In the elections of the 1980s and 1990s, roti, kapda and makan (food, clothes and shelter) dominated the political discourse. Gradually, the issue of bijli, sadak and pani (electricity, road and water) took over.
Although the previous issues were never resolved completely, the newer issues effectively pushed the political debate in a new direction. The digression of issues in electoral discourse was the result of rising aspirations of people driven by newer channels of communication.
Healthcare, education and social security are the most important indicators of Human Development Index (HDI), yet their arrival in the political discourse in India was slow and rather late.
Healthcare has never been viewed as very important. This is evident from the fact that after Independence, only three national health policies were formulated, and probably none were implemented in letter and spirit wholly.
High cost of care
As per the constitution of India, ‘health’ is primarily a state subject. Therefore, like many other development indicators, health systems also developed quite unevenly across the states in India. More significantly, due to the gross insufficiency of public health care delivery systems, the private sector mushroomed disproportionately. It has become the foremost avenue for availing health services by the majority of Indians.
At the same time, there has been a near complete absence of stewardship and effective regulation of private health systems. This has resulted in a very high cost of care.
Availing health services often results in high out-of-pocket and catastrophic expenditures. Stories of people exhausting their savings, selling assets and lands, and stacking up debt are commonplace. Amidst these challenges and risings demands, access to perceived good quality healthcare has slowly become a prime concern over the last two decades.
Article 21 of the constitution of India guarantees equal ‘right to life’ to all citizens and Article 47, which is a directive principle, says that it is the duty of the state to improve public health and nutrition. This effectively makes people’s health and healthcare as the responsibility of the state. Despite this fact, the response of the government to improve healthcare have rather been sluggish.
The politics of healthcare
The launch of the National Rural Health Mission (NRHM) in 2005 was probably one of the major pushes to deliver oxygen to the gasping public health systems. Another significant development was the entry of the health insurance market over the last two decades.
Many state governments started implementing health insurance schemes with varying coverage and benefits package. Subsequently, the launch of the Rashtriya Swasthya Bima Yozana (RSBY) in 2008 became a watershed moment for health insurance with a profound impact on health systems. By 2016, around 17 states and four union territories already had a health insurance scheme running.
In many states, such health insurance schemes caught the conscience of people and probably gifted political dividends too. Thus, healthcare slowly started receiving higher priority in political discourse.
Prime Minister Narendra Modi, after winning in 2014, had constituted a group to work on health assurance within two months of assuming office. But unfortunately, the assurance mission never saw the light of day.
In the meantime, healthcare issues started getting space in political debates during state assembly elections. Finally, the announcement of the Ayushman Bharat scheme by the Union government in 2018 proved to be a pinnacle for the discourse. Unarguably, this was one of the biggest announcements in the health sector in many years. It readily caught the imagination of stakeholders.
But in the election manifestos of two main national parties, healthcare has received only a little higher attention as compared to previous elections. Interestingly, the health policy direction proposed by both political parties is quite contrary to each other, where the BJP continues to push for its health insurance programme while the Congress has promised to dismantle it completely.
In the absence of clarity or depth in the manifestos, a deeper debate and elaboration of implementation framework is needed. Unfortunately, we are yet to hear any detailed plan of action.
In the meantime, in the very least, one can hope that healthcare get some notice by voters as they make their choices this election.
Vikash R. Keshri is health policy and systems expert at the centre for health policy, Asian Development Research Institute, Patna, India. He can be reached at email@example.com and tweets @docvrk. Views expressed are completely personal.