Why are health reforms difficult in India?


India’s health policy confuses the lay person as much as the investor. What does the government really want to do? Does it want to provide health for all its residents (not citizens) under the Universal Health Coverage (UHC) scheme? Will it distribute medicines free to everyone? Is it seeking Foreign Direct Investment (FDI) actively in the pharma sector? If so, why does it create bureaucracy? Overall, why is there so much uncertainty over policy making in India? If the government indeed wants to reform the health sector, why does it find it so difficult?

I think it is because, political, economic and social forces drive or block policy change in India. Reforms depend on key elements such as the presence of domestic economic difficulties (inflation and rising prices), pressure from international financial institutions (S&P and Moody’s rating), a nod from groups with vested interests and strong political leadership. Since India’s economic reforms in the 1990s, the typical ‘back-scratching/palm-greasing’ environment under the ‘license raj’ has been replaced by stronger dependence between politicians and their constituencies, commonly called ‘vote-banks’. Vote-bank politics and its necessary appeasement divert scarce resources and create inefficiencies.

TNMSCOn the other hand, the concentration of power with State Governments has intensified. Health is a state subject in India. This often means that the problem (broken health care system), its solution (UHC) and the political climate to implement that solution are rarely aligned and precious time for agenda setting and political capital is wasted. Policy paralysis appears to be the outcome of incentives created by dependence on parties with different interests. This implies that the government of the day has little influence and is at a disadvantage. However, one sees more willingness from States ruled by political parties that do not hold power at the Centre such as Chattisgarh (BJP), Tamil Nadu (DMK), and Karnataka (BJP). Rajasthan is the only exception. This leaves the Central Government at the mercy of the States to implement its health policy.


Something interesting to note is that reforms by their very nature intend to introduce radical shifts into the accepted system. This requires those who are comfortable in status quo to adapt to environmental changes that affect society. Only a relatively narrow range of policy changes are considered politically acceptable. This “window”,  known as the “Overton Window“,  of politically acceptable options is primarily defined not by what politicians prefer, but rather by what they believe they can support and still win re-election. Therefore politicians are more likely to consider implementing policy reforms not when ideas change among politicians, but when ideas change in the society that elects them. This concept flies in the face of the general assumption that politicians are fools. On the contrary, politicians accept only those ideas that gain amplification through public discourse. In short, the more you lobby, the more the idea gets closer to implementation. How many public debates on health care can you remember watching?

This explains why politicians prefer incremental change to a paradigm shift, since such ideas are rarely adjacent to existing policy and fall outside the ‘window’ making them a political impossibility. Politicians will therefore, prefer to wait until the problem, its solution and the political climate align favorably. If you have ever wondered why there are hardly any programs that encourage disease prevention, it is because the government will move to change something only when pushed to the wall and left with no alternative. This explains the failure to strengthen institutions and governance structures well in advance since politicians like to cross a bridge only when they come to it.
17smOver the years, because of an indecisive government and the ensuing policy paralysis,  India’s bureaucracy has become more politicized and powerful, performing both administrative and political functions as politicians rely on a few ‘hand-picked’ technocrats to formulate and implement policy. This has led to a greater blurring of transparency and accountability in policy decisions, and a distancing of policymakers and elected politicians from their constituencies when they bring to bear their personal views and interests to decision-making. They would rather work to assuage public opinion as represented by a publicity-hungry mainstream and more recently, the alternate media, than talk to the man on the street to understand the problems he faces.

Despite the federal system of government, there is a large decentralization of power to state governments. As in organizations, it is easy to see why decisions taken at the Centre are sometimes out rightly opposed by state governments or regional parties (eg: land acquisition and FDI in retail) and sometimes simply not implemented (eg: NRHM in UP). This makes the task of implementing policy reforms extremely difficult in sectors such as health care, which is directly controlled by state governments, despite its glaring need and total absence.

Image courtesy: www.topnews.in

As responsible citizens, it is up to us to ensure that we create the right environment that aligns the problem, its solution and the political environment. It is unlikely that the agenda for the 2014 elections can include health. But, we only have a year to create a difference and get into the politician’s mind-space if we want to see the 2019 elections fought on the plank of quality health care for all Indians.

Image courtesy: http://www.topnews.in

3 thoughts on “Why are health reforms difficult in India?

  1. Good and timely post.

    We need more health evangelists/advocates/activists who not only understand the issues clearly but are also aware of the forces/factors that influence/impede policy making and implementation.

    If govt can co-ordinate all development issues like access to education and healthcare into something universal like ‘Aadhar’ and have experts like Dr. Devi Shetty, who have pioneered low cost healthcare at the apex of decision-making, we can reduce bureau-crazy and create a scenario where patients-physicians-pharma and payers benefit.


  2. Nice article, and as Salil mentioned about Rajasthan, let me bring in some great initiatives of the state. Few months back Rajasthan government start the free medicine (though limited) to all its residents (all living beings including animals) . Now for me that’s a paradigm shift and adding further to it were the medical tests (currently in pilot stage in 4 districts) and will be launched in entire state from April.

    Now with this are they killing the pharmaceutical industry, the answer is big NO, the government is providing free medicine manufactured with highest quality standards. It will result in more patients going to dispensaries, hospitals (of course the government one), hence one can expect improvement in infrastructure, low treatment cost. Moreover the famous nexus of Doctor-Pharma and Doctor-Lab will be addresses if it existing in any form. Though I understand there will be many challenges of all kind, including change in government I wish this model should be made more strong and should be implemented across the country.


  3. Salil, Nice article. My two cents.

    In a federal structure like India where state governments control decision making w.r.t healthcare, it is imperative that politics will play a major role in the implementation of any policy fostered by the Union government.

    Having said that, the Union government should try to engage all state governments in a professional manner and role out programs/ allot healthcare budgets from national schemes, track outcomes etc. based on performance of the existing state level departments.

    I recollect one personal experience of my father who retired as a senior healthcare professional in the Govt. of Assam. He had attended a national training program on healthcare management, effective implementation of policies, courses on public healthcare etc. under the aegis of European Commission. There were participants from across the country and every one was expected to utilise learning from the program in their respective states. When my dad came back, he did try to implement some of the learning but the whole state machinery is such a large set-up in itself that one person cannot implement anything new unless there is push from the top. It boils down to the kind of people you have in each of these departments – lethargic, averse to any changes, unprofessional and in general unproductive.

    The central government should institutionalize programs in such a way that the money is utilized and state governments are rated on the basis of their performance. And that rating should have overall impact on the future sponsorship/ budgets etc. And to that, the central government should also be clear about what it wants to achieve. Rather than having mega vague visions like healthcare for all, they should have small incremental objectives like – healthcare centre for every X number of villages, 1 doctor for every Y number of people and start working towards having the same in place through structural changes like infrastructure, education etc.

    I think as every one knows, we make good plans in India but the challenge lies with the implementation. More usage of technology and professionalism in the way government departments are run will make material changes.

    Otherwise, it is a long way to go my friend. 😐



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