Decentralization and decision space in the health sector: a case study from Karnataka, India

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.

Who should decide for local health services? A mixed methods study of preferences for decision-making in the decentralized Philippine health system

“…In Kenya, a country with a much younger history of devolution since 2013, one study described how devolution ironically decreased local level decision space and recommended transferring more autonomy to county hospitals [46]. Other studies likewise reported a preference to expand decentralization by increasing capacities in Tanzania [47] and India [17], and by widening local decision space further for human resources management in Ghana [48] and Uganda [13], and for several functions in Fiji [16].…”

“…A number of studies, drawing from the decision space framework, have assessed the extent of autonomy enjoyed by local decision-makers in countries that have decentralized or devolved their health systems [12][13][14][15][16][17]. Most have attempted to come up with an overall or summative assessment of local decision space yet, in practice, decision-making for health services often involve multiple actors, each of whom may be wielding varying degrees of influence into the decision-making process.…”

The Sub-National Politics of Setting Health Development Agenda: An Insight Into Yobe Health Development Plan

“…Within the broader perspective, this indicates that since Nigeria is a UN member state, the influence of international health development goals like the GHI which prescribed how health funding, functioning and functionaries were to be achieved at the lower levels of government (Seshadri et al, 2016) is similarly felt in the country and in Yobe state. In fact, Nigeria's NSHDP adopted from the GHI like the health-related MDGs have emphasised reduction of child mortality, improvement in maternal health and efforts to combat communicable and non-communicable diseases by 2015 (Oyibocha et al, 2014).…”

“…However, as policy makers and politicians are faced with numerous public health issues among other socio-economic challenges in Low and Middle-Income Countries (LMICs), how such decisions are made are often limited and challenging (Yang and Qian, 2016).To advance this key argument, we pose the question: what persuades policy makers to select certain public health priorities from competing for policy issues particularly in LMICs like Nigeria and Yobe state in particular? This is important as although there are various regional and national studies on HDA, the current literature simply ignored the roles of sub-national governments where in most cases such responsibilities lie with them (Seshadri et al;Umar and Bawa, 2016). Similarly, McCollum et al (2016) have argued that the while the global and national goals remain similar, the performance at sub-national national may depict different scenario with discrepancies that may bring about the potential for prioritisation in terms of goals in achieving health development in a particular place.…”

Decision Space and Capacities in the Decentralization of Health Services in FijiComment on "Decentralisation of Health Services in Fiji: A Decision Space Analysis"

“…3 It has proven to be a useful framework to several other researchers, including most recently in Karnataka, India. 4 It is interesting to note that the approach does not seem to depend on the size of the country and that it can be applied to large states in India as well as to a small island country like Fiji. My approach also examines the relationship between "decision space" and the local capacities to exercise better choices.…”