The power of popular opinion in everyday primary care provision in urban India

ABSTRACT

Studies of power in health care settings in low- and middle-income countries largely describe providers’ exercise of discretionary power in frontline roles, leaving under-specified the macro-institutions and mechanisms of power that drive health care outcomes. In this study I conceptualise providers’ actions not in terms of discretionary power but as obligatory responses to ‘authority’ over them. Authority denotes an actor’s rightfully held social power over others, who accept to follow that actor's directives. Explaining authority’s workings entails studying how it operates from its subjects’ perspectives. I analyse in particular the authority of popular opinion—which derives from citizens’ claims to state services—over primary care doctors in municipal health facilities in Pune, India. Through year-long ethnographic fieldwork, I examine doctors’ experience of popular opinion, social relations between doctors and communities, and the institutional history of state-provided urban primary care. Findings show that doctors routinely confront popular disregard for their services. But under conditions of long-standing neglect of municipal services, tenuous state-society relations, and an avid, widely preferred private sector, doctors appear unable and wary to deliver more than minimum clinical care. Their circumscribed response reflects mechanisms by which the power of popular opinion, under policy neglect, impels them to maintain a deficient status quo.

KEYWORDS:

• Power
• authority
• health care
• urban politics
• popular opinion

Introduction

How do the workings of power shape frontline health service delivery? An emerging scholarship examines this question in low- and middle-income countries, covering frontline providers ranging from community health workers to primary care nurses to medical practitioners (Erasmus, 2014; Erasmus, Orgill, Schneider, & Gilson, 2014; Storeng & Mishra, 2014). Two themes feature prominently in these studies. One theme concerns providers’ vulnerabilities and inability to exercise power, such as by expressing their opinions or having their knowledge counted in the course of health service delivery, policy decision-making processes, and community-based health programmes (Kielmann, Datye, Pradhan, & Rangan, 2014; Mishra, 2014; Sheikh & Porter, 2011; Walker & Gilson, 2004). The other theme concerns providers’ exercise of power in ways that often infringe guidelines, flout regulations, or violate protocols. Studies show how providers may supplant rules with their own decision-making logic to aid patients or may deny services or sidestep guidelines as they cope with policy implementation demands (Diarra & Ousseini, 2015; Erasmus, 2014; George, 2009; Gilson, Schneider, & Orgill, 2014; Kaler & Watkins, 2001; Lehmann & Gilson, 2013).

Research on power thus suggests what we might find in frontline service delivery: that actors face hierarchies that undermine their local knowledge and views, and that actors do nonetheless exercise power, such as when they circumvent rules. This thematic scope, however, reflects a narrow empirical focus and theoretical range.

Empirically, most studies examine health workers’ behaviour with respect to a specific, often newly instituted, programme. As a result, they tell us little about base conditions of work outside of that programme. Studies have covered, for example, how frontline health staff respond to user fee removal in South Africa (Walker & Gilson, 2004) and Niger (Diarra & Ousseini, 2015), implement family planning directives in Kenya (Kaler & Watkins, 2001), and conduct village-level outreach under national health reforms in India (Mishra, 2014). New programmes and guidelines, however, can introduce new resources, challenges, and power relations for actors (Gilson et al., 2014). In examining power in the context of such programmes, researchers can miss the underlying social conditions in which actors receive and interpret mandates. In focusing on disease- and programme-specific interventions, researchers can omit to apprehend national and subnational institutions of the state and the economy in which health system actors are embedded (Sheikh et al., 2011).

Limited theorisation of power in health research also leaves under-examined the social conditions in which actors deliver health care. Researchers have tended to describe and categorise forms of power rather than theorise how power functions. For instance, categories such as informal power (discretionary, dispersed, personal) and formal power (bureaucratic, managerial, top-down) (George, 2009; Gilson et al., 2014) do not account for the discretionary latitude that policymakers may deliberately build into formal policy design (Meier & Krause, 2003). Categories that describe how actors exercise power, such as power to, over, with, and within (Lehmann & Gilson, 2013), may be useful to organise empirical observations but less helpful to abstract from them, that is, to hypothesise mechanisms of power in conjunction with social theories about how actors’ interests, reflexivity, and social constraints shape their actions (Hayward & Lukes, 2008; Ortner, 2010). As Hupe and Buffat (2014) observe, in focusing mostly on ‘what happens’ in frontline service delivery, street-level bureaucracy studies ignore the nature of ‘macro-institutional factors’ that impact actors’ work (p. 554). These analytical omissions reflect the generally more descriptive than explanatory nature of health systems research (Adam et al., 2012; Gilson & Raphaely, 2008), which stands to gain from deeper engagement with the social sciences and humanities (Gomez, 2016; Ooms, 2015).

