The pandemic has exposed the precariousness of the Indian health system. Earlier, many social scientists, doctors and observers were in favour of allocating a bigger share from the Union government’s annual budget to the country’s health sector. On the other hand, another section talked about the lack of funds in the budget.
The ongoing 15th Finance Commission (FC) has suggested that the subject of ‘health’ should be transferred to the concurrent list of the Indian Constitution from the state list. A high-level group (HLG) has also been formed for this purpose. The purpose of this change has been to make the sector well-developed with quality infrastructure.
State list and concurrent list in the Indian Constitution
The subjects under the state list are legislated by the state governments whereas the concurrent list includes subjects that give legislative powers to both centre and the state governments. The concurrent list or List III (Seventh Schedule) is a list of 52 items given in the Seventh Schedule of the Constitution of India.
The present constitutional status of the health sector in India
Public health and allied subjects, such as sanitation, hospitals and dispensaries are under the states’ responsibility under the seventh schedule of the Indian Constitution. On the other hand, prevention of the infectious and contiguous diseases from one state to another, falls under the concurrent list. In practice, the centre has consistently played an active role in shaping public health policies. Additionally, various health related subjects such as food adulteration, drug and poisons, population control, family planning and medical profession have been operating under the concurrent list. The centre determines the national standards and governance framework about these subjects and the states implement these according to the standards.
The HLG and some of its observations
The HLG is chaired by Dr. Randeep Guleria, Director, All India Institute of Medical Sciences, New Delhi. Among other members are Devi Shetty (Narayana Health City), Deelip Govind Mhaisekar (Maharashtra University of Health Sciences), Bhabatosh Biswas (RG Kar Medical College) and K Srinath Reddy (Public Health Foundation). The HLG supports the PPP model for development of the health system. It also observes that India would not be able to spend 2.5% of its GDP on health by 2025 unless the centre does not increase its allocation according to the timeline it had proposed. The HLG also proposes that the states need to allocate at least 8% of their GDP to the health sector. Now their allocation has been around 4.7%.
At present the share of expenditure of the state and central governments is in the ratio of 63:35. That means the central government’s share is much lower than the states. This needs to be changed quickly for the development of health infrastructure in the country. The Finance Commission has the power to allocate additional funds on some basis. The framework would consist of four indicators, such as the total state budget (40%), health system performance (30%), public health system cadre (20%) and stunting declining rate (10%).
Shifting health to the concurrent list
Shifting health to the concurrent list is not the only suggestion of the HLG. The initiation of a Development Finance Institute (DFI) dedicated to healthcare investment has also been suggested. Additionally, suggestions for enhancement of the Union government’s share of health spending of the GDP by 2025, coordinating all states to establish their fundamental commitment for the development of healthcare and allocating two-third of the whole health related spending in this area are all welcome suggestions. When the health sector is in the concurrent list, the central government would allocate more funds in this sector and give more attention and develop the sector by coordinating with the state governments.
All the suggestions mentioned above, if implemented properly, will boost the healthcare sector of the country. But from experience, it is also seen that at times, the state and the central governments get involved in legal and political disputes among themselves in dealing with the subjects in the concurrent list. Professor Ashim Dasgupta, economist and former Finance Minister of West Bengal said that pandemics or managing other large disasters may be brought under the concurrent list but shifting health as a whole to the concurrent list might not be sufficient for creating a vibrant health system in the country.