Given the rapid internationalisation of many dimensions of health and disruptive technologies reshaping health strategy, India needs an inter-governmental institution for the health domain
This essay is part of the series titled: World Health Day 2024: My Health, My Right
Like most federal countries, India’s Constitution has listed health as a state subject. This means the states or the subnational governments are the primary actors in providing healthcare services. Thus, the Seventh Schedule of the Constitution which allocates powers and functions between the Centre and states makes it explicitly clear that on issues of public health and sanitation; hospital and dispensaries and their management, states are supreme. While this may be true on paper, in multiple ways the federal government holds disproportionate powers over health portfolio. The federal government dominates the programme and policy spaces related to healthcare in both policy design and financing. Importantly, it directly exercises legislative and executive powers concerning healthcare through the Union and Concurrent lists. Thus, functions like “population control and family planning” (Entry 20A), “legal, medical and other professions” (Entry26) under the Concurrent list allow the Central government to shape health policies nationally, the Entries 28, 64, and 66 of the Union List enables the federal government power over port quarantine and scientific and technical education related to health. Further, with its overwhelming dominance over finance (given most lucrative sources of taxes are with the Centre), major policies and programmes related to the health sector have been provided by the Central government, contrary to the experience of major federal systems. While the states are tasked to implement, it is the Centre that designs and rolls out various national programmes such as leprosy mission, malaria, polio, diarrhoea, HIV/AIDS, etc. with the states having very little say in the design and financing.
The federal government dominates the programme and policy spaces related to healthcare in both policy design and financing.
Lately, the Central dominance on healthcare has grown even further due to the confluence of multiple factors. One of them is the growing internationalisation of public health which is having a major impact on the Centre-state relations. In the last decade or so, global jurisdiction around public health has grown phenomenally. Several initiatives particularly undertaken by the World Health Organisation (WHO) on international health regulations place major obligations on member states (national governments) with regards to surveillance and disease responses. With international health regulations giving priority to health threats (such as the pandemic) over national sovereignty under certain situations, increasingly national governments are expected to handle international health regulations/treaty obligations.
In fact, federal countries across the world (including India) have used international treaty-making jurisdictions to enact national legislation on health which at times bypasses the roles/powers of subnational governments. A good example of this is the passage of the National Rural Health Mission (NRHM) by the United Progressive Alliance government in 2005 (ideas emanated from international bodies particularly the World Bank and WHO) where the states had little say in policymaking/design. The current thrust has been to make the district a unit of intervention and bypass states due to the challenges of intergovernmental coordination.
Federal countries across the world (including India) have used international treaty-making jurisdictions to enact national legislation on health which at times bypasses the roles/powers of subnational governments.
The second major shift in health federalism has been triggered by rapid technological transformations, particularly the ongoing data revolution (via data clouds which transcend the physical boundaries). Thus the health data emerging in all shapes and from multi-levels has necessitated centralised management for effective policymaking, albeit with ramifications on local autonomy. For instance, the federal government’s flagship National Digital Health Blueprint (NDHB) is developing an integrated health information system that aims to improve transparency, efficiency and quality of citizen experience. It needs to be mentioned that NDHB is federally controlled and aims to be interoperable while seeking cooperation and collaboration from public and private agencies. What is missing in this is the active involvement of the states. In short, the disruptive digital technology and the data revolution in healthcare have major implications for health federalism.
The third and most significant shift in health federalism has been triggered by the impact of the COVID-19 pandemic. The health pandemic and its rapid spread necessitated swift actions from the Central government. In the absence of clear laws to handle the health pandemic, the central government activated emergency powers under Disaster Management Act, 2005 to impose national lockdowns and take rapid measures (such as vaccine production, procurement, pricing, distribution, etc.) to control the spread of disease. While this was necessary given the nature of the pandemic, this had its ramifications on Centre-state relations. As the pandemic management panned out for a longer period of time, many states particularly the Opposition-ruled governments blamed the federal government for trampling on their autonomous space on health service delivery and related functions. However, the pandemic experience of Centre-state coordination (going haywire on many occasions causing serious challenges in pandemic management) has prompted many analysts and policymakers to advocate for reforms that can provide more powers to the federal government over the states. They claim that the ‘vulnerability’ of the Indian federal system to the pandemic should prompt the policymakers to think of moving health to the “Concurrent list”, thereby handing the federal government more say on health matters, something akin to education.
As the pandemic management panned out for a longer period of time, many states particularly the Opposition-ruled governments blamed the federal government for trampling on their autonomous space on health service delivery and related functions.
Yet, there are an equal number of analysts who advocate maintaining a federal balance by preserving the subnational autonomy and existing decentralised model of healthcare delivery in a country of continental size. As seen from the preceding discussion, India’s health federalism notwithstanding the original constitutional scheme (giving primacy to states) has over the years veered towards the Centre. However, the pandemic exposed the limits of highly centralised intervention. While the internationalisation of health, the spread of disruptive technologies and the data revolution make a compelling case for centralisation of health in certain realms, the experiences from the pandemic reveal the imperative of decentralisation and critical roles of sub-national governments. What the pandemic further revealed (particularly centre-state acrimony over the nature and jurisdictions of interventions) was the absence of intergovernmental or federal building institutions. The empowerment and activation of intergovernmental forums such as the Inter-State Council would have reduced the needless friction between the Centre and states in managing the pandemic. Given the rapid internationalisation of many dimensions of health and disruptive technologies reshaping health strategy and management, India urgently needs an inter-governmental institution something equivalent to the GST Council for the health sector. The pandemic experience should serve as a wake-up call.
Niranjan Sahoo is a Senior Fellow at the Observer Research Foundation
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Niranjan Sahoo, PhD, is a Senior Fellow with ORF’s Governance and Politics Initiative. With years of expertise in governance and public policy, he now anchors ...
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