Manifestos for health: what the Indian political parties have promisedBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2703 (Published 09 April 2014) Cite this as: BMJ 2014;348:g2703
Health is a critical question in a country that still has some of the worst indicators despite impressive economic growth over the past two decades. Yet in the raucous din of the public discourse about electoral arithmetic—which party gets how many seats in which constituency and the likelihood of post-poll alliances—there has been little discussion around health and healthcare.
This year’s general elections end on 12 May, and the focus has been on corruption scandals, the slowing economy, price rises, and governance. However, health is beginning to climb up the political agenda. Two national political parties have framed healthcare as a “rights” issue in their manifestos, though specifics on how this would work and be funded have not been detailed, and a third is promising radical reform.
Indian Congress Party
The Indian Congress Party, which leads the ruling coalition United Progressive Alliance (UPA) in Delhi, has promised a new charter of “rights” including the right to health, if it is voted back to power.1
This is part of the rights based agenda that UPA has been following. In 2009, the UPA enacted the Right of Children to Free and Compulsory Education Act or Right to Education Act. The legislation, introduced with the promise of providing free and compulsory education to all primary school children, has pushed up enrolment. The proportion of out of school girls in the 11 to 14 age group has also gone down since last year. But learning outcomes, in terms of quality, have not improved.2 UPA has also brought in other rights based legislation.
Congress Party sources say the UPA recognises the bottlenecks in implementing such measures. A high level expert group, constituted by India’s Planning Commission in 2010, says that it is financially feasible for India to offer universal health coverage to every citizen.3 Financing the proposed system will require public expenditures on health to be stepped up from around 1.2% of gross domestic product (GDP) today to at least 2.5% by 2017 and 3% by 2022, says the report.4
But Congress spokespeople acknowledge that selling the right to health on the campaign trail is not an easy matter in a country where many people have no rights consciousness. The party’s manifesto promises to increase public health expenditure to 3% of GDP. It also mentions a three year diploma course in public health; the creation of six million new jobs in the health sector by 2020; and functional toilets for every household and school. Other items on the agenda include the expansion of the Rashtriya Swasthya Bima Yojana, a cashless health insurance scheme for people living below the poverty line.
Ajay Maken, the Congress Party’s general secretary and a former minister in the UPA government, told The BMJ that the right to health promised in the Congress manifesto was a derivative of the “hugely successful” National Rural Health Mission and the National Urban Health Mission (now merged as the National Health Mission). He contended that the Congress led UPA government had ploughed “phenomenal resources” into healthcare, leading to improvement in health indicators. For example, in March India and the World Health Organization’s southeast Asia region were certified polio-free by an independent commission; Indians are living longer; and maternal and infant mortality rates have improved.
Salman Anees Soz, a Congress spokesperson, told The BMJ that a right to health was necessary because India still had 300 million people living in extreme poverty. Soz conceded that there would be challenges implementing the policy, as had been the case with the right to education, and that better monitoring and evaluation mechanisms were needed.
Critics slammed the Congress Party’s proposals on healthcare and its broad welfare agenda as “sops.” The party is mired in several corruption scandals. Many of UPA’s flagship programmes have been riddled with irregularities and found to have inadequate oversight. All this translates into a credibility crisis for the party.
Dr Narayanan Devadasan, who works at the Institute of Public Health in Bangalore, told The BMJ that the Congress manifesto was “basically more of the same.”
“They do not define the right to health. Does this mean that everybody should be able to access health services without a financial burden? If so, then how are they going to do it? What is the strategy? They need thousands of new primary healthcare centres, new medical officers for hospitals? How is all this going to happen in five years?”
Devadasan was also sceptical about the Congress party’s promise to create new jobs in the health sector. “The government of India cannot create jobs at the state level. That is the prerogative of the state governments. So is the government of India going to hand over money to the state governments to create jobs? And for how long?”
