MSc DISSERTATION - Development Studies Institute (DESTIN), 1999

Effectiveness of Public Action in Rural Health Service Delivery: A Case Study from Kerala

Supervisor: Dr. John Harriss, London School of Economics (LSE)



List of Tables

1.1 Scope and Objectives of the Study
1.2 Organisation of the Dissertation

2.1 Public Action
2.2 Public Action in Kerala
2.3 Explaining Public Action in Kerala
2.4 Effectiveness of Public Action in Kerala

3.1 Methodology of the Study
3.2 Study Area
3.3 The Primary Health Centre (PHC)
3.4 Public Action Regarding the Primary Health Centre
3.5 Newspapers in Public Action

4.1 Does Education Explain Public Action in Kerala?
4.2 When is Public Action Effective?
4.3 Do Newspapers in Kerala Contribute to Effective Public Action?

5.1 Conclusions
5.2 Recommendations
5.3 Limitations of the Study
5.4 Scope for Further Research



3.1 Questionnaire on the basis of which interviews were conducted with patients
3.2 Coverage of Public Action in Health in 3 Major Vernacular Newspapers in Kerala (Not included in this HTML version)
4.1 Categorisation of Patients in Kunnathukal


Since the mid-1970s, Kerala - the picturesque state in southern India - has occupied a prominent place in development studies. Despite low income levels, the region has made remarkable progress in education and health - near universal literacy, low infant mortality rate and low death rate being some of the indicators. A prominent lesson drawn from the Kerala experience is the salience of public action in efficient delivery of services.

It has been argued that collective action by educated, politically conscious people and monitoring of service delivery in education, health and other sectors have contributed to the advancements made by the region.

If, as the literature suggests, public action was effective in Kerala as early as in the 1970s, threat of public action would have been sufficient to deter inefficient service delivery in subsequent decades. However, at the end of the 1990s too, newspapers in Kerala contain reports of doctor absenteeism, lack of medicines and inadequate health facilities. Clearly, "deterrence" has not worked fully with regard to public action and health service delivery in Kerala. This suggests that there are limits to public action and it is possible that the existence of public action does not imply its effectiveness.


The value of public action, as a mechanism for improved service delivery, rests on its ability to achieve intended results. The challenge therefore lies not only in finding ways to ensure public action, but also to ensure its effectiveness. The present study explores this terrain in the next four chapters.

The specific objectives of the study are the following:
(1) to examine the role of education in public action
(2) to identify variables of effective public action
(3) to assess the role of Kerala newspapers in effective public action


Chapter 2 reviews the literature on public action, relating to Kerala in the field of health. Field-study conducted in a Kerala village where public action took place is reported in Chapter 3. The evidence is analysed in Chapter 4. Chapter 5 summarises the conclusions and suggests directions for further research.



The term 'public action' has been used in development literature to signify a range of activities.

Some activities are better carried out collectively because they are too costly to be done individually. For example, instead of each individual setting up a school and hospital to meet his/her educational and health needs, collective action might reduce the cost by widening the circle of beneficiaries, and cost sharing. Building infrastructure like roads, dams and telecommunication facilities are popular examples of public goods built and maintained by organisations, rather than individuals.

Based on the above worldview, and drawing strength from welfarist notions of the state, 'public action' has been equated with state action. In this view, the State is the legitimate organisation that can serve as the agent of collective action. Thus, public action would cover the establishment of schools and hospitals by the State but not similar activities by private bodies like firms and trusts (though collective bodies in themselves).

Jean Dreze and Amartya Sen, in a seminal study of famines, opine that public action should not be confused with State action only (Dreze and Sen 1989: 18; Dreze and Sen 1995: 87-92). Extending the contours of public action, they argue that in a strategy of public action for development outcomes, multiple levers have to be considered - (a) the state (b) the market (c) non-Governmental organisations; and (d) public activism for swaying Government policy as well as influencing social and personal behaviour. The authors note that the roles played by the Opposition parties and the Press are important variables of effective public action.

For Gita Sen, the public sphere is one where people participate along with Governments in defining needs, making choices appropriate to those needs, and enforcing accountability (Sen 1992). Public action involves people having a direct say in governance on an ongoing basis - as participants in decision-making and watchdogs of implementation.

While both Government action and people's action have the expressed objective of being for the public, the difference is that, the latter is also action by the public. Far from being passive recipients of public services, persons are active agents in service provision.

The discussion above highlights that there are various elements in the matrix of public action. One of them - public activism - is chosen for detailed examination of the evidence surrounding its working and effectiveness.

Since the mid-1970s, Kerala - a small state in southern India - has occupied a prominent place in development studies. Despite low income levels, the region has made remarkable progress in education and health - near universal literacy, low infant mortality rate and low death rate being some of the indicators. With active social spending by the State, and politically aware citizens acting as enforcers of accountability, the 'Kerala model', it has been observed, is a classic case of public action at work in all its hues.


How does public action take place in Kerala?


Reviewing the achievements of Kerala, V K Ramachandran notes that health programmes in Kerala have been far better implemented than in other states, "largely due to the vigilance of an educated and politically conscious public" (Ramachandran 1996: 321). Sen recalls one such instance of vigilance and political consciousness in the pre-independence era (1992: 275). Between 1927 and 1937, the Rockefeller Foundation was engaged in activities aimed at improving healthcare in the region. Methods suggested by the Foundation in its hookworm eradication campaign were subjected to public debate. Members of the Legislative Assembly, far from being indifferent or passive observers of external aid, attempted to channelise the Foundation's resources in line with the region's perceived realities. The incident, which culminated in the non-renewal of permission to the Foundation to continue its programme, reflected the society's ability to enforce accountability.

