The three tiers of government in public health

by K. P. Krishnan.

The Covid-19 pandemic has provided us with fresh insights on health policy in India. One key element of this thinking lies in a careful understanding of what elements of public health are best done at the city/district level, at the state level or at the union government. The Constitution of India has allocated the tasks in some detail. Considerable policy research work is now required, to bring life to the Constitutional scheme, based on a first principles understanding of the work that is required in public health, drawing on our experiences of 2020.

Market failure in health policy

There are great insights that can be obtained in the field of health policy by applying the toolkit of market failure. It is best to define the task of government as addressing market failure, and market failure comes in four categories: concentration of market power, presence of positive or negative externalities, presence of information asymmetry, and the need to provide public goods. There is a neat split in the field of health: public health is about public goods and externalities, while health care may contain market power and asymmetric information.

Public goods are a compelling example where the government is central, and the things that are not done by the government are hard to achieve through purely private initiatives other than pure philanthropy. Knowledge is the ultimate public good -- once a research paper is released on a website it is non-rival and non-excludable -- and we need public funding for research. When one person coughs and communicates Covid-19 to another, this is a negative externality, and there is some role for the government in reducing this externality. The main task of health policy thinking lies in analysing the landscape of public health, identifying the market failures (public goods and externalities), defining the tasks of the government, and finding a path to achieving state capacity on these functions.

Where should each function be placed?

Once we have a picture of the various functions which have to be performed in public health, we come to the question of the best place where it should be performed: the union government or the state government or the local government. The famous `Subsidiarity principle' of public economics asserts that every function should be placed at the lowest level of government where it can possibly be performed.

As an example, Amy Harman and Farah Stockman have an article in the New York Times which describes the treatment of travellers from China into the US. The federal government (which we in India call the union government) is the right agency to track flights and obtain lists of passengers. After this, there is a handover of information, that person x flew in from China, to the local government where that person resides. At this point, the local government is the one best equipped to work on contact tracing, testing, and isolation. This is an optimal allocation of the two tasks. It is hard for a local government to keep track of who flew in from China. It is hard for the union government to manage front line staff in a city or a district.

It is interesting and important to think about the elements of a public health system, and to think about the optimal placement of each of these elements, between the union, state and local governments. However, we do not engage in policy thinking on a tabula rasa. We do policy thinking in India where the Constitution of India has a well-developed point of view on these questions, and amendments to the Constitution on this aspect are rare. Hence, our puzzle in thinking about public health in India lies in taking full cognisance of the Constitutional scheme and best adapting it for our present understanding.

Health in the Indian Constitution

The distribution of subjects in the Constitution is reasonably elaborate. It sets up a division of labour between different levels of government, viz, the union, state, panchayat (rural local bodies), and municipalities through a list of subjects which are enumerated in its schedules VII, XI, and XII.

The Seventh Schedule of the Constitution lists the distribution of the subjects between the union and the states, while the eleventh and twelfth schedules deal with the distribution of responsibilities at the local level, i.e., panchayats and municipalities. Every policy thinker in India needs to fully understand these three schedules. Table 1 summarises the distribution of subjects in the domain of public health.

Table 1: Distribution of 'health' related subjects in the Indian Constitution

Government	Subject	Reference
Union	Port Quarantine	Schedule VII, List I, Item 28
Union	Union agencies and institutions for professional, vocational or technical training, etc.	Schedule VII, List I, Item 65
Union	Co-ordination and determination of standards in institutions for higher education or research and scientific and technical institutions	Schedule VII, List I, Item 66
Union	Inter-state migration and inter-state quarantine	Schedule VII, List I, Item 81
State	Public health and sanitation; hospitals and dispensaries	Schedule VII, List II, Item 6
Concurrent (both union and state subjects)	Lunacy and mental deficiency, including places for reception or treatment of lunatics and mental deficients	Schedule VII, List III, Item 16
Concurrent	Medical education and profession	Schedule VII, List III, Items 25 and 26
Concurrent	Prevention of the extension from one State to another of infectious or contagious diseases	Schedule VII, List III, Item 29
Panchayat	Health and sanitation, including hospitals, primary health centres and dispensaries	Schedule XI, Item 23
Panchayat	Family welfare, women and child development	Schedule XI, Items 24 and 25
Panchayat	Social welfare, including welfare of the handicapped and mentally retarded	Schedule XI, Item 26
Municipality	Public health, sanitation conservancy and solid waste management	Schedule XII, Item 6
Municipality	Safeguarding the interests of weaker sections of society, including the handicapped and mentally retarded	Schedule XII, Item 9

There is a significant role of union government in subjects relating to contagious diseases and pandemics. It is also responsible for setting standards of medical education and profession along with the state government. On the other hand, state and local bodies are responsible for most public health functions such as sanitisation and family welfare.

A simple reading of the distribution of functions induces many questions. For instance, vaccination is a public health function which is a part of state list under the Constitution. This is logical, given that immunisation programs require a large front-line workforce that interacts with the population. However, the design of the standard package of vaccinations for all kids, and envisioning ambitious projects like the eradication of smallpox or polio, require thinking and coordinating by the union government.