Aam Aadmi (Common Man) Party
The national manifesto of the Aam Aadmi (Common Man) Party (AAP), the new force on India’s electoral scene, is also promising comprehensive “right to healthcare” legislation that it says would enable access to high quality healthcare for all the citizens irrespective of wealth along the lines of the existing right to education legislation.5
AAP, which is campaigning on an anticorruption plank, has emphasised its commitment to improving the accountability of public health systems by decentralisation of funds and empowering local bodies and village councils to have a greater say in how public money is spent. AAP was in control of the Delhi state government for 49 days last year. If voted to power on the national stage, it promises that all essential drugs would be available in public health facilities free of charge. The AAP said that it will create incentives for states to adopt a transparent system for the bulk procurement of generic drugs. It would also improve accountability by making it mandatory for private hospitals to display and observe a charter of patients’ rights and to display rates and charges of services and ensure that private healthcare providers subsidised by the government meet their legal requirement to provide free treatment to the poor. AAP has also promised that it would create a well trained cadre of frontline grassroots workers and fill all vacancies at primary health centres.
Bharatiya Janata Party
The right wing Bharatiya Janata Party (BJP), India’s leading opposition party and currently ahead of the Congress in opinion polls, issued its manifesto on 7 April, the day the nine phase general elections kicked off.6 The BJP manifesto promises “radical reforms” in healthcare delivery, medical education, and the financing of healthcare. The long list of promises includes a reduction in out of pocket spending on health, a “National Health Assurance Mission”; reorganisation of the Ministry of Health and Family Welfare to converge departments that deal with healthcare, food and nutrition, and pharmaceuticals; a push for Indian systems of medicine such as Ayurveda; and establishment of top class medical colleges in every state.
“I have been studying the rights based approach. What is more important is to implement effectively those new rights. Conferring them in law and not implementing them renders them mere slogans. So you have a right to health but your public health system does not improve. I think the Congress is looking for legislation. We prefer the actual implementation,” Arun Jaitley, a senior BJP leader told The BMJ last week in response to a question about his party’s reactions to the right to health promised by the Congress.
The BJP has not said how much it would spend on health or detailed the measures it would undertake to slash out of pocket spending on treatment.
Rajendra Pratap Gupta, member of the global agenda council on digital health, 2012-14, at the World Economic Forum and a key member of the BJP’s manifesto team, told The BMJ that as a policy document the manifesto could not include every detail on finance.
“India needs a new healthcare policy (the last one dates from 2002), and we need a clear idea of needs before such projections can be made.” Gupta stressed the need to merge departments: “We talk about promoting generics. But currently, the health ministry does not have any say over pharmaceutical related issues. The department of pharmaceuticals is with the Ministry of Chemicals and Fertilizers.”
The Communist Party of India (Marxist) is the only political party that has specifically committed to defending India’s patent regime, currently under attack from multinational pharmaceutical companies.7 8
In the 15th general elections held in 2009, the UPA was able to cobble together a left of centre coalition government led by the Congress Party, which won 200 seats out of the total 543 seats in the Lok Sabha, the lower house of parliament. This time, however, Congress is on the back foot. Indian pollsters see a surge of support for the rightwing BJP and its prime ministerial candidate Narendra Modi, the controversial chief minister of Gujarat. If the pollsters are correct, there could be another coalition government led by the BJP. The election results will be announced on 16 May. The government formation will depend on coalition talks after that, since no single party is expected to get an absolute majority.
What India spends on healthcare
“India currently spends only 1.2% of its gross domestic product (GDP) on publicly funded health. Total Indian health spending is conventionally estimated at a little over 4% of GDP. . . . The public healthcare system has been strengthened since the start of the 21st century by initiatives such as the National Rural Health Mission, but it still suffers from significant limitations in areas such as the (free) provision of essential medicines to the 400-600 million poorest,” notes a 2013 report by Jennifer Gill and David Taylor of the UCL School of Pharmacy in London, UK.9 Nearly 70% of overall Indian health spending is accounted for by private out of pocket expenditure, and 70% of this is on medicines, the report adds.
Many studies in India have also indicated that out of pocket expenses on healthcare lead to an average increase in poverty by as much as 3.6% for rural and 2.9% for urban India.10
Cite this as: BMJ 2014;348:g2703
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Anant Bhan, a public health researcher in Pune, has been tweeting about party manifestos (@AnantBhan) and has also created a Facebook page that considers them from a health point of view (www.facebook.com/notes/anant-bhan/health-components-of-manifestos-of-some-political-parties-2014-union-indian-elec/10152021624983016).
Provenance and peer review: Commissioned; not externally peer reviewed.