Estado del arte

4.2.2.3.4. Motivation for Participation

The government in Maharashtra offers no incentives or benefits to motivate MOs for participation, the situation is similar to Himachal Pradesh. Work motivation among the MOs is also low. Although MOs said that they are satisfied with their work, they rated their working conditions as not so good (see Figure 4.53 and 4.54). Major problem areas are political interference (64 %), lack of financial power and lack of infrastructure (56 % both) (see Figure 4.55). Work overburden, no budget for repairs, lack of medicine and lack of staff were also important problems mentioned by the majority of MOs. Political interference already points towards the influence of local elites on the work of MOs. Hence, it can be translated as interference of other powerful groups. The purpose of community participation is interference and control over resources. NGOs in Pune and Raigarh see their major working areas in “pressure public health system for better performance”, “make public health system aware of community needs” (88 % each) and “inform villagers about their rights” (82 %) (see Figure 4.56). Their goal is thus political interference as well. MOs motivation for participation is negatively affected through this conflict of interests. Furthermore, previous discussions have already shown that they are more interested in “top-down” participation. Other incentives or benefits for participation

MO Satisfaction with Their Work (in %) 0 5 10 15 20 25 30 35 40 45 very much satisfied

satisfied not satisfied with some

not satisfied n = 97

MO Rating of Their Working Conditions (in %)

0 10 20 30 40 50 60

very good good not so good bad

n = 98

could come from the community or NGO side. In fact, NGOs support MOs through small donations in kind or through motivation of villagers for the health programmes. NGOs also voiced their opinion that they can further motivate public health personnel (76 %) as one task to improve the public health system. High attendance of PHC outreach activities and fulfilment of targets are positive for the MO’s image in front of his/her superiors. Although some interest for participation and some benefits exist, motivation for participation is set back through the lack of infrastructure which is the foremost problem of all MOs in the two districts. The chance of successful participation is thus moderate (see Table 4.8). The motivation for NGOs to participate is high. They receive benefits and incentives from their funding agencies including the government and from the community. Improvements in the public health system or the health status of the population as well as more empowerment of the communities they serve immediately translate into work satisfaction, because the overall goal of NGOs is the uplift of society. Hence, the chance of successful participation is high (see Table 4.8).

Figure 4.53: MO Satisfaction with Their Work in Pune and Raigarh

Figure 4.54: MO Rating of Their Working Conditions in Pune and Raigarh

Problems MOs Face (in %) 53 64 33 56 51 46 54 56 27 0 10 20 30 40 50 60 70 work overburden political interference unmotivated staff lack of infrastructure lack of medicine lack of staff no budget for repairs no financial powers ignorant patients

n = 91

Activities for NGOs from NGO Perspective (in %)

82 41 76 88 88 65 29 0 20 40 60 80 100

inform villagers about rights control work absenteeism motivate public health personnel pressure public health system make public health system aware help community to complain fight corruption

n = 17

Figure 4.55: Problems MOs Face in Pune and Raigarh

Accountability of NGOs (in %) 0 10 20 30 40 50 60 70 80 90 100 Own Organization/ Director Own Board of Control External Board of Control Funding Agencies

Community Nobody Other

n = 17

4.2.2.3.5. Accountability

Accountability of MOs to community is low. The example of handling complaints showed that accountability depends on the individual attitude of the MO. MOs are mostly accountable to their superiors and the higher government authorities at the district level as discussed under the heading of decision space. Meetings with local government authorities like PRIs take place regularly in the community health committees but the lack of education among the members and the lack of understanding of public health issues among them prevent the questioning of the MO. NGOs can only control MOs indirectly through informing villagers about their rights and through exercising pressure. A large minority however felt that they can also control work absenteeism (41 %) (see Figure 4.56).

NGOs are accountable to higher government authorities and to their donors through their dependence on registration procedures and funds, to local government authorities and local organizations through their working relationship and to the community. Accountability of NGOs to funding agencies is higher (93 %) than to their own board of control (73 %) or to the community (64 %) (see Figure 4.57). Since funding does mainly come from international sources or the state and only a very small share is received from membership fees or from the community, accountability to higher entities is even more important for NGOs. An example of excellent accountability to the community is the joint management of project funds of the community and one NGO (NGO 13.02.2004). Otherwise, accountability to the community is usually not institutionalised by the NGOs and mainly takes place through joint discussions and interactions within the SHGs. The chance of successful participation is thus moderate (see Table 4.8).

