“Health appears in the manifestoes of all the major parties, but with a stark ideological difference between the approach of the right-wing BJP and the centrist and leftist parties opposing it.“

World Report

Contrasting health visions in the Indian election

Opposition parties promise to increase health spending, while the ruling National Democratic Alliance plans to continue existing policies. Dinesh C Sharma reports.

The ongoing election to choose

expenditure on health and provide members of the lower house of the

ways to roll out UHC. Emphasising Indian Parliament, Lok Sabha, is

that “health of the people and health halfway through, with four phases

of polling ending on May 13. It is the

largest such exercise globally, with

960 million eligible electors. The

National Democratic Alliance (NDA),

consisting of the Bharatiya Janata

Party (BJP) led by Prime Minister

Narendra Modi and some regional

parties, is seeking a third term in

office. Its main challenger is the Indian

care are the responsibility of the National Developmental Inclusive

government and that all citizens Alliance (INDIA), which includes the

have the right to health”, the INC Indian National Congress (INC) and

has promised to provide “universal several national and regional parties.

and free” health care, including Health appears in the manifestoes of

diagnostics, treatment, and medicines all the major parties, but with a stark

in the public sector. The budgetary ideological difference between the

allocation for health will be gradually increased to 4% of total govern- approach of the right-wing BJP and the

ment expenditure by 2028–29, the centrist and leftist parties opposing it.

manifesto says.

The BJP manifesto, styled as Modi’s

The All India Trinamool Congress Guarantees, promises a continuation

(AITC), which is in power in the state of the Pradhan Mantri Jan Arogya

of West Bengal, seeks to enhance Yojana (PM-JAY)—a government-

funded, private insurance-led health-

the allocation for health care to 6% of the total budget, to enable delivery scheme for people with low

upgradation of health infrastructure or no income launched in 2018—and

expansion of tertiary-care hospitals

in villages and improve primary care delivery to susceptible populations similar to the All-India Institute of

such as children with anaemia, Medical Sciences and the generic

medicine-store network.

The BJP manifesto makes no

explicit reference to increasing

public expenditure on health or

ways to achieve universal health care

(UHC). The National Health Policy,

announced in 2017, set the target

of increasing public expenditure

on health to 2·5% of GDP by 2025.

Currently, public expenditure on

health is 1·35% of GDP, with the

central government contributing a

mere 0·3%.

Conversely, manifestoes of the

centrist and leftist parties promise

a substantial increase in public

http://www.thelancet.com Vol 403 May 18, 2024

pregnant women, and ageing people with low or no income in rural areas. Another regional party, Dravida Munnetra Kazhagam, in power in the state of Tamil Nadu, says it would strive for health allocation to reach 3% of GDP. The Communist Party of India (Marxist; CPI[M]), in power in the state of Kerala, has promised the “right to free health care” and an increase in public expenditure on health to 5% of GDP, with at least 2% contributed by the central government. The Aam Aadmi Party, in power in the states of Delhi and Punjab, also supports enhanced public expenditure on health. Most parties have favoured strengthening the health workforce and increased compensation for front-line health workers.

PM-JAY, the flagship health scheme of the NDA Government, has been severely criticised in the manifestoes of all non-BJP parties, with most of them promising to scrap the scheme if voted into power. The INC said that “the current universal health-care programme will be redesigned for different sections of the people and will allow the enlistment of private hospitals, non-profit health facilities,

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http://www.thelancet.com Vol 403 May 18, 2024

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and health centres under the scheme”. The CPI(M) would like PM-JAY to be replaced with a “public-centred UHC system”.

