Governing healthcare in India: a policy capacity perspective
| Author | M. Ramesh,Azad Singh Bali |
| Published date | 01 June 2021 |
| Date | 01 June 2021 |
| DOI | http://doi.org/10.1177/00208523211001499 |
| Subject Matter | Special Issue Articles |
Article
International
Review of
Administrative
Sciences
Governing healthcare in
India: a policy capacity
perspective
Azad Singh Bali
Australian National University, Australia
M. Ramesh
National University of Singapore, Singapore
Abstract
After decades of neglect, in 2008, the Indian government launched a national health
insurance programme to address the needs of the bulk of the population that could not
afford healthcare. This was followed by the launch of another national programme in
2018 that further expanded insurance coverage. These schemes envision a large single-
payer, insurance-based system covering about 110 million families. The central objective
of this article is to assess the government’s capacity to implement these ambitious
programmes. We employ the policy capacity framework developed by Wu et al. to
examine the types of capacities needed to achieve desired objectives in the health
sector. The central argument of the article is that there are critical capacity deficits,
especially along operational dimensions. Our conclusions are generalisable to other
middle-income countries currently in the process of implementing similar prospective-
payment health policy reforms.
Points for practitioners
This article highlights the need for governments to prioritise the capacity for imple-
menting health policy reforms. Efforts to achieve and sustain universal healthcare are
contingent not only on appropriate policy design, mobilising required resources and
building political support, but also on overcoming capacity deficits in implementation.
The framework presented in this article serves as a useful tool for governments to
Corresponding author:
Azad Singh Bali, Crawford School of Public Policy, School of Politics & International Relations, Australian
National University, Canberra, ACT 2600, Australia.
Email: azadsingh.bali@anu.edu.au
International Review of Administrative
Sciences
2021, Vol. 87(2) 275–293
!The Author(s) 2021
Article reuse guidelines:
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DOI: 10.1177/00208523211001499
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diagnose strengths and weaknesses in the specific types of capacities (analytical, oper-
ational, and political) needed for universal health coverage.
Keywords
healthcare governance, health systems, health policy, health reform, India, policy capac-
ity, universal coverage
Introduction
Following the announcement of the 2017 National Health Policy, in 2018, the
Indian government launched Pradhan Mantri-Jan Arogya Yojana (PM-JAY),
offering health insurance to 110 million of India’s poorest families. It is not only
the world’s largest health insurance programme, but also one of the most complex
policy reforms undertaken by the Indian government. The programme is charac-
terised by sophisticated design features, whose success depends on extensive coor-
dination across government agencies, collaboration with private insurers and
providers, and enforcement of elaborate accountability mechanisms.
Effective implementation of PM-JAY is, however, challenging, for several rea-
sons. First, India has a fragmented health system, with multiple programmes man-
aged by different agencies at different levels of government (Maurya and Ramesh,
2019). Layering a new programme on such a fragmented system requires extensive
coordination and design work to ensure that individual programmes cohere and
work in concert (Peters, 2015). Second, prospective-payment arrangements, on
which PM-JAY is based, require policy stewardship and strong governance rela-
tionships among key stakeholders (Brinkerhoff and Bossert, 2013; Ramesh et al.,
2013). However, in India, these agency relationships are weak and the government
has limited policy instruments to steer the sector (Bali and Ramesh, 2015a;
Khetrapal et al., 2019). Third, India has a poor track record in healthcare and
lags behind other countries at similar levels of economic development on conven-
tional health indicators (Government of India, 2021: 156–157).
The central question this article addresses is whether India has the policy
capacity necessary to implement the ambitious health policy reforms it has
adopted. To do this, we extend and apply Wu et al.’s (2015) capacity framework
along three dimensions (analytical, operational and political), with the aim to
assess India’s health policy capacity. We show that weaknesses in the operational
dimension of India’s health policy capabilities impede its reform efforts. The
article’s findings echo a popular refrain in the contemporary policy sciences on
how capacity deficits can unravel the most sophisticated designs (Peters et al.,
2018). While international organisations and the health policy community
debate sophisticated designs to achieve and sustain universal coverage, they pay
inadequate attention to the range of capabilities required to implement them
276 International Review of Administrative Sciences 87(2)
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