1. Decentralisation Experiences from Haryana

2. Haryana Haryana Profile Population : 2.1crores Districts: 20 Blocks: 116

3. Background Health Sector Reforms: Need of the day WHY? Rising cost in health care Rising expectations of community Limited capacity to meet out of pocket expense.

4. Decentralisation Why Reform Agenda? Increased local ownership Improved community participation and responsiveness to local needs Strengthening integration of services at local levels Enhancing the streamlining of services Promoting innovation and experimentation

5. Decentralisation Defined as the transfer of authority and responsibility for public functions from the Central Government to: peripheral departments within the same agency, intermediate and local government, quasi-independent government organizations. Depending on the types and scope of functions transferred, as well as the level or agency to which the functions are transferred, different political, fiscal and administrative arrangements developed. Decentralization and delegation of powers depend upon the political will.

6. Decentralisation- Haryana Structural changes Constitution of SCOVA – 1997 merged societies and Swasthya Kalyan Samities in 3 pilot districts- initiative under SIP: 2001-2002 merged Society at State and in all the districts of State: 2004 SKS in all the health institutions (PHC and above) 2004 Delegation of powers financial and administrative- 1997 Reviewed, revised and implemented – 2005 Explains the time required

7. Structures State Health Society District Health and Family Welfare Societies (DHFWS). Swasthya Kalyan Samities (SKS). Program Committees SubCommittees

9. Financial Arrangements Transfer of program funds to DHFWS & SKS. Retention and utilization of user fees at institutions. Delegation of powers circulated. Financial management manual introduced

10. Administrative Arrangements Regular Governing Council meetings. Regular Executive Council meetings. Meetings of SKS and subcommittees as per need. Administrative manual- yet to be introduced

11. Resource generation at Districts Grant -in –Aid User fee Accepting donations Leasing out of vacant land BPL families, freedom fighters and Govt. employees exempted Services under national health program - free

12. PRIs Management of Sub centers to PRIs - 3 pilot SIP districts Referral transport - RCH I. Capacity building of PRI members -3 pilot SIPdistricts. Untied funds under NRHM with ANM and PRI members for sub centre improvement.

13. Experiences – User Fee G.O issued on retaining and utilising user fee at SKS. Very positive for infrastructural development- mostly at district hospital. Some Districts pool funds and redistribute. Some institutions yet to take up SKS meetings for execution of decisions Some districts do not recognise the delegation of powers to PHCs and CHCs

14. Lessons Learnt Decentralization itself does not always improve the efficiency, equity and effectiveness of the health sector. Need to be careful as this poses a serious threat to accessibility and delivery of reproductive health services, some of which (e.g. family planning) are controversial and thus susceptible to local pressures, and others of which (e.g. emergency obstetric care) require a functioning and effective health system. Need to take account of the impact of non-health factors as well as other reforms that interact with decentralization to affect accessibility, affordability and quality of services, included for reproductive health.

15. Experience also demonstrates…. Shared authority between the centre and local units - to achieve national health objectives and respond to local health needs. Adjustments to be made during implementation to correct for both emerging and pre-existing problems and requirements. Not easy to break the status quo as it always shifts the power relations without providing understanding on attached roles and responsibilities. Understanding that rights and duties are the two sides of the same coin, one from the other does not mean anything- may help and facilitate the process.

16. Important simultaneously build the capacities of health personnel in team work, value orientation and rights based approach. capacity to delegate and use powers need to be built at all levels.

17. Unfinished Agenda Physical merger of societies and formation of Management and Monitoring cell. Capacity building of senior officers at Health directorate and of 17 districts. Capacity Building of PRIs. Financial Merger of program committees – based on experiences from other states. Institutionalising administrative rules.