Three states—West Bengal, Odisha, and Delhi—where non-BJP parties are in power did not implement PM-JAY and continued with their respective state-level UHC models. The financial protection scheme Swasthya Sathi in West Bengal, according to the AITC manifesto, has helped the state to achieve UHC and vastly improve health indicators. For example, it states that the infant mortality rate decreased from 32 to 19 per 1000 livebirths and that the maternal mortality rate decreased from 117 to 103 per 100 000 livebirths between 2011 and 2020 due to the promotion of institutional deliveries. If voted to power in the central government as part of INDIA, the opposition alliance, AITC has promised to replace PM-JAY with a scheme similar to Swasthya Sathi. The Biju Janata Dal, in power in the state of Odisha, has promised to extend the Biju Swasthya Kalyan Yojana, a health- protection scheme for people who are economically vulnerable launched in the state in 2018, to families with middle income as well.

The BJP has reiterated a promise made in its 2019 manifesto—the elimination of tuberculosis by 2025. “We will intensify existing efforts to ensure elimination of [tuberculosis], leprosy, lymphatic filariasis, measles and rubella, trachoma, and kala- azar by facilitating timely testing and access to medicines”, the 2024 manifesto says. “These diseases affect primarily the poorest of the poor and those with no or poor access to quality health-care services”, said Jai Prakash Narain, a global health expert (Kullu, India). To translate this commitment into reality, he said, “the next government will have to ensure a high level of political will both at central and state levels; stringent monitoring and evaluation system and accountability; and, most

important, lending high priority to health-system strengthening and financing at the district level”.

Although manifestoes mention health-related promises, the subject is generally missing from speeches and campaigns, except for occasional references to PM-JAY in Modi’s speeches. “Health is usually a poll issue during state assembly elections, and it has helped parties win elections in the recent past, as it happened in Delhi and Kerala. But it is not so in parliamentary elections”, R V Asokan, President of the Indian Medical Association (IMA), told The Lancet. The IMA is trying to highlight health-related issues during electioneering by advocating its own heath manifesto.

“We were anticipating drastic changes in the health system after the experience of the pandemic, but this did not happen. So, we decided to release a health manifesto”, Asokan said. UHC, the IMA manifesto notes, should be ensured primarily by the public sector, supplemented with strategic purchases from the private sector. “UHC should move from an aspirational goal to an entitled provision”, it says. For this idea to become reality, the manifesto states that public investment in health should increase to 5% of GDP, with a focus on strengthening primary care. In addition, it emphasises disease prevention, health education, and health promotion, moving beyond the current trend of disproportionately prioritising curative approaches in the public sector.

IMA branches across the country have been told to engage with candidates of different parties. As of May 10, more than 280 candidates in 181 constituencies have been briefed by IMA functionaries. The target is to reach candidates in 4is isnt it!encies by the end of the campaign. “We hope that some of these candidates will make it to the new parliament and they will advocate the issues raised in our manifesto”, Asokan said.

Jan Swasthya Abhiyan (JSA), a

coalition of health non-governmental organisations that issued the People’s Health Manifesto in March, is contacting voters through social media, highlighting the needs to increase public health expenditure in health and scrap the private insurance- led delivery model. “Resources should be redirected towards strengthening public health-care systems and ensuring universal access to quality care”, said Indranil Mukhopadhyay, a member of JSA.

The promises made in most of the political manifestoes appear to be in line with the voter preference towards a primary role for the government in providing health-care services. A voter survey conducted by Lokniti, part of the Centre for the Study of Developing Societies; King’s India Institute, part of King’s College London; Royal Holloway, University of London; and the Centre for Social and Economic Progress (CSEP) in 2023 found that voters viewed health as one of the most important issues for improving development—the same level of priority as education and less important than job creation only. Voters prioritised improvements to government health-care facilities rather than improved access to private facilities.

“It is not clear if voters are disappointed about the lack of salience of health in electoral campaigns, but what emerged in our survey was that, despite it being an important issue for citizens, it is not something that they bring up often with their elected representatives”, said Sandhya Venkateswaran, Senior Fellow at the CSEP and a member of the research team. “Compared to employment, which is the highest priority for most people, health is a less emotive issue, and campaigns invariably focus on emotive narratives.” The ongoing election campaign is no different.

Dinesh C Sharma