Strengthening Governance of District Health Administration

Table of Content

Dedication

Acknowledgement

Table of Content

List of tables

List of Figures

Appendices

Abbreviations

Executive Summary

CHAPTER ONE: Introduction to Dissertation: Framework of strengthening governance of health administration
1.1 Introduction
1.2 Background and
1.3 Aims and
1.4 Output of the dissertation
1.5 Methodology
1.5.1 Type of dissertation
1.5.2 Search strategy
1.5.3 Sources of data
1.6 Governance and its framework
1.6.1 Definitions of governance
1.6.2 Governance in health sectors
1.6.3 A framework of strengthening governance
1.6.4 Possible effects of good governance of the DHA in Bihar
1.7 Limitations
1.8 Target
1.9 Structure of the dissertation
1.10 Summary

CHAPTER TWO: Overview of the state, problems and issues of governance in the DHA
2.1 Introduction
2.2 State background
2.3 District health system and its links with PRIs
2.4 Structure and functions of the health Department
2.4.1 Organisational structure and functions of the DHA with its links to the department of health and family welfare, Bihar (DHFW)
2.4.2 Major functions of the DHA
2.5 Problem analysis of governance in the District Health Administration
2.5.1 Introduction
2.5.2 Weak leadership capacity
2.5.3 Weak management capacity
2.5.4 Poor accountability to the public
2.5.5 Low Participation of people in decision making and planning
2.5.6 Poor transparency in decision making
2.6 Summary

CHAPTER THREE: Strengthening governance of health administration: Theories and practical experiences
3.1 Introduction
3.2 Theories and documented examples on governance in health administration
3.2.1 Improving leadership capacity
3.2.2 Improving Management Capacity
3.2.3 Promoting accountability
3.2.4 Increasing community participation in decision making and planning
3.2.5 Ensuring transparency in decision making
3.3 Summary

CHAPTER FOUR: Application of theories and the practical experiences in the context of Bihar
4.1 Introduction
4.2 Strengthening governance of the DHA in Bihar
4.2.1 Improving leadership capacity
4.2.1.1 Leadership Style
4.2.1.2 Training on Leadership Bihar
4.2.2 Improving management capacity
4.2.3 Promoting accountability to people
4.2.4 Community participation in decision making
4.2.5 Transparency in decision making
4.3 Strategy for strengthening governance of the DHA in Bihar
4.4 Summary

CHAPTER FIVE: Issues for dissemination and implementation of the proposed strategies for strengthening governance of the DHA in B
5.1 Introduction
5.2 Dissemination of the proposed strategy for strengthening governance in the DHA
5.3 Issues for implementation
5.4 Conclusion
5.5 Reflective

References

Bibliography

Appendices

Dedication

This study is dedicated

To

KISHORI PANCHAYAT

A group of adolescent girls for their endeavour to strengthening governance in the remote rural areas in the state of Bihar

Acknowledgement

I would like to express my gratitude to the Ford Foundation for providing me with this distinctive opportunity to complete my study at the Nuffield Centre for International Health and Development, University of Leeds.

I am extremely grateful to my supervisor Dr. Ricky Kalliecharan for his continuous guidance, invaluable comments and support in writing this dissertation. I would also like to express my sincere thanks to my personal tutor Dr. Maye Omar for his guidance and counselling throughout the course.

My sincere gratitude to Professor Andrew Green for his encouraging classes on planning, health economics and financing, which enriched my academic knowledge and skills. My deepest gratitude to Dr. Reinhard Huss and Mr. Tom Dessoffy for their excellent guidance on my topic of the dissertation.

I wish to express my special thanks to Susan Mottram and Taf Cheffo for their classes on database research and computer applications. I would like to thank all the courteous and dedicated academic and support staff in the Nuffield Centre for International Health and Development. I would like to thank my friends and colleague in the Nuffield Centre for their valuable input on health and governance.

