Mainstream, VOL LIV No 6 New Delhi January 30, 2016
Reflections on Decentralised Health Delivery System in Kerala
Saturday 30 January 2016
by Jos Chathukulam
The much acclaimed Kerala model of health care system (Elamon, Franke and Ekbal, 2004) had faced serious challenges in the mid-1980s and early 1990s due to the dilution of the politics of collective action and deficit in delivery of public goods in general and health care in particular by the State Government. Further the stagnation in the economy of Kerala, witnessed during the period, contributed to the decline of the quality of service delivery in the health sector. (Ramankutty and Panikar, 1995) The crisis in the health sector was multifaceted and manifested mainly in the cyclical incidence of infectious diseases, vector-borne diseases, high prevalence of life-style diseases, degene-rative diseases, poor public investment in the health sector, proliferation of the private health industry and high expenditure on healthcare. (Oommen, 2009) As a result, public healthcare units became less attractive even for the low income groups. (Kunhikannan and Aravindan, 2000)
In this backdrop the Seventythird and Seventyfourth Constitutional Amendment Acts and the conformity legislations in the State of Kerala (Kerala Panchayat Act 1994 and Kerala Municipalities Act 1994) provided an oppor-tunity to bring public healthcare units and their delivery of service under the control of local governments. (Varatharaj, Thankappan and Jayapalan, 2004) The subject of public health has been emphasised in the State Acts as a key governance task of the local governments at all levels, which implies both the first and second generation health-related issues. All the cardinal principles of devolution of functions have been adhered to while devolving functions relating to public health to local governments and fixing responsibilities among different tiers, whereas in other sectors they have not been followed to the same extent. This is mainly due to four factors: (i) the public health department had a long history of decentralised administrative governance even in the pre-amendment phase, (ii) the very subject domain of public health has special affinity towards decentralisation by default, (iii) the existing knowledge domain and protocol, including checklist-based treatment procedures, are sound enough, and (iv)there is spatial division and functional distribution of primary and secondary healthcare institutions. The multilevel planning process, known as the People’s Planning Campaign (PPC), started in the State in mid-1990s, was also expected to deal with the politics of the delivery of public goods.
Historically, the delivery of public goods is synonymous, first with the health sector and then with education in Kerala. Immediately after launching the PPC, all the major public health care institutions at the sub-State level (both primary and secondary) were transferred to the local governments. A reasonable amount of untied fund was made available with the local governments through a budgetary mecha-nism, known as the ‘budget window for local governments’. Though not fully in a comfortable zone, hardly anyone of the elected authorities makes serious allegations against the volume of financial allocations to the local governments. Subsequently, functionaries of the transferred healthcare institutions were put under the control of the local governments.
By looking at the outward volume and intensity of the package of decentralisation in the health sector under the 3Fs (functions, finance and functionaries), one may formulate a hypothesis that there has been an enabling and advantageous foundation in Kerala to utilise the opportunities of decentralisation during the last two decades. In this paper, we are primarily concerned with the post-73rd and 74th Constitu-tional Amendment scenario. We attempt to examine the nature and content of decentrali-sation in the health sector and its overall impacts on the well-being of the citizens in general and marginalised communities in particular. Therefore, the major discussions in the paper are based on certain specific issues under the health sector, such as (i) the nature and level of decentralisation, (ii) the level and type of decentralisation, (iii) the potential of the existing decentralisation to utilise the health- care system efficiently, and (iv) whether the local governments have utilised the opportu-nities of decentralisation during the last two decades.
The literature review on the broad area gives an impression that there is a dearth of studies to evaluate the impact of decentralisation in the health sector based on achievements in attaining quantifiable targets. However, mention may be made of a few studies during the campaign and the post-campaign phases of decentralisation. Mainly three types of enquiries have been made and they are (i) studies on healthcare institutions based on the performance of the decentralisation/ local governments, (ii) studies which show the overall changes in the healthcare institutions over the period, and (iii) academic exercises to establish correlations between healthcare institutions and the performance of the local governments after decentralisation. These studies are limited to a particular time-period and none of these made any attempt either to revisit the study area or to place in context the earlier findings with the recent developments. The authors who made the studies are either from the medical profession or from the conventional social science background and both the groups have their own inbuilt limitations in crossing the traditional boundaries of the subject domains.
