Health has been a neglected issue in past Indian general elections. But this year, it has received more recognition by those vying to lead the world’s largest democracy. Dinsa Sachan reports.
India began general elections for a new Parliament and prime minister on April 7. While the world awaits the results, due in mid-May, health activists are questioning if a new government will lead to improved health care in a country that accounts for 21% of the world’s global burden of disease.
Bucking the trend
While roads, infrastructure, jobs, and poverty have been important campaign issues in past elections, health issues have rarely got a billing. Amit Sengupta of the Delhi Science Forum explains that “because there is rarely a political demand for health reforms, the politicians can get away with ignoring them”.
Leena Menghaney, a New Delhi-based lawyer and public health activist, says that the candidates lack the political will to raise tough issues such as access to health care and regulation of the private health-care sector. “If they put health on their agendas, it would pit parties against big businesses and the private sector—doctors, private diagnostic labs, corporate hospitals, pharmaceutical companies, and pharmacy shops”, she says.
But the 2014 elections seem to have signalled a change in the dismal trend. Joe Varghese, an activist with the People’s Health Movement, India, believes that the situation has improved since 2004. “They’re at least beginning to talk about health in their manifestos now”, he says.
Health is yet to become a major campaigning issue in the general elections, but there’s evidence it is becoming increasingly important for garnering votes at the state level, Varghese says. “The Rajiv Aarogyasri Community Health Insurance Scheme was one of the major reasons the Andhra Pradesh chief minister YSR Reddy rode back to power in 2009 for a second term”, Varghese points out. Under the scheme, launched in 2007, the government covers the cost of treatment for serious disorders like cancer and heart disease for people living below the poverty line by providing cover of up to INR200 000 (US$3323) to beneficiary families.
Anuradha Gupta, additional secretary with the health ministry, agrees with Varghese. “States that have focused on health reforms have been rewarded with public goodwill time and again. With health reforms, you touch millions of lives with one stroke”, Gupta contends.
The 2014 manifesto of the Indian National Congress has promised to enact a right to health services. “It is a welcome move, but, unfortunately, it appears populist”, says Rakhal Gaitonde, a community medicine expert with People’s Health Movement, India. “The congress is only ‘promising’ access to health care. There is no talk of quality, regulation, or accountability.”
The only political formation that has taken health seriously is the Left Front alliance, Varghese says. “They really listened to our suggestions on strengthening the public health system, and were critical in mobilising the central government in launching the National Rural Health Mission [NRHM] in 2005”, he points out.
Varghese adds that the fledgling Aam Aadmi Party (AAP), which surprised everyone with a strong result in the recent Delhi assembly polls, offered hope to civil society. “They incorporated most of our recommendations in their manifesto for the Delhi assembly elections”, Varghese says. The AAP general election manifesto has also mentioned a right to health care, and the party has pledged to provide access to free medicines at public hospitals. Additionally, party leader Reena Gupta told The Lancet they hope to bring in a new bill to keep tabs on the private health sector.
There has been an increasing demand among civil society to monitor the largely unregulated private sector, which provides 80% of outpatient and 60% of inpatient care in the country. The out-of-pocket spending on medical care is so high that it pushes an estimated 2·2% of population into poverty every year.
BJP or Congress?
The two main contenders in the elections are the reigning Congress party and the current opposition—Bhartiya Janta Party (BJP). Several polls have indicated that a BJP-led National Democratic Alliance is likely to come to power. Experts say a BJP government could increase privatisation in health care. Varghese cites the Chiranjeevi Yojana as an example. The public-private scheme to encourage women to deliver their babies in hospitals rather than at home was launched in the BJP-ruled state of Gujarat in 2006. As part of the endeavour, the Gujarat Government collaborated with select private hospitals to provide free delivery to underprivileged women in the state. “The public-private model is going to only put public money into private hands”, Varghese warns. Moreover, the Chiranjeevi Yojana drew flak for not meeting its objectives, fuelling further criticism of the model. An analysis published in Bulletin of World Health Organization in December last year shows that the initiative did not have a significant effect on institutional delivery rates, contrary to what was suggested by some previous studies. Amar Jesani, editor of the Indian Journal of Medical Ethics, says, “There’s no mechanism to regulate these private entities and no standards for quality control. How can you expect these schemes to deliver?”