Figure 4.57: Accountability of NGOs in Pune and Raigarh

4.2.2.3.6. Sustainability, Control over Resources and Experience of Participation

Sustainability depends on several factors, which have already been discussed above such as interest in participation, motivation or depth, scope and mode of community participation. Moderate interest and motivation from the MO side on the one hand meet high interest and motivation from the NGO side on the other hand. Depth, scope and mode of community participation in the two districts only reach a middle degree. The decentralization programmes of the government have not shown the desired output in

participation or improvement of quality of services, they might therefore be tempted to revise their programmes and go back to a more centralized health service provision. Policies can change after elections. Sustainability can only be ensured by success and anchorage of programmes in the population. Since the public health system mainly works through “top-down” approaches, community involvement in the sense of the “bottom-up” approach is still rare. The chance of successful participation is moderate. NGOs use the “bottom-up” approach and rely on community involvement but they are also dependent on funding. Their anchorage in the population is nevertheless strong. The chance of successful participation is high (see Table 4.8).

Control over resources for MOs is defined by law and higher-level authorities (see above) while NGOs have several models for control of resources depending on their source. Chances of successful participation are thus low for MOs and moderate for NGOs. Both parties have gained good experiences with participation. Participation helps MOs and NGOs in their work. Therefore, chances of successful participation are high for both of them (see Table 4.8).

Table 4.8: Map of Participation for Maharashtra, Pune and Raigarh District (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 Top-down, bottom-up 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 or other groups (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

4.2.3. Conclusion of Case Study Maharashtra

Maharashtra has a long tradition of community participation and possesses a well- established NGO sector. Decentralization mechanisms are in place since the 1970ies. Therefore, it is understandable that NGOs and the public health system in Maharashtra work together and have good experiences with participation. All indicators for NGOs point towards successful community participation except for accountability and control over resources (see Table 4.8). The good ratings could be explained by internal NGO features or by funding requirements. It is overly optimistic to assume that all NGOs perceive community participation as an essential commodity. Although some outstanding examples for community participation like the doctor-patient dialogue or the joint management of project funds have been encountered, they are only an example from one NGO and do not represent the whole sector. NGOs are all very different in their organizational structures and working habits, which represents an advantage for them as it facilitates innovation. Streamlining diverse NGOs into the government programmes means not only a loss of diversity and innovation; it also changes NGOs from advocates to service deliverers. Looking into the different understandings of community participation the same mismatch between NGOs and MOs like in Himachal Pradesh becomes obvious in Maharastra as well. NGOs want to exercise pressure and to empower the community. MOs want NGOs help to fulfil their targets. There is agreement that education is important for both goals.

The indicators selected for the map of participation mostly show a moderate range for MOs and the public health sector (see Table 4.8). Exceptions are accountability and control over resources where the indicator has a low value and experience with participation where the high value indicates a high chance for successful participation. The map of participation again proved useful for the identification of problem areas for participation in detail. The lower values for MOs and the public health system are strongly linked to the lack of decision space in case of accountability and control over resources. For other indicators the influence of organization of work and internal management seems to be more important.

In the selected districts community participation has only a middle degree (see Table 4.8). Participation mainly takes place through invitation by the government and people act as members of small collectives like PRIs, Mahila Mandals, SHGs or community health committees. The targets for community participation are relatively easy-to-reach people in the districts. Powerful groups represent community. Furthermore, community participation at the district level is seen as a means to expand the outreach of public health services and to support infrastructure. More accountability or effectiveness is not included in the rationales yet. In view of Maharashtra’s history higher levels of community participation could be expected. The same holds true for the level of decentralization.

The decision space for MOs in Maharashtra is narrow (see Table 4.6). Functions for finance, service organization, human resources, access rules and governance rules all show a high level of control through the state or central government. The role of MOs as stakeholders in community participation has again been examined. They do not have

more autonomy than their colleagues in Himachal Pradesh. In fact, the only difference encountered between the sample districts in Himachal Pradesh and Maharashtra is that the motivation for participation is higher among the MOs in the later state. Hence, more experience with participation seems to influence motivation positively. Although Maharashtra’s district health systems are under the control of PRIs, no quality difference is traceable. According to the study about performance of public health services Maharashtra performed second best, while Himachal Pradesh took the 5th _{rank (see Table}

3.1). The different performance indicators as well as the economical differences between the states do not seem to influence the outcome of decentralization or community participation in the health sector either.

