Decentralization and Local Governance of the Health Sector in India

CHAPTER I: INTRODUCTION

Governance is a multi- facet mechanism which embraces authority of decision making in order to ensure welfare of the people. It is a process whereby societies or organizations make their important decisions, determine whom they involve in the process and how they render account (Graham et.al 2003).

UNDP (1990) defines Governance as “the exercise of political, economic and administrative authority in the management of country’s affairs”. The term good governance has become part and parcel of development arena of every country. It implies that decisions are taken and implemented in a manner which is free of abuse and corruption, and with regard for the rule of law, it is participatory, transparent, responsive, consensus-oriented, equitable and inclusive, effective and efficient, and accountable.

UNDP in 1997enunciated five principles for good governance (UNDP, 1997), ie, Legitimacy and Voice, Direction, Performance, Accountability and Fairness. These principles are regarded as imperative factors for successful governance.

The term ‘Legitimacy and Voice’ implies that all men and women should have a voice in decision making and there should be compromise on what is best interest of the group.

The ‘Direction’ entails strategic vision among the leaders and public for the good governance and human development.

The ‘Performance’ includes responsiveness, effectiveness and efficiency of the system which requires sustainable use of resources and produces the best results that meets the needs of society within a reasonable time frame.

‘Accountability’ involves transparency in process and decisions with free availability and direct accessibility of information and the institutions and decision makers should be accountable to the public.

The ‘Fairness’ includes equity and rule of law which implies all men and women have opportunity to maintain the well being and there should be an impartial legal frame work.

Governance is prominently classified as Centralised and Decentralised Governance. Centralized governance was the only feature of every country up to 1950s; it is a top-down approach under which decisions are taken by central authority by giving emphasis on national priorities.

There are several criticism raised against centralised governance. Centrally-administered bureaucracies represent an inefficient and potentially destructive means of allocating resources and generating wealth within society. Central and state agencies lack the ‘time and place knowledge’ to implement policies and programmes matching to people’s need. Under this form of governance Social welfare, the ultimate goal of governance was limited due to the failure of authorities to involve in the local matters.

Despite stirring statements in planning documents on the centrality of health and health care, the field has suffered from persistent neglect in public policy in general and development planning in particular (Dreze and Sen 2002).

The centralised policy frame work was first challenged with the introduction of the Community Development Programme (CDP) in 1952. The community development programme was intended to ensure the direct participation of people in the rural development programmes.

The strategy of the community development programme was to develop the capacity of the people to undertake development initiatives with the best possible use of the available technical know-how. In order to introduce the programme throughout India, the union government created development blocks in all the districts.

Under the new structure, programmes like social education, public health, construction of roads and buildings, etc were introduced in the rural areas with a team of grama sevaks, sevikas and extension officers under the control of the Block Development Officer (BDO) (John, 2013).

Decentralization regarded as a crucial factor that contributes good governance. It is a bottom- up approach where decisions are based on the priority made by the people at grass root level. There is a restructuring of authority, setting up of government institutions at local levels known as Local Self Governments (LSGs) and transfers decision making authority.

Since 1980s the term ‘decentralization’ had been in the forefront of the development agenda of developing countries. Twelve of the seventy five developing countries with more than five million inhabitants have implemented some form of decentralization with varying degree of financial and political power (World Bank, 2000).

1.2 Meaning and Definition of Decentralization

The conception of decentralization is very hard, it acquires different meaning in different contexts and to different people and there are multiple ways along which a system can decentralize. Invariably, the ways are non-comparable and occasionally assume conflicting entities.

Decentralization simply means extension of authority to local levels. It is a complex and multi – facade concept which has great profound. There is a transfer of power, resources, responsibility, institutions, functions and functionaries at the same time, it enables the local peoples to participate in the public decision making process that affects their living conditions. The successful transfer and establishment of these aspects direct the accomplishment of decentralization. It is regarded as ‘… both a right in itself and a means of ensuring basic human rights observance’ (Gloppen et al., 2003).

The Encyclopedia of Social Sciences (1968) defines decentralization as ‘… the transference of authority, legislative, judicial or administrative, from a higher level of government to a lower level’.

Cheema and Rondinelli’s definition is regarded as one of the good definition, describes decentralization as “the transfer of authority to plan, make the decisions and manage public functions from the national levels to any individual organization at the sub- national level” (Rondinelli et al 1981).

