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

摘要

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.