Chapter 7 Assessing Urban Governance through the Prism of Healthcare Services in Delhi, Hyderabad and Mumbai Loraine Kennedy, Ravi Duggal and Stéphanie Tawa Lama-Rewal The aim of this empirical study is to reflect on urban governance in India’s large metropolitan cities by examining healthcare services in Delhi, Hyderabad and Mumbai. The objective is not a strict comparison of the cities per se, indeed the data sets available are not identical for the three cities, rather the idea is to use a comparative perspective to tease out general findings about the evolution of supply and demand for a given service in relation to a particular governance situation. These three cities are situated in different regions of the country, characterised by distinct political cultures and they occupy dissimilar positions in the urban hierarchy. It will be seen that this heritage contributes in a significant way to explaining the variance we observe with regard to governance between the three cities. Notwithstanding, they are exposed to a common overall policy framework and similar forces are clearly at work in each, reshaping service delivery and redefining the respective roles of different categories of actors. As outlined in Chapter 1, the main analytical focus is on changes that have occurred over the last 10–15 years as a result of decentralisation and economic reform. Before presenting the findings from the city-level studies, we provide a brief overview of the evolution of healthcare services in India over the last few decades. In addition to providing a kind of benchmark, it is a useful reminder that many of the trends we observe are linked to overall conditions in India and not to localised contexts. The subsequent sections compare the functions of each municipal corporation with regard to healthcare services, followed by an analysis of the ways in which delivery systems have been
Transcript
Chapter 7
Assessing Urban Governance through the Prism of Healthcare Services in
Delhi, Hyderabad and Mumbai
Loraine Kennedy, Ravi Duggal and Stéphanie Tawa Lama-Rewal
The aim of this empirical study is to refl ect on urban governance in India’s large metropolitan cities by examining healthcare services in Delhi, Hyderabad and Mumbai. The objective is not a strict comparison of the cities per se, indeed the data sets available are not identical for the three cities, rather the idea is to use a comparative perspective to tease out general fi ndings about the evolution of supply and demand for a given service in relation to a particular governance situation. These three cities are situated in different regions of the country, characterised by distinct political cultures and they occupy dissimilar positions in the urban hierarchy. It will be seen that this heritage contributes in a signifi cant way to explaining the variance we observe with regard to governance between the three cities. Notwithstanding, they are exposed to a common overall policy framework and similar forces are clearly at work in each, reshaping service delivery and redefi ning the respective roles of different categories of actors. As outlined in Chapter 1, the main analytical focus is on changes that have occurred over the last 10–15 years as a result of decentralisation and economic reform.
Before presenting the fi ndings from the city-level studies, we provide a brief overview of the evolution of healthcare services in India over the last few decades. In addition to providing a kind of benchmark, it is a useful reminder that many of the trends we observe are linked to overall conditions in India and not to localised contexts. The subsequent sections compare the functions of each municipal corporation with regard to healthcare services, followed by an analysis of the ways in which delivery systems have been
162 KENNEDY, DUGGAL AND LAMA-REWAL
redesigned, including the principles guiding the reforms and the actors involved. For each city, we question whether the creation of Ward Committees has resulted in greater participation of the elected municipal councillors in issues related to health services. Finally, we assess the implications of the changes observed within this sector for urban governance.
The Health Scenario in India
Given the nature of the health sector in India, several levels of an-alysis are necessary to grasp current trends: macro, meso and micro. Constitutionally speaking, health is a state subject, but in reality the union government plays a critical role both with regard to policy and to specifi c programmes, and it constitutes a major provider of funds.
In the 50 years since India’s independence there have been re-markable achievements on the health front, as Table 7.1 illustrates.
While the evolution of health indicators is generally positive, the public health system has had only limited success in providing basic care to the majority of the population. There is high reliance
Source: adapted from Box 1, National Health Policy (Government of India 2002). Note that some data in column 4 is from years prior to 2000.
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on private, out-of-pocket expenditure on health, which imposes a disproportionate burden on the poor: the poorest 20 per cent of the population have more than double the mortality rates, malnutrition and fertility of the richest quintile (Narayan n.d.: 17). In addition to inequalities among income groups, there are striking urban–rural disparities, refl ected in the fact that out-of-pocket expenses in urban areas are about twice of what the state spends on healthcare in urban areas in contrast to rural areas where the out-of-pocket bur-den is ten times what the state spends on healthcare (National Sample Survey Organisation [NSSO] 1998). In general, urban areas tend to have much higher levels of access. According to a recent government report, the availability of hospitals per 100,000 urban population is more than six times higher than for 100,000 rural population (cited by Paul et al. 2004: 923). Metropolitan regions like Mumbai corner almost half the public health resources of the state government and also about 40 per cent of private health resources.
