Offline: India's health crisis: will democracy deliver?

Abstract

Last weekend, on Jan 26, India celebrated its 70th Republic Day. The theme was the 150th anniversary of Mahatma Gandhi's birth. 2019 is indeed a year to pause and reflect on India's past achievements and future prospects. Soon, India's Election Commission will announce dates for elections to the Lok Sabha, the House of the People (the lower and more powerful House in India's bicameral Parliament). Elections for 543 seats are held in phases and, based on recent history, will probably take place in April and May. The battle for the votes of 850 million people is between the current Prime Minister, Narendra Modi, who leads the Bharatiya Janata Party (BJP), and Rahul Gandhi, who leads the India National Congress. In the 2014 election, Congress was destroyed by a landslide victory for Modi (he won 282 seats, the Modi wave). Until recently, Modi was expected to win again in 2019. But his popularity seems to be waning, while political momentum is now behind Gandhi. In December last year, Congress won three state elections—in Madhya Pradesh, Rajasthan, and Chhattisgarh—propelling Gandhi into the unexpected position of being (possibly) India's next Prime Minister. Shashi Tharoor, a Congress member of the Lok Sabha in Kerala, has called the forthcoming election “a battle for India's soul”. What issues will shape this election? Modi is basing his campaign on the twin claims that he has successfully established India as one of the world's fastest growing economies and has had the courage to tackle endemic corruption. Earlier this month, speaking to non-resident Indians in Dubai, Rahul Gandhi also identified two priorities. First, the “crisis of unemployment”, especially unemployment among young people. Second, the challenge facing Indian farmers who “are in deep trouble” and who need “a new green revolution”. His focus on farmers is strategic: two-thirds of voters earn their living from agriculture in some way. He called Modi's record one of “sad years” in which “my beloved country is being divided for political reasons and political benefits”. He called for “humility and tolerance” after years of “intolerance” under Modi. Gandhi argued that India is not merely a “geographical idea”. The idea of India is about the nation's values. “India is a particular way of looking at the world.” But India's values and its way of looking at the world raise difficult and uncomfortable questions. Disappointingly, health does not yet seem to be an important factor in India's election. The best that Rahul Gandhi could do in Dubai was cite health care as a future industrial opportunity—“We have the most complex DNA structures on the planet”, he said (rather inexplicably). Meanwhile, Modi might point to his Ayushman Bharat health reforms, launched last year. The BJP has promised to deliver universal free primary health care, together with health insurance for 500 million people. (Although observers, such as Gro Harlem Brundtland, have raised concerns that “Modicare” will favour hospital over primary care.) The extent of India's failure to address its health crisis was analysed by Jean Drèze and Amartya Sen in their book, An Uncertain Glory (2013). While praising India's economic revival, they pointed out that “the majority of Indian people have been left behind” (which amounts to 80–90% of a population of 1·4 billion). The result has been what Drèze and Sen call “unaimed opulence”: economic growth with little attention to the consequences for people's lives. The fault lies with India's democracy, including “huge failings of the Indian media”: “health is virtually absent from public debates and democratic politics in India”, write Drèze and Sen. India needs a new narrative—“India has to cultivate democratic engagement in demanding universal health care.” For that to happen, the nation's media have to overcome “a lack of serious involvement in the diagnosis of significant injustices and inefficiencies”. For a country with such a “shockingly defective record” in health—from childhood immunisation to nutrition, from public health care to sanitation—it seems inconceivable that the 2019 election would not be informed by a debate about health, “perhaps the biggest adversity facing India today”. But modern India is a divided land. Privileged political elites and biased and indifferent media serve only a small part of the population. India faces a challenge: not to squander this opportunity to make the health of its most deprived people the country's supreme political priority.