paper

EMERGING NORMS IN NATIONAL HEALTH GOVERNANCE: AN EXAMINATION OF NEW AUTHORITY STRUCTURES AND THE GROWING IMPORTANCE OF NEW FORMS OF GOVERNANCE IN INDIA
Sophia N. Johnson, Ph.D. Candidate
Division of Global Affairs
Rutgers, The State University of New Jersey
Paper prepared for ISA’s 49th Annual Convention: Bridging Multiple Divides
San Francisco, CA, USA, March 26-29, 2008
This is a working paper. Please do not cite without the written permission from the author, available at sophiaj@pegasus.rutgers.edu (03/25/2008)
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INTRODUCTION
The changing nature and role of the territorial state is a central preoccupation of postinternational thinking. James N. Rosenau coined the term "post internationalism" to describe "an apparent trend in which more and more of the interactions that sustain world politics unfold without the direct involvement of nations and states."1 Postinternational theory accounts for the centralizing and decentralizing tendencies on the world stage after 1945; for the shifting orientations that have been transforming authority relations among actors; and for the dynamics and structural bifurcation shaping the arrangements through which diverse actors pursue their goals.2 Under this framework, governance in general and national governance in particular has shifted. Governance can be defined as "the actions and means adopted by a society to promote collective action and deliver collective solutions in pursuit of common goals."3 National governance then, "is not only a consequence of domestic politics and structures but a cause … international relations and domestic politics…are so interrelated that they should be analyzed simultaneously, as wholes."4 Together, these terms apply to what Rosenau describes as the ‘mobius-web governance,’ which accounts for the diversity of micro-macro interactions that contribute to governance in both state centric and multi-centric worlds. Consequently, the dynamics of Rosenau’s described fragmegration, and perhaps especially the complexities inherent
1 Rosenau, James N. Turbulence in World Politics: A Theory of Change and Continuity. Princeton: Princeton University Press, 1990. pp. 6.
2 Rosenau, James N. Turbulence in World Politics: A Theory of Change and Continuity. Princeton: Princeton University Press, 1990. pp. 7.
3 Dodgson, Richard and Kelly Lee. "Global health governance: a conceptual review" in Global Governance: critical perspectives edited by Rorden Wilkinson and Steve Hughes. London: Routledge, 2002. pp. 93.
4 Ferguson, Yale H. and Richard W. Mansbach. Remapping Global Politics: History’s Revenge and Future Schock. Cambridge University Press, 2004. pp. 93.
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in the extensive disaggregation of authority it has fostered, brings forward the question of whether governance on a national scale can be achieved in the emergent epoch.
India is an important case for examining emerging norms in national health governance. While the locus of political authority is territorially bounded to sovereign states, national economic, social, and security relations have internationalized through key networks of international organizations, strategic alliances, and nonstate actors. This is especially true as we see what happens as long term global dynamics and short term immediate circumstances interact in such a way that any unexpected development can serve as a tipping point and trigger collective actions seeking to bring about basic changes.5 Old rules and arrangements that prevailed throughout the industrial era are giving way to new forms of governance, and without the presence of formal state or interstate institutions. Some states have yielded to the pressures of new actors and have cooperatively formed both formal and informal relationships, an avenue through which the spreading of norms is translated into mechanism of governance.6 Health governance is broadly interpreted as the "action and means adopted by a society to organize itself in the promotion and protection of health of its population."7 In turn, the "pressures generated by bottom-up governance has given rise to top down and side-by-side governance that has become a vast network encompassing all levels of governance and diverse flows of authority."8
5 Rosenau, James N. Distant Proximities: Dynamics beyond globalization. Princeton: Princeton University Press, 2003. pp. 291.
6 Rosenau, James N. Distant Proximities: Dynamics beyond globalization. Princeton: Princeton University Press, 2003. pp. 393.
7 Dodgson, Richard and Kelly Lee. "Global health governance: a conceptual review" in Global Governance: critical perspectives edited by Rorden Wilkinson and Steve Hughes. London: Routledge, 2002. pp. 94.
8 Rosenau, James N. Distant Proximities: Dynamics beyond globalization. Princeton: Princeton University Press, 2003. pp. 398.
