India’s under-investment in its health system has been long and persistent. The country has one of the lowest public expenditures on health (as a percentage of GDP) of any major economy. Public expenditure on health in India constitutes about one percent of its GDP per annum compared to three percent in China, four percent in Brazil, and 4.5 percent in South Africa.
With high dependence on privately provided services, and evidence that catastrophic out-of-pocket expenditure is responsible for pushing millions into poverty, it is surprising that the demand for better healthcare is not more of an electoral priority in India.
In a recent survey conducted by Lokniti (Centre for the Study of Developing Societies) in partnership with the Centre for Social and Economic Progress (CSEP), King’s India Institute and Royal Holloway, University of London, we set out to examine in greater depth how Indian citizens view health, what they view as the role of the government in delivering healthcare and whether electoral democracy serves to hold state and national governments to account for the performance of the health system. This five-state survey is the first systematic interrogation of electoral perceptions around health in India.
Between March-April 2022, we interviewed 1,500 voters across five Indian states— Bihar, Gujarat, Rajasthan, Tamil Nadu and Uttar Pradesh. These states represent a range of health outcomes and have different degrees of reliance on public vs private healthcare. They are also governed by different political parties— some are aligned with the Bharatiya Janata Party (BJP) government in New Delhi while others are governed by non-BJP parties. Within each state, we sampled three districts to reflect a range of health sector performance using indicators drawn from India’s National Family Health Survey (NFHS) round 5. One hundred interviews were conducted in two villages, one town and one district headquarter within each district, using random sampling to select households and quota sampling (based on age and gender) to select respondents within households.
Research on performance-based voting in India is generally quite limited. Most election studies have focused on questions of identity or clientelism as determining factors in voting behaviour, although some have suggested that ideology may also be at play. A few recent studies have found some evidence that voters who think the economy has performed well are more likely to vote for the ruling party, but there has been little attention to how other aspects of government performance influence voting behaviour. Instead, it is often thought that Indian voters do not pay attention to health as a political issue when voting, and perhaps either as a cause or a consequence, politicians do not foreground health in their electoral campaigns or priorities in office.
When asked open-ended questions about the factors on their mind when voting in elections, respondents to previous election surveys have seldom highlighted health. After the 2019 Lok Sabha elections, less than one percent of voters said health was the ‘most important issue’ while voting in the election (Lokniti-CSDS 2019, Lokniti-CSDS 2014). The most important concerns were inflation and the amorphous term ‘development’. Even after the COVID-19 pandemic, these figures are similar. In the nine state assembly elections since the pandemic started, health was mentioned as the most important voting issue by less than one percent of voters, with development and inflation again being most cited by voters.
However, we currently know very little about what ordinary citizens actually think about the provision of health services in India or how they view health as a component of the wider category of ‘development’. In this survey, by asking more focused questions on health, we are able to develop a clearer picture and to assess the extent to which voters care about health. We also seek to understand how they attribute credit, and blame, for performance, and whether this feeds into voting behaviour.
Our findings suggest that the assumption that Indian voters don’t care about health as an election issue is incorrect.
While health remains a lower priority than a topic such as employment, the survey findings suggest that there is latent public demand for greater government prioritisation of healthcare. A majority of voters say that the provision of health facilities affects their voting choice to some extent and 80 percent say that it is the government’s responsibility to provide healthcare services. However most voters are confused about which level of government is responsible for running hospitals and different health schemes. This is not surprising in a policy area in which all levels of governments have involvement, but it does raise questions about the extent to which there is a strong accountability mechanism functioning via the ballot box.
How much do voters care about health?
Voters often mention ‘development’ or vikaas (in Hindi) as the most important issue for them at election time, but what development means in practice can cover a range of issues from employment, economic growth, infrastructure development and the provision of drinking water or sanitation. In our survey we asked what aspect of development voters thought was most important to make improvements at the local level, as well as what was the biggest concern for their own household.
We find that respondents view health as one of the top three issues for improving the level of development in their local area—on a par with education, and behind only job creation. Similar is true at the household level where 20 percent of voters say that the issue they are most concerned about over the next five years is their own health or the health of a family member.
Questions: ‘Thinking about your local area, please tell me which of these is the most important for improving the level of development?’; ‘Thinking about your own family/household, over the next 5 years, what is your biggest concern out of these five?’ DK = Don’t know.
Furthermore, among older people, health was ranked as the most important issue—those over the age of 56 were more likely to mention health as the most important issue than those under 25 years of age (26 percent vs 12 percent). We can be confident therefore that health is therefore an issue that many voters do care about. Furthermore, the vast majority of respondents, 80 percent, said that it is the government’s responsibility to provide health care.
We then asked respondents how far the provision of health services affects their vote choice in local, state and national elections. A plurality of voters said that health services affect their voting decisions ‘to some extent’ at all level of elections, and a majority say it affects their electoral choices ‘to a great extent’ or ‘to some extent’. This is most pronounced with respect to state assembly elections, where 39 percent said that health facilities affect their vote ‘to some extent’, and a further 22 percent said it affected their vote ‘to a great extent’. This makes sense given that Health is constitutionally a ‘state subject’ (although as we will show below, this is not unambiguous for voters.
