Drivers of Primary Healthcare and Elementary Education Initiatives in Rajasthan (2014–2024)

Executive Summary

This study examines the drivers of state-level initiatives in primary health care and elementary education in Rajasthan during 2014–2024, focusing on urban areas.

Rajasthan has made impressive strides in improving health and education outcomes. During 2014–2024, on many critical indicators such as Infant Mortality Rate (IMR), Under-5 Mortality Rate (U5MR), and class VIII language and mathematics outcomes, Rajasthan pulled itself up into the above-the-national-average category. It is a poor state whose PCI has consistently remained below the national average during this decade. Moreover, growth in the average net PCI of Rajasthan was lower than that of India during 2014–2024. Yet, Rajasthan continued to improve its health and education status.

Rajasthan’s case is insightful because it has had a long history of progressive social movements. These took up some of the most entrenched social issues, such as the empowerment of women, tribal groups, Dalits, and rights-based demands for food, work, and accountability. These movements contributed to key national-level legislations. For example, the Supreme Court’s Vishakha Guidelines, the Right to Information, the Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGA), and most recently, the Right to Health have benefitted from movements originating in Rajasthan. Were civil society groups the key actors driving the improvements in Rajasthan’s health and education outcomes in recent years? We explore these issues through our research question: Why and when did Rajasthan undertake state-level initiatives for primary health and elementary education in urban areas during 2014–2024?

Our study is broken into three broad sections. First, we examine the number and nature of initiatives. We selected initiatives that have been either funded or ideated by the state. We also discussed stock of the trends in the budget allocation to the health and education departments during this period. Second, we examine the objectives and the strategies of the initiatives and see whether they align with the ground-level challenges facing Urban Primary Health Centres (UPHCs) and elementary schooling. Third, we examine the drivers of initiatives, which include identifying the actors who led them.

Our findings highlighted that in Rajasthan, health and education budget allocations and expenditures, state-level initiatives, problems prioritised by the initiatives, and the challenges that the schools and UPHCs face at the ground level are not aligned with each other. For example, declining expenditures coexist with a high number of initiatives in education. To understand how these components connect and explain why and when Rajasthan undertook state-level initiatives, we identify four constructs: Policy Universe, Policy Priority, Policy Focus, and Policy Action.

Policy Universe refers to the set of institutions and potential mechanisms through which policy operates. It has five components: (a) health and education budget allocations; (b) state-level initiatives; (c) routine but large infrastructure upgrades and hiring across a majority of facilities; (d) specific problems or challenges that the initiatives focus on; and (e) the challenges that the facilities face in their everyday. The Policy Universe can exist in one of the three ways, namely, Policy Focus, Policy Action, and Policy Prioritisation, which are discussed below.

Policy Focus is when new initiatives, budgets, and routine activities undertaken by the state-level bureaucracy (such as hiring and infrastructure upgrades) are aligned with solving important ground-level challenges. This makes the Policy Universe aligned and convergent.

Policy Action refers to a situation in which many new initiatives, budget increases, and/or routine activities are being undertaken by the state-level bureaucracy, but they are less important in solving critical challenges related to the on-the-ground functioning of UPHCs/schools. This makes the Policy Action misaligned and divergent.

Policy Priority happens when (a) budgets align with health and education services at the ground level; (b) health and education services and facilities tap into the expanding needs of the population that are either being serviced by the private sector or remain unexpressed; (c) new initiatives emerge that tackle the difficult problems of quality of care/teaching and training; and (d) there is an ongoing vision of the role of public provision of health and education for all strata of society, one that is implementable and owned by all stakeholders in the system, such as bureaucrats, political leaders, and civil society groups.

In Rajasthan, the policy universes of primary health and elementary education are fundamentally different. Expenditure for both health and education has declined between 2014 and 2024, but there have been initiatives in both these domains.

