Heal-Thy Democracy! Prioritising healthcare within the 2024 Indian electoral agenda

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The COVID-19 pandemic exposed the vulnerability of India’s public health infrastructure. Yet, public health issues remain missing from the electoral agenda of Indian political parties.

 

The year 2024 is a significant one for the future of democracies and democratic values across the world. The year marks multiple elections taking place in more than 50 countries, including the United States, India, Mexico, South Africa, the United Kingdom, and the European Union. By now elections have already taken place, amongst others, in Pakistan, Bangladesh, and Indonesia. Over 2 billion voters will head to the polls this year, making it a pivotal moment for global democracy. One of the most important to keep a close watch on is India. With 1.4 billion citizens and approximately 968 million eligible voters, it is the largest democracy in the world.

The sheer size of India’s citizenry makes this election important for showcasing democracy’s currency in an increasingly destabilised world order of security issues concerning multiple wars and environmental crises. The global ramifications of India’s prioritisation of policies, both domestic and international, will no doubt shape the future of the world in the coming years. This includes issues related to regional and global geopolitical stability, global economy, poverty and inequality, climate change and sustainability.

Noticeably, since the country and the world have barely recovered from a global pandemic, what is missing from the agenda and the public and civil society debates in the run-up phase to the election is a comprehensive plan concerning public health policies. The outbreak of the COVID-19 pandemic opened the ‘Pandora’s Box’ for India, which ultimately led to the death of more than half a million of its citizens, though the WHO report claims that the actual number of fatalities was multiple times more, which was deliberately undermined by the government of India. More importantly, many of these deaths could have been avoided with a better public health infrastructure.

The question that ought to be asked is why public healthcare service continues to remain outside the realm of electoral politics by the stakeholders — political parties and the electorates — in India?

The pandemic laid bare the vulnerabilities of healthcare systems worldwide, and India stands at a pivotal juncture where bold and decisive action is imperative to safeguard the well-being of its citizens. Unfortunately, even after the pandemic triggered discussion on severe inadequacies and the necessity of building better public health infrastructure, subsequent national budgets in India lack any significant increase in allocations to health expenditures. In fact, available data and reports suggest that the health allocation in the budget actually declined in the subsequent post-COVID budgets, albeit marginally.

India grapples with multifaceted health challenges, including inadequate healthcare infrastructure, disparities in access to healthcare services, and persistent public health concerns. A child in the southern state of Kerala has a better chance of surviving to the age of five than in the US. In the northern state of Uttar Pradesh, the odds are worse than in Afghanistan (Bloomberg Op-Ed). Despite being one of the top-ranked economies of the world in terms of GDP, India’s commitment towards public health expenditures remains abysmally low. According to the Health and health systems ranking of countries worldwide in 2023, India’s position is 112; while in terms of health spending as a percentage of GDP, India spends around 3%, one of the lowest in the world (World Bank data). According to National Family Health Survey-3, the private medical sector remains the primary source of health care for 70% of households in urban areas and 63% of households in rural areas in India, thereby being one of the highest out-of-pocket health expenditure countries in the world (WHO).

However, this is not a recent phenomenon. Historically, since the independence from British colonial rule in 1947, India continued to have one of the lowest public health expenditures relative to most countries, which is further complicated by issues of inequitable access, poor quality, and weak accountability, forcing people to rely extensively on private services. Existing research notes how health has been virtually absent from public debates and democratic policies in India” (Sen & Drèze 2013:143). According to various path dependency approaches, colonial legacies partially explain the lack of democratic engagement with healthcare. These are essentially the inheritance of a weak colonial medical infrastructure and low priority to public health bureaucracy (Amrith 2007; Ramasubban 2008), or a colonial explanatory framework of epidemics and pandemics as being climatic and ‘natural’ (Arnold 2022), leaving health largely outside the realm of politics.

Similarly, postcolonial ‘development’ policies explain how health became part of the broader development agenda that gripped large parts of the world after 1945 when international organisations and pharmaceutical companies significantly shaped public health policies rather than voters or political programmes (Amrith 2006; Bose & Jalal 1999; Rao 1999). State-centric approaches explain the lack of policy engagement with health through the explanatory framework of the state and federal structure of India (Jeffery 2021; Berman & Ahuja 2008) as contributing to a low interest in the topic. Taking a different approach, ethnographic research on voters’ relation to democratic practices emphasises several social or cultural factors as interdependent and not necessarily historically rooted, such as communal belonging, resulting in voting based on leadership identity, individual benefits, and compulsion rather than policy questions (Banerjee 2013).

It is therefore quite paradoxical that health being inherently a  political choice, in spite of such severe inadequacies, inequalities, and uneven distribution (Bambra et al., 2005), the issues related to public health continues to remain outside the realm of public and political engagement in India. While billions are being spent on the construction of  religious institutionselection campaignserecting statues, and in the military (4th highest in the world), the question that ought to be asked is why has public healthcare service continues to remain such a neglected arena by the political stakeholders – political parties and the electorates – in India?? Even a cursory overview of the post-COVID last few elections in India reveal that none of the political parties, in power or in opposition, attempted to make public health issues an integral electoral agenda. One possible reason, we argue, is the unwillingness of political parties to commit themselves to  public health promises during the electoral campaigns, which requires a long term commitment and investment, beyond the scope of their five-years electoral tenure. One may of course argue that almost every major political parties in India issue political manifestos prior to elections, detailing lofty promises, including public health; but critics argue that an overwhelming number of electorates do not read  political manifestos, and that these manifestos hardly have any actual relevance towards the electoral choice of voters.

