This blog was published on the International Health Policies Blog on June 5, 2015 under the same title. It was co-written with Upendra Bhojani, my colleague at IPH, Bangalore
These are interesting times in India, no doubt. Our new prime minister, Narendra Modi is ensuring that India’s global reputation as a progressive, multi-cultural and multi-ethnic society with a rich history is not tarnished by several recent reports of sexual violence on women or inter-religious conflict. Immediately after assuming office about a year ago, Modi took India’s image very seriously, perhaps more seriously than many of us imagined. Power-packed foreign trips were strategically chosen to ensure that India is not neglected by the global power centres. India’s aspiration for the permanent seaton the UN security council and its eagerness to be seen as a sought-after destination for international investment were reinforced in most global appearances by the PM. Indians abroad loved him; the 20,000-strong gathering at New York’s Madison Square garden was only one among several well-attended public appearances abroad, showing a PM who is locally known for incisive and articulate public orations in Hindi still managing a somewhat awkward “May the force be with you” – the famous Star Wars catch phrase rendered in fact standing side by side with the Wolverine Hugh Jackman – to the roaring crowds. Recalling his humble origins and his “intention to do big things for small people,” he vowed to promote Indian economic growth, clean up the severely polluted Ganga (a river held sacred in India) and improve the situation of the country’s poor and disadvantaged. In fact, a NYT edit even compared the stage backdropto Shepard Fairey’s famous Hope poster of US President Barack Obama.
Commitment to the poor and disadvantaged by the government comes at an opportune time. In spite of apparently progressive pro-poor schemes of the previous Congress-led government targeting rural employment guarantee and a more communitised health system (see Rajani Ved’s blog on India’s ASHA programme and Arima Mishra’s blog on the mission mode for India’s programmes), corruption and mal-administration plague India’s public services, as noted by R S Rajan. Modi ran on an election platform that showcased how his governance would be exactly NOT like the previous regime. In health, the Modi election manifesto promised “health assurance to all Indians and to reduce the out-of-pocket spending on health care”.
However, in a federal state, which is still battling with worse-off governance at state levels than the relatively better-off systems at the centre, this national health assurance is slowly proving to be a difficult promise to deliver. As Neethi Rao reflects in her blog on federalism, Indian states often with their own local state-level politics are not always in line with such national commitments, more so on health services organisation and delivery which is on the so-called state list. A much more systematic support at state and district levels is possibly needed before such national commitments may be fulfilled. While this complex socio-political negotiation between a PM at the centre, who portrays clear convictions on how to chart India’s development story, and a general poverty of governance and vision at the state level (with respect to health and development) continues, there are not yet clear positive trends for India’s health on the horizon.
If financing of healthcare is any indicator of government’s commitments to health of its people, the signals are not (yet) so positive. The precious little coming to the healthcare sector has to be partitioned between pet national institutes of excellence, even as a hugely under-funded and under-performing primary and secondary care system watches, as Shreelata Rao Seshadri notes in her blog. In spite of being a prominent supplier of inexpensive medicines to several countries in the global South, access to medicines in India’s own primary health centres is not yet optimal (see Maya Annie Elias’s blog on this topic). Early pronouncements of health insurance for all later morphed into health assurance for all with no clarity on how such assurance or insurance would supplement or rather undermine India’s large public sector. Budget cuts in the social sector programmes and schemes of the central government followed; again cutting of central government spending in the social sector was accompanied by higher revenue share to states, arguably favour of co-operative federalism. However, there are doubts that such trade-offs will work, at least they may not work in all states. Many of the worse-off states where targeted central assistance was in fact unconditionally focusing on the social sector, the shift of greater revenue to states might in fact be weaned away from supporting long-term social sector spending and may succumb to low politics at the state and be used for short-term vote-gain programmes.
While the debate on whether India ought to go for a privately provided market-based insurance route for UHC or veer towards publicly provided (or purchased) care is a debate that has strident advocates on either side, Modi government’s slogan of “minimum government, maximum governance” fails India on two counts. There is the actual need of quite some “government”, at least with respect to sectors like health, education and environment, where we know from several global experiences that reducing government’s stake to mere stewards while handing over organisation, management and delivery of these systems to non-governmental entities is a dangerous trend. The need for building a strong partnership with states and investing in multi-level governance system and effective regulation of private sector in health, especially the provision of healthcare by private entities is a crucial need for Indian public health.