In this paper I extend theory-driven analysis of power in health care settings. I conceptualise providers’ actions not in terms of discretionary power but rather as obligatory responses to ‘authority’ over them. Authority—widely studied in fields of law, philosophy, sociology, and political science—is a species of social power, meaning ‘an effective capacity in human relations, the capacity of one person or body of persons to have an effect over another person or body of persons’ (McLaughlin, 2007, p. 46). Authority ‘has an exigency that advice or requests lack,’ but does not imply force or coercion (Green, 1998). Rather, as I elaborate below, it implies that the subjects of authority recognize and submit to it. Explaining authority’s workings and effects entails studying how it operates from the perspective of those who are subject to it.

I examine how authority operates over, and from the perspective of, primary care doctors working in municipal government-run clinics and hospitals (‘municipal doctors’) in Pune, India. I analyze specifically the authority of popular opinion, though I recognise and explore, in the larger project of which this study is a part, the authority of municipal administrators and elected officials over municipal doctors.

Popular opinion—reflecting people’s collective though not necessarily unified views on an issue—derives authoritative power from citizens’ claims on state-provided services, from the state’s imperative to consider people’s perspectives in democratic governance. Although municipal doctors may not directly or immediately act according to local communities’ views about public services, they are, as state agents, compelled to take them into account in their decisions and actions. People’s disfavour of public sector care in India is well documented (Barua & Pandav, 2011; Ergler, Sakdapolrak, Bohle, & Kearns, 2011; Nambiar, Ganesan, & Rao, 2016). I examine how municipal doctors perceive and respond to this popular opinion, the consequences for the care they provide, and the insights we gain into the workings of power.

Theorising authority

Meaning and mechanisms

Authority involves an actor’s claim to power, such as to rule or impose duties over subjects, where subjects recognise this claim as rightful and accept an obligation to conform to that actor’s directives (McLaughlin, 2007). By ‘rightful’ I mean that the claim is grounded in, for example, law or established social norms. Examples of authority are of a judge in a courtroom and a manager over workers. In my study, this right is premised on the legal legitimacy of citizens to express voice about public services in a democracy.

Authoritative power is theorised to operate by pre-empting subjects’ private reasons for action (Raz, 2006). Subjects are obliged to conform with authoritative directives (laws, rules, commands), and may suspend private judgment when they do so (Perry, 2013). To understand authority’s workings and effects in particular situations, we therefore have to analyze how subjects construe authoritative directives and make sense of their actions (McLaughlin, 2013, p. 54). This approach implies a study of subjects’ ‘reflexive deliberations’ (Archer, 2003), which mediate structural factors and actors’ agency. Accordingly, I examine how authority features in doctors’ practical reasoning, how they experience, interpret, and reflect upon the authoritative power that popular opinion represents.

The authority of popular opinion

Popular opinion represents citizens’ power to voice perspectives on and claims over state services in a democracy (Furedi, 2011; Price, 2008). In turn, state agents are obliged to respond to citizens’ voices—to ensure that their decisions are at least informed by the ‘will of the citizenry’—in a bid to maintain democratic legitimacy (Powers & Faden, 2008, p. 182). The manner in which state agents respond to citizens’ views may be variously subject to local and extra-local collective deliberation and negotiation, put through technocratic and political decision-making procedures. Yet global evidence suggests that popular opinion influences state-provided services through electoral, social, and political processes (Brooks & Manza, 2007; Mares & Carnes, 2009). It affirms the political nature of public services, which the state ideally provides not solely through technocratic decision-making, but in response to the public’s expressed needs and preferences.

