Creating a Model Public Health Administrative Architecture for States

Problem

Kerala’s robust healthcare system has served it well during the COVID-19 pandemic. It ranked first on the Niti Aayog’s Health Index-2018, which compared health outcomes and systems across states. The Index assessed some facets of ‘governance’ and ‘key inputs and processes’, using several indicators, such as the proportion of functioning healthcare facilities against required norms and the completeness of the Integrated Disease Surveillance Programme. Although it is difficult to compare the responses of different states to the pandemic, it is evident that the quality of public health administration(s) (‘PHA’) has a bearing on the effectiveness of their responses. The National Health Systems Resource Centre identifies decentralisation, integration and convergence being three prominent challenges to strengthening PHA. Even as the 74th Amendment to the Constitution nudges states to delegate public health and sanitation functions, states in India have undertaken limited decentralisation. For instance, in Karnataka, urban local bodies have the statutory responsibility for the management of public health. However, owing to the multiplicity of state/central level authorities contributing towards the management of epidemics in the district, it is the Deputy Commissioners (“DC”) and her officers, who become the people ‘truly in charge’. In the absence of a defined process for coordination and management during epidemics, containment becomes individual/DC specific. This points to a need for well-defined coordination processes for seamlessness in PHA.

Outside of an epidemic, public health outcomes may be adversely affected by a lack of inter-sectoral coordination. This has been observed in relation to maternal health in Gujarat and with respect to child nutrition. 

A similar lack of convergence is seen in the operation of multiple public health schemes and programmes, sometimes challenging the individual state capacity to monitor their outcomes. Even in states where the policy design is imaginative of such convergences, gaps in implementation are observed due to ‘limited supervisory mechanisms’.   

The right to health requires states to create a PHA that respects good governance principles by furthering accountability, transparency, non-discrimination and public participation.

Poor PHA has a direct impact on the right to health. The higher judiciary has repeatedly recognised the implementation failures of health schemes as violations of the right to health under Article 21 of the Constitution, whether in relation to maternal care, healthcare for the elderly or primary healthcare in general. Although Indian Public Health Standards under the National Health Mission set basic norms for healthcare delivery, they are specific to particular institutions like community health centres and district hospitals. They are not system-related governance norms and do not have any legal backing.

Solution

The right to health requires states to create a PHA that respects good governance principles by furthering accountability, transparency, non-discrimination and public participation. This requires a legal framework that can define the powers and functions of public health officials and coordinate the activities of different levels and branches of government.

While public health is a state subject, given the centralised nature of key health missions and programmes, the central government should lead in setting minimum governance standards for PHA, which can then be adopted through state-level legislation with modifications. States may create a nodal agency to administer such legislation, accounting for the need to reduce fragmentation in healthcare delivery, while recognising that the right to health also includes its underlying determinants like nutrition and sanitation.

Implementation

• Develop good governance indicators and audit all schemes related to public health on this basis, using the National Health Systems Resource Centre. 
• Draft a model, rights-based public health law that sets enforceable, system-based standards for public health administration and establishes a nodal agency to ensure observance of these standards. The nodal agency should also promote and supervise inter-sectoral coordination at all levels through appropriate mechanisms. The nodal agency should comprise health experts as well as representatives of sectors related to the underlying determinants of health. 
• Build the capacity of public health officials to adhere to and implement good governance standards.

About the Authors

Shashank Atreya

Shashank Atreya was a Associate Fellow at Vidhi, Bengaluru. He is a graduate of law and business administration. He works primarily with the Karnataka Government to advice various departments in the areas of municipal governance, urban development, urban transport and education. In his past assignments, Shashank worked as an Associate with Chase-India, a public policy consulting firm in Delhi.

Yogini Oke

Yogini is a Research Fellow working in the area of Health and Environment. Yogini completed her B.A. LL. B. (Hons.) from the West Bengal National University of Juridical Sciences, after which she pursued the Young India Fellowship at Ashoka University. Prior to joining Vidhi, Yogini worked at the Centre for Policy Research on the subject of Urban Sanitation. Yogini is interested in studying the workings of the law in the larger social, economic, and political contexts, especially with respect to health and environment and has published her work on this in various online media outlets and blogs.