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Local Self-Governance in Health: Evidences from Odisha

Explore perspectives on local self-governance in Odisha health system through focus group discussions, analyzing decision-making processes and governance factors.

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Local Self-Governance in Health: Evidences from Odisha

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  1. Local Self-Governance in Health: Evidences from Odisha Dr Bhuputra Panda IIPH-Bhubaneswar Odisha Development Conclave 20 Sep, 2016

  2. Journey of Self-Governance …. Self-Governance Blind Obedience Informed Acquiescence

  3. Background • Governance is the most crucial pillar of ‘health systems building blocks’. • Decentralization or local self-governance as a reform measure aims to improve inputs, management processes and health outcomes, and has political, administrative and financial connotations. • It is argued that the robustness of a health system in achieving desirable outcomes is contingent upon the width and depth of ‘decision space’ at the local level. • Local governance is not just about accountability, but a wide range of functions. • In public health sector, local self-governance is fostered through establishment of RKS and ZSS.

  4. Objectives • To explore the perspectives of key stakeholders about local self-governance in Odisha. • To understand the process of local decision making in primary and secondary health units of Odisha, India.

  5. Focus Group Discussions • On average, each FGD consisted of 6-9 participants. • No monetary support was given to any of the participants. • No participant denied to participate in the FGDs. • All discussions and interviews were audio recorded. • FGDs were conducted either at the meeting hall of the CHC/DHH or as decided by the respondents. • Informed written consent was obtained from all participants prior to the study. • Study was approved by an independent IEC.

  6. Methods • 15 Focus Group Discussions across six districts of Odisha The main objective of conducting FGDs was to foster an environment for interaction between participants and hearing from others in a group setting which could provide a valuable opportunity to show and discuss the differences among participants

  7. Analysis • Based on the analysis of RKS objectives and functions, organizational and governance related factors affecting local decision making were broadly divided into the following five themes: • Composition of RKS • Governance within RKS • Functions of RKS • Supportive environment • Recommendations

  8. Analysis Scheme

  9. Membership • Whenever there is a meeting, everyone comes and participates and approves the proposal. But the post meeting follow-up from the committee members who are from other departments is very less and is not as per expectations. • There are too many stakeholders in RKS such as IMA members, doctors who are involved in treatment. Even a ‘rickshaw wala’ becomes a member with INR 5000 payment. They come to take food and disappear.

  10. Composition • I think the composition is not correct…..We do item-wise discussion. We have last minutes….Everything forcefully discussed, only noise. No action. That is not a RKS. That is A****l Bidhan Sabha. (Focus group discussion, 2:11) • In the last 3 years, there had been 3 meetings. EB meeting mostly once in two months. We are so overloaded with all the programmes that it is very difficult to take out time for the meetings. When we take out some time, then BDO is not able to come. Like this, it is delayed. Gathering all the members together is too difficult for us. (Focus group discussion, 4:10)

  11. Participation • Official participants are reluctant to come. They have work in our date and we have our work in their date. That is how it is going on. For quarterly meeting, the Minister is not able to give time. Whey they give time, others are not ready. This how it is going on and the meetings get postponed. What is supposed to happen every quarter that is happening perhaps once every six months. (Focus group discussion, 1:9)

  12. Functioning of RKS • Especially in the DHH RKS, they are very supportive and proactive. They always try to see how the problems can be solved quickly. (Focus group discussion, 6:15). • There is a gap in communication as many people don’t know what RKS is and that with it which problems we can solve. (Focus group discussion, 8:35)

  13. Functioning of RKS • With RKS it has become easy as now they have to take permission just from the governing body locally and thus implementation becomes easily. (Focus group discussion, 6:10) • So many members are there, enforcement mechanisms not there. No implementation or monitoring mechanism. One or two persons can’t do anything. (Focus group discussion, 2:26)