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How India defines, let alone achieve national health governance in this emerging epoch, remains an enduring challenge. In this paper, I take a first step in analyzing the emerging debate by reviewing the meaning and defining the new features of national governance, and examining the changes in long standing patterns of national health governance in India, in particular. The study looks at the flux and transitions, and assesses the particular impacts on governance when national health is transformed through new authority structures - and the fundamental challenge this poses for promoting and protecting health in a strong nation-state is explained. From this point of departure, the theoretical context of this research lies at the intersection of governance and authority in global politics. In addition, I begin to analyze the future of governance, authority and health in developing countries, of various historical experiences with one central question: How do we account for the role of new authority structures, and should we envisage this as a normative change in governance?
RESEARCH DESIGN
This research undertakes a case study approach, with aims to examine the normative discourse on governance, authority and health across India. The overarching goal is to identify common factors that explain why and how these norms, in the form of network actors, are situated in a strong nation state. Defined here, networks are an international body of actors, which include international organizations, strategic alliances, and nonstate actors. Collectively, these arrangements deploy a form of authority whose effects are important for understanding not just the behavior of networks, but also for
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assessing the governance of states.9 In addition, the study seeks to draw lessons from the national health governance debate in India that might well improve governance in other sectors or countries. The study examines emerging norms in national health governance at three sites: Chandigarh, Punjab; Kolkata, West Bengal; and, Bhubaneswar, Orissa.
Rather than using large samples and following a rigid protocol to examine a limited number of variables, this case study involves an in-depth, longitudinal examination of India. The focus is on systematically collecting data, analyzing information and reporting the results. This research cuts across disciplines, and mixes quantitative and qualitative evidence to establish the reasons behind various aspects of national health governance. The data for this analysis will be abstracted from three key sources: first, my own comprehensive survey assessment of health governance; second, the 2006 World Bank Development Policy Review of India; finally, three recent Government of India reports: Eighth and Tenth Five-Year Plans, Census of India, 2001, and the Ministry of Health & Family Welfare annual reports of 1992-93 and 2005-2006. The objective is to define national health governance, and determine the role of new authority structures in health. In addition, I will examine whether new authority structures speak and act as the postinternational theory predicts.
First, since there is no one accepted methodology for quantifying governance indices, I rely on the World Bank’s Worldwide Governance Indicators (WGI) project, World Governance Assessment and the World Health Organization’s 26-baseline indicators, to compose my own governance assessment survey. My survey comprises 30 questions, and is divided into six parts: voice and accountability; political stability and
9 Cutler, Claire A. "Private international regimes and interfirm cooperation" in The Emergence of Private Authority in Global Governance by Rodney Bruce Hall and Thomas J. Biersteker (editors). Cambridge: Cambridge University press, 2002. pp. 23.
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absence of violence; network actor effectiveness; regulatory quality; rule of law; and, control of corruption. The questions were designed to provide insight into availability, reliability and validity of current data on network actor activity, and to further explain how different countries understand national health governance. The survey endeavors to capture opinions on governance perceptions, as perceptions may often be more meaningful than objective data, especially when it measures public faith in institutions.10 One-hundred surveys will be distributed to academics, officials in international organizations concerned with governance, health administrators, and representatives of both the private and public sectors in Chandigarh, Punjab; Kolkata, West Bengal; and, Bhubaneswar, Orissa.
Second, this study evaluates the role of emerging authority structures, beginning with a look at the World Bank’s India Development Policy Review (DPR) 2006 titled, "Inclusive Growth and Service Delivery: Building on India’s Success." The DPR is one of the World Bank’s core analytical tools. The report, produced by the Bank every few years, helps countries frame key development challenges.
Third, an important consideration for this study is to examine how the State, looking inward, views it own system of national health governance. For this, I turn to the Government of India (GOI). I will begin by reviewing the Eighth and Tenth Five-Year Plan’s published by the Planning Commission. These Plans have been instrumental for bringing about planned socio-economic development in India. Second, I will review the Census of India’s 2001 report, which estimated India had reached a benchmark 1.1
10 Daniel Kaufman, Aart Kraay, Massimo Mastruzzi. "Governance Matters VI: Aggregate and Individual Governance Indicators, 1996-2006. (July 2007) World Bank Policy Research Working Paper No. 4280. Uploaded 3/4/08 from Social Science Research Network http://papers.ssrn.com/sol3/papers.cfm?abstract_id=999979#PaperDownload
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billion population. This extraordinary figure also puts the combined populations of Punjab, West Bengal and Orissa at 141 million. Due to the sheer size of the citizenry in these states, I will examine the extent to which new authority structures in the periphery cannot be ignored. Finally, the Ministry of Health & Family Welfare 1992-93 and 2005-2006 reports will be examined to assess emerging dimensions of governance in health and development. Immediately following the 1991-economic reforms, the World Bank was the principle network actor contributing to health. By 2005-2006 however, international cooperation in health from external agencies more than quadrupled for the Ministry of Health & Family Welfare.