“. . . Decentralization, or decentralizing governance, refers to the restructuring or reorganization of authority so that there is a system of co-responsibility between institutions of governance at the central, regional and local levels according to the principle of subsidiarity, thus increasing the overall quality and effectiveness of the system of governance, while increasing the authority and capacities of sub-national levels. … Decentralization could also be expected to contribute to key elements of good governance, such as increasing people’s opportunities for participation in economic, social and political decisions; assisting in developing people’s capacities; and enhancing government responsiveness, transparency and accountability.”(UNDP 1999).

1.3 Types of decentralization

The effects of decentralization on good governance depend to a large extent on the form and nature of the decentralization involved in the particular country. The type of unit with which authority is shared or to which it is transferred in the decentralization process is critical for understanding the implications for good governance (UNDP 1999). The transfer of power, functions and resources from Central to Local level authorities assumes different forms.

Based on the nature of transfer, decentralization can be categorized in to Political, administrative and fiscal decentralization. It is an important reform all over the world, most of the countries followed one or another form of decentralization in their governance.

'Political Decentralization' is a type of decentralization which involves transfer of policy and legislative power from central government to autonomous sub national assemblies and local community that have been democratically elected by their respective constituencies. It gives more power to citizens and their representatives. Benefits of political decentralization consist of greater voice and choice, better allocative efficiency and empowerment of people at the grass root level.

‘Administrative decentralization’ transfers responsibility to grass root levels and empowers the LSGs with the authority of hire and fire the local staffs. Based on the degree of transfers, the administrative decentralization has three forms, deconcentration, delegation and devolution.

‘Deconcentration’ is considered to be the weakest form; it merely shifts responsibilities to local level administrative capacities, which are under the supervision and control of Central authority. ‘Delegation’ is more extensive form, where local authorities are not fully under the control of central Government, but they are accountable in due course. In the case of ‘devolution’, there is an independent authority at the local level with clear and legally recognised geographical boundaries. De-centralization does not mean just de-concentration where a subordinate is allowed to act on behalf of the superior without any real transfer of authority, or delegation where powers are formally conferred on a subordinate without any real transfer or authority. It implies devolution where real power and authority are transferred to enable autonomous functioning with the defined areas (KLSGs Report 2012).

Even though all the three forms of decentralization are important and should be compliment to each other, ‘fiscal decentralization’ is most important for the success of planning and decision making process at the local level. In order to perform the responsibilities devolved to local bodies, they need appropriate level of fiscal resources to cover the costs of providing public goods and services (Sankaran, 2006). Without appropriate fiscal empowerment, the autonomy of sub-national governments cannot be substantiated and, in this way, the full potential of decentralization cannot be realized (Nicoletta Feruglio, 2007). Cheema and Rondinelli (1983) have pointed out that the lack of adequate funding for lower level institutions was the single most important factor that undermined many of the decentralization attempts of the 1970s.

Fiscal decentralization is generally refers to the devolution of taxing and spending powers to lower levels of government (Fukasaker and De Mello, 1999). It is broadly defined as an empowerment of lower tiers; it ensures that all elected officials weigh carefully joys of spending someone else’s money and pains associated with raising revenues from the electorate and facing the possibility of being voted out (Shah 2005).The conditions for successful fiscal decentralization are that sub national governments should have some autonomy in determining revenue and expenditure levels and they should balance their budgets.

1.4 Decentralization and Public Service Delivery

An important argument in favor of decentralization is the delivery of public goods and services to the people based on understanding their actual need. Under centralized governance the appropriation of public goods and services are made by the officials at the central on the basis of national priority. By setting up of Local Government, it is easy to identify the necessities of the people in their area, what is needed in one area is not the need of another. Thus decentralized governance is an important revolution where the decision on the delivery of public goods and services are decided by the Local Self Governments (LSGs) in their locale with the participation of public. The local governments are more informed as to the demographics of their respective jurisdictions and therefore will allocate public resources more efficiently and more effectively than the Central Government (Liu C 2007)

Decentralized governance asserts that individuals attain greater freedom and responsibility when public goods are allocated by local government (Herber, 2004). In this regard George Stigler (1975) identifies two principles for jurisdictional design, known as Stigler Menu, i.e., closer the Government is to the people, the better it works and people should have the right to vote for the goods and services they want. These principles suggest that decision making should occur at the lowest level of Government, consistent with the goal of allocative efficiency (Shah 2005). Thus decentralization in governance leads to welfare gains; it entails the provision of public goods by sub national governments so that public consumption levels are tailored to suit the preference of a heterogeneous population and promotes efficiency as well as equity (Rangarajan and Srivastava, 2011). Decentralization has attempted to remove inefficient levels of bureaucracy allowing for decision making that is both faster and more appropriate for local circumstances.

