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Democracy and Health: Evidence from Indian States
Pushkar, Madhvi Gupta
spectacular success nor failure in addressing health challenges.
1 Democracy Makes a Difference
Democracy’s good effects are said to be realised through both electoral and nonelectoral mechanisms. Several factors inclu-
This study examines the validity of the democracy advantage thesis with reference to India’s states and shows that the impact of democracy on health, in terms of infant mortality rates, is mixed – good to moderate in a number of states but poor in most of the populous states. It explains why and how democracy is believed to make a difference to a country’s health and human development performance. Further the article highlights the significant variation in IMRs across states and the good to moderate performance among a number of states.
Earlier versions of this paper were prepared for the presentations at the annual meeting of the Canadian Political Science Association, Ottawa, 27-29 May 2009 and at the 36th All-India Sociological Conference of the Indian Sociological Society, Cuttack on 27-29 December 2010. This article is drawn from a longer manuscript by the authors. Thanks are due to Mariajosé Aguilera for able research assistance.
Pushkar (p.pushkar@mcgill.ca) and Madhvi Gupta (madhvi.gupta2@gmail.com) are with MacGill University, Montreal, Canada.
T
The article is organised as follows: in Section 1, we explain why and how democracy is believed to make a difference to a country’s health and human development performance. We summarise the role of two causal mechanisms that are believed to enable the democracy-good health link: political competition and civil society activism. Section 2 discusses two main limitations of studies on the democracy advantage thesis with reference to India: their inability to explain interstate variations in health outcomes and their denial of the important role played by states in public goods provision. Section 3 looks at IMRs in Indian states to highlight the significant variation in IMRs across states and the good to moderate performance among a number of states but with the exceptions of some of the most populous states. In Section 4, we explain why democracy has mixed impacts on health. We argue that political competition and civil society activism require a further set of enabling conditions – such as the axis of political competition or how civil society actors use their political freedoms
– which may not be assured to the extent where they have a favourable imp act on human development. In Section 5, we conclude that India has achieved neither
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ding political freedoms, freedom of expression and association, political competition, democratic norms, legitimacy of democratic institutions, civil society and others serve democratic regimes well (Gerring et al 2005, 2006; Lake and Baum 2001; McGuire 2010; Zweifel and Navia 2000). In much of the academic literature, two of these are identified as crucial:
(1) political competition; and (2) civil society activism.
1.1 Political Competition
Democratic regimes hold free and fair elections at regular intervals in which all competing political parties have a chance of winning. In order to gain power, political parties and leaders try to make credible promises to win the support of the largest possible number of voters. Once elected, their goal is to stay in power and they therefore implement those public policies which would allow them to be re-elected. The expectation is that the welfare performance of ruling parties persuades voters to reward or punish them. In a competitive political system, political leaders come to represent the interests of the people because political institutions are designed to reward those who are responsive to people’s needs and punish those who are not. Democracies are more invested in welfare than dictatorships because political competition creates incentives for the supply of public goods. Many studies have highlighted the role of political competition in explaining divergent social spending and welfare outcomes across India’s states (see for example Chhibber and Nooruddin 2004).
1.2 Civil Society Activism
The government’s responsiveness to public needs is not assured by the act of voting alone. Public action by civil society actors is believed to be necessary for better publi c goods provision. Governments are more
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responsive when non-electoral participation is high. Democracies are said to do better than dictatorships because of “what they permit indirectly” (Zweifel and Navia 2000). In particular, democracies permit freedom of information, expre ssion and association which allows civil society to flourish. A flourishing civil society – characterised by a vibrant associational life, non-governmental organisations (NGOs), free press and the like – disseminates information, engages in public action and creates the demand-side of welfare. Government officials are subjected to increased scrutiny over their performance. The existence of political rights over time also empowers oppressed social groups, whether women, lower castes and classes, workers, peasants and ethnic minorities. These groups can use their political rights to organise and make claims for welfare goods. Increased political participation compels elected leaders to be responsive and held accountable for their actions in ways other than elections.
