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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

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?
Madhvi Gupta, Pushkar

2. Democracy, Civil Society, and Claims-Making in India

The chapter discusses two main causal mechanisms believed to activate a virtuous relationship between democracy and human development, including health outcomes:
Political competition and
Civil society activism.
The focus is especially on the latter with particular reference to India. It is argued that India’s long democratic life has empowered subordinate social groups, especially lower castes, in varying degrees. However, despite the passage of time, there has only been a slow spread of a “culture of equality.” Ethnic and other divides remain pronounced. Associational life is still largely organized around ethnicity and particularistic forms of claims-making focused on narrow identity issues are the norm. This hinders the emergence of broader class coalitions that could make effective demands on the state for better health services.
Madhvi Gupta, Pushkar

3. Why Are India’s Poor Not Making Claims for Health?

The poor provision of health and related public services has adverse consequences on population health, especially low-income groups. Opinion polls show that Indians care about public services and believe that it is the state’s responsibility to provide them. However, despite high levels of deficits in health services, they do not make claims on the state. Based on field research in two low-income communities in New Delhi, four main reasons are identified for the absence of bottom-up pressures:
Citizens do not expect or trust political leaders and public officials to deliver public goods;
They believe that any claims-making efforts on their part at improving social service provision will not be successful;
They have learned to cope with (or adapted to) deficits in public services; when necessary and to the extent possible, they acquire them privately;
Differences within communities, based on ethnicity, class, andgender, diminish the willingness and ability of communities to come together to demand better social services.
Madhvi Gupta, Pushkar

4. What Will It Take for the Poor to Demand Health Services?

Building on Chapter 3, but also drawing from the academic literature on civil society and social movements in Brazil, Chapter 4 theorizes and speculates on what it will take for India’s low-income groups to make sustained collective claims on the state for health services. It is argued that the engagement and intervention of better situated individuals and groups in civil society — referred to as “external actors” by Brazilian social scientists and “citizen elites” by the Indian sociologist Dipankar Gupta — for the cause of subordinate groups is crucial in this regard. Examples from India, Brazil, and elsewhere attest to the key role of external actors in inspiring and leading a variety of social movements. Above all, citizen elites inspire confidence among low-income groups that their efforts will be successful.
Madhvi Gupta, Pushkar

5. Conclusion: Democracy, Civil Society, and Claims-Making for Public Services

The chapter sums up the main arguments and findings of the book. It also includes a brief discussion on whether — and the extent to which — public services are becoming more relevant to voting behavior and if that could, other than inspire greater political responsiveness from above, also translate into growing citizen demands for social services. At the same time, however, the chapter submits that bottom-up pressures may at best play only a secondary role in improving the state of public services in India.
Madhvi Gupta, Pushkar


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