Decentralisation of Health Services: The Kerala People’s Campaign by Elamon et al. (2004) was the first major attempt to look closely at the possibilities and potentials of decentralised public health and healthcare services. Since the authors are drawn from both the medical and social sciences the study could address the deficits caused by the narrow subject domains. The authors could evaluate the decentralisation project against its own six well-stated goals in the health sector and concluded that “the campaign achieved each of the goals to a large degree”. The study stated that “shortcomings arose from the inexperience of many local communities in drafting effective projects as well as problems deriving from the fact that some of the health bureaucracy could not be decentralised”. One would like to know the field situation after a decade since the study was undertaken. Whether the local communities could be capacitated in drafting effective projects and the health bureaucracy has been further decentralised are crucial concerns. It would be better if the focus is more on what has changed and what has not changed in the health services. Varatharajan et al. (2004) made an attempt in assessing the performance of primary health centres under the decentralised government in Kerala. Though the study is known for its precise objectives, scientific methods of sample techniques and parameters for assessment, it lacks the background knowledge on decentra-lised governance and multilevel planning. The authors could assert that active Panchayat support to the PHCs existed only in a few places, but wherever it was present, the result was positive. The study cautions that Kerala should find an alternative strategy to channel Pancha-yats in the direction of health before health loses its battle for resources. The findings of the study are opposite of the above one by Elamon et al. (2004) though the focus is limited. They could ‘claim’ that “decentralisation brought no significant change to the health sector”. How can one make such a general conclusion by assessing the performance of the PHCs alone? The authors missed the census data on health- care institutions in all the Panchayats and Municipal areas of Kerala during the latter half of the July, 1987 by the KSSP (Kannan et al., 1991). The findings of the study would have been different if the census data by the KSSP was taken as a bench-mark for assessing the performance of the PHCs under decentralised governance.
Since the study was conducted one decade back it would be interesting to see the current scenario. As part of the larger evaluation of decentralised planning and development, Oommen has given special attention to health under decentralisation. (Oommen, 2009) Though Oommen’s assessment is on the whole balanced, he has given more weight to the weaknesses at the local level while making an overview of the outcome of devolution. He admits that in the initial stages, there were efforts by many local governments to mobilise additional resources for health sector. In many places the stagnation of the earlier years of the PHCs was breached. Secondary level health facilities like Taluk hospitals also benefited much from local level planning. The study asserts that on the whole access and outreach of healthcare have improved. There were visible improvements in the facilities of the institutions. On the other side, he says: “...most of these achievements are only in patches and not universal across the State. The enthusiasm in the initial stage of the People’s Plan Campaign has died down soon after the campaign. The project which evolved later turned out to be routine or conventional and infrastructure-oriented. Even many of the innovative projects launched in the initial stages of the People’s Plan Campaign could not be sustained.”
One has to take the above findings with a pinch of salt. First, they were based on reflections and observations rather than evidence based on statistically sound samples. Second, these was no space for systemic corrections by the politics of patience. ‘Decentralisation and interventions in health sector’ by Rajesh and Thomas is a relatively current research work which tried to seek the transition in the healthcare sector during the last two decades. (Rajesh and Thomas, 2012) The researchers established the correlation between the changes in the health sector and the interventions in the area of democratic decentralisation by the local govern-ments. With the support of micro-level data from the selected village Panchayats, it was found beyond doubt that decentralisation improved infrastructure facilities, equipment and medicine in primary and secondary health care institutions. It also made a positive impact in the delivery of public health care services broadly within a rights based approach. The study also brought out the increased accoun-tability of the public healthcare system. The researchers could succeed in bridging micro- level evidence from the selected Panchayats with the State-level data. The study has captured the recent experiences in the area of solid waste management, wellbeing of differentially abled people, and management of diabetics and blood pressure clinics.
An overview of the recent outcomes of the devolution in the health sector leads us to the following points.