In the post-independence era, monitoring extended to regular health care facilities set up by the Government. Joan Mencher (1980) writes that an unmanned primary health centre in Kerala would have invited massive demonstration at the nearest collectorate, led by local Leftists. Similarly, a child's death due to doctor's callousness would have led to procession, demonstration outside the primary health centre, articles in newspapers, and questions in the state Assembly. Mencher contrasts this with her experience in neighbouring Tamil Nadu. Similarly, John Caldwell (1986) finds popular expectations and demands in adjacent Karnataka different from those in Kerala. Caldwell notes that threat of violence is not unusual in Kerala and mentions popular stories of doctors beaten up for having failed in their duty.

Defining Needs

Ramachandran also observes that people in Kerala demand more health facilities than in the rest of India. Such initiatives go beyond public scrutiny of existing programmes and signal active involvement by people in defining their needs.

Moni Nag (1989), in a comparative study of West Bengal and Kerala, observes that locally organised actions for improving health services occurred more frequently in rural Kerala in the 1970s. Submission of memoranda to the higher authorities by local bodies, trade unions and political parties, agitation by hospital patients themselves, and, publicity of such actions in widely circulated vernacular dailies, form part of the strategy in Kerala. Nag offers illustrative examples of newspaper reports of public action in rural Kerala.

Historical and comparative studies reveal public activism in the field of health -- the question is why does this happen in Kerala more than in other states?


Scholars so far, have offered three inter-related strands of reasoning for the occurrence of public action in Kerala.


The region's advancements in education date back to the second half of the nineteenth century. Greater awareness regarding health issues, especially among women, led to better utilisation of health-care facilities (Panikkar 1979; Sen 1992). Education, it is argued by Ramachandran, also made the people sensitive to their rights and duties of the State to its citizens - resulting in monitoring and other forms of public activism. Nag emphasises the structure of education -- primary education, not higher education is found to be the catalyst.

Historical influence

In the 19th and 20th centuries, Kerala was home to a host of social and political movements, including radical communist struggles. Agitations against caste oppression and class exploitation fill the pages of modern Kerala history. Nag suggests that on a terrain familiar with organisation and mass mobilisation, collective action for enhancing literacy or improving local health facilities is not surprising.

Political awareness

According to Nag, indicators like voting percentage in elections and institutionalisation of political process point to greater political awareness in Kerala. Jeffrey saw this reflected in the region's newspaper culture - communal reading of dailies, animated discussions in village tea-shops, mass circulation and readership - which had been observed for decades (Jeffrey 1987; Jeffrey 1992; Mankekar 1965). Scholars note that the politically aware make use of various institutions - political parties, trade unions, student organisations - to voice their demands, including those relating to social security (Ramachandran 1996).

Inter-relationships among the three strands are not difficult to discern -- education led to political awareness and mobilisation, which in turn encouraged collective action for greater educational opportunities. Has collective action brought the desired results?


What evidence is there regarding the effectiveness of public action in health in Kerala?

Effectiveness may be defined in terms of meeting the objectives. If in response to public activism in an unmanned health centre, the Government appoints or transfers a doctor to that centre, public activism may be considered effective. Similarly, in the supply of medicines or establishment of a health facility, if Government action has been in response to people raising the demand, public activism can be said to have been effective.

Sen (1992), reports that the Rockefeller Foundation was not granted permission to continue its programmes after the initial period of 10 years. It is reasonable to conclude from the above that public criticism was effective. From Kathleen Gough's anthropological study, Nag quotes an anecdote involving a lady (maidservant of the researcher) who threatened to thrash a doctor if he did not quit the cinema theatre to attend to a pregnant woman.

Where has all the evidence gone?

Apart from the examples mentioned above, evidence on effectiveness of public action in health in Kerala is hard to come by in the literature. This is partly because much of the evidence is presented speculatively, without exact reference to actual incidents. Mencher (1980) for instance writes, "in Kerala, if a Primary Health Centre was unmanned for a few days, there would be a massive demonstration…" (1980:1782, author's emphasis). While evidence of this kind is rooted in years of experienced anthropological field studies, it sheds little light on whether the demonstrations that the writer witnessed/heard succeeded in their aims.

Paucity of evidence regarding effectiveness also springs from the use of newspaper reports. A news story recounts an incident at a point of time; not all stories are followed-up by the newspaper. Thus, while a demonstration may make its way into the daily papers, the reader/researcher is less likely to be informed (months or even years later) whether the particular demonstration achieved its objective. The nature of the evidence presented by Nag, for instance, is such that it fails to reveal the effectiveness of public activism.

Despite insufficient attention given to the aspect of effectiveness, one scholar observes that non-medical factors like public activism account for Kerala's progress on the health front (Antia 1994). Failing to distinguish between public action per se, and effective public action, writers have assumed that public activism works in Kerala. Hence, their energies have not been expended in exploring why public activism is (not) effective.

Scholars who have highlighted public action in Kerala (Dreze and Sen 1995; Caldwell 1986; Frank and Chasin 1994) base their broader arguments on the evidence presented by Mencher, Nag, and Antia - whose writings do not distinguish between the existence of public action and the effectiveness of public action. Hence the widely accepted conclusion that public action works in Kerala. Is this extrapolation of public activism justified? What does micro-level evidence from Kerala suggest? These questions are taken up in Chapters 3, 4 and 5.



The key elements of the methodology were case-study approach, collection of data from primary and secondary sources, and triangulation. This involved going to the field and gathering information regarding processes, causalities and effectiveness of public action. Research was conducted in Kerala in July and August 1999.

Case Study Approach

Yin (1994) notes, that a single-case study approach focuses on a particular instance, and hence is more suited for understanding causal factors. To answer exploratory and explanatory questions on the working and effectiveness of public action, the present study centred on a particular case in rural Kerala - public action at the Primary Health Centre (PHC) in Kunnathukal. The selection of the case was done after a survey of four months' newspapers. It was found from the large-sized news story on public action in Kunnathukal, that the region was home to a long-standing struggle to secure in-patient facilities. The news report mentioned demands - both resolved and unresolved - making the case ideal for isolating variables of effectiveness. Hence, related instances of public action (eg: earlier public action in the village), were also incorporated to facilitate comparative analysis, wherever necessary.

