Over-Centralisation Threatens Federal Health Policy

Syllabus: GS2/Issues Related To Health; Governance

Context

• Recent trends indicate increasing centralisation in health policymaking, raising concerns about states’ autonomy and the effectiveness of federal health policies.

About the India’s Health Governance

• It follows a quasi-federal structure, where both the central and state governments share responsibilities.
• Under the Indian Constitution, health is a state subject, meaning that states have the primary responsibility for healthcare delivery.
  • However, the central government plays a significant role through policy frameworks, funding, and national health programs.

Key Incidents of Centralisation of Health Policy

• Striking Down Domicile-Based Reservations in Post-Graduate Medical Admission: Recently, the Supreme Court of India declared domicile-based reservations in post-graduate (PG) medical admissions unconstitutional for violating Article 14 of the Constitution.
  • Decision is grounded in the principle of meritocracy and the constitutional right to equality. 
• Introduction of the National Health Mission (2005): The National Rural Health Mission (NRHM) was launched in 2005, later expanded as the National Health Mission (NHM) to include urban areas.
  • It gave the central government a stronger role in funding and shaping health services in states.
  • While states still had implementation responsibilities, funding allocations and guidelines were largely controlled by the Centre.
• Epidemic Act & Disaster Management Act: Laws that empower the Centre to intervene in public health emergencies.
• Ayushman Bharat Digital Mission: While aiming for a unified health database, its implementation requires strong state cooperation.
  • However, states have limited control over its design and data-sharing mechanisms.
• Ayushman Bharat (2018): It provides financial support for secondary and tertiary healthcare to economically weaker sections.
  • The scheme reduced the role of state-run health insurance programs, increasing the Centre’s influence over healthcare funding and service delivery.
• National Medical Commission (NMC) Act (2019): Replaced the Medical Council of India (MCI) with the National Medical Commission (NMC).
  • The Centre gained greater control over medical education and licensing, reducing state authority in regulating medical institutions.
• One Nation, One Health System Approach: A proposed framework to unify state and central health insurance schemes.
  • States fear loss of autonomy over health financing and service delivery.

How Over-Centralisation Weakens Federal Health Policy?

• Limited Flexibility in Addressing Local Health Needs: Health challenges vary widely across states due to differences in demographics, disease burden, and infrastructure. A one-size-fits-all approach imposed by the Centre often ignores local priorities. For example:
  • States like Kerala require policies focusing on ageing populations, while Bihar and Uttar Pradesh need more focus on maternal and child health.
  • Imposing uniform schemes without state-specific customisation weakens healthcare outcomes.
• Reduced State Autonomy in Healthcare Governance: Centralisation has led to states losing decision-making power in key health schemes.
  • AB-PMJAY is a clear example where states have limited flexibility in implementation, despite healthcare being a state subject.
  • Many states preferred their own insurance models, yet they had to align with central directives.
• Bureaucratic Delays and Inefficiencies: Excessive dependence on the Centre for funds and approvals often results in bureaucratic bottlenecks.
  • States have reported delays in fund disbursements under NHM, affecting the timely execution of health programs.
  • During the COVID-19 pandemic, vaccine distribution and oxygen supply were heavily centralised initially, leading to logistical challenges and delays.
• Financial Dependence on the Centre: States heavily rely on centrally sponsored schemes (CSS) for healthcare funding.
  • The 15th Finance Commission’s health grants have been criticised for imposing central conditions on how states should spend resources.
• Weakening of Grassroots Public Health Systems: Strong state and local health systems are critical for effective service delivery.
  • Over-centralisation often sidelines state health departments and local governance structures like panchayats and municipal bodies, which are better positioned to manage public health at the ground level.

Way Forward: Balancing Centralisation and State Autonomy

• Greater Fiscal Autonomy for States: Allow states more flexibility in utilizing central funds for healthcare based on regional priorities.
• State-specific Policy Frameworks: Encourage states to develop localized strategies rather than imposing uniform national policies.
• Strengthening State Health Capacities & Local Governance: Investing in state health departments and local governance structures can improve service delivery.
  • Empower municipalities and panchayats to manage primary healthcare services efficiently.
• Cooperative Federalism in Health Planning: Establish mechanisms for collaborative decision-making between the Centre and states, ensuring inclusive policy formulation.
• Investing in Capacity Building: Providing technical and financial support to states can help them strengthen their healthcare infrastructure and workforce.

Conclusion

• Over-centralisation in health policy poses significant risks to India’s federal structure and the effectiveness of its healthcare system. 
• By fostering a balanced approach that respects state autonomy while leveraging central support, India can build a more equitable and efficient healthcare system.
• As the nation continues to navigate the complexities of health governance, it is crucial to prioritise cooperative federalism to ensure the well-being of all its citizens.

Source: TH