in the way policy actors shaped their views on what constituted innovations for PHC by LSGIs. There existed a discernible urgency among policy actors to prioritize strategies that facilitated primary health centres in measuring prevalences and providing services to reduce local disease numbers. Thus, actions following the compilation of HSR by LSGIs tend to include mostly, screening camps, facilitation of improved supply of medicines for chronic diseases as well as provision of speciality clinics at a primary care level (Box 5). A clear pattern is emerging in terms of strategies that begin with improved disease detection followed by the provision of quality curative care through improved medicine supply and speciality care at a primary care level.

Disproportionate priority attributed to infrastructural improvements

Although the mission in parts emphasizes the preventive and promotive dimensions of comprehensive PHC, the ways in which it seeks to operationalize it remains ambiguous at best. The ambiguity exists not only in the policy statements but also within the policy actor narratives. Despite the larger aim of achieving comprehensive PHC, the mission pivots on infrastructural improvement as its operational strategy to achieve the transition from the primary health centre to the FHC model. The policy openly asserts infrastructural and administrative improvements as one of its main strategies to achieve the objective of comprehensive PHC. By converting existing primary health centres into FHCs with better infrastructure, the FHC initiative is, therefore, imagined as a viable alternative to private health care facilities in the state (Box 6).

A closer examination of the strategies within the mission document also suggests this pattern. The four key strategies of FHC are: (1) strengthening PHC; (2) improving the quality of services; (3) addressing social determinants of health; and (4) community participation. However, analysis of the strategies and associated activities reveals the rather subdued priority of preventive, promotive as well as social determinants dimensions. Though the document aspires to address social determinants, the detailing of the strategies to address them remains generic in comparison to those on curative and infrastructural domains (Box 2). Further analysis of the policy document for activities on social determinants also points to the relatively low priority attributed to social determinants aspects of PHC, e.g. discussion on the social determinants covers fewer than 3 pages in the 140-page policy document on the FHC concept (State Health Systems Resource Centre Kerala, 2019).

The narratives on innovation among senior policy-level actors too demonstrate a similar tendency to disproportionately link the idea of infrastructural improvement with perspectives on innovation for PHC (Box 7). These were reflected in their affinity to perceive infrastructural additions that improved facility-based ‘primary care’ provisioning as innovations, like procuring newer devices as part of the existing NCDs, palliative care, and mother and childcare programmes by various FHCs. Narratives like providing ‘innovative’ services using fetal heart monitors to attract more pregnant women to visit the subcentres arguably also harken back to the selective PHC era that prioritized maternal and child health. Tendency to prioritize infrastructural improvements also included strategies like providing facilities at the FHC like airconditioned waiting halls that matched the amenities provided at for-profit private sector hospitals in the state.

To reiterate, the intent here is in no way to dismiss or disregard the possible impact of the mission through initiatives that aim to strengthen an already over-burdened PHC system. In fact, the mission can have a positive impact by improving the availability of an infrastructurally strong primary care system to the community. It is also beyond contention that comprehensive PHC includes strategies for improving secondary prevention through effective screening and quality curative care. Nevertheless, in the urgency to prioritize strategies that improve access to medicines, curative services and infrastructural improvements, the mission and related policy discourse tends to miss out on other critical dimensions of PHC. It remains silent about the causative dimensions of diseases, disparities in health outcomes across groups and strategies needed to address them. This silence is apparent in the lack of references within the discourse around strategies aimed at tackling the various forms of inequities in the state shaped by caste and gender identities or through their intersections.

‘Sanitized’ discourse on social determinants

The policy discourse on social determinants, including the FHC document and policy actor narratives, mostly equated the idea of ‘social determinants’ with that of access to drinking water, sanitation, hygiene etc., which may be more appropriately called ‘basic determinants’ of health. This is reflected in this case through policy actors’ assertions that allude to their perspective that strategies to address ‘social determinants’ like drinking water and waste management can almost completely prevent communicable diseases (Box 8).

