HEALTH AND DECENTRALISATION: INITIATIVES AND THE LESSONS

1
HEALTH AND DECENTRALISATION INITIATIVES AND
THE LESSONS

• JOY ELAMON

2
DECENTRALISATION

• DIRECT ACCOUNTABILITY OF PUBLIC HEALTH AND
  INSTITUTIONS
• MORE EFFICIENT MANAGEMENT OF RESOURCES
• BETTER LINKAGES BETWEEN INFORMATION AND PLANNING
• EASIER INTER-AGENCY COORDINATION
• RESPOND EFFECTIVELY TO THE DIFFERENT NEEDS AND
  CAPACITIES

3
REFORMS

• PUBLIC-PRIVATE PARTNERSHIP
• CONTRACTING OUT
• NEW MANAGEMENT STRUCTURES

• DECONCENTRATION
• DELEGATION
• DEVOLUTION

4
KERALA PROFILE

• 38,863 sq kms, (1.2 of India )
• 14 districts 63 taluks
• 31.84 million population (3.4)
• High population density (819/sq km)
• Total literacy rate 90.9 (87.9 F)
• Sex Ratio 1058 women/1000 men

5
THE Kerala model

• Low cost of health care
• Universal accessibility and availability
• Even to the poorer sections of society

6
HEALTH SECTOR
Kerala at a glance, DHS Economic review,
2000-01, GoK
7
Kerala model financial significance

• Kerala spends 10 US per capita per year
• US spends about 3500 per capita per year
• GDP less than the national average

8
Kerala model

• Highly literate population especially the high
  female literacy
• Fairly long period of struggle for social reforms
  with thrust on education and organization of the
  downtrodden people

9
Kerala model

• Land reforms improved the social living
  conditions of the landless poor
• The public distribution system of food through
  fair-priced rations shops
• The universally available public health system in
  Kerala - a three-tier system of health care

10
Kerala model

• Evenly distributed health facilities both in the
  urban and rural areas
• More thrust on preventive promotive primary
  health care
• Popularity usage of other alternative systems

11
KERALA CRISIS

• RETURN OF COMMUNICABLE DISEASES
• LIFE STYLE DISEASES
• LESSER PUBLIC SPENDING ON HEALTH
• DECLINE OF PUBLIC HEALTH SYSTEM
• GROWTH OF PRIVATE SECTOR
• INCREASING OUT OF POCKET EXPENSES

12
DEVOLUTION

• POWERS TO PLAN
• MAKE DECISIONS
• RAISE REVENUES
• EMPLOY STAFF
• MONITOR ACTIVITIES

13
KERALA DEVOLUTION

• INSTITUTIONS TRANSFERRED
• PHC -Gram Panchayats
• CHC -Block Panchayats
• TALUK HOSPITALS -Municipalities
• DISTRICT HOSPITALS -ZPs
• FUNCTIONARIES
• ADMIN. CONTROL WITH LSGIs
• PLAN AND NON-PLAN

14
Community Involvement in Health Development
Challenging Health Services-Report of a WHO Study
Group WHO Geneva 1991

• A critical step will be the decentralization of
  health services and the corresponding
  strengthening of the local health services that
  will serve as the basis for CIH
• Structural changes in health systems will be
  necessary to support the CIH process. These
  changes include decentralization of planning,
  management, and budgeting.

15
PANCHAYATI RAJ AND HEALTH

• The control of infectious diseases and even the
  prevention, early detection, and management of
  the life style diseases can be achieved only by
  strengthening the primary and secondary level
  health care facilities, with better community
  involvement.

16
PANCHAYATI RAJ AND HEALTH

• Once the primary and secondary health care
  facilities are improved through the local bodies
  , the tertiary care centers like the medical
  colleges can entirely concentrate on medical
  education, research, and tertiary health care.
• Provisions in the Panchayati Raj Act can be
  invoked for the social control of both the
  government and private sector

17
PANCHAYATI RAJ AND HEALTH

• More need-based reallocation of resources and
  generating local resources through community
  participation.
• A better relationship between the health workers,
  peoples representatives, and the people
• Public health system reinforcement ensures social
  equity in health care

18
RESULTS

• PREPARED LOCAL PLANS
• ADDRESSED PROXIMATE DETERMINANTS
• ADDITIONAL RESOURCE MOBILIZATION
• ACCESS AND OUTREACH IMPROVED
• PUBLIC-PRIVATE PARTNERSHIPS
• STRENGTHENED SECONDARY LEVEL INSTITUTIONS
• COMPREHENSIVE HEALTH PROGRAMMES

19
PUBLIC-PRIVATE PARTNERSHIP

• PONNANI BP
• Society for community mental health
• Centre for community mental health studies
• Mental health survey
• School mental health programme
• Suicide prevention activities
• Adolescent marriage-an awareness programme
• Addressing issues of old age health problems
• Pain and palliative care
• Role of IMA and private sector

