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Policy capacity and effectiveness are two themes that have opened new pathways for academic and empirical enquiry throughout the policy sciences. In the contemporary discourse of policy design, effectiveness has taken on a more foundational meaning that goes beyond what is understood as only the attainment of specific policy goals. Rather, it has come to occupy a central position in the study of policy design, signifying the broader logic of deliberate policy action used to articulate policy problems and present alternative ways of addressing them. Effectiveness thus signals both effectual processes as well as successful policy outcomes. However, what constitutes effective design is a question that still reflects a largely dispersed body of research within the policy sciences. This article and others in this special issue, aim to address the topic of effective design from the perspective of capacity, defined as the inherent analytical, managerial and political capabilities of policymakers to bring about effective policy solutions.

AbstractThis article evaluates the efforts underway in India to achieve universal health care coverage and the conditions that fostered its contemporary evolution. It finds that India's health system is characterized by private provision and financing, horizontal and vertical fragmentation, and weak governance arrangements. The article argues that these defining characteristics, which have solidified over time, account for poor health outcomes and make the system impervious to reforms as they deny the government levers to intervene and shape outcomes in the sector. While the government's recent efforts of increased public funding of national programmes have helped to reduce out of pocket spending, these are unlikely to work in the long run unless the government addresses the sources of the problems. The article argues that building health care governance, strengthening regulatory architecture, and stewardship over the system, in conjunction with increased public spending, are essential if the health care system is to provide affordable care to the entire population.

India's first health policy document in 1946 envisaged an ambitious health system comprising delivery of public health programs by the national governments and primary and secondary care by the state governments. Nearly seven decades later, neither of the ambitions have been realised. The delivery of public health programs is limited and uncoordinated, whilst primary and especially secondary care is of poor quality and unaffordable to the bulk of the population. This article assesses India's health policy reforms and argues that at each juncture the policy instruments it utilised were inconsistent with the goals it was trying to achieve. The health care sector required more intervention than the central and state governments offered. The meagre funds allocated to public health programs and the unwillingness and inability of state governments to shoulder responsibility for primary and secondary care led to the dominance of the private sector in delivery, out-of-pocket financing, and fee-for-service payment to providers. Recent reforms have made some progress in addressing the lacunae but are handicapped by the pervasive dominance of the private sector which severely limits the choice of policy tools available to the government.