(i) The local governments have succeeded in achieving better individual household latrines, anganwadi latrines and school latrines. (The number of NGP Panchayats, joint projects of three-tier Panchayats for total sanitation, open defecation free (ODF) villages and the sanitation profile of government schools are testimony to the performance of the local governments. The poor sanitation profile of aided schools has nothing to do with the local governments and it is due to the lack of clarity on state policy. Of course, many aided schools are yet to achieve acceptable levels of water availability, sanitation and hygiene. The present status of the anganwadi may be compared with the situation in the early 2000s. ‘Performance of Anganwadi Centres in Kerala: An Evaluation and Experiment to Develop a Model Centre with Community Participation’ by Seema T.N. (2001) can be made a bench-mark to understand the changing profile of anganwadis by the intervention of local governments. A number of initiatives on solid and liquid waste management by the local governments has been initiated across the State. (Chathukulam Jos and Devavrathan S., 2014)
(ii) The quality and quantity of drinking water availability has improved. (Even during the summer season there was not much coverage on the issue of water scarcity by local dailies. There has been a good number of rain water harvesting structures and drinking water projects in place and an extension of pipelines which substantiate the improved performance in water sector.]
(iii) Improvements are found across the State both in terms of facilities available in health care institutions and service delivery. [The institutional profile of the Sub-Centres, PHCs, CHCs, Taluk Hospitals and District Hospitals are cases in point. Field evidences suggest that infrastructure facilities, equipment (medical and paramedical), modern facilities and services for patients and bystanders are visible and medicines are being provided by the local governments as per the requirement with the participation of local community and hospital management committee (HMC). The Cuba model of public health delivery system is another success story. (John Jacob, 2012) The primary and secondary healthcare institutions are properly equipped and looked after by the respective local governments. A majority of the institutions are equipped with sufficient quantity of medicines, as per the protocol checklist. The data of ‘Health and Development in Rural Kerala’ by Kannan, K.P. et al. (1991) can be made as a bench-mark to understand the changing profile of the PHCs by the intervention of local govern-ments.]
(iv) Plans and projects of the local govern-ments are slowly moving from a short-term to a long-term nature. (The sustainability question is also addressed by integrating projects both at the vertical and horizontal levels. For example, projects for ‘palliative care’ became sustainable and long term in nature by the proper integration of ASHA workers, anganwadi workers and NRHM staff. There is evidence to suggest that local governments are taking decisions based on economic rationality rather than political expediency.)
(v) Infrastructure-based/facilities-based health sector projects have moved to the status of integrated health-based projects. (Special projects for ‘palliative care’ can be found in all the village Panchayats. Special projects for autism, children, differentially abled, aged, victims of alzheimer’s disease/cognitive disorder, kidney patients and community psychiatry are included in the list of projects by the local governments. This is an indication to substan-tiate that local governments are responding to the specific health situations of the locality based on felt need of the community. These type of projects resulted in ‘voting by feet‘ in some cases.)
(vi) The medical officers started acting in the planning process and projectisation with the available data on the health sector. (The District Medical Officers of different medical systems such as the Superintendent of the District Hospitals, are now attending the Health and Education Standing Committees of the District Panchayats routinely. The same situation is reported in other tiers of Panchayats and Munici-palities with the respective health personnel at the appropriate levels.)
(vii) Local governments have started inter-ventions during incidences/causalities. Some amount of sensitivity is noticed among the local governments. (For example, District Panchayat, Kasargodu has developed a specialised health project for multiple drug-resistant tuberculosis (MDR-TB) patient with food and drug adminis-tration (FDA) protocol checklist. Another health project was for endosulfan victims by the same local government. Post-recovery project of the tsunami-hit fishing villages from Kollam District by different local governments was another case which shows compassion and non-conven-tional intervention of the local governments. )
(viii) the capacity for public health manage-ment of the professionals and elected authorities has been enhanced. (Many schools are reported to have undergone deworming programme thanks to the motivation of the health standing committees of the local governments. The projec-tisation and its implementation of integrated school health management with napkin vending machine and incinerator are seen in many schools by the local governments. Menstrual health is also a component in the package. It gives an impression that the capacity of the professionals and elected authorities has been enhanced to develop a gender perspective in sanitation and menstruation and its implications for girls’ education.)
