A doctor treats a child with Acute Encephalitis Syndrome (AES)-like symptoms at Patna Medical College and Hospital on June 17.
A doctor treats a child with Acute Encephalitis Syndrome (AES)-like symptoms at Patna Medical College and Hospital on June 17.

What ails India’s health care?

Parties often ignore policy incentives as they know they can gain votes along caste and religious lines
UPDATED ON JUN 23, 2019 11:04 AM IST

More than 140 children have died of Acute Encephalitis Syndrome (AES) in Bihar in June. The Bihar government has received a lot of flak over the state’s poor health infrastructure. But it is unlikely that it will pay a major political price for the outbreak. The Muzaffarpur deaths are not the only such disaster in India. Many poor people, especially children, die of entirely curable ailments. Most tragedies such as the Muzaffarpur one are the result of poor health care facilities. This can be seen from Chart 1, which plots normalised values of the child mortality rate in Indian states with their relative share in the number of doctors in the country (adjusted for the state’s population) .


States such as Madhya Pradesh and Bihar, which have a lower share of doctors, also have higher child mortality rates. In contrast, southern states such as Kerala and Tamil Nadu fare well on share of doctors and child mortality.

It is not very difficult to generate more doctors if a state government is willing to devote resources for it. Why do governments not do this then? An even bigger question is, why are such governments not punished by voters? For, if politicians feared retribution for failing to perform such duties, they would have gone out of their way to improve matters.

In India, this question is even more intriguing. The burden of poor provision of social services such as health care has a skewed impact beyond class lines. Because the caste hierarchy in India is closely linked to economic backwardness, those at the bottom of the social ladder bear a disproportionate burden of poor provision of health care services.

Child mortality is the highest among households not just in the lowest wealth quintile, but also Scheduled Castes and Scheduled Tribes, which are the most backward social groups. These indicators are the best among households belonging to upper castes and highest wealth quintiles.


Caste is considered to be an important factor in driving political choices in India. Why do politicians from socially deprived groups, which constitute a majority in India, not do enough to overhaul the provision of such social services?

It is not the case that there is no discontent among the socio-economically deprived sections of the population vis-àvis such policies.

For example, pre-poll survey findings from the National Election Study conducted by Centre for the Study of Developing Societies (CSDS)-Lokniti show that the feeling of development not being inclusive was greater among the socioeconomically deprived sections than the relatively better-off ones before the 2019 elections.


These grudges, it seems, did not translate into voting in the 2019 elections. The Bharatiya Janata Party (BJP) has done extremely well in parliamentary constituencies (PCs) located in India’s poorest districts in the 2019 elections, showed an HT analysis by Zia Haq.

The question of why voters do not make development, or lack of it, into a political or electoral issue goes beyond what has transpired in India between 2014 and 2019.

There is also the question of why some states in India have done well do provide such services to their citizens while the others have not.

A 2015 article by Pramit Bhattacharya in Mint cited research by a US-based political scientist, Prerna Singh, to offer an interesting answer to this question. Singh looked at the experience of Uttar Pradesh and Kerala, both of which had similar levels of backwardness around the middle to late 19th century.

Kerala surged way ahead of Uttar Pradesh in terms of development outcomes later.

Singh argued in her research that the reason politicians in Kerala paid greater attention to egalitarian provisions, such as health care facilities, unlike their counterparts in Uttar Pradesh, is that their actions were driven by a sense of solidarity due to a common sub-national Malayali identity.

The Uttar Pradesh political elite, on the other hand, did not develop any such feelings and was more interested in national politics while exploiting sectarian fault-lines in the state. Singh’s observations hold true in other areas as well. For example, the Kerala diaspora launched a huge effort to contribute to the relief work after the Kerala floods in 2018. Such efforts are never seen for states such as Bihar, where floods cause havoc year after year.

This kind of research tells us that the link between social services such as health care and the attitude of voters and the political elite stems from long-term social processes rather than recent political developments. While giving Singh’s work due credit, Bhattacharya cited the example of the Assamese versus non-Assamese conflict taking a huge toll on socio-economic development of Assam to argue that sub-nationalism need not always lead to positive outcomes for a society.

These questions can be extended beyond the realm of social services provisions. Often, politicians implement policies that are harmful to the economic interests of a large section of voters.

For example, the legal and extra-legal disruptions to cattle markets under the BJP government have created immense economic hardships for farmers, most of whom are Hindus, in the northern and central parts of the country.

Yet, the BJP did not pay any political price for them.

A 2018 paper by Nikhar Gaikwad, a political scientist at Columbia University, has looked at this question. Gaikwad’s main argument is that, in an ethnically diverse society, politicians face a choice between employing a suitable mix of identity and economic policy incentives to the electorate. Gaikwad argues that whether or not an office-driven (only interested in winning) politician plays more on identity than economic policy promises depends on two factors: “ethnic electoral bounce effect” and “identity dispersion effect”.

Ethnic electoral bounce effect is described as the process wherein the ethnic community being courted by a politician mobilises in his/her favour, but it also creates a reverse polarisation among the other (vilified) community. The identity dispersion effect is described as the process which captures the divergence in intra-community preferences for the politician trying to polarise people on ethnic lines. The former could be described as Hindu-Muslim polarisation in Indian politics, while the latter captures the degree of dispersion of political preferences among Hindus and Muslims.

The identity factors need not be on the basis of religion alone. In many Indian states, caste is an equally big polarising factor in politics.

Gaikwad’s main argument is that whether or not politicians prioritise economic incentives over identity politics to attract voters depends on the magnitude of both the electoral bounce and identity dispersion effects.

If a society comprises of a large share of population where voters are happy to mobilise on ethnic lines with low dispersion, politicians need not bother about giving economic incentives to voters. The reverse would hold true when larger numbers of voters belonging to the courted ethnic group are not swayed by attempts to create polarisation by playing the identity card.

His research offers an important insight into why voters might not care about poor provision of services such as health care in some societies. If political parties know that they will eventually be able to polarise voters along caste and religious lines, as is often the case in many parts of India, they will not care about offering them policy incentives such as better health care and education. This makes all the more sense, as not deploying scarce resources in such sectors gives political parties room to divert funds towards placating the influential local elite or building on existing identity-based polarisation.

Such research can also help us understand why some caste-based parties in Uttar Pradesh and Bihar continued to prosper politically despite not doing enough to take care of the underdevelopment in the state.

The social polarisation among upper castes and backward castes was reason enough for voters to keep voting for the parties despite economic policy or development-related issues being neglected.

The bottom line is that the battle for better provisioning of social and economic services cannot be fought and won without a struggle to reduce, if not eradicate, ethnic tensions in a society.

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