4 min read.Updated: 14 Jun 2021, 01:43 AM ISTLouise Tillin,Sandhya Venkateswaran
Covid-alarmed voters making public healthcare a priority could alter the incentive structure of Indian politics for the better
The second wave of covid has laid bare the parlous consequences of decades of under-investment in India’s health system. India’s public health expenditure is stubbornly low in comparative terms—just over 1% of gross domestic product (GDP) per annum, compared to 3% in China, 4% in Brazil or 4.5% in South Africa.
Private out-of-pocket expenditure, at 64% of total health expenditure, including by low income households, far exceeds the public financial commitment to health expenditure.
Yet, it is not just in financial terms that India under-invests. India’s voters and its politicians also politically under-invest in health.
Numerous cross-national studies (bit.ly/3xfspGs) have shown that on average democracies are better for health because they encourage politicians to respond to the needs of the electorate (bit.ly/3izEbqQ). Yet, in the world’s largest democracy, building back better from the pandemic will require breaking the cycle in which democracy perpetuates a lack of public accountability for healthcare improvements.
India’s voters appear to place curiously little emphasis on health as they decide how to vote. For instance, in the state elections in Bihar in October-November 2020, only 0.3% of voters in Lokniti-CSDS’s post-election survey (bit.ly/3zn6Q8S) highlighted health as a priority—even against the backdrop of the covid pandemic. Unemployment and development loomed larger as voter priorities.
The reasons for the low prioritization of health are complex. Citizens may have low expectations of government as a healthcare provider, as the health system has remained unresponsive and unaccountable for long. But it may also be because political parties and politicians do not place promises of improving healthcare at the centre of their election campaigns.
Political leaders stay away from promising improved healthcare, either because they don’t have the answers, or because timelines for improving the system are well beyond the life of their political regimes. However, where political leaders have delivered well on health, such as in Kerala, it has created an expectation among citizens that compels leaders to prioritize health.
The low political prioritization of health by voters and politicians (bit.ly/3wgj29d) is puzzling because catastrophic individual out-of-pocket health expenditure is one of the biggest risk factors for falling back into poverty. We should expect voters to demand more and for politicians to see the electoral incentives for prioritizing health.
It might reasonably be asked if it is just health that suffers from low political prioritization, or is it also seen in other areas of public service delivery?
We know from wider research (bit.ly/3izcOgU) that in places where state capacity is weak, political leaders face incentives to perpetuate clientelistic relationships with voters rather than focus on improving public service delivery. The logic of clientelism privileges discretionary quid pro quo exchanges of private goods in return for political support. This can serve as a barrier to strengthening state capacity to deliver a range of public goods in lower-income democracies.
Yet in recent decades, India—like a number of other lower- and middle-income democracies (bit.ly/2U0hySn)—had moved to embrace a number of more programmatic social policies that were better financed, more rule-bound and were also electorally popular.
These included the rights-based social legislation introduced by the Congress Party-led United Progressive Alliance between 2004 and 2014, such as the Mahatma Gandhi National Rural Employment Guarantee Act and the National Food Security Act. The Narendra Modi-led Bharatiya Janata Party has also seen the benefit of maintaining a raft of welfare schemes since 2014, adding several of its own, and heavily promoting these during elections. While we should not overstate the extent to which political parties have benefited electorally from welfare programmes, they have probably made a difference at the margins, as an analysis of Lokniti-CSDS post-poll data from the 2019 Lok Sabha elections showed (bit.ly/3waxiAm).
Yet, it has been much harder to identify a similar shift in the electoral politics of health provision. One of the reasons for this may be because reforms in the health sector are harder to enact and slower to yield tangible outcomes. Foregrounding health sector investments may be politically riskier than, for instance, improvements in the distribution of cheap foodgrains , gas cylinders or direct benefit transfers. Such welfare schemes are based on ‘delivery’ of a product, whereas services like health and education are more complex. They depend on a system that includes infrastructure, human resources, medical protocols and resources, accountability and capacity. For this reason, perhaps, the main electoral pledge in the health sector in recent years has been on health insurance, rather than reforming the system within which this product can be effectively utilized.
The pandemic offers India an opportunity to re-imagine the political foundations of health. It is in this state of emergency that citizens have so clearly understood how deeply broken the health systems are and have recognized the role that the government must play in ensuring healthcare for all. Rebuilding India’s health systems will require focusing on multiple elements, including financing for health, role clarity for the national and state governments, strong and empowered institutions for health policy, governance and administration that are driven by evidence. The motivation for these will likely emerge from creating or making more visible the demands of voters for improved health. It will require building cross-class coalitions to hold the government to account for strengthening universal access to healthcare.
This essay is part of the series ‘Build Back Better Together: A Blueprint for a Better World’ published by the School of Global Affairs, King’s College London (bit.ly/3cB4w45).
Louise Tillin & Sandhya Venkateswaran are, respectively, reader in politics and director, King’s India Institute; and fellow with the Lancet Citizen’s Commission on Reimagining India’s Health System.
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