Beyond Blueprints: Health Reforms from the Ground Up

Why decentralization and community engagement are key to delivering Universal Health Coverage in India.

- Himani Sethi , Global Director, Programs, ACCESS Health International

Universal Health Coverage (UHC) is often envisioned through neat diagrams- cascading hierarchies of authority, uniform implementation pathways, and seamless scale-up. But the reality of health reforms in India, especially when implementing flagship schemes like the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY), tells a different story. It’s shaped by local contexts, leadership, institutional histories, and the quiet resilience of state systems navigating complex terrains.

ACCESS Health International, is privileged to be part of the implementation journey of the Ayushman Bharat reforms in Uttar Pradesh. We have learned that the success of large-scale health initiatives does not rest solely on the strength of central blueprints. It rests on how well those blueprints are adapted, internalized, and innovated at the ground level. While the standardization of the implementation process is good—even indispensable—success lies in localized adaptation through user-centric approaches.

To summarize, UHC succeeds when it is decentralized—not just in design, but in spirit.

The Comfort of Uniformity

There’s a common, if unspoken, belief in health policy: national programs should look more or less the same everywhere. The idea of “uniform implementation” is surely appealing, for it suggests control, comparability, and ease of evaluation. But India’s vast diversity—across geographies, institutions, and human capital—makes uniformity not just unrealistic, but counterproductive.

India is a federal system, and health is a state subject. And central initiatives negotiate this federal reality to be effective. Each state begins from a different baseline. Rolling out an identical approach often stretches local systems too thin and results in schematic compliance rather than deep reform.

Our implementation support for AB PM-JAY has made this evident. The state of Uttar Pradesh swiftly established foundational governance protocols, decentralized implementation teams, invested in capacity building, and engaged the private sector to enhance service availability and access. It also began developing mechanisms to use data for informed decision-making. In doing so, the state translated national guidance into meaningful, context-specific implementation.

Community Engagement as System Glue

Decentralization unlocks state-level innovation, while community engagement anchors reforms in the lived experience of people. Programs like AB PM-JAY are built for citizens, yet when people are not actively involved in shaping, monitoring, or even understanding these schemes, implementation can feel disconnected. In Uttar Pradesh, building trust via health camps, IEC drives, and grievance redress mechanisms has helped improve uptake and accountability.

When communities are treated as co-creators instead of as passive recipients, they become the most powerful feedback loop in the system. State helplines played a proactive role by reaching out to citizens and supporting them in accessing care.

Institutions like the Village Health, Sanitation, and Nutrition Committees (VHSNCs) were designed for this purpose under the National Health Mission; however, their connections with new-age schemes need to be strengthened. Reinvigorating and integrating these platforms can bridge the gap between policy and practice and between intention and impact.

As the High-Level Expert Group on UHC (Planning Commission, 2011) noted: “Community participation ensures accountability, enhances utilization, and helps tailor services to local needs.”

Our experience echoes the work of the Lancet Citizens’ Commission on Reimagining India’s Health System, which stresses the importance of “context-specific institutional strengthening to advance UHC, recognizing the asymmetries in state capacity.”

Even the Ayushman Bharat Digital Mission (ABDM) has embraced a federated architecture, allowing states to adopt and scale at their own pace—thus, implicitly acknowledging that a standardized vision does not need standardized methods.

Other states, too, have adapted national programs creatively. For instance,

• Tamil Nadu’s drug procurement model influenced national logistics strategies

•Gujarat’s claim processing systems enhanced AB PM-JAY efficiency

•Himachal Pradesh leveraged a robust Primary Health Care network for remote access

•Kerala institutionalized multi-sectoral coordination for health delivery

Each example demonstrates that local ingenuity, not uniformity, drives reform.

From Blueprint to Compass

At ACCESS Health, we support states by co-developing fit-for-purpose processes. Bypassing the cookie-cutter approach, our services include:

•          Embedding technical support teams in state health agencies

•          Translating policy into local workflows and tools

•          Creating dashboards that evolve with user needs

•          Demonstrating implementation models that solve structural issues

•          Empowering health workers to adapt, not just implement

It’s patient work that makes reforms stick.

To deliver on the promise of UHC, we must re-envision decentralization as collaboration, not loss of control. Health reforms don’t fail when central blueprints aren’t followed to the letter. They fail when we mistake procedural fidelity for systemic transformation.

In Uttar Pradesh, Ayushman Bharat has shown what’s possible when national ambition meets local adaptation. From expanding access to care in underserved areas to strengthening health infrastructure—these achievements underscore the power of collaborative implementation.

The real question isn’t “How do we implement UHC?” It’s:

“How do we create the conditions for UHC to take root in different soils, with different seeds?”

The answers will vary. The results will yield systems that listen, learn, and highlight local communities; as well as those that build on the unique strengths of each state. This is a call to design with more room for variation, more trust in local actors, and more humility about what meaningful change demands.

If we want UHC to be real in people’s lives, we must adapt the blueprints and begin from the ground up.

Join the conversation: What lessons have you learned from decentralized implementation in your work? What models of community engagement or state-level innovation have moved the needle?