A History of Indian Government spending on public health
Although the Indian Constitution does not explicitly include a Right to Healthcare within its Fundamental Rights, several articles such as 38, 39, 41, 42, 47 and 48 A included within the Directive Principles of State Policy in Part IV, emphasize the state’s need to intervene in the crucial area of public health (Mathiharan, 2003). The Supreme Court, taking into consideration these provisions, as well as interpreting the government’s duty in consonance with international agreements such as the Universal Declaration of Human Rights and the International Covenant on Economic, Social and Cultural Rights, has declared that Article 21 of the Constitution that speaks of the Right to Life, includes within its purview the promotion of public health and the right of citizens to live with human dignity (Jhawar, 2017).
Apart from legal compulsions, the mere circumstantial factors of the nation’s health have obliged state intervention for decades. Public health has occupied a central place in the election manifestos of several parties since independence, due to the dire need of addressing the concerns of a malnourished, starving population on the brink of extermination at the hands of another possible famine (Zodpey, 2018). With life expectancy being merely 32 years, to infant mortality forming 146 deaths out of 1000 births, the necessity for the state to intervene was crucial, due to the inaccessibility of the citizens to essential medical aid, low purchasing power of the citizens at the time, a lack of medical and scientific infrastructure, the rise in population after the influx of refugees from Pakistan and the diverting of available funds to the more pressing need of war against Pakistan. Centuries of colonial rule and an enforced stagnation in scientific temper and advancements had rendered the country in such a state (Amrith, 2007).
From Nehru setting up the All India Institute of Medical Sciences (AIIMS) at the culmination of the Second Five Year Plan and as a precursor to the 1957 elections, to more elaborate plans and disease targeting being promised today, India finds itself at an awkward position in 2019, due to several inherent contradictions within its system (Zodpey, 2018).
The current state of public health in India
India’s public healthcare represents one of the cheapest systems in the world, but yet one of the most inaccessible for its own people (Bhattacharjee, 2017). With almost 95% of the 45,000 medical graduates India produces every year choosing to remain in India rather than work abroad, a study by Amartya Sen produced results that ranked India alongside Sierra Leone and Haiti, two extremely impoverished nations even in comparison to India (Roche, 2017). Most doctors in India are agglomerated around urban areas and seldom find themselves serving the rural population, where a majority of preventable deaths occur. In 2016, over 838,000 Indians died of preventable causes arising out of a lack of accessibility, but alarmingly, around 1.6 million died after having gained access, but due to the poor quality of healthcare in public hospitals (Yadavar, 2018). On the contrary, the private pharmaceutical companies or healthcare organizations accounted for an $81.3 billion business in 2013, which is estimated to grow by 17% by 2020 (Mokkapati, 2019).
With such a situation prevailing in 2019, coupled with an ever-increasing population that is growing at a rate of 1.1% per annum, the manifestos released by the major parties represent positive changes in comparison to their predecessors (Sharma, 2019).
Promises in the 2019 Manifestos
The 2019 Bharatiya Janata Party (BJP) Manifesto in specific has displayed an improvement in promises in terms of abstaining from making generic statements with no definitive direction to their plan of action, as witnessed in their 1996 and 1998 manifestos. After having witnessed the deaths of several infants suffering from encephalitis in a Gorakhpur hospital in 2017 due to a lack of oxygen, the BJP has been forced to re-evaluate their modus operandi (Jadid, 2017). The 2019 manifesto, although extremely brief, speaks of the Modicare scheme, or the National Health Protection Mission, which promises free healthcare to a selected section within the population (Bhaduri, 2019). 500 million of the poorest in India are eligible for this scheme; the efficacy of which has been under serious doubt, as India still spends only 1% of its GDP on governmental spending on public health, as compared to the global average of 6% or the World Health Organization (WHO) recommended share of 5% (Dey, 2018). Dubbing this plan as an unparalleled success due to the sheer volume of the population it has apparently lent itself to, the manifesto speaks of no new initiative to be implemented. The feasibility of such an initiative in the long run and its usage to canvas in the upcoming elections is questionable, as the funds for such a genre of healthcare by the BJP have not been obtained by diverting already existing ones from another budgetary priority or sector of the economy. They are obtained instead by levying a health and education surtax on an already disgruntled population post the Goods and Service Tax initiative by the government, who has failed to pay heed to the worst state the Indian Rupee has found itself in, in history (Sisodia, 2017; Goyal, 2019). Abstaining from the mention of curbing illness by the practice of yoga, as seen in the 2014 manifesto, the BJP has however failed to address the issues of drinking water, sanitation and open defecation; issues majorly tied to caste politics and identity that have found mention in their previous manifestos.
