Poor health: Credit and blame attribution in India’s multi-level democracy

• Satisfaction with health services affects how voters attribute policy responsibility to different levels of government within a federal system. • Less satisfied voters are more likely to misattribute responsibility – or to blame – local government when things go badly. • State and national governments receive credit from voters who are satisfied with services but are not punished by those who are dissatisfied. • A key link in the chain of electoral accountability for health is missing in India. Lines of accountability for the provision of health services in many federal systems are complex. Institutional structures and political strategies that blur lines of responsibility make it more difficult for voters to claim their rights, to assign responsibility and reward or sanction governments on the basis of their performance. Based on a survey of 1500 voters across five states in India, this paper examines how voters attribute credit and blame for health system performance. In India, central, state and local governments are involved in the delivery and financing of different elements of health care provision from running hospitals, providing health insurance to running vaccination programmes. Contrary to expectations, we find that most voters can broadly attribute responsibility to the relevant level of government for different health services and programmes, however a significant minority consistently misattribute responsibility by holding the local government responsible. We find that perceptions of health system performance matter more than partisanship in explaining when voters hold different levels of government responsible. Those who are less satisfied with the health system are more likely to blame the local government for poor performance, even where it is not constitutionally responsible. This suggests that state and national governments receive credit from voters who perceive services as functioning well but are not punished by those who are dissatisfied. In other words, political leaders are able to capture credit among voters who are more satisfied with health provision while deflecting blame from those who are less satisfied. These findings demonstrate important weaknesses in the chain of electoral accountability for health. The paper suggests possible parallels to authoritarian contexts such as China where recent research has shown that strong centralised political leadership claims credit for public goods provision while deflecting blame for corruption and inefficiency to lower levels of government.