LITERATURE REVIEW
Until recently, most explanations of international behavior have concentrated on the self interested motivations of individual states, with little recognition by states of the authority of new structures operating in the system. The literature wrestles with the complexity of governance, and forces an examination of actions within and between states. Just as the market and the state have their supporters, normative action is sometimes advocated as a simple remedy for a wide range of governance problems.11 The rules defining such organization and its functioning can be formal or informal to prescribe and proscribe behavior.12 The governance mechanism employed in this process can in turn be situated at the local, national, regional, international and the global level.
11 Dreze, Jean and Amartya Sen. India: development and participation. Oxford: Oxford University Press, 2002. pp. 60.
12 Dodgson, Richard and Kelley Lee "Global health governance: a conceptual review" in Global governance: critical perspectives edited by Rorden Wilkinson and Steve Hughes. London: Routledge, 2002. pp. 94.
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In other instances, national health governance may rely on mechanisms such as custom, common law, cultural norms, and values that are not legally formalized.13
This notion of national authority derives from Weberian conceptions of the state. There is a presumption within much of international relations theory, that the domain of the domestic is fundamentally different from the domain of the international. For Weber however, the essence of the state is its ability to claim "the monopoly of the legitimate use of physical force within a given territory." Because of their claims to legitimate authority, most states "can rely on the habitual obedience of their citizens by establishing legal codes in which the threat of physical coercion is only implicit."14 This ability to rely upon legitimate authority for habitual obedience is largely absent in the international system however. Instead, international politics takes place in a realm where anarchy reigns and states act in their own best interest and sometimes employ force to achieve their objectives. States are both the source and exclusive location of legitimate public authority.15 In sum, the state is no longer the leading force providing advantage to regions, ethnic groups and classes in health. India, in common with an increasing number of states responds to issues produced by uneven economic development and social change with the support of network actors.
13 Dodgson, Richard and Kelley Lee "Global health governance: a conceptual review" in Global governance: critical perspectives edited by Rorden Wilkinson and Steve Hughes. London: Routledge, 2002. pp. 94.
14 Hall, Rodney Bruce and Thomas J. Biersteker. "The emergence of private authority in the international system" in The emergence of Private Authority in Global Governance. Edited by Rodney Bruce Hall and Thomas J. Biersteker. Cambridge: Cambridge University Press, 2002. pp. 3.
15 Hall, Rodney Bruce and Thomas J. Biersteker. "The emergence of private authority in the international system" in The emergence of Private Authority in Global Governance. Edited by Rodney Bruce Hall and Thomas J. Biersteker. Cambridge: Cambridge University Press, 2002. pp. 3
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Globalization also challenges the state-centric system of health governance.16 Through network actors, health goals have been redefined in terms of interests, and these interests, associated with the state, seek not only to survive but also to achieve viability and protection of what they deem to be their core public values. There are agreements on a range of formal and informal matters which support this argument. Others acknowledge the challenges, but suggest the focus should be on finding a better way to identify actors who should be taken as ‘authoritative.’ According to Friedman, being public, does not imply that a state or structure within must be involved, or be wielding authority.
THE POSTINTERNATIONAL MODEL
What follows, in other words, consists of theoretical claims rather than empirical proof. As such, it offers readers a choice: they can dismiss the delineation of a postinternational politics as absurd speculation, or they can allow for the possibility that the claims are sufficiently plausible to justify consideration as a basis for interpreting the course of events.17
As the above quote imply, the structures and processes depicted by this paradigm are still in the process of taking shape. However, "postinternational politics" is an appropriate marker for the changes taking place because it highlights the decline of long-standing patterns.18 Postinternational theory also represents a break with realism and neorealism in the analysis of politics. In this section, I address some foundational questions relating to postinternationalism.
16 Dodgson, Richard and Kelley Lee "Global health governance: a conceptual review" in Global governance: critical perspectives edited by Rorden Wilkinson and Steve Hughes. London: Routledge, 2002. pp. 97.
