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A democratic health check: why India shows the need for democracies to prioritise healthcare

G7 Build Back Better Together
Dr Louise Tillin and Sandhya Venkateswaran

09 June 2021

The second wave of COVID-19 has hit India hard and laid bare the parlous consequences of decades of under-investment in its health system. India’s public health expenditure is stubbornly low in comparative terms – just 1 per cent of GDP per annum compared to 3 per cent in China, 4 per cent in Brazil or 4.5 per cent in South Africa. Private out-of-pocket expenditure at 64 per cent 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.

Concerns have increasingly been raised about the erosion of democracy and political freedoms in India since the re-election of the Hindu nationalist Narendra Modi-led BJP in 2019. In this article, we also argue that for a longer time, India’s health system has been eroded because of the lack of prioritisation of health within its democracy.

That does not mean that a more authoritarian government would have an advantage when it comes to health provision. Numerous cross-national studies have shown that on average democracies are better for health because they encourage politicians to respond to the needs of the electorate. 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 health care 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 per cent of voters surveyed in a post-election survey highlighted health as a priority – even against the backdrop of the COVID-19 pandemic. Unemployment and development loomed larger as voter priorities.

Why don’t voters prioritise health

The reasons for the low prioritisation of health are complex. Citizens may have low expectations of government as a healthcare provider, because 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 health care 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 from citizens which compels leaders to prioritise health.

The inter-linked problem of low political prioritisation of health by voters and politicians is a key political economy explanation for India’s weak health system capacity and the challenges it faces in meeting the goal of universal health care. It 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 prioritising health.

Is it just health that suffers?

It might reasonably be asked whether it is just health that suffers from low political prioritisation, or is this also seen in other areas of public service delivery?

We know from wider research 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 – had moved to embrace a number of more programmatic social policies that were better financed, more rule bound and were also electorally popular.

In India these included a raft of rights-based social legislation introduced by the Congress Party led United Progressive Alliance between 2004–14 such as the Mahatma Gandhi National Rural Employment Guarantee Act and the National Food Security Act. Or in Brazil, for example, the conditional cash transfer programme Bolsa Familia. When implemented well, some studies suggested that political leaders were rewarded by voters for these programmes. Some of our earlier work provided evidence to show that voters also became less susceptible to attempts to buy their vote with small gifts in kind, where programmes such as that for the delivery of heavily subsidised food reached beneficiaries reliably and almost universally.

The Modi-led BJP has also seen the benefit of maintaining a raft of welfare schemes since 2014, adding several of their 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.

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 or gas cylinders (Ujjwala). Such welfare schemes are based on ‘delivery’ of a product whereas services on the other hand, like health and also 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 utilised.

The pandemic offers the opportunity to reimagine the political foundations of health in India. It is in this state of emergency that citizens have so clearly understood how deeply broken the health systems are and have recognised the role that the government must play in ensuring healthcare for all. Rebuilding India’s health systems will require focus in multiple directions, 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 decent health care.

Read the whole report

About the authors

Dr Louise Tillin is Reader in Politics and Director, King’s India Institute.

Sandhya Venkateswaran is a Fellow with the Lancet Citizen’s Commission on Reimagining India’s Health System

In this story

Louise Tillin

Louise Tillin

Professor of Politics

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