There remain tremendous challenges in the health sector, too vast in fact for the government to handle on its own. Increasingly, policy-makers recognise that the private sector has a crucial role to play. As shown in Table 7.2, in the mid-1980s, almost three-quarters of the out-patient care in rural areas was provided by the private sector, and 40 per cent of in-patient care. A decade later, the proportion of care provided by the private sector rose considerably: to roughly 80 per cent for in-patient care and to 55 per cent for out-patient care.
Table 7.2 confi rms a general trend towards the privatisation of healthcare services throughout the country, and underscores the convergence of this trend across rural and urban areas.
Table 7.2: Public–Private Sector Provision of Healthcare in Urban and Rural India (Percentage Distribution)
Rural Urban
1986–87 1995–96 1986–87 1995–96
Out-patient care Public sector 26 19 27 19 Private sector 74 80 73 81
In-patient care Public sector 60 45 60 43 Private sector 40 55 40 57
Source: Reproduced from Narayan (n.d.: 20), based on the from 42nd and 52nd rounds of the National Sample Survey.
Note: All fi gures have been rounded off.
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A second trend, no doubt related to the fi rst is the decline in total investment in public health in the 1990s as a percentage of GDP, from 1.3 per cent in 1990 to 0.9 per cent in 1999: ‘The aggregate expenditure in the Health sector is 5.2 per cent of the GDP. Out of this, about 17 percent of the aggregate expenditure is public health spending, the balance being out-of-pocket expenditure. The central budgetary allocation for health over this period, as a percentage of the total Central Budget, has been stagnant at 1.3 percent, while that in the States has declined from 7.0 percent to 5.5 percent.’ (Government of India 2002: 5). International comparisons suggest that India would need to invest a much larger proportion of pub-lic fi nance in total health expenditure if it is to improve access to healthcare. India’s equity record in access and health outcomes, compares poorly with China, Malaysia, South Korea, and Sri Lanka, where public fi nance accounts for 30 to 60 per cent of total healthcare expenditure (Duggal 2007, citing data from WHO 2004). Recognising the ‘stark reality’ of this extremely limited public health investment, in part because of the diffi cult fi scal positions of the state governments, the national health policy recommends that the union government augment its relative contribution. In view of reaching overall objectives aimed at reducing inequalities, the policy advocates strengthening the primary health sector (to 55 per cent of total public health investment) including better provisioning of essential drugs, because of the greater accessibility it affords for the population, and because it facilitates preventive care (Government of India 2002: 24).
Although the general trend towards privatisation of healthcare services is evident throughout the country, there are regional vari-ations, and regional contexts can be expected to affect the local en-vironment of healthcare services in the cities that we have studied.
One of the characteristics of Delhi’s governance is the overlap within a given territory of several politico-administrative entities: the Municipal Corporation of Delhi (MCD), with which we are primarily concerned here, the government of the National Capital Territory of Delhi (GoNCTD or Delhi government), the New Delhi Municipal Corporation (NDMC) and the union or central government.1 The
1 Under the central government’s control are major hospitals such as the All India Institute of Medical Sciences (AIIMS), institutions such as the Indian Council for Medical Research, and dispensaries that only cater to the needs of specifi c clients (i.e., government employees).
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Delhi government operates through the Health Department, the Social Welfare Department and the Health Directorate whose mission is to co-ordinate the action of the different health services providers (including private providers), to avoid overlaps and to control the quality of services. The crucial need to co-ordinate the work of these different agencies has been the subject of discussions and proposals for the past decade. It was recently decided that the Delhi government would be in charge of all curative healthcare except primary healthcare — which would remain with the MCD along with public health, i.e., preventive care. But from 1999 on-wards, the proposed transfer of curative functions from the MCD to the Delhi government has evoked recurring tensions between these two levels of government.2 A division of labour according to the type of medicine was also proposed: while the Delhi government would be in charge of allopathic medicine, the MCD would provide only Indian systems of medicine (ayurveda and unani) and homeopathy. However, according to senior MCD offi cials, this proposal was never strictly implemented. The latest co-ordination proposal, fi nalised in 2002, is more comprehensive: it plans to make the nine revenue districts of the National Capital Territory of Delhi reference units for the co-ordination of all medical facilities; a chief District Medical Offi cer will be in charge of coordination, s/he will check the registration of all medical practitioners, nursing homes, etc.,3 and be in charge of total health planning for the concerned district.4 In that scheme of things, all new dispensaries will offer Indian sys-tems of medicine and homeopathy along with allopathy.