Efficiency and welfare are the two gains as far as decentralization is concerned. Such gains are best achieved by assigning responsibility for each type of expenditure to the level of Government that most closely represent the beneficiaries of these outlays (Musgrave & Musgrave, 1989; De Mello, 2000; Bird &Vailliancourt, 1997). Local governments possess knowledge of both local preferences and cost conditions that a central agency is likely to have and there are typically political pressures that limit the capacity of central governments to provide higher levels of public services in some jurisdictions than others. These political constraints prevent central programmes from generating an optimal pattern of local output.

1.5 Decentralization and Local Governance in India: A Historical Overview

India is the largest democratic federal polity; federalism in the country is characterized by constitutional demarcation of revenue and expenditure powers among the three levels of government. Although the country has the federal system with separate legislative, executive and judicial wings at both central and state levels, in its functioning it is considered to be a quasi- federal system because of the very high concentration of powers with the central government (Rao 2005). All state in India introduced decentralization with varying degree of financial and political power with the aim of equitable distribution of services, more fruitful allocation and mobilisation of resources, enhancing accountability, accessibility, availability, efficiency and transparency of services through the participation of local people in decision making process.

In India the idea of decentralization is not new; it has a history equivalent to the record history of India. The setting up of panchayats at local level is the footstep towards decentralization. Panchayat is a traditional institution formed by the inhabitants having a good understanding of the village to solve their problems through deliberations.

As in many other Democracies, Decentralization in India has been a process of advances and retreats, and struggle between advocates of conflicting perspectives on governance and development strategy (World Bank, 2000). The Panchayat Raj movement in India was placed in the national agenda in 1957 with set up of the Belwant Rai Mehta committee to recommend measures for Community Development and National Extension Service Programmes. The committee recommended the organisation of a three tier structure of the PRIs for effective decentralization with elected panchayats, finance, power and authority supportive of Community Development Projects. However , the Panchayat Raj movement failed to take roots since there was a deliberate attempt by the bureaucracy, vested interest groups and elected representatives to thwart regular elections because their ascend was fear (Mathew, 2001). The Panchayat Raj System was left in hibernation until the Janatha Government, inspired by the ideals of Jayaprakash Narain constituted the Asok Mehta committee to review the system. The GVK Rao committee (1985) and the L N Singhvi Committee (1986) further reviewed the system. Such assessments made the Government to think in terms of giving the panchayats a constitutional status. Subsequently the 64^th Amendment Bill (1989) in the parliament suggested setting up of three tier panchayats system at village, intermediate and district levels; the Bill culminated in to the 73^rd Amendment to the Constitution, which was passed in both Houses of Parliament in December1992, a land mark in Indian history, conferred Constitutional status on the Panchayat Raj Institutions (PRIs). It envisages the establishment of a democratic decentralized development process through people’s participation in decision-making, implementation and delivery of services.

In Gandhi’s dream Independent India was seen a highly decentralized polity, with its villages having extensive political and economic autonomy known as Grama Swaraj (a five tier Government system at village, taluk, district, state and central level). While shaping the first draft of the Indian constitution (November 4, 1948) enough importance was not given to Mahatma Gandhi’s concept of Grama Swaraj, which leads to controversies and Santhanam’s compromise Amendment Act was accepted. As a moral exhortation to state Governments, the Article 4 of the Indian Constitution among Directive Principle added “State has to take necessary measures to organize Grama Panchayats and provide it with the power and operational authority necessary for it to function as a constituent of the Government Machinery”.  By 1954, panchayats were came into exist all over India. A large number of villages came under the rule of 98255 panchayat administrative councils. The central Government took initiative to form the council of Local Self Government Institutions. To make justice available to the people at a lower cost Nyaya Panchayats were formed in many states. Government of India in 1958 viewed that without an agency at the village level, ‘which could represent the whole community, assume responsibility and provide the necessary leadership for implementing the development programmes’, real progress in rural development could not come out. It is seems that a number of committees were appointed by the Government of India for improving the decentralization set up of the country.

