PUBLIC HEALTH CARE SERVICES UNDER PANCHAYAT RAJ SYSTEM IN KARNATAKA: A REVIEW
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- Title
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PUBLIC HEALTH CARE SERVICES UNDER
PANCHAYAT RAJ SYSTEM IN KARNATAKA:
A REVIEW - extracted text
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PUBLIC HEALTH CARE SERVICES UNDER
PANCHAYAT RAJ SYSTEM IN KARNATAKA:
A REVIEW
Draft Report
'G;
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By
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e
Ramesh Kanbargi
o
s
&
Centre for Social Development
No.8, Shantishree
Nagarabhavi Post
Bangalore 560 072
v:^
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5)
PUBLIC HEALTH CARE SERVICES UNDER
PANCHAYAT RAJ SYSTEM IN KARNATAKA : A REVIEW
Draft Report
>)
By
RAMESH KANBARGI
Centre for Social Development
3
©
©
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a
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o
Introduction
Independent
India
inherited a well articulated system of central
administration from the British. ~
There was little change in this situation except to
create States and charge them with the
u responsibility for establishing effective
local governments. However, not much
was accomplished in this direction as the
states were more interested in protecting their
own powers from encroachment
by the Union Government than in
divesting themselves of any portion of such
powers for the benefit of untried, and
probably highly inefficient, subordinate
authorities.
For several years there was a lively, informed and sophisticated debate
among the Indian intellectuals on development policy which was strongly critical
about the centnst strategy of governance.
The concept of “Community
evelopment” was a reflection of this debate and the Community Development
©
Programme which unfolded during the initial development plans (1952-61) was
3
a major effort to attract wider peoples participation in development
programmes.
During the mid sixties the programme reached its peak when the
a
then Ministry of Community Development proudly announced" the entire country
9
is now covered by Community Development Blocks”. But soon the Ministry was
down graded to a department and was made a part of Ministry of Food and
3
Agriculture and Community Development concept lost its aura. The Community
3
Development wrote its own obituary in its annual report as "at this juncture
efining future approaches to community development and Panchayati Raj
$
□
3
appears very necessary" and CD was replaced by Rural Development and
Panchayats as agency for carrying on development activities
Development
became centralised and Integrated Rural Development Programme (IRDP) came
in vogue with insignificant role to Panchayats.
The
efforts
of
decentralisation
through
Community
Development
programmes that intended to give shape to Gandhijis concept of 'little republics'
3
failed to make any headway.
The concept of Gandhiji’s little republics was
vehemently opposed by none other than Dr.Ambedkar in a Constituent Assembly
3
as ‘these village republics have been the ruination of India .... What is a village
but
e
a
sink
of localism,
a
den
of
ignorance,
narrow
mindedness
and
communalism”. But the strong belief that the Indian village can be resurrected as
a device for popular movement to accelerate pace of development still continued
■:)
in some pockets.
3
Decentralisation in Karnataka
•3
The reorganisation of States in the Indian Union in 1956 on linguistic basis
3
brought in the State of Mysore by bringing together the erstwhile Mysore State,
four districts of Bombay, three districts of Hyderabad, two from Madras
Presidency and the Centrally administered district ‘Coorg’. The State was
3
renamed as Karnataka in 1973.
The amalgamated districts had their own
experience with decentralised governance though devolution of powers and
resources were a shade better in the areas that joined the Princely State of
3
Mysore.
3
development in the State of Karnataka which would be in*order.
We will not deal with the details of their experience but focus on the
The formation of the new State in 1956 based on language was followed
by the release of Balawant Rai Mehta Committee Report that brought a new life
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in Panchayat Raj concept. The young State passed a bill “The Mysore Village
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Panchayats and Local Boards Act 1959’ and a three tier structure was introduced
- directly elected bodies at village and taluk level and indirectly constituted body
at district level. All the presidents of taluk development board, elected members
2>
&
of the State Legislature, parliament and some officials constituted the District
3
leve, devebpment counci) which was headed by .he Depu.y Comm)ss,c„e.
Tnere were also nom.na.ed members from depnved secton and women
The crealion of bod.es of elected representatives was not accompanied by
required resources and supporting political will that ultimately led lo the visible
echne in the new system. At national level Nehru s demise and the subsequent
potocai
J
change proved hazardous to the growth and
development of
decentralised governance.
The political scenario drastically changed - the emergency and the arrival
•3
of Janata Party to power at Centre revived the interest. The Centre was quick to
appoint Ashok Mehta Comm.ttee whose report was published in 1978
©
3
In
Karnataka lhe Janata Party ushered into power in 1983 with a view to -take
power to lhe people'
The preamble to the 1983 Act entitled 'The Karnataka
aa Panshats. Ta,uk Panchayat Sam.th.s, Marrda! Panchayats and Nyaya
3
Panchayats Ac, 1983' notes 'whereas It Is expedient to prov.de rura. areas qf
£
Z.«a Parishads, Taluk Panchayat Samilhis. Mandal Panchayats and Nyaya
3
Panchayats to assign them local government and judicial functions and to entrust
a
the execution of certain works and development schemes of lhe Stale Five Year
Plans to the Zilla Parishads. Taluk Panchayat Samilhis. Mandal Panchayats and
provide for the decentralisation of powers and functions under certain
aments Io those local bodies for the purpose of promoting the development
3
emocratic institutions and securing a greater measure of participation by lhe
3
people m the sard plans and in local and governmental affairs and for purposes
3
connected with and incidental there to.. .”
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The statement in the Preamble to the Act
i) It aims at promoting democratic institutions to
are significant in several ways
act as government in their local
areas ii) The institutions created would be
entrusted with development schemes
These in turn would
create greater
pportumties for peoples participation in the execution of the plans and
in local
governance. There will be decentralisation of powers and functions
to enable
Panchayat Raj Institutions to d.scharge responsibilities entrusted to them
designed under Five Year Plans.
4
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A careful look at the Act and its Preamble suggest that it was not just
another
superfluous
effort
made
to
enhance
efficacy
of
programme
implementation that had received severe criticisms from several quarters. But it
visualised the PRIs as mini governments having a great deal of autonomy.
Its
nearness to the community was assumed to ensure greater transparency and
also accountability to the people.
Since the local governments are very much
familiar with local problems and needs it was believed that planning process to
become much more relevant and effective with due regard to priorities.
Local
9
government functionaries are closer to the elected representatives and hence
e
supervision and accountability of bureaucracy would be enhanced.
It would be necessary to understand how the revolutionary process in
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3
governance was perceived when it was introduced by the group of visionaries politicians and administrators together so as to realise the subsequent changes
that have been brought in decentralised governance.
The PRI system in Karnataka vested powers in Zilla Parishads at district
level and in Mandat Panchayats that covered a number of villages having 8-12
3
O
thousand population. There was Taluk Panchayat Samithi in between Zilla
Panshad and Mandal Panchayat that comprised the local MLA and Chairpersons
of all the Mandal Panchayats in the taluk.
The Zilla Parishad was perceived to play a major role in planning and
3
development of the entire district while Taluk Panchayat Samithis were perceived
a
as essentially a co-ordinating body with no executive powers.
&
personnel of all development departments including that of Health and Family
Welfare were placed at Zilla Parishad’s hands.
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The various
The ZP administration was lead
by Chief Secretary or Indian Administrative Service (IAS) Officer of senior level in
the State. In order to carry the planning process at the district level and below a
team of experts that included a statistician was formed.
The Mandal Panchayats were conceived as a plenary body and like ZP
was constituted directly and was to operate mainly as an implementing body.
