Using administrative data on over 4 million hospital visits, we document striking gender disparities within a government health insurance program that entitles 46 million poor individuals to free hospital care in Rajasthan, India. Females account for only 33% of hospital visits among children and 43% among the elderly. These shares are lower for more expensive types of care, and far lower than sex differences in illness prevalence can explain. Almost two-thirds of non-childbirth spending is on males. We combine these data with patient survey, census, and electoral data to show that 1) the program is unable to fully offset the costs of care-seeking, which results in disparities in hospital utilization because some households are willing to allocate more resources to male than female health; 2) lowering costs does not reduce disparities, because males benefit as much as females do; and 3) long-term exposure to village-level female leaders reduces the gender gap in utilization, but effects are modest and limited to girls and young women. In the presence of gender bias, increasing access to and subsidizing social services may increase levels of female utilization but fail to address gender inequalities without actions that specifically target females.

The Ladakh crisis between China and India seems to have settled into a stalemate, marked by somewhat reduced tactical tensions and continuing fruitless talks on disengagement—but its trajectory could again turn suddenly, even flaring into a limited conventional war. Despite a limited disengagement, both sides continue to make military preparations near the Line of Actual Control (LAC) to increase their readiness for potential conflict. While China proved its revisionist intent with its 2020 incursions, its specific goals and plans remain opaque. The broader political context is marked by distrust and hostility, and bilateral relations are at their lowest ebb in decades. War remains unlikely—both sides can ill-afford the distraction from higher national priorities and have demonstrated a recent keenness to step back from the brink. But, with growing capabilities and unclear intent, and with military operations no longer impaired by winter, the Ladakh crisis may still escalate to conflict.

The crisis has been full of surprises. Despite observing major military maneuvers in China, India didn’t anticipate the multiple incursions across the LAC in May 2020. For weeks thereafter, the Indian Army leadership insisted the incursions were nothing out of the ordinary. After both sides agreed to an early disengagement plan, the crisis took a shocking turn with a deadly skirmish in June — the first loss of life on the LAC in 45 years. India also mustered its own surprises, deploying troops to occupy tactically valuable heights in late August, to gain some bargaining leverage. And the crisis also abated with a surprise, with the sudden announcement of disengagement from heavily militarised stand-off sites around Pangong Tso Lake in February 2021.

Future surprises may yet occur. This paper argues that the risk of China–India conflict is significant because, even if its likelihood is low, its consequences may be considerable. A limited conventional war would be likely to impose significant costs on India, but, depending on the reactions of its partners, it may also reinforce latent Indian suspicions over the utility and reliability of its strategic partnerships. In that way, even a localized limited war on the LAC may have far-reaching implications, if it incidentally drives a wedge between India and its partners in the Quad. Mitigating that risk will require sound policy settings and astute diplomatic and public messaging from Canberra, Washington, Tokyo, and other like-minded capitals.

The remainder of this paper is in three parts: first, why a border war is plausible; second, what costs it would impose on India and how it might stir distrust of India’s Quad partners; and, finally, a framework to mitigate those risks.

This report uses a novel alternative futures methodology to demonstrate that India’s strategic preferences are not fixed but could vary discontinuously under different environmental conditions.

Main Argument

The method of major/minor trends developed in this report suggests that the roots of apparently surprising future behavior can be found in a close reading of a target state’s history. Using this method, the report outlines three unlikely but plausible alternative futures of India as a strategic actor. The first scenario envisions India as a Hindu-nationalist revisionist power hostile to Pakistan but accommodating of China; in the second, it is a militarily risk-acceptant state that provokes dangerous crises with China; and in the third scenario, India is a staunch competitor to China that achieves some success through partnerships with other U.S. rivals like Russia and Iran. These scenarios are designed not to predict the future but to sensitize U.S. policymakers to possible strategic disruptions. They also serve to highlight risks and tensions in current policy.

Policy Implications

The scenarios yield at least three major analytic insights that are relevant for today’s policymakers:

• India will continue to face difficult trade-offs in managing security threats from Pakistan and China. A redoubled strategic focus on Pakistan will almost certainly come at the expense of Indian capacity to compete with China in the Indian Ocean region.
• A more confident and risk-acceptant Indian military may inadvertently pose strategic threats to the U.S. The U.S. may feel compelled to support India in future crises involving China; or even absent such a commitment trap, India-China crises are likely to jeopardize regional stability.
• To effectively compete with China, the U.S. must prioritize its interests and adversaries. Successful competition against China may require the U.S. to tolerate or even tacitly support other erstwhile rivals.

