Methodological Issues in Decentralization Under Health Care Reforms

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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
Stream: Research Methodologies, Quantitative and Qualitative Methods
Presentation Type: Paper Presentation in English
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Prof. K. R. Nayar

Professor, Centre of Social Medicine and Community Health, Centre of Social Medicine and Community Health
New Delhi, Delhi, India

Professor K.R Nayar has been on the faculty of CSMCH since 1985. He has been teaching courses on research methodology, social sciences in public health and environmental health. He has guided the doctoral work of 14 candidates and nearly 50 M.Phil dissertations apart from two Masters theses at the Heidelberg University and field tutoring two other Heidelberg candidates in New Delhi. He has authored a book on Ecology and Health: A Systems Approach and co-edited a book on Public Health and the poverty of reforms: A South Asian predicament. He has authored nearly 50 papers on public health which were published in national and international academic journals. During 2001-2002, he has been DAAD-INNOVATEC guest professor at the Department of Tropical Hygiene and Public Health, Heidelberg University and a visiting external examiner for the Heidelberg University for three years. His current research interests are Decentralization and health, Health Sector Reforms, Self-help in health and Critical issues in international public health. He edits the Journal of Health and Development. He is directing two projects; one on Monitoring Shifts in Health Sector Policies in South Asia funded by the European Commission and another on E-Learning in public health funded by the German Academic Exchange and Bielefeld University, Germany. Professor Nayar co-organizes the annual International summer school on public health at Bielefeld University, Germany with Prof. Oliver Razum and Prof. Seval Akgun.

Ref: I08P0154