Democracy, Civil Society and Health in India

Madhavi Gupta, Pushkar

• Publisher: Palgrave Pivot
• Year: 2014
• ISBN:
  9781137365750
• Topic: Politik & Internationale Beziehungen
• Subtopic: Sozialpolitik

India's health failures remain visible and pronounced despite high rates of economic growth since the 1980s and more than six decades of democratic rule. The authors address the key issues that emerge from the country's health situation, speculating on what it will take for low-income groups to begin claiming for better social services

1

Introduction: India’s Health Puzzle

Abstract: A large number of studies show that an extended period of democratic rule benefits population health. Among other things, democracy brings about improvements in the provision of social services, which, in turn, lead to broad health gains in a country. The expansion of and improvements in social services typically come about through some combination of top-down interventions and bottom-up pressures. Looking at the health performance of India, which lags behind many developing countries despite 65 years of democratic rule, this book examines the role of bottom-up pressures in improving social services. Specifically, the book addresses the following question: Why don’t subordinate social groups utilize their political freedoms to make concerted demands for improvements in health services even though they suffer deeply from health deficits?

Gupta, Madhvi and Pushkar. Democracy, Civil Society, and Health in India. Basingstoke: Palgrave Macmillan, 2015. DOI: 10.1057/9781137365750.0004.

India’s basic health indicators – infant, child, and maternal mortality rates, and life expectancy – lag behind many developing countries at similar and even lower income levels. Health advances over the past two–three decades have at best been modest despite high rates of economic growth (Drèze and Sen 2013). The burden of infectious diseases remains high (John et al. 2011) and the toll from chronic diseases is mounting (Patel et al. 2011; on diabetes, see Kleinfield 2006). All this is not big news either to Indians or to India observers. The nation’s health system is in poor shape and it shows. The reasons for such accumulating health problems are quite obvious to India-observers. As the journalist P. Sainath (1996: 25) sees it, “[f]ew nations have addressed the health needs of their citizens with such callousness and contempt.” Even political leaders such as Jairam Ramesh, a former minister under the Congress government, acknowledge the worst in conceding that “the health system in India has collapsed” (cited in Hindustan Times, November 16, 2012).

India’s poor health performance, as well as its overall human development record – 136th among 187 countries in the most recent Human Development Report (UNDP 2013) – is puzzling since it is a long-standing and successful democracy (Ganguly et al 2007; Kohli 2001).¹ Since Amartya Sen (1981, 1999) argued that famines do not occur in democracies like India, because free and fair elections at regular intervals and freedom of information prompt rulers to respond positively to the threat of famines so that they can avoid electoral defeat and/or public embarrassment, a voluminous amount of academic scholarship has extended his thesis to examine the broader relationship between political regimes and human development (Altman and Castiglioni 2009; Baum and Lake 2003; Lake and Baum 2001; Norris 2012; Przeworski et al. 2000; Ross 2006). Some of these include studies that are specifically on the relationship between political regimes and health (Besley and Kudamatsu 2006; Franco et al. 2004; Gerring et al. 2012; Ghobarah et al. 2004; Halperin et al. 2005; Klomp and de Haan 2009; McGuire 2010; Ruger 2005; Wigley and Unlu-Wigley 2011). Many of them report that democracies outperform dictatorships in their health performance. According to Zweifel and Navia (2000: 99), “fewer children die in democracies than in dictatorships.” Similarly, Mesquita et al. (2003: 194) find that “infants have a vastly better prospect of surviving and going on to live a long, prosperous life if they are born in a democratic, large-coalition society than if they are born anywhere else.” Another set of studies, though fewer in number, have found evidence to the contrary (Ross 2006; Shandra et al. 2004) – that democracy has no particular beneficial effects on human development. Finally, some studies find that democracy’s effects are mixed (Norris 2012), with positive consequences for some human development indicators but not for others.²