Whereas the co-existence of different levels of government is a major feature of healthcare delivery in Delhi, the striking thing about Andhra Pradesh is the high proportion of healthcare services provided by the private sector, a trend that started here earlier than in other states. Already in the 1980s, the private sector provided about 70 per cent of in-patient care in the rural areas and 62 per cent in the urban areas, which was the highest proportion in the
2 In 2000, 4 of the 7 hospitals that had been taken over by the Delhi government went back to the MCD.
3 In 2003, a survey conducted by the Health Department found 1,603 illegal nursing homes and only 400 registered ones (Times of India, 14 March 2003).
4 Interview with a senior offi cial of the Health Directorate, Delhi, November 2004.
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country (Narayana 2003: 342).5 Regarding out-patient care, the predominance of the private sector is even more remarkable: 77 per cent in the rural areas and 89 per cent in urban areas. Although various factors have contributed to this situation, it has been noted that Andhra Pradesh government policy has at times directly supported the development of private facilities by providing sub-sidies and tax breaks. In the early 1980s, an offi cial policy document recognised the role of the private sector and the NGOs in achieving the state’s healthcare goals (Narayana 2003: 355). Reforms aimed at introducing new institutional arrangements and governance prac-tices were also implemented in the 1990s, building on the those started a decade earlier: 6 these reforms included measures to achieve greater fi nancial effi ciency in public hospitals through user charges and by contracting out supportive services, and the formation of Hospital Advisory Committees to improve accountability and transparency of public institutions. In the second half of the 1990s, the Telugu Desam Party (TDP)-led government implemented sig-nifi cant policy changes, including in the health fi eld. For instance, Andhra Pradesh was the fi rst state to formulate a State Population Policy in 1997, setting clear goals with regard to population growth and family planning. The results have been quite striking: currently the state has the highest percentage of female sterilisations in the country (the contraceptive prevalence rate is 59.3 per cent) (Academy of Nursing Studies [ANS] 2002: 7).7
In Maharashtra, the same trend is underway, but less explicitly: it is the unwritten policy of the state health department that curative care, especially hospitals, should be largely left to the private sector.
5 The corresponding all-India averages were roughly 40 per cent in 1986–87, as shown in Table 7.2.
6 In 1986, the Andhra Pradesh Vaidya Vidhana Parishad, an autonomous commission for the management of secondary hospitals was created in the framework of a World Bank funded programme. For more information on this reform and its effects, see Mooij and Prasad (2006).
7 Refl ecting a more gradual change, the total fertility rate declined to 2.5 children per woman in 1997, which is near the replacement level. These results have drawn much attention in both research and policy circles because they were achieved despite the young age at which women are married in Andhra Pradesh (according to the 2001 Census, 45 per cent of the girls were married by the time they were 19 years old) and low female literacy rates. See ANS (2002).
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It is for this reason that over the last decade or so no new investments in curative care have been made in Mumbai by the Brihanmumbai Municipal Corporation (BMC), which is a major provider of public healthcare. While there is no written evidence of this, our interviews with different stakeholders clearly indicated an arena of confl ict between elected representatives and the bureaucracy on these issues. The standing committee of the BMC has been opposing the privatisation of healthcare but the bureaucracy has been promoting this surreptitiously if not vigorously. There are also very large vested interests involved in this policy shift, including politicians, councillors, builders and the private health industry. This is because BMC hospitals are located on large plots, situated on prime property. The deal being offered by BMC’s privatisation cell is that anyone offering to redevelop dilapidated public hospitals will get a fl oor space index of four, that is, for every 100 square meters the developer will receive 400 square meters for development, of which 100 square meters will be given back to BMC as an equivalent of the existing hospital and the rest would be theirs to develop.
City-level Analysis of Healthcare Services
What are the functions of the municipal corporation with regard to healthcare services? Strong variations were observed even on this basic parameter. At one extreme is Hyderabad, where municipal authorities have very limited involvement in healthcare provision and administration is largely in the hands of the state government machinery; at the other extreme, Mumbai’s municipal corporation is in charge of running a vast network of hospitals including four teaching hospitals. Delhi is situated somewhere in between. A brief description of each case follows.
As mentioned there is overlap in Delhi: in addition to a few national-level institutions, a number of hospitals, polyclinics, dis-pensaries and medical colleges function under the Delhi government. As Table 7.3 shows, all these levels of government are involved in supplying primary-level facilities, which usually comes under the purview of local government. The MCD, i.e., Delhi’s largest civic body,8 has a diverse portfolio, managing a series of hospitals,
8 The other two civic bodies — the New Delhi Municipal Council (NDMC) and the Delhi Cantonment Board — are also providers of health services for their respective constituencies.