Belwant Rai Mehta Committee in 1958 reported that Democratic Decentralization was essential for social development and also proposed the idea of three- tier panchayat system. Dantwala Committee Report in 1978 recommended for block level planning, Asok Mehta committee in 1978 suggested that the constitutional recognition was needed for functioning of panchayat,  Hanumanth Rao committee in 1984 recommended district based planning, Rao Committee- 1985 recommended financial resources were to be made available for Local Self Governments to carry out developmental activities at the local level with people’s participation. Parliamentary Consultive Committee (1998) under the chairmanship of Thugmon recommended that Panchayat Raj system should be accorded constitutional recognition. Taking in to consider all these report Rajiv Gandhi Government introduced Panchayati Raj Bill in the parliament as the 64^th Constitutional Amendment Bill, but the bill could not be passed due to lack of majority. Again Narasimha Rao Government in 1992 passed the bill by the  Loksabha on 22^nd December and Rajya Sabha on 23^rd December 1992, known as 73^rd and 74^th Amendment of the Constitution.

The World Bank has realized that India is the only country where democratic decentralization at grassroots level is going on in the true sense in the light of 73rd and 74th Constitutional Amendment Acts (World Bank, 2000)

The main features of the 73^rd and 74^th Amendment Act are:

1. Constitution of panchayats at village, intermediate (block) and district level; however, panchayats at the intermediate level may not be constituted in a State having a population not exceeding twenty lakh
2. Regular elections to Panchayats
3. Reservation of seats for Scheduled Castes /Scheduled Tribes and Women (33%);
4. Setting up of an independent State Finance Commission for strengthening finances of local bodies at all levels
5. Constitution of an independent State Election Commission to hold PRIs elections on a regular basis
6. Legal status to Gram Sabah
7. Addition of Eleventh Schedule to the Constitution listing 29 Subjects within the jurisdiction of PRIs.

1.6 Rationale of the present study

Health is one of the important subjects transferred to the LSGs as a part of 73^rd and 74^th Amendment Act based on the rule that what can be done at the lower level should be done only at that level, not higher. Health is a major public good; non- excludability and non- rivalry are its important characteristics. Many advances in health tend to prove these characteristics, consumption by one does not precludes the consumption of others and denial to the other is difficult. There can be many social externalities from the good health of others, less risk of infection to us. It is regarded as a merit good in the sense that all citizens with in the country should have an acceptable level of access and utilization of health services. Different individuals have varying capacity to attain health, for equalizing this capacity; the disadvantaged groups should receive more support in attaining their highest level of health.

Decentralization has been identified as a means of achieving health equity in many reform initiatives across the world, it may be perceived as a tool for change in the regime of health sector reform initiatives underway striving to maximize the use of scarce resources in meeting the ever increasing demand for health (Mishra 2012).  WHO (1978) argued that decentralization can make health system functions more efficiently and can increase community involvement in oversight and locally relevant decision making. Once the Panchayati Raj System becomes fully operational there will have local authorities more involved in understanding their problems, so that they can participate better in the health care delivery services (Bajaj Committee, 1996).

Kerala is a state in south-west of India, which is known to have decentralised its governance in ways far more advanced than most Indian states and the state has a well known health model. The health status of Kerala is far advanced and higher than the all India average and is even comparable with advanced countries (Gangadharan, 2005). Kerala’s decentralised planning is different from the rest of India because it initiated institutional reforms and moved ahead sufficiently early to devolve powers, responsibilities and funds to the local governments (Oommen, 2014). It is generally held that no other Indian state has deepened decentralization to the extent of Kerala (Sebastian et al, 2014). The Panchayat Empowerment and Accountability Scheme (PEAIS) of the Ministry of Panchayat Raj under which states are ranked in 2012-13 in terms of their decentralization efforts, where Kerala is an outstanding exception. Despites of its poverty, Kerala shows high development indicator and stands out very high among low income countries in adult literacy, life expectancy, infant mortality and birth rate.