In primary health, out of a total of 11 state initiatives for the health sector, two focused exclusively on urban primary health: Urban Ayushman Arogya Mandirs (U-AAM), which were known as Janta Clinics (JCs) when they were established in 2019. The second initiative was the outsourcing of select UPHCs, which were facing staffing challenges, to external agencies in a Public–Private Partnership (PPP) mode. This initiative is no longer in operation. Additionally, UPHCs have received prominent infrastructure upgrades and staff hiring drives during the study period. Mukhyamantri Nishulk Dava Yojana (MNDY) and Mukhyamantri Nishulk Jaanch Yojana (MNJY)—two initiatives that look at the health sector as a whole—have improved the uptake of UPHCs. They provide free medicines and tests across public health facilities, including UPHCs. They have tackled the critical problem of high out-of-pocket expenditure (OOPE) for medical treatment.

In education, out of the 14 initiatives, none have focused on urban elementary schools. Many have focused on the education sector as a whole or on elementary education for both rural and urban areas together, such as the State Initiative for Quality Education (SIQE), Free Uniforms, and Free Textbooks. Initiatives that focus on education include model school initiatives, such as Adarsh Schools, Mahatma Gandhi English Medium Schools (MG English Medium Schools), Shala Darpan (SD), and Gyan Sankalp.

We find that Rajasthan’s Policy Universe in primary health is one of Policy Focus; it is convergent and aligned. In contrast, the Policy Universe in elementary education is one of Policy Action, and it is divergent and misaligned.

The policy universes of both primary health and elementary education are driven by an interplay of contextual factors and key stakeholders. Rajasthan’s socio-economic context is such that, historically, health has been considered more important than education within policy circles. COVID-19 reinforced the focus on publicly provided health care. For elementary education (particularly in urban areas where the poor who lost livelihoods sent their children to government schools), COVID-19 could not rebuild that trust.

The key actors driving the initiatives during 2014–2024 are the senior-most state-level bureaucrats and political leaders. Civil society organisations (CSOs), particularly those that have focused on community mobilisation, have been less prominent. The incentives and ambitions that drive the senior bureaucracy and political leadership are not always about solving the most critical education and health challenges. For senior bureaucrats, it is the professional dynamics—that is, the pressures they face within the bureaucracy on the one hand and their relationship with senior political leadership on the other—that shape their role in initiative-making. Professionally, senior bureaucrats often have very little time in the health and education departments, and they have to distinguish their tenure with distinctive contributions. These contributions have to align with the vision of the senior political leaders, which in turn has to align with the political imperatives of the day. Bureaucrats also have to work within the constraints of departmental capacity. They take up ideas and problems that can be addressed in a clear, visible manner. They need access to implementable solutions whose outcomes are not complex and are observable to all stakeholders and partners, who can support them in this process. This limits the scope to tackle the deeper, structural challenges that impact primary care and elementary education, for example, quality of care.

The incentives driving political leaders are related to the creation of brand identity and political capital during non-election periods and visibility during election times. Political leaders use health and education initiatives to create a brand for themselves as supporters of social welfare, which is a critical aspect of being seen as a leader. They also use these initiatives to build coalitions with groups that can help them during elections. Creating visibility of their own efforts, therefore, is an important political objective during the electoral period. Each of the initiatives that we found to be important meets this matrix of incentives of senior bureaucrats and political leaders. The alignment that has happened in primary health is a result of the benefits that some initiatives gave to the political leadership. Health and education do not win or lose elections, but they are important enough to generate responsiveness among senior political leaders during non-election periods. If a good initiative is discontinued or marginalised, elected political leaders have to take note based on the feedback they have received from the ground level. Curiously, in health, the initiatives have been such that successive regimes have not discontinued useful initiatives such as MNDY; however, this has not occurred in education.

We make four policy recommendations to improve the drivers of state-level policy initiatives. First, the limited focus on health and education in urban areas, particularly in education, is because a defined policy agenda on the challenges in urban areas—including those “distinct” and those “shared” with rural areas—is missing. It is important to understand what it is that the initiatives need to solve. Therefore, Rajasthan needs to define the agenda for urban health and education. For this, we recommend that a government-appointed commission be set up that would have clear, implementable outputs. The commission would define the urban health and education agenda and provide measurable steps and initiatives in the short run (1.5 years, which is the usual tenure of a health and education secretary), medium run (5 years), and long run (10+ years).