Due to problems of generalisation like representativeness of the selected case, a single-case study was insufficient to construct a theory of public action. However, choice of a typical case of public action, helped to test existing theories. Further, to extend the contours of the existing corpus of knowledge, a beginning was attempted by identifying variables of effectiveness.

Collection of Primary Data

Multiple methods -- structured and semi-structured interviews, and observation -- were used to collect data.

In Kunnathukal, interviewees included protesters, medical personnel, local political leaders, journalists, Government officials and other local citizens. Audio-taped semi-structured interviews were held with the medical officer, the pharmacist and a former village chief, while unstructured interviews were conducted with a news-agent and other public activists, local people and the staff at the PHC. 25 patients were interviewed orally on the basis of a questionnaire, to gather standardised data on their background, awareness and attitudes towards public action. Respondents were not asked to choose from a preset list of answers, but clarifications were offered when sought. In the process, particular care was taken to minimise 'guiding' the respondent to particular answers. Respondents were selected at random from among those standing in the queue.

Questionnaire on the basis of which interviews were conducted with patients

1. Upto what level have you studied?
2. Do you read newspaper regularly? Which newspaper do you read?
3. Are you a member of any organisation or club? If not, why?
4. Do you attend Gram Sabha meetings? If not, why?
5. Are you satisfied with the quality of service offered at the PHC?
6. When/If you are dissatisfied, what do you do?
7. Do you pay for medicines from the PHC? Why?
8. Do you know of any protest that has taken place regarding this PHC?
9. Have you joined any protest regarding this PHC? If not, why?
10. Do you think protests are effective?

Collection of Secondary Data

Documentary evidence included Government reports, public notices, and newspaper stories relating to public action. To examine the role of newspapers in public action, a survey of three leading vernacular dailies (Malayala Manorama, Mathrubhumi, Kerala Kaumudi) was undertaken. Daily editions of March, April and May 1999 were scanned to ascertain the coverage of public action in health - its nature and scope. Relevant stories were tested on a range of parameters including rural/urban, violence/non-violence, political parties, elected representatives and non-governmental organisations.

Observation technique was adopted to enhance understanding regarding the functioning of the health centre. No demonstration or protest took place during the period of study.


Combination of the above methods and unstructured interviews held with a cross-section of urban people (public activists, journalists, officials) facilitated triangulation. Triangulation was useful not only for gaining multiple perspectives but also for corroborating the evidence gathered.

The services of a research assistant (graduate student), were utilised in the collection of data. He was also asked to monitor the conduct of interviews, and suggestions were incorporated as the study progressed. All interviews were conducted in the local language (Malayalam) which is also the researcher's mother-tongue.


Kunnathukal village, located in the Thiruvananthapuram district of Southern Kerala, borders the neighbouring state of Tamil Nadu. 35 kilometres south-east of the district headquarters and state capital Thiruvananthapuram, the village - like most villages in Kerala - is accessible by motorable roads. The nearest town Parassala is 5 kilometres away.

The village covers an area of 26.85 and is home to a population of 33,648, according to the 1991 census.

Socio-economic profile

The north-western and south-eastern parts of the village are marked by hilly terrain, while the central lands are less undulating and of lower altitude. Agriculture is the major occupation of the people. A large number of men and women work as daily-wage labourers in the plantations that dot the mountain slopes. Some families also engage in animal husbandry and livestock farming.

With ten schools (Government and private) imparting education, literacy rate in the region is high (90%), as in other parts of Kerala. The 1989 mass literacy campaign also was a contributing factor in this regard. The first vernacular school was established in the village more than 80 years ago. At present, there are 10 Government and private schools, three of which are high schools.

Religion plays an important role in the lives of the people - many of whom are converts to Christianity. Though religion influences politics, especially in electoral battles, there is no record of violent communal clashes. However, the growing strength of Hindu organisations in the 1990s, has clouded the air with tension, albeit not significantly.

Politics and Administration

The area administered by Kunnathukal panchayat (local council) is divided into 13 'wards'.

By universal adult franchise, voters in each ward elect one person to represent them in the panchayat, which is headed by a President. Elections are fought on party lines. Apart from the leading parties -- Communist Party of India (Marxist) and Congress-I -- Congress-S and Bharatiya Janata Party are active in the region. Feeder organisations too (student organisations, trade unions, agricultural unions) maintain their presence in Kunnathukal. Since 1979, the CPI(M) has been the ruling party in the panchayat. The Party enjoys a wafer-thin majority in the current panchayat.

Parassala (the electoral constituency) has elected people from different parties to the state and national legislatures. In the 1987 and 1991 Kerala ministries, Parassala representatives were Cabinet Ministers.

People of the region associated themselves with the country's freedom struggle in the early decades of this century. The village also witnessed a historic agitation of agricultural workers demanding higher wages, and freedom from untouchability and exploitation. Today, following Government directives, parent-teacher associations have been established in all schools. At one programme involving distribution of school uniforms, organised by a local club in conjunction with the parent-teacher association, large numbers of parents (mostly mothers) were visible. 8 village libraries, 20 arts and sports clubs, 14 women's groups, 5 co-operative institutions and 6 milk producers' unions are among the voluntary initiatives in Kunnathukal.


Before the advent of modern medicine in Kunnathukal, traditional systems of medicine (ayurveda, siddha and marma) were in vogue. Private practitioners of these systems aside, there is a Government ayurveda dispensary in the village today. The first allopathic hospital was set up by Christian missionaries in 1894, and continues to function as the major private hospital in the vicinity. To counter a fatal malaria outbreak, a dispensary was inaugurated by the Government in the early 1930s. In the 1980s, the dispensary was upgraded to Primary Health Centre (PHC) status.


