India’s Decentralized Health Policy Guidance System is Hiding in Plain Sight: Time to Strengthen it

BACKGROUND India’s health systems reform journey has been marked by institutional innovations that have reshaped service delivery, governance, financing, and beyond. Among these, a foundational yet often overlooked innovation is the creation of a structured ecosystem for health policy guidance: a network of State Health Systems Resource Centres (SHSRCs), supported by the National Health Systems Resource Centre (NHSRC). These institutions were not intended as parallel implementation units. Rather, they were envisioned as embedded policy advisory bodies that are intended to synthesize evidence, support strategic planning, and enable system-wide reforms. While NHSRC continues to serve as the apex technical institution supporting the Ministry of Health and Family Welfare (MoHFW), the SHSRCs were designed to play a decentralized and synergistic role within states. However, they remain variably recognized and underutilized. Unlocking their full potential could substantially enhance the capacity for state-level, evidence-informed decision-making and strategic design. AN INSTITUTIONAL DESIGN WITH PURPOSE Established in 2007, NHSRC functions as the principal technical support agency for MoHFW, with a mandate that includes policy and strategy development, technical assistance to states, and capacity building under the National Health Mission (NHM). Over time, it has played a pivotal role in institutionalizing quality improvement processes, advancing health financing reforms, guiding human resource strategies, strengthening secondary care and governance, innovations in community processes, and improved primary health care. Its enhanced role over the past 5 years, particularly through expanded expertise in evidence generation, implementation research, and the information technology realm, has been well appreciated and acknowledged. The SHSRCs, supported under the NHM and guided by NHSRC, were first envisioned under the National Rural Health Mission as in-house technical institutions to support health systems strengthening and policy development, particularly in the Empowered Action Group states.[1] However, their formation varies widely. Maharashtra and Madhya Pradesh, for instance, have established autonomous SHSRCs with independent governance and operational flexibility. Others, like Kerala, have adopted a fully embedded model within the state health department, with no legal autonomy but strong proximity to decision-making. Gujarat has adopted a hybrid approach, combining knowledge management cells, technical support functions, and programmatic units aligned with NHM priorities. In Chhattisgarh, the model transitioned from a registered society to an outsourced public–private partnership structure. Newer entrants like Meghalaya illustrate growing development partner involvement in SHSRC functions through philanthropic support. In the absence of a unified design, this diversity has led to fragmentation in roles, mandates, and institutional identity. To address this, the MoHFW released a national SHSRC Framework in 2024, formalizing key principles of governance, technical leadership, and accountability.[2] The framework aims to guide states in repositioning SHSRCs as embedded policy support institutions that are context-specific yet aligned with national health priorities. AN UNEVEN LANDSCAPE OF UTILIZATION Despite the clarity of this institutional design, the operational landscape of SHSRCs across India remains uneven. While some centers have emerged as credible partners to their state governments, others face challenges ranging from intermittent staffing and fragmented mandates to unclear positioning within state bureaucracies. In several instances, donor-funded Technical Support Units (TSUs) have taken on overlapping roles. These arrangements may address immediate programmatic needs but often lack the institutional continuity, embedded authority, and public accountability required for long-term reform.[3] Overreliance on donor-funded TSUs risks fragmenting institutional ownership and accountability, weakening the state’s own capacity to generate and use evidence for policy guidance. Recognizing these risks, NHSRC has begun working with state governments to revitalize SHSRCs and help align them with national and state-level priorities, while safeguarding their role as government-owned and state-anchored policy advisory bodies. EARLY EVIDENCE OF WHAT WORKS Where SHSRCs have been clearly institutionalized, their contributions to health policy and systems strengthening are evident. In Chhattisgarh, SHSRC was central to the design and implementation of the Mitanin program, which later became the foundation for the national ASHA model. Its positioning as a public, in-house technical agency enabled long-term continuity, responsiveness to state-specific challenges, and innovation uptake.[4] In Odisha, the SHSRC has supported district health planning, capacity building, and institutional development initiatives across program areas. In Tamil Nadu, it has supported quality assurance mechanisms and monitoring systems within the health department. These cases suggest that, when adequately structured and supported, SHSRCs can serve as trusted intermediaries that connect evidence, program strategy, and systemic reform. STRENGTHENING SHSRCS FOR HEALTH POLICY GUIDANCE For SHSRCs to fulfil their intended role as policy advisory institutions, four strategic actions are necessary. First, states must clearly define the mandate and governance of SHSRCs based on the MoHFW’s framework. This includes formalizing their distinct identity from TSUs, clarifying reporting structures, and embedding them within state health departments with a long-term vision. Second, sustainable financing should be assured through NHM provisions to reduce dependence on external actors. While TSUs may continue to serve specialized programmatic functions, they should not be equated as substitutes for in-house capacity. Third, investment in technical leadership and multidisciplinary staffing is essential. SHSRCs must attract professionals across epidemiology, public finance, implementation research, health systems, and data analytics. These are all disciplines critical to robust policy guidance. Establishing leadership structures that ensure continuity and accountability will further enhance operational coherence and effectiveness. Fourth, SHSRCs should continually expand their engagement with emerging health system interventions and institutionalize mechanisms. This includes supporting research, evaluation, and evidence-based decision-making. Their potential as platforms for resource optimization and collaboration with academic and public health institutions remains significantly underleveraged. NHSRC, through its existing mandate, can continue to play a catalytic role in this transformation by facilitating peer learning, technical handholding, and capacity strengthening. A STRATEGIC ASSET FOR THE NEXT PHASE OF REFORM As India deepens its health system reforms through initiatives such as Ayushman Bharat, and ongoing programme interventions under NHM, the need for decentralized, embedded policy guidance becomes more urgent. SHSRCs are already positioned to fulfil this role, not as supplementary structures but as enduring public institutions grounded in local systems and aligned with national goals. The imperative now is not to create new structures but to recognize and invest in the institutional capacities already in place. Authors’ contributions Maj. Gen. (Prof) Dr Atul Kotwal: Conceptualization; Writing – Original Draft, Writing – Review and Editing; Supervision. Dr Tarannum Ahmed: Conceptualization; Writing – Original Draft, Writing – Review and Editing. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest to declare.