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polyclinics, dispensaries, maternity and child welfare centres, mobile vans and PHCs. The MCD is directly involved with both policy and implementation. Within the executive wing, the health department has been divided into three subsections: public health (i.e., preventive healthcare), hospital administration (i.e., curative healthcare) and veterinary services. The deliberative wing has thematic committees that mirror the departments of the executive wing, and these muni-cipal committees hold regular meetings. Interestingly, the municipal health department has the largest departmental budget in the MCD.
In Hyderabad, healthcare services are largely administered by the state government’s Department of Health. Indeed, Hyderabad city is treated as Hyderabad district for the purposes of administrative organisation, and a District Medical & Health Offi cer (DM&HO) is deputed to the Municipal Corporation of Hyderabad (MCH) and
Table 7.3: Primary Level Health Facilities in Delhi
Types of Centres Nos. Beds
A. Dispensaries Delhi Government 166 NA MCD 38 NA NDMC 11 NA Central Government 68 NA Railways 12 NA Statutory Bodies 117 NA
B. Primary Health Centre MCD 5 47 Directorate General of Health Services (DGHS) 2 32 Sub-Centres attached to Primary Health Centres (PHCs) 48 NAC. Maternity Hospital/Home MCD 23 301 NDMC 1 50
D. Mother and Child Welfare Centre MCD 109 NA IPP VIIIa (Maternity Homes) 6 90 NDMC 14 NA
E. Health Centre MCD (IPP VIII) 21 NA
F. Urban Family Welfare Centre 69 NA
G. Health Post 28 NA
Source: Health Facilities in Delhi 2005, Directorate of Health Services, GoNCTD.Note: a Indian Population Project, a project funded by the World Bank.
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occupies at the same time the position of Chief Medical Offi cer of MCH. But this offi cer continues to answer to the district collector and the state government’s line department for health. There is no health committee in the deliberative wing of the MCH, it is a minor player in the overall supply of healthcare facilities in the city. It mainly oversees primary healthcare centres (or urban health posts) and small maternity hospitals, as the box below indicates. In the late 1990s, the municipality redefi ned its focus area and target group, as part of its participation in the Indian Population Project (IPP-VIII). Following the guidelines of that project, the main objective is to cater its services to target the urban poor, through an extended network of urban health-posts, in particular for women and children, including ante- and post-natal care and family planning. New health-posts were constructed, and existing Family Welfare Centres were renovated.
Facilities under the purview of the MCH: 5 Maternity Centres (30 beds) 16 Family Welfare Centres (10 beds) 44 Urban Health Posts (out-patient & out-reach services) 5 Dispensaries
In Mumbai, in contrast, the BMC has much greater autonomy vis-à-vis the state government apparatus, because of its long history of providing healthcare infrastructure and services. BMC is a major provider of healthcare services and is in charge of running an extensive network of out-patient and in-patient facilities, with a combined strength of 2871 beds (Government of Maharashtra 2001a, 2001b).
BMC public healthcare network includes: 4 Teaching Hospitals (including one dental hospital) 16 Municipal General Hospitals 5 Special Hospitals 26 Maternity Homes 30 Postpartum centres, attached to either maternity homes or hospitals
176 Municipal Dispensaries 168 Health Posts for out-patient care and public health activities
Given its strong involvement in the sector, BMC has a certain degree of autonomy with regard to policy issues and fi nancial management. Notwithstanding this, our fi eld studies indicated that decision-making power resides with the administration (executive wing)
170 KENNEDY, DUGGAL AND LAMA-REWAL
rather than with the elected representatives. While technically responsible for policy-making and the sanctioning of budgets, elected representatives in fact have very little control over key decisions within the BMC, and especially in the health domain. Discussions with the various stakeholders indicated that the health department of the BMC is extremely centralised and that councillors can exercise very little infl uence. One reason is that medical bureaucracies tend to have command structures similar to that of the military, and in fact before independence, the Indian Medical Service was dominated by the armed forces. This history has infl uenced the organisation of medical services in Mumbai, and elsewhere in the country, and helps explain the ongoing resistance within medical bureaucracies to democratic decision-making.
