1 University of London London School of Economics and Political Science Development Studies Institute (DESTIN) Local Governance: Bureaucratic Performance and Health Care Delivery in Calcutta Indranil Chakrabarti Submitted for the Degree of Doctor of Philosophy August 2001 i UMI Number: U162944 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Dissertation Publishing UMI U162944 Published by ProQuest LLC 2014. Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 POLITICAL AND 2 Abstract This thesis is based on a comparative case study of two bustee neighbourhoods located in two separate wards of Calcutta, and of the factors which have affected the performance of public officials providing primary health care services to their inhabitants. It is argued that poor bureaucratic performance and a lack of accountability lie at the heart of problems with the health system in West Bengal. The thesis evaluates the effectiveness of ‘governance’ reforms, comprising decentralisation and the application of the principles of New Public Management (NPM), on the performance of public officials. NPM and decentralisation apply the core assumptions of neo-classical economics to the study of bureaucratic decision-making. The thesis argues that local officials in Calcutta may not always have chosen to behave in a way which maxmised their personal welfare, but that history, culture and politics may have affected the choices that they made. The thesis questions the view that decentralisation necessarily leads to greater community participation challenges contemporary notions of what constitutes ‘civil society’ and suggests a more nuanced view of the relationship between civil society and good government. 2 3 It questions NPM’s claims to universality, which have resulted in its widespread application without due regard to local context, and argues that NPM inspired reforms have had a limited effect on health officials in Calcutta, in part, because of their failure to address the underlying causes of poor bureaucratic performance. The final chapter argues that the political influence of public sector workers has affected the willingness of the ruling Party to enforce the incentives to improve the performance of health care officials in West Bengal. 3 4 Table of Contents List of Tables 9 List of Diagrams 10 List of Abbreviations 11 Glossary 12 Acknowledgements 13 Chapter 1: Introduction Page 1.1 Background 16 1.2 Governance 16 1.3 Local Governance and Basic Health Care in West Bengal 17 1.3.1 Health and the Urban Poor in Calcutta 19 1.4 Primary Health Care and Bureaucratic Performance 22 1.5 Outline 24 1.6 Methodology 26 1.6.1 Case Study of the Bustees 26 1.7 Selection of Case Study Sites 28 1.7.1 Wards 28 1.7.2 Selecting a Bustee 30 1.8 The Survey 31 1.8.1 Sampling, Piloting and Problems 31 1.9 Preliminary Information: Gatekeepers, Mapping and Group Interviews 32 1.10 Studying Local Politics: Listening, Observing and Asking Questions 35 1.11 Comparative Case Study and the Health Care Bureaucracy 38 1.11.1 Target Group 38 1.12 The Effect of Rules and Regulations on Bureaucratic Behaviour 39 1.13 Internal Norms 40 1.14 Pressure from Clients and/or Politicians 41 1.15 Conclusion 42 Chapter 2: Governance, Decentralisation and Bureaucratic Page Performance in Service Delivery 2.1 Introduction 43 2.2 What is Decentralisation 45 2.2.1 Democracy, Popular Participation and the Valorisation of the Local 47 2.2.2 Civil Society and the State 49 2.2.3 Social Capital 52 2.2.4 State-Society Synergy 54 2.2.5 Enhancing Governmental Performance 56 2.2.6 Rational Individuals, Social Norms and Informal Rules 57 2.3 New Public Management (NPM) 61 2.3.1 Theory 61 2.4 Criticisms of NPM 63 2.4.1 Low Morale 63 2.4.2 Accountability 64 2.5 Ignoring the Local Context 64 4 5 2.5.1 Changes to Relationships within the Executive 64 2.5.2 Organisational Capacity and Systemic Constraints 65 2.5.3 Organisational Cultures 66 2.6 NPM and the Bureaucracy in India 68 2.6.1 NPM and the health Bureaucracy in West Bengal 69 2.7 Conclusion 73 Chapter 3: Health Care in India and West Bengal Page 3.1 Introduction 76 3.2 Challenges to Effective Health Care Provision in India: Equity and Efficiency 78 3.3 Sources of Inequity 78 3.3.1 Urban-Rural Differences in the Distribution of Resources 78 3.3.2 Barriers to Access in Urban Areas 80 3.3.3 Misplaced Priorities: Curative Care and Doctors 81 3.3.4 Medicare and Vertical Programmes 82 3.3.5 Gender Inequality and Health Care 84 3.3.6 The Bureaucracy: Health-Care Providers 85 3.4 Explanations 86 3.4.1 Political Economy Approaches 86 3.4.2 Transfer Mechanism 87 3.4.3 Conceptual Lacunae: Health Care v Medicare 88 3.5 The Scenario in West Bengal 89 3.5. 