Decentralization and delivery of public health services

Abstract

This paper looks at a specific governance reform initiative-decentralization-and studies its impact on the delivery of public health services in the tribal areas of Chhattisgarh State. The study examines the assumption that decentralization can lead to a strengthening of accountability relationships between actors in the service delivery chain i.e., between clients/citizens, policymakers and frontline public service providers. The study also addresses the issue whether strengthening of social accountability of frontline health service providers is leading to better process control in the delivery of public health services that can potentially lead to better health outcomes. Finally, the study analyses the degree of choice /discretion in decision making that rural local bodies possess in several functional areas regarding public health services delivery and how this expanded decision space is being utilized. The study analyses the operationalization of social accountability and concludes that for the frontline health service providers, there has been a shift away from the traditional hierarchical system of accountability in which health workers were accountable for performance only towards their official superiors. The service providers are now accountable for their performance to the community also and the community enforces this accountability through the rural local bodies. The study also concludes that strengthening of social accountability in health service provisioning has led to greater empowerment of rural local bodies vis-a-vis the service providers. There is greater awareness and discussion of health related issues in the panchayats and the gram sabhas and there is better access to primary and preventive healthcare services due to the availability of health workers in the villages. Regarding the use of the expanded 'decision space' post decentralization, it was seen that rural local bodies have a moderate range of choice in some human resource functions. The authority to review and monitor health service providers is being put to good use in enforcing availability of health workers in their service areas. However, the potential created by an expanded decision space in some other areas is not being used. This is an exploratory study based on a survey conducted on panchayat representatives and frontline health service providers in Bastar district of Chhattisgarh state. The primary data was analyzed using simple descriptive statistics.