Delivery Systems Design and New Urban Actors
Delivery system design has undergone much change in the last 15 years in the three cities studied, although in a gradual manner that has not necessarily attracted much attention. As mentioned above, there is a growing trend towards the privatisation of healthcare as a result of both demand and supply factors. Without always recognising it explicitly, policy-makers and government offi cials appear to have integrated into their deliberations the fact that the private sector now occupies a critical place in the supply of healthcare. At the same time, economic restructuring in the context of liberalisation has put constraints on state government fi nances and hence on local government fi nances, and has led to pressures for cost-recovery in public services. In both direct and indirect ways, costs are being shifted onto the public. For instance, many public facilities lack medicines, as the 2002 national health policy recognises, due to rising costs of drugs as well as inadequate allocations in the budgets for medicines, forcing patients to purchase them from the market.9 Likewise, diagnostic tests are increasingly prescribed to be done outside public institutions, at the cost of patients. In some places in the country, user charges have been put in place. In Mumbai, user charges have gradually been introduced in public hospitals for
9 In 2004–05 only 6 per cent of the revenue health expenditure was incurred on medicines and instruments (BMC 2006).
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various services and are now being hiked to virtually market levels in some cases. They were introduced in Andhra Pradesh under the TDP government in the late 1990s, but later removed when the Congress government came to power in 2004.
Within this changing scenario, the public sector remains a major provider of primary and preventive healthcare, mainly immunisation, and family planning services. Often these functions are assigned to local governments, and indeed in both Hyderabad and Delhi, they have been specifi cally delegated to the municipality, leaving curative care to higher levels of administration. There is a similar tendency in Mumbai also, although the BMC has under its jurisdiction a large amount of curative care infrastructure and personnel. According to a recent survey, in addition to immunisation and family planning ser-vices, a sizeable proportion of the population in Mumbai depends on public sector for antenatal care services (40 per cent) and childbirth (48 per cent) Centre for Operation Research and Training [CORT] 2000). Data from the National Family Health Survey 1998–99 indicates that in Andhra Pradesh almost 60 per cent of vaccinations in urban areas were provided by the public sector (almost 80 per cent in rural areas), compared to 70 per cent in Maharashtra (almost 72 per cent for Mumbai) and 64 per cent in Delhi. In this context, it is useful to recall that public health facilities in the city also cater to people from rural areas, who come in from nearby districts.
Apart from fi nancial pressures resulting from economic reforms, externally funded projects have also contributed to inducing changes in delivery systems, such as the imposition of user fees and out-sourcing of specifi c types of services to the voluntary sector. As noted in the fi rst chapters of this volume, non-state actors have become more prevalent in service delivery, and this trend holds for the health sector also.
In the study of Delhi, it was observed that two types of actors serve as intermediaries between the people and public providers of health services: elected representatives like Municipal Councillors (MCs), and Members of Legislative Assembly (MLAs) and civil society organisations like Residents Welfare Associations (RWAs), and NGOs. RWAs are the newest actors on the scene, and although they have been around for some time, it was the Bhagidari scheme launched by Chief Minister Sheila Dixit in 2000 that gave them a new status. As a result, their numbers have increased rapidly, to more than 1,100 today. As far as healthcare is concerned, RWAs
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are a key instrument of communication between local people and the municipal administration, in both directions: they inform the administration about local needs, for instance in terms of anti-mosquito measures; and they convey public health recommendations from the administration to the people. Their role is quite formal in this regard: in each of the 12 MCD zones (each zone encompasses a dozen electoral wards), the MCD zonal health offi cer, and sometimes the deputy commissioner, holds monthly meetings with RWAs in order to exchange information regarding public health issues. Less systematically, RWAs may also play a central role in local initiatives such as the organisation of an informal ambulance service, or the set-ting up of a health camp in their locality. In this regard, RWAs reveal a capacity to mobilise local resources (money, the use of private cars, private houses or private furniture, the co-operation of local doctors) which is closely related with their ability to ensure the co-operation of elected representatives, and points to problematic aspects of their recent ‘empowerment’. In particular, the Bhagidari scheme, by giving RWAs the option to compete with councillors as mediators between the people and the government (be it at the local or at the NCTD level), may appear to be a way for the Delhi government to bypass elected (and hence more legitimate) local representatives (Tawa Lama-Rewal forthcoming).
In Hyderabad, the voluntary sector appears to play a signifi cant role in delivery systems, often within the framework of government-sponsored schemes. At the same time, the private for-profi t sector continues to expand, including a remarkable increase in corporate hospitals in recent years.10 Recently, the IPP-VIII programme (1994–2002), funded by the World Bank, left a very strong mark on municipal-level health services, including the types of services pro-vided, the target population, the physical infrastructure, the staffi ng patterns, and introduced contract-based employment both for medical personnel and non-medical personnel (security, main-tenance). As a key component of the project, NGOs were given a central role in implementation: they were engaged to identify ‘link volunteers’ among women in the target population, i.e., slum-dwellers, in order to ensure community participation and
