1. FORMULACIÓN DEL PROBLEMA
7.2 ANALISIS DEL DESARROLLO
Shimla and Kangra are typical districts for Himachal Pradesh (see Picture 4.1 and 4.2). Shimla has a population of 700,000 of which 77 % reside in rural areas. Kangra has 1.34 million inhabitants with 95 % living in rural areas (Ministry of Home Affairs 2005a). The share of scheduled castes is very high. They compose 19 to 28 % of the block population (Ibid.). The majority of the population works in the agricultural sector, especially women are dominant in this employment sector (see Figure 4.3). The possession of household assets is low (see Figure 4.4). One quarter of all households does not have any household asset. Ownership of motorized vehicles is rare. In Kangra more people have a scooter, motor cycle, moped or bicycle than in Shimla. While the availability of televisions in both districts is higher than of telephones, television is more common in Kangra. Radio in turn is more spread in Shimla. The significant difference in television and radio ownership could be the result of the different landscapes, Kangra has more flat areas, or of different socio-economic factors, more affluent household in Kangra.
Figure 4.3: Percentage of Workers in the Agri-sector in Shimla and Kangra
Figure 4.4: Available Assets in Rural Kangra and Shimla
Available Assets in Rural Kangra and Shimla 2001 (in % of population)
0 10 20 30 40 50 60 70
Radio, Transistor Television Telephone Bicycle Scooter, Motor Cycle, Moped Car, Jeep, Van None
Shimla Kangra
Source: own design; data: Ministry of Home Affairs 2005a
Percentage of Workers in the Agri-sector in Selected Blocks of Shimla and Kangra
0 10 20 30 40 50 60 70 80 90 100
Thural Shahpur Chaupal Chirgaon
Workers in Agri-sector Men Women
Access to drinking water sources for rural households in both districts is good, more than three quarters of the population have tap water at their disposal (see Figure 4.5). The rest relies on wells and handpumps. Although electricity is used for lighting in most households, fire wood is the dominant fuel for cooking (see Figure 4.6). The second source for cooking is Liquefied Petroleum Gas (LPG) followed by kerosene. Fire wood is not energy-efficient and further causes indoor air pollution. Deforestation is another negative result of fire wood use. It is common for rural households in the two districts to have no latrine and no drainage facilities (see Figure 4.7). Villagers use the fields and surrounding grounds of their houses to get rid of their excrements. Garbage is left outside for decay. The concept of composts or biogas plants has only recently come up, but is not widespread in backward areas. The lack of latrines and drainage facilities leads to pollution of surface water. Although the overall population and the population density in the districts are low, environmental degradation and pollution are serious problems also affecting health. Literacy rates in the four blocks are not sufficient (see Figure 4.8). Female literacy is far below male literacy in all blocks, because girls drop out of school earlier to help with the household chores. The above-mentioned household characteristics show that the majority of people in the selected districts and blocks mainly work in agriculture, seem to be deprived of household assets especially transport facilities, seem to use fire wood for cooking and seem to have no access to sanitation facilities. Positive features are good access to tap water and electricity. These attributes significantly outline that overall living conditions are low in the districts and blocks. The effect of poverty on health has been highlighted several times (see above), health outcomes in the selected blocks will therefore be unsatisfactory as well. Participation and decentralization have to take these conditions into account.
Figure 4.5: Drinking Water Source in Rural Shimla and Kangra
Drinking Water Source in Rural Shimla and Kangra 2001 (in %)
0 10 20 30 40 50 60 70 80 90 100
Tap Handpump Tubewell Well Tank, Pond, Lake River, Canal Spring Other
Shimla Kangra
Figure 4.6: Fuel Used for Cooking in Rural Shimla and Kangra
Figure 4.7: Drainage and Latrine Facilities in Rural Households in Shimla and Kangra
Fuel Used for Cooking in Rural Shimla and Kangra 2001 (in %)
0 10 20 30 40 50 60 70 80
Fire Wood Crop Residue Cowdung Cake Coal, Lignite, Charcoal Kerosene LPG Electricity Biogas
Shimla Kangra
Source: own design; data: Ministry of Home Affairs 2005a
Drainage and Latrine Facilities in Rural Households in Shimla and Kangra 2001 (in %) 0 10 20 30 40 50 60 70 80 closed open no pit latrine water closet other latrine no latrine dr ainage lat rin e Shimla Kangra
Figure 4.8: Female and Male Literacy Rates in Selected Blocks
4.1.2. Analysis
The analysis of participation and decentralization in the selected districts will follow the theories outlined in 2. First decentralization at the PHC level will be evaluated with Bossert’s decision space approach (see Bossert 1998; Table 4.1). Table 4.1 shows the indicators for the functions finance, service organization, human resources, access rules and governance rules and the range of choice which exist for these indicators. The functions “Insurance Plans” and “Payment Mechanisms” were excluded (compare Table 2.2 and 4.1) as they are not relevant for the discussion here. Health insurance is virtually absent and public health services are free of charge (see 3.2.). The decision space grows with the range of choice. The wider the range of choice, the more decision space the individual actors have. Narrow range of choice points towards a centralized health system, while wide range of choice would apply to a decentralized health system. Decentralization within the public health system to lower levels of the hierarchy, district and below, will be at the centre of the analysis.