Similarly, the words social determinants appear 33 times within the 140-page FHC document. However, not once does it differentiate between the idea of basic health determinants and social determinants. The policy also refers to marginalized and vulnerable groups 13 times within the document. However, nowhere does it try to locate the idea of access to health determinants in the context of the marginalized or vulnerable social groups in the state. Similarly, neither does it speak about the possibility of differential distribution of basic determinants due to social causes across various groups, specifically among the socially and economically vulnerable sections in the state.

This discourse on social determinants remains reductionist and problematic on two counts. First and foremost, they erroneously equate two very distinct concepts, that of ‘basic’ or ‘immediate’ determinants with ‘social’ determinants of health. This is a deviation from the accepted definitions of social determinants globally, which discuss the existence of larger societal, political and economic factors that dictate differential access of basic determinants to diverse social groups. Consequently, the policy creates a discourse that equates ‘social determinants’ with ‘basic determinants’ like water, sanitary conditions etc. and their availability to communities in general. By failing to recognize the existence of possible disparities in the distribution of health determinants between social groups in the state, it mainstreams a de-politicized social determinant discourse. One that is shorn of the ‘social’ dimension, which could potentially have wider ramifications in terms of the achievement of the larger goals of health equity through the comprehensive PHC reforms envisaged for the state.

Discussion

Kerala’s Aardram mission articulates an intent to revive PHC provisioning in the state and move away from the grip of a market-driven private sector. However, we argue that despite this stated intent it continues to reflect an ideology that is arguably shaped by the same market-driven ideas about health and health care. This discrepancy between stated intent and operationalization follows a pattern noted in other initiatives to evolve alternatives to and challenge the market-oriented approaches to health and health care. These include experiments like the Latin American Social Movements, termed as ‘post-neoliberal’ health care reforms. These were championed by the political left as they sought to address the widening social inequalities, following sustained neoliberal regimes, specifically within the realm of public health care (Hartmann, 2016; Sánchez and Polga-Hecimovich, 2019).

However, a drawback that constrained the post-neoliberal shift was the persistence of neoliberal rationalities within policies that attempted to challenge the same. These experiments failed to fully assimilate the ideas of social medicine and were characterized by the incomplete rejection of the neoliberal tendencies within health care (Hartmann, 2016). The current policy discourse on PHC and related innovations in Kerala too suggests a similar issue. The Aardram mission was vocal in its emphasis on comprehensive PHC and social determinants of health. However, it fails to completely shrug off the neoliberal influences within its discursive construction of comprehensive PHC. A good frame of reference we adopt is the Foucauldian assertion that ‘not everything is bad, but that everything is dangerous, which is not exactly the same as bad’ (Dreyfus and Rabinow, 1982). The idea, therefore, is not to argue that Aardram mission and its strategies are self-evidently good or bad but to shed light on the unanticipated yet predictable dangers within its approaches.

A central theme of relevance here would be the historical context that warranted the emergence of PHC modalities and therefore the significance of its gatekeeping function. The gatekeeping function allows PHC to limit the dependence on specialist care and reduce the overburdening of secondary care facilities. This function enables the PHC modalities to effectively use limited resources and further its goals of health equity through prioritizing actions related to socio-economic factors affecting health (WHO Evaluation Office, 2019). Nevertheless, the Aardram mission and related discourse on PHC seem to give undue predominance to curative care rationalities, a digression from the gatekeeping function within PHC. The contention here is not so much the importance of curative care in the health care landscape of Kerala as the over-reliance on it, particularly within a discourse on PHC. Without sufficient emphasis on supportive strategies to address social determinants of health and subsequent preventive and promotive dimensions, strengthened detection and curative care can only heighten the strain on existing primary and secondary care facilities. In doing so, they also maintain a resemblance to the individual-centric curative care priorities on health of the private sector (Hartmann, 2016).