It is also important to note, following Gerring et al (2005, 2006), that democracy’s benefits are more likely to be realised when a country remains democratic over the long term. The existence of democracy over an extended period leads to the accumulation of “democratic stock” so that the causal mechanisms that link democracy to better human development
– political competition, freedom of expression and association, civil society, democratic norms and others – become more effective. As Gerring et al (2006) put it, “the effects of political institutions are likely to unfold over time – sometimes a great deal of time”. Elsewhere, they argue that
insofar as strong civil societies encourage better governance and greater attention to the needs of the less advantaged citizens in a society, we can expect these causal mechanisms to kick in only over several decades.
Briefly then, a supply-side of public goods is created in the context of competitive politics. Since political parties are interested in winning elections, they have an incentive to supply public goods based on the expectation that they will be rewarded for doing so and punished if they fail to. At the same time, democracy creates a demand-side for public goods.
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People have political rights and are free to express their preferences. When they face acute welfare deficits – as is common in low- and middle-income countries – whether in terms of access to health or education, they can make collective claims for those public goods that are in short supply as well as reward or punish political partie s for their success or failure in addressin g welfare deficits. Within this stylised framework, we can see why democracies are expected to improve human development.
2 Democracy Advantage Thesis
India’s democracy has flourished against all expectations (Ganguly et al 2007). At the same time, the country’s human development performance – it ranked 119 in 2010 – also defies expectations. India’s health record is quite dismal with IMRs at 50 per 1,000 live births in 2009 (GoI 2011: 1). A number of studies show that the long-standing democratic rule has positive effects on infant and child mortality (Lake and Baum 2001; Gerring et al 2006, Halperin et al 2005; Zweifel and Navia 2000). However, India appears to be an exception to the rule. In a widelycited study, Zweifel and Navia (2000) reported that, with the notable exceptions of China and India, IMRs are lower in democracies than in dictatorships.
There are two main weaknesses of the democracy advantage thesis: (1) they cannot explain interstate variations in health outcomes; and (2) they deny the important role played by states in public goods provision:
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health. In India, state governments are the main decision-makers in determining the allocation of public goods and in the delivery of social services. There are significant differences in the quantity and quality of health and other public goods provided by the states (Besley and Burgess 2002; Betancourt and Gleason 2000; Drèze and Sen 1996; Kathuria and Sankar 2005) because they differ in their policy choices. Interstate variations in health outcomes are substantially determined by state-level (rather than nation-level) factors and centre-state relations. Studies on the democracy advantage thesis have ignored the key role of states in health provision and assign credit or blame to national governments .
India’s poor health performance at the aggregate level and marked interstate variations in health outcomes call for a re-examination of the causal mechanisms believed to activate the democracy-good health link and for a greater focus on state-level characteristics and comparisons. Sub-national comparisons have a distinct set of advantages and have been utilised to examine variations in health indicators across and within Indian states (Betancourt and Gleason 2000; Gaudin and Yazbeck 2006; Measham et al 1999; Pande and Yazbeck 2003). However, prior studies have not addressed interstate variations across India with a specific focus on political factors within a democracy advantage framework.
