Critical Reflections on Health Services Development in India by Nayar Kesavan Rajasekharan;

Author:Nayar, Kesavan Rajasekharan; [Nayar, Kesavan Rajasekharan]
Language: eng
Format: epub
Publisher: Lexington Books
Published: 2014-08-15T00:00:00+00:00

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Centrality of Decentralization and Marginalization of the People

Decentralization in recent years has become a buzzword to make governance more acceptable to the people. From the operational point of view, decentralization has become necessary given the extreme form of centralization especially in development and welfare sectors and in some way to give a sense of people’s participation in the programs evolved by the state although the paternalistic character of the state-driven programs continue to be strong. However, the legislation and decentralization initiatives of the center have led to some dilution and devolution of power to the peripheries. The Weberian justification of centralization based on cost-effectiveness, efficiency, and coverage has also been diluted which led to a sense of uncertainty and disquiet. And it was in the nineties and at the beginning of the new millennium that there was a renewed interest in decentralization which was largely due to the funding strategies and the implementation of structural adjustment and reform strategies in many countries and we find proliferating literature on different dimensions of decentralization. However, the interest has waned in recent times and the initial enthusiasm for decentralization has also reduced probably due to the lack of interest among the funding agencies such as the World Bank. There is also a trend toward re-centralization in some European countries where decentralization was implemented earlier (Saltman, 2008). A large number of state institutions are seizing the opportunity to capture financial and political powers devolved earlier to lower levels. Saltman suggests that the future will see many European countries tightening their controls over fiscal and quality matters in health care which could also weaken democratization at the regional and municipal levels.

Notwithstanding these waning interests, the role of the people in decision-making and governance is realized through processes such as decentralization and therefore with respect to health and health services, it becomes necessary to examine decentralization and its complexities in this chapter. And, in this context, there are both negative and positive forces which shape these processes at the individual, organizational, and societal levels (Huss et al., 2011). The whole approach of decentralization also has a number of tools, paraphernalia and methodologies and we may examine some of these complexities in detail while we will provide some indicative analysis in other areas. The chapter is mainly based on a review of salient literature and an iterative use of writings and papers on decentralization and allied themes and partly based on studies and fieldwork carried out for writing those papers.

A number of approaches to decentralization have been evolved, and it is interesting that they are targeted on the so-called resource-poor settings in terms of money, material and even intellectual resources! (Bossert, 1998). Rondinelli’s much used categorization of decentralization process as devolution, deconcentration, delegation, and privatization was also addressed to developing countries (Rondinelli, 1983). In fact, such a categorization has been used to usher in privatization under health sector reforms as one of the strategies toward decentralization. The World Bank adopted such an approach to categorize

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