In fact, if the current weakening of environmental norms in favour of quick-winsis any indication of times to come, then India’s short-term gains in infrastructure, investment and global image may come at a long-term health and environmental cost. As Shankar Raman reminds us, environmental effects on health are not marginal concerns any more. In its eagerness to make sure we all feel the development, the Modi government may be over-enthusiastically cosying up to big business. India’s environment ministry has been delivering clearances for clearing forest land for industry faster than ever before, and the rural development ministry has been steering land acquisition for industry directly, while the health ministry, after bold declarations against big tobacco delivered in much fanfare by Modi government’s own previous health minister, backtracked on implementing large-size health warnings on tobacco products. Corporate and industry interests are high priority and not without reason, but their influence on health, development and environmental policy is indeed worrisome. More so, when India’s biggest business interest groups that are involved in public policymaking bodies and several Indian parliamentarians in important committees related to health and development have very close ties to big tobacco. Indeed India’s finance minister, a close aide of Modi minces no words when he characterises his government as being “pro-poor and pro-industry“. How this marriage between unusual partners – pro-poor and pro-industry- works, time only will tell, as Ramaswami Balasubramaniam notes in his 1st year report card for the Modi government.
Commitment to co-operative federalism and decentralisation may be a mantra on one hand, but the government’s attitude towards publicly expressed dissent has not always been well received. Many NGOs are on the Modi government’s radar, including environment campaigner Greenpeace, which has faced the ire of the government. Several NGOs being cracked down upon were dubious and were deservedly at the wrong end of the stick, but slowly and steadily an atmosphere intolerant of criticism and dissent seems to be cropping up; not a healthy trend warns Adithya Pradyumna in the blog ‘health of NGOs in India’.
Image consciousness is of course not always a bad thing. Modi’s leadership is clearly visible in his administration embracing social media and being accessible on the several government-run online platforms that are mushrooming. Many leading government officials are today on social media and sharing decisions and developments in their offices. Online platforms such as mygov widens reach of the somewhat common (wo)man (access to the Internet and more so, being vocal on that platform is still not so commonplace here). The trend of ministers making frequent public statements and not hesitating for open media debates is also healthy. However, it is still unclear as to how such social media and online platform engagement by citizens is used or feeds the policy process.
Amidst public debate on apparently farmer-unfriendly policies, the government faces stiff pressure to show a more human face to the large farmer base in the country. As Shridhar Kadam notes in his blog, India’s villages are unsure whether to enjoy the fruits of globalisation or miss the comfort of their erstwhile sustainable living. This is of course not only an Indian story but a global one, playing out differently in many of the emerging economies.
Clearly, the first year of Modi government has been different from the previous regime on most counts albeit the difference does not (yet) augur too well for health and environment. In any case, assessing a nation’s health based on one year of a new PM is a flawed enterprise. Nonetheless, broad public policy trends in favour of public health are not (yet) evident. If at all, close association with big business could indeed mean higher private sector role in healthcare delivery. What form this will take, how much of collaboration and how much of regulation is still to be seen (see for instance Vijayashree Yellappa’s reflection on this). Whether invited or not to the healthcare party, the private sector is here to stay. If indeed public health has to prevail, an effective regulatory system that reins in India’s unbridled private sector is a very large unfinished agenda in India. And irrespective of how private, or how public India’s healthcare future is, the Modi government needs to put more government (not less as they are hoping) in healthcare regulation (see Sunil Nandraj’s post on reining in India’s private sector). One only hopes that the crushing of bureaucratic barriers for big business will not be the downfall of public health and public institutions in India. Time only will tell. But, on one thing there is no doubt; health, education and environment in India require quite some government (not less) and certainly better regulation. In this respect the proposal in the draft national health policy 2015 to make access to healthcare a constitutional right in India is a bold and a very welcome move, only if Modi’s government in the remaining four years of its term make it into reality.