Decentralisation of the health care sector in Kerala: Some issues

Kerala is in the forefront of decentralisation of powers following the 73rd and 74th Constitutional Amendments. The existence of a large number of health care, educational and other institutions in every Panchayat in Kerala has necessitated decentralisation of every sector as part of the overall decentralisation. The government order of 1995 has transferred the health care institutions at various levels to the local self government institutions (LSGI). This study seeks to analyse decentralisation of the health care sector in Kerala and the associated problems as perceived by the elected members. The study argues that three basic problems of decentralising the health care sector, namely spill over effect, role and relevance of a pre existing body (Hospital Development Committee or HDC), and the level of minimum health care service to be provided by the health care institutions, have not been adequately addressed. The problem of benefit spill over is quite serious with regard to the secondary health care services accessed from the Taluk Head Quarters Hospitals, which have been brought under the Municipal Councils. The problem arises from the concentration of hospital beds in municipal towns. The system of "matching transfers" might address the problem of benefit spill over but it will introduce a new problem owing to the inequality in the distribution of hospital beds across the taluks of the state. A separate fund on the lines of the "social investment" fund in Columbia might address this problem. Alternatively, private health care sector may be drawn in through a reimbursement scheme so as to ensure a minimum level of service. The presence of HDC in a decentralised system is difficult to sustain. Its continuance comes in the way of a proper functioning and accountability of the LSGI with regard to the provision of health care services. How exactly the functions of HDC should be integrated with the LSGI calls for further discussion.