It
was to identify and select beneficiaries in relevant programmes and also to
9
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prioritise development works to be undertaken in their area
The PRis in Karnataka received finances directly from the State through
the budgetary allocation passed in the legislature
Initially the share of PRIs in
the State Finances accounted for about 33 per cent. “Public Health" was one of
the important development activities of the Zilla Panshad.
Act provides
9
1
Section 182 of KPR
management of hospitals and dispensaries (excluding District
Hospitals and those
managed
by
Municipalities).
is a
There
statutory
requirement to constitute a “Health Committee" which was to perform the
functions relating to health services, hospitals, water supply, family welfare and
other allied matters".
9
©
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The Mandal Panchayats also had to take the responsibility of sanitation
and health.
Maintaining sanitary conditions and it was mandatory to constitute
an Amenities Committee to perform functions in respect of “education, public
health, public works and other functions of the Mandal Panchayat".
It becomes clear from the above that Zilla Parishad was entrusted with the
crucial role in monitoring health sector in the district while Mandala Panchayat s
role was vague. And indeed 79 per cent of the plan and non-plan outlay for rural
health services was transferred to ZPs during 1990-91 which accounted for four
□
9
fifths of the health budget allotted for rural areas controlled by the ZPs.
The remarkable transition in power structure seen in Karnataka was not
sustained.
3
The state faced financial constraints and the
situation was
compounded by fluid political situation that adversely affected flow of resources
3
to Panchayat Raj Institutions.
9
deprived of the warmth and care of the state that would have had considerable
3
positive impact on their growth and development in the appropriate direction.
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The new born democratic institutions were
The State government constituted a review committee to evaluate the
impact of decentralisation on the administration of development programmes.
The committee submitted its report in 1989 that noted “there had been significant
progress in the area of medical and public health facilities.
Besides a big
3
improvement in the attendance of doctors and other medical personnel, steps
3
have been taken to secure the supply of drugs and medicines more regularly in
9
accordance with local requirements. Pressure from local governments has also
3
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led the State Government to make substantial modifications in its medical stores
purchase policy and ZPs have been able to procure more of their supplies locally
more cheaply”.
Though the improvements brought in such a short period and
attributed to decentralised governance by the eminent members of the committee
is hard to believe the spirit behind appreciation is well taken.
The brief note above indicates the real intention of the then government to
■3
3
decentralise governance - the designation of head of the district administration
as Chief Secretary and who was a senior level officer of Indian Administrative
Service (IAS) suggest that he was indeed perceived as Chief Secretary of the
3
©
government at district level and was senior to the Deputy Commissioner of the
district is notable.
The State government did not posses any powers of
supervision and control over the ZPs. The preparation of the budget of Mandal
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Panchayat also was not to be approved by higher level structure but was limited
by provisions of the act.
There was also a State Development Council constituted with Chief
3
Minister as Chairman and Presidents of ZP as members.
3
important Ministers like Minister of Rural Development and the council provided a
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It included some
forum for exchange of views among the elected heads of the ZPs and their
counterparts at the State. While there were indications of improvements in the
functioning of primary schools, primary health centre and health care services
fissures appeared in the political arena - factionalism and a weak resistance to
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the idealism of PRIs. The strong Janata Party was weakened with factionalism
Q
which had its own adverse impact on PRIs functioning. This ultimately resulted
3
in loss of power and assumption of power by Congress Party in 1990.
3
neglect and reservation shown by the party in power led to postponing the
The
elections and superseding the ZPs and Mandal Panchayats by appointment of
3
administrators for these bodies.
3
The 73rd amendment to the Constitution was passed by the Parliament in
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1992 and the Congress led government in Karnataka brought a new piece of
3
legislation. “The Karnataka Panchayat Raj Act, 1993” came into existence from
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amendments requirements and since then has undergone several amendments.
May 1993..
The act was passed in accordance with the constitutional
The new act brought many significant changes. Every village having 5000
- 7000 population will have a Gram Panchayat (2500 population in Hilly areas).
The voters will elect one member for every four hundred population.
Every Taluk will Constitute a Taluk Panchayat and for every 10.000
population there will be an elected member.
Members of Parliament and State
3
Legislative Assembly representing the Taluk - wholly or partially would be
$
members of the Taluk Panchayat.
3
one in five will be members of Taluk Panchayats for one year by rotation.
Among the Chairmen of Gram panchayats
The ZPs have one elected members for every 40,000 population (30,000
population if the district is hilly).
3
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Members of Parliament, State Legislature and
all Adhyakshas of Taluk panchayats will be members of ZP by virtue of their
office.
The
reservation
policy
was
strictly
adhered
to
in
electing
the
representatives. Reservation for Scheduled Castes and Tribes were proportional
to their size in the population with a minimum of 15 per cent and 3 per cent
respectively. 30 per cent were reserved for backward castes and 33 per cent for
o
o
women.
The new legislation compared very poorly with the earlier legislation which
perceived local bodies as local government where as they were reverted back as
government controlled subordinate agencies. It is obvious that there is a reversal
of decentralisation of the process set-in by the earlier Act of 1983.
3
Naturally it
was criticised in strong terms. When the new bill was introduced the preamble
also did not mention about the concept of self-government. But the act contained
powers of the government to inspect and control of the PRIs as contrary to the
earlier provisions in 1983 Act.
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The President and Vice Presidents were
considered as on par with the Minister of State and Deputy Ministers whereas the
present law withdrew the provision. Similarly the ZP president was the Executive
3
Head of the district and Chief Secretary was more powerful than the D C. of the
S>
district which the new act did not provide for its continuation.
Q
£
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Chief Secretary
X
'•5
was redesignated as Chief Executive Officer (CEO) an IAS Officer Junior to DC
of the district and was empowered to withheld any action of ZP if it was
inconsistent with the provision of law and seek governments’ instructions to
resolve. Thus the new act seems to strengthen the hands of bureaucracy and
weaken PRIs influence.
3
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It is important to note that the new Act introduced hierarchical relation in
the
power structure in the PRIs - ZP was authorised to enquire into the
complaints of non-performance of duty by the Taluk Panchayats and Taluk
3
Panchayats in turn that of Gram Panchayats.
Establishment of health and
maternity centers became obligatory function of ZP which was subject to the
availability of resources.
The new act was amended several times and several Government Orders
J
are issued in respect of functioning of PRIs. As rightly pointed out by a widely
3
known expert on Decentralised governance, ‘Panchayat Raj in Karnataka
3
turned into GO Raj now”. As a result several far reaching changes were made.
3
Important among them was the reducing the term of office of ZPs and TPs
3
Presidents and Vice Presidents from a Five Year term to a mere 20 months
has
period (Sept. 1996). Due to the increasing pressure from Presidents of ZPs and
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TPs
and
subsequent
recommendation
of
Expert
Committee
(1996)
an
amendment was brought to confer 'Executive Heads’ recognition. Despite the
mounting pressure the term of office of these elected representatives was not
extended and as most of the ZPs are under Congress Party’s control the move
was weakened.
A careful examination of the devolution of powehs and functions reveal
that the State government through amendments is making efforts to weaken the
democratic institutions at district, taluk and village levels. The State government
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has retained many controls - regulatory and supervisory powers and also some
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important functions like Public Distribution System. More significant for this study
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is to note the control over the personnel who are on deputation to the PRIs lies
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| with the State government. The recruitments, transfers and regulatory functions
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- disciplinary actions are retained by the State government.
Though the P R
*’
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Nayak Committee recommended that PRIs should have powers of transferring
group 'C and ‘D’ employees, the State government is yet to accept it.