Similarly, in a public health crisis such as COVID-19 all levels of government are required to perform their specific functions that are elements of the overall public health response. These elements include tasks such as planning, funding, managing and on-ground implementation. These elements are not described in detail in the Constitution but are an important part of the legal and policy mechanisms adopted by the government.

There is at present relatively little in place, in India, by way of Parliamentary law which shapes and circumscribes the work of public health. The British-era Epidemic Diseases Act, 1897, has many problems. The legal framework under which India is responding to the COVID-19 crisis is the Disaster Management Act, 2005 which sets up a National Authority whose role is briefly discussed below.

The role of the National Authority

The Disaster Management Act, 2005 is the union law that was used by the union government in its Covid-19 response. In this Act, a disaster is defined to be:

a catastrophe, mishap, calamity or grave occurrence in any area, arising from natural or man-made causes, or by accident or negligence which results in substantial loss of life or human suffering or damage to, and destruction of, property, or damage to, or degradation of, environment, and is of such a nature or magnitude as to be beyond the coping capacity of the community of the affected area;

Under this law, the National Authority is responsible for drawing a national plan for disaster mitigation, prevention, and preparedness. This plan is to be reviewed and updated periodically. The law also recognises the role of multi-level governments as it sets up the national, state and district level authorities which are responsible to follow the guidelines of the National Authority.

The National Disaster Management Plan in India was last updated in November 2019, its only revision after the first plan was released in 2016. While the plan deals with Biological and Public Health Emergencies (BPHE), it does not provide detailed guidelines on the structural frameworks required for dealing with a global pandemic at the scale of COVID-19. In this sense, India does not have a national plan to deal with the COVID-19 crisis as of now. It would be useful to design a national plan which guides the government in undertaking a well-coordinated action to deal with the crisis. The national plan should be mindful of the spatial element of the public health interventions in COVID-19 such as:

1. Inter-state migrations, operations of flights require intervention by the union government.
2. Hospital preparedness, such as the presence of an adequate number of hospital beds, medical equipment such as ventilators and oxygen etc. require intervention at the state level.
3. Contact tracing and quarantine enforcement require intervention at the municipal or local level.

A guidance document by the National Authority with conceptual clarity about the elements of public health will be useful to minimise policy failures in COVID-19 management. At present, some clear policy failures in COVID-19 management are being observed. These failures are at all levels of the government, the union, state, and local levels. Some of them are described below as illustrations:

Union-state coordination

Actions taken by the government during a pandemic have political repercussions and therefore, a tension between the state and union government priorities can exist. For instance, in Delhi, the elected government and the Lieutenant governor had disagreed on the conditions being imposed on businesses during the lockdown period leading to uncertainty for the public.

Varying state priorities

Border state conflicts relating to inter-state travel of persons became common in the early period of the COVID-19 pandemic. In the first week of April, Karnataka state sought intervention of the Supreme Court to resolve a dispute regarding border movement with the neighbouring state of Kerala during lockdown imposed due to COVID-19. This was after the Kerala High Court passed a verdict asking Karnataka to allow movement of persons between the states. Eventually, the union government was involved in reaching an amicable settlement between the states regarding conditions of movement of persons during the lockdown.

Varying priorities of local bodies

The local bodies are empowered to take action in public interest under the Disaster Management Act. During the COVID-19 crisis, it was observed that local bodies failed to take into consideration the impact of their decision on neighbouring districts. For instance, the Noida district administration barred entry of persons from the Delhi border without a pass issued by them. This caused trouble to essential workers such as doctors and nurses who worked across the district border who would be left stuck at the border without knowledge of requirements for such a pass.

Heterogeneity within the vast country

There is great heterogeneity within the 3.3 million square kilometres of India, in the state of the epidemic, in trade-offs between mobility and disease control, and in state capacity. There is great value in having democratic legitimacy in each city or each district in choosing the optimal path.

While working through the Disaster Management Act was expedient when faced with the pandemic, as the dust settles, there is a need for health policy thinkers to envision a public health system for India. It is important to, lay this on sound legal foundations, whereby the Disaster Management Act is ultimately focused on natural disasters like earthquakes, and public health has its own legal and institutional architecture that is fit for this purpose.

Conclusion

There is a need to bring greater coherence to all the elements of state power that are in play in the response to Covid-19. This has led to twin challenges of a) micromanagement by the union bodies, and b) excessive delegation of powers to the state and local governments without adequate checks and balances. For instance, approval for Covid-19 testing labs throughout the country is done by a single body, the ICMR, an approach that has difficulties. Similarly, certain orders by district and state authorities have also been criticised during the course of the pandemic for being arbitrary.

We should utilise our fresh understanding of the present problems, to build a body of knowledge on (a) What are the tasks of public health in India (b) What is the role of the union / state / local government in each of these and (c) How to achieve state capacity on each of these components?

K. P. Krishnan is Professor at National Council of Applied Economic Research (NCAER).