Second, one pathway that drives policy is demands from citizen constituents, particularly users of schools and UPHCs. In the present policy design, government primary care and elementary education facilities are primarily imagined as options of the last resort for the poorest of the poor, particularly in urban areas. In fact, large sections of the users of primary health and education facilities also come from this section of the population. It is important that these facilities should be used by a large section of the non-poor in the catchment areas of the facilities and have the resources to demand better quality services and drive more initiatives. However, within this stratum, government facilities are seen as being of poor quality. To address this, legitimacy needs to be created for both UPHCs and elementary schools beyond that of the urban poor. For this, the local UPHC and its services need to be advertised aggressively within its catchment area. Specific emphasis should be given to audit, quality, and performance reports and to highlighting the cost savings and quality of care to be gained by households if they access UPHCs.

In education, the requirement for school principals to raise funds should be removed, as this indicates to people that the state has given up on urban schools. Additionally, a hierarchy of basic requirements for school strengthening should be created. The weaknesses of the schools should be publicised with an action plan of what needs to be done in a phased manner and then accomplished. This process must be a widely publicised one. Once the key problems for urban elementary education are identified, they must be matched with solutions that can be implemented by the State machinery. It is most important that the State machinery is seen as the key and the only implementation pathway.

Third, there is a small cohort of actors, particularly for urban areas, that ideates policy: namely, the senior bureaucrats and political leaders. This limits both the range of ideas and partners on health and education for policymaking. It is important to invigorate CSOs that have historically played a defining role in highlighting challenges and policy ideas. There is already a model for engaging with civil society in Rajasthan. The Association for Rural Advancement through Voluntary Action (ARAVALI) is a state-supported platform that engages with non-governmental organisations (NGOs), research organisations, private sector bodies, and Panchayati Raj Institutions (PRIs) to address socio-economic challenges impacting rural areas. It particularly supports NGOs with capacity development and engages them to work in partnership with government initiatives. We need to replicate this model for urban areas as well.

Fourth, health and education outcomes are not the political responsibility at any level of government in Rajasthan. While providing formal roles for Members of the Legislative Assembly (MLAs) and Members of Parliament (MPs) may lead to over-politicisation, providing a pathway through which the state of schools and UPHCs in assembly and parliament areas is made visible to users, CSOs, and other actors can drive new initiatives. Creating assembly and parliamentary constituency-level profiles with data on the availability of health and education facilities and outcomes is one way to link political leaders with health and education outcomes in their areas.

We used qualitative methods in this study, conducting KIIs and reviewing government reports (Economic Survey, Project Approval Board [PAB] minutes, National Health Mission [NHM] Record of Proceedings [ROP]) and policy documents (state-level task force reports, Comptroller and Auditor General [CAG] Reports, Finance Commission Reports). Our analysis was conducted at four levels: state, selected districts, sub-district (i.e., taluka), and school/PHC. The study districts included one district in Central Rajasthan and another in South Rajasthan, each with a prominent urban centre under a municipal corporation. The two districts include one below and one above the state average in select health and education indicators. Key informants included state-district- and frontline-level health and education bureaucrats, civil society leaders, academics, policy researchers, journalists, engaged citizens, and ordinary users of health and education facilities.

This report is divided into five sections. In Section 1, we discuss Rajasthan’s social and economic indicators and its performance in health and education. In Section 2, we outline the questions this study addresses and argue for a focus on primary health and elementary education in urban areas. In Section 3, we detail the key methods used in this study, the study sites, and the analytical framework. In Section 4, we present the main findings of this study in four subsections. In the final section, we synthesize the arguments and discuss their implications for policymaking in health and education in Rajasthan, offering policy recommendations.