People may individually and collectively express views through various routes of accountability, ranging from mechanisms for monitoring service providers to social movements that bring about ‘broader social and political change’ (Molyneux, Atela, Angwenyi, & Goodman, 2012, p. 542). Everyday state-society interactions, such as in municipal health care facilities, also constitute instances where actors construct and may challenge ideas about the state—its powers, boundaries, and responsibilities (Sharma & Gupta, 2006). Conceptions of welfare and state responsibility, in turn, can guide care-seeking behaviour (Levitsky, 2008). In urban India, absent organised mechanisms for citizen participation in health care issues (Agarwal, Satyavada, Patra, & Kumar, 2008; More et al., 2012), clinical encounters comprise the primary spaces where patients express—and municipal doctors come to understand—popular opinion about state-provided services. Examining such encounters to discern municipal doctors’ perceptions of and responses to popular opinion is the focus of this study.

Methods and field site

I conducted a year of ethnographic fieldwork (2013–2014) in Pune’s municipal health service. Pune is a rising hub of economic activity, but its slum population has remained over 30% of the total population since 1981 (Pune Municipal Corporation, 2014). Health care-seeking behaviour among India’s urban poor is complex. People navigate an ‘ecology of care’ (Das & Das, 2006, p. 73), choosing among providers depending in part on their financial capacity and perceptions of the illness (Geldsetzer et al., 2014). Poorer households access the less-qualified end of a largely unregulated, diverse spectrum of private providers (Hanson et al., 2008), but they are also the foremost users of state-provided health services, including in Pune (Kroll, Butsch, & Kraas, 2011).

During my fieldwork I observed primary care encounters in municipal clinics and hospitals, accompanied doctors on community outreach activities, and joined them for lunch and tea. Primary care, the main health care responsibility of municipal government (Ministry of Health and Family Welfare [MOHFW], 2013b), implies basic care for illness and injury for all ages, initial diagnosis and treatment for a broad range of ailments, and coordination of patients’ care with specialists (MOHFW, 2013a). Primary care services are ideally the first point of contact between people and the health system and are shown to contribute to more equitable health outcomes than specialist care alone (Kruk, Porignon, Rockers, & Van Lerberghe, 2010).

I conducted 30 semi-structured interviews with municipal doctors, 15 with other health workers, and a further 35 with nongovernmental organizations’ (NGO) staff, private providers, municipal administrators, and local elected officials. Interviews lasted one-half to 2.5 h, were conducted in Marathi and English, and were not audio-recorded. Names of all interviewees are anonymized and certain identifying details have been withheld or altered to maintain anonymity. I refer to doctors with the prefix ‘Dr’ followed by a pseudonymous first name; I avoid last names to preclude suggesting ethnic affiliation and to blind identities.

To contextualise these street-level perspectives against the state’s historical governance of urban primary care, I used policy texts and research studies to identify the state’s mandate for urban primary care in independent India (1947 onward). I especially cover the 1980s to the present, years marking the beginning and deepening of India’s economic liberalisation, under which health care has become increasingly commercialised (Baru, 2003; Mackintosh & Koivusalo, 2005).

I analyzed these multiple sources of data iteratively, using a reflexive relationship between theory and data (Emerson, Fretz, & Shaw, 1995). The study was approved by the Columbia University institutional ethics review board and a Mumbai-based medical ethics review board.

Encountering the authority of popular opinion

Municipal doctors did not deny that the authority of popular opinion was rightful. The doctors understood a core objective of the municipal health service to be to serve the city’s population, particularly poorer residents. The service was ‘for the slums,’ said one municipal doctor, pointing outside her clinic windows in the direction of a low-income neighbourhood. ‘We treat the poorest here. Those who cannot pay,’ said another doctor. An activist for workers’ rights affirmed that ‘People who work in government hospitals … have a general understanding that they and [activists] are working for the poor.’ Citizens’ claims to municipal services were thus not a point of contention among municipal doctors. What they railed against was people’s misplaced value for private over public health care services, as I demonstrate in this section.

Situating urban primary care in historical context

Urban health care has long received scant attention in India’s health and urban development policy. In independent India, plans for fostering national economic growth, calibrating federal balance of power, and establishing a national health service all featured agrarian rural populations as priority targets of development, as socially and economically ‘backward’ and in need of compensation for the projected shift to industrialisation (Thakur, 2014; Weinstein, Sami, & Shatkin, 2014). Health programmes predominantly addressed rural populations as national leaders sought to eradicate disease, control rural population growth, and ameliorate rural poverty in a bid to achieve national progress (Amrith, 2007; Rao, 2004).