17 Rosenau, James N. Turbulence in world politics: a theory of change and continuity. Princeton: Princeton University Press, 1990. pp. 3.
18 Ferguson, Yale H. and Richard W. Mansbach. Remapping Global Politics: History’s Revenge and Future Shock. Cambridge: Cambridge University Press, 2004. pp. 18.
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What are the sources of change for postinternational theorist?
According to Rosenau, the ever-growing interdependencies of economic, political and social life have been hastened and refined by five parametric transformations, as evidenced in India. The first source of change represents a shift from the largely industrial to postinternational order. As noted journalist T. Friedman recounts from a journey to India, globalization changed core economic concepts.19 He argues that the world is ‘flat,’ in the sense that globalization leveled the competitive playing fields between industrial and emerging market economies. Indian companies have become integral parts of a complex global supply chain for American-based corporations. This makes the "interdependence of people and events so much greater."20 A second source of change is evidenced in the emergence of world issues. For example, AIDS, TB, malaria and other environmental issues in India have been globalized, and are distinguished from traditional political issues by virtue of them being transnational rather than local in scope.21 A third dynamic is the reduced capacity of states and governments like India to provide satisfactory solutions to the major issues on their political agendas. For health, "authority does not necessarily have to be associated with government institutions."22 For example, the SARS epidemic highlighted both how easily new diseases spread and how effectively they can be identified and controlled by medical experts working in
19 Friedman, Thomas. The World is Flat: A brief history of the twenty-first century. New York: Farrar, Strauss, and Giroux, 2005.
20 Rosenau, James N. Turbulence in world politics: a theory of change and continuity. Princeton: Princeton University Press, 1990. pp. 12.
21 Rosenau, James N. Turbulence in world politics: a theory of change and continuity. Princeton: Princeton University Press, 1990. pp. 13.
22 Hall, Rodney Bruce and Thomas J. Biersteker. "The emergence of private authority in the international system" in The emergence of Private Authority in Global Governance. Edited by Rodney Bruce Hall and Thomas J. Biersteker. Cambridge: Cambridge University Press, 2002. pp. 5.
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Fourth, with the weakening of whole systems, subsystems have acquired greater coherence and effectiveness, fostering tendencies towards decentralization. National health governance may now rely on informal mechanisms such as custom, common law, cultural norms, and values that are not legally formalized.Finally, Rosenau suggests there is a new feedback mechanism, which links actors to consequences. "With their analytic skills enlarged and their orientation toward authority more self-conscious,"groups, states, and other collectivities can demand social adjustments from either network or state actors. tandem with government and WHO.23 24 25
The postinternational model is then not based on a single-cause, static model. Rather, these sources of change are seen as responses to the upheavals that underlay the ever-growing independencies of economic, political and social life.
What theoretical tools should we use to approach the postinternational experience?
Theories are filtered through and colored by a kaleidoscope of preferences and perceived interests, expectations, normative commitments and personal experiences.26 The great realist and neorealist debates insist that network actors, as we have been discussing, are endogenous. However, non-realists envision a world where competition in the international arena is less fierce than on the domestic front; hence, institutions in maladapted states can survive for decades and centuries. This section goes beyond the theoretical and epistemological rationality of realist and non-realist arguments, and
23 Ferguson, Yale H. and Richard W. Mansbach. Remapping Global Politics: History’s Revenge and Future Shock. Cambridge: Cambridge University Press, 2004. pp. 280-81.
24 Dodgson, Richard and Kelley Lee "Global health governance: a conceptual review" in Global governance: critical perspectives edited by Rorden Wilkinson and Steve Hughes. London: Routledge, 2002. pp. 94.
25 Rosenau, James N. Turbulence in world politics: a theory of change and continuity. Princeton: Princeton University Press, 1990. pp. 13.
26 Ferguson, Yale H. and Richard W. Mansbach. Remapping Global Politics: History’s Revenge and Future Shock. Cambridge: Cambridge University Press, 2004. pp. 35.
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instead considers constructivism, an alternative approach that offers meaningful explanations of postinternational politics.
The general constructivist is focused on the role of individuals as units of analysis in global politics.27 Constructivists emphasize that actors and their environments are mutually essential, and they are generally unwilling to separate actors from their environment even for analytic purposes.28 As R. B. Hall puts it, "changes in the collective identity of societal actors transform the interests of relevant collective actors." In addition, "group interests are strongly conditioned by the self-identifications of members of these groups with respect to other groupings."29 The degree of influence varies according to the context, and factors such as nature of polity, systemic distribution of capability and attitudes, and personality of leaders must also be considered.