  14. Functioning of RKS • Back here I asked the hospital manager to look down and look up while doing the round duty. You are running behind the money at so young age. In one case, he was involved in money matters and he was terminated by the MD-NHM. (Focus group discussion, 3:11) • There is no vested interest in RKS but in GKS where ward members are the chairman, there are definitely vested interests. (Focus group discussion, 5:61)

  15. Service delivery • Need more money. Construction is now dealt with the centre. No monitoring. No quality is controlled. The MO is not having any monitoring jurisdiction. Handover is not done immediately. How do we know what is the problem? (Focus group discussion, 1:42)

  16. Local responsiveness • Complaint box is there but there are not many complaints. Rather than putting a written complaint into the box they directly go to the MO. (Focus group discussion, 5:52) • There were a lot of vague and false complaints that used to come. So I stopped it. (Focus group discussion, 4:5)

  17. Local responsiveness • Since the time patient arrives at the hospital to till he is discharged all the works related to it, whether direct or indirect, are the functions of RKS. (Focus group discussion, 9:6) • Suppose a very poor person, or a BPL patient is there then even medicines are bought for them from RKS, their tests are also free. So it is not everyone. This is not for everyone; free service is given to those who are not capable of paying. And I will like to mention, here I am really thankful that we are not facing any major challenges in the RKS. (Focus group discussion, 9:17)

  18. Convergence • Whenever I am asking JEE or Assistant Engineer, they are saying ‘sir, we have given it to the RD’. I am now their enemy. I don’t care. I want the defects to be rectified. (Focus group discussion, 1:43) • The MO should be given the powers to monitor the local construction activities. (Focus group discussion, 1:44) • NRHM people are not cooperating with other wings. How health improvement will be done? (Focus group discussion, 2:1)

  19. Success stories • There has been a lot of change from the last years’ attitude. They are coming voluntarily to cooperate us. (Focus group discussion, 7:21) • Earlier the decision making authority was only in the state. Now they are giving importance to decision makers in the periphery to understand what the local needs in the field are. (Focus group discussion, 6:6)

  20. Success stories • What we did from RKS is the announcements in mike, leaflets and posters were developed on how to use the water, what to do with the water, where should they go for defecation? Everything we did for 7 days and only with a meager budget of 7000- 8000 INR we could drive out hepatitis from the village. (Focus group discussion, 9:11)

  21. Challenges • There is no urinal or toilet for staff nurses anywhere, they don’t have facility for changing dresses. (Focus group discussion, 8:3 • Many unnecessary medicines are coming and unnecessarily they are being destroyed. (Focus group discussion, 8:31) • Some 30- 40% of patients might be buying from outside. (Focus group discussion, 11:6)

  22. Recommendations • They should keep a criteria to become a member. (Focus group discussion, 2:6) • Those who don’t have any knowledge about health sector, what advice they will give? Only ‘hungama’ is the moto. Only fault finding aspect is being focused. No positive attitude to work. How many are genuine to improve the hospital, tell me. 5000 or 20000 is paid to become a member. Your intention is how to expose someone on the day. (Focus group discussion, 2:7)

  23. Recommendations • There is a need of refresher or orientation of the RKS members. But no such steps have been taken. (Focus group discussion, 5:45) • RKS needs more financial support….then hospitals day to day management could be effectively managed. We could have done more work if there is sufficient amount of funding. (Focus group discussion, 6:42) • In charge of every ward should be involved in the RK meeting. Along with training hand holding support is also required. Hospital manager should be empowered and along with that there should be a separate manager for the OG word for managing the issues (Focus group discussion, 6:48)

  24. Recommendations • Something should be done to improve their mentality, their responsibility towards an organization. I mean specifically non-medical persons like the PRI members; they are not willing to attend. Without their presence the meetings are a complete failure. (Focus group discussion, 8:44) • RKS grant should be increased to 20 lakhs and we had suggested for FRU grant increase, now we are getting INR 45per bed per day that should be hiked to around 80 INR per bed per day. (Focus group discussion, 11:17)

  25. Thank you

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