Urban spaces were not ignored, but in the nationalist vision they were sites of modernisation and industrial progress (Chatterjee, 1997). This stance has intensified under liberalisation beginning in the 1980s. Urban policies have emphasised cities as drivers of economic growth engaged with global markets (Banerjee-Guha, 2009; Roy, 2009) and urban development programmes have invested largely in cities’ physical infrastructure and commercial viability and marginally in basic social services in cities (Coelho & Maringanti, 2012; Weinstein et al., 2014). Market reforms have enabled health care commercialisation, giving a fillip to specialised medicine over primary care and to private over public investment in medical education and practice (Baru, 2003; Choudhury, 2016; Zachariah, 2014). Medical specialists and credentialed private providers are especially dense in cities (Rao, Bhatnagar, & Berman, 2012).

Extensions to basic urban health services, however, have consistently lagged rural health system reforms (Dasgupta & Bisht, 2010). Partly because state-level governments’ primary concern is their majority rural electorate, and because central government interest in cities has focused on fostering their economic potential, the quality of municipal government has remained inadequate to the task of realising urban public needs (Weinstein et al., 2014). As government reports acknowledge, ‘unlike the rural health services there have been no efforts to provide well-planned and organised primary, secondary and tertiary care services in geographically delineated urban areas’ (Planning Commission, 2002, p. 89). National health and decentralisation reforms have established rural institutions for community participation in village-level health care decision-making (MOHFW, 2013a), but such institutions elude India’s cities (MOHFW, 2013b).

Municipal governments, charged with providing primary care to urban residents, therefore have limited financial resources, guidelines, autonomy, and administrative apparatus to meet growing urban health needs (MOHFW, 2014). Moreover, they operate without institutional mechanisms to foster social ties with urban communities. Communities have few opportunities to deliberate health care needs and appeal to municipal governments and, in turn, municipal actors have few opportunities to systemically apprehend community views and respond (Agarwal et al., 2008; More et al., 2012). It is this context of health policy neglect and institutional insulation that municipal doctors encountered the popular opinion of local communities.

Public health care as an entitlement, private health care as a paid exchange

As most mornings, the waiting area of the municipal hospital—one of over a dozen in the city—was full with patients queuing up for an outpatient consultation. Above the buzz of people streaming in and finding their way, an altercation erupted between a seated patient and a security guard. The fight concerned the patient queue. Municipal hospitals neither took appointments nor recorded the order in which patients arrived, so patients sat in rows and their position in this seated queue marked their turn to see a doctor. Patients played a sort of musical chairs: everyone got up and re-seated themselves one place closer to the consultation room to move the queue forward.

The irate patient was a tall young man with a trim moustache, dressed in pressed shirt and pants as if on his way to an office job. Standing up amid a row of seated patients, he angrily told the guard not to talk to him this way. ‘This is not a private company!’ he said. ‘This is a sarkari [government] hospital!’ The guard had asked the man to move up, to occupy the next seat. The man had not done this, he said, because he did not want to crowd the woman in the next seat. After a brief but heated exchange with the guard, the man finally sat down.

I later asked Dr Nina, a municipal doctor who worked in the hospital but had not witnessed the incident, what the man possibly meant when he said, ‘This is not a private company.’ Dr Nina grimaced. ‘Yes, that’s typical. That is what they think, that because this is a sarkari hospital, they can behave as they like, as though they own it because it is the government.’ I asked her if people interacted differently in private facilities. Dr Nina replied yes, they did, and reasoned the difference as such:

We can’t tell them to go, we have to see everyone who comes, we have to treat them, we can’t tell them to leave. In the private sector, the patient would never speak that way to the doctor, and if he did, then the doctor would just tell the patient to leave, because it is his personal clinic. But we can’t tell them that.