Back home, I would like to convey my sincere gratitude to Dr. B. K. Sinha and Dr. Indu Sinha for their continuous support and guidance in building my professional knowledge in the social field. I wish to express my sincere gratitude and respect to my mother, father and all my family members for always being supportive to me in my professional achievements.

Finally, I would like to thank government medical officers in the DHA Bihar, experts on governance and all my friends working in the social sector for providing the valuable information and input on my dissertation.

Leeds , August 2008.

List of tables

Table 1 Mechanisms for information flow between health systems and people

Table 2 Options appraisal for the most appropriate leadership style for the DHA

Table 3 Capacity building inputs and potential trainees in the DHA

Table 4 Options appraisal for the most appropriate means of building management capacity of the DHA

Table 5 Issues and strategies for strengthening governance of the DHA in Bihar

Table 6 The dissemination plan of the proposed strategy

Table 7 Issues for implementation.

List of Figures

Figure 1 Voice and accountability relations under governance framework

Figure 2 Possible effects of good governance of the DHA in Bihar

Figure 3 the outline of chapters

Figure 4 Institutional mechanisms of Health Missions and Committees and its links with Panchayat Raj Institutions

Figure 5 Structure of the DHA with its regional and state linkage

Figure 6 Problem analyses

Appendices

Appendix 1 Map of Bihar, India

Appendix 2 Demographic indicators, state at a glance

Appendix 3 Structure of the Department of Health and Family Welfare, Bihar

Appendix 4 Health centres/hospitals in Bihar

Appendix 5 Functions of the Department of Health and Family Welfare, and the DHA Word Count 13750

Abbreviations

Abbildung in dieser Leseprobe nicht enthalten

Executive Summary

In recent years, the governance of the health system has become a key issue of discussion for international organisations such as the WHO, the WB, UNDP, USAID and the EC. Furthermore, they state that spending on health would not alone achieve the intended results in health without addressing governance.

The District Health Administration (DHA), generally called the office of the Civil Surgeon in Bihar, India, is considered a bridging administrative unit from national and state government to the community at village level. Moreover, this is a full-bodied unit with management and the administrative power under the leadership of Chief Medical Officer/Civil Surgeon and Assistant Chief Medical Officer with various health programme officers and support staff. Although health service delivery is seen to have improved in Bihar in recent years, issues such as leadership, management, accountability and transparency would seen to be weak in the DHA.

This study aims to recommend specific strategies to strengthen governance of the DHA in Bihar. In doing so, it first identifies and critically analyses the causes of poor governance of the DHA. Moreover, it reviews theories and documented effective examples of strengthening governance in the district level health systems in low and middle income countries. This study finally analyses various strategies for strengthening governance and outlines appropriate governance for the DHA in Bihar.

To undertake this study, a framework for strengthening governance developed by Brinkerhoff et al. (2008) is used, which covers leadership and management capacity, accountability, community participation and transparency in decision making. The methodology primarily involves reviewing secondary data; however, a number of health and development professionals and legal experts were contacted to obtain a number of practical experiences.

In chapter two, one central issue is identified as an old policy of the health system in Bihar in that it leads the DHA to focus only on clinical care. This eventually results in undermining the importance of governance in the DHA. In addition, information related to plans, policies and decisions concerning public health are not disseminated effectively despite having the legal provision of the right to information. Similarly, stakeholder such as the local government bodies, women group, NGOs and CSOs are also found to be excluded from the planning and decision making process.

A number of theories and documented examples of strengthening governance of the health system are reviewed in chapter three. This further analysed in chapter four based on the contextual factors of Bihar, and outlined strategies for strengthening governance of the DHA in Bihar. Building leadership and management capacity of the DHA through training and site visit, restructuring organisation with explicit roles and responsibilities and sharing information are recommended. Enacting new legislation for information sharing and incentive-based motivation for the DHA are proposed to ensure accountability of the DHA. Moreover, a district level forum of stakeholders is also recommended to ensure community participation in decision making. Furthermore, regular auditing and sharing with the community through annual reports and public meetings is suggested for reasons of transparency. The key recommendation of the study is to reform health policy including governance components.