Thus, we find that health is one of the top three priorities for development identified by voters at both the level of their local community and their household. Furthermore, a plurality of voters say that health does affect their vote to some or a great extent, especially in state level elections.
How satisfied are voters with the provision of health services?
The survey also examined how satisfied voters are with the provision of health services, and how satisfaction is linked to perceptions and experience of health system performance. Overall, the survey results suggest relatively high levels of satisfaction. Most people (79 percent) report that they are either fully or somewhat satisfied with the health system. Over a third are fully satisfied with the overall healthcare system in India, and nearly half of all people are fully satisfied with the hospital treatment they received in the hospital the last time they had to visit.
We should read headline levels of satisfaction with a degree of caution since they are likely to be connected with levels of expectations. High expectations can breed low satisfaction, and low expectations can produce higher satisfaction.
People who report being in very good health are much more satisfied with the provision of health services (57 percent ‘fully satisfied’) than people in poor health (24 percent ‘fully satisfied’). People who are relatively rich are more satisfied with the overall health system than people who are relatively poor (45 percent vs 32 percent respectively). There is also variation across states with people in Gujarat and Rajasthan reporting higher levels of satisfaction than people in Bihar, Tamil Nadu and Uttar Pradesh. People in villages also have higher levels of satisfaction with the provision of health services than those in cities.
Unsurprisingly, people who had to wait an hour or less to receive treatment when they last visited a hospital were more likely to be satisfied than those who waited between 2-3 hours (63 percent vs 35 percent reported being ‘fully satisfied’). People who had benefited from different health schemes such as health insurance or free vaccination for children also tended to be more satisfied with the provision of health services.
Who do voters credit, or blame, for the quality of health services?
Here we see some mixed results. Most people (37 percent) correctly say state governments are the most responsible for the functioning of government hospitals. But a significant number attribute responsibility to either central government (14 percent), local government (17 percent) or all three levels (21 percent). This is not surprising given the complexity of the legislative and administrative dimensions of health care in India. Health is usually described as a state responsibility because public health and sanitation, hospitals, and dispensaries fall under the State list of the Seventh Schedule in the Indian Constitution. However, the central government is also heavily involved in health policy design, financing and monitoring; and in recent decades health reforms have involved a greater role for local governments—even if unevenly executed across regions.
We also find that people who are fully satisfied with the service they received the last time they visited hospital are more likely to credit the state government with responsibility than people who were fully dissatisfied with their experience (40 percent vs 26 percent). People who were dissatisfied with their experience were more likely to hold the local administration responsible (26 percent vs 14 percent).
There is less ambiguity when it comes to identification of who is responsible for specific health schemes. A majority (59 percent) correctly identified the central government as responsible for the provision of Pradhan Mantri Jan Arogya Yojana or Ayushman Bharat—the flagship national health insurance policy. Almost half of respondents (45 percent) credit their state government for state-level health insurance schemes.
This suggests that there has been a less pronounced pattern of centralisation of credit attribution for hospitals than specific health schemes or other areas of welfare policies. This lack of clarity relating to where credit lies for health system functioning, in contrast to the clearer attribution of welfare schemes, is also found in other federal systems in the global South. The picture of unclear attribution may incentivise inter-governmental collaboration to improve health services where one level of government does not monopolise electoral credit so that credit can be shared between multiple levels of government. But the lack of clarity over attribution can also undermine mechanisms of electoral accountability.
Furthermore, the curious finding that a substantial proportion of voters attribute responsibility to their local government for the functioning of hospitals, especially where they are less satisfied with their own experience of health services suggests that there may be a very localised pattern of credit and blame attribution occurring. One interpretation of our findings would be that voters who are less satisfied with their experience of health services seem to blame local governments for poor performance, while voters who are more satisfied attribute credit to their state government. If true, this would mean that state governments are able to claim some credit for good performance, but evade punishment for poorer performance.
Conclusion
Our research has shown that health looms larger as a concern for Indian voters than has previously been assumed. Health is one of three priority areas (after employment, and alongside education) for voters; and for significant numbers of older people and those from more disadvantaged backgrounds it is a top priority. While we cannot say on the basis of our survey evidence that demands for better health care are a determining factor in shaping voting decisions or election outcomes, we can be confident that health is on the minds of voters and that it plays some role in how they vote.
This suggests that political leaders may gain electoral capital from prioritising health in their electoral campaigns and during their terms in office. The evidence presented in this report suggests that there is a latent demand from voters for health sector improvements and a strong appetite for government leadership in this field.
The full survey report can be downloaded from the Lokniti-CSDS website.
Authors: Oliver Heath, Jyoti Mishra, Louise Tillin and Sandhya Venkateswaran.
The survey received funding from a British Academy small grant.
Image: A child being vaccinated in India. Credit: UN Development Program/Flickr.
