Why we Need to Study Drivers of State-Level Initiatives for Health and Education: Unpacking the Case of Karnataka

Who would guess that a state widely recognised for strong social indicators would actually be a lagging one? Karnataka is one such example. Praised in important government studies such as the 15^th Finance Commission report, NITI Aayog SDG report, on closer examination, Karnataka lags behind national averages in critical health and education indicators. For example, according to NFHS 5, for immunisation based on vaccination card for babies aged 12-23 months, the national average, is 89% and Karnataka stands at a lower point of 88%. More worryingly, there are chronic intra-state disparities even in the indicators in which it is doing well. For the example, in Karnataka women who were married before 21 is at 21.3% according to NFHS 5. In several districts of North Karnataka it is between 30-40% (HDR, 2022, p.133). The disparities are not just between the rich South Karnataka and the poor North Karnataka but also present within south Karnataka too. For example, immunisation (12 to 23 month olds) which is 88% for Karnataka is only 78% for the affluent Bangalore district. Low budgetary allocation to health and education, program design and inefficiencies in program implementation are frequently examined to understand why outcomes are not being achieved. This line of enquiry tells us the limitations of the existing system in getting the outcomes. We don’t have enough money or we are not spending the money in the right way or that we won’t have the right solutions and so on.

What is driving the making of state-level initiatives? Why and when does a state make new initiatives for its health and education systems, irrespective of whether the initiatives end up improving the systems or not? These questions would not tell us why outcomes are not being met. They will; however, tell us where the solutions are coming from and what kinds of solutions are being proposed. One may ask, why do we need to know what is driving the initiatives, so long as the initiatives themselves are solving the problems? Does it really matter if a solution to a health and education challenge is led by a junior level bureaucrat or an NGO leader or an MLA or a strategy consulting firm. Why is the ‘origin of intent’ for a policy, the raison d’etre, whose interest the policy meets important, if the idea is great? The answer is, in the short run, it should not matter but it does. In the long run, it most definitely does.

One may ask, why do we need to know what is driving the initiatives, so long as the initiatives themselves are solving the problems? Does it really matter if a solution to a health and education challenge is led by a junior level bureaucrat or an NGO leader or an MLA or a strategy consulting firm. Why is the ‘origin of intent’ for a policy, the raison d’etre, whose interest the policy meets important, if the idea is great?

The drivers of policy making impact the outcomes in four ways. First, perhaps the most obvious is that when outcomes are not being met and the new initiatives are not able to solve the problems, we need to know what’s preventing better initiatives from emerging. Second, the drivers of policy reflect the policy solutions proposed. For example, if a focus on governance challenges is driving new initiatives, the solutions may result in lesser community ownership of schools and poor connect between parents and frontline staff. A focus on hiring of staff at UPHCs may prioritise setting up of systems which make it easy to hire over identifying those candidates who are comfortable with working at the primary care level. If policy emerges only when a small group of stakeholders push for it, say only senior bureaucrats at the state level, or top politicians, or just civil society led social movements, without engagement with other groups, both the ideas in the policy and the support it gets in its implementation would miss out critical components. Third, the very process of policy making is not just about proposing a solution to a problem, it is also about building consensus on the ground level challenges which are to be prioritised. Every actor within health and education sector, from the poor parents to the local leaders of teacher’s associations to the state-level education secretary has different perspectives. New initiatives work when there is convergence, in ideal cases, consensus, on the problem priority. If none of these happen, there needs to be at least some kind of bargaining between opposing groups around their disagreements. If the drivers of new initiatives are not inclusive, both the implementation of the solution as well as its value in solving the problem becomes complicated. For example, if an initiative prioritises providing pre-school education while parents want English speaking classes, then the initiative would not enhance the value of government schools to parents. Fourth, policy-making, just like much of social and political life around the world, runs on institutional and long-established pathways. When new health and education challenges emerge, at times they don’t get addressed because the old pathways cannot bring new challenges to light. For example in the Health sector, Maternal and Child health have been a part of policy focus for decades. It is difficult for issues of geriatric care, non-communicable diseases to gain prominence (and funding) for new initiatives. In recent years, insurance has been widely accepted solution to achieve UHC and the cost of strengthening primary health care has received lesser focus.

To improve outcomes, policy discourse must not just focus on budgets and program implementation, but ask deeper questions, why is that big, system focused initiatives in a state like Karnataka are limited and largely driven by external pressures and a limited cohort high state level actors.   

What we see in Karnataka, during the decade of 2014-2024 is that there have been very few initiatives which focus on strengthening elementary education and urban primary health care which are led and/or financed by the state government on its own. The few which are there have emerged due to a policy push from the central government and the restrictions imposed by a local policy context. Due to this, it is less likely for new initiatives to emerge which require significant increase in the state health and education budget or deep structural changes in hiring or accountability framework for frontline bureaucracy to emerge. Initiatives which are populist in nature and which can be used to create visibility for local political leaders are the possible ones. It’s the senior bureaucracy and political leaders who push for new initiatives with other pathways and stakeholders being less prominent, such as internal bureaucratic feedback, social movements, electoral pressures and expert bodies and commissions.

This particular configuration through which new initiatives emerge in Karnataka provides some insight about why it is not a world leader in public primary health and elementary education. Karnataka is not a poor state, or one without local capacities for policy ideation and implementation. It is a state where the drivers of policymaking are such that primary health and elementary education have not been focused by the state political and bureaucratic leaders over the last decade.

To improve outcomes, policy discourse must not only focus on budgets and program implementation, but ask deeper questions, why is that big, system focused initiatives in a state like Karnataka are limited and largely driven by external pressures and a limited cohort of high state level actors.