Finally, issues for dissemination and implementation of the proposed strategies are discussed in chapter five.

Strengthening Governance of District Health Administration in Bihar, India

Chapter one: Introduction to Dissertation: Framework of strengthening governance of health administration

1.1 Introduction

This chapter deals with the introduction to the dissertation, which covers the background and rationale; the aims and objectives; and the output of the dissertation. It also outlines the methodology for carrying out the study. Furthermore, it reviews definitions of governance designed by various authors and international agencies. In doing so, it illustrates a framework for strengthening governance of a health administration, developed by Brinkerhoff, et al. (2008), which the author has utilised to develop his analysis. In addition, it identifies the primary and secondary target audiences which will use the findings. At the end of the chapter, the structure of the dissertation is outlined.

1.2 Background and rationale

The importance of good governance in the health sector, is widely discussed in international organisations such as the World Health Organisation (WHO), and economic and development organisations such as the World Bank (WB), the United States Agency for International Development (USAID), European Commission (EC) and the United Nations Development Programme (UNDP). However, before going into greater detail, it is necessary to question the importance that good governance possesses in health administration matter has a great importance. Various studies have been conducted to measure the relationship between public spending and outcomes, as the health sector is financed by state, national and international bodies. Rajkumar et al. (2002), for example, found that good governance influences the relationship between public spending and outcomes. Similarly, it is argued by Brinkerhoff, et al. (2008) that strengthening governance is a cornerstone for the health sector. They argued that:

Country health officials and donors have increasingly realized that resources allocated to health will not achieve their intended results without attention to governance (Brinkerhoff, et al. 2008 p1)

Decentralisation of authority is considered to be a necessary step to promote accountability in governance at various levels. Francis, et al. (2003 p326), for example, argue that the local needs can be addressed properly when the decision-making power is devolved to the local level. In India, after the 73rd and 74th Constitutional Amendment Act (CAA) 1992, the country legally became decentralised in all major social sector departments including health, education and social care—from national level to village level through the formation of local government (LG): Panchayati Raj Institutions (PRIs) in the rural areas and Urban Local Bodies (ULBs) in the urban areas (LGI, 2008). Such local government bodies comprise of people’s representatives at the village, block and district level.^[1] Moreover, the LG is considered a key stakeholder in the District Health Administration (hereafter referred to DHA), as it is constitutionally provided the power to monitor health service delivery (SECB, 2008).

In India, the DHA has been envisioned as the vital link between the government-at both the state and national level and the community. Furthermore, the DHA under the leadership of the Chief Medical Officer (CMO) and the Assistant Chief Medical Officer (ACMO) manages various state-led public health programmes, having major financial and administrative roles (DHFW, 2006).

Given the importance of the DHA and its accessibility to the community, a national level health programme called the National Rural Health Mission (NRHM) was launched across the country in general and in 18 special focus states in particular. The 7 year (2005-2012) district-focused and target-oriented NRHM establishes health societies at the state as well as district level involving health officers, people’s representatives, civil society organisations (CSOs) and non-government organisations (NGOs) working on health (NRHM, 2005a). The DHA is considered to be one of the key stakeholders of the District Health Society under NRHM (NRHM, 2005b).

Bihar, a province of India, is recognised as one of the poorest states in India. According to the National Human Development Report, India (NHDR, 2001), Bihar stands at the bottom (15th position) among 15 states and union territories on its human development indices (HDIs). Therefore, the state is considered a special focus area together with 17 other states, by the central government as part of its national health programme (NRHM, 2005a). In terms of health, education and employment, 23 out of 38 districts of Bihar are identified as the most backward districts in the country (NREGA, 2005).

