Why does a public health issue (not) get priority? Agenda setting for the national burns programme in India

Abstract

There is growing scholarly interest in what leads to global or national prioritization of specific health issues. By retrospectively analysing agenda setting for India’s national burn programme, this study aimed to better understand how the agenda-setting process influenced its design, implementation and performance. We conducted document reviews and key informant interviews with stakeholders and used a combination of analytical frameworks on policy prioritization and issue framing for analysis. The READ (readying material, extracting data, analysing data and distilling findings) approach was used for document reviews, and qualitative thematic analysis was used for coding and analysis of documents and interviews. The findings suggest three critical features of burns care policy prioritization in India: challenges of issue characteristics, divergent portrayal of ideas and its framing as a social and/or health issue and over-centralization of agenda setting. First, lack of credible indicators on the magnitude of the problem and evidence on interventions limited issue framing, advocacy and agenda setting. Second, the policy response to burns has two dimensions in India: response to gender-based intentional injuries and the healthcare response. While intentional burns have received policy attention, the healthcare response was limited until the national programme was initiated in 2010 and scaled up in 2014. Third, over-centralization of agenda setting (dominated by a few homogenous actors, located in the national capital, with attention focused on the national ministry of health) contributed to limitations in programme design and implementation. We note following elements to consider when analysing issues of significant burden but limited priority: the need to analyse how actors influence issue framing, the particularities of issues, the inadequacy of any one dominant frame and the limited intersection of frames. Based on this analysis in India, we recommend a decentralized approach to agenda setting and for the design and implementation of national programmes from the outset.

Key messages.

• The study examines burn injury, an issue with significant mortality and morbidity burden that did not get policy priority in India, despite the country initiating a national burns programme.

• A combination of frameworks for policy prioritization and issue framing was used to analyse agenda setting and policy prioritization for burns in India.

• Policy response to burns was affected by the complexity of the issue, limitations of issue framing (some of which were inherent to burns as an issue and some were because of the nature of actors involved), the divergent views of actors and diverging ideas and the centralized and vertical approach of policymaking and implementation.

• The findings add new dimensions to analysing policy prioritization in health, by highlighting factors that explain the non-prioritization of an issue.

Introduction

Healthcare is receiving greater national and sub-national political priority across countries (Chatterjee, 2014; Kruk et al., 2018; Venkateswaran et al., 2022), including in the voting decisions of citizens (Blendon et al., 2005; Health et al., 2023). Despite this, many other factors interact to determine policy attention for an issue (Bertelli and John, 2013). Health is complex, and the health policy process is even more intricate. Health policy prioritization faces multiple challenges and requires long-term political commitment for effective outcomes (Duggal, 2005). Multiple actors, including civil society, academia, healthcare practitioners, global actors and institutions and the media, influence health policy prioritization nationally and sub-nationally (Shiffman, 2017). Other factors, such as market forces, the geopolitical location of an issue or concerned actors, influence policy decisions (Baru and Mohan, 2018; Persaud et al., 2021). There is a growing body of literature on the prioritization of health issues at national and sub-national levels, including in India (Shiffman and Ved, 2007; Smith, 2014; Abiiro et al., 2021).

Burn injury is a significant public health problem in India, with the highest mortality and disability burden in the world. The 2019 Global Burden of Disease study estimates more than 25 000 deaths and 1.5 million Disability Adjusted Life Years in India (Yakupu et al., 2022). The high incidence of burns in India is closely linked with gender and social determinants, with much higher mortality among females than males and poorer outcomes among lower socio-economic groups (Keshri and Jagnoor, 2022). Despite this high burden, there has been a limited policy response to non-communicable diseases and injuries including burns (Jagnoor et al., 2012).

Yet, attention to burn injury as a public health issue emerged slowly over decades and has evolved over time, globally. A large burn centre was set up in Edinburgh, UK, in 1944 during World War II (Davies, 1991; Bateman et al., 2016). The first network of professional burn practitioners, the International Society of Burns Injuries was formed in 1965 (International Society of Burn Injuries (ISBI), 2023). In India, the first organized burn centre (1959), the first paediatric burn unit (1975) and the first skin bank (1978) were established in Mumbai, which became an early hub for burns care activities in India (Chittoria, 2010). Early epidemiological studies on burns in India showing a huge burden of unintentional burn injuries were conducted by a Mumbai-based surgeon and presented at the second International Society of Burns Injuries conference in 1965 (Davies, 1991). Many pioneering and low-cost techniques for burn care emerged from practitioners based in Mumbai (Chittoria, 2010). The first formal network of burn care providers, the Burn Association of India (BAI), was also started in Mumbai in 1972 (Chittoria, 2010). Later Mumbai-based Dr M. H. Keswani became the permanent executive of the BAI (Gupta, 2005). A few other pioneering and low-cost treatment approaches, including burn centres, emerged in different parts of India from 1970s to 1990s (Chittoria, 2010). Notably, a burn centre at Safdarjung Hospital in Delhi—one of the largest speciality hospitals in India—was established in 1963 and gradually became the country’s biggest and best resourced burn centre (Gupta et al., 2010; also refer Figure 2).

Figure 2.