10 Incidentally, Andhra Pradesh is one of the states most actively involved in promoting health tourism.
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‘ownership’.11 Although considered successful by municipal authorities and the World Bank (Gill 1999), as well as by some local organisations and health professionals involved with the project, field studies indicated problems of sustainability. The system of link volunteers has weakened since the project ended, and in some cases completed dissipated.12 Although the women involved were essentially volunteers, the IPP-VIII project provided them motivation through monetary and non-monetary means. Where the non-sustainability of the project is perhaps the most striking is with regard to personnel in the new Urban Health Posts (UHPs): many are understaffed, and new positions are primarily on a contract-basis. While this was part of the design, aimed at fl exibility and cutting costs, the resulting situation is demoralizing for the contract employees, especially because their salaries compare very poorly with permanent public-sector employees. Moreover, a recent study has shown that the inconvenient location and timings of the health posts also hinder their accessibility (Lok Satta 2005).
As part of this same IPP project, NGOs were given the responsi-bility of running some of the UHPs, an experiment that has produced mixed results. One noticeable difference is that, although they fol-low the same staffi ng patterns, NGOs pay doctors and nursing staff (Auxiliary Nurse Midwives or ANMs) much lower salaries than in the public sector and in the private not-for-profi t (or charity) sector. It is estimated that NGO-run health posts can be run at half the cost of those managed by the government, and under the new scheme these costs are shared between the municipality and the NGO.13 Evidently, the decision to turn over UHPs to the voluntary sector can be partly explained by fi nancial reasons. The cost-recovery principles are shaping service delivery, and partly explain the participation of new actors.
11 The fi nal report indicates there were 8,324 link volunteers.12 This was confi rmed by Confederation of Voluntary Associations
(COVA), who had helped to identify the Link Volunteers in the Old City through their network of NGOs and CBOs.
13 According to one NGO in Hyderabad, the government run UHP costs Rs 100,000 per month, compared to approximately Rs 50,000 for the one it was managing. The agreement with the municipality was for Rs 19,600 per month, but the NGO complained that the funds were not released in a timely fashion.
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It is useful to point out that even before economic reforms took place, NGOs were playing a very important role in providing health-care and in implementing specifi c government programmes such as leprosy and tuberculosis. Although fi nancial factors may have come in for consideration, the main reason cited for this ‘delegation’ was the commitment of the voluntary sector (often Christian missionaries), since for some diseases, like tuberculosis or leprosy, patients have to be treated and closely monitored for a long period of time.14
In Mumbai there is a long tradition of hospitals managed by non-profi t charitable trusts. In fact some of the early public hospitals of the late nineteenth and early twentieth centuries were originally set up by merchant capitalists and handed over to the BMC. Apart from these, many other hospitals in the city have continued to be run as genuine charities, a tradition that is now changing. Post 1970s, charity hospitals started getting ‘corporatised’, at the same time that there was a massive expansion of private hospitals. Not coincidentally, from the 1970s onwards, the growth of the public hospital sector in Mumbai slowed down and even began to decline as a proportion to population growth. Like in Hyderabad, the IPP project (IPP-V, 1988–96), with funding from the World Bank, was implemented, similarly focused on improving the quality and availability of health and family-welfare services through strengthening of the service delivery infrastructure. This resulted in a shift towards setting up health posts for providing preventive health services and family planning. Like in other cities where it has been implemented, this project is contributing to making public health services selective and target-oriented, instead of being integrated and comprehensive.15 By the 1990s, curative care was being neglected in Mumbai, most notably by underfi nancing such care in public hospitals. The introduction of enhanced user fees in 1998 sounded the death knell of public health services in Mumbai as they had existed earlier. The
14 Interview with Dr P. Hrishikesh, Sivananda Rehabilitation Home, Hyderabad, 7 October 2006.
15 Notwithstanding this targeted approach, public services remain inadequate for reaching the poor in Mumbai. A recent study indicates that nearly one-third of the reported ailments remained untreated and high levels of malnutrition persist amongst children and women in reproductive age group (IIPS and ORC Macro 2000; Hatekar 2003). Like for Hyderabad, studies in Mumbai have shown that inconvenient location or timings of the health posts hinder their accessibility (CORT 2000; Nandraj et al. 2001).
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present BMC bureaucracy clearly favours privatisation strategies, as mentioned above.
A Renewed Role for Municipal Councillors?
One of the objectives of this study is to evaluate the relative em-powerment of elected representatives, keeping in mind recent reforms aimed at political decentralisation. Since the level of involvement of the local government in healthcare services varies across the three cities, it is not surprising that the role of the councillors also differs to some extent.
