|Year : 2017 | Volume
| Issue : 3 | Page : 455-459
Pattern of health promises for Indian democracy: A qualitative review of political manifestos
Dinesh Kumar1, Raman Kumar2, Raman Chauhan1, Vishav Chander3, Sunil Kumar Raina1
1 Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
2 Academy of Family Physicians of India, New Delhi, India
3 Department of Medicine, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
|Date of Web Publication||29-Dec-2017|
Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Kangra - 176 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: India is a multiparty parliamentary democracy and second most populous country in the world. In spite of pressing needs of the population, healthcare is still not considered a driving electoral mobilizer as compared to the older democracies such as the UK and USA. Only three National Health Policies (1983, 2002 and 2017) have been promulgated by the respective governments during the past 70 years of India's independence. National policies are often preceded by commitment of political parties documented in the manifestos. Type and nature of promises in the manifesto of National Political Parties (NPPs) are reflective of vision and intentions of parties. The present study was done to qualitatively analyze the pattern of expressed intensions in terms of health promises made for 16th Lok Sabha (people house) elections of India in the year 2014 by its NPPs. Methods: Manifestos of NPP, as notified by election commission of India, were retrieved from their respective website and effort was also made with an online search. Manifesto of five out of total seven NPPs could be accessed and analyzed. Consensus-based criteria of assessment were developed by public health experts and each manifesto was assessed independently by two experts. In a case of difference in scoring, independent opinion was sought from the third expert for adjudication. Results: Two NPPs mentioned majority of statements as goals and rest focused for health strategies. The focus of statements was for public health problems (11.5%), public health financing (9.0%), and improving infrastructure (9.0%). All parties were committed for improving health services as it shared 30.8% space as statements in all five manifestos. All statements were of primary or secondary prevention in nature and focused more on improving processes (47.4%) and increasing inputs (31.6%). Whereas, Communist Party of India focused only on inputs (60.0%) and outputs (40.0%). Conclusion: Promises made by all NPPs were quite progressive, inclusive, and comprehensive in nature; however, much of these do not find space in public debates on television and election speeches.
Keywords: Health, India, manifesto, national political parties
|How to cite this article:|
Kumar D, Kumar R, Chauhan R, Chander V, Raina SK. Pattern of health promises for Indian democracy: A qualitative review of political manifestos. J Family Med Prim Care 2017;6:455-9
|How to cite this URL:|
Kumar D, Kumar R, Chauhan R, Chander V, Raina SK. Pattern of health promises for Indian democracy: A qualitative review of political manifestos. J Family Med Prim Care [serial online] 2017 [cited 2018 Jul 15];6:455-9. Available from: http://www.jfmpc.com/text.asp?2017/6/3/455/222046
| Introduction|| |
India is considered as the largest democracy in the world which functions through multiparty parliamentary representative system. As per the notification (2016) of the election commission (EC) of India, there are seven national political parties (NPPs) and 1786 State Political Parties (SPPs) in India. In a democratic setup, government is usually elected by the people and for the people to fulfill the desired needs of the people. Historically healthcare issues have dominated the political campaigns during several elections held in countries such as the UK and USA. Political manifestos often set the ground and tone of the presidential and prime ministerial debates. National health system of UK was an outcome of political commitment of labor party in its manifesto of 1945. Obamacare or no Obamacare was one of the widely debated reforms during recently held presidential elections held in the USA. In India, healthcare is yet to take political centre stage.
In India, the political parties contest the general election once in a 5 years to justify their position and capacity to form the government. While doing so, manifesto is published by political party as a reference document to the people which explains likely services and benefits that would be provided once party forms a government. According to EC of India, a manifesto usually defines a published declaration of the intentions, motives, or views of an individual, group, political party or government or whosoever issues it. Election manifesto normally consists of an ideology of the political party and its policies and programs for the country, which is then placed for electors to cast their vote in the favor of party.
