We discuss lessons from a research study undertaken for the Lancet Citizen’s Commission on Reimagining India’s Health Systems. The study highlights how healthcare came to be seen as a politically viable and electorally rewarding issue in some, but not nearly enough, States.

Author: Nikhil Iyer
Published: August 11, 2022 in The Hindu Business Line

Ask any politician at random if they think healthcare needs to be prioritised in India, and they are likely to say yes. Yet, there seems to be a sense of reluctance in making healthcare a political priority.

As India turns 75, we discuss lessons from a research study undertaken for the Lancet Citizen’s Commission on Reimagining India’s Health Systems. The study highlights how healthcare came to be seen as a politically viable and electorally rewarding issue in some, but not nearly enough, States.

Early 2022, Tamil Nadu and Rajasthan indicated they would legislate a Right to Health for their citizens. An emphatic political expression by the respective Chief Ministers, these bills signify a culture where politicians feel incentivised to deliver better healthcare as their competitors try to one up them.

Take Tamil Nadu’s case. The Right to Health Bill’s antecedents include a maternity benefits scheme for women’s nutritional security (1987), procurement and distribution of free medicines (1994), health insurance (2009), and so on. Over decades, motivated by the Dravidian ideology, leaders like K Karunanidhi, MG Ramachandran and J Jayalalithaa pursued initiatives which have embedded an expectation of health among voters. Present-day politicians, who seek to sustain their legacies, thus have an incentive to continue reforms.

Competitive political issue

In Rajasthan, health has become a thriving, competitive political issue in the past decade. In 2011, then Chief Minister Ashok Gehlot introduced the free medicines and diagnostics schemes, which went on to become so popular even his successor Vasundhara Raje had to continue it, despite murmurs about watering it down. Later in 2013, as CM, Raje introduced a health insurance scheme, and set up ‘Model PHCs’. On returning as CM in 2018, Gehlot first expanded the coverage and eligibility under the insurance scheme, and has now introduced the Right to Health Bill.

There have been few more instances where Chief Ministers decided to bet big on health, in turn affecting voter expectations of other politicians in the State. A relevant example is the legacy of YS Rajasekhara Reddy in Andhra Pradesh, which is claimed by his son Jaganmohan Reddy today. YSR introduced the Rajiv Aarogyashri Scheme, the first State-wide health insurance scheme for families below the poverty line in India, in 2007, seeking to create a pro-welfare, rural-centric image for himself.

The insurance scheme’s ensuing popularity ensured that even when the opposition led by Chandrababu Naidu came to office, they could not roll it back, due to pressure from both citizens as well as hospital associations who benefited from the scheme. Jaganmohan Reddy, as the incumbent CM, has expanded the list of procedures and benefits under the scheme.

These examples indicate a much warranted shift. We can observe a virtuous loop of political action and voter demand — as most apparently has happened in Rajasthan. What started off as a free medicines and diagnostics scheme has today snowballed into a political plank for both major parties in Rajasthan. Good service delivery arguably leads to loss aversion among the voters, which builds pressure on competitor politicians to continue the scheme, and build on it. Even smaller reforms, such as guaranteeing delivery of medicines, may begin to change the political culture, and eventually lay the path for the State to pursue systemic reform.

Healthcare is by no means an easy issue to fix. Even after 75 years, our health system pushes more than 50 million people into poverty each year, with out-of-pocket-expenditure as high as 70 per cent in some States. The Covid-19 pandemic further uncovered the deficiencies of the Indian public health system.

One might expect politicians would have adequate incentives to care for this issue that virtually affects every voter. Yet, there is a marked absence of mainstream political discourse around health financing, outcomes, human resources in health, etc. This must change, and maybe our politicians, inspired by the examples above, will be incentivised to surprise the voters with a new political agenda involving healthcare.

Author: Nikhil Iyer is Senior Public Policy Analyst at The Quantum Hub Consulting