-
The Present Study
In this background of one step forward and two steps backward policies
■-T)
;..A
persued during the last two decades the present study has attempted to examine
the working of PubHc Health Care System under the contemporary Panchayat
Raj System in Karnataka.
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Objectives
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©
The main objectives of the study are :
1)
To identify areas of confrontation/friction between elected representatives
and the officials of health departments at district level and below and
3
identify the underlying causes as attitudinal, legal, procedural and others.
2)
<3
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effective functioning of PRIs and health functionaries.
3)
a
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To examine the legal procedural factors that need modification for smooth
To study the disparities in health indicators across the districts and across
social class within the districts and how PRIs intervention can reduce
them.
4)
To study the delivery of public health care services, identify best practices
followed that can be replicated in the state to improve the outreach
services.
Data and Methodology
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Considering the lim.ted time and resources it was decided that the study
■3
would confine to three districts of the state. The required data was collected from
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vanous elected representatives at district, taluk and gram panchayat levels, from
health staff working at various levels like District Health Officer, Taluk Medical
Officer Medical Officer at PHCs, PHUs, CHCs, Para medical staff, staff dealing
dministrative work and most importantly the general public from 31 villages
randomly selected.
it was focus group discussion on various issues that
provided valuable insights for the study.
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The general public, however, was
!(•
administered a questionna/e to understand the extent of their participation in
PRIs and their understanding of quality of health care services delivered
At the outset we met the members of the Karnataka Government Medical
?)
Officers Association - a strong body of over 500 medical officers as its members
The discussion revolved around various issues confronting them in general like
the reported corruption in the department - particularly charges against the
3
medical officers, their perception of decentralised governance and its pros-cons
on their functioning and the contemporary service conditions.
•9
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Emerging Issues : Confrontation
The prolonged discussion with the office bearers at the state brought out
the issue of working under decentralised system of governance and their strong
resistance to it. It was also revealed that in the current situation all the medical
officers would not aspire for the post of District Health Officer as compared to the
earlier days when there was a rush to hold the coveted post that carry not only
3
enormous responsibilities but also a high status - equivalent to any other district
level high officials like Deputy Commissioner. Today he is at the receiving end
only - ZP will hold him responsible for every thing that may go wrong like a
cholera cases, malaria cases detection in his area which rightly cannot be
considered as his responsibility only. .It is concerned with water supply or supply
•3
of DDT for spraying that cuts across the departments.
The health department officials also are harassed by the elected
0
representatives as revealed by the Association of office bearers. It was told that
□
DHO has left with little time to attend to his enormous responsibilities because of
3
several meetings he has to attend during a month (at least 6 statutory) and there
are visits from Ministers that need DHOs presence and there is hardly any time
left for his work that results in poor supervision and monitoring the health
3
programmes in the district.
In addition, the elected representatives who are
drawn from different socio-economic background and new to their work do not
know how to conduct themselves with the bureaucrats who expect respect regard from every one. The Association expressed strong reservation about the
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way Medical Officers are treated by the elected representatives and reported that
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it was most inappropriate.
In addition to the above mentioned confrontations the Association was
more disturbed with the way promotions were given, how a very junior medical
3
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officer became his senior boss because he possessed a Diploma / Degree in
Public Health. Their view was that public health and its intricacies can be learnt
by any medical officer through his experience and he may perform better than a
■^
person who possesses the degree/diploma in public health.
'3
It is not very
relevant for this study to deal with this issue in detail as the ZPs or TPs are not
authorised to deal with such issues which lies with the State government. It was
clear from the above discussion that the strong resistance to work under PRI by
□
•3
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the Karnataka Government Medical Officers Association was not on any
on
ideological or legal - structural issue but based more on their stray - scattered
experience with some elected representatives. The meeting, however, provided
valuable insights for conducting the study.
The Study Area
The study was to be confined to three districts but another district was
19
added to it based on the reported problems of confrontation between health
bureaucracy and ZP there.
The
three districts were
selected on
the
achievements in health sector. Udupi - a newly carved district is much ahead of
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most of the districts in the state in terms of education particularly female
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education, health and also other development indicators. Tumkur is situated in
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the middle level and Gulbarga district is still a backward district (Table 1).
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Table 1 provides valuable insights in the existing disparities in the selected
districts in terms of health and education. Udupi is an advanced district, whereas
Gulbarga has
retained its backward status during last five decades
reorganisation of States.
Tumkur has performed better than Gulbarga but is
poorer compared to Udupi.
Thus the findings from this study would present a
representative picture of the state.
9
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of
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Table 1
Development Indicators in the Selected Districts
District/
State
Crude
Birth Rate
1999
Percent
Percent
women
safe
contra I deliveries
cepting |
Rates
1990-91
Percent
females
literates
1996
Crude
Death
J Udupi
1
19.7
2
63.7
3
91.5
4
7.0
5
78.5
Percent
children
aged 12-36
months
immunised
fully
____ 6_
86.0
Tumkur
24.1
61.3
63.5
8.2
51.1
88.0
2047
I Gulbarga
30.1
39.2
47.7
10.7
30.9
25.3
2431
State
22.5
58.1
68.2
8.5
52.7
70.5
2558
Per capita ■ ■_
income
1995-96 '
(Rs.)
7
2632
©
Source: 1,2,3 and 6. ROH Survey 1998 (Phase 1)
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4,5 & 7. Human Development Report (Karnataka) 1999, p.78, 255, 212
The presentation of the report will be in four sections.
The first section
would present the health status of people and highlight the observed disparities
3
by social class and caste.
The second part would discuss, given these
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3
disparities, what the PRIs can do to improve the situation and the third part would
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present the findings of the data collected from the PRI visits followed by
summary of the findings and recommendations.
Section I
3
Health status of a population is determined by several factors including
a
health care services.
3
cultural and political factors.
*3
multidirectional and complex, it is increasingly being realised that an integrated
It is closely associated with genetic, social, economic,
Although interaction among these factors is
approach to development would minimise conflicts and undesirable side effects
□
of sectoral approach. But what should be the critical mix of these interventions to
obtain the desired results is not very clear and planning in most of the countries
and at states within the country is still dominated by sectoral approach.
3
The
significance of health care services is that they can reduce pain, sufferings and
deaths many of which could have been minimised by an integrated approach to
3
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development.
The health care services have to ensure quality at an affordable
cost to the population There are differentials in access to health care services in
India and also in the State of Karnataka by urban / rural residence Good health
care services are concentrated in urban areas and do provide a choice to people
- either avail public health care services - which are also relatively better
in
urban areas as compared to rural, or and also avail private health care services
that are more concentrated in urban areas.
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Residents in rural areas have to
increasingly depend on public health care services particularly deprived sections
like Scheduled Caste and Scheduled Tribe population or those living in remote
inaccessible areas where either private services are not existing or scarcely
available.
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If public health care services are not easily accessible it will have
more adverse impact on rural poor particularly the SC/ST population.
In order to improve the accessibility to public health care services the
Central and State governments have been trying to expand these services
hoping that all sections in rural areas are benefited from them. As a result it is
3
observed that during 1960-61 on an average a Primary Health Centre (PHC)
served 81,000 population whereas at present (1996-97) a PHC serves only about
21,500 persons. Similarly a female health worker (ANM) was serving about 8000
0
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persons during 1980-81 while in 1996-97 she is serving only about half of that
population.
These public health care services are supposed to be free and
therefore the poorer sections who may find private health care relatively
expensive may use them more than the affluent rural population. Particularly the
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women belonging to SC/ST may benefit from the free care provided by the
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government.
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different picture which is very disturbing.