Ensuring healthy people is prerequisite for any country to move toward growth and prosperity. A healthy nation contributes to economic development, and status of gross indicators for morbidity and mortality is reflective of position of any nation. Government sets its vision and formulates policies and programs for service delivery to ensure sustained development across various sectors. In the health sector, a policy is argued as set of decisions, plans, actions, that are required or to be undertaken to achieve specific set of health goals. The policy then translated into programs which further encompass strategies which are rooted down through health systems to ensure accessible and effective health services. In a democratic setup, the authority to draft and execute policies is given to the government, which is selected time to time by elections. Interestingly, only three National Health Policies (1983, 2002 and 2017) have been promulgated by the respective governments during the past 70 years of India's independence.
Political parties, though differ in their ideologies, committed to protect and promote health along with provision of affordable and effective health services to the people. During elections, speeches are delivered by the public leaders, in light of their published manifesto, to make aware people so that they can take an informed decision. Manifesto covers all areas of development and serves as an official reference document of a party to understand the scope and nature of services it will offer to the people. It also hints toward nature of enabling environment for effective translation of said policies. The present study was focused for health area in party manifesto and was done to qualitatively analyze the pattern of expressed intensions in terms of health promises made for 16th Lok Sabha (people house) elections of India in the year 2014 by its various NPPs.
| Methods|| |
A political party was considered to be national based on the notification issued by EC of India on December 13, 2016 and was published in the Gazette of India (extraordinary) Part-II, Section-3, Subsection-iii. As per the said notification, there are 7 NPPs and 1786 SPPs in India. List for SPPs was amended on November 1, 2017, which declares to have 1837 SPPs and was published on Gazette on India. A descriptive analysis was based on subjective review of manifesto released by NPPs. The seven NPPs are Indian National Congress (INC), Bharatiya Janata Party (BJP), All India Trinamool Congress (AITC), Communist Party of India-Marxist (CPI-M), CPI, Nationalist Congress Party (NCP), and Bahujan Samaj Party (BSP). The manifestos were accessed from the official websites of NPPs. During search, manifesto of five NPP was available form assessment from the party website ,,,, but was not available and traced for NCP and BSP.
Method of assessment was designed by a group of public health experts, and it was agreed upon that each statement published in the manifesto will be assessed for five sections. The areas of assessment of each section were First, whether it is a vision, goal, objective, or strategy?; second, whether related to finance, health service, specific public health problem, demography, infrastructure, reform, or program?; third, whether it focuses for gross domestic product (GDP), service accessibility, workforce, education for health, insurance, traditional medicine (TM), health laws, medicines, maternal and child health, insurance, specific health issues, or diseases such as sex ratio, HIV, malnutrition, and acute diarrheal disease (ADD)?; fourth, whether the statement reflect primary, secondary, or tertiary level of prevention?; and fifth, whether statement likely to increase inputs, improve processes, and meeting outcomes?. After download, manifesto was shared among public health experts for assessment for promises made for “health” by the NPPs in mentioned five areas. These areas and criteria of assessment were agreed upon during discussion among public health experts. As per the agreed areas of assessment, each statement mentioned in manifesto (for health issues only) was assessed independently by two experts and categorized. Third and final opinion was sought only in case discordant opinions for adjudication.
| Results|| |
Statements were assessed and the pattern was assessed for the following sections nature, area, focus, levels of prevention, and management [Table 1]. All political parties submitted “health” as a priority area and gave it a sufficient space in relation to their manifesto. Content evaluation revealed that three out of five NPP have given a subject heading for health like; “right to health” by INC, “Health services: increase the access, improve the quality, lower the cost” by BJP, and “Health for all in time bound manner” by AITC. Instead as a subject heading, CPI-M and CPI flagged issues for health in their manifesto. Thereafter, assessment was done for total 78 health statements of all manifesto of 5 NPPs: 19 of INC, 29 of BJP, 12 of AITC, 13 of CPI-M, and 5 of CPI. Issue was stated in the form of statements in the manifesto of NPP and reading of each statement revealed that CPI and BJP gave statements as goals as 80.0% and 65.5%, respectively. Manifestos included statements which were in the form of health strategies; 84.6% in CPI-M, 66.7% in AITC, and 52.6% in INC. Inclusion of vision and objective in statements was observed to be rare in manifesto of NPPs.
