Why Are India’s Poor Not Demanding Better Healthcare?

Madhvi Gupta and Pushkar look for the answer to this question - of missing collective action by India’s poor - in a chapter of their book Democracy, Civil Society and Health in India

Despite high levels of economic growth and many decades of democracy, India’s health failures abound. We may realise this more surely today, when confronting the COVID-19 crisis, but this has been a sad truth of our country for many years now. 

Authors Madhvi Gupta and Pushkar, in their book Democracy, Civil Society and Health in India (published, 2015), dig deep into the reasons for this. In the chapter ‘Why Are India’s Poor Not Making Claims for Health’, they ask why collective action (joint action by individuals pursuing a common goal) by low income groups to demand key ‘public goods’ (a commodity or service made available to all members of a society, typically by the state; eg. water, sanitation and healthcare) is not forthcoming, despite them being the worst affected by the inadequate provision of these goods by the state. 

They base their arguments on a survey of academic writings as well as field research in two low-income Delhi communities— Dakshinpuri and Subhash Camp. 

Here are the important takeaways:

1. Low income groups in India turn out to vote in large numbers and participate in protests and demonstrations. However these protests and movements are mostly identity focused and not ones that revolve around deficits in social services. Protests that do emerge for public goods and services do not endure beyond securing partial and immediate relief, not lasting change.

2. Ethnic diversity (stemming from differences in caste, religion, region of origin) leads to ethnic elites preferring fellow ethnics and discriminating against others when it comes to the supply of public goods. In India, Betancourt and Gleason found caste and religious discrimination in the provision of medical services at district level. 

3. When it comes to demanding public goods, through collective action, the authors survey various academic writings to show the following effects of ethnic differences:

(a) Ethnic differences are associated with lower associational activity (eg. religious or secular gatherings and common customs and rituals) which, in turn, correlates with lower political participation. 

(b) Also, different ethnic groups may have different sets of preferences (determined by location, socio-economic status, history, culture etc.) when it comes to public goods. 

(c) Finally, members of an ethnic group may, discriminatorily, only care for fellow ethnics and not care as much for an increase in public goods and services that benefits other ethnics as well. 

(d) Different ethnic groups occupying different spaces (eg. two different castes located in different districts) are more likely to demand public goods from the state than when they occupy the same or proximate spaces. 

(e) This is because, even when they occupy the same space social distance remains (eg. fewer inter-ethnic marriages, friendships, participation in religious festivals, everyday social interactions) and this leads to lower levels of trust between members of different ethnic groups. This affects the social capital (networks of relationships between people enabling them to function effectively as a community) of communities and, consequently, their ability to organise themselves to collectively demand essential public goods. 

(f) Besides ethnic differences other factors affecting this social capital, for community action, include class and gender differences (more on this in the results of the field studies the authors conducted, below). 

4. Collective action for public goods is reliant on:

(a) Specific features of the public good. How important is it? Is it necessary for survival (eg. water)? Does it yield direct measurable benefit (eg. education, over the long term— a growing number of Indians, among low income groups, are sending their children to school)? How quickly does it yield this benefit? Can it be gotten privately instead? At what cost? Collective action will also rely on people’s knowledge of these features, and awareness regarding the potential availability of these public goods. 

(b) Expectations individuals have from the state and fellow citizens. Has the provision of public goods improved over time? Has this been a result of demands by citizens and state action? Will fellow citizens also mobilize to demand this public good from the state? Have past attempts at collective action succeeded or failed? Is the state likely to respond positively? Are political leaders and officials credible? Do people trust them? 

5. India’s urban poor are worse off than the rural poor in many aspects (60% urban poor children do not receive complete immunization compared to 58% in rural India. 47.1% urban poor children <3 are under-weight compared to 45% in rural areas and 59% of women (aged 15–49) are anemic compared to 57% in rural India). In Delhi 38% of households live in one room units and 45% of the population in slums (Govt of NCT, 2006 figures). 25% of households don’t have access to tap water (ibid) and rely on the informal water market. 29% don’t have access to toilet facilities (Census of India 2001) within the house and 45% of the population have no sewerage services (Govt of NCT, 2006 figures). When sewerage services exist, in low income areas, they are of poor quality. Lack of garbage disposal in such areas is a prime concern. Many diseases abound. Infant mortality rates are double that of Kerala. 

6. The authors carried out field research in two adjacent, low-income, multi-ethnic communities in Delhi: Dakshinpuri (a resettlement colony or legalized, “planned slum”) and Subhash Camp (an illegal squatter settlement classified as JJC or Juggi-Jhopri Cluster):

(a) Both areas had deficits in water supply, garbage disposal, electricity, roads, health and schools. 

(b) However Dakshinpuri, the resettlement colony, was better off where public goods were concerned and residents had greater security because of its legalized status. 

(c) Water supply in Dakshinpuri came very late at night, for 10 minutes, in a trickle. Water had to be stored for days or bought from a public tap shared by tens of people, a long walk away. And the quality of this water was poor. 

(d) Most residents did not have toilet facilities at home. Open defecation was common in both areas (but worse in Subhash Camp). 

(e) The lack of sanitation created unhygienic conditions leading to disease.

7. Why then, were the residents of Dakshinpuri and Subhash Camp not mobilizing themselves for collective action to demand these public goods? 