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But intensive research studies carried out in the state present a /
It would be in order to note how the public health care services are
delivared before presenting the observed disparities reported in the research
studies.
Looking at the disproportionately high mortality and morbidity among
3
women and children at national and state level delivary of services are
3
concentrated on women and children.
3
popularly known as ANM provides these basic services.
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1
The grassroot female health worker
In order to make child
14
births safe she is trained to provide antenatal care at the home of the pregnant
women in her area that has about 4000 population. On an average there are 165
_.JZ£ eJiS'kle couples per 1000 population.
She has about 500 - 600 eligible
•
women some of whom need this service. The ANC package includes a list of
□
services that she is supposed to provide to every pregnant woman to ensure safe
delivery, survival of woman and her baby.
The following table provides some
insights into how these services widely differ among the community by caste,
economic status, education of the woman and by rural/urban residence in 10
districts of Karnataka.
Table 2 :
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i)
2)
Access to Antenatal Care by Social and Economic Background of
Women in 10 Districts of Karnataka 1998
Type of service
Residence
Caste
Education
Type of House
|NoANC
Rural
Urban
72.9
51
SC/ST
ITT)
8?9
18.9
ol
72.0
20.1
2.3
48.5
29.4
5.1
62.0
25.1
4.0
42.7
31.7
6.8
Others
SSLC +
Kuchha
221
Pucca
84.1
14.5
0.8
37.9
32.4
80.4
15.0
7.1
I 1-2
First ANC visit during
First Trimester
3
a)
b)
3
c) Third Trimester
52.6
28.9
5.6
All 3+ ANC visits
74.0
88.0
68.7
81.0
65.3
95.9
58.9
92.6
3)
Second Trimester
Percent women
C5
4)
Whose
taken
weight
was
41.7
77.5>
37.1
56.1
32.9
58 7
: 23.5
80.9
5)
Whose
recorded
B/P
was
57.2
86.3
49.8
70.3
46.3
78.0
39.7
90.4
6)
Who were given IFA
tablets
72.5
72.5
66.9
75.2
65.9
77.7
61.1
78.0
7)
Who were given 2TT
injections
65.0
78.7
58.9
72.3
56.5
75.0
49.0
84.6
Whose
abdominal
check-up was done
72.2
91.9
74.4
84.2
69.7
97.4
65.3
93.0
Total No.of women
2222
896
i 772
1811
1571
692
685
619
$
0
J
I 8)
The data clearly brings out the differential access to the public health care
services in the State. It is the Scheduled Caste women, illiterate and those who
0
■3
15
.-.v
live in kuchha house, in other words ‘poor’ are relatively more deprived of these
essential services. Though we do not have data on infant mortality and maternal
mortality the NFHS II reports very high IMR in rural Karnataka areas for SC/St
and illiterate women.
The information on place of delivery also reveal differentials by caste.
3
While for the state as a whole RCH First Phase reported 52.4 percent
institutional deliveries it was only 42.4 percent in rural areas while it was 77.3
percent in urban areas. Among Scheduled Caste women only one in 3 deliveries
were in an institution whereas it was 57 percent among others. Out of those who
lived in kuchha houses only 29.6 percent were able to go for delivery to a health
facility while those better of 81.7 percent delivered in a health facility. It is worth
□
noting that the home deliveries of SC women mainly were attended by
neighbours/relatives or untrained dai (74 percent).
In other words, even those
who give birth at home are deprived of ANMs’ or trained dais' services that
increase the risks associated with child-birth among the poorer sections.
The new born babies are protected against killer diseases by vaccinations.
9
The data provided by the RCH Survey reveal wide disparities in its utilisation and
a
poor accessibility.
Table 3 ;
; Type of
Service
3
1)
3
O Polio
j 2) BCG
' 3)
DPT
Accessibility to Immunisation Services in Karnataka by Social Economic Background of Children Born During 1.1.1995
to 10.6.1997 (percent not received)
Residence
Gender
Caste
Education
Urban
M
F
SC/ST
Others
lllit-
10 yrs+
Kuchha
Pucca
61.8
30.8
53.0
53.0
69.7
50.0
72.6
22.9
75.5
22.9
18.5
9.4
13.7
18.2
27.6
11.5
26.6
1.3
34.6
18.3
11.3
14.7
18.1
26.6
12.6
26.7
1.1
32.6
5.2
11.6
8.2
9.0
12.3
17.3
8.2
17.8
1.4
21.7
3.7
52.8
49.2
49.8
53.9
59.1
48.0
61.2
35.6
—
66.1
39.7
>
&
4)
7
5)
&
&
a
a
Polio
Vitamin A
Housing
Rural
___i
!
4.7
16
■n
The differentials observed at state level hide the regional differentials
which are more pronounced. The following table provides these differentials in
the selected districts.
‘-y
a
0
o
Table 4 :
Access to Antenatal Care in the Study Area by Socio-Economic
Background of Women 1998 (per cent not received)
District
Residence
Caste
Housing
Education
1 Rural
Urban
SC/ST
Others
(Hit.
10 years +
Kuchha
Pucca
Udupi
2.0
00
5.2
00
4.7
00
2.2
00
Tumkur
4.8
2.4
5.9
3.8
8.5
00
4.8
00
Gulbarga
34.0
14.8
28.5
26.8
35.5
3.1
32.1
27.2
3
The tables 4 and 5 are self explanatory and in this background it was not
surprising that the RCH survey reports maximum number of infant deaths in
a
Gulbarga district (17) during the reference period and all in rural area whereas
9
Tumkur reported 9 deaths - 8 in rural areas whereas Udupi reported only 3 infant
9
deaths all in rural areas.
0
Table 5 :
*9
o
3
District
Access to Immunisation of Children Born During 1.1.1995
to 30.6.1997 (per cent not received)
Residence
Sex
Caste
Education
Housing
Rural
Urban
M
F
SC/ST
Others
Hit.
10 yrs+
Udupi
15.0
8.0
“17.0
10.0
20.0
13.0
17.0
4.4
15.0
14.1
Tumkur
13.0
6.0
11.4
12.8
16.0
11.5
13.7
3.00
20.0
4.5
Gulbarga
80.0
53.6
76.0
73.3
78.9
73.8
83.4
25.0
72.3
Kuchha | Pucca I
9
9
9
I
The information for 10 districts of Karnataka and the 3 districts in the study
area bring out clearly that delivery of public health care services do not reach all
$
those who need them because of various factors. Given the skewed distribution
&
O
9
□
45.2
I____
r
of basic health care services related with maternity and child survival it is not
-..4J
surprising that health outcomes differ widely among districts - regions and also
social class in the state.
Reasons for such poor delivary of public health services in Gulbarga as
compared to other districts were not difficult to understand.
The Research
Teams visit to Community Health Centres, Primary Health Centres and Sub
3
Centres revealed that many of these health centres do not function regularly.
3
Infact, the day of our visit to selected health institutions in Gulbarga they were
0
locked and we learnt from the villagers that medical officers are very irregular in
attending to their work. Similarly the ANMs instead of visiting the households in
the sub-centre jurisdiction expect that women or children with problems should
□
come to them. No PHC had displayed the scheduled travel programme of ANMs
as is done in other districts. It is not, therefore, surprising that old women in the
■3
neighbourhood or village ‘Soolagitti’ (village untrained dai) conduct most of the
deliveries in rural areas (every 3 of A).
3
The problem is more complicated by the large number of vacancies
3
particularly of ANMs which is crucial in ensuring delivary of health care services.
0
When the vacancies of ANMs by taluks and PHCs within taluks were obtained
o
from the DHO s office and examined we were in for several surprises.
