Understanding Drivers of Government Initiatives in Primary Health and Elementary Education

Executive Summary

India has made significant strides in reducing poverty over the past two decades. Yet, its health and education indicators have fallen behind global standards, hindering labour productivity, GDP growth, and overall well-being. This policy brief examines the key drivers influencing government initiatives in health care and education, highlighting the need for prioritisation amid competing fiscal demands. The brief identifies systemic gaps, such as inadequate funding, poor service quality, and weak demand from marginalised populations. It argues that while economic liberalisation since the 1990s has spurred GDP growth and welfare measures, achievements in basic health and education remain suboptimal. Budget allocations tend to be overwhelmed by salaries over items that would enable quality of delivery, contributing to high enrolment but dismal learning outcomes. Urban areas face particular neglect, with a 39.7% shortfall in Urban Primary Health Centres (UPHCs) and only 30.1% government school enrolment in cities versus 66% in rural areas (National Sample Survey [NSS], 2025). Rapid urbanisation, projected to double India’s urban population by 2050 and drive 70% of GDP growth, underscores the urgency for affordable, high-quality services for poor migrant households.

The question of why initiatives in these sectors remain limited despite strong economic rationales for greater investment deserves greater attention. At the central level, infrastructure, defence, subsidies, and rural development compete for funds, overshadowing health and education. State-level efforts focus on operational efficiency rather than budget expansion, often driven by electoral appeal rather than addressing core challenges. Financial stress constrains ambitious outlays, but this does not fully explain the neglect. A critical factor is the weak demand side: poor households, preoccupied with daily survival, exhibit behaviour driven by managing scarcity and a focus on immediate priorities. The poor, therefore, rarely mobilise for better services, while non-poor households have largely abandoned public systems, opting for private alternatives. This exodus reduces political pressure for improvements, unlike in sectors like roads or electricity, where non-poor stakeholders drive demand.

Moreover, policies emphasise access over quality, with new schools and PHCs offering visibility in electoral manifestos but failing to ensure high-quality services. Urban governance exacerbates issues, as municipal corporations lack fiscal power under the 74th Constitutional Amendment, leaving health and education functions underdeveloped compared to rural Zilla Panchayats.

The brief places special emphasis on recommended drivers for meaningful policy actions, advocating a multifaceted approach to catalyse change. Central to this is re-engaging non-poor households in public systems to create vocal constituencies for quality improvements. Highlighting successful government facilities and the link between quality of delivery and outcomes, through the dissemination of relevant findings, can position them as viable alternatives to private ones, fostering demand-side pressure similar to other public services.

Policy advocates and civil society must package initiatives with electoral appeal. Examples include Rajasthan’s well-functioning UPHCs with quality certifications, which outperform private counterparts but remain under-promoted. Initiatives should respect budget constraints, prioritising low-cost, high-impact measures in the short term while pushing for increased central allocations.

Addressing ground-level gaps requires targeted, understandable proposals with popular resonance. In primary health care, recommendations include: (i) mandating 24/7 operations for all urban PHCs to handle emergencies and deliveries; (ii) introducing evening OPDs staffed by private doctors for accessibility; (iii) adding branded medicines for non-communicable diseases (NCDs); and (iv) refurbishing select community hospitals to match private standards. For elementary education: (i) hiring qualified English teachers to meet aspirations; (ii) upgrading infrastructure to private school levels; (iii) integrating nursery classes in primary schools; and (iv) awarding schools that achieve foundational literacy and numeracy.

To amplify impact, it is important to link expenditure and investments to outcomes through extensive studies on lifestyle and economic benefits, emphasising both wealth creation and aspirations. This evidence can inform political messaging on how improving the quality of health and education services contributes to better lifestyles and higher income gains. A novel “Diversity Index” proposed by Singh (2025a) in a recent CSEP working paper titled “Drivers of Primary Healthcare and Elementary Education Initiatives in Karnataka (2014–2024))” is further recommended for measuring economic diversity in facility uptake (e.g., poor vs non-poor) alongside inputs and outcomes. For schools, this could include learning levels and infrastructure; for PHCs, utilisation, 24/7 operations, deliveries, and immunisation rates. Such an index would guide resource allocation, empower civil society advocacy, and provide politicians with metrics for messaging, akin to successful rankings like the Swachh Survekshan or the Annual Status of Education Report (ASER) state comparisons.

In conclusion, the brief urges policy advocates, civil society, and the bureaucracy to prioritise visible, electorally attractive initiatives that bridge supply-demand gaps and reiterate the importance of quality. By re-integrating non-poor users, leveraging budget-realistic proposals, and using tools like the Diversity Index, governments can drive sustainable improvements in health and education, ultimately fostering inclusive growth and well-being.