The unregulated private health care sector increased the out of pocket medical care expenditure for both inpatient and outpatient care, which in particular deteriorated the health status of the poor and other vulnerable sections. Specific steps have been taken by the Government of Kerala in the post independence period to improve the preventive and curative health care policies and programmes through diversified primary, secondary and tertiary level health care institutions. Kerala has been promoting population health and the people friendly democratic decentralized health care system is an effective option in addressing and reducing health problems (Ashokan, 2009).  After decentralization, both primary and secondary level health institutions were transferred to the local governments.  Now the decentralization in Kerala crossed two decades, the LSGs are more experienced; they can control and involve the local matters with full potentiality, especially in the health sector. Kerala has a good network of public health care starting from primary health centres to medical colleges. (Sebastian et al, 2014).But the recent trend in health sector of Kerala is worrying, emergence of different diseases questioning the sustainability of health achievements. In this context a study on Decentralization and Health sector development in Kerala will helps to understand the achievements and lacunas existing in decentralization of health sector of Kerala at present.

1.7 Research Problem

Government of Kerala decided to delegate 17 institutions as LSGs empowered with the duties and responsibilities assigned by the Panchayati Raj Act 1994 (GO. P 189-95/LAD, dated 18/9/95), this order is a landmark in the administrative decentralization in Kerala. As far as health sector is concerned, the primary and secondary institutions working under the health department were transferred to the LSGs. As per this order, the family welfare sub-centres (SCs) and Primary Health Centres(PHCs) were transferred to the Gram Panchayats, Community Health Centres (CHCs) to the Block Panchayats, Taluk Hospitals to Municipalities or Corporations and the District Hospitals to the District Panchayats. As health is a regional subject, these helps to better management of health system and instant availability and accessibility of health care services to the grass root level. It is most beneficial for the rural people; they are most depending government health care services due to lack of income.

Financial resources are the essential factor for the successful implementation of these tasks. For this the Government of Kerala decided to allocate 35 to 40 per cent of budget allocations to the LSGs in 1996. It specified that the LSGs could spend up to 40 per cent of their budget allocation for the improvement of the service sector, health is one of the major component of service sector. Providing medicine and health accessories to the healthcare centres, intervening during epidemics, promoting health practices, curative and preventive health care services were the services comes under LSGs. Thus, the protection and the promotion of public health at the local level became a pivotal responsibility of the LSGs.

The utilisation of health care services mostly depends on nature and condition of health centres and availability of health care services. For better provision of services, physical and human infrastructures are crucial. Lacks of proper facilities are one of the overwhelming reasons for the low utilisation of Government health care service (Varatharajanetal, 2004). Decentralization implemented for mitigating the problems existing in health sector in the grassroots level. For this, the LSGs were empowered with resources and resource mobilisation power, transferred necessary institutions, functions, functionaries and authority. As far as rural areas are concerned it is the Panchayats, which can develop rural health by implementing various programmes and policies by knowing the actual demand of the society and delivery of proper health care services by creating and maintaining adequate infrastructure to the health centres.

1.8 Research Questions

• What is the intensity and magnitude in the allocation and expenditure of funds by local bodies in the health sector?
• Does the entire district in Kerala have a uniform rate of allocation and expenditure for the health sector?
• What are the basic determinants of allocation and expenditure of funds for the health sector?
• What are the basic hurdles in the effective expenditure of funds allocated to the health sector under decentralization?
• How decentralization is linked to infrastructure development of health sector?
• Does Government Health Centres has shown any improvement in utilization after the decentralization packages implemented in Kerala?
• What are the basic land marks and achievements in health sector of Kerala as part and parcel of decentralization?

1.9 Objectives

The specific objectives of the present study are;

• To examine the allocation and utilisation pattern of funds  by the panchayats for health sector development in Kerala
• To study the achievements in the health infrastructure and delivery of health care services of rural health centres in Kerala after decentralization.
• To understand the problems of health care service utilisation in public health centres in the wake of decentralisation

1.10 Methodology

Kannur district of Kerala was selected for the presented study. The district has highest percentage of health expenditure among northern states of Kerala during the last five year plan (XI^th FYP) followed good health scenario and decentralised governance system. The district keeps parity with the state in many respects and ranks seven in the state on human development. The overall health status of Kannur district indicates satisfactory level. The general health status of the population can be understood from the level of life expectancy at birth. According to the report of Government of Kerala (2009), the life expectancy of the district was 75.6 which indicates overall satisfactory levels of health standards as well. The crude birth rate per 1000 population for Kannur was 17 which is almost the same as that of Kerala at 16.6. Among the major Indian states, Kerala’s Infant Mortality Rate is the lowest at 14 per 1000 live births, while it is 12 for Kannur district and it keeps parity with the state on fertility rate of 1.7 per woman and also having fine sex ratio of 1133.

