Federalism, Decentralization, and Health Care Policy Reform in India
Pahwa, Divya H., Beland, Daniel, Public Administration Research
This article explores how the Indian federal structure impacts health care. India has a history of central planning and concentration of power at the federal level. This concentration of power has left state and local levels of government in a subordinate position. Such a situation has distorted incentives, and a by-product of this has been a rather disorganized health care system. Disorganization and fiscal limitations have become major obstacles to large-scale reform of India's health care system. However, reform is necessary. As argued, a stronger, more decentralized, and better regulated public health care system should improve human welfare in India, while fostering the development of a stronger sense of national identity derived from shared, universal social citizenship.
Keywords: India, health care, policy reform, federalism, decentralization, citizenship, national identity
In recent years, a growing number of scholars have explored the relationship between federalism, decentralization, and social policy, including health care (e.g., Noël, 1999; Obinger et al., 2005; Théret, 1999). More specifically, single-country and comparative studies have considered the federalism-health care nexus (e.g., Banting and Corbett, 2002; Holahan et al., 2003; Maioni, 1998; Weissert and Scheller, 2008). In this article, we explore how the Indian federal structure impacts health care policy in such a large, diverse, and fragmented country. The Indian federal structure has been shaped by a history of central planning and concentration of power at the federal level. This concentration of power has left state and local levels of government in a subordinate position (Bagchi, 2003: 21). This subordination has created distorted incentives within the political institutions of India. Local level governments are unable to wield the power necessary to properly execute region-specific policies. A by-product of this has been a disorganized health care system. This disorganization materializes, for example, in the form of mismatched funding to state and local governments, or of a concentration of health care professionals in urban areas. Reform to the Indian health care system is necessary. As argued in this article, one of the most effective ways to strengthen citizenship and national unity is to ensure that the health care needs of those living in rural areas are being met. Ensuring rural health care needs would show that the Indian government cares about the welfare of its entire people, and not only urban dwellers. In turn, this would help create a sense of universal social citizenship in India (Note 1). We are aware that these policy suggestions do not inclusively address all the issues and difficulties present in the current Indian health care system. The suggestions offered are argued to be an initial step to greater reform.
In order to analyze health care reform and its potential consequences for citizenship and national unity, we must examine how India's federal institutions shape the country's health care system and, in particular, its connection with rural citizens. This analysis features a look at the territorial and institutional organization of health services in India in order to address the following questions: how does Indian federalism impact the health care system and, in the end, can this system offer "comparable levels of health services" (Banting and Corbett, 2002: 18) to all regions of the country? To address these questions, we place the Indian case in the broader context of the existing international and comparative literature on federalism and social policy. At the broadest level, the article combines detached institutional analysis and normative policy prescriptions.
Four main sections comprise this article. Drawing on the best international literature available, the first section explores the relationship between federalism and health care while making a case for the effective decentralization of health services as a way to improve care delivery. …