Health issues sidelined in India's general election. The Lancet

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Health issues sidelined in India's general election

beth Solberg

The Lancet, Volume 373, Issue 9674, Pages 1509 - 1511, 2 May 2009

doi:10.1016/S0140-6736(09)60839-4

Politicians have paid too little attention to India's major health challenges in

their election manifestos and campaigns, say critics. beth Solberg

reports from New Dehli.

Life in an Indian slum was never easy, but for Hiraman Ram, a migrant

construction worker, it has recently become a lot harder. 5 months ago, the

father-of-three was hospitalised with an intestinal infection, and had to cover

the expensive treatment from his own pocket. He has since been unable to work,

and the family has been pushed deeper into poverty. " We now survive on borrowed

money and other people's goodwill " , Ram told The Lancet, sitting outside his

house in a small slum near one of Delhi's congested highways.

The family's rising debt only adds to their problems. Every day, India's

millions of slum-dwellers are exposed to health risks such as poor sanitation,

pollution, malnutrition, and a constant shortage of clean drinking water. With

India's 15th general election underway, Hiraman Ram is in no doubt about what he

thinks the country's politicians should do to make life for slum-dwellers a

little better. " I want more drinking water facilities and a sewage system here " ,

he said.

More clean drinking water is one of many promises offered by India's leading

politicians this election. Many of the proposals by the ruling Indian National

Congress and their main rival, the centre-right Bharatiya Janata Party (BJP),

would directly benefit Ram and others like him. The proposals include health

insurance for everyone below the poverty line, more focus on child and maternal

health, and new schemes to combat the county's rampant rates of malnutrition.

The main parties also pledge increased spending on health, which currently

stands at a disappointing 1% of gross domestic product (GDP).

Critics nonetheless argue that politicians have paid too little attention to

health and welfare in the campaign, and that their proposals do little to

address the underlying health problems on the subcontinent. " Everybody says:

`Health for all.' To me, that doesn't make sense " , said Imrana Qadeer, one of

the country's foremost public health experts and a retired professor at the

Centre for Social Medicine and Community Health at Delhi's Jawaharlal Nehru

University. " They are making promises, but they are not mentioning the concrete

steps that they are going to take to meet those promises. And after 60 years of

independence, promises aren't good enough " , she said.

Ranked 132 out of 179 countries in the 2008 UN Human Development Index, India

still faces major health challenges. 46% of its children under 5 years are

underweight, which is more than in most African countries. More than half of

Indian households have no toilets, and over 200 million people still have no

access to safe drinking water.

WHO estimates that 900 000 Indians die each year from drinking contaminated

water and breathing in polluted air.

Giving birth on the subcontinent also remains a risky business. The UN estimates

that a woman dies during pregnancy or in childbirth somewhere in India every 5

minutes. Being born is equally dangerous: some 2•1 million children under age 5

years die each year, accounting for almost a quarter of global child deaths,

according to UNICEF.

Meanwhile, female feticide remains rife, and recent studies suggest that India's

child sex ratio, at 927 girls per 1000 boys in 2001, continues to decline. And

while poorer Indians still die from dengue, malaria, tuberculosis, and HIV/AIDS,

lifestyle diseases such as diabetes and heart attacks are on the rise in

wealthier segments of society.

Public health experts and politicians alike agree that India's ailing

health-care sector is ill equipped to deal with the country's myriad of

challenges. Although world-class health care is readily available for the rich

urban elite, the poor struggle to get access. An acute shortage of health

professionals is one of the more pressing problems. There are no more than seven

doctors per 10 000 patients on the subcontinent.

The health-care sector also crumbles under a lack of facilities and equipment. A

little over 20 000 primary health centres struggle to serve the vast country's

600 000 villages. Many centres lack facilities, medicines, and staff. " We have

inadequate, under-resourced, and poor outreach of primary health care in rural

areas " , commented Srinath Reddy, president of the Public Health Foundation of

India, adding that health care for the urban poor is no better.