Timeline of the emergence of burn care issue and national programme development

Over time, the number of well-resourced burn units located within medical institutions in Delhi increased due to central government funding—Delhi being India’s capital. Many clinical and academic leaders in burn management emerged from these centres. Burn centres and surgeons interested in burn injury also grew across the country. Later, at a national conference in 1988, burn surgeons held a meeting and concluded that the BAI had failed as a national network of burns on the basis that the organization had been captured by one leader in Mumbai (Gupta, 2005). In a subsequent meeting in 1990, a new professional association, the National Academy of Burns-India (NABI) was formed in Delhi. Although NABI’s first president and other executive members were from different parts of India, key officers, like the secretary, treasurer and editor of the Indian Journal of Burns (IJB), were based in Delhi. Later, Dr J. L. Gupta, then head of Safdarjung Hospital’s burn centre, became its permanent patron (Gupta, 2005).

The formation of the NABI helped experts based in Delhi take leadership roles. In 1995, the editor of the IJB wrote an editorial calling for the ‘Indian model’ of burn care and for a national burn programme (Ahuja, 1995). In 2006, Dr J. L. Gupta wrote a letter to the Prime Minister of India to request a national response to burns. This led to a political action, and a committee was formed under the Directorate General of Health Services (Dte GHS) within the Ministry of Health and Family Welfare (MoHFW) to plan the national response. This committee held 40 rounds of meetings over three years before designing a pilot programme in 2010, covering three tertiary burn units within medical institutions and three district hospitals in three different states of India (Gupta et al., 2010). In 2014, the programme was scaled up as the National Programme for Prevention and Management of Burn Injuries (NPPMBI).

NPPMBI had five ambitious objectives: (1) to establish burn units in 67 identified medical institutions and district hospitals; (2) to improve awareness; (3) to establish a burn registry; (4) to carry out research and (5) to organize trainings on burn care for healthcare providers. The task of strengthening of district hospitals was delegated to the National Health Mission (NHM)—an ongoing health system strengthening initiative in India (Government of India, 2021). However, nine years later, the current official status of NPPMBI shows limited outcomes in implementation. Evaluation reports suggest several challenges in implementation, such as partially developed infrastructure, inability to recruit required number of human resources and inadequacy in training. The report recommended for improving coordination and need for stewardship by a central institution and increased flexibility to states to design burn centres (Government of India, 2021). Many published works also highlight continuing challenges for health system responses to burn management in India (Chamania, 2018; Jagnoor et al., 2018; Singh, 2018; Keshri and Jagnoor, 2022). This study aims to retrospectively analyse agenda setting for India’s national burn programme (NPPMBI) from 1990 to 2010 to better understand how this process influenced its design, implementation and performance.

Methods

Study design and setting

We carried out a retrospective policy analysis of burn programme agenda setting using qualitative methods. The study was conducted in India involving the stakeholders in national policy response to burns.

Analytical framework

The overall analysis is based on a combination of frameworks: Shiffman and Smith’s health issue prioritization framework (Shiffman and Smith, 2007) with an additional fifth dimension of ‘outcomes’ as suggested by Walt and Gilson (Walt and Gilson, 2014) and the three issue framing process described by Shiffman and Shawar (Shiffman and Shawar, 2022). The Shiffman and Smith framework proposes four dimensions: actor power, ideas, political context and issue characteristics. ‘Actor power’ deals with the positionality and strengths of individuals involved with the issue of concern. ‘Ideas’ refer to the way actors involved frame the issue. ‘Political context’ denotes the governance and political economic context in which actors operate, and ‘issue characteristics’ refer to attributes of problems. ‘Outcome’ was suggested as the fifth dimension to consider whether or not the issue reaches the policy agenda (Walt and Gilson, 2014). In addition to this, the issue framing within ‘ideas’ was elaborated under the three dominant framings of securitization, moralization and technification (Shiffman and Shawar, 2022) (Figure 1).

Figure 1.

The analytical framework

Adopted from Shiffman and Smith, Shiffman and Shawar and Walt and Gilson.

Sampling and data collection

Selection of documents

We used two methods to collect data: document reviews and key informant (KI) interviews. Combining these two data-capturing methods is well suited for policy analysis (Bardach, 2019). For the first step, we searched for relevant, peer-reviewed published literature from India in PubMed using the broad search terms (((Burn AND (India)) AND (Program)) OR (Polic)). We also searched the IJB (not indexed in PubMed) with the same search terms. We scanned all results to obtain relevant papers and then searched reference lists to identify additional relevant papers. For official documents, we searched the official websites of the Dte GHS, NHM, MoHFW, National Injury Surveillance Centre, NABI and the Association of Plastic Surgeons of India. Thereafter, we ran a Google search (BURN AND PROGRAM AND INDIA) to scan for any further relevant documents. Later, during the interviews, KIs were requested to suggest relevant documents, which were included if they were not already in the list.

Sampling

KIs were initially identified during the document reviews. The number of stakeholders identified in the documents were limited and homogeneous. We therefore expanded the list by snowballing based on interviewees’ suggestions and identifying more experts with documented contributions to burn injuries in India. They were from diverse groups, such as clinicians, researchers, media, civil society and international organizations.

Data collection

To steer KI interviews, an interview guide was developed based on key insights from the documents as well as an analytical framework (Supplementary File 1). The KI interview guide included basic demographic information of participants, and questions about the history of the national burn response in India, stakeholders involved, participants’ own engagement in the process, factors influencing policy prioritization of burns programme, planning, and policy challenges for burns response in India, implementation challenges, and what could have been done differently.

