Being Insider-Outsider: Public Policy, Social Identity, and Delivery of Healthcare Services in India

Abstract The pivotal role of community level workers in the delivery of public services is well-recognized. But, they often fail to provide equal opportunities to all ‘eligible’ beneficiaries to utilize a variety of public services. Although several predisposing household factors are held responsible for inequalities in access to the public services, in recent times, one factor that has been recognised as critical to such unequal access to public services is the ‘exclusionary nature of social relations’ based on social identity embedded in the social life of village community. It is also argued that certain sections of the population are deprived of equal access to public services due to their social identity, which is different from service providers. However, the question remains–whether it is the social identity of users or providers of public services that is critical to unequal access to various services? What will be the extent of utilization of public services when the social identity of both users and providers of the services remain same? Do the social dynamics of the community life play any role in the delivery of public services? This essay addresses these questions in the context of delivery of integrated nutrition and healthcare services at the community level under the largest national flagship scheme of Integrated Child Development Services (ICDS). Drawing evidence from a larger sample survey of over 4000 household beneficiaries and 200 service providers, the essay sheds light on how the delivery of healthcare services is fraught with social injustice due to dominant socio-cultural norms around social identity despite the values of healthcare centres to cater to the health needs of all sections of society.