20
RESOURCE MOBILISATION

• Malappuram district hospital
• District hospital welfare fund and plan
• Appeal to all sections of people
• Fund raising campaign as movement
• 14 BPs, 5 Municipalities and 100 GPs and DP
  putting their share
• M.Ps, M.L.As of the district from their local
  area development fund
• Non-resident Indians

21
STRENGTHENING SECONDARY LEVEL INSTITUTIONS

• Nedumangad Taluk hospital
• Hospital was in decline
• Dilapidated condition
• Renovation
• Fair price store
• Blood bank
• Renovated the maternity ward
• X-ray unit, ECG machine, and laboratory
• Funds to complete a 100-bed expansion ward

22
INTERVENTION IN A PHC

• MANGALAPURAM
• Steps for providing basic medical needs
• Implementing new health programmes
• Creating a positive atmosphere among the
  employees
• Organizing a voluntary group
• Additional resource mobilisation
• Drawing support from institutions

23
NEW HOSPITAL

• THRIKKAKKARA GP
• An urbanised village
• PHC is not adequate
• Cooperative hospital initiated by GP
• Curative as well as preventive
• Break even now

24
COMPREHENSIVE HEALTH PROGRAMME

• ERATTUPETTAH
• HEALTHY VILLAGE COMMITTEE
• HOUSE HOLD SANITATION
• SOCIAL SANITATION
• DRINKING WATER
• HEALTH CARDS
• HOTELS AND OTHER PUBLIC PLACES
• SCHOOL HEALTH
• PHC

25
LESSONS

• DIRECT ACCOUNTABILITY OF PUBLIC HEALTH AND HEALTH
  CARE INSTITUTIONS
• BETTER LINKAGES BETWEEN INFORMATION AND PLANNING
• ABILITY TO RESPOND EFFECTIVELY TO DIFFERENT NEEDS
  AND CAPACITIES
• MORE EFFICIENT MANAGEMENT OF RESOURCES ?
• EASIER INTERAGENCY COORDINATION?

26
EXPERTS VIEWS

• INADEQUATE ALLOCATION
• INFRASTRUCTURE BASED PLANS
• LACK OF EXPERTISE
• LACK OF PROFESSIONALS SUPPORT
• POTENTIALS NOT TAPPED

27
WEAKNESSES

• IMPROVEMENTS IN PATCHES ONLY
• INEFFICIENCY OF COMMUNITY BASED MONITORING SYSTEM
• ONLY SHORT TERM PLANS
• INFRASTRUCTURE BASED PLANNING
• SUSTAINABILITY QUESTION
• QUALITY OF SERVICES NOT IMPROVED
• NO PROFESSIONAL MANAGEMENT

28
REASONS

• POOR PLANNING FOR DECENTRALIZATION
• CONFLICTS BETWEEN HEALTH DEPARTMENT AND LOCAL
  BODIES
• DUAL CONTROL
• PROBLEMS OF STAFF AND SALARIES
• FAILURE TO ALLOCATE ADEQUATE RESOURCES
• LACK OF PROFESSIONALS SUPPORT
• VAGUENESS ABOUT OF DECENTRALIZATION

29
CONCLUSIONS

• NOT HEALTH SECTOR REFORMS only
• NOT TO ADDRESS THE CRISIS
• NO MOTIVATION NOR POLITICAL WILL
• REFORMS FOR THE SAKE OF REFORMS
• NO SCIENTIFIC SYSTEM ANALYSIS
• STRENGTHS AND WEAKNESSES OVERLOOKED

30
POLICY OPTIONS

• SITUATION MORE COMPLEX
• SECOND-GENERATION PROBLEMS
• DECENTRALISATION TO BE STRENGTHENED, NOT IN
  ISOLATION
• INTEGRATE WITH MULTILEVEL PLANNING
• STATE TO FOCUS ON TERTIARY LEVEL
• EXPLORE RESOURCE MOBILIZATION
• EQUITY CONCERNS
• HOSPITAL DEVELOPMENT COMMITTEES
• PRIVATE-PUBLIC PARTNERSHIPS

31
POLICY OPTIONS

• NEED NOT PAVE WAY FOR THE GOVERNMENT TO WITHDRAW
• MORE ACTIVE INVOLVEMENT OF THE GOVERNMENTS
• NEEDS PROPER INTEGRATION
• COMPREHENSIVE HEALTH POLICY AND REFORMS

32
RESEARCH OPTIONS

• NEEDS, DEMANDS, REALITY
• DUAL CONTROL AND MANAGEMENT
• SERVICE DELIVERY
• OWNERSHIP ISSUES
• HEALTH AND DECENTRALISATION
• RESOURCES MANAGEMENT
• ROLE OF THE STATE

33
KEEP IN MIND

• MULTI LEVEL PLANNING
• BASELINE
• LIMITATIONS
• DATA VS. INFORMATION
• LINKAGES
• FOCUS ON PROCESSES
• METHODOLOGY