Constructivists make a methodological bet that by focusing on the processes of socialization, in which agents and structures are mutually essential, they can explain important patterns and features of politics. At one extreme is Waltz’s parsimonious model in which the overall distribution of states’ power capabilities accounts for everything of importance. At the other end, scholars consider Gramsci’s endogenous position that everything is dependent on everything else. Intellectuals, Gramsci write, are the dominant group who exercise the subaltern functions of social hegemony and political government.30 This union of social forces serves as a ‘historic bloc,’31 which forms the
27 Ferguson, Yale H. and Richard W. Mansbach. Remapping Global Politics: History’s Revenge and Future Shock. Cambridge: Cambridge University Press, 2004. pp. 49.
28 Lake, David A. and Robert Powell, editors. Strategic Choice and International Relations. Princeton: Princeton University Press, 1999. pp. 32.
29 Ferguson, Yale H. and Richard W. Mansbach. Remapping Global Politics: History’s Revenge and Future Shock. Cambridge: Cambridge University Press, 2004. pp. 50.
30 Gramsci, Antonio. Selections from the prison notebooks edited and translated by Quintin Hoare and Geoffrey Nowell Smith. New York: International publishers, 1971. pp. 12.
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basis of consent to social order, and which produces and reproduces the hegemony of the dominant class through a nexus of institutions, social relations and ideas.32
J. G. Ruggie and his colleagues33 offer another branch of constructivism, which accept the ‘subjective aspects’ of decision-making and the impact of actors’ behavior upon structures and trends. Constructivists of this mindset are especially interested in formal and less-formal international regimes and forms of governance.34 The argument here is that the actors that make up the system are themselves changing as they develop new conceptions of identity and political community. For example, the rise of nationalism in India significantly transformed the character and identity of people after independence. Similarly, new conceptions of identity and political community may result in different normative values at the local or national levels.
Not all constructivism is helpful for examining postinternational politics. For example, A. Wendt’s constructivism, while highlighting the role of ideas and perceptions in shaping behavior, shares the conservative realist school of state primacy. He writes: "It may be that nonstate actors are becoming more important than states as initiators of change, but system change ultimately happens through states."35 In this context, states are at the center of the international system, and ‘anarchy’ is still what states make of it.
31 Gramsci borrows the term ‘historic bloc’ from French philosopher George Sorel (1847-1922), who held that the only way for change to occur, was through the application of force. For example, a general strike can serve to enforce solidarity, class-consciousness, and ‘energize’ the working class.
32 Gramsci, Antonio. Selections from the prison notebooks edited and translated by Quintin Hoare and Geoffrey Nowell Smith. New York: International publishers, 1971. pp. 13.
33 This branch of constructivism emerges from the collective writings of Ruggie and his colleagues Nicholas Onuf and Fredrich Kratochwil. However, its origins are based on the works of Durkheim and Weber.
34 Keohane, Robert O. After Hegemony: Cooperation and Discord in the world political economy. Princeton: Princeton University press, 1984. pp. 78-80.
35 Ferguson, Yale H. and Richard W. Mansbach. Remapping Global Politics: History’s Revenge and Future Shock. Cambridge: Cambridge University Press, 2004. pp. 51.
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For example, states that wish to survive are rational, in a sense that if you change the nature of states or their interactions, their ‘identities’ and ‘practice’ will change as well.36
The central preoccupations of the constructivist approach are what make it useful for postinternational analysis, and developing India’s social context. Core concepts acquire meaning through examining how people act, and that meaning evolves through this understanding of actions and belief. Constructivism gains explanatory power through its emphasis on identity and interest construction, and this allows for alternative explanations of global politics. For example, like liberals, constructivists also "insist on the importance of social processes that generate changes in normative beliefs, such as those prompted by the antislavery movement of the nineteenth century, the contemporary campaign for women’s rights as human rights, or nationalist propaganda."37 In addition, even though concrete advice can sometimes be hard to find, constructivism is particularly important for international relations theory as a mitigating factor for precipitant approaches put forward by the realist paradigm. Finally, constructivism ranges outside of paradigmatic boundaries, which enables it to prove that self-help and anarchy are not conditions that antecede international relations, but that are a creation – a construction.