3
In the
district of Gulbarga about 28 per cent - more than one in four positions were
vacant for ANMs (see table 6) and the LHVs.
Supervision of their work and
monitoring the performance has stopped for several years. The result of such an
O
apathy is very clearly reflected in several indicators reported earlier. One of the
major cause for poor performance reported by the staff at PHC/CHC was the
3
existing poverty in the rural parts of the district where traditional practices still
dominate and the department cannot be blamed for all the ills in health sector.
3
■3
3
'&
Q
3
is
Table 6
si.
Vacancies of Female Health Workers (ANMs and LHVs) in
Gulbarga District by Taluks
District/Taluk
Per cent Vacant
No.
P-V
ANMs
LHVs
Per cent
484/134
58/00
39/2
57/18
40/11
41/10
57/15
35/13
48/17
56/18
53/20
27.7
0.0
30.8
31.6
27.5
24.4
26.3
37.1
35.4
83/40
6/0
10/2
6/4
9/7
8/1
10/5
7/2
7/5
10/7
10/7
4872
00
20.0
66.7
77.8
12.5
50.0
28.6
71.4
70.0
70.0
&
D
□
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
-3
Gulbarga Dist.
Gulbarga Taluk
Jevargi
Aland
Afzalpur
Chincholi
Chitapur
Sedam
Shahpur
Surpur
Yadagir
32.1
37.7
Note: P = Total Positions: V - Vacant Positions.
3
3
But the traditional practices have to continue because the modern health
services provided by the public services have miserably failed to entrench in the
society.
3
It was repeatedly emphasised that rural people prefer to conduct
deliveries at home and ANMs are helpless.
But when there are so many
uncertainties in the services - medical officer may not be there, drugs may be in
short supply and ANMs posts are vacant and naturally people stick to their
traditional practices.
□
3
The positions of specialists in the district showed that 37
per cent positions were vacant.
In Udupi district also about 30 per cent of ANMs positions were vacant but
easy accessibility to quality care in Private Sector Hospitals either free or at an
affordable cost has not made any adverse impact on the health of women and
3
children.
Most of the births about 92 percent take place in institutions that has
sharply reduced Infant Mortality Rate in the district (lowest in the State).
The
ANMs working in sub-centre reported that most of them have not conducted a
3
<3
□
a
single delivery during last 5-6 years as there are maternity homes run by
missionaries, Mampal group and other private trusts that provide a choice to
everyone irrespective of their economic position. The public make an mformec
choice of public and private services and have benefited to a large extent as
revealed by several indicators.
3
3
Tumkur district placed in between these two extremes provide different
problems. The public health care providing institutions generally work regularly
Our visits to several PHCs, CHCs and Sub-Centres convinced us that there is
3
regularity in attendance of the staff to a large extent except in a few pockets. But
3
accessibility to the services is severely restricted to the poorer sections because
0
of corrupt practices in these institutions. The Medical Officer in a PHC working
©
for more than 15 years, people reported, has ensured that the Lady Medical
officers post remains vacant. A child birth conducted in this PHC will cost about
3
3
Rs. 1000/-.
If there is a LMO this income will be reduced to a large extent
another PHC it was found that LMO frowns at ANMs if they conduct home
deliveries and insists that they should bong delivery cases to the PHCs and
charges a minimum of Rs.500/- per delivery.
3
In
Efficient and competent ANMs
complained of harassments by the MOs and LMOs. With Malaria incidence still
high in some pockets spraying of DDT has been stopped for 3 years and water
3
3
0
sources like wells have not received chlorination to make them safe for drinking.
The public health measures have affected badly.
The vacant positions in the department has its own adverse impact but is
not severe as there were only 15 percent ANMs' and about 20 percent LHVs'
3
positions were vacant for varying periods some for 4-5 years that has
3
compounded the problem of outreach services in the district. Even then there is
3
some semblance of service in the district. The buildings and other infrastructure
3
are m poor shape and are begging for some action to improve but not received
any attention from authorities.
3
3
What the Panchayat Raj Institutions Can Do?
The decentralisation of governance in Karnataka in its first 'avatara’ came
with the perception of “Power to the People'.
3
3
3
3
The 1983 Act was based on the
principles enunciated in the Ashok Mehta Committee Report
The objectives of
the Act were to give highest priority to rural development, increase agricultural
development, eradicate poverty and bring in overall development.
To attain
these objectives the Act provided maximum degree of decentralisation both in
Planning and implementation.
'-3
But there were unresolved issues, with the planning structure at the
national level and state level is it feasible to have district planning with the
consent of people and their participation? If not how the PRIs would participate only implementation of the plans that come from the State with resources? Who
would ensure ‘good governance’ at lower levels? And How? are not cleared yet.
But the State government that provides resources to PRIs - resources that have
reached four to five fold increase during the decade believes that there has to be
greater transparency, social justice and accountability in PRIs to achieve the twin
goals
of
development
and
social
justice.
The
voluminous
writings
on
£
decentralised
&
reservations, elections, provisions of rules, rights and procedures to be followed
governance
at
sub-state
level
are
more
concerned
with
than assessing what positive changes the new system has achieved and how to
improve it further, which can reduce the ‘politics only’ attitude observed at PRIs
□
Despite our serious efforts to find some special studies that have examined
functions of the health sectors under decentralised system we could not trace a
single except the evaluation report submitted in 1989 that praised PRIs
O
eloquently for the good changes they had observed.
a
We conceptualise a very simple mechanism that exists in PRI system to a
large extent useful in streamlining the functioning of health-care service delivary
system and bring in much needed discipline in the sector. The importance given
□
to ‘holding gramasabhas’ of village voters who are ultimately the masters can be
exploited. Already in six districts “Citizens Initiatives in Elementary Education” an
NGO initiative to activate Grama Sabhas to improve primary education is going
on.
People who are not happy with the delivary of services, can bring it in the
meeting which will be passed on to Gram Panchayat that in turn can reach Taluk
and Zilla Parishad for action. The ZP based on the resolutions passed by the
□
9
?!
Gram Sabhas can keep themselves abreast of developments
\a-
in health sector
and plan for its improvements.
The Zilla Panshad also has a statutory Committee called ‘Standing
Committee on Health and Education" that includes elected ZP members and also
-
some experts co-opted. They have to meet once a month and transact business
pertaining to health.
However, the role of Zilla Panshad in decentralised
governance and planning is one of a facilitator and co-ordinator.
a
Integrating
plans submitted by Taluk Panchayats, approving employment generating action
plans, allocation of resources to development programmes and monitoring
functioning of Taluk and Gram Panchayats. The President and Chief Executive
Officer (CEO) have been endowed with powers to supervise and inspection.
3
3
However, CEO has upper hand (section 180) to ask any record from TPs and
GPs pertaining to property, recovering arrears of land revenue, and supervise
and control the execution of ZP works.
Panchayats are entrusted with
giving,
giving,
prohibitory, supervisory and sanctioning powers. They have powers for taxation
Gram
3
regulatory,
and acquire movable and immovable properties.
licence
-
Providing civic amenities,
promoting health and educational services are other responsibilities entrusted
with Gram Panchayats.
O
The Taluk Panchayat have controlling and supervisory powers over Gram
Panchayats. They are perce.ved as highly resourceful and powerful intermediary
level institutions. They approve employment generating action plans, they give
□
concurrence to action plans pertaining to education, health and family welfare
3
etc. The executive officer can supervise in functioning of PHCs, Sub-centres and
3
report to DHO for action. He does not enjoy powers to take disciplinary action on
health staff.
5
3
3
There is a mechanism to receive the public grievances regarding health
care services throughjhej>pwecful Grama Sabhas for further
action to improve
the equity and accessibility - both if there is a desire.