Interestingly, however, existing research informs us that health has not been considered an important electoral agenda by the Indian voters, even otherwise. Lokniti-CSDS, a research organisation that studies electoral patterns and voting behaviour in India, reveal that less than 1% of voters consider health as an important voting issue, a trend that continues to remain more or less constant even after the COVID pandemic. This is further corroborated by the pilot studies conducted by the authors and their research collaborator in India between August 2023 and January 2024, involving ethnographic research methods and about 124 semi-structured interviews. When enquired about the factors that would determine their voting choice in the coming election, the responses almost always revolved around “unemployment”, “economy”, “inflation”, “strong leadership”, “corruption”, “development”, and though not always explicitly, but indicative of “Hindu State”. Responses were, of course, not always unanimous, and the priorities of the issues mentioned above varied according to the socio-political, economic, and/or religious identities of the respondents.

For instance, to most of the Muslim respondents, the need to halt the juggernaut of the incumbent Hindu-Nationalist government at the centre, Bharatiya Janata Party, led by the Prime Minister of India Narendra Modi, ranked high on the agenda. However, none of these respondents mentioned or talked about, even fleetingly, public health as a possible electoral agenda. Interestingly, upon further enquiry, it was revealed that many of these respondents have been direct casualties during the COVID pandemic—some of them lost their jobs/income during the pandemic lockdown and still struggling to come out of it, while a few lost their family members, which according to them could have otherwise been prevented with better medical infrastructure in the government hospitals.

Public health in India is in desperate need of reform. At the heart of this reform must lie a commitment to equitable access to healthcare for all, regardless of socioeconomic status or geographic location. This entails not only bolstering the capacity of existing healthcare facilities but also investing in outreach programs to bridge the gap between urban and rural areas. Mobile clinics, telemedicine initiatives, and community health workers can play a pivotal role in extending essential services to underserved populations, ensuring that no one is left behind in the pursuit of good health. Furthermore, the Indian government must prioritise preventive care and health education to tackle the root causes of disease and promote healthy lifestyles. Initiatives aimed at improving sanitation, hygiene, and nutrition can yield significant dividends in reducing the burden of preventable illnesses, thereby relieving pressure on an overburdened healthcare system.

By empowering individuals to take charge of their own health, India can lay the foundation for a more resilient and sustainable future. In tandem with efforts to strengthen primary healthcare, the Indian government must also address systemic challenges that impede access to specialised care. Long wait times, exorbitant costs, and a shortage of skilled professionals are just some of the barriers that hinder access to critical services, particularly for marginalised communities. By investing in medical education and infrastructure, expanding insurance coverage, streamlining regulatory processes, and prioritising investments in research and innovation to drive advancements in medical science and technology, the government of  India can create a more responsive and inclusive healthcare system that meets the diverse needs of its population. From vaccine development to precision medicine, India has the potential to emerge as a global leader in healthcare innovation, provided adequate resources and support are allocated to research institutions.

Of course, the road to comprehensive healthcare reform will not be without its challenges. Most importantly, it would require political will and sustained commitment from stakeholders. This can only be achieved with adequate public engagements and civil society debates on health as an integral part of the electoral agenda over a longer period. The stakes could not be higher, nor the imperative more urgent. As India stands on the cusp of a new era, the citizens of India may, in the aftermath of the pandemic, have been ready to seize the opportunity to prioritise health and well-being in the election of 2024. Yet the fundament for such a vision as part of India’s future is missing.

 

 

References:

Amrith, Sunil S. 2007. “Political Culture of Health in India: A Historical Perspective”, Economic and Political Weekly, 42(2) pp. 114–121.

———. 2006. Decolonizing International Health: India and South-East Asia, 1930–65. Palgrave Macmillan.

Arnold, David. 2022. Pandemic India: From Cholera to Covid-19, Oxford University Press.

———.1993. Colonising the Body: State medicine and epidemic disease in nineteenth century India. University of California Press.

Bambra, Clare, Debbie Fox & Alex Scott-Samuel. 2005. “Towards a politics of health”, Health Promotion International, 20(2), pp. 187–93.

Banerjee, Mukulika. 2014. Why India Votes? Routledge.

Berman, Peter & Rajeev Ahuja. 2008. “Government Health Spending in India”, Economic and Political Weekly,43(26/27), pp. 209–216.

Bose, Sugata & Ayesha Jalal, eds. 1999. Nationalism, Democracy & Development: State and Politics in India. Oxford University Press.

Chatterjee, Niladri, Zaad Mahmood & Eleonor Marcussen. 2021. “Politics of Vaccine Nationalism in India: Global and Domestic Implications”, Forum for Development Studies 48:2, pp. 357–369.

Dréze, Jean & Amartya Sen. 2013. An Uncertain Glory: India and its Contradictions. Princeton University Press.

McGuire, James W. 2020. Democracy and Population Health. Cambridge University Press.

Ramasubban, Radhika. 2008. “History of Public Health in Modern India 1857–2005”, in Lewis, Milton James & Kerrie L. Macpherson, eds., Public Health in Asia and the Pacific: Historical and Comparative Perspectives. Routledge, pp. 87–105.

Rao, Mohan, ed. 1999. Disinvesting in Health: The World Bank’s Prescriptions for Health. Sage Publications.

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