Despite the nation's obvious sickness, politicians focused largely on issues

related to national security and the economic crisis in the run-up to the

election. " In this election, welfare is a marginal thing " , commented Imrana

Qadeer, adding that to improve Indian's health, lawmakers must also better

people's opportunities for education, housing, and employment.

Two main coalitions are competing for power in the election: The Congress-led

United Progressive Alliance (UPA) and the BJP-led National Democratic Alliance

(NDA). Congress, led by Gandhi, the Italian-born widow of assassinated

former Prime Minister Rajiv Gandhi, campaigned on a platform of secularism and

economic growth for all, especially for the aam admi, the common man. The Hindu

nationalist BJP, led by the 81-year-old firebrand Lal Krishna Advani, focused

mainly on national security and protecting India from terrorist attacks.

A third bloc, the United National Progressive Alliance, or the " Third front " ,

could also become a major force in the election. The leftist bloc is dominated

by the Bahujan Samaj Party (BSP), which champions the rights of dalit and lower

caste Indians. Some analysts say their leader, the ambitious Mayawati, currently

the Chief Minister of the populous state of Uttar Pradesh, could become India's

first dalit Prime Minister.

The current UPA government introduced a major health reform during their 5-year

term in office. The National Rural Health Mission (NRHM), launched in 2005, was

regarded by many as a bold move designed to decentralise and improve health care

in rural areas. " It has been going for 3 years only, so it is difficult to say

if its goals are being achieved. But it is advancing in the right direction " ,

said Reddy of the Public Health Foundation of India. If elected, Congress

pledges to continue the NRHM, and also to launch its urban counterpart, of which

few details have been released.

Among Congress's other election promises is a national food security act,

designed to tackle malnutrition. This act will enable every family below the

poverty line to buy 25 kg of rice or wheat a month at a price of 3 rupees per

kilo. Subsidised kitchens for homeless people and urban migrants will also be

set up.

In an attempt to combat mal-nutrition in children, Congress vows to strengthen

the Integrated Child Development Services programme. Launched in 1975, the

scheme's mother and child centres, the so-called anganwadi, today cater for poor

children between 0 and 6 years of age, and provide everything from immunisation

and nutrition to clean water and early education. Congress promises an anganwadi

" in every habitation " and full coverage before 2012.

The party also pledges to pump more money into vital public sectors such as

education, health, agriculture, social security and infrastructure. But critics

point out that this is nothing new.

Before their election victory in 2004, Congress promised to increase spending on

health from 1 to 3% of GDP. 5 years later, spending is still around 1%.

Congress's manifesto also states that the party will increase the number of

schools, make education at all levels free for dalit and adivasi (tribal)

children, and, in an attempt to improve the country's skewed sex ratio,

introduce financial rewards for parents who let their daughters complete school.

For Hiraman Ram in the Delhi slum, the proposed extension of a health insurance

scheme for people below the poverty line could be life-changing. Known by its

Hindi name Rashtriya Swasthya Bima Yojana, the scheme was launched under the

current government, but its coverage is still limited. If elected, Congress

pledges that every family below the poverty line will be covered within the next

3 years.

Ram is not the only Indian pushed deeper into poverty by medical bills. Over a

quarter of hospitalised Indians fall below the poverty line because of the high

cost of care, according to the Ministry of Health and Family Welfare. The figure

is high, but perhaps unsurprising given that only one in ten Indians are covered

by some form of health insurance, and that people treated in hospital on average

spend 58% of their annual expenditure on health. Many, like Ram, end up in a

downward spiral of increased poverty and deteriorating health.

Health insurance for poor people is also a major point in BJP's manifesto. Like

their rival, the party promises a " Health for all " scheme, with the government

covering the cost of the insurance for families living below the poverty line.

