The district hospital of Muzaffarpur, 100 km north of Patna, Bihar’s capital, is struggling with a shortage of doctors.
With 160 beds and an estimated inflow of 500-600 new patients each day, the hospital should have 48 full-time doctors and 52 nurses, said one of its administrators. What it has, instead, is 12 full-time doctors, 24 part-time doctors and 28 nurses. The Intensive Care Unit should have four doctors but has just one. The unit for newborn babies, which should have four pediatricians, is managing with just one.
Given such understaffing, the hospital doesn’t meet the district’s healthcare needs.
When Madina Begum, a resident of Ratnauli village, took a neighbour with a temperature of 104 degrees Fahrenheit to the hospital, she said, “All the doctors did was give her a bottle of saline. Nothing else. No medicine.” The woman’s companions had to put wet clothes on her all night to cool the fever down.
That is the story across Bihar. Seventy years after Independence, the state’s healthcare infrastructure continues to be grossly inadequate. Seventeen of the 38 districts in the state have no more than three government doctors for every 100,000 people. One district, Siwan, has just one doctor for 100,000 people. The highest, Sheikhpura, has eight doctors per 100,000 – or one for every 12,500 people. To put that in perspective, the WHO-prescribed level is 1:1,000.
In the same way, while the Right To Education law mandates student-teacher ratios at 30:1 in primary schools and 35:1 in upper primary, the ratio in Bihar districts hovers between 43:1 and 96:1. As a result, learning outcomes are poor in the state.
In the last 12 years under chief minister Nitish Kumar, Bihar has notched up improvements in law and order, road connectivity and electricity supply. But its performance on issues crucial for the poor – like health, education and land redistribution – remains weak.
Underperformance on these fronts till 1990 is easy to explain. Bihar was ruled by politicians and bureaucrats from the so-called upper castes, which were both socially and economically powerful by virtue of controlling the state’s land and resources. Their hegemony, as this article will elaborate, resulted in the state avoiding pro-poor projects like land redistribution.
But from 1990, Bihar’s political spaces began to get more democratic. First came the government of Lalu Prasad Yadav of the Janata Dal, later rechristened Rashtriya Janata Dal, which gave political power to the backward castes, also known as Other Backward Classes. The situation improved further in 2005 when Nitish Kumar of the Janata Dal (United) stitched together an alliance between the upper-caste support base of its ally, the Bharatiya Janata Party, and the extremely backward castes.
In 2015, Lalu Yadav and Nitish Kumar came together to fight the assembly elections. Their victory consolidated the power of the backward castes in the state.
Despite more than 25 years of rule by backward caste leaders, who have risen to power by appealing to the poor, why is Bihar’s track record on crucial issues that most affect the poor underwhelming?
In states like Punjab and Mizoram, Scroll’s “Ear To The Ground” project traced poor healthcare back to weak state finances. That is not the case in Bihar. The state’s financial condition has improved since 2005. “As the national economy improved, Bihar found itself getting more money from the Centre,” said Shaibal Gupta, the founder of Asian Development Research Institute in Patna. The size of the state budget rose from Rs 28,944 crore in 2006-’07 to Rs 1.6 lakh crore in 2017-’18.
As a result, unlike Punjab, which spends most of its revenues on debt-servicing, Bihar now has a revenue surplus. But, even with debt-servicing, Punjab’s per capita healthcare spend is higher than that of Bihar – Rs 1,189 as compared to Rs 831. This is partly explained by the fact that Bihar is more populous than Punjab. But population alone does not account for the paradox of a pro-poor government failing to deliver services to the poor.
The baggage of history
Bihar’s underdevelopment is rooted in its colonial history, said Gupta. The British used different tax collection mechanisms in India. In southern and western India, under the ryotwari and mahalwari systems, they conducted regular surveys to set the annual tax that peasants would pay them directly. But in eastern India, including Bihar, they worked through local zamindars who would collect taxes, maintain law and order, and pay the British a fixed tax each year.
It was a consequential choice that has shaped how people in these areas experience the state till today. In post-Independence Bihar, the landowning elite – Bhumihars, Rajputs, Thakurs and Brahmins – came to control both the state unit of the Congress and the bureaucracy. Unsurprisingly, land redistribution did not take off, despite both peaceful movements like Bhoodan and violent uprisings like Naxalism.
The arrival of Lalu
This phase ended in 1990 when a great subaltern assertion swept Lalu Prasad Yadav to power. It was a period when the vast majority of Bihar’s people began getting a voice in the state, said DM Diwakar, a professor at Patna’s AN Sinha Institute of Social Studies. “With him demanding more from the bureaucracy, a confidence-building began among the people,” he said. This offered a valve at a time when violent clashes were building up between feudal forces and those opposed to them.
In the next 15 years, however, the state’s administrative capacities did not improve. In fact, they worsened. Part of the reason, as academic Jeffrey Witsoe wrote in Democracy Against Development, his book on lower caste politics and development in Bihar in the Yadav years, was the structural adjustment policies adopted by India in post-liberalisation 1990s that resulted in an increasing precariousness of state finances. This constrained the government’s capacity to hire.
Another reason was Lalu Yadav’s response to the resistance he encountered from the bureaucracy. Realising that the upper caste dominated bureaucracy was not supporting him, Yadav began weakening it, said Diwakar. When he could not find lower caste candidates, positions were left vacant.