|Table 1: Assessment of statements made in manifestos of National Political Parties for 16th Lok Sabha (people house) elections in the year 2014, India|
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Categorically, commitment to increase the health expenditure to GDP was observed in the manifesto of INC (3.0% of GDP), AITC (significant higher proportion of GDP for healthcare), CPI-M (public expenditure 5.0% of GDP), and CPI (3.0% of GDP on healthcare). BJP focused on devising national policy in view of changing demography and development in healthcare sector, initiating national health assurance mission, national mosquito control mission, and revisiting national rural health mission. INC showed its commitment to save the girl child by launch of “National Strategy for care and protection of girl child” form her birth to adolescence. Furthermore, an arrest of declining child sex ratio was committed by CPI. Social insurance by INC and health insurance to every citizen was promised by AITC. Specifically, focus for rural health care delivery was committed by BJP and AITC. Next level of assessment observed that largely, all NPPs focused on improving health services as it shared 30.8% space of all statements in their manifestos. All statements observed direct mention of public health problems (11.5%), public health financing (9.0%), improving infrastructure (9.0%), each, of allotted space for health in manifestos. Party-specific analysis found that INC focused more on health services (47.4%), specific public health problems (15.8%), clear outcome indicators (10.5%), and infrastructure (5.3%). Manifesto of BJP related largely to health services (27.6%), reforms (17.2%), public health problems (13.8%), and infrastructure (6.9%). Similarly, health services was focus for AITC (41.7%) and CPI-M (15.4%). AITC also focused on building infrastructure (16.7%), whereas, CPI-M focused on finance (15.4%), placing restriction on, and regulation of private sector (30.8%). Finally, CPI focused more on public health problems (20.0%).
Specific focus was assessed for each manifesto, and NPP-wise analysis shows that INC focused increasing workforce (15.8%) and health insurance (10.5%). ADD, anemia, and maternal and child health were focused as important public health problems in INC (21.0%), BJP (10.3%), and AITC (25.0%). AITC and BJP also focused on insurance, geriatrics, building tertiary care facilities, and workforce. BJP was only party which gave priority to chronic diseases (3.4%) and INC to HIV (5.3%). CPI-M has laid its attention on provision of medicines (23.1%), limiting role of private sector in service and research (23.1%) and geriatrics (7.7%), and CPI on health laws (20.0%), sex ratio at birth (20.0%), and malnutrition (20.0%). Thereafter, assessment of statements for levels of prevention was done, and it was observed that most of the statements (88.4%) were of primary prevention in nature. Of which, AITC and CPI focused entirely (100.0%) on primary level of prevention followed by BJP (96.3%), CPI-M (75.0%), and INC (69.2%). In the last, it was found that all NPP focused largely on increasing inputs (42.3%) and improving process (48.7%) whereas only INC focused on outputs (21.1%) followed by improving process (47.4%) and increasing inputs (31.6%). Whereas, CPI focused only on inputs (60.0%) and outputs (40.0%).
| Discussion|| |
In 1978, at Alma-Ata, an action was expected by all the governments and their development partners to promote and protect health of all the people of its highest possible level. It should be without any gross inequality in health status of people within and between countries. Health is considered as a responsibility of the government by provision of adequate health and social measures. Reliance on primary health care as an essential health care was shown as and asked to be integral part of health system. Health has been rated as a priority by the people with subject to income, employment, cost of living, and wages. People want to be healthy, rather disease free, and expect better health care services both preventive and curative in nature. Health care is assured by government through its health system and mode of governance. Not only for the people but health is a substantial issue for the people by the various NPPs in a democratic setup. In India, NPPs gave due attention to improve health and promised to invest in inputs and process in terms of building environment to enhance workforce for health, investing in infrastructure, and prioritizing public health problems. Looking the manifestos from people's eye, it shows a commitment by the NPP to provide better avenues to improve and sustain good health. It does include accessibility to preventive approaches, quality diagnosis, and treatment. On review of all statements made by the NPP in their manifesto, very few were directed at goals or objectives and most were focused on health strategies or broad health issues.