In addition the Taluk
Medical Officer has supervisory powers to report for action to DHO
1
DHO is
head of the department and is responsible officer at district level
In addition
£>
.
$
©
HO
3
88069
faf
y-y
'
■
J
there is Executive Officer at Taluk Panchayat with supervisory powers and report
his findings to DHO. It is very clear from the above that there are enough ways
and means to improve the health care services directly through PRIs, through the
live of control existing in the departments and also more importantly through the
Grama Sabhas.
Given the situation described in the study area it would be in
a')
order to examine how they work.
The Grama Sabha
The Gram Sabha is a statutory requirement that provides a unique
0
opportunity to village residents to vent their grievances which will reach the
concerned authority for redressal. It also provides an opportunity to the voters to
0
make their elected representatives accountable to them.
One of the main
architects of decentralisation in Karnataka considered Gram Sabha as a “more
powerful weapon created for the sake of accountability is Grama Sabha which
5
will not be elected nor has it vested with any executive power. But it is going to
$
play a crucial role in real politics because of their voting power and all elected
£
members are accountable to Grama Sabha”. It is mandatory on the part of PRIs
3
to explain their activities within the jurisdiction of the village. It also leads to right
to information.
■3
3
Section II
How the Grama Sabhas are conducted if at all they are conducted^5
3
Whether people bring their grievances to the forum?
J
conducted in the study area enquired from the randomly selected 82 heads of the
The Household Survey
households whether the Gram Panchayat, Taluk Panchayat or Zilla Panshad of
their area are taking any interest for the improvement of the local PHC?
Not
surprisingly in Tumkur and Gulbarga districts the response was an emphatic No
from each head of the household (100 percent in negative). They were very firm
&
about their view.
3
improve further the services in PHC (Table 7).
3
But in Udupi district one in four felt that they are trying to
The selected heads of the households were also asked whether there was
any discussion in the Grama Sabha meeting held recently on the functioning of
?<x.
the ANM. LHV. PHC doctor and PHC.
The findings of these are presented
below.
•3
Table 7
Peoples Assessment of PRIs interest in Public Health
SI
No
Activity
n
2)
3
3
PRIs try to improve the
PHC
Udupj
Yes
No
23.0 77.0
Districts
Tumkur
| Gulbarga
Yes
No
Yes
No
00
100.0 00
100.0
TotaJ____
Yes
No
11.0
89.0
8.6
8.6
8.6
13.0
13.0
13.0
11.0
11.0
11.0
Gram Sabha Discussed
about the Functioning
0
ii)
iii)
Of ANMs
Of LHVs
Of MO in PHC and
PHC
91.4
91.4
91.4
87.0
87.0
87.0
12.5
12.5
12.5
87.5
87.5
87.5
89.0
89.0
89.0
3
9
a
3
It is clear from the data that public view of PRIs interest in improving
health care service delivery of PHC level or about the functioning of crucial
personnel like ANM, LHV or MO of PHC is_extremely poor. An important route to
bring critical assessment of health services for improvement was found to be
9
very insignificant.
‘
The Bureaucracy
□
3
There are multiple authorities who are supposed to supervise functioning
of their subordinates, monitor the performance and enforce discipline in the
health department. They are Taluk Medical officers, Executive Officers at Taluk
Panchayats, Chief Executive Officer, President at ZP and also DHO the Head of
3
the department of health at district. In addition to all these levels of supervision,
there is another Deputy Secretary 1 in ZP who is entrusted with supervisory
□
powers who will report to the CEO.
With so many authorities entrusted with
powers to ensure free flow of
services it was surprising that Public Health Care Services
are of so poor quality
o
3
d
24
in the two districts of the study area viz. Gulbarga and Tumkur. Our discussion
with the young and energetic CEO in Gulbarga was surprising. He was unaware
of the way PHCs are functioning in the district. On the contrary he said often he
receives representations from people to retain some Medical officers in their
4
place and cancel the transfer order issued that gave him an impression that the
MO must be good and therefore people want to retain him. We met the Deputy
J
Commissioner of Gulbarga also and briefed him about our observation. Both the
3
CEO and DC asked for a copy of our findings for initiating action against erring
Z3
officials in the health department
Similarly we discussed with the Deputy
Secretary (Dy S 1) and briefed him of our observations and he was non-
9
commital.
Our discussion with the Secretary ZP Council, Gulbarga was little
revealing. He reported that the meetings of the Standing Committees on Health
1 and Education mainly deal with approval of plans, proposals and programmes.
3
There is hardly any scope to discuss about the services their quality or its out
reach to all sections of the society.
How well the DHO is informed about the
happenings in his department? Does he also think that everything is fine with the
□
functioning of PHCs, CHCs and Sub-Centres in his district? Our discussion with
him was frank and free.
Z)
He is aware about the irregular attendance of Medical
officers and has initiated disciplinary action against one or two.
disciplinary action takes a very long time.
But taking
There are interference from higher
authorities, elected representatives to thwart these initiatives because the
0
authorities take a benevolent view of such things and consider it on humanitarian
3
grounds - the person accused is married and have children why punish him/her?
9
The whole work culture in the district reflects that even for a petty issue there is
interference from the highest authority.
Every one in public service has links
upward and use it to save himself from any punitive action.
Tumkur district was slightly better as the Executive Officers at Taluk level
3
also visit some PHCs and reported that if the MO is absent on the day it will be
3
reported to ETHO for treating it as leave without pay.
3
that report or not was not clear. DHO Tumkur is aware about corruption that is
3
making public health care services inaccessible to the poor in the district but
a
3
3
3
3
But whether DHO acts on
*»»
reported like Executive Officer at Taluk level that they have not received a single
complaint from people in this regard and hence cannot aci without evidence-
It was in Udupi that the in-built mechanism of monitoring and supervision
was working. Even the MOs appointed on contract basis are regular in their work
and provide service to the people.
3
5
If there is regularity in the functioning of
health institutions that itself satisfies the clients who arrive there for relief.
Our
visit to PHCs, CHCs and some remote-placed Sub-Centres was very satisfying.
Perhaps if one wants to see what is equity and accessibility to health care
3
services should visit this part for getting acquainted with. The results are visible.
0
ZP Presidents
The Executive Head of the district is the President and certainly they can
D
3
to people. The Presidents of the ZPs in the study area were very enlightening.
J
In addition to 3 ZP presidents of Udupi, Gulbarga, and Tumkur, we met ZP
a
President of Kolar. They were all young, educated and enthusiastic about their
3
office that they were holding only for few months.
3
□
make considerable impact on the quality services provided and their accessibility
The women presidents of
Tumkur and Udupi were keen to improve health services. One of them was very
young, just married with no experience of either politics or holding a public office.
But her father was a leader and was holding a public office by getting elected.
.3
The other was having some experience at Gram Panchayat.
■3
President was keen to learn the ropes of administration to act and improve. She
3
had visited some PHCs and believed that women still prefer to give births at
□
home as it is more convenient. She was aware that some-MOs and ANMs are
9
Tumkur ZP
not regular and was planning to discuss with the administration for possible
action.
J
The Gulbarga ZP president was very open and said that “MOs not only
3
are irregular but also sell the medicines in the open market. For days they do not
•3
visit PHCs. But I do not have powers to set things right”. The President said that
a
he would set things right in two weeks if he had powers.
j
3
3
3
He was sorry that the
State Government that belongs to his party is not receptive to their views.
2(>
The ZP President of Kolar was more dynamic and when we met he had
visited a PHC (where he had gone for attending a public function) on the request
of the public who complained that the MO is very irregular.