The consolidated minutes of national seminar and regional workshops on improving governance, Transparency International India (TII, 2007 p4) states that corruption in the public sector is found to be a critical issue in Bihar. In addition, a number of governance issues in the DHA in Bihar, such as accountability, information dissemination, community participation, leadership and management eventually affect people’s health. Chapter two has dealt in detail with evidences of poor governance exhibited by the DHA in Bihar which profoundly affects public health.

It is argued by Brinkerhoff et al. (2008) that good governance, in one way, ensures transparency and the accountability of the DHA to the community and the government. On the other hand, this improves leadership and management skills for resources to be used more effectively and efficiently, which would eventually result in the improved health of people in Bihar.

1.3 Aims and objectives

The aim of this study is to recommend specific strategies to strengthen governance of the DHA in Bihar

In order to achieve the aim of the study, the following objectives are laid down:

a) To identify and critically analyse the causes of poor governance of the DHA
b) To review theories, and the experiences of strengthening governance in district level health systems by low and middle income countries
c) To analyses various strategies for strengthening governance and outline an appropriate governance for the DHA in Bihar

1.4 Output of the dissertation

Based on an analysis of the current context and the best practice of governance of health systems from national and international evidence, strategies for strengthening governance of the DHA will be outlined.

1.5 Methodology

1.5.1 Type of dissertation

A review of the governance of the DHA in Bihar is carried out in order to outline recommendations through an analysis of the current situation, a review of national and international experiences and a feasibility analysis. Problem tree analysis and a conceptual framework of governance are employed to carry-out contextual analysis and to study causes and effects within the given framework.

1.5.2 Search strategy

For a situational analysis of poor governance of the DHA in the state, data is obtained through available online literature and websites. The main criterion used for the literatures review was theoretical and documented effective examples of strengthening governance of health system. Theoretical empirical examples are used from literature developed over the past 15 years; however, empirical examples quoted are from the last 10 years. Further, the author has consciously cited examples from low and middle income countries, which relate to the context of Bihar. In addition, keywords related to governance and its components with truncation were used as methodology for searching online literature. Furthermore, some proxy examples are used as there is a dearth of information on governance of the health sector in the state. Examples of governance from those of developed countries were avoided using in the dissertation, unless it was relevant to the state context. Theories concerning governance of health service delivery were also excluded, as this study only focuses on strengthening system management of the DHA.

1.5.3 Sources of data

- Primary sources

To obtain relevant data, Chief Medical Officers (CMOs), Programme Managers of district health society, social development professionals working in NGO sector and legal experts of the local government of Bihar were contacted through telephone.

- Secondary Sources

a) The University of Leeds libraries particularly Health Sciences, Brotherton and Edward Boyle for literature on governance in health, policy reform social policy, strategic management and governance, leadership and management theories

b) Electronic databases

Global Health, Pubmed, Elsevier, Google Scholar, Science Direct, Institute of Health Management and Research, Earth Institute Columbia, Bio-Medicine, CHSJ, Panconference India, Equinet Africa and Transparency International.

Online news paper: Dainik Jagran, Hindustan, the Hindu , Web India and The Times of India (ToI).

c) Specialised website

International organisations: UNAIDS, DFID, USAID, EC, WHO, UNDP and the WB

Government of India Website: Ministry of Health and Family Welfare, Education, Rural Development, Local Government (Panchayati Raj), NREGA, Information Commission and the Planning Commission of India.

d) Email Alert:

The author registered for email alert in Global Research (GR), Eldis, Oxford Journals (OJ) and the Centre for Global Development (CGD). Till date 38 such alerts from GR, 25 from Eldis, 28 from OJ and 16 from CGD were received. A great deal of information particularly from Eldis and OJ was used to identify key issues for this study.

1.6 Governance and its framework

1.6.1 Definitions of governance

As Kaufmann et al. (2008) argue that the concept of governance is not new; however, national and international organisations have still not come to a commonly agreed definition of governance, though there are some widely used general components of governance frameworks.