3 Infant Mortality
To understand democracy’s effects on infant mortality in Indian states, we created three clusters of high, moderate and poor performers in two ways, first, we looked at current IMRs and second, we considered the pace of reduction in IMRs between 1981 and 2009.1
Table 1 (p 40) shows three clusters of high, moderate and poor performers based on (1) the IMRs achieved by Goa, Kerala and Manipur – identified as high performers – in 2009 which converge to around 15 per 1,000 live births; and (2) the performance of other states in comparison to the leaders. We categorised moderate performers as those states where the IMR is less than three times that of the leaders. Poor performers are states with IMRs of
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Table 1: Infant Mortality in Indian States (2009) six decades of independence, it does not that political parties are rewarded or
State IMR
tell us if the impacts of democracy have punished for their ability to deliver wel
High-performers (<15)
improved over time. The causal mecha-fare goods. However, all electoral systems
Goa 11
nisms that link democracy to good health are burdened by institutional, informa-
Kerala 12
– political competition and civil society tional, cultural and other constraints. As a
Manipur 16
activism – are said to have become more result, electoral mechanisms typically
Moderate performers (d45)
Arunachal Pradesh 32 effective over time (Gerring et al 2006). operate under suboptimal conditions and Delhi 33 Therefore, we examine the pace of reduc-may not lead to expected outcomes. For a Himachal Pradesh 45
tion in IMRs between 1981 and 2009 since competitive political system to supply
Jammu and Kashmir 45
it is from the 1980s on that India’s demo-public goods, other conditions need to be
Jharkhand 44
cracy became consolidated, more compet-applied. Two of these appear to be espe-
Karnataka 41
itive and characterised by more wide-cially important: (a) the axis of political
Maharashtra 31
spread civil society activism. competition; and (b) the size of the mini-
Mizoram 36
In Table 2, high, moderate and poor mum winning coalition.
Nagaland 26
performers are identified on the basis of
Punjab 38 Sikkim 34 the pace at which they reduced IMRs over (a) The Axis of Political Competition: Tamil Nadu 28 a period of nearly three decades. We The axis of political competition indicates
Tripura 31 ranked states as high performers if they what voters consider to be “things of Uttarakhand 41 reduced their IMRs to at least one-third of value” (Bueno de Mesquita et al 2003). West Bengal 33
their 1981 levels; moderate performers if Political competition may be organised
Poor performers (>45)
they reduced their IMRs by as much as around class or, as is common in multi-
Andhra Pradesh 49
India did overall; and poor performers if ethnic societies in the developing world,
Assam 61
IMRs fell by less than India’s overall around ethnicity. In India, “with isolated
Bihar 54
decline. Manipur is an exceptional case exceptions, caste rather than class has Chhattisgarh 54 Gujaratsince it had the lowest IMR among Indian
48
Table 2: Rate of Infant Mortality Decline in Indian
Haryana 51 states in 1981 and remains among the
States (1981-2009) Madhya Pradesh 67 leaders today. State 1981 2009 % Decline
Meghalaya 59 The health performance is quite mixed High-performers
Orissa 65 for the period 1981-2009. As many as 10 Arunachal Pradesh 126 32 75 Rajasthan 59 Goa 90 11 88
states reduced their IMRs to one-third of
Uttar Pradesh 63 Himachal Pradesh 143 45 69
1981 levels and another eight performed as
Mean 41.6 Kerala 54 12 78
well or better than India overall. However,
India 50 Maharashtra 119 31 74
seven states count as poor performers and
Source: SRS Bulletin, January 2011, p 1.
Manipur 32 16 50
a number of them are the same states with
Punjab 127 38 70
more than 45 or three times higher than high IMRs in 2009. It is fair to surmise that
Sikkim 127 34 73
that of the best performing states.2 the promise of democracy remains unful-
Tamil Nadu 104 28 73 As Table 1 indicates, 18 states count as filled in populous states like AP, Bihar, MP Tripura 130 31 76 good or moderate performers and 11 and UP. Moderate performers Gujarat 115 48 58
states as poor performers. The difference
Haryana 126 51 60
between the best performing states and 4 Democracy’s Mixed Effects
Jammu and Kashmir 108 45 58
the poor performers is significant. IMRs in To explain democracy’s uneven effects on
Mizoram 83 36 57
Assam, Madhya Pradesh (MP), Orissa and health outcomes across India’s states, this
Nagaland 68 26 62
UP are more than five times higher than in section revisits the two causal mecha-
Orissa 163 65 60 Kerala. It is also interesting to note that nisms – (1) political competition; and Rajasthan 141 59 58 the nation’s IMR of 50 is significantly higher (2) civil society activism – that are consid-West Bengal 95 33 65
Poor performers
than the mean of 41.6 for the 29 states. This ered to activate the democracy-good
Andhra Pradesh 91 49 46
is due to the fact that only four of the 10 health link. We argue that a set of other
Assam NA 61 NA
most populous states – Maharashtra, West enabling conditions, which may or may
Bihar 94 54 43
Bengal (WB), Karnataka and Tamil Nadu not be operational, are needed for political
Karnataka 81 41 49 (TN) – have achieved a moderate health competition and civil society activism to Meghalaya59
79 25 status while the remaining six – UP, Bihar, lead to health improvements. Uttar Pradesh 130 63 52 MP, Andhra Pradesh (AP), Rajasthan, Gujarat Madhya Pradesh 150 67 55
– with a combined population of 590 mil- 4.1 Political Competition India 115 50 57 No census was held in Assam in 1981. The state is ranked as a
lion are among the poor performers.3 The “electoral connection” thesis bets on
poor performer on the basis of its infant mortality rate in 2009. While Table 1 tells us what the net effect political competition to improve public Source: Planning Commission (2002: 226) for 1981 infant
mortality rates; SRS Bulletin (January 2011: 1) for 2009 infant of democracy is across Indian states after goods provision based on the assumption mortality rates.