The BJP's approach to malnutrition is also similar to that of their rival. Like

Congress, the party said it would subsidise food for poor people, and promises

35 kg of rice or wheat a month at a price of 2 rupees per kg for everyone below

the poverty line.

But the centre-right party's manifesto differs from that of the centrist

Congress in its approach to privatisation of the social sector. The BJP

advocates further privatisation of health care, but also wants to set up a

national regulatory body to oversee the quality and cost of care in the

country's many unregulated private hospitals and clinics.

In addition to more public—private partnerships, the party will also increase

public spending on health, said Chandreshwar Prasad Thakur, a former health

minister in the 1999—2004 NDA government, speaking at a press conference in New

Delhi. " We are saying 3—4% of GDP " , he promised.

Outlining his party's health proposals, Thakur said the BJP will invest in urban

infrastructure, and improve access to water, drainage, electricity, and waste

management. The party will also introduce financial rewards to encourage girls

to complete school, launch a national hepatitis vaccination scheme, and

establish a national 108 telephone service for medical emergencies within 1 year

of taking office.

The party also proposes to strengthen existing laws protecting women's rights,

such as laws banning female feticide, dowry, child marriage, trafficking, rape,

and family violence. It also wants to promote alternative forms of medicine,

such as ayurveda and homoeopathy, Thakur said.

Thakur said the party will focus more on India's ageing population, and promised

to introduce interest-free government loans to enable young couples to build an

extra room in their homes for their parents. " At the one end, we need to take

care of children with malnutrition, and at the other, we need to take care of an

ageing population " , he said at the press conference.

The third main contestant, the BSP, offers few policy proposals. Pramod K

Kureel, executive editor of the party's monthly magazine, said that the BSP had

decided not to publish a manifesto. " Our policy is to fulfil the manifesto of

other parties. They all make lofty promises that they don't fulfil " , he said,

sitting in the BSP office in New Delhi, a short distance from the Lok Sabha, the

country's parliament.

The BSP views the struggle for health care in India as part of a larger social

battle, Kureel explained. " Because of the caste based system, the majority of

people here do not get their basic human rights " , he said, adding that the

answer to all social ills, including poor health and health care, is to rid the

country of the caste system. Annihilation of caste would be the ultimate

preventative approach to health, Kureel said.

Many public health experts criticise the Indian parties' approach to health. " If

you look at the manifestos, they give only very broad directions. Nowhere do

they list specific steps, and the mention of welfare and health is marginal " ,

said Imrana Qadeer. Referring to the campaign promise of improved access to

clean water, she said: " Every election they have said the same thing, but the

proportion of coverage doesn't improve significantly. Why will it be different

this time? "

Chandrakant S Pandav, vice-president of the Indian Public Health Association and

a regional coordinator for the International Council for Control of Iodine

Deficiency disorders, called many of the proposals populist. He argued that

Indian lawmakers need to adopt a more preventive approach to health, and should

focus on treating the root causes of poor health, not merely its symptoms. Most

importantly, Pandav argued, India needs safe drinking water, sanitation, and

waste disposal for all.

During the interview with The Lancet, Pandav pointed to a picture hanging in his

office. It illustrated a man mopping water off the floor while two taps were

still running. " We are just very good at mopping the floor, when we really

should be turning off the tap " , he said.

In the Delhi slum, Hiraman Ram is still an undecided voter. " They are all

equally bad " , he said, referring to the country's politicians. But he still

insisted he will vote when Delhi goes to the ballot box on May 7.

India's politicians and their election promises seem distant in this small slum,

where the children play barefooted on piles of rubbish next to the highway. The

people living in this illegal settlement claim that local authorities recently

bulldozed 65 houses here.

Although the government often promises new and better housing for slum-dwellers,

the unregistered migrant families living here have been offered nothing. Hiraman

Ram fears his family, including his three young children could end up on the

streets.

The 45-year-old does not believe life will change for the better after the

election: " Every election, there are a lot of promises " , he said, staring into

space. " But nothing happens. "