Health policy and federalism in India

Abstract

This paper addresses the question of how the position of Indian states in terms of their approach to welfare state policies interacts with the centre-state relationships that characterise health policymaking. In India's version of federalism health policymaking has been influenced by four mutually interacting sources: international public health discourses; Indian government programmes and policies; civil society organisations concerned with health; and the political economy of the different states and their associated political regimes. Public health issues sometimes achieve high policy profile at the government of India but very rarely do so at state level. This divergence provides fertile spaces for negotiation and conflict. An analysis of the path-dependency of the allocation of health functions to different national and sub-national levels of government contextualises a case study of the National Rural Health Mission, 2004Mission, -2014. This shows the limits to the central government's ability to implement a universalising, rights-based programme across the country. An explanation for the different outcomes can be found in the variety of state systems within the country. Finally, the paper assesses whether the changes introduced since 2014 show a new federal order in the making and provides preliminary insights from state responses to the 2020 Covid-19 outbreak.

The making of India's COVID-19 disaster: A Disaster Risk Management (DRM) Assemblage analysis

“…The lack of the latter was a result of a severely inadequate per capita investment in health services and infrastructure over many years, putting India's health development indicators lower than many of its poorer South Asian neighbours [ 109 ]. 15 The securitised approach that emerged was also made possible by consecutive governments over many years not developing legal, political, and financial mechanisms that would allow rights-based, decentralised, consensual, and ultimately just approaches to pandemic and disaster management to emerge [ 38 , 94 , 95 ]. The policies underpinning the approach taken were rendered largely meaningless at the point of implementation.…”

“…The latter has been posited as creating a greater level of trust and cooperation between state, civil society, and public [ 36 ] – or a more embedded and resilient assemblage of more-than-social contracts [ 37 ]. These appeared to be lacking in other Indian states [ 38 ]. Nonetheless, even those states with these greater systemic and institutional capacities were ultimately hampered by the centralised and rigid DRM Assemblage imposed on them by the central government [ 39 ].…”

Understanding multilevel dynamics in India: constituent power and multilevel governance

“…(Attempted) constitutional reforms in this period (e.g., associated with indirect tax reform or the introduction of a GST predating the recent 2016 GST constitutional amendment) were seen as means to 'integrate', rather than 'federalize', the Indian polity and market. As various contributions to this issue attest (Jeffery, 2021;Kumar, 2021;Sharma, 2021;Tillin, 2021b, all in this issue), this period also coincides with a significant rise in the number and relative amount spent on national development programmes (or centrally sponsored schemes), even in areas of exclusive state competence.…”

Health Insurance Coverage in India

“…Since the creation of the Employees' State Insurance (ESI) in 1952 and the Central Government Health Scheme (CGHS) in 1954, the central government has aimed to develop social and health protection for its citizens. At the time, these programs were seen as the first steps before an extension to the entire population (Jeffery, 1988). Later, in the 1980s, Community-Based Health Insurance schemes (CBHI) were created to provide better protection for the rural population and the poor (Devadasan et al, 2004).…”