In Dr Nina’s perspective, patients visiting a private doctor were in that doctor’s private space at the behest of that doctor. By contrast, patients in a public hospital, as citizens, ‘owned’ that public space, in which the municipal doctor, as state agent, happened to practice medicine. Dr Biren, a municipal doctor who had previously worked in other public health care facilities, observed that some people behaved as though municipal doctors were literally their ‘servants.’ Dr Manisha, a private practitioner who held pro bono consultation hours at municipal hospitals for specialist clinical services, agreed that people ‘see public sector doctors as servants. In the private sector, they need to pay to see the doctor.’

In municipal doctors’ narratives, people asserted their claims to public services and, by extension, to the dispensations of municipal doctors. At the same time, people held the worth of municipal health care in low regard.

People’s low regard for municipal health care

In studies across India, people say they prefer private health care and hold state-provided health care to be an inconvenient and unpleasant option (Barua & Pandav, 2011; Ergler et al., 2011; Gupta, Arnold, & Lhungdim, 2009). As events at Dr Nina’s vaccination camp below demonstrate, when municipal doctors encountered people’s disfavour, they could assume defensive positions against the communities they were meant to serve.

The vaccination camp was conducted in a community space in a low-income neighbourhood. Dr Nina and health workers assisting her had repositioned its sparse furniture along one wall so that Dr Nina could first examine a child and determine the vaccinations the child needed and a nurse could follow through. Dr Nina questioned each mother about her child’s growth. She reprimanded those who had failed to keep up with the immunisation schedule; the mothers said little in response to these scolds. She cautioned a new mother against lining her baby’s eyes with kajal (potentially lead-containing kohl), a common custom. Throughout the morning she fielded questions from the nurse: one infant girl had diarrhea. Should they wait until the baby was better? Dr Nina told the nurse to wait and instructed the mother to take the baby to the municipal hospital as soon as she was better. Several other children were unwell. She repeated firmly to their mothers not to wait until next month’s camp and to visit the municipal hospital located a short distance away.

When the time neared 12:30pm, Dr Nina had to wrap up. She could not examine the latecomers, she noted to the staff of the NGO on whose initiative the municipal health service had planned the camp. She reminded the mothers they could visit the municipal hospital nearby.

When I met Dr Nina again a few days later, she informed me with dismay that community members had been critical of her behaviour. She explained that according to immunisation protocols, after health workers administered the last vaccination, they had to remain in the locality for a half-hour in case a child had an adverse reaction. Mothers who arrived late thought the camp was running but could not get their children immunised. Community members had not understood this, and Dr Nina was perturbed by their misperception of her efforts: ‘She said that I did not speak properly to patients, that I didn’t examine patients, that I didn’t give injections … ’ For Dr Nina, these charges ran contrary to her attempts that morning to bring order to the makeshift room, advise mothers about their child’s health, maintain offsite vaccination protocols. ‘I feel there is no point in working so hard,’ she said. The experience conveyed to her the community’s low regard for her work, potentially straining her future encounters with them.

The contrast with favourable popular opinion about private health care

Popular views about private health care, which doctors felt were misinformed, further frustrated their social relations with the communities they served. ‘It’s like the ration,’ explained Dr Mala as she contrasted people’s perceptions of municipal and private health care. ‘Ration shops’ were the retail stores through which the state sold subsidised rice and other grains through the Public Distribution System. Dr Mala said that the ration shop rice was indeed at times of low quality, but people thought the same way about health care at state-run facilities. ‘They think the government doctor means a free service means that he or she is bad. [They think] if you pay, then you get better services.’ People were more accepting of the inconveniences of seeking health care at private doctors’ offices—they tolerated long waiting times, they assented to medical fees.

In municipal doctors’ narratives, popular opinion held that health care obtained in a municipal facility did not simply cost less, it was also worth less than that obtained in a private clinic. Doctors chafed at the misinformation that fuelled people’s determination of the low quality of municipal health care. Dr Mala observed:

We distribute vaccines; we get our stock and distribute the same stock to the private providers also. But when people get the vaccines here, they think ‘government ka maal’ [a government product]. They don’t want it. … . Patients want you to open a new vial of the vaccine each time they come in. … Actually, for tetanus, the vaccine comes in a 10-dose vial. It’s not meant for a single dose. In the private sector, they will open a new vial for you and charge you for it. Here we don’t do that.

Municipal doctors acknowledged that people preferred to visit private providers because the experience was more agreeable. But private providers’ ‘sweet talk,’ said one municipal doctor, did not always mean better care.

