4 THE PARTICIPATORY APPROACH IN THE NATIONAL HEALTH POLICY 2002
4.2. CASE STUDY: MAHARASHTRA
4.2.2. Analysis
4.2.2.1. Decision Space of Medical Officers
Sufficiency of Budget for MOs (in %)
0 10 20 30 40 50 60 70
more than sufficient
sufficient insufficient by far insufficient
n = 95
Picture 4.10: Rural Hospital Mahad, Raigarh District
Picture 4.11: PHC Wada, Khed Block, Pune District
Figure 4.34: Sufficiency of Budget for MOs in Pune and Raigarh
The allocation of expenditure is also decided at higher authorities at the state level. All local spending is earmarked for specific programmes or activities. The system of allotted budget is the same as in Himachal Pradesh (see 4.1). Service fees are decided at the state level too. The registration fee for outpatient service at the PHC is Rs. 2 in all of Maharashtra, otherwise all services at the PHC are free. Patients below the poverty line are exempted from this fee. MOs cannot award contracts for major works but they can use the funds from the registration fees to hire locals for minor work (ADHO 06.12.2003). In case of major works funds have to be released from the state level Health Department to the Public Works Department (PWD), which is responsible for the maintenance of PHCs as in Himachal Pradesh. The PWD is not under the administrative control of the Health Department. At the district level the executive engineer Zilla Parishad is responsible for the maintenance of PHCs and SCs (DHO 09.02.2004). The usual procedure in case of broken equipment for MOs is to call their superiors, 92 % do call their superiors at the district level. The superior performs all following action in most of the cases (57 %) or advises the MOs what to do (35 %). Half of the MOs also call the PWD. On an average it takes 7 weeks to have a repair carried out. External repair is called by 53 % of MOs, in these cases it takes 2 weeks for repair. If equipment is broken and cannot be repaired, purchase of new equipment is rare. Only 29 % of MOs reported new purchases in these cases. The major reasons for no new acquisitions are financial shortage (60 %) and no permission (38 %). The example shows that even in case of repairs money has to be allocated by higher authorities and the decision space for MOs is narrow (see Table 4.6).
The range of choice for external contracts for repairs depends on the available funds and the decisions of the community health committee. Only half of all MOs use this chance.
Therefore, the range of choice is still narrow and the maintenance of PHCs is very bad (see Picture 4.12 and 4.13).
Picture 4.12 (left): IPD in PHC Abtali, Junnar Block, Pune District
Picture 4.13 (above): Non-functioning Operation Theatre, PHC, Raigarh District
Sufficiency of Salary for MOs (in %)
0 5 10 15 20 25 30 35 40 45 50
more than sufficient
sufficient insufficient by far insufficient n = 95
The functions for service organization are hospital autonomy and required programmes. It has already been outlined above that the decision space is narrow for finance. The range of autonomy for PHCs is defined by law or higher authorities as even the rules for community health committees are made at state level. Therefore, MOs cannot make free decisions or use the budget for other purposes than the ones stated in the rules. Norms or targets for local programmes are also decided at state level, due to rigid norms the range of choice is narrow (see Table 4.6). Targets for family planning for example are set according to the number of eligible couples in the area and the couple protection rate26 (ADHO 06.12.2003). The ground data is collected by MPWs. Although Maharashtra has adopted the target-free approach in 1997 (Public Health Department 2002: 12), targets are still felt to be there (MO 30.04.2003).
Salaries, contracts and civil service come under the function human resources. The salary for MOs ranges from Rs. 10,000 to 20,000 per month depending on their years of service (ADHO 06.12.2003). Extra allowance of Rs. 300 to 400 is paid to MOs serving in tribal areas27. Half of the MOs interviewed (53 %) find the salary insufficient or by far insufficient (see Figure 4.35). Salary range is defined by law or higher authorities. The decision is made at the state level, indicating a narrow range of choice (see Table 4.6).
Figure 4.35: Sufficiency of Salary for MOs in Pune and Raigarh
Contracting non-permanent staff is not possible at the PHC level. The range of choice is thus narrow. The lack of staff is experienced at 75 % of PHCs questioned in Pune and Raigarh district. Most PHCs require MOs, MPW and nurses but service personnel and specialists are also needed (see Figure 4.36). Among the specialists lab assistant and gynaecologists are most sought after. Although two MPWs are required for each SC by law, every PHC in the two districts has in its service area a mean of one SC without MPW, four SCs with one MPW and three SCs with two MPWs. SCs with none or only one MPW are not fully functionable. Hence, 63 % of SCs under the supervision of one PHC cannot perform the required tasks.