The opportunity to play the role of facilitator and distribute patronage acts as an incentive for elected offi cials to supervise the functioning of dispensaries, polyclinics and maternity hospitals. In the study of Delhi, it was found that councillors act as ‘vigils, ombudsmen and errand runners’: they take rounds to visit the various dispensaries and polyclinics of their ward and keep a check on their functioning; they report people’s grievances concerning medical personnel’s misbehaviour to concerned senior offi cials. They also provide recommendation letters to reduce waiting periods for government hospitals. In Mumbai too, where the municipality runs various hospital facilities, it is common for the public to approach councillors to request them to intercede in their favour. In Hyderabad, this was apparently limited mostly to MLAs, perhaps because councillors are seldom members of hospital advisory committees. In general, councillors in Hyderabad appear to have little involvement with healthcare issues, no doubt refl ecting the limited medical services provided at the local level.
As mentioned above, there are municipal committees dedicated to health in Delhi and Mumbai. In principle, they provide opportunities to the member-councillors to participate directly in deliberations and problem-solving. In Delhi, the MCD’s Medical Relief and Public Health Committee is composed of 10–20 councillors selected for one year by their respective parties. Like other municipal committees, it comes together about once every month to discuss a number of issues. Its role consists of examining recommendations made by the executive wing and making new recommendations. Councillors wanting to open or maintain a particular health centre may submit their request individually and directly to offi cials in the health department; but the Municipal Health Committee is the privileged site for such demands to be put forward.
176 KENNEDY, DUGGAL AND LAMA-REWAL
In Mumbai too there are deliberative committees including a Women and Child Welfare Committee and a Public Health Com-mittee. The latter has a role in the certain senior-level appointments, but beyond that it is not proactive in any other signifi cant decision-making process; in particular, it does not venture into the areas of policy-making and planning. The meetings are mostly devoted to discussing complaints received from the different wards about health facilities, medical staff, etc., and they can only make suggestions to the Commissioner for appropriate action. However, in situations of crises/emergencies the public health committee has taken action and put pressure on the administration to execute its decisions. This was evident for instance during the 2005 fl oods, when the councillors effectively pressured the BMC bureaucracy to provide support quickly to the line staff of the health department, who are in direct contact with patients/victims. But such examples are exceptions, and studies indicate that in Mumbai, like in Delhi, decision-making power resides primarily with the bureaucracy.
As for the functioning of the Ward Committees in Mumbai, a pre-liminary assessment based on discussions with various stakeholders shows that while they have been active in taking decisions about construction and repair work for roads, water and sewerage systems, health-related institutions like dispensaries and health posts have generally been neglected. Similarly, in Hyderabad, an analysis of the minutes of the Wards Committees’ meetings in two distinct areas of the city indicated that issues related to public sanitation, such as garbage collection, water and drainage, and overall cleanliness were by far the issues most frequently raised by the councillors. In contrast, healthcare issues were almost entirely absent. Clearly, councillors are not signifi cant participants in the governance framework for routine healthcare services. As mentioned earlier, the main offi cer at the MCH, the DM&HO, answers to the state government, as do the doctors, and not to the local government. However, the MCH has recently instituted the Hyderabad Urban Community Development and Services Fund, intended to ensure a sustained fl ow of resources towards poverty alleviation and slum improvement.16 This is a signifi cant development, which suggests a political commitment to
16 Its sources include: 20 per cent of the property tax collected annually and 30 per cent of annual per capital grants from the state government, in addition to funds received from central and state governments under various anti-poverty programmes (Sreedevi 2005).
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reducing urban poverty and a willingness to direct public services towards the economically weaker sections, and in particular the slum-dwellers.17
In Delhi, a detailed study of administrative archives was used to estimate the degree to which local, elected representatives, both MLAs and MCs, take an interest in health issues (Tawa Lama-Rewal 2007). The study revealed that Delhi’s MLAs do take an interest, but rather than being involved in policy-making, their interest appears closely linked to political patronage. For instance, they organise health camps and support the creation of health infrastructure. According to a senior offi cial of the Health Secretariat, about 60 per cent of medical infrastructure provision is a result of MLAs’ ini-tiatives. Municipal councillors too have a preference for creating new infrastructure (maternity wards, dispensaries) as these involve formal inauguration ceremonies that allow them to highlight their own role in improving service delivery. An analysis of the minutes of the MCD health department compared two periods of fi ve years each: 1991–96, when the MCD was a purely administrative civic body and 1997–2001, when the MCD became a politico-administrative institution of local self-government as a result of the implementation of the 74th CAA. It shows, fi rstly, that many more items were discussed after 1997, i.e. after the election of the fi rst batch of councillors under the 74th Constitutional Amendment Act (CAA). Secondly, a clear contrast appears in the focus of discussions in these two periods: ‘Personnel management’ is the subject of 57.8 per cent of offi cials’ discussions, but only of 15.9 per cent of councillors’ discussions.18 Councillors’ discussions focus on the opening or upkeep of various types of health centres (21.4 per cent, as opposed to 11.3 per cent of discussions before 1997), and to a lesser extent on their maintenance (6 per cent). These fi gures indicate that councillors are in fact very, keen to create new healthcare infrastructure, like the MLAs, even though, as mentioned above, they also monitor the functioning of existing facilities. On the whole, a constant tension is perceptible between councillors and MCD offi cials, whether administrators or doctors. Despite their lifeless character, these archives reveal that councillors struggle to assert their authority, to defi ne their role in an organisation that did function (albeit differently) without them.
