Healthcare Is A National Priority That Must Gain Electoral Traction

Context: Covid-alarmed voters making public healthcare a priority could alter the incentive structure of Indian politics for the better.

Perennial problems in India’s healthcare sector

• Decades of under-investment: India’s public health expenditure is just over 1% of gross domestic product (GDP) per annum, compared to 3% in China, 4% in Brazil or 4.5% in South Africa.
• Burden of huge private out-of-pocket expenditure: At 64% of total health expenditure, major factor in pushing people back to poverty, especially during pandemic.
• Political under-investment in healthcare: Little emphasis on health as people decide how to vote.
  • E.g. In the state elections in Bihar in October-November 2020, only 0.3% of voters in Lokniti-CSDS’s post-election survey highlighted health as a priority.
  • Unemployment and development loomed larger as voter priorities.

Reasons for low political prioritization of health:

• Low expectations of government as a healthcare provider: As health system has remained unresponsive and unaccountable for a long.
• Political leaders stay away from promising improved healthcare: Either because they don’t have answers or because timelines for improving system are well beyond the life of their political regimes.
• Complexities in health sector reforms: Harder to enact reforms, slower to yield tangible outcomes as it requires re-jigging the system that includes infrastructure, human resources, medical protocols and resources, accountability and capacity.
• Politically riskier: Schemes based on delivery of products like cheap foodgrains, gas cylinders or direct benefit transfers yield better political returns compared to health and education services.
• Low state capacity: 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.

Way forward: The pandemic offers India an opportunity to re-imagine the political foundations of health

• 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.