Populism and health policy: The case of community health volunteers in India

The Indian Community Health Volunteer (CHV) Scheme is a major large scale experiment in people's participation into primary health care. This study intended to elicit the origins, the formulation and decision making process and the implementation of this programme. The evolution of the CHV programme is a particularly striking example of the contradictions of participation policies in a populist regime. Political awakening of the rural masses makes it absolutely necessary to take action so as to re-direct a portion of state interventions for their benefit. But the determining influence of the dominant classes, in both political and intermediate level bureaucracy of the state apparatus, tends to divert most of the resources made available by the State from their initial object, while inevitable reforms are constantly delayed. Thus the development of a popular participation policy would seem to be the necessary complement to the centre's reform policies. Yet the implementation of this participation policy can be realized only through the intermediary apparatus which must be verified and reoriented. Participation policy is thus distorted in order to reinforce the patronage capacities of existing political apparatus. In its present configuration, the CHV programme would appear first as an effort to constitute a poor-people's medicine circuit, answering the aspirations awakened by a populist political system, and much less the springboard for collective mobilization of communities in order to master their own development. As a whole, the order of priorities has been deeply altered in the course of implementation. The curative action took precedence over preventive action; individual action over collective action. This distortion could be explained both by the nature of people's demand and by the prevalence of clientelism and patronage as mode of political control.