Methodological Issues in Decentralization Under Health Care Reforms
Decentralization is normally understood in relation to power and resources. As a parallel process, decentralization has in recent years become a tool for ushering in a neo-liberal developmental agenda. In this backdrop, it is indeed challenging to study the process of decentralization in a developing country-context especially given the conflicts and confusions that have arisen. Another major problem is the lack of existing studies as the new process of decentralization is still in its infancy. Developing an exploratory design is the first methodological challenge. The challenge is to understand the process as it exists, identify the gaps, probe deeper, and undertake case studies to develop assumptions and hypotheses for future studies. The methodological approach to decentralization and health has to focus on two issues. These are: Studying the technical and political spheres and; studying the process and dynamics of decentralization. Understanding the conflict between the technical and the political spheres is one of the most important methodological challenges. Firstly, there exist at considerable legal and administrative initiatives for decentralization within the political sphere while there are only marginal efforts to decentralize the health services system. Most of the decision-making within the health services system is still concentrated at the district level and above. Secondly, the conflict between the two spheres may not be revealed or may be captured only superficially in survey research as both the actors within the spheres tend to deny any such conflicts. Thirdly, even within the respective spheres, there exist ambiguities regarding the process of decentralization. The technical sphere tend to consider this as a political initiative while the political sphere would like to believe that without corresponding decentralization within the health service system, it is possible to have the administrative control over the technical staff such as doctors and health workers. Another important methodological issue is the different dimensions of decentralization itself such as the process and the dynamics. The “process’ of decentralization refers to an examination of the historical, legislative, policy and administrative dimensions. It also needs to examine how the functionaries both in the technical and political spheres perceives decentralization as it can be assumed that their worldviews - perceptions, views, attitudes and approaches influence it to considerable extent. In order to bring out some of the complexities within the process and dynamics of decentralization, a complex framework is necessary. The need for an iterative process which moves from simple level exploratory approaches to more complex and abstract constructions is to be recognized. Qualitative exploratory phases can help in generating hypotheses and insights into both the process and dynamics of decentralization. In-depth case studies of women elected members and their experience with governance, guide-line interviews and group discussions with different sections in the community would help to unravel the dynamics. This paper suggests that based on the qualitative data, studies can be designed to get a quantitative picture regarding the extent of felt needs within the community, gender and class differentials with regard to responses towards decentralization, budget and resource analysis etc which will provide a quantitative dimension. This could be utilized to evolve a model for decentralization which is context-specific.
Keywords: Decntralization, Health Reforms, Inter-Disciplinary Methodological Issues
Prof. K. R. Nayar
Professor, Centre of Social Medicine and Community Health, Centre of Social Medicine and Community Health