(a) Awareness of the Importance of Public Goods: 

Despite low literacy rates, residents took the provision of public goods like water supply, sanitation and education seriously. They were aware of the physical as well as economic benefits of water supply and education. Women - who would in many cases have to spend most of the day in the area - gave them greater priority than men. Some residents had moved to Delhi so that their children could be educated, besides reasons of employment. 

(b) Busy Trying to Survive:

Despite this dissatisfaction residents didn’t find the time or inclination to do more than was necessary to survive. Belonging to low income groups employed in the informal sector, their primary concern was jobs and inflation (particularly food prices). Manoj, a resident, said, “Other issues can be solved once we are employed. If I am unemployed my family suffers.” Traveling to and back from work and trying to earn more money left residents with little time to worry about living conditions. Women who stayed at home - more directly affected by living conditions - defined their core responsibility as taking care of the family and putting food on the table. 

(c) The Belief that Nothing Will Change:

The widespread belief was that government officials and political leaders or parties didn’t care and wouldn’t do anything. Urmila, another resident, said, “When we complain about water, garbage, public toilets, electricity or anything else to government officials, they do nothing.” Promises made by politicians weren’t seen to be fulfilled. Occasional ad hoc improvements were meaningless because things soon became the same or even worse. Though the poor recognized their situation was unjust, they didn’t believe they could do anything to change it. 

(d) Private Options: 

Even in low income settlements, families procured their water from water tankers and a parallel, private bottling industry. Residents sometimes pooled money to pay and have garbage removed. Even JJC residents have been known to collect money to install a working drainage system. Some residents would travel long distances and wait in lines for water. Sometimes garbage would simply be allowed to rot. When disease arose, residents would seek medical attention from private providers or avail of the unsatisfactory health services. The belief that nothing would change from their collective efforts led them to either private options, or whatever public goods were available, or simply tolerating their living conditions. 

(e) The Feeling that Things were still Better than Where They Came From:

Between 1991 and 2001, 2.2 million migrants moved to Delhi with nearly 70% from UP, Uttaranchal and Bihar. More than 70% of the slum population was from UP and Bihar. Despite the adverse living conditions in slums, migrant residents in Dakshinpur and Subhash Camp were better off than in their place of origin in terms of employment opportunities, access to education and either a better provision of public goods or the ability to acquire them privately. For many residents the prevailing sense was that things could be worse - “back home” - but that they were better. 

(f) Differences Within the Communities:

Dakshinpuri and Subhash Camp were ethnically diverse (different castes, religions and origin states, including non-Hindi speaking states). In Dakshinpuri the primary differences were of class, ethnicity and gender. 

(i) Class differences between Dakshinpuri and Subhash Camp were expectedly pronounced (the former being a resettlement colony and the latter a JJC) and within Dakshinpuri there were differences between those who had made it, with relatively higher incomes, and those who hadn’t. Anjali, a resident, said, “One reason people don’t have unity is a lot of people think they are better than the other. When they start earning better than the others… they can’t wait to get away.” Another resident, Maya, explained: “We would like to move away from here… My mentality is different from people here.” 

(ii) In terms of ethnic differences the story was mixed. There were neighbours from different castes and religions who helped one another and came through in times of need as well as those who didn’t. 

(iii) On the question of caste, however, write the authors, “bhangis” were treated as outcasts by both “upper” and “lower” castes who resented that they didn’t do their job properly or asked for money despite being paid by the government. The “bhangis” complained that residents treated them badly and would dump garbage soon after they had cleaned up, expecting them to clean it up immediately. Kailash, a sweeper, said, “We can’t clean the drains the whole day, we will do it once a day and it is the people’s responsibility to not throw anything once we are done cleaning… Because we are bhangis, they give us no respect and believe it is our job to clean their garbage.”

(iv) While residents cooperated on occasions, this didn’t extend to collective action. A resident, Manorma, explained, “People are unified in sharing each other’s personal troubles... But try to act collectively for public goods, to storm government offices, or run a signature campaign against the government for better services and everyone has their work... ” 

(v) Women, who stayed at home or worked part-time as domestic help, were most affected by the poor provision of public goods. But as a resident, Manju, explained, “There are so many household duties and some of us also have part-time work... Women here are involved with their own families. They don’t want to do anything political. Our men work hard, come back tired. They have no time for our complaints... They [the men] don’t like us to go out and do something, to get involved too much with all this, with politics.” The political involvement of women would have been key to collective action for public goods, but this was prevented because the problems of women - because of their subordinate status as the consequence of a patriarchal family space - were considered less important. Also because a majority of women accepted this lower status as a natural order of things, prioritizing men’s needs. 

8. And so, despite surveys showing that a majority of Indians understand “democracy” in terms of “justice/welfare” and “basic necessities (public goods) for all”, they don’t use their political rights to demand these necessities or goods, through collective action, for the above reasons. This also explains why claims-making for health and health-related services are largely absent in India. 

The above chapter ‘Why Are India’s Poor Not Making Claims for Health’ from Democracy, Civil Society and Health in India has been summarized with permission from the authors Madhvi Gupta and Pushkar. You can buy the book here. 

Madhvi Gupta is Visiting Associate Professor, Birla Institute of Technology and Science, Pilani-Goa. You can read more about her and her work here; Pushkar is Associate Professor, Birla Institute of Technology and Science, Pilani-Goa and Director, The International Centre, Goa. You can read more about him and his work here

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