The first author, a male medical doctor specializing in public health and currently doing doctoral research in health policy and systems response to burns in India, conducted all the interviews. The interviewer has experience of working in similar health system contexts, with national and sub-national health policy stakeholders and conducting qualitative interviews. A detailed author reflexivity statement is provided below. Participants were approached by email or telephone message to establish initial contact, share study objectives and introduce the interviewer. Twenty-three stakeholders were contacted, out of which eight did not respond despite reminders. Three declined the interview invitation citing inability to respond without official approval from higher authorities, interview without professional fee, and on health grounds. For those who agreed, the participant information sheet and consent form were shared with a request to read and return the signed consent form, or based on the respondent’s preference, verbal informed consent was recorded before the interview.

All interviews were conducted via telephone or video conferencing, in English, except one which was conducted in Hindi, the participant’s preferred language. All interviews were recorded except one in which the respondent did not consent to the recording—extensive interview notes were taken instead. The average duration of the interviews was 46 minutes (range: 30 to 62 minutes). Interview recordings were transcribed verbatim by the first author. The transcript in Hindi was translated into English by the first author, who is proficient in both languages. Saturation was achieved around the eighth or ninth interview, but a few more interviews were conducted to validate the pattern.

Ethical approval for the study was obtained from the authors’ institute in India and Australia.

Analysis

Twenty-one documents, including journal articles, a book, a book chapter, programme reports, a court judgement and newspaper reports, were included for final coding and analysis (Supplementary File 2). We used the READ (readying material, extracting data, analysing data and distilling findings) approach for document analysis (Dalglish et al., 2021). Readying included conducting initial screening of all documents identified through the search strategy and listing them in an excel sheet with reasons for inclusion (Supplementary File 2). Extraction of data was done by simultaneously reading, coding in NVivo and taking notes (NVivo, 2020). Analysis and distilling of findings of documents were done simultaneously with the analysis of interview transcripts. The first author did the initial coding of interview transcripts in NVivo and held regular discussions on coding with other authors to ensure consistency. We then combined the codes from documents and interviews and did a thematic analysis. Themes were generated by combining similar codes and categorizing them into dimensions and issues within the adopted analytical framework (Figure 1 and Table 2). Regular discussion between the first and the last author helped in ensuring homogeneity in identifying themes. There were 80 initial codes from documents and 170 initial codes from the interviews; the codebook is available in Supplementary File 3. We reviewed the implementation status of the NPPMBI using multiple approaches, including information on official website, questions, parliament proceedings, published reports and the responses of KIs.

Table 2.

Factor shaping prioritization of the national burns programme in India

	Opportunities	Challenges
Actor power	Strongly organized policy community with central location. Elderly patriarch leader. NABI as powerful professional network. Civil society mobilization around violence against women.	Homogenous group of epistemic community (plastic surgeons). Leadership restricted to centralized group. Vertical institutions for policy implementation. Lack of social mobilization for unintentional burns.
	Opportunities	Challenges
Ideas and framing Ideas	Neglect of non-intentional burns. Need for health policy action on intentional burns against women.	Lack of consultation on ideas and limited vision on implementation. Missed opportunity to connect with the moral aspect of burn injury. Outcome goals not well defined.
Framing
Securitization	Burns linked with violence against women. Securitization framing limited to intentional burns. Civil society organizations and media focus on intentional burns. Judicial intervention for the prevention of intentional burns.	Not a global concern, limited to regions or countries. Global actors—not mobilized. In India   Limited to justice framing. Judicial and law, minimal focus on healthcare rights. Lack policy advocacy.
Moralization	Issue of burn injuries—related to poverty and vulnerable population. The necessity for prevention, access to care. Emotional connect, sentiment. Limited civil society mobilization.	Affluent society not mobilized. Very limited advocates/agencies. Lack of credible data. Policymakers not effectively engaged.
Technification	Improved clinical practice and recovery outcomes. Medical doctors, surgeons and technological advocates. Actor’s epistemic interests and moral high ground. Professional network, access to policy entrepreneurs.	Limited data on the magnitude, effectiveness of interventions, costs. Limited motivation, number, and epistemic community.
	Opportunities	Challenges
Political context	Union government coalition led by technocrat. Reform initiatives in social sector, including health and health systems strengthening. Specialized burns centres with better recovery outcomes. Public attention and demand for action on violence against women and intentional burns such as acid attacks. Judicial intervention for acid burns. Preference for vertical national health programmes.	No state-level mobilization of political stream. Health sector reform mostly focused on strengthening RMNCH services. No media, political attention on unintentional burn problem. Healthcare delivery is a state subject according to constitution, with variable development and capacity of states.
	Opportunities	Challenges
Issue characteristics	Visibly recognizable trauma, major burns are life-threatening. New data revealing patterns of burn injuries. Evidence on delayed presentation and poor outcome. Improved treatment outcomes.	Lack of nationally representative data on mortality and morbidity with fragmented data collection. Paucity of health systems research on burns. Treatment model more than prevention.
	Opportunities	Challenges
Outcome	Funding available for strengthening burn centres. Learnings for future programme.	Limited mobilization of states and limited outcome. Implementation challenges. Missed opportunities.