The emphasis on the counting and reduction of disease prevalence numbers is also reflective of the predominance of ‘managerialism’ within modern neoliberal development discourse. This emphasis reflects a tendency to reduce elements of public services (PHC in this case) as something to be managed using numerical indices. Health administrators within this rationality are ‘managers’ trying to validate their purported effectiveness through the reduction of invented numerical targets. They are echoed here through the emphasis on early detection and treatment strategies and the aspiration for facility-based speciality services and infrastructural improvements to reduce disease prevalence. However, the fallacy within managerialism is its disconnectedness from the actual substance of the activity they are entrusted with. In this case, the disconnectedness from the objective of health equity through PHC, by falsely equating disease prevalence numbers as proxy indicators of the overall health of the community. Through the primacy of numerical targets, managerial rationales, therefore, remain incapable of engaging with the question of their effectiveness to achieve the real intended goals they envision (Sivaramakrishnan, 2012). Such managerial rationales born out of individualized, illness-driven ideas of health care, therefore, can have a bearing on the larger goals of a PHC approach like social justice and equity. The separation of health and illness from its larger social contexts comes at the cost of leaving the possibilities of providing comprehensive, integrated, community-driven PHC unaddressed. Missing within these medicalized notions of PHC are also the crucial dimensions of population-based protective, preventive and promotive aspects of care. By extension, they risk engendering grassroots-level primary health care services that are anything but equitable, without ever engaging with and providing a counter to the societal determinants of health (WHO, UNICEF, 2018).

At one level the Aardram mission’s PHC discourse puts forward a holistic approach by invoking attention to social determinants. However, the way it is used within the current policy, as against the interpretations in the international literature, points to what may be referred to as a ‘buzzword’. Buzzwords are words that largely combine clandestine performativity without a real intrinsic definition and yet inspire strong belief in an aspirational idea (Rist, 2007). The ‘social determinants’ concept within this policy discourse can also be argued to possess the attributes of a buzzword. The accepted interpretation of social determinants demands the embeddedness of ‘basic determinants’ within the larger social, economic, political and environmental contexts, thus warranting coordinated efforts from different sectors of government (WHO, UNICEF, 2018). However, by erroneously equating ‘social determinants’ with ‘basic determinants’ of health they bear no resemblance to the globally accepted definitions of the same.

The current policy discourse on ‘social determinants’ thus obfuscates the existing reality of social origins of disparities in the distribution of basic health determinants within the state. It thus maintains a perilous silence about the historically shaped unjust social hierarchies and subsequent disparities in resource distribution and resultant health inequities operating through the intersections of caste, gender, class and/or religion in Indian contexts (Raphael, 2006; Baru et al., 2010; Scaria, 2017; Mahapatro et al., 2021). Through the disavowal of these social dimensions of health disparities, the ‘social determinants’ narrative within the mission serves merely as a policy ‘buzzword’ that is vague yet unavoidable within any modern PHC discourse. No matter how vague it appears it still remains powerful enough to facilitate ‘inside’ agendas, thanks precisely to its ambiguity (Cornwall, 2007). This ambiguity holds power to shape the social practices of PHC and related innovations that are blind to health inequities shaped by the axes of caste, ethnicities, class, gender, religion etc. at the grassroots in Kerala.

The impact of the mission is also quite tangible in the state today, reflected through the current primary health infrastructure across Kerala. FHCs in the state are marked by their attractive paint schemes, air-conditioned patient-waiting areas, modern furniture, television and internet connectivity (National Health Mission, 2022). Indeed, this is a welcome change and a landmark in the primary care landscape in the state. The FHC initiative can be considered to have provided the much-needed jump start for improving primary care delivery in the state through better patient amenities and better human resources for health. In addition, the FHCs have improved patient access through longer working hours and deployment of adequately trained health care staff, resulting in improved footfall at FHCs in the state (Krishnan and Nair, 2021). Yet, studies suggest that despite Kerala’s developmental achievements (OXFAM India, 2021) deeper disparities continue to persist within various sectors including schooling, nutrition, salaried jobs, drinking water and practices like open defaecation among Dalit and Aadivasi households (World Bank Group, 2017; Thresia, 2018; Kothari et al., 2019). Such a development paradigm is increasingly argued to be riddled with structural inequities driven by caste, gender, ethnic status and economic class. All of this has invariably translated as persisting inequities in the distribution of health outcomes among various underprivileged social groups in Kerala, and Dalits in particular (Thresia, 2018).