The heterogeneity of popular opinion

Municipal doctors did not uniformly report negative popular opinion, demonstrating that the public’s views encompass varied positions and perspectives (Price, 2008). Dr Priya, a long-serving municipal doctor, said patients did acknowledge doctors’ good work and stressed that this gratification was one main reason she did this work at all. Patients sometimes travelled across the city to visit a particular municipal doctor, she noted. When I suggested that people’s mistrust and under-appreciation could diminish municipal doctors’ ability to perform effectively, Dr Priya demurred. Her own experience ran to the contrary: municipal authorities may not recognise doctors’ efforts, she said, but individual patients did, and their recognition represented a vital reward.

However, such positive relationships were grounded in individual doctors’ prudent handling of the power of their asymmetric technical knowledge and social position relative to poor, disadvantaged patients (Grimen, 2009). Individual doctors’ constructive actions were not supported by the institutional norms that undergirded state-provided care and medical practice more broadly, with the result that care-seeking experiences, as in the example below, often ran contrary to a patient’s favourable view.

Early one morning in a municipal hospital, I conversed with a young couple seated with their baby daughter outside an outpatient consultation room as they waited for the doctor to arrive. It was almost 15 min past opening time, but the parents seemed unperturbed. The baby was due for scheduled vaccinations. She looked rosy, calm, and alert in her mother’s arms. When I asked if they typically visited public hospitals, the father stated his preference for them. Asked about the curt treatment patients tended to receive in public facilities, he replied that one had to accommodate it given doctors’ expertise, his stance reflecting Grimen’s (2009) notion of patients’ structural inferiority vis-à-vis providers. The father added that he didn’t trust the private sector, recounting an example: when one worker among his small team of carpenters had suffered a hand injury and insisted on going to a private doctor, the doctor sewed the wound but did not apply a malam (ointment) that would have prevented the bandage from sticking to it. They had to pay the private doctor over many visits; each time the doctor would do something and charge for it. The father said the family had recently moved here from Mumbai, where they visited only public hospitals.

That morning’s consultation, however, belied a positive view of public sector care. The municipal doctor, baby’s vaccination card in hand, scolded the parents, noting that the baby was wearing a sleeveless cotton frock on an early winter morning and asking why they hadn’t put a sweater on the child. The father quietly replied that they had rushed out of the house (neither parent was wearing warm clothes), but the doctor snapped again at the alleged errors of their parenting. The baby received her vaccinations and the family quickly left.

In previous instances I had observed the doctor counselling troubled mothers of teen-age girls and young mothers-to-be. She took seriously what she saw as a charge to inform and advise patients. But, like Dr Nina at the vaccination camp, she was, though well-intentioned, at times short and paternalistic with patients, thus reinforcing the popular view of public sector doctors as brusque and disinterested.

Such fraught interactions evince not only doctors’ power in the clinical encounter, but long-standing systemic deficiencies: medical education and health care practice norms that are focused ‘excessively on behavioural modification at the individual level’ (Baru & Sivaramakrishnan, 2009, p. 33) and provide doctors scant ability and opportunity to address the structural conditions of patients’ lives (Metzl & Hansen, 2014; Zachariah, 2014), as well as processes of social exclusion in state and non-state spaces that shape how doctors apprehend, and often elide, the complexity of patients’ personal histories and identities (Mander, Xaxa, Lingam, & Bhide, 2009). In these conditions, while patients might repudiate public sector care, doctors perceive their patients as intractable (Kutty, 2010) and their public-service task as Sisyphean. Positive encounters could generate patients’ salutary views of individual municipal doctors. But shifting negative opinion wholesale entailed forging state-society ties, which was not, as I discuss below, an institutional norm supported by the state.

Responding to the authoritative power of popular opinion

The disregard municipal doctors encountered was not customer dissatisfaction, which a private provider could choose to address or not. Rather, expressions of popular opinion, overt and implied, presented municipal doctors with authoritative directives they could neither ignore nor fulfil. Doctors felt unable to respond to citizens’ claims and unwilling to invest effort beyond minimal clinical services, effort that often required them to address the social conditions in which their patients lived and sought municipal health care. Meeting this challenge depended not just on the doctors’ skills and incentives to perform, but on community-clinic relations and on collective narratives about the municipal health service that shaped its meaning for both doctors and the communities they served (Evans, 2009; Hall & Lamont, 2009). Doctors were steeped in popular disfavour of municipal services, which they could not overcome for at least three reasons.

