Ensuring the ordinary: Politics and public service in municipal primary care in India

This paper examines the political embeddedness of public-sector primary care in urban India. The low quality of urban healthcare in many low- and middle-income countries is well documented. But there is relatively little analysis showing how the politics of urban healthcare delivery contribute to quality shortfalls. This study integrates urban and political theory and draws on ethnographic fieldwork in municipal government-run primary care clinics in Pune, India. I conceptualize Pune's municipal doctors as street-level bureaucrats: frontline state agents charged with delivering public services, who regularly confront conflicts between their mandate and its realization in practice. I observe how the municipal doctors experience and respond to these conflicts; delineate the historical design of the municipal institutions in which they operate; and interview doctors, nurses, nonclinical staff, administrators, and elected officials, who collectively shape primary care delivery in municipal clinics. My findings show how the doctors' work is characterized by routine departures from public service ideals. The departures stem from local electoral politics (politicians' patronage and clientelistic relations with municipal employees and patients) and weak administrative capacity (misuse and incompetent planning of public resources). The doctors are compelled to follow extra-policy directives, meaning instructions that have little to do with healthcare goals and that emphasize the political utility rather than medical purpose of their work. In response, the doctors circumscribe their clinical practice. They aim, as one doctor put it, only to "ensure the ordinary," or to sustain a deficient status quo. In these conditions, improving quality of care requires not just behavioral interventions targeted at doctors. It requires normative, social, and organizational shifts in public service planning and delivery so that doctors are positioned - materially and affectively - to meet urban healthcare challenges in low-resource contexts.