Can Elected Minority Representatives Affect Health Worker Visits? Evidence from India

• DOI: http://doi.org/10.1111/rode.12255
• Date: 01 February 2017
• Author: Nishith Prakash,Elizabeth Kaletski
• Published date: 01 February 2017

Can Elected Minority Representatives Affect

Health Worker Visits? Evidence from India

Elizabeth Kaletski and Nishith Prakash*

Abstract

This paper examines the relationship between elected minority representatives, i.e. Scheduled Castes

(SC) and Scheduled Tribes (ST) and health worker visits in rural India. We estimate the effect of

minority representation on the frequency of visits to villages by health workers by exploiting the state

variation in the share of seats reserved for the two minority groups in state legislative assemblies

mandated by the Constitution of India. Using data from state and village level surveys on 15 major

Indian states, we find that ST representatives increase the frequency of visits by both doctors and mobile

medical units. In contrast, SC representatives have a tendency to decrease the frequency of visits by

mobile medical units. Potential explanations for the differential impact of SC and ST representatives are

also explored, including geographic isolation, support for the Congress Party, a shift in power, and

relative population shares.

1. Introduction

Despite the rapid growth India has experienced, health outcomes remain poor for a

large portion of the population. This inequity stems partly from historical

discrimination that has created large socioeconomic deficits for disadvantaged

groups, including minorities, the poor and rural populations. Despite the fact that

health outcomes significantly impact both current and future populations, provision

of health care in India remains dismal. Public service delivery, including the

frequency of visits to villages by health workers, is plagued by issues of

absenteeism, resulting in poorer outcomes, particularly in areas most in need of

improvement. In response to these ingrained inequalities, which also include an

under-representation in politics and public sector employment, the Indian

Constitution mandates that a certain share of seats be reserved in the state

legislative assemblies and the national parliament (i.e. the Lok Sabha or the lower

house) for two minority groups, namely Scheduled Castes (SCs) and Scheduled

Tribes (STs). These elected representatives have the ability to address present

issues with public service delivery through a variety of mechanisms, potentially

resulting in lasting long-run consequences for the vast majority of the population.

Previous studies have estimated the impact of political reservation for minorities on

a variety of policy outcomes including welfare spending, land reforms, employment

and poverty (Chin and Prakash, 2011; Pande, 2003; Prakash, 2009; Mookherjee,

2014). Despite the importance of these studies, to the best of our knowledge there

is no empirical evidence on how these policies impact health provision. This paper

*Kaletski (Corresponding author): Department of Economics, School of Humanities and Sciences, Ithaca

College, Ithaca, NY, 14850, USA. E-mail: ekaletski@ithaca.edu. Prakash: Department of Economics and

Human Rights Institute, University of Connecticut, Storrs, CT, 06269, USA. Prakash: IZA, CReAM &

HiCN. The authors are responsible for any errors that may remain.

Review of Development Economics, 21(1), 67–102, 2017

DOI:10.1111/rode.12255

©2016 John Wiley & Sons Ltd

then adds to the literature by examining the relationship between elected minority

representatives and the frequency of visits to rural villages by health workers for

various health related purposes. Estimating the impact elected officials could have

on health service delivery is difficult because minority representation itself is likely

endogenous to the outcome variables of interest. This could occur because the

percentage of minorities elected in certain areas or states may vary in ways that

also impact public goods allocation. In order to address endogeneity concerns we

use the empirical strategy first established in Pande (2003) and later implemented

in Chin and Prakash (2011) and Kaletski and Prakash (2014), which involves

isolating the effect of other omitted variables. In this paper, we are limited by the

availability of only two rounds of nationally representative rural household data

from 1982 and 1999. Therefore, we can only exploit the across-state variation in the

share of seats reserved to calculate a reduced form estimate of the relationship. We

further elaborate on this strategy in section 3. Our main findings indicate that ST

representatives are associated with increased frequency of visits by both doctors

and mobile medical units, while SC representatives tend to decrease the frequency

of visits by mobile medical units. We further explore potential explanations for the

differential impact of SC and ST elected officials in section 6.

Elected representatives have the potential to affect health generally, and public

service delivery more formally, as a quarter of all legislators in India come from

reserved jurisdictions. The specific focus on health service delivery is twofold. First,

the poor state of health services in India is well documented and known to be

particularly problematic for the minority groups discussed here, thus elected

officials may use their power to improve outcomes.