Gaitonde is also critical of the BJP approach. “While they are in power in Chhattisgarh, there have been several attempts at privatisation, which can only mean a weakening of the public health system and increasing inequity”, he says.
Notably, in its 2004 manifesto, the BJP had championed privatisation: “Private and foreign investment in tertiary and super-specialty health care should be encouraged.” Although the current manifesto steers clear of such suggestions, it mentions their government would start a national assurance mission to provide affordable health care. “This is basically slick lingo for insurance-based approach”, Gaitonde says.
However, Jesani thinks a Congress government will not be much better. “Their focus on providing universal access to health care has also focused on insurance. Insurance schemes only transfer money to private sector. They should rather focus on providing free access to health care by improving public hospitals.”
Even though polls suggest a Congress win is unlikely, experts commend the party for its flagship scheme, NRHM, which has now been expanded into National Health Mission. Shailaja Chandra, former secretary in the health ministry, calls the NRHM “the biggest achievement of the health sector” in the past two decades.
“In terms of maternal health, institutional deliveries have shot up to 90% in some states, and even [poor] states like Uttar Pradesh and Bihar have registered gains. It has made a huge difference to the maternal and child mortality rates in the country”, she says. “It will be a pity if the next government abandons the maternal health programmes of the NRHM.” According to the latest data from India’s Office of the Registrar General the maternal mortality ratio (MMR) fell from 212 to 178 (a fall of about 16%) between 2007—09 and 2010—12. This decrease is still a far cry from an MMR of 109 by 2015—India’s Millennium Development Goal 5 target.
T Sundararaman, former executive director of National Health Systems Resource Center, an agency that guided the design and implementation of NRHM, agrees with Chandra, but quickly adds that the programme has become more bureaucratic and centralised in recent years. “The release of funds did not match requirements or even come close to the promised allocation”, he says.
According to a recent report by People’s Health Movement, India, the actual amount released for the NRHM in the 11th Plan period—INR680 billion ($11 billion)—was only a third of the approved amount. Reflecting on these figures, Sundararaman says, “Not surprisingly the physical achievements were also proportional. While the target was to establish 24 000 round-the-clock primary health care centres by 2012, only 8743 had achieved that level of performance by that deadline.”
The BJP manifesto states that the NRHM has failed to meet its objectives and will be “radically reformed”. Gaitonde is concerned by this statement. “What are they going to undo?”, he says. “I fear that the focus on public health sector strengthening in the NRHM is going to be dangerously diluted.”
Gaitonde adds the BJP manifesto is a “typical right-wing” document, but welcomes their intention to recast the health ministry to include nutrition and pharmaceuticals under its remit.
On May 16, it will become clear who will lead the Indian democracy. However, irrespective of who wins, public health activists agree on a few fundamental issues that need to be addressed by the next government. “All the governments over the last two decades have failed to deliver on the promise of raising the health budget”, Sengupta says. “We would like the next government to really work towards increasing health spending from 1·4% to 3—5% of GDP.”
The Congress party has promised to increase health expenditure to 3% of GDP in its manifesto, while the BJP has not pledged any increase.
Chandra says if health is to become a mainstream political agenda, an economic spin needs to be put on it. “We need an imaginative political leader to champion the economic benefits of four to five essential health reforms.” For example, she says one such reform could be in family planning provision and popularisation of intra-uterine devices and even injectables for spacing and limiting families. “It would push women’s skill-learning and wage earning with huge spin-offs for productivity”, Chandra says.