The political pathway to health system improvements in India
The piece has been authored by Sandhya Venkateswaran, Senior Fellow at the Centre for Social & Economic Progress, Shruti Slaria Policy Associate, Swaniti Initiative; Nachiket Mor, Visiting Scientist, The Banyan Academy of Leadership in Mental Health, Tamil Nadu.
The Indian health care sector has made significant progress in the last few decades. The under-five child mortality rate dropped from 126 in 1990 to 34 in 2019, life expectancy rose from 58 years in 1990 to 69.4 years in 2018, and polio, guinea worm disease, maternal, and neonatal tetanus were successfully eradicated from the country.
Despite the progress, healthcare delivery in India remains largely focused on periodic treatment, with inadequate attention to preventive and primary care. With a predominantly family health and infectious disease focus, India’s health system is not well geared to deal with the increasing burden of non-communicable diseases. Lack of access, availability, affordability and quality care have resulted in suboptimal health outcomes for India, well below many of its peer countries, and a significant financial burden of health expenditure at the individual and household level.
In this paper, the authors analyse the political determinants of improved health outcomes, making a case for political attention to healthcare, through increased investments, health care reforms and improved capacity to deliver curative and public health. This paper builds on both theoretical frameworks and global and sub-national experience, to develop hypotheses for greater political priority to health in India.
The shortcomings of low public investment in health, a fragmented provider landscape across public and private providers as well as across levels of care, an equally fragmented health financing landscape, and challenges with quality care and accountability, have all combined to create challenges in access, quality, expenditure and contributed to poor health outcomes, impeding India’s move towards Universal Health Coverage (UHC).
The challenge of reform and its effective implementation (where reform has indeed taken place) has its roots in the lack of political priority to healthcare. Health has rarely made it to be a key policy agenda, possibly because of the contestation in the policy and priority making process across competing priorities in the country. Budget 2021 underlines this, where despite the pandemic through 2020, the budget failed to see any significant priority to health, in allocations, or system reform. Health spending has not seen any significant increase over several years, either by the Union government (as a percentage of Gross Domestic Product (GDP) or an apercentage of its total budget), or Centre and states combined. Continued low investments in health; lack of investments in primary care; absence of reforms that can address fragmentation (in provision and financing), quality and accountability; all combine to suggest that political attention to health has continued to be weak. Health promotion in the country now needsto focus on the political barriers to health care priority.
Political leaders in other countries have been influenced by a combination of drivers, leading to healthcare reforms being a political priority; resulting in increased resources, efficient and effective use of existing resources, improved design of and outcomes from healthcare systems, increased responsiveness to citizens’ needs, and reduced financial risk. India remains an outlier to such processes (admittedly with cross-state variations), where despite continuing poor health outcomes and household level financial burden due to health expenditure, impairing social and economic progress at individual and national levels, this area has not witnessed adequate political attention.
We view political commitment as central to health policy, improving health outcomes and financial risk protection, through its ability to drive: resource allocation; capacity and accountability in public systems; reforms that can, in turn, strengthen preventive, promotive and curative health; improved budget utilisation through allocative and technical efficiencies. Political commitment is fundamental to each of these pillars, which in turn impact and enable other shifts, such as the combination of relevant reforms and increased public resources contributing to financial risk protection for individuals.
Based on existing theoretical frameworks for analysing the political economy of health and the specific context of India, we identify five related elements through which health policy and systems in India can gain greater priority. These include 1) recognition and acknowledgement of a problem by political leaders; 2) the presence of feasible and viable policy solutions; 3) interest groups that promote policy change; 4) institutions that sustain momentum around policy change; 5) a political opportunity for introducing the policy. While these would typically be sequential, given that actual policy processes are not an exact science, the starting point and trajectories for political attention could vary significantly by political context.
The landscape of national (or sub-national) problems is a contested one and issues compete with each other for public and political attention. In such a context, making healthcare a policy priority in India requires, as a first step, that it be recognised as a problem that impacts key stakeholders, and thus acknowledged as a key agenda. Studies point to the need for going beyond identifying a problem in its objective form, to categorising and promoting it as a problem that is worthy of attention by key stakeholders through a social construction that drives attention and prioritisation. It has to be viewed as an issue which leaders have a stake in. But the mere recognition of an issue as a problem worthy of attention is not enough; action requires a solution, and it is here that experts and others underline the need for a financially viable, politically and publicly acceptable and technically feasible solution. Despite the acknowledgement of a problem and its solution by some key leaders, there are likely to be a variety of stakeholders with different interests who exert different kinds of power and influence in promoting or obstructing issues. The interplay of these invariably has a strong bearing on the issues that get political priority, and therefore mobilising and engaging with different groups, with incentives to such prioritisation, is key to moving an agenda forward. These processes can take time, during which momentum around the issue needs to be sustained. Global experience has underlined the role of institutions in sustaining such momentum. Finally, the convergence of these factors and forces lead to converting an issue to a policy through a specific political moment or opportunity.
It is in this frame that understanding the political economy of healthcare and its political prioritisation in India becomes meaningful. Currently, the challenges of health care in India are known. The lack of political attention suggests that the political or economic incentives to improving health care are not clear to leaders. At a macro level, the role of health care (or human development more broadly) in India’s growth strategy has not been recognised or articulated, nor has the health-poverty link from a policy perspective. The ‘problem’ of health care in India, therefore, is not adequately acknowledged as a problem for India’s development. Electoral demands often incentivise political priority, but India has not seen health as a citizen priority during elections. Post-poll surveys of the 2019 and 2014 national elections in India, carried out by Lokniti, revealed health as a key voting issue for a mere 0.3% and 0.4% of the sample respectively. The disproportionately higher use of private health facilities by India’s population (even the poor) suggests a lack of trust in the public delivery system, leading to low expectations; a trust which can only be built through adoption of reforms and demonstration of successfully delivered health services. The governance of health, in India’s federal structure, make unclear the political incentives and space to ‘own’ health as an agenda across the centre and state governments. All of these lead us to suggest the following hypotheses for increasing political attention to and salience for health care in India.
*Political attention to health will increase with a positioning of health care that makes its political and economic incentives clear.
Improved healthcare builds human capital, which can contribute to increased growth;
Improved health systems can reduce out of pocket expenses on health, thereby reducing levels of poverty and inequality.
In a federal structure, space (fiscal and political) and ownership can be available to state leadership to own policy reform, demonstrate leadership and take political ‘credit’.
*Political priority for health in India will increase with increased demand from citizens, making health electorally salient.
Citizen demand for healthcare can be enhanced by mobilising citizens and creating greater awareness around an increased understanding of the role of the state in delivering healthcare, the role of health in citizens’ aspirational journey and the potential for reduction in out of pocket health expenditures, thereby impacting household economic status.
*Demonstrated solution pathways at different governance and administrative levels (sub national and sub state) will garner political interest from relevant leaders, both bureaucratic and political.
Identification of clear pathways to health system reform and strengthening, through a combination of public and private provision, with the state as steward and regulator, can offer a coherent response to current constraints.
Demonstrated solutions can strengthen citizen confidence and trust in public delivery of health, leading to electoral expectations and incentives.
(Sandhya Venkateswaran is a senior fellow at the Centre for Social and Economic Progress and fellow, Lancet Citizen’s Commission on Reimagining India’s Health System; Shruti Slaria is policy associate, Swaniti Initiative and fellow, Lancet Citizen’s Commission on Reimagining India’s Health System; Nachiket Mor is a visiting scientist, The Banyan Academy of Leadership in Mental Health, Tamil Nadu.)