Lack of institutional resources to forge social ties and deliver high-quality care

Dr Biren pointed to the difficulties and irrelevance of building a reputation for oneself as a municipal doctor. ‘No-one asks my name! Not even by mistake!’ he said, observing that most patients arrived not to see a particular doctor but to avail of the public service, often as a last resort. Dr Nina contended that patients’ misinformed antipathy towards municipal services and the difficult and unsupportive working conditions diminished her zeal to take initiative, to extend care: ‘You finally tend to say: ‘Why should I take a risk?’’ Risk here referred to the public’s misperceiving her efforts, of their grievances escalating as complaints she would have to field in the course of clinical interactions.

When individual doctors built positive patient relations, these were often personalistic efforts, unlikely to reorient the dominant imaginary of an unresponsive municipal health service. Patients, too, expressed grievances mostly in the course of individual clinical encounters rather than collectively and systemically. Absent participatory institutions in India’s cities, communities had little opportunity to deliberate and articulate their views to state agencies, and municipal actors had few occasions to comprehend community needs. Only a handful of NGOs mobilised urban communities for health care in Pune. For NGOs, mobilising people was challenged by conditions of urbanism: poor people’s time-poverty, transient housing, urgent livelihood struggles, and reluctance to collectively strategize even if they were willing to help each other individually (More et al., 2012).

In this situation of institutional disconnection between state and societal actors, patients did not always know when they were being badly or well served, and doctors could not ‘signal’ to patients their ‘commitment to quality’ (Leonard, Bloom, Hanson, O’Farrell, & Spicer, 2013, p. 78). The state’s inattention to urban health care and lack of investment in ‘establishing a reputation for institutional quality’ (Leonard et al., 2013, p. 78) effectively impaired municipal doctors' ability to build community ties, especially with low-income communities. As one doctor observed, the municipal health service offered little succour for poor families, such as speedy, affordable access to tests, treatments, or specialist care unavailable in the municipal hospital.

Imaginary of the state at large

People form an idea of the state ‘with close regard for past memories, accounts that circulate in the public sphere, and how [they] see other people getting on and being treated’ (Corbridge, Williams, Srivastava, & Véron, 2005, p. 8). The state has launched food, housing, and social security programmes to support vulnerable groups, but state functioning regularly breaches such programmes’ purported universality (Gupta, 2012; Mander et al., 2009). The programmes are marked by errors, inefficiencies, and poor allocation strategies and are effectively hostile to ‘urban poor migrants, street and slum residents, and unorganised workers’ (Mander et al., 2009, p. 27). In the informal economy that is a mainstay of livelihoods for the urban poor, people continuously negotiate with a vast ‘shadow state,’ meaning networks of brokers, gatekeepers, advisers, and contractors, among others who surround the ‘official state’ (Anjaria, 2011). Unsurprisingly, people come to anticipate state agencies as spaces of denial and tribulation.

Dr Mala’s example of ration shops illustrated people’s experience of state agencies other than the municipal health service. When people compared, as Dr Mala contended, municipal health care to ration shop rice, the comparison underscored how people’s encounters with one facet of the state inflected their presumptions about other aspects of state functioning. Popular opinion about municipal health care was forged in, and reinforced by, people’s general ‘disenchantment’ with the state’s welfare agencies (Kaviraj, 2005).

Private sector dominance

In doctors’ narratives, people were misinformed about municipal health services and overvalued private health care. Doctors perceived private providers as profit-driven and unscrupulous, terms similar to those reported in studies in other Indian cities, such as Bhopal (De Costa, Johansson, & Diwan, 2008) and Chennai (Ergler et al., 2011). In Chennai, public providers ‘spoke of recent improvements in treatment [in the public sector] and pointed to a reinforcing and stigmatising discourse of low quality care provision, which the public sector has yet to overcome’ (Ergler et al., 2011, p. 331).

