Decentralization in India's health sector: insights from a capacity building intervention in Karnataka

The Government of India has adopted decentralization/devolution as a vehicle for promoting greater equity and supporting people-centred, responsive health systems. This article reports on our year-long intervention project in Karnataka, South India, and articulates insights of both practical and theoretical significance. It explores the intersection of the political goal of enhanced local level autonomy and the programmatic goal of more responsive health service delivery. Focusing on the Village Health, Sanitation and Nutrition Committees (VHSNCs) set up under the National (Rural) Health Mission (NHM), the project set out to explore the extent to which political and programmatic decentralization are functional at the village level; the consonance between the design and objectives of decentralization under NHM; and whether sustained supportive capacity building can create the necessary conditions for more genuine decentralization and effective collaboration between village-level functionaries. Our methodology uses exploratory research with Panchayati Raj Institution (PRI) members and functionaries of the Health Department, followed by a year-long capacity building programme aimed at strengthening co-ordination and synergy between functionaries responsible for political and programmatic decentralization. We find that health sector decentralization at the village level in Karnataka is at risk due to lack of convergence between political and programmatic arms of government. This is compounded by problems inherent in the design of the decentralization mechanism at the district level and below. Sustained capacity building of the VHSNC can contribute to more effective decentralization, as part of a larger package of interventions that (1) provides for financial and other resources from the district (or higher) level to political and programme functionaries at the periphery; (2) helps the functionaries to develop a shared understanding of the salience of the VHSNC in addressing the health needs of their community; and (3) supports them to collaborate effectively to achieve clearly articulated outcomes.