The Case for Decentralised Health Policies in India
Decentralization is the new buzz word in global health. What does it mean and what are its benefits?
Growing up in Bihar, I vividly remember general knowledge lessons from my father. Health and healthcare systems and especially primary health centres (PHC) would often figure in the discussion, and he would convincingly tell me that each block has the provision of one PHC. I had internalised this until I entered a medical college in Maharashtra with a heavy focus on community-oriented medical education. There I learned that there is actually more than one PHC in a block, and the ideal recommendation is one PHC for every 30,000 population in general and every 20000 population in tribal or hilly areas.
Indeed, the two states have significant variations in public health systems and health outcome indicators. The current maternal mortality ratio in Bihar is 118 compared to 33 per 100,000 live births in Maharashtra. Bihar ranks in the bottom five, while Maharashtra ranks in the top five in the NITI Aayog health index. Such disparities raise concerns about whether a single national health policy or a national health program can improve health indicators nationwide.
India is a Union of states, and the Indian Constitution allocates duties to the union and state governments. Healthcare delivery and health facilities are primarily a state subject, listed under the state list. On the union list are items like international health regulations, maintenance, and regulation of the quality of goods, inter-state migration and quarantine, tobacco, and alcohol control, etc. Many essential health functions are listed in the concurrent list, such as family planning, medical education, medical professionals, and vital statistics.
Due to general political and economic factors, each Indian state has developed differently, leading to diverse health systems and health metrics. The Health of Indian States Report emphasizes how epidemiological transitions vary across states, reflecting demographic, economic, nutritional, and obstetric transitions. For example, the report highlights how the burden of diseases differs in Empowered Action Group1 (EAG) and North-East states as compared to other states. Infectious diseases like diarrhoea, tuberculosis, and lower respiratory tract infections are among top-5 disease burdens in EAG states, while non-communicable diseases, such as stroke and COPD figure among the top-five causes in other states.
The Union government is responsible for helping states, particularly those lagging in development trajectories. Over the last 76 years, the Union government has launched numerous projects to assist in improving healthcare delivery. Earlier, the implementation of vertical national programs supported tackling major disease challenges and family planning. Subsequently, Reproductive and Child Health (RCH) programs supported population control, reducing maternal and child mortality, and improving services. The National Rural Health Mission, launched in 2005 and later expanded to be National Health Mission (NHM), has significantly contributed to strengthening health systems in the states and has been a landmark moment in this regard.
The NHM was a watershed moment that changed the healthcare scenario in states, however, this program also required states to deliver programs as per national guidelines. The already weak state health systems in many states, especially the Empowered Action Group (EAG) states, could not get breathing space to think about reorganising their systems to make responsive healthcare and struggled to comply with the national guidelines. Thus, inter-state discrepancies in state health systems persisted despite making strides in improving selective health outcome indicators.
Recent initiatives by the Union government too have similar challenges. Though these schemes help states in improving healthcare delivery, they also limit the development of state capacities to plan, innovate and improve health systems governance and management. For example, the Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana is being implemented in a similar manner, where national guidelines are supposed to be closely followed. Though there is clear scope for state-level innovation, weaker states struggling with implementation, hardly get breathing space to align the scheme with state goals. As a result, all these well-intentioned initiatives for strengthening health systems eventually limit health policy thinking and planning at the state level.
Another similar example is the expansion of the Union government-led medical education network and hospitals such as the All India Institute of Medical Sciences (AIIMS). The expansion of the AIIMS network is well-intentioned to improve the outreach of quality healthcare across the country, but these efforts also face similar challenges. As a side effect, they created a class system in medical education and treatment preference within the state, where the patients see state government institutions as second class and AIIMS as better, though these institutions can still not fulfil all the required healthcare needs of the population of respective states.
Peters and Rao in their paper ‘Lumping and Splitting’ highlighted the challenges of health policymaking in India. It is time that the Union of India supports health policy and systems thinking and planning at the state level. We have seen exemplary work during COVID-19 when the national government supported, and states led the efforts to fight the pandemic. The same approach should also be adopted for policy and programs during routine times.
The Union of India developed three distinct national health policies in 1983, 2002, and 2017. Now, it is high time to support and develop state health policies and state health plans based on contextual and operational factors and build state health systems' capacity. Health systems in India are not one but rather an amalgamation of all state health systems. Therefore, decentralised health policy and planning is the key to improving healthcare in India.
[1] EAG states are eight socio-economically backward states of India, which include Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttaranchal, and Uttar Pradesh.
About the author:
Dr. Vikash R. Keshri is a medical doctor, public health expert, and health policy and systems researcher. He can be reached at vrkeshri@gmail.com. He tweets @docVRK.
Photo by Felix Mittermeier on Unsplash
This article was originally published on Nivarana.org