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been the primary mode of subaltern experience” (Varshney 2000b: 7). Under such conditions, political parties are rewarded or punished on the basis of their ability to provide ethnic goods rather than public goods.4 Ethnic goods effectively substitute public goods when competing ethnic groups appear more interested in “writing all the wrongs of yesterday (rather than) focus on what would give them a better tomorrow” (Banerjee 2004: 209). Voters choose between ethnic parties and multiethnic parties that make credible claims to deliver ethnic goods and seem capable of winning (Chandra 2004; Keefer and Khemani 2005). India’s political parties, “especially state-level parties, contest elections to provide supporters access to the state” in terms of state resources (Chhibber 1995: 92). The beneficiaries are limited to the selectorate of supporters to the exclusion of others by using state resources “to provide (targetable) jobs rather than (less targetable) high quality services” such as public goods (Keefer and Khemani 2005: 3).
What matters for public goods provision then is the prominence of class as the axis of political competition. The implication also is that left wing parties must be credible political competitors. Kohli’s (19831984) study of poverty reduction in Indian states was one of the first to emphasise the key role of Left parties at the sub-national level. He argued that “barring the ascension of a well-organised, left-of-centre regime in India, the prospects of alleviating rural poverty by deliberate political intervention will remain slight” (p 670).
(b) The Size of the Minimum Winning Coalition: Another influential view holds that party ideologies or Left parties are either inconsequential or not necessary for the expansion of public goods provision (McGuire 2010). What matters is the number of effective political parties which determines whether a political party needs more or less than a plurality of votes to win (Chhibber and Nooruddin 2004). The number of effective competing parties affects the size of the minimum winning coalition needed to secure office. In multiparty systems where there are three competing parties, a political party can win elections based on the support of
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a selectorate (Bueno de Mesquita et al 2003). In contrast, in a two-party system, the winner needs 50 + percentage of the vote. Since two-party systems require the winner to secure a majority of the vote, public goods provision is likely to be superior to multiparty systems where the winner needs a smaller proportion of the vote (Persson and Tabellini 1999). In sum, majoritarian systems create more incentives for leaders to provide public goods to a larger number of people than the systems with smaller winning coalitions (Bueno de Mesquita et al 2003).
In multi-ethnic countries with two competing parties, each party needs to build alliances across different ethnic groups and provide benefits to a larger and varied section of the population. When multiple parties are competitive, political parties can win by mobilising only those segments of the population whose support is needed to secure office. In multiparty systems, a significantly smaller section of the population needs to be rewarded. In their study of government performance in Indian states, Chhibber and Nooruddin (2004) argue that the variation in state government expenditures “is primarily a consequence of the differences in the party systems across the states” (p 153). They found that in states with multiparty systems, there was a greater focus on providing jobs in exchange for political support, and these exchanges were based on caste appeals.