In a seminal study on the relationship between democracy and economic growth, Gerring et al. (2005) drew attention to the fact that prior as well as several current cross-national studies on regime effects have at best looked at a period of one or two decades after a country became democratic. The authors argued that the institutional effects often unfold over a great deal of time; therefore, it is a country’s historical experience with democracy that is more crucial than its current political status (also see Persson and Tabellini 2009; Woolcock et al. 2011). Briefly, a country accumulates “democratic stock” when it remains democratic over an extended period and builds greater amounts of physical, human, social and political capital, all of which have positive effects on economic growth (Gerring et al. 2005). These good effects become visible only over the long term.³ In a subsequent study, Gerring et al. (2012) extended their thesis to test the distal – as distinct from proximate or contemporaneous – relationship between democracy and human development – with infant mortality rates (IMRs) as the key indicator – and found that there is indeed a “democracy advantage” (Halperin et al. 2005).

China and India

Irrespective of whether or not there is a democracy advantage with respect to human development, China and India stand out as exceptions to the rule (Zweifel and Navia 2000; Navia and Zweifel 2003).⁴ Both countries have experienced a long period of political regime stability – China as a communist dictatorship since 1949 and India as a democracy since 1947.⁵ Although China faces a number of health challenges (see for example, Huang 2012; Duckett 2011; Economy 2004; Ho and Nielson 2007), it has outperformed India by a fair margin in terms of basic health indicators – IMRs, under-five mortality and life expectancy. Between 1990 and 2013, IMRs in China fell from 42 to 11 per 1,000 live births, and under-five mortality from 54 to 13 per 1,000. During the same period, India’s IMRs fell far more slowly, from 88 to 41 per 1,000 live births, while under-five mortality fell from 126 to 53 per 1,000 live births. Whereas life expectancy in India increased from 59 to 66 (2012), China’s went up from 69 to 75 years (2012).⁶ Furthermore, India’s health performance is not only inferior to that of China but is worse than its South Asian neighbours in terms of underweight children, infant mortality, and under-five mortality (Drèze and Sen 2013; Planning Commission 2011). India’s health performance defies the claim that “if a democratic form of government is maintained over a longer period of time the net effect of that regime type will be positive for the welfare of its citizens” (Gerring et al. 2012: 2). Curiously, India is an underperformer not only despite 65 years of nearly uninterrupted democratic rule but also despite high rates of economic growth since the 1980s (Balakrishnan 2010; Bhagwati and Panagariya 2012; Frankel 2008; Mukherji 2007; Panagariya 2008; Srinivasan 2011).⁷

How can we explain the Indian paradox of “a booming private economy” with citizen “despair over the lack of the simplest public goods” (Das 2006: 9) and attendant poor human development? Why has even long-term democratic rule and growing prosperity not improved the country’s health situation so that most Indian states appear unlikely to attain the millennium development goal of achieving IMRs of 26 per 1,000 live births by 2015 (Sinha 2012)?

Top-down interventions versus bottom-up pressures

There are no straightforward answers to the questions raised earlier. In his seminal contributions, Thomas McKeown (1976, 1979) identified a rising standard of living – especially its positive influence on an improved diet – as the main cause of health improvements in England since the 18th century (also see Fogel 2004), displacing competing arguments about the role of modern medicine and public health. Since then, the central role of a rising standard of living – in terms of a nation’s wealth (per capita income) and economic growth – has been applied to other nations in the 20th century, including developing countries (Pritchett and Summers 1996; Filmer and Pritchett 1999). However, a fairly large number of historical, comparative, and quantitative studies, including Preston (1975), Caldwell (1986), Szreter (1988, 1997) and others have challenged the “McKeown thesis” and placed public health at the forefront. They have argued that measures such as the provision of clean water and sanitation played a greater role in improving population health than is acknowledged by McKeown. Preston (1975) estimated that only 15 per cent of the increase in life expectancy between the 1930s and the 1960s was accounted for by income increases. After reexamining the British experience, Szreter (1988: 5) argued that it is “human agency, in the form of a gradually negotiated expansion of preventive public health provisions and services,” which brought about significant mortality decline in Britain as well as elsewhere. Others, like the historian James C. Riley (2001), have proposed that nations have achieved “health transitions” – a reduction of mortality in the long run – through advances or interventions in one or more of the following six areas: public health, medicine, wealth and income, nutrition, behavior and education. Still, one of the more widely accepted propositions in the broader theoretical and empirical literature is that a nation’s wealth is important and even crucial in improving health outcomes.