(ix) Though primary and secondary health- care institutions are known as ‘transferred institutions’, in reality they have accrued the status of ‘absorbed institutions’. These institutions are being owned by the elected authorities as part of local government. (In the initial stages, the healthcare institutions were not treated on par with other transferred institutions due to many reasons. Frequent conflicts were reported between the medical professionals and elected authorities. And lack of trust, confidence, reciprocity and communication between them were seen while engaging in the projects on health. The situation has changed and at present, the primary and secondary healthcare institu-tions are recognised as part of the local governments. While discussing with the elected authorities, particularly the members of the health standing committee, the members said: ‘these are our institutions.’ The ownership feeling is very much manifested. This is also reflected in the financial support to the healthcare institu-tions. The district hospitals are the first priority of the District Panchayats while preparing the budget and plan. Usually, no conflict has been reported among the elected authorities while sanctioning the health projects.)
(x) The conflicts/ego clash between the personnel of the healthcare institutions including medical professional and the elected authorities have been settled. (When the healthcare institutions were transferred to local govern-ments, high voltage resistance was reported among the health professionals. The ‘conflicts based on sense of self’ were relatively high at the grassroots level, between the elected autho-rities of the Village Panchayats and the medical personnel of the PHCs. This has been addressed by different methods including administrative orders, discussions, involvements of the social and health activists and change in the behavioural pattern of the stake-holders. The hospital development committees (HDCs) also played an active role in creating a conducive atmosphere. Replicable models were worked out in many places. Wherever good relationships exist between the Panchayats and PHCs, the result was positive.)
(xi) The dual control of the personnel of the healthcare institutions and the related adminis-trative issues have been settled based on practical considerations and natural wisdom without losing administrative supervision of the local government and technical supervision of the line department . [When the functionaries of the transferred institutions were put under the administrative control of the local govern-ments the system of dual control mechanism had been identified as one of the stumbling blocks. There was resistance from the vertical authorities of the line departments and associations of the category organisations to devolve the adminis-trative control to the local governments. In the initial stages the local governments were also not properly equipped with tool kits to engage the personnel of the line departments. By experience, the elected authorities could realise the limitations of dual control whereas the personnel of the transferred institutions came to appreciate the advantages of working with local representatives. As a result, a ‘conciliation mechanism’ has been evolved by default in many cases. It is observed that practical solutions with workable models based on the ‘non-zero sum approach’ emerged in many local governments. The phenomenon of ‘questionable and doubting ownership’, as observed by Oommen, has evaporated.] (Oom-men, 2009)
(xii) The issues related to parallel and vertical development programmes such as (a) NRHM, (b) HIV/AIDs control society, (c) ICDS, (d) Kudumbashree, (e) MSS , (f) SSA and (g) NBA/SBA have weakened and some degree of integration of them has been brought about by the local governments. [Theoretically, the parallel and vertical development programmes are against the true spirit of democratic decentralisation and therefore local governments are not very comfortable with them. However, as long as the programmes continue, the local governments have to deal with them either by envisioning joint programmes or list them in the plan document as stand-alone projects. However, a large number of local governments could succeed in making integrated projects by employing common sense and the wealth of experiences. Moreover, integration has been worked out in such a way as a means of additional resource mobilisation. Participation from the local community has strengthened the collaborative efforts in the field of public health delivery system of local governments. (John Jacob, 2012) There are successful replicable models across the State.)
The purpose of the above overview of the recent outcomes of the devolution in the health sector is not to generalise on the basis of successful cases or to present a rosy picture. The attempt is only to suggest that the decentralised healthcare institutions and service delivery by the local governments are moving in a positive direction that can be proven on the basis of an index of achievement. After the above narration, of course, one may raise a simple question: if things are better in this part of the country, how could one explain the aberrations in the health care system in present-day Kerala? “The local governments are not solely responsible” (Rajesh and Thomas, 2012) may not be a convincing answer. If one expects a better output than the present one, of course, the input side of the local governments has to be improved in terms of design, technology, resource and capacity of the system and the actors. The overall perfor-mance of the local governments in the area of public health may be directly correlated to the existing level of autonomy and decentralisation. If one intends to attain a high rate of achievement from the local governments, more investment is needed in terms of autonomy and financial devolution.
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Dr Jos Chathukulam is the Director, Centre for Rural Management, Perumpaikadu P.O., Kottayam (Kerala).