Kunnathukal PHC has 24 personnel attached to it. This includes the medical officer who has overall-charge of the PHC and health in the region, the pharmacist, the laboratory technician, medical assistants, clerical staff, junior public health nurses, the health inspector, junior health inspectors and leprosy inspectors. The minimum requirement for a PHC is two medical officers, one of whom should be a lady medical officer. The centre at Kunnathukal does not have a lady medical officer and was therefore considered a 'mini-PHC' - a tag those attached to the centre used, but one which had no definite Government rules to accompany. The competence of health inspectors was doubted by the medical officer who also pointed out that the field workers had no supervisor.

The PHC attracted 150 patients every day, most of whom were very poor. According to PHC officials, of the 36,000 people in the panchayat (1995-96 estimate), about 20,000 opted for private hospitals or bigger Government hospitals in nearby towns -- Parassala and Neyyatinkara. Long queues of women were visible at the PHC on all visits. Those who lined up at the Kunnathukal health centre were primary school educated (if not higher), regular readers of at least one newspaper, and aware of their rights. Most of them were members of at least one organisation (women's group, a co-operative, or work-related unions), but there were also respondents who cited financial constraints in joining groups. Most of them attended grama sabhas (village meetings) regularly and even those who did not attend said that at least one member from the household always attended, often the male head of the family.

Not all those who came to Kunnathukal PHC belonged to the village. Some patients shifted centres along with the doctor, while some came from across the border.


Information relating to public action regarding the PHC was gathered from interviews with public activists, patients, medical personnel and local people, as well as newspaper reports.

Chronicle of Public Action

In the early 1980s, local pressure mounted regarding conversion of the dispensary into a PHC. The demands of the people were channelled through the elected panchayat. Neither any agitation by the people nor publicity via newspapers was attempted in this effort. Instead, elected representatives went to Thiruvananthapuram, and met officials in the Government Departments to press the case. Sustained contact with those in the capital paid dividends, and the Kunnathukal dispensary was declared a Primary Health Centre.

In 1987, the absence of in-patient facilities was taken up by the people, to whom a "hospital" without beds was unthinkable. A memorandum was submitted under the leadership of a political party. The Health Department refused to build a new in-patient ward citing financial constraints. It however suggested that if the local people themselves were to construct a building for housing an in-patient ward, the Department would consider the matter. Around the same time, the Central Government introduced the Jawahar Rozgar Yojana (JRY) - a scheme that allowed panchayats to allocate resources for construction aimed at health improvement. Consequently, Rs.3 lakh (0.3 million rupees) was earmarked by the elected body towards building an in-patient ward and a doctor's quarter on the PHC premises.

However, construction of the buildings was not smooth sailing. A few months into construction in 1989, the panchayat and the people came to know that the Health Department had guidelines and regulations for such buildings - different from the design planned by the locals. But, the panchayat went ahead with the original plan and built the ward and the quarter for Rs.3.60 lakh (0.36 million rupees).

The then Government ruled by a Leftist coalition having the Parassala representative as a Minister, however, did not take over the hospital after its construction. The Government argued that there was no sufficient staff for running the hospital and sang the familiar tune of "financial constraints." The succeeding Government of the centrist coalition, which came to power in 1991, also had the Parassala member in the Cabinet, but one who belonged to a rival party. The Government said that it would take over the new buildings, only if there were water and electricity facilities. According to JRY norms, the funds could not be utilised for such purposes. The leaders of Kunnathukal saw it as non-co-operation by the Government due to political reasons.

A PHC Development Council was established, which turned to the people to raise money for water and electricity in the new buildings. Elected representatives belonging to Opposition parties in the panchayat, did not co-operate in the raising of funds. However, local people raised Rs.38,000 and ensured the project's success. A delegation from the panchayat spoke to the District Medical Officer, but the Government continued to drag its feet until the election.

In 1996, the Leftist coalition returned to power and elected representatives (of both panchayat and the state legislature) went to Thiruvananthapuram and pressed the case. In June 1997, the Government took over the buildings formally. But, even after this, the PHC did not offer in-patient facilities.

Meanwhile, another problem cropped up - doctor absenteeism. The Government would send a doctor to this region, but none remained there for long. With fewer opportunities for private consultancy in rural areas, doctors used their political influence to secure a transfer to urban centres. Conflicts regarding the in-patient ward also contributed to doctor absenteeism. Local people demanded that the appointed doctor should provide in-patient care. Successive doctors maintained that a single medical officer was insufficient to run both out-patient and in-patient facilities. They pointed out that the doctor's quarter had a leaking roof and was too small for the doctor to accommodate his/her family. With no arrangements for nurses also to stay overnight, doctors ruled out the opening of in-patient facilities which demanded round-the-clock service. Repeated harassment of the only serving doctor, by public activists, led to reluctance on the part of doctors to stay in Kunnathukal for long.

Political parties and elected representatives met the District Medical Officer as well as the Minister and demanded that a doctor be posted in Kunnathukal. Demonstrations in front of the PHC were organised by political parties and their feeder organisations. These involved speeches by local leaders, dharna (sit-in) and slogan-shouting. In response, a doctor from the nearest PHC (Vellarada) was given additional charge of Kunnathukal PHC.

The doctor appointed via the Employment Exchange served at Kunnathukal for one year, a feat not emulated by any other doctor in the recent past. After months of public action, a doctor was transferred from the neighbouring Vellarada PHC to Kunnathukal. The problem of doctor absenteeism was solved, but in-patient care continued to be unavailable in Kunnathukal at the time of writing this report.

Patients and Public Action

Only a handful of patients participated in the demonstrations connected with the health centre. Though educated and aware, patients at Kunnathukal PHC were not significant agents of public action. Those who shouted slogans, inserted news stories in the dailies, or met politicians and Government officials in the capital, were mostly educated non-consumers.

Some patients, especially first-timers, were unaware of protest regarding Kunnathukal PHC. When asked what they would do if they were dissatisfied with the service delivered, most of them promptly replied that they would go to another hospital. A few others said that they would tell the doctor. Protest was seen by female patients as a male activity. However, women active in political parties reported that they participated in demonstrations, if they came to know of it. In general, they said, only those who visited the PHC or the nearby junction on the day of protest were likely to know of public action.

