Impact of Over-centralisation in health policy

Context

Over-centralisation in health policy has emerged as a significant challenge to India’s federal structure and the effectiveness of its healthcare system. This trend involves the central government exerting greater control over health services, funding, and policy-making, often at the expense of state autonomy. The implications of such centralisation are multifaceted, affecting not only the delivery of healthcare but also the broader federal framework of governance.

Context of Centralisation

Recent developments, such as the Supreme Court’s ruling on domicile-based reservations in medical admissions, have highlighted the tension between central control and state autonomy in health policy. This ruling, while promoting meritocracy, has been criticized for undermining state-specific health strategies and potentially exacerbating regional disparities in healthcare access.

Impact of Over-Centralisation

• Limited Flexibility in Addressing Local Health Needs: One of the primary concerns with over-centralisation is its tendency to impose a one-size-fits-all approach to healthcare policy. This ignores the diverse health challenges faced by different states due to variations in demographics, disease burden, and infrastructure. For instance, states like Kerala require policies tailored to an ageing population, while Bihar and Uttar Pradesh need more focus on maternal and child health.
• Reduced State Autonomy in Healthcare Governance: Centralisation has led to states losing decision-making power in key health schemes. The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), for example, is a central scheme where states have limited flexibility in implementation, despite healthcare being a state subject. Many states preferred their own insurance models but had to align with central directives, reducing their autonomy.
• 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 the National Health Mission (NHM), affecting the timely execution of health programs. During the COVID-19 pandemic, centralised vaccine distribution and oxygen supply initially led 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 criticized for imposing central conditions on how states should spend resources, further limiting state autonomy.
• Weakening of Grassroots Public Health Systems: 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. Strengthening these local systems is crucial for effective service delivery.

Specific Policies and Their Impact

Ayushman Bharat and the National Medical Commission Act

• Ayushman Bharat (2018): This scheme provides financial support for secondary and tertiary healthcare to economically weaker sections. However, it has 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), giving the Centre greater control over medical education and licensing, thereby reducing state authority in regulating medical institutions.

Supreme Court Ruling on Domicile Quotas

The recent Supreme Court judgment eliminating domicile-based reservations for post-graduate medical admissions has significant implications for state health planning. Domicile quotas were crucial for ensuring a stable and locally rooted medical workforce, addressing chronic specialist shortages. Their removal may lead to states relying on external recruitment, which is often inefficient.

Risks to Federalism and Public Health

• Constitutional and Public Health Link: Article 21 of the Constitution guarantees the right to life, which includes access to adequate healthcare—a responsibility primarily borne by states under their legislative competence over public health. Over-centralisation hinders state-specific health strategies, compromising both state-level public health governance and the right to health.
• Disparities in Healthcare Access: Premier central institutions like AIIMS, PGIMER, and JIPMER enjoy greater autonomy, while state government medical colleges, critical for public health delivery at the grassroots level, are denied this autonomy. This disparity can worsen regional health disparities and discourage state investments in medical education.

Way Forward: Balancing Centralisation and State Autonomy

• Greater Fiscal Autonomy for States: Allowing states more flexibility in utilizing central funds for healthcare based on regional priorities can help address local health needs more effectively. This approach ensures that states can allocate resources according to their specific challenges and opportunities.
• State-Specific Policy Frameworks: Encouraging states to develop localized strategies rather than imposing uniform national policies can improve healthcare outcomes. States should be empowered to formulate policies suited to their socio-economic and health conditions.
• Strengthening State Health Capacities & Local Governance: Investing in state health departments and local governance structures can improve service delivery. Empowering municipalities and panchayats to manage primary healthcare services efficiently is crucial for effective public health management.
• Cooperative Federalism in Health Planning: Establishing mechanisms for collaborative decision-making between the Centre and states ensures inclusive policy formulation. This cooperative approach can help leverage central support while respecting state autonomy, leading to a more equitable and efficient healthcare system.

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. Prioritizing cooperative federalism is crucial to ensure the well-being of all citizens and address the diverse health challenges across different regions effectively.

Source: The Hindu

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