Conclusion of Case Study Himachal Pradesh

The National Health Policy 2002 envisions NGOs to deliver health services, participate in National Health Programmes and to motivate and inform community to participate.

Himachal Pradesh’s small NGO sector is involved in health programmes and PARIKAS.

The current status of community participation only reaches a middle degree (see Table 4.4). Participation in Himachal Pradesh mainly concentrates on relatively easy-to-reach people. Community is represented through powerful groups in the population and NGOs.

At district level community participation is used as a means to expand outreach and support the infrastructure. People participate through small collectives like PRIs or PARIKAS which are established through invitation by the government. Advice, consultation and service delivery for the community are the focus of community participation as well as some community involvement in the management of health facilities at the periphery. The heterogeneity of communities and their fragmentation through class and caste barriers hinder community participation. Low living standards in the selected districts and the low literacy rates are further obstacles to community participation.

Decentralization in Himachal Pradesh’s public health sector focuses on PRIs and PARIKAS, but fails to create more decision space for MOs and BMOHs (see Table 4.3).

Decision space is narrow in the districts. Control of the agents by central levels of administration at the state or national level is thus strong. MOs lack the means to implement PRI suggestions and recommendations as they do not have the autonomy to react. Responsiveness of the public health system is moderate (see Table 4.5).

Furthermore, dependency on allocated budgets is strong up to the district level, disabling public health officials to respond to community demands.

Although the interviewed NGOs in the two selected districts show a high chance for successful participation (see Table 4.5), their number is limited. The map of participation discussed the indicators for successful participation in detail and proved useful for the identification of problem areas for participation at the local level. Accountability, control over resources, sustainability and motivation have the lowest values (see Table 4.5). Lack of accountability negatively affects responsiveness. The key role of MOs as stakeholders in the community participation process has been overlooked by policy makers. Incentives and benefits to enhance their motivation are missing. Another obstacle to successful participation is the conflict of interests between MOs and NGOs, who both have different conceptions of community participation (see Figure 4.21 and 4.22). While NGOs want to empower the community to request better public services, MOs want the community to comply with their health programmes. Empowerment of the community especially of marginalized groups endangers the existing local power structures including the position of the MO. Hence, his/her attitude towards community participation is rather “top-down”

oriented. The educational gap between the doctor and his/her patients enhances the MO’s distrust. The lack of decision space not only disables the MO to react to community demands, but also leads to inactivity on his/her side. Doctors rather blame the government for the lack of facilities, staff and budget than to take responsibility for their

own actions and search for solutions. Narrow decision space in the public health sector and dependency on funding of NGOs limit the control over resources. Sustainability cannot be achieved with low motivation and lack of accountability.

At the district level low quality of health services has always been explained by the low budget and the lack of staff too, motivation did not figure in these explanations. However, from the case studies and field visits it became obvious that work motivation of MOs can make a difference regarding cleanliness for example. MOs are under high pressure to fulfil all their administrative tasks, to manage the health facility, the staff and the National Health Programmes and to treat patients at the same time. Furthermore, it is the MOs who are blamed if the targets are not reached. Thus, their resignation in view of all these problems is comprehensible.

MOs expect from community participation through NGOs a reduction of their tasks and relief for their work. The majority of them like to treat patients and rather want to concentrate on this part of work. The health services at the facilities suffer from the administrative work, not only due to time constraints but also as MOs have to travel to attend meetings and trainings and to control subordinate facilities. Therefore, it is the organization of work as such which requires improvement. The case study shows that the establishment of trust relationships between NGOs and the community requires time.

Dialogue between the community and the doctor takes time as well. Up to now the framework for community participation is missing. The multi-sectoral approach as recommended by the Primary Health Care Approach is also needed here. The basic requirements in the population have to be created first before community participation can take place. The government seems to skip that step but will not be able to achieve the expected results.

Quality of care is influenced by the degree of decentralization, community participation, empowerment, accountability and responsiveness (see Figure 2.2; Atkinson et al. 2000).

Figure 4.25 shows the range of indicators in their relation to quality of care. Narrow decision space stands for a low degree of local autonomy in the public health sector, which has a negative influence on participation. The less local autonomy is available the less space for local voice exists. Community participation takes a middle degree (see Table 4.4). Hence, its impact on empowerment and accountability will also be moderate.

The findings from the study show that accountability in the public health sector is low (see Table 4.5). Low accountability and narrow decision space cannot improve the moderate responsiveness. The current policy of decentralization and participation is not fit to improve the quality of health care. The benefits of decentralization for quality of care will thus be low to moderate (see Figure 4.25).

The current status of quality of public health care has been highlighted in 3.2. The findings from this case study support the literature. Following the explanations from above, it is unlikely that utilization rates for public services in the sample districts will increase through decentralization and community participation. Incidences of diseases will hardly be influenced through these measures. It can be anticipated that people will further rely on private health services. Inequalities in utilization and inequalities in access to health

services will remain. The primary health care goal of equity thus continues to be out of reach.

Figure 4.25: Benefits of Decentralization in Himachal Pradesh

Source: adapted from Atkinson et al. 2000: 620 Quality

of Health Care LOW to MODERATE Responsiveness of

Health System MODERATE

Accountability of Health System

LOW Decision Space

NARROW

Benefits of Decentralization

Participation MIDDLE

Empowerment