In a PHC, patients are entitled to free medicines. However, due to poor drug-supply condition in Kunnathukal, not all patients were offered medicines free of cost. Those who could afford were encouraged to purchase from the medical shops in the market. Similarly, when the PHC ran out of 'out-patient tickets', patients were asked to buy paper from the nearby store at a price for use at the PHC. No protest had taken place regarding inadequate supply of medicines or insufficient 'out-patient tickets', though patients mentioned the latter as a problem they faced.


Findings from Kunnathukal

News regarding Kunnathukal, including problems at the PHC, found space in the vernacular dailies through news agents. Apart from delivering newspapers to houses, tea-shops and local libraries, these news agents conveyed popular sentiments to the wider public by penning stories, which they submitted at newspaper offices in the city for publication. Public activists recalled that, in the 1990s, newspapers allotted more space to rural concerns than they did in the past.

Six news reports relating to Kunnathukal PHC, most of them demanding a doctor (not in-patient care), appeared during the past year. In May 1999, a large-sized news story appeared in a leading vernacular daily, detailing conditions at the unmanned Kunnathukal PHC. The doctor admitted that the story was factually correct but said that there was no connection between the news story and his appointment in June 1999. Native to the region, the doctor said that he had opted for Kunnathukal at the time of annual Departmental transfer.

The news-agent who wrote the story, however, felt that his story had made an impact. A matriculate with a keen eye for detail, and a regular participant in grama sabhas, he was also aware of the provision for temporary appointment of a doctor by the panchayat (not the Government). Not a user of the PHC himself, the news agent felt that follow-up action (like meeting the District Medical Officer) was not his responsibility.

Often, a newspaper report triggered an inquiry by a team from the Health Department. Veterans of such "eyewash" inquiries, medical personnel said that improvements were possible only by pulling "appropriate" political strings.

Political leaders in Kunnathukal did not use newspapers for informing officials in the city about conditions in the health centre. Meeting officials personally and follow-up actions were considered more effective than merely conducting a campaign through newspapers. They remarked that media coverage had to be taken with a pinch of salt.

Interviews with people in the city revealed that they had images of poor health facilities in rural areas. They recalled reading reports of inadequate facilities and doctor absenteeism, but shrugged when asked to suggest possible remedies.

Findings from the Survey of Newspapers

Table 3.2 (Not included in this HTML version) gives a snapshot of how public action in health is covered in 3 leading vernacular newspapers.

Qualitative findings from the survey of newspapers are worthy of mention. No vernacular newspaper had a regular health section catering to public action in health. One paper occasionally compiled a consumer grievance section, that included demands and complaints regarding health facilities. In general, grievances of citizens, majority of them relating to the poor state of roads and bridges, found space on pages reserved for 'local' news, along with reports of cultural programmes and religious events. Editorials and lead articles on rural health were absent but articles on general health and violence against doctors were published. A rapid appraisal of English-language newspapers revealed that urban health issues systematically figured in their city supplements, but coverage of rural health was negligible.

Analysis of the data collected by the above methods is the subject matter of the next chapter.



Before entering the uncharted terrain of effectiveness, the role of education in public action requires clarification, in the light of findings from Kunnathukal. Prominent among the theories outlined in Chapter 2, is the explanation that public action occurs in Kerala due to widespread education that fosters awareness and mobilisation. Considering the above, education should be a good predictor of public action. However, a feature of public action in Kunnathukal was that patients, though educated, were not active in public action at the health centre; educated non-consumers were. Attempting to illustrate why this happened sheds new light on why public action takes place in Kerala.

It has been theorised that high level of literacy and extensive primary education cultivate awareness of political and health issues, and pave the way for public action.

Evidence from Kunnathukal does not go against the logic of education as a facilitating factor in public action. Those who participated in public action were educated, the majority of them non-consumers. The cleft into which a wedge is driven is the non-participation in public action, of educated consumers, who were aware of their rights, but rarely publicised their dissatisfaction with the quality of health care.

4.1.1 Why would educated consumers not participate in public action?

In a classic analysis of consumer response to decline in quality of service, Hirschman (1970) outlined two options available to the consumer -- exit (stop buying the product or leave the organisation), and voice (express dissatisfaction directly to the authorities concerned or register public protest).

Public action is conceptually intimately linked to the voice option -- both are recuperative mechanisms involving the expression of dissatisfaction with the quality of existing service delivery.

Hirschman noted that voice may be used by consumers when exit is unavailable, as in monopoly situations. When exit option is available too, voice may be used -- until the cost of voice exceeds the cost of exiting. Cost of voice would include the opportunity cost of not exiting and cost in terms of time, money and other resources. Use of voice would also depend on the prospects for its effectiveness (personal ability to change the situation and faith in the ability of like-minded consumers).

Patients at Kunnathukal primary health centre may be categorised as in Table 4.1


Category: First
Reason(s) for using the Kunnathukal PHC: Personal doctor posted there
If dissatisfied, likely to…: Exit; or no response

Category: Second
Reason(s) for using the Kunnathukal PHC: "Trying out" having exited from another PHC
If dissatisfied, likely to…: Exit

Category: Third
Reason(s) for using the Kunnathukal PHC: Nearest PHC, cheapest option
If dissatisfied, likely to…: Voice up to a point and then Exit; or Exit immediately

Category: Fourth
Reason(s) for using the Kunnathukal PHC: No other option due to income constraints
If dissatisfied, likely to…: Voice up to a point; or no response

People in the first category valued personal relations with the doctor and would hesitate to participate in protests that wreck the goodwill generated. They moved along with the doctor and had no permanent stake in the Kunnathukal PHC. People in the second category would be alert to decline in quality but were accustomed to exiting, rather than using voice.

Hence, among the four categories, the groups having an incentive to express dissatisfaction were the latter two. The ability of the daily wage-earners -- poorest people (fourth category) -- to bring about change was limited; they lacked money, time and other resources.