17 Approximately one-third of Hyderabad’s population lives in slums.18 In 2004, the total staff of the MCD amounted to 150,000 employees.
178 KENNEDY, DUGGAL AND LAMA-REWAL
Conclusion
More than all other basic urban services, it is health and education perhaps that have been exposed to a privatising trend. This trend has been reinforced and accelerated as a result of economic reforms, but in fact it predates the offi cial adoption of market reforms in the early 1990s. To explain this shift, there are both push and pull factors at work that must be considered. People are attracted to private health facilities because they seem to offer better quality healthcare, and are often more convenient. The shift to private care refl ects problems of access, inconvenient timing, and an objective deterioration of material conditions within public institutions. With poor working conditions, the morale of healthcare professionals declines and results in poor personal commitment to the service, refl ected in the massive defection of experienced doctors and nurses to the private sector across the country.
In part, as a result of externally funded projects, public health services, which mostly concern primary/preventive healthcare, are increasingly being targeted to the poor. While this shift can be justifi ed on various grounds — indeed, studies show that the poor use public services more than other income groups — it also raises serious questions about the consequences of this explicit or implicit policy of ‘reserving’ public services for the poor. One can expect that in healthcare, like in education, the defection of the middle classes will lead to a deterioration of services, because of a lack of public ‘ownership’ and the lower capacity of economically-weaker social groups to demand accountability from the administration. In India, as elsewhere, the middle classes are the vocal classes. Moreover, as international examples show, the principle of universal access is a key component to obtaining better health outcomes; the current proportion of public fi nance in total health expenditure, a mere 17 per cent, is largely to blame for the inequitable access to healthcare in India.
Concerning the impact of decentralisation, the 74th amendment does not appear to have prompted greater formal involvement of the municipal government in health services delivery. Other local actors, notably NGOs, have continued to gain importance, in part because of their capacity to enhance community participation, which has become a stated goal of many health programmes, including those aimed at prevention. But delegating services to the voluntary sector is
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also a way for the government to cut its costs. State-level budgetary constraints in the last 10–15 years have led to the introduction of cost recovery principles and outsourcing as means to reduce expenditure. However, to be effective, this new relationship or ‘partnership’ requires the state to evolve new rules and practices, and fi eld surveys suggest this does not always happen. For instance, municipalities do not always make timely payments to NGOs with whom it has agree-ments. Likewise, by delaying payments to private companies that employ personnel on a contract-basis (an increasing proportion, especially in Hyderabad), the local government creates additional problems for already vulnerable sections of the population. The conclusion is that whereas new models and norms are infl uencing service delivery design, the state has not necessarily adopted new modes of governing that will ensure greater accountability to the public through more stringent regulation.
The amount of attention shown by councillors to health issues varies, according to each municipality’s direct involvement in ad-ministering healthcare and its control over healthcare infrastruc-ture. For now, the evidence does not support the argument that decentralisation has led to the empowerment of councillors. How-ever, in all cities it was remarked that elected offi cials could play an effective role in fi re-fi ghting situations like epidemics, fl oods, riots, public rage in a hospital, etc. — times of crisis when the bureau-cracy is unable to control the situation. Generally speaking, elected representatives in Delhi and Mumbai are more implicated than in Hyderabad, and in both cases, there is a constant struggle with the bureaucracy to assert their views. Two factors inhibit a more democratic and participatory decision-making process from emerging: the strong bureaucratic tradition within the health sector, inherited from the military tradition, and the ‘target disease’, i.e., policies that give strong incentives to health workers to focus on specifi c quantitative targets, making them foot soldiers of the health ‘army’ (immunisation, sterilisation, etc.). This tradition of bureaucratic health management appears fundamentally incompatible with popular participation, and may explain why councillors have not succeeded in playing a more signifi cant role in shaping healthcare policies and service delivery systems.19
19 We would like to acknowledge the contribution of Prof. Bruno Jobert, whose remarks during the fi nal seminar helped us to formulate this idea.
180 KENNEDY, DUGGAL AND LAMA-REWAL
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