RMNCH: reproductive, maternal, newborn and child health.

The Consolidated criteria for Reporting Qualitative Research (COREQ) checklist for reporting qualitative research was followed for reporting this study, and the completed COREQ checklist is available as Supplementary File 4.

Results

Description of study participants

Twelve interviews were conducted with KIs, seven men and five women. Six KIs were senior plastic or general surgeons, each with more than 30 years of experience and significant contributions to burns care in India, including in leadership roles in their organization. Three of them were actively involved in the early development and implementation of NPPMBI. The other three have led innovative burn care, training of primary healthcare and district level health workers in their states and are respected experts in the field of burn care in India. Others included the former programme officer at Dte GHS engaged in the designing NPPMBI during the inception phase; a public health researcher who has studied gender-based violence and burns; a journalist who has written detailed investigative reports about burn injuries in India and has lost a family member to burn injuries; and a civil society activist who helped file a public interest litigation in the Supreme Court of India, which led to a historical judgement on strengthening burn centres, free treatment and compensation for acid burns survivors. Two experts from multilateral and humanitarian organizations who have extensive experience of India’s response to burns care were also interviewed (Table 1).

Table 1.

Key Informants’ profile

S.No.	Professional background	Role in burns
KI_1	Senior plastic and burn surgeon	Leader in the field, part of the NPPMBI* programme design committee
KI_2	Senior plastic and burn surgeon	Leader in the field, part of the NPPMBI* design committee
KI_3	Senior plastic and burn surgeon	Leader in the field, led implementation of the NPPMBI* programme in a state
KI_4	Senior plastic and burn surgeon	Leader in the field, contribution to innovative burn management and historical knowledge
KI_5	Senior general and burn surgeon	Leader in the field, led pilot burns trainings for a state public health system
KI_6	Senior general and burn surgeon	Senior leader in the field, led an exemplary non-government private burn unit and innovative training programmes
KI_7	Former programme officer	Programme officer for the NPPMBI* in the Dte GHS during initial pilot phase
KI_8	Public health researcher	PhD research on gender-based violence and burns while working closely in large burn centres
KI_9	Media representative	Wrote critical media articles on the burns and NPPMBI
KI_10	Civil society organization representative	Lead a non-government organization that fights for acid burn victims
KI_11	Multinational organization representative	Member of a leading multinational organization and injury expert responding in a personal capacity
KI_12	Global humanitarian organization and international non-government organization	Founder of a dedicated international organization for burns, experience in implementing public health programmes in India and several low- and middle-income countries

^*National Programme for Prevention and Mangement of Burn Injuries.

The evolution of the burn care agenda and the national programme in India

The emergence of burns as a recognized public health problem, leading to the national programme formulation in India, had two distinct phases. The first phase was development of gradual understanding of the magnitude of unintentional burns, cost-effective interventions, need for prevention, the emergence of general surgeons and plastic surgeons with expertise in burn and their networks. The second phase started with the formation of the NABI, the rising authority of burn surgeons based in Delhi hospitals and consolidated efforts to push for the national burns programme. This phase culminated in the establishment of the burns programme in 2010. The detailed timeline in Figure 2 depicts this evolution.

Factors shaping the burn care agenda and development of the national programme

Actor power

The process that led to the national burns programme shows the evolving role of actors and their networks. It started with the emergence of burn surgeons as de-facto leaders and the formation and consolidation of their networks. The legitimacy of centrally located actors (in Delhi) also increased over the period due to their recognition as experts by the union/national government and through their leadership in NABI; and there was very limited contestation in the policy process (their power was not challenged). In addition, the absence of international actors (such as WHO or other multilateral or international humanitarian organizations) meant that there was a limited external influence on the agenda-setting process which could have diversified the range of actors involved beyond those in Delhi. The limited range of actors involved in the policy process led a KI to challenge whether the national burns programme is indeed a national programme at all:

It might have been expanded, but whether it has become a National Health Program which is implemented in all the states, all the districts? This I’m not aware. When it becomes a national program, definitely the priority will be there and all kind of funds (KI_7).

The development of plastic surgery as a speciality in India coincided with the recognition of unintentional burns as a major health concern. Burns care required reconstructive surgeries, so a few plastic surgeons and some general surgeons in bigger cities got engaged in burn care. Burn care became a part of the plastic surgery speciality, and plastic surgeons became stewards of clinical burn care. Some plastic surgeons championed the cause of burn care with innovative and cost-effective interventions in public facilities mostly in big cities. They also compiled data from burn units to describe the emerging patterns of burns: first from Mumbai, Chennai, and Jamshedpur and later from the northeastern, central states and Delhi. With the growing number of clinicians interested in burns and the number of burn centres in big cities came the founding of burn associations—first in Mumbai and later in Delhi: Dr Keswani and the Burns Association of India (BAI) flourished with contributions like Boiled Potato Peel (BPP) dressings, prevention campaigns by way of radio and TV talks, small documentary ads, ‘School Education Program’ in burns etc ‘Pour water on Burns’ has received worldwide popularity (D_1) (Chittoria, 2010).