Third category patients were the most likely candidates to exercise voice -- educated and not very poor, the common thread of geographical proximity to the health centre made collective action easy for them. Unlike patients from afar, they were more likely to know of a protest at the health centre. Yet, they had exit option to fall back on -- which prompted them to throw in the towel beyond a point.

The Kunnathukal situation demonstrates that, where opportunities for exit exist, education is not a good predictor of public action.

4.1.2 Why would non-consumers be more active agents of public action?

Public action need not necessarily be carried on by consumers. A consumer may raise the matter (because he/she is likely to be more aware than somebody not using the service), and it may subsequently be taken up by non-users. Why would non-consumers participate in public action at Kunnathukal or elsewhere?

Local Responsibilities

An individual's position in society determines his participation in public action, regardless of whether he is educated or a consumer. As the person-in-charge who would get the credit (or blame), the elected chief of Kunnathukal panchayat was motivated to ensure the success of public action. His participation diminished once he stepped down from the position. Similarly, the newspaper agent publicised the cause, because he was the acknowledged link between newspapers and the village, and the social respect he enjoyed hinged on the fulfilment of his responsibilities. It may be recalled that he did not go beyond reporting existing conditions.

Organisational interests

A political party gets involved in public action, even when members do not stand to benefit directly from the particular cause. To further the interest of the organisation, 'visible' forms of protest are arranged. Ruling party activists participate more actively than others, as it happened in Kunnathukal when funds were raised for electricity and water facilities. The subordination of all interests to party goals solves Olson's free-rider problem (1968), and, the prospects for effective use of voice being high, participation does not atrophy.

Social Capital

It has been argued, most notably by Robert Putnam, that horizontal "networks of civic engagement" and "generalised norms of reciprocity" foster civic consciousness and collective action (1993: 163-185). Proud of its mobilisational past, Kunnathukal with its various associations (literary, cultural, sporting and youth) as well as co-operatives and reading rooms, is home to numerous group initiatives with overlapping membership. Trust and other generalised norms of reciprocity generated by this network, foster joint celebration of religious festivals, voluntary public works enterprises, and public action to improve health facilities. Social capital can thus explain the contribution of money by non-consumers towards the development of the PHC.

4.1.3 Is there no role for education?

Among the reasons theorised for public action in Kerala, it is important to note that local responsibilities and organisational interests have their roots in education and political awareness. In the absence of an educated politically conscious public, political incentives for public action would be minimal, as representatives and organisations would succeed in elections irrespective of their performance and visibility in the region.

Now that the reasons for public action in Kerala have been clarified, it is time to address the central issue of effectiveness.


Chapter 2 noted that evidence regarding effectiveness of public action in Kerala is scanty, given the nature of examples presented. The study of public action relating to Kunnathukal PHC took particular care to address the aspect of effectiveness - defined in terms of whether the objective was achieved or not.

Public action in Kunnathukal in the early 1980s demanded upgrading the dispensary to primary health centre. The need was identified by the local community and communicated to the elected representatives of the village, who pursued the matter at appropriate political and official levels. A bottom-up process, it did not involve mobilisation of people, demonstrations, publicity via newspapers or other high-visibility tactics. Sustained personal contact with officials concerned brought intended results, and public action in Kunnathukal for upgrading the dispensary was effective.

Public action since the mid-1980s, demanding establishment of in-patient facilities involved petitions and personal contact as well as visible manoeuvres like demonstrations and publicity through newspapers. Public action was also more organised with a PHC Development Council. In spite of apparently "better" public action, in-patient care was not established. Hence, public action in Kunnathukal for providing in-patient care was not effective.

Evidence from Kunnathukal indicates that (a) the existence of public action does not imply it is effective; and (b) effectiveness of public action varies within the same region. The inadequacy of public action theories surveyed in Chapter 2 being evident, it becomes necessary to identify variables that explain effectiveness.

4.2.1 Effective Public Action -- Variables

Literacy has increased in Kunnathukal since the mid-1980s; presumably political awareness has risen too. Following Putnam's line of reasoning, over time, the virtuous cycle of trust would have strengthened the network and contributed to greater stock of social capital in the region. Despite being nurtured in ostensibly "more fertile" soil, the plant of public action has not borne fruits in Kunnathukal in the 1990s. This suggests that though education, political awareness, and social capital are helpful in explaining the existence of public action, these facilitating factors cannot fully account for its effectiveness. If so, in the light of the present study, what are some of the variables that can explain the effectiveness of public action?

Nature of the Demand

Upgrading the dispensary to primary health centre was essentially a matter of nomenclature, achieved by a bureaucrat's proverbial stroke. Even in its new incarnation as a PHC, the centre continued to function as a dispensary. On the other hand, the demand to provide in-patient care was more complex, given the fiscal conditions of Kerala. It may be deduced from the Kunnathukal story that when the nature of demand is complex, chances of public action proving to be effective are less.

In the case of developing regions, additional fiscal commitment, can be an indicator of complexity. Public action is more likely to be effective when it demands qualitative improvements (better treatment from the present doctor, transfer of a doctor) rather than quantitative changes (setting up of new facilities, appointment of a doctor). This is probably because, in the face of resource constraints, Governments are favourably responsive to juggling the existing allocation (rather than pumping in more resources) to meet increasing claims in all sectors.

Duration of Public Action

In Kunnathukal, initial enthusiasm declined over time as the Government delayed taking over the facilities. Even after it finally took over the buildings, in-patient care was not provided. Cynicism set in and the decade-long public action came to be seen as a lost cause.

In a democratic polity where competing demands fill the air, it is almost always necessary to adopt a sustained crusade, for which continued interest, support and participation of the activists are important. As the process drags on without signs of success, these crucial elements languish and weaken public action, reducing chances of its effectiveness.

Availability of Exit Options

When exit options are unavailable, voice continues beyond anticipated costs (upto a point) even when benefits are not in sight. But when exit options are available, benefits (of exit) are at hand, and voice becomes less attractive, thus reducing the threshold for withdrawal.