In May 2020, China launched several near-simultaneous incursions across the Line of Actual Control (LAC) in Ladakh, into territory hitherto controlled by India. Both sides reinforced their positions with tens of thousands of troops, engaged in a deadly skirmish, and reportedly came close to war. An agreement to disengage troops was announced in February 2021, but implementation has been halting. Regardless of how disengagement progresses, the crisis poses significant challenges for India’s long-term strategic competition with China.

As a result of the Ladakh crisis, India faces a new strategic reality in which China is a clear and abiding adversary. For India, the political relationship is now defined by hostility and distrust, and the LAC will remain more heavily militarised and violence-prone. Given this new reality, India is likely to further defer military modernisation and maritime expansion into the Indian Ocean. In the face of unremitting Chinese naval expansion, India risks losing significant political and military leverage in the Indian Ocean. At the same time, China appears to have escaped significant harm. Its better-resourced military could better absorb the material costs of the mobilisation. It may have been more concerned by the prospect of an increasingly hostile India, but the disengagement agreement has limited even those modest political costs.

The central policy challenge for India is balancing the heightened Chinese military threat on the northern border with the rapidly growing Chinese military presence in the Indian Ocean. It can manage this challenge by focusing on military strategies of denial rather than punishment, focusing on imposing political rather than material costs on China, and accepting more risk at the LAC in exchange for long-term leverage in the Indian Ocean region. How India responds will shape not only its strategic competition with China, but also the interests of likeminded partners including Australia, which depend on an increasingly capable and active India.
 

Key Findings

• The still-unresolved Ladakh crisis has created a new strategic reality for India, marked by renewed political hostility with China, and an increased militarisation of the Line of Actual Control.
• This new strategic reality imposes unequal costs on India and China. India is likely to defer much-needed military modernisation and maritime expansion into the Indian Ocean — which would impair its ability to compete strategically with China.
• In contrast, China incurred only marginal material costs; it was probably more concerned with the prospect of continued deterioration in its relationship with India. Even that cost was more threatened rather than realised, and largely reduced when the disengagement plan was agreed.

In the Media

• ABC Radio
• The Hindu
• The Stimson Center's South Asian Voices (view also the related panel discussion below)

This paper describes and analyzes the quantitative results of the mixed-methods study by Eggleston and her colleagues. For the qualitative results of the study, read the June 2021 paper in the journal BMJ Open. Also, watch and read our full story and interview with Eggleston.

Background

People with chronic conditions are disproportionately prone to be affected by the COVID-19 pandemic but there are limited data documenting this. We aimed to assess the health, psychosocial and economic impacts of the COVID-19 pandemic on people with chronic conditions in India.

Methods

Between July 29, to September 12, 2020, we telephonically surveyed adults (n = 2335) with chronic conditions across four sites in India. Data on participants’ demographic, socio-economic status, comorbidities, access to health care, treatment satisfaction, self-care behaviors, employment, and income were collected using pre-tested questionnaires. We performed multivariable logistic regression analysis to examine the factors associated with difficulty in accessing medicines and worsening of diabetes or hypertension symptoms. Further, a diverse sample of 40 participants completed qualitative interviews that focused on eliciting patient’s experiences during the COVID-19 lockdowns and data analyzed using thematic analysis.

Results

One thousand seven hundred thirty-four individuals completed the survey (response rate = 74%). The mean (SD) age of respondents was 57.8 years (11.3) and 50% were men. During the COVID-19 lockdowns in India, 83% of participants reported difficulty in accessing healthcare, 17% faced difficulties in accessing medicines, 59% reported loss of income, 38% lost jobs, and 28% reduced fruit and vegetable consumption. In the final-adjusted regression model, rural residence (OR, 95%CI: 4.01,2.90–5.53), having diabetes (2.42, 1.81–3.25) and hypertension (1.70,1.27–2.27), and loss of income (2.30,1.62–3.26) were significantly associated with difficulty in accessing medicines. Further, difficulties in accessing medicines (3.67,2.52–5.35), and job loss (1.90,1.25–2.89) were associated with worsening of diabetes or hypertension symptoms. Qualitative data suggest most participants experienced psychosocial distress due to loss of job or income and had difficulties in accessing in-patient services.

Conclusion

People with chronic conditions, particularly among poor, rural, and marginalized populations, have experienced difficulties in accessing healthcare and been severely affected both socially and financially by the COVID-19 pandemic.