During the initial years (1960–90), the peripheral actors located in big cities, such as Mumbai, Chennai, Indore, Guwahati and Jamshedpur championed burn care with innovative low-cost treatments and prevention, but later, actors located centrally in Delhi and affiliated with institutions supported by the central government started to gain authority within the growing network of burn clinicians and centres. Their power was facilitated not only by their technical contributions to burn care but also by the resources available to them and their proximity to central policymakers. The emergence of the NABI with national membership and Dr J L Gupta as its permanent patron with senior Delhi-based burn surgeons as key office bearers helped consolidate the power and policy influence of central actors. At the beginning of the programme, all committee members deliberating on the national programme design were based in Delhi.

Peripheral actors interpreted this as ‘centralization’ and ‘elite capture’ of the agenda-setting process of the national programme. Senior members from the community expressed complete unawareness about the advocacy process that led to the national programme and the level of secrecy and a lack of consultative approach by central actors: I feel that there is a very big ego issue. That’s one straightforward thing. They want to be The Pioneers. They want to be known as the people who did everything for improving burn care in India (KI_6). Another peripheral actor said: I don’t know what it is. I don’t know what it contains, and I don’t know who is supposed to implement and where it is to be implemented and what is to be done. So, I don’t know anything, it is the kind of secret that has been kept for years together (KI_5).

Consultation with broader networks of public health experts, civil society organizations and the international community was also limited. However, some contestation was noted between technical advocates and the bureaucratic elite in the central government, as evident by the need for several meetings, budgetary negotiations and delays in the programme’s initiation.

The concentration of actors had implications for implementation. There was minimal engagement with the complex and decentralized health systems governance structures in India during the development of the national programme on burns. Healthcare delivery and public health in federal India are responsibilities of state government. Although states were supposed to implement the programme, there was limited consultation with state-level health administrators, whether technocrats or bureaucrats, regarding implementation. Inadequate mobilization of the state affected their ownership and constrained adoption and scale up of the programme by state governments: When this national program was developed, they should have had at length discussion with state governments… That was probably not discussed properly: after the central government leaves the program how do states run the programme (KI_5).

KIs highlighted the limited outcome of the programme and sustainability concerns in the absence of state ownership. The central government supports healthcare by delivering national health programmes through the MoHFW. The MoHFW has three separate vertical units: the Department of Health and Family Welfare (DoHFW), the Dte GHS and the Department of Health Research. Dte GHS historically implemented vertical disease control health programmes, while DoHFW implements immunization, reproductive and child health programmes and health systems strengthening, such as NHM. The initial responsibilities for formulating the burn programme were assigned to Dte GHS, but the scale up phase also included strengthening district hospitals for burn care under the NHM. According to KIs, there was minimal or no consultation with the NHM programme: At that time, NHM was not much in our loop. We had sought funds directly from the ministry for strengthening these units at Medical College, District Hospitals and down below (KI_7).

Indeed, the NPPMBI implementation in states reflected only individual interests and individual champions of implementation and their efforts rather than organized response:

So, I gave my introduction and wrote everything about the project and sent a message to the health minister. He is a very dynamic person. He is the chief minister now. He responded within half an hour and said—I have given instructions to the principal secretary to the government and your work will be done. And next day by 1:00 p.m. I got a call from central team that the MoU letter is received (KI_3).

Issue characteristics

Burn injuries, especially in India, have some unique characteristics. First, estimates on its magnitude vary according to different data sources and under-estimate the true burden. Second, it is considered a problem of the women, and underprivileged, so the men and affluent society are less concerned. Third, treating burns is complex and expensive, requiring intensive long-term care. In the last two decades, survival and recovery following major burns have improved significantly, but there are limited data to show the clinical effectiveness and cost-effectiveness of the relevant interventions in India. Moreover, there was very little awareness of public health approaches to burn prevention or their implementation feasibility in India: it’s easy to say that burns are preventable, in practice you know it’s not easy to implement… I mean, yes, in theory they are, but you know in practice that’s a lot harder to actually put into practice (KI_12).

These issue characteristics influenced how burn injuries were framed by policy advocates with downstream implications for programme design and implementation (see next section).

Ideas and framing

Given the complex characteristics of burn injuries in India, the homogenous group of actors engaged in advocacy for the burns programme struggled to frame the issue comprehensively. We therefore examined the ways in which the issue characteristics in India intersect with how it was framed during agenda setting, with bearings on programme design and implementation.

Securitization

Burns is not generally perceived as a universal problem with international dimensions (such as infectious diseases that can cross national boundaries). In addition, prevention and advancement in treatment and rehabilitation have already significantly reduced the burden in High Income Countries. So, globally, this issue does not get the attention it deserves as it has few security concerns. Very few global development organizations work on the issue of burns, and the WHO also give very limited focus on burns: WHO is not a not a funding organization. They’re not a research organization. They’re not actually implementing burn prevention in India or any other country (KI_11).

In India, civil society organizations and activists extensively used the securitization framing to mobilize policy and seek judicial interventions for intentional burn prevention. However, they did not effectively emphasize the gaps in health systems for care and prevention and the need to ensure better and affordable care. The securitization framing remained focused on crime prevention, punishment for the culprit and compensation. Actors engaged in advocacy for the national burn programmes could minimally use this framing, even though burn injury in India is closely linked with securitization due to the connection to violence against women and fire safety:

So, if you look at, you know the causes of the entire percentage of burns. You’ll find that it is gendered… and that it the reason it’s neglected. Or I would say the mortality is highest amongst women. …largely these burn incidents are taking place in the home (KI_8).