4.2 Civil Society Activism
There are several caveats that apply for progressive civil society activism to drive the demand-side of welfare. At least two deserve close attention: (1) How citizens use their political freedoms; and (2) The ability of citizens to make claims for public goods.
(1) How Citizens Use Their Political Freedoms: Chatterjee (2004) reminds us that “desired political institutions cannot be made to work effectively merely by legislating them into existence” but require that they “be nested in a network of norms in civil society” (p 33). While democracies provide political and other freedoms, these by themselves do nothing more than facilitate a public action. Much depends
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on how and to what ends political freedoms are used (Sen 1999). It is well established that civil society associations act in different ways. While “a vibrant civil society can promote trust and cooperation, it can also promote particularism” (Heller 2000: 498). The civil society actors may not even make effective claims for public goods such as health and education (Mehta 2003). The relationship between political freedoms and progressive public action cannot be assumed but must be empirically determined.
While the civil society actors in India demand “equality” and “social justice” with great frequency and intensity, they do not commonly demand better social services. This is because equality and social justice are largely framed with reference to caste and religion. The “mediating institutions” of civil society are penetrated and contaminated by caste and religious groups (Béteille 2000). It has been suggested that “the articulation of the problems of the poor requires a larger ideological frame which is not available” so that “the poor do not become a category of popular mobilisation” and are commonly mobilised on religious and ethnic lines (SDSA Team 2008: 128). Accordingly, the most vibrant popular mobilisations are organised around identity issues. The proliferation of identity-based movements and parties has led to demands for greater equality, but each having “a different conception of what it is that needs to be equalised” (Weiner 2001: 208).
Religious mobilisations have undermined India’s democratic credentials and most commentators would agree that they represent “counter-civil society movements” (Chandhoke 1995). On the other hand, caste-based movements – which are looked upon in more favourable light (Jaffrelot 2003; Varshney 2000b) – are simultaneously progressive (in that they seek to improve the social and material conditions of lower castes) and particu laristic (because they are narrow and seek benefits for their own to the exclusion of others). While material issues are not entirely missing in the narrative of caste politics, the emphasis of caste mobilisations has been on respect and dignity for the lower castes, the lack of which is seen to constitute the “profoundest
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| burden” (Mehta 2003). Material improve- | Indian s from any meaningful access to |
| ments for the lower castes – other than for | democratic rights other than the act of |
| a small number of those who have bene | voting. Political participation in the non |
| fited from their close ties to party bosses – | electoral domain favours those with |
| in the heavily populated northern states | greater resources, not the larger public, |
| have so far been rather limited (Planning | which has few resources and is lacking in |
| Commission 2002). | organisation. Hasan (2009), therefore, |
| laments that in a highly unequal society | |
| (2) The Ability of Citizens to Make | like India, “the ability of the poor to give |
| Claims for Public Goods: In a somewhat | voice to their basic needs is constrained or |
| forgotten study on rural anti-poverty pro | enabled by the structure of social relations |
| grammes in Maharashtra, West Bengal | and distribution of resources and power” |
| and the United States in the New Deal era, | (p 139). |
| Echeverri-Gent (1993) drew attention to | The potential of civil society is contin |
| the “paradox of participation” where citi | gent on the creation of solidarities between |
| zens have formal political equality but | antagonistic social groups divided by |
| there are marked differences in the social | fundamental cleavages. Given the persist |
| power of the many and the few. This para | ence of acute social distance between |
| dox points to the fact that the existence of | members of different ethnic groups and |
| political freedoms may not (and usually | classes, civil society itself is in need of |
| do not) compensate for class- or gender | democratisation (Chandhoke 1995). Pro |
| based or other disadvantages. While the | gressive public action requires bridging |
| poor in India and elsewhere value democ | social relations across ethnic and other |
| racy and are active participants in terms | divides. The most successful cases of |
