A major problem currently engaging the attention of health professionals concerns the low efficiency and poor quality of health service delivery in the health sector in rural India. This is despite a fairly well developed rural health infrastructure. Highly centralised health services with very little local autonomy either over programmes or over resources is regarded as one of the major contributory factors for poor service delivery owing to the following two typical problems:
(a) the unresponsiveness of health services to local needs, and
(b) staff assigned – rotated and paid with little relationship to output of services and/or patient satisfaction – are often inadequately or under-trained, ill-equipped and frequently, as a consequence indulging in private practice.
In order to improve the quality of health service delivery in publicly run health care facilities and to mitigate the problems associated with centralisation two significant initiatives of the government are worth mentioning: (a) Increasing reliance on user fees with varying degrees of control over the utilisation of revenues generated through user fees. This is usually done to provide greater flexibility to health care functionaries in funds utilisation for emergent or other similar needs, not otherwise provided in the budget, and (b) Devolution of central responsibilities to lower levels of government (district, block, village levels) such as the Panchayati Raj Institutions.
Although the Panchayati Raj has been the system of democratic representation of the community at three levels (the village, block, and district) almost since the late 1950s, it was only in 1993 that the PRIs were incorporated into the Constitution, and health, sanitation, and family welfare at the local level fell under their jurisdiction. Thus local self-government became the main vehicle for community participation in the delivery of services.
Linking of the health sector with the Panchayati Raj system is a complex chain process involving numerous stakeholders. Our experience in this context so far is mixed. The PRIs have often been dominated by the local elite, obstructed by the politicians at the state level, and have mostly been seen as advisory rather than decision making. Allocated financial resources, often inadequate, are usually governed by tied budget lines, leaving little flexibility at the local level to meet the specific needs of the local populations. However, based on a recentl a review of Union health budget, a new budget line was introduced which provides flexibility in the use of at least a part of the health budget (pattern of funding in the recently launched NRHM).
The PRIs and the Health sector – Working and the lessons learned
There are a number of studies that help us get some idea of what has worked and what has not worked. A recent study, using the empirical evidence from India shows that fiscal decentralisation plays a significant role in reducing infant mortality rate in India. The study further shows that the effectiveness of fiscal decentralisation can be affected by other complementary factors such as the level of political decntralisation. States which have good fiscal and political decentralisation index are twice more effective in reducing IMRs than states with high fiscal but low political decentralisation index.
A study of Karnataka experience found that creation of elected councils (at local level) have helped in reducing absenteeism and in enhancing employees’ work rate when they were on the job, although they felt that these achievements sometimes tend to be exaggerated. It si also suggested that moral pressure from councils at both district and block levels have been more important than formal disciplinary action. The power of district councils to move formally against civil servants was limited in that they could suspend but not dismiss. A study of West Bengal shows that the panchayats have helped, among other things, in efficient and cost effective implementation of several rural development programmes including the construction of health centres.
In yet another field based study linking primary health care and PRIs in the states of Gujarat, Maharashtra, Karnataka, and West Bengal it is seen that there is a definitive role for PRIs in improving the quality of health care services. It shows that PRIs have a significant role in improving the functioning of the health care system at the local level.
All evidence clearly suggests the positive role of PRIs in improving the quality of health care services, especially through ensuring better attendance of health care functionaries at the local level, as well as exerting moral pressure on health staff not to shirk from work. Also watchful participation of local communities has contributed in some measure in improving the supplies of drug and equipment by assisting the local health staff by bringing the deficiencies in the supplies to the attention of higher authorities. In addition the PRIs can play a significant role by assuming responsibilities of monitoring and supervision in preventive health care. The PRIs have yet another role which they are capable of playing; this concerns participation in programmes of health education and awareness creation.
There is however a serious concern in a situation where different political parties have control over the state administration and the administration of the PRIs. Thus, some amount of caution is needed in devolving powers to the PRIs. Another serious issue is related to financial resources with the PRIs. As is well know the PRIs have very limited financial resources of their own, and hence hugely dependent on grants, etc. Until the PRIs are empowered with financial resources, their involvement in strengthening health service delivery will remain only supplementary rather than decisive.
Prof. D.B.Gupta, a PhD from University of Birmingham, UK has been an active development economist for more than 40 years. He has taught at a number of universities and institutions in India and abroad and has worked extensively with the World Bank, UNICEF, WHO, Institute of Economic Growth, NIPFP, NCAER and similar organisations.