Bridge widening gaps in health outcomes, services

A couple of days before the Interim Budget was presented, the Union finance ministry published ‘The Indian Economy: A Review’ which focuses on the state of India’s economy from 1950 to 2024. The document, interestingly, does not discuss public health service delivery, which has been at the centre of the government’s economic policies over the last few years, especially since the Covid-19 pandemic.

The Interim Budget of 2024-2025 focussed on setting up more medical colleges, which is a welcome move as it’ll help in meeting the local healthcare needs of the public. Is this sufficient in providing affordable and easily accessible healthcare services to all which is the target of the Government of India to achieve universal health coverage?

India has been witnessing a rising trend in Emerging Infectious Diseases among Southeast Asian countries over the last decade. This comes against the backdrop of socioeconomic inequalities that have played a significant role in widening the gaps in health outcomes and access to health services across India.

Before we understand the emerging state of healthcare in India, let us step back and understand how healthcare governance is structured in India. India has a quasi-federal governance structure where health policies are formulated at the national or sub-national level of governance but are eventually implemented at the grassroots level by the local governments. This makes it imperative for the higher tiers of governance to work closely with local bodies as they are the first point of contact for the public while implementing health policies. This need for greater co-ordination was also witnessed during the health emergencies that India faced over the last two decades, such as Chikungunya, Nipah, and Covid-19.

While Covid-19 shook the structural and functional capacity of even the best health systems in the world, different states in India were pushed to actively collaborate with local governments to ensure their health infrastructure stability. This is because the local government institutions are responsible for managing vector and waterborne infectious diseases. Hence, the government and policymakers must understand their effectiveness in handling health emergencies in the wake of a rising number of infectious diseases in the world.

How effective is collaborative governance during a health shock? Evidence-based studies have shown mixed outcomes on local governments’ role in managing epidemics. For example, in Italy, the spread of Covid-19 was attributed to the decentralisation of health services to local governments, which slowed down the overall response rate; in other places like New York and Kerala, the local leaders were praised for their pro-activeness during the initial phase of the pandemic.

This highlights the role of leadership at the local level as well as the role of collective action in public health during a crisis, which partly explains the effectiveness of local governance in specific settings. This is because the activities of local bodies can be monitored and complemented by the efforts of the population under their governance.

In her groundbreaking work on the evolution of institutions for collective action, Elinor Ostrom (Nobel Prize winner in 2009) introduced the concept of ‘nestedness’ to solve challenges associated with externalities. This concept can also be applied to public health problems globally. ‘Nestedness’ in the context of public health implies increasing or reducing collaborative efforts between the different tiers of governance as per the need. Understanding the relevance of ‘nestedness’ is crucial in a post-pandemic world. In most parts of the world, greater decentralisation of health services helped in managing the Covid-19 outbreak; yet in Italy, co-ordination between the centre and the sub-regional governments was weak, which worsened pandemic management.

Learning from this experience, health specialists are proposing a holistic approach to determine solutions to tackle public health emergencies in the future. The systems approach to public health is one tool that can help analyse the increasing complexity of health systems and design more resilient health systems. This is because a health crisis not just affects the health sector, but it spreads beyond and can potentially affect other systems over time and across countries.

The post-Covid-19 world has made it essential to understand the strength of institutional structures of a country while analysing its public health challenges. So, apart from the positive initiative of setting up new medical colleges, it is also important that the Union government strengthen public health services at the grassroot levels, to make India’s overall health delivery system a vibrant one.


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