Plan campaign comes under review

By Our Staff Reporter

THIRUVANANTHAPURAM, JULY 8. The failure to evolve a consensus on development priorities and political biases of panchayat leaders had adversely affected the implementation of the People's Plan campaign, according to experts and researchers who attended a seminar here.

Participants at the seminar on "Health Sector and Decentralisation in Kerala" felt that technical incompetence was yet another crucial factor which had resulted in the eventual achievement levels falling way short of expectations.

However, the broad agreement among the experts was that inspite of pitfalls in its implementation, the People's Plan held out several benefits for the health sector, especially in terms of infusing a new dynamism and introducing a higher level of local accountability in the sector.

The seminar was organised under the auspices of the Achutha Menon Centre for Health Science Studies, a wing of the Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST).

Dr. Joe Varghese, Dr. D. Varatharajan and Dr. K. R. Thankappan of the Achutha Menon Centre pointed out that the People's Plan process which was initiated in the State in 1996, included a specific decentralisation package relating to the administration of health care institutions and planning and allocation of 35 to 40 per cent of the State's Plan fund. The reallocation process was governed by two elements- the State Planning Board's guidelines and the people's real needs.

The authors, who attempted to evaluate the resources reallocation process of the panchayats from this perspective, concluded that, contrary to initial fears of an over-emphasis on construction of buildings and a heavy orientation towards curative care projects, the resource allocation to these categories, actually constituted only about 6 per cent of the outlay, and less than 45 per cent of the total number of proposals advocating investment on this received funding.

According to the authors, the results of their review also indicated that a significant proportion of the resources for health had flowed towards either public or merit goods. However, as the participation rate in the decision-making process had increased, the investment flowed more towards private goods.

The authors also noted that direct investment in health projects was pegged at the minimum level inspite of a surplus of proposals. They felt that the increasing tendency towards more number of smaller projects, with the extent of investment ranging upto 28 per cent.

The authors had reviewed allocation decisions made by 35 panchayats during the second (1998), third (1999) and fourth (2000) years. The selected panchayats were from three districts, each representing three geographic regions of Kerala and the allocations classified into four categories- public goods, private goods, merit goods and aggregate investment.

In another presentation, Dr. Varatharajan, Dr. Thankappan and Dr. Sabeena Jayapalan, suggested a community-backed decentralised control mechanism to address the health care needs of the people. The justification for this, according to the authors, was the scope for maximising the benefits of efficient allocation and utilisation of available resources- the twin potentialities of panchayati raj.

""Decentralisation also leads to maximisation of welfare, narrowing down of information asymmetry and mobilisation of social capital,"" the authors said.

According to the authors, who essentially examined whether a panchayati raj structure led to better facilities and improved efficiency of PHCs, and whether it ensured better access and quality of care to the patients, the PHCs which received better support from the panchayat could cater to an increased patient load. Moreover, they (PHCs) were able to attract more patients, even from distant places, for treatment of common ailments. Moreover, the access and quality of care too were comparatively better than in the case of PHCs which lacked adequate panchayat backing.

According to the authors, the contribution of the panchayat to the increase in patient load and cost reduction was estimated at 28.9 per cent and 42.2 per cent respectively. In monetary terms, they estimated the amount to be approximately an annual support of roughly Rs. 45,000, which could extend the reach of the PHC facility to about 3,000 (14.3 per cent) more patients.

However, while pressing the case for increased panchayat support to PHCs, the authors have expressed concern over the declining support of local bodies to baseline health care units (PHCs).

The share of health in the total plan outlay had dropped from 1.98 per cent in 1997-98 to 1.83 per cent in 1998-99 while the grant-in-aid resources had come down from 1.91 per cent to 1.61 in the corresponding period. The financial support extended by the surveyed panchayats to their respective PHCs was a mere 0.11 per cent of the aggregate panchayat income contributing around 1- 3 per cent to the annual PHC cost.

The results of the study which surveyed 10 panchayats, 10 PHCs, 104 patients, 20 PHC staffers and 16 panchayat members, indicated a 13-14 per cent increase in net resources availability for non- salary expenditure of a PHC. This, in turn, had triggered an over two-fold increase in patient load and a three-fold decline in unit cost.

While the campaign itself reflected a genuine decentralisation of power to the panchayats as it involved the transfer of managerial, financial and political functions from the "centre" to the "periphery", the authors pointed to the major concern about the public health services system becoming alienated from the people.

According to the authors, only between 30 to 40 per cent of the people appeared to be seeking medical help from the Government health care facilities. The utilisation of PHCs, the authors noted, too fell short of the desirable levels.

According to the authors, this trend affected largely the poor social strata as it was this segment that expended a major portion (around 40 per cent) of the household income on health care. The overwhelming reason for low spending ratio on public health delivery system was found to be lack of medicines, doctors and other facilities. As a result, the existing health care delivery staff strength remained under-utilised to a great extent for want of additional facilities.

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