Focus on a system that responds to the capacity of the State and other stakeholders in the immediate-term, while building on such capacity in the longer term. Better responsiveness to the needs of citizens can drive trust between citizens and the State.
As India begins marking its 75th year of Independence, it is an appropriate time to take stock of the priority we have accorded to our biggest resource — human capital. Today, India has the largest population of young people; an enviable resource that can move India on to a stronger economic path. Research has highlighted the links between building human capital (through nutrition, health, and education) and growth. And yet, data on nutrition, health, and education suggests that the value of this resource has not been recognised.
When we focus on health, there has been progress, but India remains well below peer countries — and where it needs to be — in terms of the well being of citizens. This stems from multiple reasons.
One, it is not clear if national and political incentives to improve health have been clear to leaders. There are two aspects to this. The first is linked to the limited attention to the links between health and human capital, and growth promotion — a case that positions health not merely as a welfare issue, but as an influencer of India’s growth.
The second is the limited attention to the impact of health care on poverty. Health-related expenditures are estimated to push 3.5% of the population below the poverty line; with those already below the poverty line pushed only deeper. Anirudh Krishna’s research across four continents found health-related expenses to be the prime reason for households descending into poverty and that millions of households live “one illness away” from poverty.
Political incentives could also be a factor of “credit”, and in India’s federal system, a lack of clarity in “credit” from the improved health care services may further diffuse political incentives. Reforming the health care system may also be viewed as too long-term an agenda, and, therefore, not conducive to immediate political gains. Additionally, the pathways at different governance and administrative levels are often not evident, constraining political interest from relevant leaders. Two, the absence of health as an electoral demand dilutes its political salience. Data from multiple CSDS Lokniti polls has highlighted that health figures low among voter priorities. The middle-class has exited from the use of public services, and increasingly, the poor are moving in the same direction.
It is, therefore, not surprising that the health sector has one of the lowest public investments at 1.3% of the Gross Domestic Product, with a disproportionate use of private services, and 64% of health care expenditure being out of pocket at the point of service.
However, leaders have sought political legitimacy through attention to targeted sectors and the initiation of reforms. Regime shifts in several countries such as Turkey, Indonesia, and Brazil saw leaders prioritising health to establish credibility with the voter base and reaping electoral benefits. Well implemented reforms fuelled citizen expectations, leading to demand, and creating the space for further reform. India has not witnessed too many examples of this.
State capacity is a central variable in the cycle of well-implemented reforms, tangible benefits, a social compact between the government and its citizens, and electoral gains. The absence of this confidence in capacity will likely lead to a clientelist model of delivering services, rather than a systems approach.
What is the path that India should take? One, focus on a system that responds to the capacity of the State and other stakeholders in the immediate-term, while building on such capacity in the longer-term. Better responsiveness to the needs of citizens can drive trust between citizens and the State. And do this while highlighting the role of health in a nation’s journey, and building citizens’ understanding of the primacy of health and its impact on their economic status.
A lot more needs to be done to identify paths to reform, through a combination of public and private provisions, with the State as a regulator. This can offer a coherent response to constraints and political benefits at the national, state and sub-state levels.
Sandhya Venkateswaran is member, Lancet Citizens Commission on Reimagining India’s Health System and Centre for Social and Economic Progress.
Source: Hindustan Times, 29/09/21