1 FP and Vertical Programmes 89 3.5.2 Distribution of Resources 90 3.5.3 Finances 92 3.5.4 Medical and Paramedical Personnel 93 3.6 Primary Health Care and the Extension of Social Justice 93 3.7 The Problem 95 3.7.1 The Re-emergence of Fatal Diseases 95 3.8 The Roots of Poor Planning: Lack of Relevant Data on Which to evaluate Performance, Prepare Budgets and Develop Policy 97 3.9 Poor Information 99 3.9.1 Misconceptions and Distrust at the Community Level 103 3.10 Administrative Breakdown 106 3.10.1 The Condition of State Health Care Facilities 106 3.10.2 Bureaucratic Performance 107 3.11 Accounting for Bureaucratic Failure 110 3.12 Accountability 111 3.13 Institutional Arrangements for Ensuring Accountability 113 3 .13.1 Consumer Protection Act 1986 (COPA) 113 3.13.2 Health Advisory Committees and Decentralisation toPanchayats 114 3.13.3 Fixing Lines of Control 116 3.14 Conclusion 117 Chapter 4: Demographic Characteristics and Social Relations in two Calcuttabustees Page 4.1 Introduction 121 4.2 The Research Areas: Kasba and Garcha 121 4.2.1 Garcha 121 4.2.2 Kasba 122 4.2.3 Historical Background of Research Sites 12 3 5 6 4.3 Demographic Characteristics of the Research Sites 126 4.3.1 Comparative Ethnic Composition: SL (ward 67) and D T (ward 85) 127 4.4 Comparative Socio-Economic Characteristics 129 4.4.1 Occupational Status 130 4.4.2 Household Income 132 4.4.3 Distribution of Household Assets 133 4.5 Social Relations: Dover Terrace, Garcha 134 4.5.1 Residential Characteristics and Kin Ties 134 4.5.2 Social Life and Worship 136 4.5.3 Occupation and Educational Status 138 4.6 Social Relations in Swinhoe Lane 142 4.6.1 Residential Patterns and Kin Ties 142 4.6.2 Social and Economic Differences 144 4.6.3 Kin Ties 147 4.6.4 A Dominant Role in Ritual Life 148 4.7 Conclusion 151 Chapter 5: Comparing the Perfromance of Local Health Care Officials in Ward 67 and ward 85 Page 5.1 Introduction 153 5.2 Government Funded Primary Health Care in Calcutta 153 5.2.1 CMC 153 5.2.2 Calcutta Metropolitan Urban Health Organisation (CMUHO) 157 5.2.3 Calcutta Urban Development Programme III (CUDP III) and Calcutta Slum Improvement Programme (CSIP 1) 161 5.3 Health Indicators 165 5.4 Comparing Infrastructure 165 5.5 Assessing the Performance of Health Care Officials 167 5.5.1 Bureaucratic Performance of Health Care Officials in Ward 85: Confusion and Lack of Transparency 168 5.5.2 Bureaucratic Performance in Ward 67: Transparency and Responsiveness 170 5.5.3 CMUHO: Ward 67 (Zone IV) 171 5.6 Rules and Regulations: Seniority Based Promotion and the Transfer System 173 5.6.1 Circumventing Rules 174 5.6.2 Enforcement 175 5.6.3 Promotions: Seniority or Performance 178 5.6.4 Transfer Mechanism 179 5.7 Internal Norms: Ethos, Motivation and Prejudices 182 5.7.1 Doctors 183 5.7.2 Paramedical Health Workers 183 5.8 External Pressures: The Exercise of Voice 185 5.8.1 Voice in Ward 67 186 5.9 Local Civil Society Organisations 187 5.9.1 Mahila Samity 188 5.9.2 Nagorik Committee 188 5.10 Good Government and Civil Society in Ward 67 190 5.10.1 Neither Autonomous nor Separate 190 5.11 The Emergence of Collective Action 196 5.12 Social Capital: Distinguishing Between Types of Associations and Tracing their Origins 199 5.12.1 Types of Association 199 5.12.2 Tracing the Origins of Associational Life in Ward 67 202 5.13 Political Opportunity Structure and the Provision of Incentives 203 6 7 5.13.1 Access to Social Goods 204 5.13.2 The Congress Party in West Bengal 205 5.14 Internal Characteristics: Commonalities and Cleavages 207 5.14.1 Bounded Solidarity 207 5.15 Conclusion 211 Chapter6: Interrogating the Governance Agenda Page 6.1 Intoduction 215 6.2 Reforms of Local Government in West Bengal 216 6.3 CMC Act 1980 217 6.3.1 Boroughs 219 6.3.2 Wards 220 6.4 CMC Act Applied 221 6.4.1 Assessing the Capacity of the Borough Committees 221 6.4.2 Ward Committees 222 6.4.3 Mayor and Mayor in Council 222 6.4.4 Recruitment of Personnel 223 6.4.5 Financial Authority 223 6.5 The CMC Act Reconsidered: Reduced Agency Costs and Improved Governmental Performance 225 6.6 Disentangling the Assumptions: Understanding the Implications 227 6.6.1 Information and Monitoring 228 6.6.2 Transaction Costs: Monitoring and Enforcement 229 6.7 Collective Action and Transaction Costs 230 6.8 Behaving Opportunistically: Bureaucratic Responses to Admnistrative Changes 233 6.8.1 Design