1

Further, although there are

several reasons for the current state of health, allocation of resources and worker

absenteeism are two prominent factors that elected officials have the capacity to

target. For example, Pande (2003) shows that political reservation causes a shift in

the allocation of resources, and in particular, ST reservation increases spending on

ST welfare programs. This is particularly important for the present study as the

increase in welfare spending could come in the form of increased resources for

doctors and medical workers, thus improving the quality of outcomes, while also

encouraging a decline in absenteeism.

2

In contrast, some theoretical models have

shown that in certain contexts, political reservation actually reduces transfers to

poor groups (Mitra, 2015) or can create a sense of protection and security among

health workers, which encourages further absenteeism. There is evidence that

elected representatives have the ability to both improve outcomes for individuals

(Iyer et al., 2012) and exasperate existing issues (Mishra, 2014). Thus, whether or

not these elected officials actually impact the frequency of visits by health workers

is an empirical question. The potential channels through which this occurs, along

with the theoretical and empirical evidence supporting this idea, are discussed

further in section 2 below.

3

Previous literature has focused on how state level political representatives impact

aggregate policy outcomes and provides several potential links between reservation

and public goods allocation. We are not aware of any paper that examines the

effect of these elected minorities on health outcomes generally, nor the frequency

of visits by health workers more specifically. This paper then adds to the existing

literature by exploring the impacts of political representation on this village level

outcome. The remainder of this paper proceeds as follows: section 2 discusses the

background and potential links between representatives, health and absenteeism;

section 3 presents the empirical framework and section 4 describes the data;

68 Elizabeth Kaletski and Nishith Prakash

©2016 John Wiley & Sons Ltd

section 5 reports the main empirical results, while section 6 discusses the results on

the heterogeneous effects of representation for different minority groups, and

section 7 checks the robustness of the results; section 8 concludes.

2. Background

Health and Absenteeism in India

Health is well established as an important issue throughout the world, but

particularly among the poorest groups in India, including minority and rural

populations. As Muralidharan (2007) points out, despite the rapid economic growth

that has occurred in India, inclusive growth remains an issue, which necessitates

providing high quality health (and education) services to all citizens. It is further

acknowledged that improving health outcomes is a recognized desire of many poor

households. According to a survey in Poor Economics the most frequent source of

stress for individuals in Udaipur is their own health and the health of their relatives

(Banerjee and Duflo, 2011). Although the data available for this study allow for

distinguishing between visits by health workers for various reasons, in this paper we

will focus on visits related to family planning and health, fertility and malaria

eradication.

4

The reason for the focus on fertility and family planning is due to the fact that

fertility rates and health risk remain extremely high, particularly among the poorest

populations in India. For example, 99% of all maternal deaths occur in developing

countries with 20% of those pregnancy and delivery related deaths occurring within

India itself (World Health Organization et al., 2012). High fertility rates further result

in decreased human capital investment, particularly as it relates to child schooling

and slower economic growth (World Bank, 2010). Thus family planning knowledge

and resources help to resolve many of these issues and ensure increased health for

both mothers and children. Additionally, malaria is established as an important

contributor to high death rates and leaves lasting long-run consequences on exposed

populations. Malaria has been linked to lower economic growth (Gallup and Sachs,

2001), while eradication increases lifetime schooling and productivity for children

(Cutler et al., 2010; Barreca, 2010; Lucas, 2010), along with adult literacy and income

(Bleakley, 2010). Further despite eradication increasing fertility (Lucas, 2013), it has

also been shown to increase female educational attainment (Lucas, 2010).

Because of the recognized desire of improved health, on average, 6% of monthly

expenditure in extremely poor households in rural India continues to go towards

health, with large amounts being spent on single events that require borrowing

funds from moneylenders at high rates (Banerjee and Duflo, 2011). This fact leads

to the conclusion that public service delivery is an important mechanism for

reducing the burden on the poorest households and improving the overall wellbeing

of the population. The government is then charged with the task of efficiently

providing essential goods and services to the population in order to improve overall

outcomes. However, despite recognizing this, central and state governments have

focused on increasing spending rather than increasing efficiency (Muralidharan,

2007). In particular, absence among both teachers and health workers is a known

issue in India and across the world. In a 2003 study conducted on a nationally

representative sample of 3000 government-run schools and 1500 primary health

centers across India, it was found that 23% of teachers and 40% of health workers

are absent on a typical day. Further, the authors indicate that these are actually

POLITICAL REPRESENTATION AND HEALTH WORKERS 69

©2016 John Wiley & Sons Ltd