Why don’t voters value health care?

You get what you ask for. With several states in election mode, the obvious question is — what are people asking for? If the citizens of India are not getting what they need on health, education and other social policy fronts, are they are not asking for them?

Data from the CSDS-Lokniti 2019 post-poll survey highlighted development as the most important priority for voters (14.3% of voters surveyed), followed by unemployment, price rise, corruption and economy. Health/hospital facilities were mentioned as a key issue by a mere 0.3% of the sample. The 2014 post-poll survey had similar results, with health mentioned by 0.4% of the sample as a key priority.

Assembly polls seem to be no different. Lokniti’s Bihar post-poll data from the 2020 assembly elections shows development, unemployment/jobs/recruitment/lack of industries, and inflation to be the top three issues for voters. Health was important for 0.3% of the respondents. A pre-poll survey for Delhi highlighted development, employment/unemployment/lack of jobs, education and nationalism as key issues. The 2016 pre-poll survey in Kerala found 0.2% of people surveyed rating health care as the most important issue for their voting choice. Clearly, health doesn’t seem to be a priority driving voting behaviour. This is not surprising, it may be argued, in a context where citizens lack the basics of income, water and roads. Where it is indeed surprising, however, is in the context of the financial implications of health care.

Health-related expenditures are estimated to push approximately 3.5% of the population below the poverty line every year; with those below the poverty line pushed deeper into poverty. Research by Anirudha Krishna across India, Africa and Latin America found health-related expenses to be the prime reason for households descending into poverty (even when income had been secure to begin with) and that millions of households live “one illness away” from poverty. This means that even as citizens (rightly) prioritise income, health-related expenditures can so easily and dramatically change the economic status of households. Better health systems and services are key to prevent this health-related descent into poverty; yet this is not an electoral ask from citizens.

The reality is that the middle-class has exited from the use of public services. Increasingly, the poor are moving in the same direction, towards private health and education services, with 70% of in-patient care and 80% of ambulatory services provided by the private sector. In such a situation, who then will demand better public health services?

At a macro-level, research has highlighted the links between building human capital (through health and education) and growth. For a large number of Indian citizens, health, education, and nutritional levels constrain effective participation in many sectors, positioning them not merely as welfare issues, but equally a potential influencer of India’s growth, but health still does not find adequate place in India’s growth strategy.

With little citizen-demand, and limited appreciation of the health-economy link, it is not surprising that political and electoral attention to health has been limited. This has resulted in India’s health having one of the lowest public investments at approximately 1.3% of the Gross Domestic Product; disproportionate use of private services which are extremely fragmented, with solo providers and individual clinics comprising 95% of the private ambulatory market; and 64% of health care expenditure being out-of-pocket at the point of service.

It is not that policy solutions are not known. It is rather a case of health losing out as a priority in the heavily-contested policy space; a space driven by political incentives. The incentives to develop a strong health system, with benefits at the household as well as national/state level, are obvious; yet, political priority in this direction remains elusive. Other countries, as also some Indian states, have understood the electoral significance of health. Reforms in Turkey, Mexico, Thailand (to name just a few) were built on an electoral foundation. Priority to health insurance schemes in India has been linked with electoral gains. Yet, attention to the health sector in any meaningful manner has not been visible.

This gives rise to several questions. Is building human capital not viewed as nation-building, and, thus, lacks political primacy? Does India’s federal and multi-layered governance system prevent clarity on who gets credit from health care services, diffusing potential electoral gains? Or is reforming the health care system too long-term an agenda, not conducive to immediate electoral gains, which are easier with health benefits delivered in a clientelist mode? For citizens, is a health crisis a sporadic emergency over which they have no control (in an almost fatalistic way), because of which responsibility for health care is neither accorded to themselves nor their leaders?

Admittedly, the battlefield of elections seems to be increasingly moving away from the direct issues that impact the quality of life of citizens. Identity as an electoral issue, long dominant, but now predominant, has taken on newer forms such as nationalism, driving voter behaviour in a direction further away from issues of health, education, and social protection. More needs to be done to ensure that first, citizens understand the location and primacy of health in their aspirational journey and its impact on their economic status, and ask for better health care, and second, that national and state leaders acknowledge the role of health in a nation and State’s economic journey.

Sandhya Venkateswaran is a fellow, Lancet Citizens Commission on Reimagining India’s Health System The views expressed are personal