Figure 4.25 shows the range of indicators and their relation to quality of care for the Himachal Pradesh case study. Since the indicators from the Maharashtra case study have no different values, the outcome will be the same. Lack of decision space disables MOs to respond to community needs. The middle degree of community participation and low accountability further prevent pressure on the public health system for better performance. Empowerment of the community is not included in the participation process as it is planned by the government. Hence, quality of health care cannot be improved with the current decentralization and participation policies here. The benefits of decentralization for the quality of health care will be low to moderate.

The rural population of the selected districts is already deprived of access to water and sanitation as well as of household assets (see Figure 4.30, 4.32 and 4.33). Hence, they are most vulnerable to environmental and political influences. The low performance of the public health sector adds to their burden. Poor living conditions are linked to higher morbidity and mortality rates (see 3.2.2.). Therefore, the people most in need of good public health services or good policies to improve them are also the ones who lack these services the most. Thus, the goals from the Primary Health Care Approach are distant as ever.

4.3. CASE STUDY: WEST BENGAL

4.3.1. Background Information on Case Study West Bengal

West Bengal is a large state in the North-East of India, bordering Bangladesh in the East and Bhutan in the North. It stretches from the Bay of Bengal in the South up to the Himalayas and encompasses a variety of landscapes like coastal areas, plains and mountains. The state has a population of 80 million of which 72 % live in rural areas. The share of Muslim population in West Bengal is higher than in the two other states. Muslims make up 25 % of the population while Hindus still comprise the majority with 72 % (Ministry of Home Affairs 2005b). Less than one percent of the population are Christians or Buddhists. Other religions including natural religions are also important for one percent of the population. More than one fifth of the population are classified as scheduled castes and scheduled tribes (Ministry of Home Affairs 2005a). Most of them live in rural areas. The economical performance of West Bengal lags behind Himachal Pradesh and Maharashtra. The state shows a moderate performance compared to other states (see Figure 3.4). The poverty rates of the state are just behind Maharashtra, but the percentage of rural population below the poverty line is nearly twice as high as for urban population (see Figure 3.5). Rural areas in West Bengal also have much lower literacy rates and lesser assets available than urban areas as it was the case for rural Himachal Pradesh and Maharashtra too. The literacy rate in rural areas is with 63 % nearly twenty percent below the urban rate (Ibid.). The gender gap is also wider here. Only half of the women in rural areas are literate compared to three fourth of the male population. Assets like radio, television, phone, scooter or car are less available in rural areas. Only the percentage of bicycle owners is higher here. One third of the rural population does not possess any of the above mentioned assets (Ibid.). Access to tap water in rural areas is as low as 7 %. The majority of rural population has to rely on handpumps (69 %), tubewells (11 %) and wells (11 %). But even in urban areas half of the population has no access to tap water (Ibid.). Electricity in rural areas is available to 20 % of the population for lighting while the majority uses kerosene. Fire wood and crop residue but also cowdung are the most important fuels for cooking in rural areas. In the cities LPG is the dominant fuel for cooking used by 80 % of the population. Furthermore, residency in rural areas means lesser quality of houses, lack of drainage facilities for 84 % and lack of latrines for 73 % of the population. The majority of rural population (59 %) works in the agri-sector, the share of men and women in this sector, contrary to the other two states, is equal.

4.3.1.1. Health Care

In terms of infant mortality rates West Bengal shows a better performance than all other states except Kerala (see Figure 3.10). Like Maharashtra West Bengal is in an early to middle health transition and owns a health system with a low to moderate capacity (see Table 3.2). The prevalence of infectious diseases is nevertheless still high in the state,

every year more than one million cases of diarrhoea are detected (MoHFW 2003: 182). The number of infections with tuberculosis and malaria is also high. Men in West Bengal are more affected by these diseases then women (Wang 2003: 2). However, non- communicable diseases are on the rise.

West Bengal has a three-tier rural primary health care system. Similarly to Himachal Pradesh the districts are sub-divided into blocks. BPHCs and BMOHs exist and form a separate hierarchical level between the PHC at the basis and the hospitals at the district level. Contrary to Himachal Pradesh or Maharashtra Sub-Centres are not supervised by the PHC but by the BPHC. Preventive and curative care is under one administration at the district level. The health infrastructure in the state is worse than in Maharashtra or Himachal Pradesh. The lack of CHCs, PHCs and SCs is very high (see Figure 4.1). Concerning the provision of staff West Bengal experiences a lack of doctors but not of other health personnel (see Figure 4.2). Furthermore, the absence rates for doctors and