Punjab, Orissa and West Bengal
Authority and power are closely related, however, authority in postinternational analysis is used to refer to institutionalized forms of expression of power.38 What
36 Wendt, Alexander. Anarchy is what states make of it: the social construction of power politics. International Organization, Volume 46, No. 2. (Spring 1992). Pp. 391-425.
37 Ferguson, Yale H. and Richard W. Mansbach. Remapping Global Politics: History’s Revenge and Future Shock. Cambridge: Cambridge University Press, 2004. pp. 51.
38 Rosenau, James. Turbulence in world politics: a theory of change and continuity. Princeton: Princeton University Press, 1990. pp. 11.
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differentiates authority from power is the legitimacy of claims of authority. On the one hand, having legitimacy implies that there is some form of normative, un-coerced consent, or "the normative belief by an actor that a rule of institution ought to be obeyed."39 On the other hand, postinternational theorists make the argument that change is taking place within different frameworks of authority. "Self-interests have readily become equated to national interests, good citizenship to unthinking loyalty and automatic compliance with established authority."40 The experiences of Punjab, Orissa and West Bengal are especially interesting, as they provide insight into the possibilities and limitations of a particular strategy of change.
Punjab has the best infrastructure in India.41 Excluding agriculture, other major industries include manufacturing and tourism. However, rural development is the parameter of growth-oriented change. Traditionally rural areas have had limited access to infrastructural development, because cycles of poverty continues to haunt the countryside.42 District level rural development agencies have been established as nodal agencies for the implementation of centrally sponsored schemes especially anti-poverty programs per the guidelines of Government of India. The Center and the state government fund the schemes, which began as early as 1999. There is also a proliferation of anti-poverty initiatives in the rural regions, which raises the question of how and why are network actors emerging.
39 Hall, Rodney Bruce and Thomas J. Biersteker. "The emergence of private authority in the international system" in The emergence of Private Authority in Global Governance. Edited by Rodney Bruce Hall and Thomas J. Biersteker. Cambridge: Cambridge University Press, 2002. pp. 5.
40 Rosenau, James. Turbulence in world politics: a theory of change and continuity. Princeton: Princeton University Press, 1990. pp. 88.
41 www.india.gov.in
42 Government of Punjab – 11th Five Year Plan. www.punjabgov.nic.in PDF file, pp. 91
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The role of multilateral actors in health governance is critically important for Orissa. As the state having the second lowest per capita income in the country, Orissa is part of an underdeveloped region. After independence, and in the absence of an industrialization program, the upper class (as in upper castes) was the first to take advantage of social and economic opportunities. At the same time, other groups struggled for subsistence and were never able to come up as competing forces. Today, the Department for International Development (DFID), UNICEF, and the World Bank heavily fund Orissa and are of great importance to the social and economic infrastructure. To address the emerging need of health, Orissa has encouraged new forms of actors. "There is a clear need to break through traditional boundaries within the government sectors, between governmental and non-governmental organizations and between public and private sectors."43
These arguments for social intervention are made in light of the fact that the standards of public services in India are abysmally low. The state is embracing the promotion of social concerns, because new authority structures effectively provide access to social services. India benefits Dreze writes, from "the universalization of basic entitlements to health care, elementary education and social security is perhaps the most significant social achievement of western ‘market economies’ in the twentieth century."44 It also follows that in postinternational politics the relevant actors are closely linked with the relevant networks, and are prone to cross the private-public divide by mobilizing
43 Government of Orissa: Report on Activities of Health and Family Welfare Department, Bhabaneswar- 2003-2004. Addendum – Private Partnership (PPP) in Health Sector, Scheme 1-Management of PHC, A Guideline. Pp. 1.
44 Dreze, Jean and Amartya Sen. India: Development and Participation. New York: Oxford University Press, 2002. pp. 43.
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mass publics as well as elites on behalf of the values at stake.45 The collaborations embarked upon in Orissa, promote people oriented policies for the Government of Orissa, Department of Health and Family Welfare, and also, provide a platform to manage, implement, and promote preventive health services in the underserved and hard to reach community groups.46
West Bengal is unusual, and indeed one of the most unique states in the country. It is the only of the states in India to have been ruled continuously (since 1977) by a Left front government for more than a quarter of the century. This government has in turn been motivated by a vision of political, economic and social change that has been different from that observed amongst most other state governments or the central government.47 Moreover, this has resulted on a focus of two specific, but inter-related strategies at the state level: land reform, including both greater security of tenure to tenant cultivators and redistribution of vested land; and, decentralization and people’s participation through Panchayat institutions.