26 - couple protection rate = percentage of people using contraception (ADHO 06.12.2003)
27 - high percentage of scheduled tribe population in one area
Staff Needed by MOs (in %)
31 32 33 34 35 36 37 38 39
Service Personnel
Nurses MPW MO Specialists
n = 111 Figure 4.36: Staff Needed by
MOs in Pune and Raigarh
The state government thinks about hiring private doctors for public services to circumvent the lack of doctors in the public sector. However, private doctors are also unwilling to work in remote areas and decisions are again made at the state level without local involvement.
Firing of permanent staff is only possible in most severe cases. In case of very bad performance the annual rise can be frozen (ADHO 06.12.2003). Work absenteeism is punished by cuts in pay for the absent time. If doctors are absent all the time the annual rise is stopped (Ibid.). Hiring of staff is decided at the state level. The existence of the national civil service allows only a narrow range of choice in hiring and firing practice.
Sanctions for misbehaviour are thus weak in character and rare in appearance.
The definition of priority populations and the definition of size and composition of facility boards and district offices are made by higher authorities at the state level. The functions access rules and governance rules for these indicators are therefore narrow (see Table 4.6). The composition of priority population depends on the respective National Health Programme. Since the Family Welfare Programme has the largest budget, the main focus in health care delivery is on women and children. Facility boards only exist at higher levels, PHCs and SCs do not have these boards. Although the district health administration is under the control of Zilla Parishad, it has no influence on size and composition of this administration. Size and composition of Zilla Parishad is defined by central government law (see Rai et al. 2003). Community participation through community health committees, NGOs and the community needs assessment approach adopted in 1997 is codified by law or defined by higher-level authorities. Thus, the range of choice is narrow again.
So far the decision space for all functions listed in Table 4.1 is narrow (see Table 4.6).
The experiences from the MOs support this finding. The majority of them agreed that all planning is done at the district level (60 %), fewer hold the opinion that all planning is done at the state level (31 %). However, they also voiced that they deliver a plan to the district (36 %) and that planning is demand-based (61 %). Decentralization in Pune and Raigarh district involves financial and administrative decentralization, but the decision space is narrow (see Table 4.6). It can be summarised that decentralization did not create more autonomy at the lower administrative levels. Nevertheless, only 25 % of MOs recommend
Changes MOs Recommend (in %)
55 56
83 29
41 43 38 14
13
62 25
20
0 10 20 30 40 50 60 70 80 90
more decision-making power over financial issues more budget better medicine supply more interactions with health professionals better communication with superiors better communication with patients better info about health demands higher service fees more personnel better infrastructure and facilities more autonomy better patient documentation
n = 91
more autonomy to improve their health facilities and 55 % want to have more decision-making power over financial issues (see Figure 4.37).
Figure 4.37: Changes MOs Recommend to Improve Public Health Care in Pune and Raigarh
Table 4.6: Map of Decision Space for Maharashtra, Pune and Raigarh District (adapted from Bossert 1998: 1519)
Function Indicator Range of
Choice
narrow moderate wide
Finance
Sources of
revenue Intergovernmental transfers as
% of total health spending High % Mid % Low % Allocation of
expenditure % of local spending that is explicitly earmarked by higher authorities
High % Mid % Low %
Fees Range of prices local authorities are allowed to choose
No choice or narrow range
Moderate range No limits Contracts Number of models allowed None or one Several
specified No limits Service
organization
Hospital
autonomy Choice of range of autonomy for
hospitals Defined by law
or higher authority
Several models
for local choice No limits
Required
programs Specificity of norms for local
programs Rigid norms Flexible norms Few or no norms
Human Resources
Salaries Choice of salary range Defined by law or higher authority
Moderate salary range defined
No limits
Contract Contracting non-permanent staff
None or defined by higher authority
Several models for local choice
No limits
Civil service Hiring and firing permanent staff National civil
service Local civil
service No civil service Access
rules
Targeting Defining priority populations Law or defined by higher authority
Several models for local choice
No limits
Governance rules
Facility
boards Size and composition of boards Law or defined by higher authority
Several models
for local choice No limits District
offices
Size and composition of local offices
Law or defined by higher authority
Several models for local choice
No limits
Community
participation Size, number, composition, and
role of community participation Law or defined by higher authority
Several models
for local choice No limits