The Constitution of India declares India to be a Union of States. There are 29 states and seven union territories, each at different stages of economic and social development. The Constitution also lays out the jurisdictions of the states and the central governments in the form of the State, Union and Concurrent lists. Health for example is a state subject, which means that State governments are meant to be the primary drivers of health policy in India. However most of the public health delivery systems currently in place are a result of central schemes that are conceived and formulated by the central government and only implemented by state agencies. This centralized functioning of health services with little local autonomy has been repeatedly criticised.

Federalism and its consequences for public service delivery have been debated extensively not only in India but internationally. In India, political devolution of power from the central government to the state governments is gaining more momentum. Political parties such as Aam Aadmi Party and BJP have successfully used the decentralization plank to pave their road to victory. With the recent replacement of India’s Planning Commission with the NITI Aayog the new government has sought to involve state leaders in policy making as well as financial planning.

While decentralization in general is a positive trend towards increasing the agency of local actors, it is important to carefully examine and enunciate the balance of power and responsibility. The inequality of capacity and capability among the different state actors has already been pointed out. But even where all states are equal poorly considered, ad hoc devolution of power can make political accountability less transparent.  Decentralization needs to extend beyond financial devolution and be accompanied by a clear chain of accountability for policy implementation.

As seen from the poor implementation of environment and pollution control laws, too much fragmentation of mandate and vaguely defined powers and responsibilities have led to blame games and policy stagnation. We are beginning to see similar trends in health such as in the case of approvals for fixed drug combinations. These situations leave beneficiaries with no redressal except the judiciary and room for a profit-driven private sector.

Recently there is increased recognition of the social determinants of health and by extension a multi-sectoral health-in-all policies approach. Multi-sectoral consensus building becomes easier with a central administration but implementation will inevitably involve a greater variety of actors, at central, state and local community levels. Once again clarity of mandates and accountability will have to be established in addition to fiscal inclusiveness in order to ensure effective implementation of any policy. As India moves towards firming up decentralisation, one ought to carefully ensure that inadequate local structures and local capacities for governance do not make the process of decentralisation counter-productive to its purpose.