Santosh Mathew, an officer of the Indian Adminstrative Service, and Mick Moore, a professor at the Institute of Development Studies at the University of Sussex, have analysed government recruitment data for 1996-’06 in a working paper titled “State Incapacity By Design: Understanding The Bihar Story”. “Only 30,000 new primary school teachers were recruited against the 90,000 that were required,” they write. “The pupil teacher ratio, which was already 90:1 against the national norm of 40:1, worsened to 122: 1.”
Healthcare was a similar story. As recruitments were halted, “Primary Health Centres and hospitals stopped functioning”, said Sridhar, technical director of NGO Care-India’s healthcare work in Bihar. The outpatient load on PHCs came down to as low as 50 cases in a month.”
By 2005, said Vyasji, a former principal secretary for health in the state, the state lacked the administrative backend for running its public healthcare system – a machinery for procuring drugs, a corporation for managing state hospitals and so on. (For more on this, see this 2007 report by the Planning Commission.)
The transformation under Lalu Prasad Yadav remained limited. “The poor were with him.” Vyasji said. “The expectation was his regime would make land reforms happen.” But he didn’t, partly because since 1970s, land ownership had begun to shift from the upper castes to other backward classes, which formed the Rashtriya Janata Dal’s support base. His own caste group, Yadavs, had huge landholdings in districts like Madhepura.
What Nitish Kumar inherited
When Kumar took charge, he came with a dramatically different approach. Lalu Yadav had “weakened the bureaucracy and ruled through informal political networks”, said Witsoe. But Kumar sought to revive the bureaucracy by operating through a “core team” of senior IAS officers and by forcibly weakening the political class. This was a centralised, top-down model.
With him coming to power, Bihar suddenly looked like it was on the cusp of change. There were many reasons. Nitish Kumar is a Kurmi – a small middle caste, like Yadav, which accounts for just 3.5% of Bihar’s population. He could not count on support from one numerically powerful caste group. Instead, he needed to show tangible improvements to build a base. The only leverage he had, said Diwakar, was development.
Kumar’s initial decisions inspired confidence. As Witsoe writes, in key departments, even when “Nitish distributed ministerial posts out of political compulsion, corrupt ministers were teamed with secretaries with honest reputations, constraining the influence of the former”.
The bureaucracy threw its weight behind him, fearful of a possible return of Yadav. As someone who had worked at the Centre, Kumar had both an eye and memory for detail. He worked “more like a cabinet secretary than a politician”, said a senior bureaucrat.
In Kumar’s first term, Bihar gave cycles to girl students. “Extremely Backward” castes were given their own reservation quota. Kumar led a crackdown on illegal arms, said Gupta. Crimes like kidnapping came down. The state’s cities became safer at night.
Using the 2001 census, said Vyasji, the state defined the requirement of health facilities and medical staff. The norms for hiring doctors were eased. New medical colleges were approved. At the same time, it began working on the backend administration as well – trying to reform drug procurement, for instance.
Similar roadmaps, he said, were created for all major departments as part of a project announced by Kumar in 2011 – Project Manav Vikas. “The idea was to take indicators from multiple social sectors – health, education, labour, IT, social welfare and others – and to create a roadmap towards meeting them,” said Vyasji. In health, eight indicators were chosen, including infant mortality rate, maternal mortality rate, total fertility rate, malnutrition, child marriage and sanitation.
What are the results like?
Twelve years down the line, however, the state is getting mixed results. As in the Lalu years, it is making slow progress on the issues most crucial for its poor. Land ownership continues to be skewed. Big farmers own more than 1,000 acres even as the poor subsist on sharecropping.
In Muzzafarpur’s Ratnauli village, Mabina Begum and other residents have been part of a movement demanding better implementation of the rural job programme under the Mahatma Gandhi National Rural Guarantee Act. No more than 10-20 families of the 1,500 families in the panchayat own land, she said. Sharecroppers like her have to give the landowner a minimum of Rs 18 per kattha (a local unit of land approximately equivalent to 10 decimal), regardless of the crop yield. “And we have to give adhia – half the harvest,” she said. Cultivating ten kattha of land as a sharecropper, Begum’s annual income from farming is just Rs 5,000 a year.
This is why many believe land redistribution is vital for Bihar’s poor.
Kumar constituted a land reforms commission under a retired judge D Bandopadhyay but failed to implement its recommendations. The factors at work go beyond administrative ones. Both the parties that Kumar has allied with in the last 12 years – the BJP and the Rashtriya Janata Dal – have a support-base which includes land owners. Even his own caste group, the Kurmis, own large tracts of land near Nalanda.
The household economics described by Begum also explain why MNREGA work is so important for people like her. “If we get work for 100 days, that is Rs 17,700,” she said. But this is where the great paradox of Bihar rises up again. Begum did not get any work all of 2014, and just 20 days in 2015, for which she was yet to be paid when this reporter met her in October. Other schemes, like the old age pension, she said, were not reaching beneficiaries either.
All of which brings us back to the original question. Why would a government whose support-base comprises the backward and extremely backward castes, Muslims and Dalits not fix these issues?
The second part of this series will get into more answers.
This is the first part in a series on the failure of governance in Bihar. Read the other parts of the Ear to the Ground project here.
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