Indeed MO was
absent when the ZP president visited the PHC. He called DHO to know how they
can take action against such officials.
He reported that he is new (like other 3
”2
presidents) to the intricacies of the administration and though he attended some
training programmes organised for ZP presidents he has a long way to go to
master the art. He had kept a Rule Book prepared by the state government and
■5
would refer to it often when he had some confusion. He was also of the opinion
that ZP has little scope to bring in discipline among the staff working in the district
on deputation. He often requests the DHO to be strict and wants to support him
I in improving the health services for the benefit of the people.
J
3
The Vice Presidents
3
The Vice Presidents also echoed the views of their Presidents. ZP cannot
3
take any action. They have to write to the Government for action and there are
3
long delays or no action. Vacant positions in the Health Department is reported
routinely to the Government for filling but nothing is heard from them The CEO
□
position was vacant for 2 months and during that time DC was incharge CEO.
One can imagine how things will move. It was clear that transfers, recruitments
3
or suspension of any health staff is not vested with ZP. Under the circumstances
<9
poor accessibility and inequity in health care services become the order of the
3
day and both elected representatives and the bureaucracy become used to it.
3
9
It is to be noted here that none of top leadership in ZP-- elected members,
members of the Standing Committee on Health and Education, CEOs and DCs
were totally aware of the disparities that exist in the health status of people in
9
different districts, by gender, caste and economic status within the districts. The
9
next line of authority Deputy Secretary 1 were also equally ignorant of health
&
outcomes, indicators and job responsibilities of various categories of staff. The
Administration at Taluk and Districts were busy with construction of new
a
9
0
3
0
structures, equipments or drugs more than their use for public good. There was
a unanimous demand in Tumkur, Kolar and Gulbarga that there is need for
training to make them more informed and effective.
Why the DHO does not
provide them the insights of the Department? He has no time as all his time is
spent in the meetings.
The DHO also has several constraints.
Since he has
hardly any time his visits to Primary health Centres have reached minimum. It is
only when a dignitary like District-in-charge Minister (another authority over all
the happenings in the district) has a public function he may visit a PHC. The staff
at PHC could recall the past practice of frequent visits of DHO for supervision. It
3
was not only to their PHC but even to a nearby PHC would keep them alert with
a chance visit to their PHC on the way back.
This practice has almost
disappeared now.
This brief description provides how the in-built mechanisms to ensure
accessibility to health care services have become ineffective. It is not surprising
that the health status of people in health poor districts continue to be poor even
&
though public resources - more valuable looking at the scarcity, become less
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and less productive. One of the important reasons for the observed delay could
3
be the faster expansion without consideration to the enormous resources needed
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for it. Earlier the quality of services, as reported by senior staff was much better. -
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Now even though the scarcity of equipment, maintenance of assets etc. is
reported to the authority may not be heard that leads to the weakening of the
authority because of the inability to solve it quickly. The only positive change is
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the improved drug supply after decentralisation
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unsatisfactory in health poor districts.
Rest every thing is highly
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Section III
Areas of Conflicts
Given the situation described
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so far where lies the conflict between the
health bureaucracy and ZP or FRisr me tocus group discussion often led to
PRIs? The focus group discussion often
mudslinging exercise. That PRIs arrival have lead to more corruption and
harassment of personnel. To start with, the bottom line ANMs complained that
elected representatives demand service on priority basis, call the ANMs to their
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residence even for headache and stomach ache and demand medicines free and
often ANMs have to bear the costs. As most of them (elected representatives)
are not educated their behaviour is curt and without etiquettes and manners that
hurts ANMs. The MOs at PHC complained similarly in addition they reported that
the elected representatives question them if an ANM is not posted in a sub
centre which is not under his powers.
'1
The DHOs office complained of
interference in day to day administration by the Elected Representatives.
5
A Taluk Medical Officer complained that there was out break of cholera
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because of the contaminated water supply by the Taluk Panchayat. When he
0
reported that water supply has to be improved by taking some measures like
chlorination, he was abused for dereliction of his duties. When they send a
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proposal to repair a collapsing building to DHO with a copy to ZP the CEO just
does not bother.
Medicines are not supplied regularly.
They dump several
useless drugs which are of no use. PHC and MOs indent is often ignored.
The Quarters of ANM built by the PRI are of extremely poor quality. An
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ANM was in tears to report how she has to cover the roof with polythene sheet to
protect her from leakage and to re-do the electrification to save from the shocks
spent Rs.3,700 from her pocket. Complaints made to DHO, ZP and TPs were of
no use.
She was told that she has to stay there the Quarter on which lot of
money is spent to make it according to the specification given.
A meeting with all medical officers of a Taluk brought out their vent against
elected representatives.
A LMO reported that new PHC was built but the
quarters for staff are not. The PHC is in the outskirts of a village and no body
dare to stay there in the night not even a watchman
If they had constructed
housing along with the PHC it would have facilitated.
3
Another LMO who
commutes to PHC every day from Gulbarga complained that the people and
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elected representatives harass her to stay in the PHC quarter which she has not
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occupied because there is no water, electricity and building is 25 year old needs
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repairs. They are not keen to do anything to facilitate the services. Most of the
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drugs that ZP supplies are about to expire and become useless.
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The months Feb-March are two months when ZP administration is too
busy to approve medical reimbursals of staff of Health Department and they not
even consult the DHO. Registers required to compile statistics are not supplied
for over a decade. All files move only if currency notes are enclosed with them.
ROH building fund of Rs. 10 lakhs is lying for over an year but even the plan is yet
to be made and approved
Nothing moves.
Taluk Medical Officer has to write to DHO who in turn has to forward to ZP
for any action. Taluk Medical officers can not even sanction Travelling bills of his
subordinate staff and those who approve it may not know whether the travel was
3
made to those places. ZP sanctions all such TA bills with a cut of 10-20 percent.
Power
Even the DHO’s office in Gulbarga has several stories of delays.
connection to his office is not done though they have spent Rs.37,000 for it about
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19 months back but ZP is still silent. The list is endless.
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What ultimately emerges is that the conflict arise from multiple points of
authority with not a single source taking any interest in improving things.
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£
The
question that arise is who should set things right with quick decision to solve the
problem.
It is only CEO who is authorised to act after waiting for instructions
from the Government on any of the complaints made. We did not come across
any such action except issuing a memo or deducting a days salary in some one
or two complaints against ANMs. But suspension orders can be issued only by
the Government.
Generally when there is such a serious complaint against a
MO or other officials. ZP elected members or a Minister interfere and nullifies all
©
efforts.
3
couple of staff coming late when they had visited.
9
Some ZP Presidents had complained against unclean PHCs and a
The PRI elected members have many stories against the health staff.
Irregularity, showing unconcern and asking money were very common.
It was
surprising a lady member of the Standing Committee on Health and Education
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whose husband (aged 44 years) died on Jan 4th 2001 because of the neglect of
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MO in treating him.
He died of massive heart attack and MO had given him
treatment for acidity the previous day to his death.
He did not check his blood
pressure nor examined him. But she did not complain as he is well connected.
«£)
9
But the elected members of such statutory high power committees also are
ignorant as reported by many about the health situation - no idea about death
rate, infant deaths or maternal mortality which are very high in their area and
there was a strong demand to enlighten them on health issues to strengthen
them and to improve the situation.
In addition the bureaucrats at ZP believe that Medical Officers at PHC
1
CMC and district office lack badly administrative skills and management skills to
work in a team. The lack or absence of such skills go on accumulating and turn
into major issues. We also believe that managing the staff is an art that many
3
medical graduates who join the service as MO at PHC may not have and already
some programmes to train them as managers of PHC is on.
