Policy implementation in practice: a praxiographic exploration of health workers in India's national primary health reforms

Thesis Advisory Committee

Prof. Rama Mohana Turaga (Chair person)
Prof. George Kandathil (Member)
Prof. Rakesh Basant (Member)
Prof. Dileep Mavalankar (Member)

Policy reforms in developing countries are increasingly shaped by New Public Management (NPM) principles, emphasizing technological integration, contractual employment, and performance-based compensation, with the goal to enhance public service delivery. The Indian government's Ayushman Bharat (AB) initiative, aimed at providing comprehensive primary healthcare, represents one such NPMdriven reform. Situated within the NPM literature, this study examines the intersection of policy reforms and frontline implementation practices. Focusing on the transformation of health sub-centres into Health and Wellness Centres (HWCs), it explores how these reforms shape the everyday practices of frontline health workers. While existing research on HWCs addresses systemic challenges and workforce performance, it largely overlooks the perspective of frontline health workers, who are critical to the successful implementation of the policy.. This study adopts a "practice-based approach" (Bartels, 2018) as the theoretical lens to analyze the implementation of the AB-HWC policy, focusing on the everyday practices of health workers at HWCs as the unit of analysis. Based on 14 months of ethnographic fieldwork, it integrates participant observations, in-depth interviews, and policy document reviews to generate rich qualitative data. Using Straussian grounded theory as its analytical strategy, the study investigates how health workers at HWCs interpret, engage with, and adapt policies within their specific contexts through their daily practices. The analysis uncovered pathways of practice that map the progression and adaptation of health worker practices in response to specific events and contexts, offering a nuanced understanding of policy implementation processes. Community Health Officers (CHOs) and Accredited Social Health Activists (ASHAs), as temporary contractual workers, demonstrated substantial practice adoption and adaptation over time, navigating new responsibilities and aligning with directives from higher authorities. In contrast, permanent health workers adhered to established practices, displaying limited adaptation to policy changes. This divergence is theorized through precarity within critical NPM literature, extending beyond structural aspects, which dominates current scholarship, to emphasize relational dimensions influencing practice variations across employment types. By highlighting the interplay between employment conditions and relational experiences of precarity, the study sheds light on the differential responses to policy directives among frontline health workers. It also elucidates the theoretical and practical implications of policy interventions, contributing to the broader understanding of policy implementation in public organizations.