In India, during the Covid-19 pandemic three years ago, it was almost impossible to overlook how health had been turned into a political battlefield. The government was accused of underplaying the number of deaths in the country, it used the disease as an excuse to target members of the Tablighi Jamaat group in Delhi and even vaccination certificates became the opportunity to project Prime Minister Narendra Modi’s personality.
In the aftermath of the pandemic, it was reasonable to assume that in the subsequent elections, debates and questions on public health would be central. Yet, in spite of the series of state elections between 2021 and 2023 and the Lok Sabha election now underway in India, public health did not seem to find a mention in electoral discussions.
Though the pandemic brought into focus the severe inadequacies of public health infrastructure, recent national budgets in India have not significantly increased health expenditures. In fact, data and reports indicate that health allocations in the budgets following Covid-19 have actually declined.
In rankings of health and health systems ranking around the world, India came in at 112 out of 191 countries. India has one of the lowest health spending rates in the world, at about 2.1% of its GDP, according to World Bank data. The National Family Health Survey-3 shows that 70% of households in urban areas and 63% of households in rural areas still get most of their health care from the private sector. This makes India one of the countries with the highest out-of-pocket health care costs in the world.
Why does public healthcare remain such a neglected arena for political parties in India? Post-Covid, no major political party has attempted to make public health a major item on the electoral agenda.
In fact, as was evident during the second Covid wave between January and June 2021, the period with highest rate of infection and death, pandemic protocols were blatantly disregarded during the assembly elections in Assam, Kerala, Tamil Nadu, and West Bengal. None of the political parties either called for postponing the election, nor did they talk about the need for a comprehensive public health reform as part of the electoral agenda.
One possible reason is the unwillingness of political parties to promise bottom-up public health services, which require a long-term commitment and investment, beyond the scope of a five-year electoral tenure. Consequently, we have seen the proliferation of government-sponsored top-down health insurance schemes, a desperate attempt to cover up the health inadequacy in India.
But what about the other stakeholder – the voters? Research indicates that voters do not consider health an electoral priority either. Surveys by Lokniti-CSDS, a research organisation that studies electoral patterns and voting behaviour in India, show that less than 1% voters consider health as an important voting issue, a trend that continues to remain more or less constant even after the pandemic.
This corresponds with our own ethnographic research finding, conducted in West Bengal between August 2023 and January 2024. When asked about the factors that would determine their voting choice in the coming election, not a single respondent mentioned health, even fleetingly.
This was surprising, given that several of these respondents had been directly hit by the pandemic. Some of them had lost their jobs or income during the lockdown and were still struggling. A few lost family members, tragedies that by their own admission could have been prevented by better infrastructure in government hospitals.
One reason for this is that the voters in India are more often than not being swayed by the agendas set by the political leaders or parties. Since health has historically never been made an electoral agenda by the political elites in India, it continues to remain outside the realm of politics by the voters.
Public health in India is in a desperate need of comprehensive reforms. This will require political will and sustained commitment. It can only be achieved with adequate public engagement and civil society debates on health as an integral part of the electoral agenda over a long period.
Niladri Chatterjee is a historian and researcher based at the University of Oslo, Norway. Eleonor Marcussen is a researcher in history at the Department of Cultural Sciences and member of the Linnaeus University Centre for Concurrences in Colonial and Postcolonial Studies, Sweden.
