No abstract

Various attempts have been made in India with respect to decentralization, most significantly the 73rd Amendment to the Constitution of India (1993) which provided the necessary legal framework for decentralization to take place. However, the outcome has been mixed: an evaluation of the impact of decentralization in the health sector found virtually no change in health system performance and access to health services in terms of availability of health personnel or improvement in various health indicators, such as Infant Mortality Rates or Maternal Mortality Ratio. Subsequently, there has been a conscious effort under the National Rural Health Mission (NRHM)-launched in 2005-to promote decentralization of funds, functions and functionaries to lower levels of government; and Karnataka had a head-start since devolution of all 29 functions prescribed by the 73rd Amendment had already taken place in the state by the late 1990s. This study presents the findings of an on-going research effort to build empirical evidence on decentralization in the health sector and its impact on system performance. The focus here is on analyzing the responses of health personnel at the district level and below on their perceived 'Decision Space'-the range of choice or autonomy they see themselves as having along a series of functional dimensions. Overall, the data indicate that there is a substantial gap between the spirit of the NRHM guidelines on decentralization and the actual implementation on the ground. There is a need for substantial capacity building at all levels of the health system to genuinely empower functionaries, particularly at the district level, in order to translate the benefits of decentralization into reality.

This paper analyses constraints to scaling-up successful health interventions and opportunities for relaxing such constraints in Tamil Nadu and Karnataka states. The analytical framework used in the paper categorizes constraints by the level at which they operate. A comparison of the implementation of selected health programmes in Karnataka and Tamil Nadu is appropriate since there are good chances of replicating each others' successes. The case study indicates that in order to scale-up interventions, a combination of actions is required, including: adequate community involvement; clear focusing of objectives and information systems for measuring achievements against them; good technical design; and specific measures to address constraints at the policy and strategic management level. Copyright © 2003 John Wiley & Sons, Ltd.

The Government of India has adopted decentralization/devolution as a vehicle for promoting greater equity and supporting people-centred, responsive health systems. This article reports on our year-long intervention project in Karnataka, South India, and articulates insights of both practical and theoretical significance. It explores the intersection of the political goal of enhanced local level autonomy and the programmatic goal of more responsive health service delivery. Focusing on the Village Health, Sanitation and Nutrition Committees (VHSNCs) set up under the National (Rural) Health Mission (NHM), the project set out to explore the extent to which political and programmatic decentralization are functional at the village level; the consonance between the design and objectives of decentralization under NHM; and whether sustained supportive capacity building can create the necessary conditions for more genuine decentralization and effective collaboration between village-level functionaries. Our methodology uses exploratory research with Panchayati Raj Institution (PRI) members and functionaries of the Health Department, followed by a year-long capacity building programme aimed at strengthening co-ordination and synergy between functionaries responsible for political and programmatic decentralization. We find that health sector decentralization at the village level in Karnataka is at risk due to lack of convergence between political and programmatic arms of government. This is compounded by problems inherent in the design of the decentralization mechanism at the district level and below. Sustained capacity building of the VHSNC can contribute to more effective decentralization, as part of a larger package of interventions that (1) provides for financial and other resources from the district (or higher) level to political and programme functionaries at the periphery; (2) helps the functionaries to develop a shared understanding of the salience of the VHSNC in addressing the health needs of their community; and (3) supports them to collaborate effectively to achieve clearly articulated outcomes.