The World Health Organisation has been advocating the decentralisation of health sector as the primary step to ensure community participation in health care programmes to solve health problems that developing countries face. This goal was achieved by Kerala following the People’s Planning process initiated by the Left Front government in 1996. Bold and remarkable decentralisation processes have taken place in health sector in Kerala when compared to other states. An assessment of the decentralisation in the last two decades shows that the most positive and visible impact of decentralisation was largely seen in the health sector.
During the early 1980s, several health problems plagued Kerala’s health care system. Many of the infectious diseases that had been under control resurfaced and new ones emerged along with them. Lifestyle diseases such as diabetes, hypertension and heart diseases made headway, mental health status went down and number of suicides increased. Public health care facilities were stagnating owing to neglect of the government sector, which paved the way for uncontrolled growth of the private sector. The cost of health care increased at an alarming rate, pushing even the middle class below the poverty line because of catastrophic health expenditure. Improvement of the facilities of the Government sector so as to cater to the needs of the poor, strengthening of the primary and secondary care so as to promote preventive and promotive health care, control of the infectious and life style disease burden, provision of better sanitation were suggested by health planners and activists as a remedy to confront the health crisis. To realise these objectives, strengthening of the primary and secondary health care institutions through a decentralisation process was seen as the solution.
The implementation of the Panchayat Raj act provided an opportunity to bring public health care units and their services under the control of local governments. Immediately after launching the People’s Planning process in 1996 , all the public health care institutions from Primary Health Centres to District Hospitals were transferred to the local governments. Reasonable amount of untied fund was made available with the local governments to plan and implement health projects as per local needs.
An overview of the recent outcomes of the devolution in the health sector leads us to the following points. The local governments have succeeded in achieving better sanitation by providing individual and community latrines. The availability of safe drinking water has improved. A number of the primary and secondary health care institutions are properly equipped and looked after by the respective local governments. Special projects for ‘palliative care’ can be found in many village Panchayats. Special projects for autism, differently abled, aged, victims of cognitive disorders, kidney patients and community psychiatry are included in the list of projects by the local governments. This is an indication to substantiate that local governments are responding to the specific locality-based health needs. Capacity for public health management of the professionals and elected authorities has been enhanced. The conflicts and ego clash between the medical professional and the elected authorities have been largely settled.
However, the improvement of the lower level health institutions is not uniform throughout Kerala. Wherever elected representatives, health personnel and the people at large stand together, visible and positive changes can be seen. However, a large number of issues are yet to be settled. The dual control of the health care institutions by the Panchayats and by the health departments is the major problem that needs to be addressed. Doctors and other health personnel are appointed and posted by the directorate of health services, so is the distribution of drugs, purchase of high cost technologies etc.
The issues related to parallel and vertical development programmes such as National Rural Health Mission, Integrated Child Development Schemes etc. over shadow the autonomous activities of the local bodies. However, it needs to be conceded that such programmes are functioning fairly well in Kerala because of the involvement of local bodies. Though most of the Panchayats in Kerala have been awarded the Nirmal Puraskar, Kerala still could not achieve total success in environmental sanitation and waste disposal. Many major projects for waste disposal initiated by Corporations and Municipalities are yet to be completed. Though 50 per cent of the elected local body representatives are women, the specific problems of women’s health have not be addressed. Further, the local bodies have not provided clean toilets for ladies in public places.