Health policy and federalism in India

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 characterize 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 organizations concerned with health; and the political economy of the different states and their associated political regimes. Public health issues sometimes achieve a 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 subnational levels of government contextualizes a case study of the National Rural Health Mission (NRHM), 2004-14. This shows the limits to the central government's ability to implement a universalizing, 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.