Welcome to The Election Fix. On Sundays, we take a closer look at one theme that will play a significant role in India’s Lok Sabha elections, and one state that may be going under the radar.

This week, Nayantara Narayanan, who runs Pulse, writes about healthcare, from what the state of India’s healthcare system is to how this government has fared and what parties are promising. We also take a look at how things stand in Chhattisgarh.

Tell us what themes we should look at in coming weeks by emailing rohan@scroll.in. You can read previous issues of the Election Fix here, and if you haven’t already, subscribe here to get the Election Fix in your inbox.

The Big Story: Healthcare

Last week, Congress president Rahul Gandhi announced that his party will consider legislating a Right to Healthcare Act if it comes to power after the upcoming Lok Sabha elections.

The proposed law would guarantee certain minimum healthcare facilities to every Indian, raise the national healthcare expenditure to 3% of the Gross Domestic Product and increase the number of healthcare professionals.

All three are old promises – and long-standing demands of the health sector.

Perhaps, the Congress has been forced to announce a major health policy focus because the Narendra Modi government has already brought healthcare front and centre with the much publicised Pradhan Mantri Jan Aarogya Yojana, which it claims is the world’s biggest healthcare scheme. Or perhaps the Congress is demonstrating to the electorate that it stands for more than just being anti-Modi.

Either way, the announcement shows that, after years of neglect, political parties are looking at healthcare as a serious electoral issue.

There is some evidence from Chhattisgarh and Rajasthan, two states where the Congress came to power in December, that the party is serious about public health.

The Chhattisgarh government has announced its plans to replace the Modi government’s national health scheme, the Pradhan Mantri Jan Aarogya Yojana or PMJAY, with a new scheme for universal healthcare. Instead of using insurance to cover hospitalisation expenses of poor patients, the state government says it will bolster primary and preventive healthcare by strengthening public health facilities, as promised in its election manifesto. Rajasthan is in the process of drafting a Right to Healthcare Bill.

For the Record

India is among the countries with the lowest health expenditure in the world, despite facing severe health challenges. India accounts for 17% of global maternal deaths, 21% of deaths among children below five years and 29% of newborn deaths. More than a third of India’s children are stunted. The number of children who suffer wasting, an indication of acute starvation, has risen in recent years to about 21%.

Yet India’s public expenditure on health remained stagnant at between 1% and 1.3% of GDP over the last decade.

India is also undergoing and dangerous and rapid epidemiological transition with an explosion of non-communicable diseases like ischaemic heart disease, diabetes, cancer, chronic obstructive pulmonary disease. It is also facing a mental health crisis, accounting for 37% of global suicide deaths among women and 24% among men.

The health system is ill-equipped to handle these challenges. India has a severe shortage of healthcare workers – on average, there is one doctor for every 11,082 people, which is more than 10 times than the doctor-patient ratio that WHO recommends.

India’s health systems need a drastic overhaul to deal with all this.

But this sort of data makes it clear that the problem is neither new, nor can it be blamed on one government.

Judging Prime Minister Narendra Modi’s government on healthcare, however, is hard in part because its major policy initiatives only came up towards the end of its tenure. The country’s new National Health Policy only was released in 2017, three years after Modi took over as prime minister. This aimed to increase health expenditure, and set out targets for lower infant and maternal mortality rates among other indicators.

The key proposal to get there would wait until the budget of 2018, when the government announced its new “Ayushman Bharat” programme, which was also sold as “Modicare”. One part of this is an insurance scheme called the Pradhan Mantri Jan Aarogya Yojana, which aims to cover hospitalisation expenses of up to Rs 5 lakh per family for the poorest 40% of India’s population. The other portion involved creating 1,50,000 lakh health and wellness centres.

Though the government touted this as the world’s largest free healthcare scheme, critics have questioned the decision to rely on an insurance-based system, pointing out that both the PMJAY and the centres are underfunded for their avowed goals.

Health activists have been worried about the increasing role of the private sector in providing healthcare in India. Public health experts say that the PMJAY further allows the transfer of public funds for healthcare into the hands of private players – healthcare providers and insurance companies – instead of these funds going towards better public provisioning of healthcare.

These reports from Pulse, Scroll.in’s dedicated health section provide some context:

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Past tense

What about earlier policies on health?

Rahul Gandhi’s promise of a right to healthcare isn’t new. In fact, it has been in every Congress manifesto for a decade and a half. The last Congress-led government under Prime Minister Manmohan Singh launched a National Rural Health Mission in 2005, with a cadre of grassroots health workers that still forms the backbone of the country’s rural healthcare system, though the programme has had inefficiencies.

The Manmohan Singh government did commission a High Level Expert Group report, meant to be a blueprint for universal health coverage. It called for increasing health spending to 3% by 2022, ensuring the availability of free essential medicines, and not relying on insurance firms to purchase healthcare for the government.

But critics said the report was completely neglected.

Politicking

Since the parties have not come out with their manifestos yet, this what we know of the various promises. The BJP intends to run on the back of Ayushman Bharat, which it continues to tout as a massive free healthcare system for the poorest. The Congress, in comparison, is touting its Right to Healthcare Act, though details about this are still scarce.

A few of the other parties also have healthcare pitches. Delhi’s Aam Aadmi Party has touted its mohalla clinic approach. Several other organisations have also released their own “manifestos”, essentially what they would like to see from political parties

Do voters care?

Surveys by and large suggest that voters do indeed consider healthcare one of their biggest concerns. The Association for Democratic Reforms’ Mid-Term Survey reports suggest that healthcare comes second only after employment opportunities in people’s minds. A survey by the Centre for Studies of Developing Societies and Kondra-Adenaeur-Stiftung in 2016 found that young voters were most worried about their own health and that of their parents.

But does this translate into voting? Some analysts tend to cite the National Rural Employment Guarantee Act over the National Rural Health Mission as the reason the Congress-led government came back to power in 2009. Others have suggested that though it is a major concern, voters don’t necessarily trust the government, particularly at the Centre, to fix the problem and so parties are rarely punished for not providing major advances on that front.

State focus: Chhattisgarh

Chhattisgarh proved to be the most decisive of the three North Indian states that went the Congress’s way in straight fights against the Bharatiya Janata Party at the end of 2018, putting some wind in the sails of the Opposition. But with only 11 Lok Sabha seats, it is unlikely to get as much attention as other states where there is a direct BJP vs Congress fight.

At the state level, the party had been controlled by the BJP Chief Minister Raman Singh for 15 years, before his government was voted out in December.The state gave the BJP 10 out of its 11 Lok Sabha seats in 2014. But the upcoming elections are likely to be significantly different.

For one, the Congress has much more prominence and support, as evidenced by its sweeping victory in the assembly elections. It has built up its organisation and also made crucial promises, like a farm loan waiver and increasing the minimum support prices for paddy, both of which seemed to work with the electorate.

The BJP’s central leaders took a drastic step earlier this month, deciding that no existing Member of Parliament or Member of Legislative Assembly who lost in the state elections will be given a ticket. This prompted much consternation in the state unit, considering one of the leaders is an 8-time MP, and the party has since struggled to come up with names for various seats.

The tactic was meant to bring in fresh faces, but instead, the state unit has picked individuals who have been MPs or MLAs in the past. The arguments over the party’s central leadership’s decision have even turned violent. Although accurate surveys are unlikely to be available until the candidates have been decided, a NewsNation opinion poll suggested earlier this month that the Congress would win 6 of the 11 seats with the remaining going to the BJP.

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