Researchers have debated whether competition from the private sector can make public providers more responsive to users (Berlan & Shiffman, 2012; Hanson et al., 2008). But few studies have documented such an effect. Instead, researchers caution about ‘private sector provision creating unequal systems of care,’ with private providers catering, potentially ‘pandering,’ to those who can pay while public providers serve the poor (Berlan & Shiffman, 2012, p. 275). Besides creating disparities in access to care, health care markets can have ‘nondistributive’ consequences, affecting the meanings that people attach to public versus private services in ways that deepen social rifts between public providers and the communities they serve (Powers & Faden, 2008, p. 103).

Conclusion

Municipal doctors perceived negative popular opinion as a base condition of their work rather than a feature they could actively address or counteract. In working conditions marked by historically meager organisational resources, tenuous state-society relations, and an avid private sector, municipal doctors felt unable to and wary of doing more than the clinical minimum. Doctors’ retreat to a circumscribed version of primary care highlights two related points about mechanisms of power in frontline health care delivery. First, it entreats us to examine doctors’ actions not solely as discretionary acts but as responses to power over them, in this case to citizens’ authoritative claims to state services. In this framing, doctors’ (in)actions reflect mechanisms by which their imperative to respond to popular opinion under conditions of policy neglect results in low-quality care. It illustrates doctors’ practices as embedded in power relations characteristic of state-provided services, not a specific health intervention.

Second, a framing of frontline workers as subjects of authority brings into view not only how they act, but the historical and social institutions within which they work. It demonstrates the inadequacies of and popular disregard for state services at large—material and symbolic deficits that shape municipal doctors’ response to authority. These deficits stem in part from the state’s historical prioritisation of rural populations as targets of social development, the exclusions that these social programmes and associated state practices enact, and the salience of cities as drivers of economic growth. In municipal doctors’ perspective, in addition to low regard for state services, people held a high and misinformed estimation of private health care. These conditions vitiated the social contract, thwarting comprehensive primary care and reinforcing tenuous state-society ties.

A study of authority thus grants us analytical insight into a particular kind of power, the factors that shape its expression and social meaning, and the mechanisms by which it influences providers’ actions and health care quality. Globally, interventions to improve quality focus on providers’ skills and incentives to perform (Das et al., 2012; Das & Hammer, 2014). But that approach conceives of medical care primarily as a transaction, an exchange of medical advice for material and affective awards. A study of authority, by contrast, foregrounds how providers’ experiences and interpretations contribute to health care quality. It affirms Evans’ (2009) argument that population health outcomes depend not only on state agents’ judicious performance of duties, but on their seeing themselves as transformational agents who can foster and create the space for social change. Pune’s municipal doctors retained a sense that such transformation was hardly an achievable objective. Doctors’ failures to act are thus linked to authority’s workings, to the ways the power of popular opinion impels them to stick with a deficient status quo.

Importantly, these findings suggest that doctors recognise the authority of popular opinion over them, that as state agents they hold a qualitatively different relationship with patients than do private doctors. Interventions to improve quality should account for this social value. Evidence shows that focusing on how state agents understand their role and engage with community actors can be crucial to enhance population health. For example, in Kerala, India, institutions for decentralised, participatory government created mechanisms for local officials to respond to citizens’ needs, so that contentious public issues were not left as debates in the public sphere but could be concretely resolved through formal state channels (Heller, Harilal, & Chaudhuri, 2007). Uganda’s successful response to HIV is attributed to the state’s encouraging collaboration between local government councils, clan heads, and religious leaders, which activated social solidarity—people’s expectations of accountability toward one another and participation ‘in the collective process of saving one’s community’ (Swidler, 2009, p. 145). A sense of solidarity and accountability was central to the functioning of state institutions in Brazil, where, in the 1980s, the state disseminated in the popular media a positive image of its community health programme and stressed the prestige of being selected as a worker for the programme (Evans, 2009). With their contribution to community welfare recognised through official and public channels, state agents responded with high commitment (Evans, 2009). This study of municipal doctors similarly draws attention to the macro-institutional context of health care settings, where, absent community-clinic ties and a positive social imaginary of public services, the workings of power can constrain frontline agents’ ability and willingness to deliver care.

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No potential conflict of interest was reported by the author.

ORCID

Radhika Gore http://orcid.org/0000-0001-7564-6808