A health worker screens the patient quarantined next door at the High Speed Rail Training Institute in Vadodara | Photo: Praveen Jain | ThePrint
Representational image | A health worker screens a patient quarantined at the High Speed Rail Training Institute in Vadodara | Photo: Praveen Jain | ThePrint
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The fact that approximately 50 million people died around the world of the Spanish flu, which broke out in 1918, meant that it was no longer acceptable for governments to blame individuals for contracting a disease. Instead, governments everywhere channeled public outrage over health systems towards building a governance architecture to provide, what journalist Laura Spinney describes as, “healthcare for all”. This included population scale public health programmes, creation of health ministries and systematic collection of medical data.

In 2020, India has the opportunity to implement reforms that passed us by a century ago under colonial rule. Vidhi’s briefing book titled Towards a Post-Covid India provides recommendations on 25 such reforms.

The ‘centralisation’ problem

The reactions of the central and state governments to the coronavirus pandemic have demonstrated two fundamental fault-lines in India’s governance of public health.

First, though the Disaster Management Act, under which most executive action has been taken, is a central legislation, public health is a state subject. The exact delineation of powers between the Centre and the states has remained a work-in-progress over the past few months, resulting in considerable confusion on quarantine rules, closure of state borders and restarting economic activity. This is not surprising in a large, complex country. But good governance demands that such friction be mitigated.

The provenance of this problem is not new. At the time of framing of the Constitution, parliamentarian H.V. Kamath described public health as the ‘Cinderella of portfolios’ abjectly neglected during British rule. He felt that health should be a ‘top priority’ of all governments in independent India. Putting it in the Concurrent List would, in his view, achieve this objective.

Taking this further, MP Brajeshwar Prasad strongly argued for health to be transferred to the Union List. Berating the pathetic condition in state hospitals, he noted that hospitals were sites where “flies and bugs are multiplying”.


Also read: Health a state subject, but Covid proved how dependant India’s states are on Centre

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Shift health to Concurrent List

As we know, both Prasad and Kamath were unsuccessful. Though it is anybody’s guess how India’s hospitals and healthcare would have unravelled had their suggestions been adopted, the trajectory of healthcare governance in general and the coronavirus pandemic in particular have proved them right in one respect.

Even before the pandemic struck, public health, despite being a function of the states, was coordinated and strategised by the Union Health Ministry. Moreover, the National Health Mission (NHM) is a central scheme funded largely by the central government.

With the onset of the pandemic, the need for coordination and uniformity across states was even more keenly felt with regular interactions between Cabinet Secretary Rajiv Gauba and state chief secretaries, and apex level discussions between Prime Minister Narendra Modi and chief ministers. Moving public health to the Concurrent List would be a truer reflection of how it is actually handled in India.

However, such a move should not be interpreted as a prod towards greater centralisation of public health.


Also read: Doctors, nurses, paramedics, healthcare can be India’s new engine of growth after Covid-19


Improve service delivery

The second fault-line evident in the past few months is in poor service delivery by governments. The actual implementation of any public health measure is always by officials closest to the ground — district magistrates who administer health schemes, municipal corporations who run local hospitals, panchayat members and local leaders who are responsible for last-mile access to rural health centres.

It is here that the coronavirus pandemic has exposed fundamental frailties. Delhi’s famed mohalla clinics have rarely made a positive appearance in the press once the novel coronavirus struck; Mumbai’s redoubtable network of public hospitals, despite best efforts, have simply not been supple enough to adjust to changed realities; data collection from parts of rural India has remained patchy and unreliable. This is not a failure of administration. It is a failure of design.

The third tier of government, comprising municipal corporations and panchayati raj institutions, is disempowered and emaciated. It neither has the powers nor the financing necessary to carry out its functions effectively. The Constitution, in an unfortunate compromise embodied in the 73rd and 74th Amendments, left the issue of the powers of local self-governments to the discretion of states. Most states have been loath to transfer their powers. The record of states that have, speaks for itself. Kerala, which has stood out in its response to the pandemic, vests village panchayats with exclusive powers to administer dispensaries and primary health care centres in their areas.


Also read: Price controls are a terrible idea to tackle private-public healthcare gap in India


Fund local governments

At the same time, financing of local self-governments is left to the benefaction of states. Neither do they have taxation power, nor are some revenues meant for such bodies actually devolved to them. The 15th Finance Commission should, in its upcoming award, tie the devolution of certain state government funds to legal amendments by states that devolve powers related to public health to local self-governments. Such a condition was imposed earlier by the 12th Finance Commission, which mandated the enactment of a fiscal responsibility statute by states as a precondition to restructuring central loans to them. The time has come for a similar move to empower the third tier.

As ThePrint’s Opinion editor Rama Lakshmi wrote recently, India has a sterling record of reforming in crises. While the central government has, in 2020, like in 1991, moved quickly to refashion the economy, it cannot afford to lose this opportunity for structural reforms in public health governance. After all, unlike 1991, this is first and foremost a healthcare crisis, not an economic one. Let us not forget the very literal lesson for governments in the aftermath of the Spanish flu, the last similar healthcare crisis the world faced — reform or perish.

Towards a Post-Covid India is a briefing book with 25 legal reforms recommended by the Vidhi Centre for Legal Policy. Join a series of conversations — ‘Law with a Difference’ — on the book. ThePrint is the digital partner. Read all the articles here.

Arghya Sengupta is Research Director, Vidhi Centre for Legal Policy. Views are personal. 

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