Decentralisation in health is re-gaining importance, as demonstrated by the COVID-19 pandemic and recent policy initiatives such as the XV Finance Commission of India and Pradhan Mantri – Ayushman Bharat Health Infrastructure Mission (PM-ABHIM). Decentralisation has the potential to bring improvement in access to and quality of health services, particularly in rural and remote areas, while also empowering local authorities and communities to take more control over health service delivery. The 73rd and 74th Constitutional amendments in India led to creation of a three-tier system of local governance in rural and urban areas, respectively, giving local bodies significant powers and resources to manage local affairs, including health service delivery.

The state of Kerala has been a front-runner in devolving power and resources to local governments, post the constitutional amendments particularly in the health sector, and other states and low- and middle-income countries (LMICs) can draw lessons from their experiences.