Building public health resilience through institutional preparedness in India

This paper uses India as a case study to examine the policy environment, public health financing patterns, and inter-state disparities in health infrastructure that provide important context for understanding the country’s public health preparedness at the onset of a major health shock such as COVID-19. The study first outlines India’s health policy trajectory since Independence and descriptively analyses the allocation of funds across major public health programmes that were operational at the onset of the pandemic. It also investigates inter-state disparities in public health infrastructure from 2005 to 2015, drawing on data from NITI Aayog’s 2020 Report, to establish a structural baseline of long-term infrastructural disparities relevant to public health preparedness. These analyses highlight the historical policy, fiscal, and infrastructural conditions that provide a broader context for understanding India’s capacity to respond to a large-scale health crisis. In the second part of the paper, the potential role of Local Government Institutions (LGIs) in strengthening the baseline capacity of health systems is examined. Using the Control Knobs framework, a theoretical model is developed to examine how LGIs, supported by higher-tier governments, may allocate limited resources across important dimensions of the health system, subject to fiscal constraints. Accordingly, the study adopts a descriptive-analytical and theoretical research design. While India provides the empirical illustration in this study, the theoretical framework and insights are designed to be applicable across countries. The study acknowledges the limitations of the descriptive empirical analysis and the absence of empirical validation of the theoretical model, highlighting the need for future research to test the theoretical propositions developed in the study.