Moralization

Actors from different backgrounds highlighted the moral logic for prioritizing burns issues, as poor and vulnerable populations are more at risk and suffer more from adverse outcomes, especially without proper access to care. Despite this, only a few international and humanitarian organizations, national civil society organizations and technical advocates work in burns. As the clinicians in public health facilities engaged in burn care were unable to deal with patient concerns for a long time, they organized and repeatedly raised the demand for more attention to burn prevention, improving health infrastructure and reducing the cost of care. But they could not assemble other actors, such as civil society organizations and activists working to address intentional burns, as they were a separate epistemic and practice community from clinician advocates. Thus, even though the policy advocates were aware of the potential to frame burns as a moral issue, the moralization framing received limited traction:

The first statement of fact is that burns are a disease of poverty. I mean that’s across the globe, whether in a high-income country or a low-income country in general, but burns are a disease of poverty, therefore they tend to be neglected because you know it’s the impoverished, those people that have less of a voice (KI_12).

Technification

Although the securitization and moralization framing were dominant in policy advocacy around intentional burns (especially as it pertains to judicial policy processes) and could have been applicable to unintentional burns (especially in relation to health policy processes), the technification framing dominated the national burns programme agenda-setting process. The clinical advocates of the programme were enthused by clinical advancement and improved recovery outcomes in specialized burns units. Nonetheless, a major challenge for the technification framing was the absence of credible data on intervention and its cost-effectiveness. The overt technification of the burns programme also reflects in the absence of comprehensive multidisciplinary consultation which may have drawn in actors who presented a securitization and moralization framing of burns and so broadened the focus of the national programme. One respondent said:

You know the whole approach is based entirely on medical response even today. The whole issue of focusing on those who are survivable, non-survivable still exist, and many surgeons also questioned the whole medical centric approach and lack of prevention approach (KI_8).

The challenges of framing burn injuries comprehensively had implications for programme design and its implementation in being specifically clinical in orientation. For most of the population in India, burn injury most commonly resonates with gender-based violence, mostly related to dowry or intentional acid burns. A few major fires in big cities, such as the one in a South Delhi cinema in the late 1990s, raised concerns about urban fire safety, ultimately leading to policy changes for fire safety. However, the ‘health’ and ‘health systems’ aspect of burns did not get public and policy attention. In the absence of other actors raising these issues, clinicians engaged in burn care became health policy advocates, calling for greater attention to strengthen health systems and improve prevention efforts for unintentional burns. These centrally located actors prioritized specialized burn units over a public health and systems approach. Even the proposed preventive approach was also biomedical, with the attention on post-burn care and prevention, such as first aid methods. They frequently highlighted the need for prevention, but their proposals were criticized given the high focus on clinical care:

I just thought it (program) is just an eyewash because it lacks depth. It is not being run properly. When I read the (national program) document, I thought there are many more things which must be done. There are many things which should be there in the (program). (KI_9).

Regarding the programme design for burn care, there were diverging views among respondents about the value of focusing on primary prevention with a population-based approach vis-à-vis secondary prevention or high-risk strategies. The respondents identified three levels of health systems strengthening for improving burn care; (1) strengthening organized burn units at the tertiary care, (2) improving burn care response at district hospitals and (3) making primary care responsive to burn injuries. The proponents of the burn programme, both clinicians and government actors in the national capital, struggled to effectively frame these dimensions together as a package and focused largely on the specialized burn units. The responsibilities for strengthening district hospitals were given to the NHM, but the central actors, distant and limited in their influence, could not effectively engage with the larger decentralized public health system in respective states. The prevention approach in the programme was also focused on mass media campaigns, such as messages via radio channels, which other stakeholders felt was insufficient to reach people:

Don’t you listen to the Jingles on radio every now and then to ‘pour water’ and I said yes, we do listen to that occasionally, but we still get patients who don’t pour water. That means the message is not going across. You must reach them (KI_6).

By overly focusing on strengthening burn treatment facilities, the ‘centralization’ of ideas around clinical care narrowed the potential of the programme to have an overall ‘public health’ approach, a weakness that is now recognized: …they’re trying to identify what was responsible for the failure of this program or the prevention program? Where are we are failing and what can be done for having effective preventive strategies? So, they’re doing a situational analysis (KI_6).

Political context

A series of events marked the political context within which the health policy advocacy on burn injuries occurred. Mass public movements and civil society activism against violence against women and acid attack victims, and a few litigations in the Supreme Court of India on behalf of young women survivors of intentional acid burn led to some landmark judgements. The judgement directed the government to improve burn care in country and all states along with the instruction for policy reforms prevention of acid attack. These events occurred when a coalition government was in power nationally in India, headed by a technocrat (a development economist) and supported by ideologically left-leaning political parties. Many social programmes on health, education and livelihood, including transformational public health systems reform programmes, such as the NHM, were started between 2005 and 2009. The government was responsive to professionals and groups such as centrally located actors and the NABI. During this same period, a retired senior plastic surgeon took up political advocacy by writing to the Prime Minister:

…one very senior burn surgeon in India, he wrote a letter to the then Prime Minister of India. After pursuing with the Prime Minister’s Office for a while, the letter was forwarded to the Directorate of Health Services and then it was deliberated, and it took 2–3 years to have a pilot program. A few senior surgeons from Delhi were involved in initiating it (KI_2).