Use of maternal health services in Kannur shows that nearly 90% pregnant women underwent full Ante-Natal check-up which was higher than the State’s percentage which stood at 86%. Also the percentage of women who had institutional deliveries was nearly 98% again which was above the State average of 97%. However the utility of public health services seems to be rather less compared to private hospitals as only 36% women had gone to Government health centers for child birth, as against 64% women who utilized the services of private clinics or hospitals. The coverage of complete child immunization was found to be 84% in Kannur district which is almost the same as the State’s percentage of children who are completely vaccinated for their age. The occurrence of recently evolving fevers is also low in Kannur. A total 580 cases of communicable diseases were reported in Kannur district during 2009-10. Nearly 81% were reported from the rural areas, while the urban area shows 19% of cases.

Health related institutions in the district are mainly 11 Government Hospitals [Allopathic], 82 Primary Health  Centers, 1 Dispensary and Mobiles Unit, 1 TB Centre/Clinic, 9 community health  centers, and 6 Ayurvedic hospitals. The number of medical institutions in Kannur shows that 70% of the institutions are in rural areas and the rest in urban area. There are 147 private hospitals against 9 Government hospitals and 31 private dispensaries against 17 Government dispensaries. There are 82 Public Health Centers and 10 Community Health Centers in the district.

As the study focusing on the effectiveness of fiscal decentralization on health sector development of rural Kerala, Panchayats and their health centres and beneficiaries were the pedestal for the study. The study follows descriptive and analytical method based on primary and secondary data. Secondary data collected from various published and un-published sources, official records of the panchayats and health centres.  Primary data collected from the beneficiaries of the health centres and discussions were conducted to understand the lacunas existing in delivery and utilisation of health care services from public health centres in the wake of decentralisation.

The study embraces three tiers of Panchayats, via, District Panchayats (DP), Block Panchayats (BP), Grama Panchayat (GP) and health centres, via, District Hospital (DH), Community Health Centre (CHC), Primary Health Centre (PHC) and Family Welfare Sub- Centres (SC).

Kannur district consist of 81 Grama Panchayats, 11 Block Panchayats and a District Panchayat. For the selection of samples, the Panchayats were ranked in terms of their performance in utilisation of plan funds for the last three years (2010-13) and categorised them as Best, Average and least according to the range of expenditure in three years  (2010-13). Five Grama Panchayats and two Block Panchayats from each category (Best, Average and Least) were randomly selected for the study as shown in Table 1.1

Table 1.1 Selected samples of Panchayats in Kannur District of Kerala

Type	Best	Average	Least
Grama Panchayat	Chembilode	Mayyil	Aralam
	Ancharakkandy	Pinarayi	New Mahe
	Mangattidam	Kadhirur	Valapattanam
	Koodali	Sreekandapuram	Puzhathi
	Trippangattore	Pallikkunnu	Madayi
Block Panchayat	Thalassery	Edakkad	Kannur
	Kuthuparamba	Irikkur	Iritty
District Panchayat	Kannur

More over, in order to understand the developments in health infrastructure & service delivery after decentralization, Health Centres viz, Primary Health Centres and their sub- centres under Grama Panchayats, Community Health Centres under Block Panchayats and Kannur District Hospital under District Panchayat were included in the coverage of the study.  5 CHCs, 6 PHCs and 11 Sub Centres were selected for the study which is shown in table 1.2.

Table 1.2 selection of Health Centres

Health Centres under Block Panchayats (CHCs)	Health Centres under Grama Panchayats
	Primary Health Centres (PHCs)	Sub Centres (SCs)
Irivery   Pinarayi Iritty Mayyil Panoor	Ancharakkandy   Keezhpally Kadhirur Koottumugham Mangattidam Chittaripparamba	Mananthery   Veerpad Pulliod Kottur Perumachery West Ponniam Edoor Maruvambai Palayam Kannavam Kanhileri

In order to understand the performance of panchayat authorities and health workers for the development of health sector in their jurisdiction, discussion was conducted. Panchayat presidents, secretary and health standing committee chairman and medical officers, HIs, JPHNs were included for the discussion. Their opinions and information were very useful for the present study.