Governance has been defined and interpreted in various ways depending on technical and organisational requirements. It is also defined according to the organisational structure and its values. The WB, for example, defines governance as a system of involving stakeholders in planning and monitoring of programmes in order to ensure accountability and strengthen people’s voices (WB, 2004 p78).’ To develop such a system in the health sector, the key authority is expected to play a proactive role in leading people to achieve health goals. WHO outlines stewardship as a key component of governance. In addition, Saltman et al. (2000 p733) believe that ‘ stewardship to be a particular type of governance linked with agency theory and the concomitant role of the state as an agent for its citizens.’ Counting voice of the community in decision making is found to be a central issue in governance and development of a mechanism for citizen to articulate their voice is a key role of a public sector organisation (UNDP, 2004).

However, contextual factors play major role in ensuring governance. The European Commission also supports this argument. For instance, it says that:

Governance covers the fundamental interaction between the state and society. The quality of governance therefore often depends on the state's capacity to provide its citizens with the basic services needed to reduce poverty and promote development (EC, 2003 p1)

There are a significant number of critics of the above mentioned definitions and indicators of governance. For example, it can be argued that involvement of stakeholder and its voice in decision making may not strengthen governance, as stakeholder have their personal agenda to include into decision. This may eventually exclude the voice of the marginalised people. However, it is argued by Kaufmann, et al. (2007) that the worldwide governance indicator (WGI) could be applied with some minor variations depending on contextual reality.

1.6.2 Governance in health sectors

Brinkerhoff, et al. (2008 p10) state that good governance in health sector involves citizen, civil society and private sectors to address health needs of the community in a coordinated manner. This view is shared by Bossert (2008), who states that governance in health is about working principles which distribute roles and responsibilities among actors.

Figure 1 Voice and accountability relations under governance framework in health

Abbildung in dieser Leseprobe nicht enthalten

Source: adapted from WB (2004) and Brinkerhof, et al (2008)

Figure 1 illustrates voice and accountability relations between policy maker, service provider and user. There are three sets of actors who hold legitimate authority and accountability relations in the governance framework (WB, 2004). This framework depicts all three actors as sharing a voice in decision making to ensure good governance, which eventually results in effective and efficient service delivery.

1.6.3 A framework of strengthening governance

Governance of the DHA can be analysed in a number of ways. The dissertation will particularly focus on the DHA’s system management and its governance, and will not cover service delivery. There may be some overlap in the framework and analysis, as Bossert (2008) argues that the community participation in decision making may influence accountability and transparency in a public institution. Therefore, it can be assumed that intervention in a component of governance may contribute to another.

This study uses a governance framework for strengthening health administration recently developed by Brinkerhoff et al. (2008). It is used to strengthen health systems governance in USAID-supported countries. The framework is as follows:

- Leadership Capacity: vision and capacity to guide organisational staff for building collaboration with stakeholders to have a common plan
- Management Capacity: capable to manage resources, undertake planning and structure the roles and responsibility of personnel
- Accountability: accessibility of reliable information to people and address health needs of the community
- Citizen Participation: adequate administrative mechanisms to enable citizen participation in decision making
- Transparency: disclose plan and policy documents and information to the public

1.6.4 Possible effects of good governance of the DHA in Bihar

Although, there are a number of issues which need to be improved in order to strengthen governance of the DHA in Bihar, some key components being relevant to the state are outlined by Brinkerhoff et al. (2008). Based on the above mentioned framework of governance and the current contextual issues of the DHA, it is assumed that improving leadership and management capacity of the DHA and promoting accountability and ensuring transparency will increase the efficiency of the DHA. Consequently, the community and stakeholders’ participation will increase which should eventually result in reduced corruption, motivated staff and improved service delivery as it is illustrated in figure 2.

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^[1] Detail structure of PRIs in chapter two