The Kunnathukal story reveals that availability of exit options diminishes the attractiveness of voice, leads to withdrawal, weakens collective action and thus hampers the effectiveness of public action. Exit opportunities can also partly explain the difference in findings between earlier studies and the present one. Since the mid-1970s, the health sector in Kerala has undergone changes (Antia 1994). With more people able to afford expensive medical care due to remittances from the Middle East, the private sector has made significant headway. Consequently, exit opportunities have increased and the attractiveness of voice has come down.

Overdoing Public Action

In Kunnathukal, continued harassment of doctors led to fresh problems like doctor absenteeism. With the passage of time, what began as demand for in-patient care got diverted to demanding a doctor.

Overdoing public action can occur quantitatively too. A barrage of demands, many of them motivated by the interests of political parties, puts pressure on resource allocation. Consequently, many worthy demands go unmet leading to frustration and apathy on the part of officials and the general public.

In short, public action if not carried out responsibly, can boomerang so as to lose focus and blunt the mechanism's effectiveness.

Nature of Political Party Intervention

A political party may be said to be sincere in public action when the organisation's interests are subordinated to the interests of the consumers on whose behalf interest articulation is done. The Kunnathukal experience was that political parties were not always sincere. When parties went beyond visibility tactics and laboured sincerely (example: the elected representative went and met officials in the capital, ruling political parties mobilised funds), public action progressed in the right direction. The case study also revealed that chances of effectiveness increase when political parties involved in public action belong to the coalition in power in the state.

Political parties are organised, closer to the corridors of power, experienced in collective action, have greater legitimacy, and can exert greater pressure at the right places in order to make public action effective. Hence, when political parties are sincere, chances of effectiveness increase and when parties are not sincere, chances of effectiveness are low. This suggests that the involvement of political parties does not per se increase effectiveness. The quality of their intervention is important.


Caldwell (1986) hinted that violent public action was common in Kerala but did not venture further. At Kunnathukal, one doctor was threatened but it did not prove to be effective. On the contrary, it led to new urgent problems that had to be tackled by the activists, leading to loss of focus. But Kunnathukal appears to be an exception. The survey of newspapers and interviews with people, point in another direction. Violent public action stories in newspapers were nearly as numerous as rural public action stories (Table 3.2). A perusal of public action news revealed that violence was a highly effective tactic of public action. People, including educated urban-based individuals, recognised its potential for swift remedial action and justified its use. Violence appears to be a good predictor of effectiveness of public action.

What explains the effectiveness of violence? First, violence or threat of violence puts pressure on the official to respond to the demand because of the threat to life and property involved. Second, violence is not planned public action but a spontaneous emotional reaction to negligence or high-handedness of doctors, and demands are not complex. Third, violence-related stories are sensational and 'newsworthy' to be followed-up by newspapers, unlike petitions and memoranda. The question then is: how far do newspapers explain effectiveness of public action?


Writing about democracy in America, Tocqueville had noted in 1840, "When men are no longer united among themselves by firm and lasting ties, it is impossible to obtain the co-operation of any great number of them unless you can persuade every man whose help you require that his private interest obliges him voluntarily to unite his exertions to the exertions of all the others. This can be habitually and conveniently effected only by means of a newspaper" (Tocqueville 1994: 111). Since then, other means of mass communication -- radio, television, Internet -- have displayed analogous potential, but newspapers continue to have a major role in developing countries.

As noted in Chapter 2, scholars have found that regional language newspapers in Kerala command a huge readership, a finding that indicates the potential power of newspapers as agents of effective public action.

4.3.1 Role of Newspapers in Effective Public Action

In general, a newspaper can play several roles - that of a microphone, a pressure-cooker, a foundry, a beacon -- and contribute to the effectiveness of public action.

A Microphone

By reporting demands of people in far-flung areas, a newspaper can amplify and ensure that rural voices catch the attention of officials in the city. People at higher levels who are not very accessible to ordinary citizens, are easier reached via newspapers.

A Pressure-Cooker

When petitions and requests fail, a newspaper can apply pressure on unresponsive officials by repeated publication of stories. Sustained publicity adds to the heat generated by the issue, ensures that it does not escape from the officials' minds quickly and, to cap it all, increases the likelihood of political intervention (from both within and outside the Government), making bureaucratic tactics of delay unwise.

A Foundry

An editorial on lack of medicines, a chain of stories on doctor absenteeism, special reports on decaying village health centres - all carry the broader signal that rural health care is neglected by the ruling party. By projecting images through political lenses, a mass circulation newspaper can shape opinions and mould pillars of political support and opposition.

A Beacon

Tocqueville pictured the newspaper in democratic countries as a "beacon" - guiding "wandering minds, which had long sought each other in darkness" to meet and unite (1994: 112). When a newspaper highlights an issue, informational barriers crumble, like-minded individuals find one another, and collective action becomes more likely.

4.3.2 Contribution of Kerala Newspapers

Against the backdrop of roles catalogued, it is possible to evaluate the performance of Kerala newspapers and examine their contribution to effective rural public action in health. Analysis is based on interpretation of both micro- and macro-level data -- evidence from Kunnathukal and survey of three vernacular newspapers respectively.

As a microphone, the newspaper was sparingly used by ruling party leaders in Kunnathukal. This is understandably because communicating the demand can be done sans negative publicity, by mailing a petition or meeting the urban official personally. Patients and socially conscious citizens, unlike ruling party leaders, are more likely to use the newspaper as a microphone, because (a) it is convenient for them to inform the local news-agent, than trek to the district headquarters; and (b) publicity in their case is an asset, not a liability.

Macro-level evidence in Table 3.2 showed that rural demands for enhanced facilities (most of them first-time informative stories) were amplified by the newspaper. Micro-level evidence on occasional inquiry teams inspired by news reports, confirmed that as a microphone, newspapers contributed to public action in Kerala though their effectiveness was not always predictable.