It is well-known fact that the availability of sufficient funds is important for provision health resources and universal coverage. It has been observed that countries with high access to health services usually spend 5%–6% of their GDP. In the year 2014, total expenditure on health was 4.7% of GDP for India., All NPPs, except BJP, spoke categorically about increasing health expenditure in proportion to GDP. Investing into health by increasing the expenditure relative to GDP helps to design health system to deliver quality and effective health services, where needed. Along with sufficient financing, health system requires trained workforce, good facilities, effective medicines, and technologies. Contextually, leadership and mode of governance guide for utilizing the basic requirements of health system. All NPP, one way or the other, focused on building public health workforce in terms of investing in educational institutions. Inclusiveness for technology and putting restriction on private sector was observed only in CPI-M manifesto. Not only new promises, BJP gave attention to review, revisit, and reorganize existing health strategies in the existing system of health care.
Although India spends 4.7% of its GDP on health, its two-third comes from nongovernmental funds whereas significant portion of government spending in health should be expected as it had been observed in other developing countries. This has led to dependence on and utilization of private or nonformal sector for health care, which often turned out to be expensive and impoverishing. Provision of insurance services to people gives protection against out-of-pocket expenditure incurred during illness. Issue of insurance for health was observed by all NPP, except CPI whereas the same observed to be sole party which promised to declare health as a fundamental right. Expanding and recasting of employee state insurance scheme was stated by CPI-M, Rashtriya Swasthya Bima Yojna by INC, National health assurance mission by BJP, and Health insurance to every citizen by AITC.
To achieve “Health for all,” as declared in Alma Ata by WHO, targeting public health problems becomes very important. India is observing rise in chronic diseases with improvement in maternal and child health. Ischemic heart diseases are leading cause of mortality with high prevalence of physiological risk factors such as high blood pressure, high blood glucose, and obesity along with tobacco use. For Health, manifesto of various NPPs is expected and was also observed with varying focus like maternal and child health was the priority issue for INC, BJP, AITC, and CPI; HIV and anemia for INC, malnutrition for BJP and CPI, and chronic diseases and vector-borne infections for BJP. All NPPs observed to be well committed to tackle sustaining public health problems which are ailing country for a significant period of time.
Though it has a significant potential, role of TM observed to be an underplayed strategy for health care. WHO launched 2014–23 TM strategy to harness potential contribution, promoting safe and effective use of TM in health care. This move expects supportive role of TM for healthy population. TM in India has contributed significantly to health care for centuries and still offers potential to promote health. Understanding its potential, role of TM in health care was stated by BJP and AITC, latter focuses on research in TM and former gave significant space to engage TM in health care in terms of increasing investment, building workforce, infrastructure, and farming of herbal plants. Such proposed efforts are quite reflective of strengthening the existing health delivery model of TM in the country.
It observed that all NPP painted health issues well, but the current analysis has its limitations, as it was consensus-based subjective assessment which may have between group variability. Even then, it gives a sensible representation about made promises by the NPPs of India that for all of them, health is an important area and all were well committed to provide better health-care services. Most were quite progressive, inclusive, and comprehensive in nature except CPI-M, where much effort was laid for making nation as self-reliant enterprise by regulating the private sector, reviving public sector pharmaceutical units, regulating clinical trials for drugs, and even removing US government drug law enforcing agencies. Respecting ideologies of NPPs, it is well articulated that country will have sufficient, better quality, and effective health-care services, irrespective of prevailing ideology in the union government. For the purpose, the inference is limited to understand the differentials in the promises made by NPPs in their manifestos for health and which are found to be quite nondifferential.
This is only an academic and professional evaluation of the political/legislative trends related to healthcare in India. Idea is to encourage academic scrutiny and mainstreaming of wider public attention/debate on healthcare in the contemporary democratic process.
| Conclusion|| |
On review of party manifesto, it was comprehended that the promises made by all NPPs were quite progressive, inclusive, and comprehensive in nature; however, much of these do not find space in public debates on television and election speeches.
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Conflicts of interest
There are no conflicts of interest.
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