If, however, to paraphrase Pritchett and Summers (1996), wealthier is indeed healthier, India’s performance is exceptional.⁸ Despite high rates of economic growth over several decades, India’s IMRs have fallen relatively slowly. Between 1981 and 2009, India’s IMRs declined from 115 to 50 per 1,000 births – or by 57 per cent – which is significantly slower than better-performing Indian states such as Goa, Kerala, Maharashtra, and Tamil Nadu, all of whom reduced their IMRs by about 75 per cent or more during the same period.⁹ The health performance of Gujarat – which has achieved high rates of economic growth over the past two–three decades and is among India’s most prosperous states – is hardly exemplary. IMRs in the state fell only modestly – by 58 per cent over three decades (Pushkar 2012: 118).

High rates of economic growth or significant increase in per capita incomes appear to matter for human development when the benefits of growth are broadly shared and/or the state uses its wealth to bring about an expansion in the provision of a wide range of essential public services, especially for low-income groups and the poor. In a widely cited study, Anand and Ravallion (1993: 147) concluded that, “at least for basic health, average affluence matters to the extent that it delivers lower income poverty and better public services” (also see Riley 2001). In a study on 22 Latin American countries, Biggs et al. (2010: 270) found that the benefits of economic growth vary according to poverty levels and inequality – “when poverty or inequality was decreasing, there was a strong positive effect of GDP on infant mortality rates.” Another study by Nishiyama (2011) looked at 83 developing countries and found weak, mixed effects on IMRs during periods of economic growth and strong, adverse effects during economic downturns. Without disputing the “wealthier is healthier” hypothesis, McGuire (2010) shows that for countries that are unable to travel the road of steady and high economic growth, improvements in the provision of select social services – the “social service provision hypothesis” – such as childhood immunization, primary health services, sanitation and safe water provide an alternate path to good health in improving infant and child mortality rates and in raising life expectancy. His study also finds that broad improvements in the provision of social services are more likely under conditions of democratic rule although some authoritarian countries have also improved the health of their peoples in the same way.¹⁰ Thus, the reason China is said to have outperformed India is because it has done well in providing essential public services whereas India has not. As Sen (2013) writes, the “far greater gap between India and China is in the provision of essential public services – a failing that depresses living standards and is a persistent drag on growth.” According to Shekhar Gupta (2014), “[a] majority of families that earn middle-class incomes are forced to live suboptimal, BPL [below poverty line] lifestyles simply because the state fails to perform its basic tasks, like providing power, water, law and order, sanitation and connectivity.”

The expansion and improvement in the provision of social services typically comes about through top-down interventions, bottom-up pressures, and some combination of both. Top-down interventions, of course, refer to the initiatives and actions taken by the state and are considered a first step in the provision of social services. Top-down efforts have historically been the dominant method by which social service provision has been initiated and continues to be relevant today. According to Uphoff (1992: 273), “ ‘top-down’ efforts are usually needed to introduce, sustain, and institutionalize ‘bottom-up’ development.” However, since the 19th century, with the onset of industrialization, urbanization, and the growth of working and middle classes and their various associations and political parties, bottom-up demand for a variety of social services emerged with significant force. Societal actors – whether individuals, communities, organized social groups, or any other – began to express their preference for social services in multiple ways, through public criticism, protests, demonstrations, and social movements.¹¹ Therefore, according to Nathanson (1996: 610), improved access to public health services has come about either due to 1) “the actions of a strong central government with a reasonably well-educated and cooperative population” or 2) “an organized politically acti...

Table of contents

• Cover
• Title
• 1  Introduction: Indias Health Puzzle
• 2  Democracy, Civil Society, and Claims-Making in India
• 3  Why Are Indias Poor Not Making Claims for Health?
• 4  What Will It Take for the Poor to Demand Health Services?
• 5  Conclusion: Democracy, Civil Society, and Claims-Making for Public Services
• References
• Index