| of voting and other political activity | popular mobilisation are those that over |
| (Yadav 2000), non-electoral forms of par | come ethnic, class or gender differences |
| ticipation among lower-income groups – | through the intervention of individuals, |
| in social organisations and protests and | social groups and organisations which |
| demonstrations – are well below that of | rise above their narrow interests and |
| middle- and upper-income groups (SDSA | begin to consider the interests of the |
| Team 2008: 264, 268). Political participa | publi c as congruent to their own. Pro |
| tion is commonly linked to the spread of | democracy movements in Latin American |
| education (Krishna 2002) which, despite | countries or across Asia involved the crea |
| improvements over the decades, remains | tion of broad-based social movements that |
| elusive for a majority of India’s poor, lower | bridged the divisions between workers |
| castes and women (Planning Commission | and the middle-class, members of differ |
| 2002). Furthermore, political participa | ent ethnic groups and men and women |
| tion in the form of protest activity is often | (Gupta 2006). |
| tied to political parties (SDSA Team 2008: | Other than the many obstacles to col |
| 98). This suggests that political participa | lective action for public goods rooted in |
| tion is largely led by opposition parties for | the structure and ideologies of the civil |
| realising party objectives (of gaining | society (Mehta 2003), public action is con |
| power) rather than public ends. The real | tingent on: |
| influence of subaltern groups in matters | |
| that affect their lives is quite limited. | (a) The Nature and Extent of Welfare |
| The circumscribed nature of political | Deficits and How These Deficits Are |
| participation by disadvantaged groups | Perceived: Not all public goods are in |
| gives credence to the proposition that civil | equally short supply in India though defi |
| society has meaning only for a small | cits in health and education services are |
| privileged section and the larger public is | most pronounced (Banerjee et al 2008). |
| marginalised or even excluded from the | Furthermore, even when health deficits |
| domain of “civil society” (Chatterjee 2004; | are obvious and people suffer from poor |
| Jayal 2007). The persistence of social dis | health, they appear to be satisfied with |
| tance based on class, caste, language, reli | whatever healthcare they get (Banerjee et |
| gion, gender and other differences (Mehta | al 2004), perhaps because they have few |
| 2003) has excluded large sections of | expectations or do not know any better. |
| 42 | october 1, 2011 |
5 Conclusions
Cross-national studies find that, with the possible exception of China and India, a long period of democratic rule has beneficial
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consequences for the health of people. If China and India are exceptions to the democracy advantage thesis, the lives of more than 2.5 billion people are unaffected by regime type. However, cross-national studies suffer from a “whole nation bias” (Rokkan 1970) and do not consider the immense differences that may exist within nations. In India, some states have achieved IMRs comparable to China. In others, IMRs are higher than in the poorest countries in the world. The preliminary evidence reported in this article suggests that democracy’s effects on health are mixed. Recognising that democracy’s effects are uneven supports more modest claims that democracies avoid extreme outcomes, either “colossal failures” or “spectacular successes” (Varshney 2000a).
Notes
1 We only included states which existed in 1981 and 2009.
2 It must be admitted that this categorisation or any other is arbitrary and open to criticism. However, the goal of this exercise is only to make a rough comparison for the Indian states without consideration of their initial conditions, level of economic development, economic growth, regime type, or any other.
3 Deolalikar et al (2008: 980) estimated that UP contributes one-quarter of all infant deaths in the country and, along with Madhya Pradesh, Bihar and Rajasthan, accounts for slightly more than half of the total. Stated differently, if UP was not part of the country, India’s infant mortality rate would be reduced by one-fourth. Without UP, MP, Bihar and Rajasthan, India’s infant mortality would be half of what it is today.
4 By “ethnic goods” we refer to those goods that are sought by members of an ethnic group to satisfy their specific needs. These may include public goods when they benefit members of that ethnic group and not others. Spatial concentration of particular ethnic groups may permit targeting of public goods in a selective manner. More typically, ethnic goods refer to specific kinds of “private goods” which are targeted at narrow bands of supporters crucial for the incumbent to retain office, in contrast to public goods which improve everyone’s welfare (Bueno de Mesquita et al 2003).
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