Decentralization of Health Services: The Kerala People's Campaign

Abstract

The 1996-2001 Kerala People's Campaign for Decentralized Planning has provided much new information about the possibilities and potential of decentralizing public health and health care services. Analysis of investment patterns of the various government levels involved in the campaign, supplemented with case study materials, allows for an evaluation of the decentralization project against its own stated goals. These included (1) creating a functional division among government levels appropriate to the health tasks each level can best perform; (2) generating projects that reflect the felt needs of the people, as voiced through local participatory assemblies; (3) maintaining or increasing levels of equality in health, especially with regard to income, caste, and gender; (4) stimulating communities to mobilize voluntary resources to supplement devolved public funds; (5) stimulating communities to create innovative programs that could become models for others; and (6) making the health services function more effectively overall. The analysis supports the conclusion that the campaign achieved each of the goals to a large degree. Shortcomings arose from the inexperience of many local communities in drafting effective projects as well as problems deriving from the fact that some sections of the health bureaucracy could not be decentralized. Lessons of the campaign are already being applied to new programs in Kerala.

Anchoring contextual analysis in health policy and systems research: A narrative review of contextual factors influencing health committees in low and middle income countries

“…In India, while the 1993 constitutional amendment sought to increase the power of local governments across the country, this reform was most deeply implemented in the state of Kerala, largely due to the influence of leftist political parties and labor movements there (Heller et al, 2007, Elamon et al, 2004. In contrast to Scholeitner's (2006) concern about elite capture in Brazil, in Kerala only 4% of respondents thought that "powerful private interests" exerted influence over project selection by village committeesda finding they link to Kerala's history of land reforms, lower class mobilization, and the deep penetration of competitive party politics into rural life, which limited the power of landed elites (Heller et al, 2007, p. 637).…”

“…In contrast to Scholeitner's (2006) concern about elite capture in Brazil, in Kerala only 4% of respondents thought that "powerful private interests" exerted influence over project selection by village committeesda finding they link to Kerala's history of land reforms, lower class mobilization, and the deep penetration of competitive party politics into rural life, which limited the power of landed elites (Heller et al, 2007, p. 637). Several studies linked the decentralization reform to improved village level health facility infrastructure and equipment, widened health care delivery, and better provision of drinking water and sanitation facilities (Elamon et al, 2004;Rajesh and Thomas, 2012). However Varatharajan et al (2004) expressed concern that decentralization reduced overall financial resources for primary health centers, because health staff lacked skills to lobby for funding in competition with other sectors at these local levels.…”

Health System Regionalization in Canada's Provincial and Territorial Health Systems: Do Citizen Governance Boards Represent, Engage, and Empower?

“…The engagement of local citizens was cited as a means both to ensure that the system was aware of and responsive to the health needs of local communities and to increase accountability to local citizens and communities (9)(10)(11)(12)(13)(14)(15). Calls for greater citizen involvement in decision-making and governance are not limited to the Canadian health care scene and, indeed, are occurring in other public sectors and in other countries (16)(17)(18)(19)(20)(21).…”

Relying on serendipity is not enough

“…However, a key feature of Kerala’s overall governance has been a decentralised model, a variable that is notably not included in the Niti Ayog index under the domain of governance and information. The decentralised model started with the movement called People’s Campaign for Decentralised Planning, and the subsequent Kerala Panchayat Act 1994 and Kerala Municipalities Act 1994 helped ensure that decentralised planning was there to stay in the state (Elamon et al 2004 ). The participation of, and shouldering responsibility for various functions related to health, education, sanitation etc.…”