The Indian National Congress (INC) has issued a more comprehensive set of promises under a separate section. Uniquely, unlike any other recent manifesto, the 2019 INC manifesto addresses the crucial problem of ambulance deaths by promising to add more ambulances to Indian roads. It is estimated that around 1.5 lakh people die annually due to delayed ambulance service in India and such a promise seeks to meet the WHO standard of 1 ambulance per 100,000 people; a benchmark India presently, miserably falls short of (Singh, 2015). Importantly, this manifesto distinguishes itself by addressing the problems of mental health amongst the Indian population; an issue otherwise that remains otherwise neglected. However, despite mentioned two legislative acts to counter this issue, the modus operandi especially pertaining to combating social stigma and benefitting the rural populations, who remain largely distant from the more urban and affluent luxury of addressing one’s mental health, remains unaddressed.
The manifesto also mentions the digitization of medical records as part of a government initiative that raises issues of privacy and security in the aftermath of the recent Aadhaar controversy and continued reports of the data belonging to citizens being available online (Whittaker, 2019). The feasibility of this clause remains disputed due to a majority of the capital and labour of the medicine industry in India being present in the private sector, whose companies formulate strict guidelines for the non-violation of one’s privacy by means of safeguarding one’s medical records. The manifesto also promises free healthcare facilities to be provided for all citizens, not based on any socio-economic criteria, but does not mention the specifics of the funds to be generated. In addition to new initiatives, the manifesto also speaks of previously passed acts such as the 2010 Clinical Establishments Act and the Accredited Social Health Activist (ASHA) initiative that have met with limited success in terms of promoting accountability, transparency and medical employment in rural areas (Phadke, 2010).
A comparative analysis of the 2019 Party Manifestos
Both the manifestos, of the BJP and of the INC, mention an increase in staffing, graduates, specialization and institutes, but fail to address more crucial nuances of the challenges in our nation. There is no mention of measures to be undertaken to combat brain drain or the disproportionate amount of doctors present in the urban areas and the private sector (70% of all doctors) (Das, 2016). Since more casualties are witnessed in India due to the poor quality of healthcare, as compared to inaccessibility, a promised increase in medical graduates and institutions does not necessarily correlate to an improvement in quality or the spread of labour to rural areas in dire need of doctors.
While the INC seeks to pander to all citizens, rather than the poorest 500 million, it also seeks to increase the share of government spending on health to 3% of the GDP. There is also a stark penchant in the BJP manifesto to prefer an insurance-based system that is better connected to the private sector that only provides finances over and above one’s budgetary constraints when it comes to healthcare. The INC, on the other hand, rejects such a measure along with the “separate pricing policy” of the BJP and instead, advocates increased state intervention for the provision of free services to all, rather than assistance as and when the need arises.
The BJP manifesto speaks of the need to curb Tuberculosis, unlike the INC one that abstains from mentioning any illness in specific. Unfortunately, both manifestos fail to address more rampant diseases in India such as anaemia, cholera, dysentery and other water-borne diseases; issues previously finding mention in the 2014 and 2009 manifestos of both parties. Such diseases are detrimental to India’s population and the child mortality rate, with one casualty occurring every 4 hours in the nation (Basu, 2015).
Several studies undertaken by public health experts and economists such as Jean Dreze, Anamika Pandey and K. Loganathan have found that India can exceed expectations in terms of government provisions for public health, if certain systemic and institutional challenges such as wealth disparity, regional imbalances and bureaucratic leakage are addressed (Loganathan, 2017; Pandey, 2018). While the 2019 manifestos do represent one step ahead in the larger scheme of proceedings in the nation, their implementation can only be effective once such hurdles at the grassroots level are taken into consideration.
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