India has relatively poor health outcomes, despite having a well-developed administrative system, good technical skills in many fields, and an extensive network of public health institutions for research, training, and diagnostics. This suggests that the health system may be misdirecting its efforts, or may be poorly designed. To explore this, the authors use instruments developed to assess the performance of public health systems in the United States and Latin America based on the framework of the Essential Public Health Functions, identified as the basic functions that an effective public health system must fulfill. The authors focus on the federal level in India, using data obtained from senior health officials in the central government. The data indicate that the reported strengths of the system lie in having the capacity to carry out most of the public health functions. Its reported weaknesses lie in three broad areas. First, it has overlooked some fundamental public health functions such as public health regulations and their enforcement. Second, deep management flaws hinder effective use of resources-including inadequate focus on evaluation, on assessing quality of services, on dissemination and use of information, and on openness to learning and innovation. Resources could also be much better used with small changes, such as the use of incentives and challenge funds, and greater flexibility to reassign resources as priorities and needs change. Third, the central government functions too much in isolation and needs to work more closely with other key actors, especially with sub-national governments, as well as with the private sector and with communities. The authors conclude that with some reassessment of priorities and better management practices, health outcomes could be substantially improved.