After that, the degree of community participation will be measured using Murthy and Klugman’s framework (see Table 2.1, Murthy/ Klugman 2004: i79). Definition of community, representation of community, rationale for participation in health, depth, scope, and mode of community participation will be rated from lower to higher degrees of community participation. The higher the degree of community participation, the higher are the expected positive influences on the health system and the health status of the population.
Female and Male Literacy Rates in Blocks 2001 (in %)
85 74 87 90 68 47 70 76 0 10 20 30 40 50 60 70 80 90 100
Chaupal Chirgaon Shahpur Thural
Male Female
Table 4.1: Map of Decision Space for Analysis (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
Having assessed the degree of decentralization and participation, the study will look into the chances for success of community participation as it is emphasised in the new National Health Policy 2002. Table 4.2 shows the indicators for successful participation like interest in participation, communication and information transfer, responsiveness, motivation, accountability, sustainability and control over resources. The indicators for this table are derived from the theoretical discussion of participation in the previous chapters (see 2.2.1.2./ 2.3.2.1.-2.3.2.2.; Table 2.3). The two major players at the community level as defined by the government, Medical Officers (MO) and NGOs, were selected for the
analysis. Community participation is dependent on their decisions and behaviour. The ranges for the indicators follow a similar pattern like Bossert’s map of decision space. The higher the range for the indicators, the higher is the chance of successful participation. The approach to community participation is essential for many of the indicators. The indicators are ranked using Rifkin’s distinction between “bottom-up” and “top-down” approach (Rifkin 1996). The “bottom-up” approach stands for community participation in the tradition of the Primary Health Care Approach, therefore indicating a high chance of successful participation (see 2.2.1.2./ 2.3.2.2.). “Top-down” community participation in turn rather stands for a moderate chance, because it does not include empowerment. However, it is the first step towards community participation. The map of participation is a new tool to evaluate the chances for successful participation. Even though it will be used in these case studies for the local level, it could also be valuable for other scales. The following case studies will prove its usefulness for researchers and policy makers.
Table 4.2: Map of Participation for Analysis
(adapted from Atkinson 2002; Murthy/ Klugman 2004; Metzger 2001; Rifkin 1996; Westergaard 1986)
Indicator for successful participation
Range of indicators
low moderate high
Interest in participation
for MO No interest Interested in top-down participation
Interested in bottom-up participation
for NGO No interest Interested in top-down participation
Interested in bottom-up participation
Communication and Information Transfer
within public health system
Top-down, limited information
Top-down and within the same hierarchy, selected information
Top-down, bottom-up and within the same hierarchy, all information within NGOs Top-down, limited
information
Top-down and within the same hierarchy, selected information
Top-down, bottom-up and within the same hierarchy, all information between public health
system and community
No communication, no information transfer
Top-down, only programme related
Top-down, bottom-up, demand oriented and culturally sensitive between NGOs and
community No communication, no information transfer Top-down, only programme related Top-down, bottom-up, demand oriented and culturally sensitive between public health
system and NGOs
No communication, no information transfer
Top-down, only programme related
Responsiveness MO No responsiveness to community needs Responsiveness to community needs as defined by the programme (top-down) Open responsiveness to all community needs
NGO No responsiveness to community needs Responsiveness to community needs as defined by the programme (top-down) Open responsiveness to all community needs
Motivation for participation
MO No incentives/ benefits Incentives/ benefits by government (extrinsic)
Incentives/ benefits by government and
community (extrinsic and intrinsic)
NGO No incentives/ benefits Incentives/ benefits by government and donors (extrinsic)
Incentives/ benefits by government, donors and community (extrinsic and intrinsic) Accountability MO To higher government authorities To local government authorities To community
NGO To higher government
authorities, donors To local government authorities, local organizations To community Sustainability
MO Top-down approach Top-down with
community involvement
Bottom-up approach, community involvement
NGO Top-down approach Top-down with
community involvement
Bottom-up approach, community involvement
Control over resources
MO Defined by law or higher authorities
Several models for control over resources
Free control over resources NGO Defined by law or higher
authorities, donors
Several models for control over resources
Free control over resources
Experience of participation
MO No or bad experience Indifferent experience, participation was not helpful
Good experience, participation was helpful
NGO No or bad experience Indifferent experience, participation was not helpful
Good experience, participation was helpful
In the analysis none of the interview partners will be cited by name, because of official discretion. Since most interview partners are either employed by the civil service or in other ways dependent on the government, their statements could lead to inconveniences for them. Therefore, citations are composed of the position of the interviewee and the date of the interview. However, a complete list of all interview partners can be found in Annex V.
4.1.2.1. Decision Space of Medical Officers
In Shimla and Kangra district 27 Medical Officers were interviewed with the aid of a standardized questionnaire (see Annex I) of which 16 were assigned BMOH and two hold the post of Senior Medical Officers (SMO) from Community Hospitals. Pictures 4.3 and 4.4 show the workplace for MOs and BMOHs. Expert interviews were held with seven district officials including the CMOH Shimla. The district officials were met twice or trice in the monthly meeting with BMOHs and in several visits. At the state level expert interviews took place with the Deputy Director Health and the Deputy Director Management Information Systems.
Picture 4.3: PHC Bhadyara, Chirgaon