IMPLICATION OF STUDY
There are several crucial entry points through which an evaluation of new forms of governance can be made. The first lies in understanding why actors behave the way they do. An argument can be made that the behavior of actors is a consequence of widespread dissatisfaction with large-scale collectivities and the performance of existing authorities underscores the need to look for organizations that are more fully embracing.
45 Rosenau, James N. Distant Proximities: Dynamics beyond globalization. Princeton: Princeton University Press, 2003. pp. 398.
46 Government of Orissa: Report on Activities of Health and Family Welfare Department, Bhabaneswar- 2003-2004. Addendum – Private Partnership (PPP) in Health Sector, Scheme 1-Management of PHC, A Guideline. Pp. 1.
47 West Bengal Human Development Report, 2004. Online PDF file. Chapter 1, pp. 1.
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Relevant here is the fact that the process of globalization has given citizens more access to information, which in turn has enabled them to join in collective actions that serve as avenues for expressing their discontent.48
Second, the state-centric world has undergone substantial expansion, and this has contributed to exponential increase in actors in the multi-centric world. According to Rosenau, the sheer number of movements has been a prime stimulus to the evolution of new loci of authority in the multi-centric world, and to the authority crisis that have wracked the state-centric world.49
Third, two level games also provide a way to evaluate politics. According to Putnam, state leaders in such games consider both the international and domestic audiences for their policies. They choose policy to satisfy both domestic and international conditions. The negotiation of treaties under the pressure of ratification is the common example of a two-level game. Negotiators must consider what treaties can be ratified when they negotiate. They do not have complete freedom to pursue their nation’s interests as they define it. Instead, they must keep an eye over their shoulder for what domestic groups will accept.50
From this point of departure, the implication of this study reaches beyond the 141 million Indians living in Punjab, West Bengal, and Orissa.51 Taken together, these states depict a world in which new authority structures either oppose or support the historically framed national structure. This study broadens the scope of analysis to account for
48 Rosenau, James D. and Mary Durfee. Thinking theory thoroughly: coherent approaches to an incoherent world, second. Oxford: Westview Press, 2000. pp. 62.
49 Rosenau, James D. and Mary Durfee. Thinking theory thoroughly: coherent approaches to an incoherent world, second. Oxford: Westview Press, 2000. pp. 62.
50 Putnam, Robert D. "Diplomacy and Domestic Politics: The Logic of Two-Level Games," International Organization, vol. 42, No. 3 (Summer 1988), pp. 427-60.
51 Data according to 2001 census: Punjab, 24 million; West Bengal 80 million; Orissa, 37 million. Total population for three states: 141 million.
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among other key issues, shifting orientations that have been transforming national governance and health authority. The proliferation of new authority structures is epiphenomenal of elements of power relationships as described above however, new forms of governance also underscore the interconnectedness between economic development, public action and social progress.52 The dynamics of governance are intricate, and overlap several levels to form a singular, weblike process, which like a mobius neither begins nor culminates with the passage of a law or compliance with its regulations. The choices of many network actors determine outcomes in national politics because collectively, these arrangements deploy a form of authority whose effects are important for understanding not just the behavior of actors, but also for assessing the governance of states.53 As described by Wapner, "all of these actors devote themselves exclusively to setting up institutions to guide behavior with regard to public issues, thus clearly indicating the social function of governance."54 For Cox, these structures extend the range of stakeholders, diversify social goals, and produce greater complexity for the institutions where action takes place. This new perspective suggests authority structures govern by lending themselves both to the representations of diverse interests and to the universalization of policy.
52 Dreze, Jean and Amartya Sen. India: Development and participation. Oxford: Oxford University Press, 2002. pp. 83.
53 Cutler, Claire A. "Private international regimes and interfirm cooperation" in The Emergence of Private Authority in Global Governance by Rodney Bruce Hall and Thomas J. Biersteker (editors). Cambridge: Cambridge University press, 2002. pp. 23.
54 Wapner, Paul "Governance in global civil society" in Global Governance: Drawing Insights from the Environmental Experience. Oran Young (ed). MIT Press, p 80.
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