As a pressure cooker, the newspaper was effective in public action for a doctor at Kunnathukal. The demand for in-patient care stretched more than 10 years and there was no evidence of pressure cooker stories being scripted regularly. This may also explain the campaign's ineffectiveness. Evidence at the macro-level indicated that pressure cooker stories on rural health were infrequent. Excepting one, all follow-up stories involved negligence or violence - hinting that rural public action had to create a flutter to be worth a second look.

As a foundry on rural health, shaping opinions and building political attitudes, evidence on Kerala newspapers was discouraging. Partly due to microphone stories, urban people were aware that rural health care was in a state of neglect. But deliberate attempts to highlight rural health problems through editorials and lead articles, or link rural health care with the Government's agenda, were singularly lacking in Kerala newspapers. Consequently, awareness was passive and not translated into public action. The number of letters addressed to the editor (an indicator of how strongly people feel about a particular issue) was zero in the case of rural health in contrast to 16 on urban health.

As a beacon, bringing together people concerned with rural health, newspapers in Kerala offered no evidence. Patients in Kunnathukal noted that they were not informed of planned protests. At the macro-level, the number of stories involving non-consumer groups was more than three times that of health-related consumer organisations. Consumer public action groups in health were predominantly urban, hospital-centric or issue-specific 'action councils'. Organised efforts to promote rural health facilities did not figure prominently in the dailies; nor was there any example of organisations formed as a result of newspapers playing the beacon role.


Whether it is public action in general, public action in health, or health in general, there is an unmistakable urban-bias in newspaper reportage. Rural-urban disparity is least evident in public action in health, but even there 63 stories out of 104 were urban (Table 3.2).

An instance of urban public action in health is more likely to find space in a Kerala newspaper than a similar case in rural areas. Why? Is it because there are more instances of public action in urban areas where educated people are more aware of their rights? Though it is plausible that urban areas witness more public action, there is no supporting evidence. At the same time, some instances of public action in Kunnathukal did not make it to the papers, revealing that not all rural public action was covered.

What are some alternative explanations for urban-bias?
(1) Urban medical centres cater to urban as well as rural people, and lack of facilities in such places is of immediate concern to a wider population. Flow from urban to rural areas for healthcare being rare, newspapers cover urban health issues more than rural.
(2) Urban public activists have easier access to newspaper offices and hence are able to insert stories without much difficulty.
(3) Newspaper offices are city-based and reporters seldom venture beyond urban limits to gather stories. Appearance of rural news depends on how frequently rural agents (who are primarily newspaper suppliers, not full-time professional journalists) contribute stories.
(4) Newspapers do not see rural health as a priority issue that requires special attention. Incentive problem exists - urban reporters have greater inducement to rectify problems in urban health facilities which they utilise.

Conclusions arising from the above analysis are summarised in the following chapter.



Analysis of public action in Kerala, based on evidence gathered from a case-study of public action in Kunnathukal village and survey of vernacular newspapers, leads to the following conclusions:

1. Education and political awareness facilitate public action by keeping political incentives alive

2. An explanation for the occurrence of public action must incorporate a constellation of determining factors like availability of exit options, organisational interests, and existence of social capital

3. Existence of public action does not imply its effectiveness; a distinction is necessary to isolate variables and enhance the value of the mechanism

4. Nature of the demand, duration of public action, availability of exit opportunities, excessive public action, nature of intervention of political parties, and violence are some variables that can be used to predict the effectiveness of public action

5. Newspapers in Kerala contribute to the effectiveness of public action in health, but well below their potential. On a positive note, they raise health concerns and provide space for 'microphone' stories. At the same time, preference for sensational news, political apathy in the matter of rural health, and urban bias limit effectiveness of newspapers.


Findings from the present study point towards the need for involvement of external agencies to promote rural health. As exit opportunities increase along with income and spread of private health care, chances of effective public action for rural health decline. In such circumstances, working of the mechanism depends on the poorest people who are not in a position to raise voice due to resource constraints and vulnerability. Effectiveness will be further blunted when the poorest segment becomes electorally insignificant. Hence, when quality of service delivered to the rural poor declines, external agencies (non-governmental organisations, newspapers) have to step in and boost voice signals.

In contemporary Kerala, the onus is on newspapers to identify rural health care as a social concern and improve its coverage qualitatively. Highlighting rural health will help like-minded people to come together and work out innovative solutions. Further, to ensure that microphone stories catch the attention of urban officials, newspaper layout can be realigned and stories of similar nature may be compiled for publication on a particular day of the week. Civil society groups and unemployed youth may be encouraged to contribute rural reports, analysing health issues from a political economy perspective. This will help the newspaper play its foundry role effectively.


The dissertation adopted a case-study approach to understand in detail the working and effectiveness of public action in Kerala. In a region where numerous instances of public action occur, selection of the case is bound to involve inescapable biases that legitimately invite accusations of unrepresentativeness. For the same reason, case-study of a single village is insufficient to draw generalised conclusions, on public action and its effectiveness, for the whole region.

A second limitation, arising from the choice of the qualitative route for data analysis, is the greater scope for researcher bias. Native to the region and having lived in Kerala during the formative years, the researcher's political socialisation is likely to have influenced the collection and interpretation of evidence.


Future research in the field of public action could examine the role of the State in promoting the mechanism. The scope for establishment of institutions to channel public action in order to increase its cohesiveness could be explored. Studies focussing on effectiveness of public action, in Kerala and other developing regions are scarce. By studying in detail particular cases of public action in different areas, constructive suggestions, to improve the mechanism which has wide application in other fields like education, are likely to arise. It is hoped that such regional studies that are also the building blocks of theory will be undertaken in the coming years.


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Kerala Kaumudi
Malayala Manorama
The Hindu

Official Publications

Kunnathukal Grama Panchayat, People's Campaign Development Plan - 1997-2002
Kunnathukal Grama Panchayat, Draft Plan Document 1998-'99
Kunnathukal Grama Panchayat, Draft Plan Document 1999-2000

Summary of Dissertation
World Development Report 2004
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Copyright © 1999 Ashok R Chandran