Introduction
Under Article 21 (Right to Life) and Article 47 (Directive Principles regarding the duty of the State to raise nutrition and public health), healthcare is a fundamental constitutional priority. While initiatives like Ayushman Bharat (PM-JAY and Ayushman Arogya Mandirs) have widened access, public health governance remains structurally challenged, reflected in low public funding stagnant at approximately 1.7% of GDP, falling short of the National Health Policy 2017 target of 2.5%.
1. Federal Friction and Financing Architecture
- Asymmetric Capacity: While public health is a State subject under Entry 6 of the State List, states remain heavily dependent on Centrally Sponsored Schemes such as the National Health Mission (NHM) and PM-ABHIM. This leads to inter-governmental friction over fund-matching formulas, delayed fiscal disbursements, and rigid programmatic targets.
- High Out-of-Pocket Burden: Out-of-Pocket Expenditure (OOPE) accounts for approximately 39.4% of total health expenditure according to National Health Accounts (2021-22), indicating persistent gaps in public financial risk-pooling.
2. Regulatory Governance and Private Sector Oversight
- Weak Enforcement: Poor state-level adoption and enforcement of the Clinical Establishments (Registration and Regulation) Act, 2010 has resulted in an under-regulated private sector characterized by unstandardized costs, predatory billing, and variable clinical protocols.
- Workforce Maldistribution: Deficits in human resource governance and deployment guidelines have led to an acute shortfall of nearly 80% of specialist doctors at rural Community Health Centres (CHCs).
3. Decentralisation and Local Governance Deficits
- Unfulfilled Constitutional Mandate: Despite provisions in the 11th and 12th Schedules of the Constitution, Panchayati Raj Institutions (PRIs) and Urban Local Bodies (ULBs) lack the devolved "Funds, Functions, and Functionaries" (3Fs) needed to govern primary care centers and sanitation infrastructure effectively.
4. Digital Governance and Disease Surveillance
- Fragmented Ecosystems: Although platforms such as the Ayushman Bharat Digital Mission (ABDM) and the Integrated Disease Surveillance Programme (IDSP) have been rolled out, data silos persist between private care providers and state epidemiologists, constraining real-time response to disease outbreaks.
Conclusion
Addressing these public health governance deficits requires transitioning from scheme-driven interventions to an integrated systems-based approach. Strictly enforcing the Clinical Establishments Act, empowering local self-government institutions with functional autonomy, and creating an All-India Medical and Health Service (AIMHS) are vital steps toward building an equitable and resilient health architecture.