India’s under-investment in its health system has been long and persistent. The country has one of the lowest public expenditures on health (as a percentage of gross domestic product) of any major economy. Public expenditure on health in India constitutes about 1% of its GDP per annum compared to 3% in China, 4% in Brazil, and 4.5% in South Africa.

With high dependence on privately provided services and evidence that catastrophic out-of-pocket expenditure is responsible for pushing millions into poverty, it is surprising that the demand for better healthcare is not more of an electoral priority in India.

In a recent survey conducted by Lokniti-Centre for the Study of Developing Societies in partnership with the Centre for Social and Economic Progress, King’s India Institute and Royal Holloway, University of London, we set out to examine in greater depth how Indian citizens view health.

This five-state survey is the first systematic interrogation of electoral perceptions around health in India. Between March-April 2022, we interviewed 1,500 voters across five Indian states – Bihar, Gujarat, Rajasthan, Tamil Nadu and Uttar Pradesh. These states represent a range of health outcomes and have different degrees of reliance on public vs private healthcare. They are also governed by different political parties.

Voters often mention “development” or “vikas” as the most important issue for them at election time, but what development means in practice can cover a range of issues from employment, economic growth, infrastructure development and the provision of drinking water or sanitation.

In our survey we asked what aspect of development voters thought was most important to make improvements at the local level, as well as what was the biggest concern for their own household.

We find that respondents view health as one of the top three issues for improving the level of development in their local area – on par with education, and behind only job creation. Similar is true at the household level where 20% of voters say that the issue they are most concerned about over the next five years is their own health or the health of a family member.

Questions: Thinking about your local area, please tell me which of these is the most important for improving the level of development?; Thinking about your own family/household, over the next 5 years, what is your biggest concern out of these five? DK = Don’t know

Furthermore, among older people, health was ranked as the most important issue – those over the age of 56 were more likely to mention health as the most important issue than those under 25 years of age (26% vs 12%).

We can be confident therefore that health is an issue that many voters do care about. Furthermore, the vast majority of respondents, 80%, said that it is the government’s responsibility to provide health care.

We then asked respondents how far the provision of health services affects their vote choice in local, state and national elections. A plurality of voters said that health facilities (hospitals and doctors) affect their voting decisions “to some extent” at all levels of election, and a majority say they affect their electoral choices “to a great extent” or “to some extent”.

This is most pronounced with respect to state assembly elections, where 39% said that health facilities affect their vote “to some extent”, and a further 22% said they affected their vote “to a great extent”. This makes sense given that health is constitutionally a “state subject” although this is not unambiguous for voters. Many people also said that health affects their vote choice in local and national elections.

Thus, we find that health is one of the top three priorities for development identified by voters at both the level of their local community and their household. Furthermore, a plurality of voters say that health does affect their vote choice to some or a great extent.

While we cannot say on the basis of our survey evidence that demands for better health care are a determining factor in shaping voting decisions or election outcomes, we can be confident that health is on the minds of voters and that it plays some role in how they vote.

This suggests that political leaders may gain electoral capital from prioritising health in their electoral campaigns and during their terms in office. The evidence presented in this report suggests that there is a latent demand from voters for health sector improvements and an appetite for government leadership in this field.

Oliver Heath is Professor of Politics and co-director of the Democracy and Elections Centre, Royal Holloway, University of London.

Jyoti Mishra Research Associate at Lokniti-CSDS.

Louise Tillin is Director, King’s India Institute and Professor of Politics, King’s College London.

Sandhya Venkateswaran is Senior Fellow at Centre for Social and Economic Progress (CSEP); and leads the Human Development work at CSEP, with a specific focus on Health Policy.

The full survey report can be downloaded from the Lokniti-CSDS website. The survey received funding from a British Academy small grant. A longer version of this article was originally published by Melbourne Asia Review, Asia Institute, University of Melbourne.