To understand the utilisation nature of health care services from government health centres, primary data has been collected from the beneficiaries of health centres and discussions were followed. Total sample size of beneficiaries was fixed to 600 which includes 150 each from each health centres (150 from Kannur District Hospital, 30 each from five CHCs PHCs and sub centres). The centres for primary data collection has been randomly selected, which is shown in table 1.3

Table 1.3 selection of sample respondent

DH		CHC	PHC	SC
Kannur DH      150		Panoor         30	Keezhpally                 30	Koottur               30
		Irivery          30	Koottumugham          30	Veerpad               30
		Mayyil          30	Anjarakkandy            30	Perumachery        30
		Pinarayi        30	Mangattidam              30	Edoor                    30
		Iritty             30	Iritty                           30	Palayam                30
Total	150	150	150	150

Data and tools for the Study

Ten years [2002-2012, (X^th& XI^th FYP)] health expenditure details of the three tiers of selected panchayats were collected from the official records of Panchayats and sulekha web. Health infrastructure details of health centres were obtained from the office records of health centres. Apart from these in-depth interviews were conducted with the Panchayat & Health Centres Authorities (Presidents, Secretary and Health standing committee chair persons, Medical Officers, Health Inspectors, Health Nurses, Junior Health Inspectors and Junior Public Health Nurses etc).

The performances of Panchayats for the health sector development were measured through their resource allocation- expenditure pattern, health care service delivery, its utilisation. The primary data was collected from the beneficiaries of health centres through structured interview schedule and focus group discussion was conducted.

For the purpose of analysis statistical tools like percentage, averages, range, growth rate, correlation, panel regression, Garret ranking scale were applied in the study. Moreover statistical tests were applied to know the scientific relevance of the results.

Garrett’s Ranking Technique

Garrett’s ranking technique was used to rank the preference indicated by the respondents on different factors. As per this method, respondents have been asked to assign the rank for all factors and the outcomes of such ranking have been converted into score value with the help of the following formula:

Percent position = 100 (Rij – 0.5) / Nj

Where Rij = Rank given for the ith variable by jth respondent

Nj = Number of variables ranked by jth respondent

With the help of Garrett’s Table, the percent position estimated is converted into mean scores. For this, the score for each factor by all individual are added and then the total value of scores and mean values of the score is calculated. The factors having lowest mean value is considered to be the most important factor. For the above mean score, Garrett’s ranking table gives the Garrets scores that represent the equivalent rank on a scale of 100 points.

1.11 LIMITATIONS

The most limitation of studies on decentralization was the lack of adequate information. There are no clear documents about devolution of funds at the earliest stages of decentralization. Even though decentralization implemented since 1995 in Kerala, the data used for the presented study were limited to X^th and XI^th plan due to the problem of availability of information. The details about allocation and expenditure pattern of micro sectors during the IXth plan were not properly recorded. Execution of e-governance and establishment of sulekha web were very useful for the present study at the stage of data gathering, computerisation in Panchayats helped lot.

The study focusing health sector developments in Kerala on the basis of allocation and utilisation of resources, infrastructure development, service delivery and improvements in utilisation of services. Apart from that the samples for the study were limited to rural areas. Governments and their health centres in urban areas were not incorporated for the present study.

Moreover, the different aspects of decentralization (political, administrative and fiscal) have combined effect, the present study focusing only fiscal aspects of the decentralization.

Non- co-operative attitude of the officials in the panchayats and Health centres were also a challenge for getting adequate information easily.

Apart from secondary data, primary survey and discussion was conducted to fulfil the objective of understanding the problems of health care service utilisation in public health centres in the wake of decentralisation. The accuracy of responses and bias from the respondents forms another limitation faced by the study.

1.12 Chapter Scheme

The present study is divided in to seven chapters for the sake of clear and meaningful presentation. The first chapter gives introduction to decentralised governance, its origin and scenario in India, statement of the research problem, objectives, methodology and limitations. The second chapter carries out review of literature, which includes theoretical and empirical reviews. The third chapter focuses concepts and method of decision making under decentralisation. Fourth is an over view of decentralised governance and health sector development in Kerala. The fifth chapter discussed allocation and utilisation of resources in panchayats under study area. Sixth chapter presents health infrastructure in Kannur district and seventh chapter analysed utilisation pattern and problems of health care service delivery in the wake of decentralisation. The final chapter is the summing up of the study gives summary, conclusion and findings.

REFERENCES

Ashokan A (2009), “Health Care Development in Kerala: Some issues and policy options” , Kerala Economy: Trends during the post reform period (etd) Rajan K Serial Publications, New Delhi.

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