Such individualistic approaches to PHC, blind to the preventive, promotive dimensions and societal determinants of health, invariably demonstrate their parallels with the neoliberal ideas of development, including poverty, that are driven from an exclusively individualistic level. Such ideas around poverty invoke individualistic notions and focus on the individuals’ character and the various biological, racial and ethnic aspects that ‘made’ them poor. However, such an endeavour completely ignores the analysis and exploration of various class relations and social power structures that determine outcomes like poverty or health at a larger level (Hänninen et al., 2019). The question, therefore, is whether we can anymore afford the luxury of having newer policies and strategies that miss out on the opportunity of addressing chronic historical inequities that persist amongst us? This question is pertinent, given the ample evidence of growing inequalities in Kerala among various social groups, both in terms of access to basic health determinants as well as health outcomes, despite the achievements (Thresia, 2018).

Conclusion

While critical of the Aardram mission, this paper does not aim to diminish the significance of the attempts to rejuvenate a flagging public system as an alternative to the market-driven private sector. It also merits applause given the emphasis on comprehensive PHC as the strategy to achieve its goal of strengthening the public health system. However, for a policy that openly commits to the ideals of social justice and health equity, it is imperative to have a clear acknowledgement of the existing gaps and a roadmap in terms of how it envisions to overcome them. These include identifying the existing inequities within health care provisioning as well as in the larger power structures and social hierarchies that shape health disparities within the population. The current bias towards early detection and curative strategies and its reductionist approach to social determinants within Kerala’s primary health care discourse, therefore, remains deeply dangerous. Through its emphasis on attractive infrastructure and good-quality facility-based care, the mission evidently risks limiting itself to being an imitation of the very private health sector it seeks to replace. The idea that PHC should extend beyond facility-based care seems lost within these notions of PHC innovations and contradicts the premise of the comprehensive approaches envisioned through Alma Ata and Astana Declarations. This remains detrimental to achieving its goals and calls for immediate attention and course corrections.

Acknowledgements

The authors would like to acknowledge the support and guidance received from Dr Rakhal Gaitonde, Professor, Achutha Menon Centre for Health Science Studies, Thiruvananthapuram, Kerala. Dr Gaitonde provided valuable guidance in terms of conceptualizing key concepts of critical discourse analysis, structuring the findings from the study and language editing, without which this current study would not have been complete. We also thank our colleague Dr Harisankar D for his reflections and support in language editing of the manuscript. Above all, we would like to thank the respondents in the study for their time and willingness to be part of the study.

Reflexivity statement

The principal investigator is a male doctoral research fellow from a middle-class background and the second author is a woman and a retired professor of public health and the doctoral research guide of the principal investigator. We strongly believe that our research has greatly benefitted from our social identities as belonging to privileged caste backgrounds and supported also by the reputation of the institute where the research was based; this included the otherwise difficult task of getting time and willingness from senior officials from the Department of Health in Kerala to participate in the study. We also realize that biases drawn from our privileges could have crept into the conceptualization and analysis of such a study. While it is impossible to fully avoid such biases, we have made our best efforts to overcome this by deliberately and consciously anchoring the research from an equity and social justice lens, specifically for the underprivileged social groups in Kerala, which primarily drove this specific exploration of the policy discourse on primary health care.

Ethical approval

Ethical approval for the study was obtained from the Institute Ethics Committee at Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala. The study was cleared by IEC vide SCT/IEC-1355/FEBRUARY-2019.

Funding

No funding was received to conduct the research.

Conflict of interest

None declared.

References