Although the political context enabled policy attention to burn injuries, the attention was of the receptive national government as the policy advocates were located centrally, in proximity to the national government. However, this had implications for the limited engagement by state governments in programme design and their limited ownership of its implementation.

Outcome

While the outcome of the policy advocacy resulted in the formulation of a national programme, the issues of burn did not make it onto the agenda holistically or comprehensively. First, it made it onto the agenda as a predominantly clinical issue. Secondly, it made it onto the agenda of the national government and not more broadly of the state governments who have primary responsibility for the implementation of the programme and improving healthcare in respective states.

The clinical and national focus of the agenda-setting process had direct implications for programme design and implementation. Current information on the NPPMBI website indicates that funds have been released to respective states for 47 burn units, although there is no further information on the number of burn units so far operationalized (Government of India, 2021). Proceedings of parliament deliberation confirm that funds have been transferred from MoHFW to respective state governments and states are responsible for timely completion of burn units (Lok Sabha, 2017). Besides this, a national injury surveillance centre has been established, a burn registry tool was developed, training packages for doctors and dressers were developed, and 80 doctors working as medical officers in the public health system and 25 dressers were trained in Delhi. Standard treatment guidelines have also been developed, and information, education and counselling materials for burn prevention were shared with states (Government of India, 2021). However, an independent evaluation report on the NPPMBI found implementation challenges in states and recommended the formation of committees, allowing implementation flexibility to the states and expanding the prevention approach (Government of India, 2021) (Table 2). This suggests that although the issue made it onto the health policy agenda, a holistic programme design and robust implementation plan were missing.

Discussion

Health policy processes are complex. In the last two decades, a growing body of literature on global and national health policy prioritization has sought to describe and conceptualize the intricacies of these process (Shiffman and Smith, 2007; Shiffman and Ved, 2007; Hafner and Shiffman, 2013; Shawar and Shiffman, 2017; Abiiro et al., 2021). In this study, we attempted to analyse agenda setting for India’s national burn programme (NPPMBI), to better understand the factors that influenced its design, implementation and performance. Our findings indicate three major challenges that affected policy prioritization: first, the peculiarities of the issue of burn injuries coupled with challenges of issue framing in the Indian context; second, diverging ideas about burns as either a social or a healthcare issue; and third, over-centralization of the health agenda in a federal structure. Addressing burn injuries in India requires two forms of responses: social/legal and healthcare. In addition, what to prioritize can diverge or be restricted depending on the cause of injury: for example, differences emerged in the priority actions taken for intentional and unintentional burn injuries, notably, the centralized agenda-setting process leading to the national burns programme being restricted in design, implementation, and impact. Centralization of health policy and programmes, limiting the impact, has been highlighted by several studies in India and in similar federal or decentralized governance contexts globally (Peters, 2003; Rao et al., 2014; Ezenwaka et al., 2022).

The findings suggest multiple challenges of issue framing of burn injuries in India. Furthermore, burn injuries, as a health concern, do not fully fit into securitization, moralization or technification frames, and as such, none of these framings could be sufficiently advanced to effect adequate policy response. The securitization framing was limited to intentional burns against women and led to some significant policy action for violence prevention but was not sufficient to influence the health systems response. Moralization was linked to the poor and vulnerable being at higher risk of burns and of adverse outcomes from burns than the well-off, which limited the attention the issue received. The technification framing was promoted by clinicians, but lack of adequate contextual evidence on effectiveness of technical approaches and cost-effectiveness of intervention restricted the impact of this framing. The role of frames (i.e. the way actors perceive an issue), and framing (i.e. the way issues are interpreted and portrayed) remains under-studied in research on health policy, especially in low- and middle-income countries (Koon et al., 2016; Shiffman and Shawar, 2022). Our analysis points to the role of framing challenges due to the epistemological limitations of dominant actors (clinicians) who used only a dominant frame and limited wider coalition of actors and framing as factors that limited the policy prioritization and implementation.

The study findings suggest centralization of actor power and elite influence on the policy agenda-setting process. Actors based in the national capital, Delhi, could draw power and legitimacy through their long-term contribution to burn care and research, their affiliations with institutions funded by the central government, their control over professional associations and their strategic access to policymakers. Such centralization helped improve actor cohesion among this group of policy advocates, limited contestation, facilitated faster institutional access and quickened policy action. But it also posed several challenges, such as narrow programme content, limited ownership of the policy by states and peripheral actors (i.e. the implementation partners in the programme), post hoc contestation and, ultimately, limited outcomes. The influence of elite actors on agenda setting in India and other countries is well documented, including positive impacts on prioritization and implementation (Heaney, 2006; Sriram et al., 2018; Mukuru et al., 2021) However, our findings also indicate inadequate numbers of proactive actors (at the centre or periphery) on burns in India and may have contributed to limited contestation, thus limiting impact.