The proceedings of the Standing Committee on Health and Education of
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Tumkur District however reflects what we noted about the district.
It says 11
administration in health department has collapsed and DHO has no control over
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his department” (page 4 of 24/10/2000).
It also notes the ZP Presidents
suggestion that priority should be given to patients in rural areas by the Medical
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Officers.
It also questions about MOs saying that there is no medicines in the
PHCs and prescribing drugs to be purchased by the patients in the market.
The proceedings of Udupi ZP’s Standing Committee that meets every
month regularly reveal that there is evidence of some efforts to improve the
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services further.
3
any complaint to make about the functioning of the PHC they are provided a post
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card free and they can mail it to the concerned authority for action.
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such complaints the Committee resolved to examine such complaints and
3
PHCs in Udupi display boldly that if the visitors to PHC have
Based on
recommend action to be taken (either terminate the services of contract MOs or
transfer them).
It also instructed the DHO to recruit group ‘D; employees on
3
temporary basis in place where there is need to ensure cleanliness of health
3
institutions.
It notes of disciplinary action by issuing show cause notice to
unauthorised absence of a Taluk Medical Officer to consider his absence as
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leave without pay. These resolutions certainly indicate the efficient mechanism
31
of receiving complaints and quick action within the limitations of ZP which
i-.?’
are
worth emulating by other ZPs in the State.
The proceedings of Gulbarga ZP is silent on the situation in health
service
delivary system in the district but emphasise more on building model Primary
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Health Centre, resource mobilisation, etc. that shows there is no in-built
is no
mechanism of receiving public grievances or they are ignored.
Section IV
Summary of the Findings and Recommendations
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The intensive study carried out with time constraint has been able to
effectively explore a complicated area ignored
so far in academic circles. The
policy statement issued recently on population by the Government of India has
given the prominence to PRIs that they deserve.
It is brought out by the study
that multiple_power centres and poor co-ordination among them for effective
>
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decision making is hampering the smooth functioning of ZP and Health
Department at district level.
Appointment, transfer, suspension are the crucial
areas where ZP acts only as a Post Office.
Unless the State Government
approves they cannot act. The key post of DHO has been weakened because of
interference of elected representatives.
5
a
Even simple act like posting a
Laboratory Technician from a place where there is no serious demand for his
services to a place where there is an out break of an epidemic is resisted by
highest authority. Infact instructions come to him if he acts in his way he will be
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in trouble.
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another place has become just impossible.
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several meetings he has to attend. This was the view of all high officials also in
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Such instances have demoralised him.
Transferring an ANM to
Time constraint is imposed by
Bangalore that they find little time to work in their office.
The Grama_Sabha - a most powerful instrument the people have to air
their grievances for redressal and which is given lot of importance in
decentralised system of
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governance is almost non-functional as found in the
household survey responses,
People complained in Gulbarga and Tumkur
districts that meeting is not
announced by Tam-Tam (drum beating) and contrary
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U8069
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it is held when most of the residents go for work and only few whom they want
attend it and non complaints are entertained.
The Udupi District that is in the
forefront in health sector has developed a good system of receiving public
grievances directly by the authorities concerned and redressal is quick. In other
two districts complaints are unheard and neglected on the ground that there are
no written complaints.
Decentralisation is still in infancy in the state and suffers from several
0
constraints to be effective government at district level.
How to monitor the
functioning of the system of health care services delivery? Is not known to even
top officials like CEO, Dy. Secretary 1 and other officers at Taluk levels. Official
inspections are more ceremonial and unproductive even though such inspections
by different categories of authority are rare and routine.
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There is no effort to
understand the problems and solve to improve the performance is not seen any
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where except in Udupi. Therefore there was a strong demand to enlighten them
with one day programme at ZP for all concerned officers. The officers in health
department were not even aware of research finding that should guide them in
their work.
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The guiding principle of any public health care service delivery is equity
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and universal accessibility. The state has a very very long way to go to achieve
it. Even then equity and universal accessibility will not be an automatic fall back
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from expanding services or bringing in a semblance of quality in care. It can be
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achieved by monitoring crucial services like basic primary care which is
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absolutely missing at ZP level. There is need to intensify the efforts, if already
there are, to reach the goal of equity. For this there is need-to equip PRI elected
members, general public about the importance of health and its effective
utilisation.
The elected representatives have to develop responsibility towards
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their activities. They come from diverse socio-economic and cultural background
3
and over the years grow as leaders. They have started asking questions about
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services which is in the right direction.
Health personnel who were used to
departmental control are perturbed over the authority of representatives.
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They
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will have to realise that their services are for them and they are the real mastpr?
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in a democratic system. There is nothing to worry.
But till the PRIs become more effective in their functions the department
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has the crucial role to play. Efficiency and quality care and ensuring its outreach
of services have to be managed by them which will go a long way in building of
credibility of the department which is at a very low ebb now. PRIs will be happy
3
and stop interfering if they are convinced about good services to all.
3
The main questions that still remains to be answered is how decentralised
the state is really? Can ZPs be considered as Local Self Government? A short
3
term study such as this would not try to explain the extent of decentralisation
the state today.
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It seems there is a make-believe effort to show we are
decentralised while all the powers are centralised with the state (because of
several reasons stated and believed). One of the important factor for the mess in
health department is the multiple power centre without any direction - pulling the
3
cart in different direction.
a
Medical Officers to occupy this role reflects very clearly the situation.
3
care services are to be improved his position has to be strengthened.
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studies ideally need at least an year but an effort is made here to bring out
The lost aura of DHOs and reluctance of efficient
If health
Such
several complex issues that a longitudinal study should explore in the future.
Recommendation
1)
There is an urgent need to make ZPs to consider health sector as an
3
important input in development and to educate officials ranging from Chief
3
Executive officer to Executive Officer at Taluk level on monitoring health
services and on health indicators that reflect it.
There is unbelievable
ignorance in the administration and also in the health department who are
major health care providers in rural areas on the status of health of their
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people.
2)
The Elected Representatives from Gram Panchayat to ZP level also need
to be educated about importance of health and their role in monitoring
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health outcomes. Only ensuring presence of doctor or supply of drugs is
not adequate to achieve equity.
Monitoring plays a crucial role and it is
totally absent at all levels.
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3)
The Health Department should be made responsible in improving health
care services in the districts and they should be ensured the support of
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ZP, TP and GP in carrying out their responsibilities efficiently.
For this
there' is need to build-up the credibility that is lost. The health services
would be considered good if the indicators of health improve and become
comparable with the‘best in the state to start with.
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4)
There is an urgent need to establish fool proof mechanism to receive
public grievances for redressal as is effectively done in Udupi District.
3
Strengthening Grama Sabhas would play an important role if they are
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conducted properly. PHCs in health poor district should provide free post
cards to public who should mail it to responsible authority for redressal
and quick action on the complaints will strengthen this mechanism in due
course of time.
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5)
not is a wider question we would avoid answering here. But they can play
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Whether ZP Presidents should be fully empowered for taking any action or
t
an important role within the powers they enjoy now. Just calling an erring
officer and reprimanding him in public will do the trick. Even an indication
that they are serious will go a long way than proceeding on legal terms.
6)
The ZP and health bureaucracy at district level should learn to respect
each other and the need to understand their complimentary role. Health is
a technical subject best known to health staff and they need all the
support, encouragement and appreciation when they do a good job.
Health staff should realise that elected members to PRI though may not
be educated represent peoples views and respect them for that. There is
>
need to meet informally for achieving this by both.
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