1How can Indian public health policies take into consideration the country’s immense geographical, demographic, economic, and sociocultural diversity while still maintaining a certain degree of central supervision and control? How can the pluralism at the core of India’s democratic tradition be balanced with the perspective of homogenization and standardization of medical care, which is considered crucial in domains such as epidemic management or drug safety? Or more generally, as Mohan Rao and Balveer Arora put it: “What mix of decentralised and centralised policies best serves the people’s health?” (p. 1).
2The sixteen contributions collected in Public Health and Federalism in India: Dissonant Discourses (2025) explore these questions through a variety of approaches (history of health institutions, policy analysis, and quantitative economy) while addressing diverse fields such as rural health, the pharmaceutical industry, public health emergencies, and women’s health. The volume situates its scholarly contribution within broader debates on federalism, particularly the extent to which states and sub-state units should be empowered to achieve “participatory democracy” (p. 2). An ample body of literature on these questions already exists. Nirmal Mukarji and Balveer Arora (1992), for example, propose to generalize the idea of self-governance at lower levels, suggesting a kind of “cascading federalism, a federation of federations” (p. 270) that would implement an actual form of “multilevel governance and planning” (p. 2). In comparison, however, scholarship engaging with the challenges of multilayered health governance remains somewhat limited, even though decentralization and standardization of healthcare are two central concerns within public health debates. The book Public Health and Federalism in India aims to fill this gap.
3The Seventh Schedule (article 246) of the Constitution of India defines “health and sanitation; hospitals and dispensaries” as a state subject. However, since Independence, the central government has systematically played a leading role in defining and financing health policies. This tension between state autonomy and central interventionism could be clearly observed during the Covid-19 pandemic. During the first wave, Prime Minister Narendra Modi imposed an abrupt nationwide lockdown without consulting state authorities, triggering mass migration and hardship. This measure was widely criticized both for its severe social and economic impact and for its naïve “one-size-fits-all” logic. On the contrary, during the second wave, the central government largely withdrew, leaving states to manage the crisis with uneven results—only to later face criticism from the center.
4Several chapters take the pandemic as a starting point, but most situate their analyses beyond it. In their introduction to the volume, Mohan Rao and Balveer Arora remind us that the dire consequences of the pandemic in India stem less from the biological characteristics of the virus than the sociopolitical circumstances in which it spread: the poor condition of healthcare infrastructures and the workforce, which were weakened by the long-term effects of neoliberal policies. Several contributions in the book highlight concretely how the very presence of neoliberal logics within health policies challenges some of the premises of federalism.
5The first section traces the political foundations of Indian health federalism. K.K. Kailash’s chapter stands out for showing how health debates in the Constituent Assembly became central to nation-building and therefore to constitutional debates. Excerpts from these debates demonstrate a recurring concern over excessive centralization, a preoccupation that has remained a defining feature of Indian federalism, particularly in the health sector. Kevin James’s chapter proves a valuable case study highlighting how India’s complex legal architecture allows for a diversity of possible responses to public health emergencies. During the Covid-19 pandemic, while states were initially encouraged to invoke the Epidemic Diseases Act (1897) to implement local lockdowns, “the mode of pandemic governance transformed overnight” when central authorities decided to direct states “to submit daily implementation reports of central DMA [Disaster Management Act, 2005] directives” (p. 69). To this day, there is still no law on public health emergencies that clearly defines the respective perimeters of states and central authority.
6The second section explores the reasons behind the disparities between states in terms of development of health services. Rama Baru shows how the growth of the private
hospitals sector relies on caste-based investment networks, both regional and transnational. Though heavily relying on the author’s unpublished MPhil dissertation defended in 1987, this is a crucial chapter in the book, since it adds another layer of analytical depth to its argument regarding the expansion of the private sector. Indeed, whereas several contributions criticize the liberalization of healthcare in India and point out the negative consequences, particularly for the most vulnerable categories of population, Rama Baru’s work on caste networks contributes to a better understanding of the social form that the liberalization of health assumes in India. It is also the only contribution in the book that deals with the issue of caste.
7The third section highlights how the regulatory architecture of health federalism can generate friction or contradictions. Shreya Shrivastava and Dhvani Mehta, for instance, examine India’s fragmented landscape of drug regulation: each state has its own Drug Regulatory Authority, existing alongside the Central Drugs Standards Control Organisation (CDSCO). There is no central drug authority, and regulatory standards vary widely. Certain recent tragedies, like the deaths of children who consumed Indian-made cough syrups in Gambia and Uzbekistan in 2022, remind us of the dangers of a patchworked legal framework for drug licensing and producing. In its concluding sections, the chapter advocates for certain reforms, particularly “creating a new central statutory body or making the CDSCO itself a statutory body” (p. 138). However, since this recommendation was already made by the Hathi Committee in 1975, the National Drug Policies of 1986, 1994, and 2002, and the Mashelkar Committee in 2003, it is difficult to imagine what would make it more appealing to health authorities in the political context of 2025.
8The final section addresses the issues of security and equity. In particular, it includes Ramila Bisht’s nuanced chapter on women’s health and how it is targeted as part of the National Rural Health Mission programme. The author shows how “increased fund transfers from the Centre to the states through novel mechanisms and processes” led to better accessibility to the infrastructure and use of services for women but failed to create significant health benefits in terms of morbidities, everyday experience of disease, and “risk of discrimination and subordination in homes” (pp. 201-2). Observing the limited capacity of targeted healthcare programs to alleviate the stigma attached to disease, the author concludes that health federalism is neither inherently good or bad. Instead, she concludes that it “all depends on the details of the federal systems and the contexts in which they operate,” insisting that it is “the character of federal citizens, rather than the federal system itself, that could be inherently beneficial to gender equality” (p. 202).
9As a collective undertaking, this book, whose list of authors includes a number of scholars working in the field of public health, offers several recommendations and lays the groundwork for both a conceptual and practical rethinking of health federalism in India. It proves an engaging reading thanks to its variety of perspectives, methods, and materials (archival debates, policy analyses, quantitative data, and experiential accounts). This book will undoubtedly remain a reference on the question of health and federalism for a long time to come.
10It does, however, present a certain number of shortcomings. Some chapters only engage with general issues pertaining to public health instead of clearly discussing the challenges of federalism, weakening the overall coherence of the book. While comparative analyses with other federations (such as the USA or Brazil) appear in a few contributions, they could have been pursued more systematically and in greater depth.
11Finally, the book’s contribution to the understanding of health policies and institutions in India could be fruitfully complemented by ethnographic studies examining how federalism is enacted in everyday practices. The complete absence of ethnographic perspectives in the book is acknowledged by the editors, who attribute it to “the impact of the pandemic that brought all data collection to a halt” (p. 10). I would nuance this explanation by saying that the context of the pandemic stimulated anthropological reflections based on fieldwork conducted during that period, notably within healthcare settings and among healthcare practitioners (Caduff, 2025; Ranganathan et al., 2023). However, rather than a criticism, this remark should be read as an invitation to extend the book’s rigorous enterprise of institutional analysis into qualitative, field-based investigations. In her contribution to the volume, Louise Tillin stresses the role of intermediate bodies in the implementation of federalism. As a medical anthropologist and an ethnographer of healthcare settings, I read her argument as an encouragement to direct ethnographic attention to the everyday negotiations in medical bureaucracies, where federalism is brought to life. Indeed, bureaucrats, medical staff, and patients all contribute to shaping health policies in practice (Jullien, 2019; McDowell, 2024). Taking this dimension into account could help to flesh out the book’s theoretical insights and illuminate health federalism in India through the lens of lived experiences.