The study findings also point towards the downside of centralizing the policy process. In addition to the individual actors and institutions engaged in the policy process, a central health agency (Dte GHS) led the programme development in a vertical top-down implementation approach, with minimal mobilization of policy actors in states and other implementing entities. Many factors may have led to centralization and a vertical approach: actors’ interest or motivation to control narrative and get credits, the fragmented and vertical design of departments within the MoHFW, the 5-year planning cycle which centralizes planning and inadequate funding. The burns programme shows an initial vertical approach, with centralization of agenda settings and policy processes. Vertical national disease control programmes in India have been positively impacted by centralization—in terms of additional resources and services and negatively impacted by centralization—in terms of disrupting health systems governance, and compromising sub-national capacity for health planning and run the risk of a lack of sustainability (Rao et al., 2014). The evolution of India’s reproductive and child health programmes is a noteworthy example of gradual horizontalization of a vertical national health programme. The NHM, started in 2005, was designed to facilitate the horizontalization of reproductive and child health programmes and various vertical disease control programmes (Paul et al., 2011). Evidence from similar contexts globally suggests benefits of decentralized health planning and programmes from inception (Abimbola et al., 2014; 2015; Ezenwaka et al., 2022).

The governance of India’s national health programmes is fragmented by design. The Dte GHS implements most vertical national health programmes, while the DoHFW implements health systems strengthening programmes, such as the NHM, and agencies such as the National Health Authority—an autonomous body that implements the Pradhan Mantri Jan Arogya Abhiyan, a large health insurance scheme. At the state level, similar arrangements are in place for national programme implementation. Successful implementation of these programmes is contingent on the capacity of respective states, which differs significantly (Peters, 2003). The experience of the national burns programme echoes the limitations of centralized vertical approaches to health programmes in a federal structure. Our analysis identified many lessons for future planning of national health programmes on burns care or other similar health issues in India. Such programmes should begin with a thorough evidence-based situational analysis and wide stakeholder consultations with active engagement of state governments. Each state should be encouraged to develop a plan based on their socio-economic and health systems context. The bottom-up approach to planning, starting from blocks, district to state and national level, in line with the planning process in NHM, should get precedence over a vertical top-down approach.

Our analysis adds significant new dimensions to the existing body of literature on health policy prioritization. We demonstrate the inadequate prioritization of burn injury—a neglected and complex health problem with high mortality and disability in India—due to the limited impact of the predominantly clinical focus and centralized national programme. This study has some limitations, such as no response from current government stakeholders and no access to historical unpublished government files and proceedings, a recognized challenge in policy analysis. However, we reviewed all published documents by expert group members engaged in the programme and interviewed former programme committee members to gain a broader perspective. We recommend further investigations on the non-prioritization of priority health issues in the national and sub-national health context, even when there are initial efforts aimed at prioritization. We also recommend further studies on issue framing by exploring the intersections of securitization, moralization and technification.

Conclusions

This study used a combination of existing theoretical frameworks to examine the policy prioritization of burn injuries in India. Our findings contribute to the growing understanding of health policy prioritization by analysing why an issue, such as burn injuries, has not received sufficient policy attention, although a national burns programme was established. We found that peculiarities of issue characteristics, divergence of ideas, limitations in issue framing, the influence of a small group of central actors and policy context, all factors influencing agenda setting, also contributed to limitations in programme design, implementation and impact. None of the three issue frames of securitization, moralization and technification was effective in raising and sustaining policy attention on burns. Our findings reiterate the limitations of a centralized approach to agenda setting for a national programme especially in a decentralized or federal governance setting and highlight the need for a distributed or decentralized approach from the outset.

Supplementary data

Supplementary data is available at HEAPOL Journal online.

Data availability

The data underlying this article cannot be shared publicly due to questions of privacy for the participating interviewees. Their participation in the study was on condition of confidentiality and anonymous reporting.

Funding

There was no specific funding for this work. V.R.K. is supported by Tuition Fee Scholarship by the University of New South Wales. J.J. is supported by Emerging Leadership Level 2 fellowship by the National Health and Medical Research Council, Australia. S.A. is supported by a Discovery Early Career Researcher Award (DE230101551) from the Australian Research Council.

Author contributions

V.R.K. conceptualized the study with inputs from S.A. and J.J.; V.R.K. collected data and conducted analysis; J.J. and S.A. provided critical input to the analysis. V.R.K. drafted the manuscript. J.J., S.A., M.P., and R.N. provided critical inputs to revise the manuscript. All authors read and approved the final manuscript.

Reflexivity statement

The author team consisted of five researchers, two males and three females, who are diverse in terms of research interests, experiences and locations. V.R.K. is a medical doctor specializing in public health and trained in health policy and systems research and currently doing doctoral research on the ‘health policy and systems’ response to burn care in India. He is based in India and has experience of working closely with district, sub-national and national level public health stakeholders. J.J. is a mid-career injury and health systems and policy researcher from India and has been working on burns in India for over 13 years. She is currently affiliated with institutions in India and Australia. M.P. is a senior global injury researcher with an experience of working across international, multinational and research organizations. R.N. is a senior leader in global health, injury and women’s health and works globally with institutional affiliations across Australia and the United Kingdom. S.A. is a mid-career health policy and systems researcher from Nigeria, currently based in a university in Australia. He has an extensive experience in health policy analysis and has conducted health system governance and policy research in Nigeria and elsewhere.

Ethical approval.

Ethical approval for the study was obtained from the George Institute Ethics Committee, India (13/2019) and ratified by the Human Research Ethics Committee of the University of New South Wales, Australia.

Conflict of interest.

All authors declare no conflict of interest.