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Executive Summary of PRI and HFW programmes

Panchayati Raj Institutions & Health & Family Welfare Programmes an Executive Summary

1. Background

1.1 Panchayats in India are an age-old institution for governance at village level. Through the 73rd Constitutional Amendment, Panchayati Raj Institutions (PRI) were strengthened with clear areas of jurisdiction, authority and funds. PRIs have been assigned several development activities including health and population stabilization. The Gram Sabha acts as a community level accountability mechanism to ensure that the functions of the PRI respond to peoples needs.
1.2 Progress in engaging PRI has been uneven across states. While fiscal devolution is a significant issue, lack of institutional modalities and clear guidelines on PRI participation and variable capacity among PRI are key lacunae.

2. Articulation of Pri Engagement in Policy Documents

2.1 The National Population Policy 2000 and the National Health Policy, 2001, include decentralization and convergence of service delivery at village levels and recognize the PRI as the agency responsible to ensure this. In 2001, the Planning Commissions Task Force reviewed PRI involvement and found that: Currently the PRI are not equipped to take on such planning and monitoring functions, nor is there a cognizance in the health system of the role of PRI. The Tenth Plan document also emphasizes the critical role and function of PRI in development.
2.2 In August 2003, the Central Council of Ministers of Health and Family Welfare, resolved that the States would involve PRI in the implementation of HFW programmes by progressive transfer of funds, functions and functionaries, by training, equipping and empowering them suitably to manage and supervise the functioning of health care infrastructure and manpower and further to coordinate the activities of the works of different departments such as: Health and Family Welfare, Social Welfare, and Education which are functioning at the Village and Block Levels.

3. Experiences So Far

3.1 Despite geographic disparity, social inequity, poor status of women, illiteracy and the caste system, Panchayat elections do take place in most states every five years. In the context of health and family welfare, perhaps the most significant impact of the amendments is the ability of women to get elected to local bodies. In some areas, women PRI members take an active role in polio eradication, health camps, mobilize women for services and monitor attendance of staff.
3.2 Initiatives by MOHFW and donors in various states have focused on engaging PRIs in health programmes. MOHFW has supported the development of a training module for community and womens health, which deals with Panchayat engagement. MOHFW has also implemented the community needs assessment, the National Maternity Benefit Scheme and the Referral Transport scheme through PRI in various states. Most experiences have been positive, but recognize that the enabling environment for panchayats to function needs strengthening.
3.3 The Kerala experience in strengthening PRIs, while not immediately and completely replicable, offers useful insights and lessons. Several factors influence the progress of decentralized planning and implementation, not the least being political will, and peoples readiness to engage with decentralization.

4. Issues and Recommendations

4.1 Critical Role of Panchayati Raj Institutions in the success of the National Rural Health Mission
  4.1.1 The National Rural Health Mission (NHM) is seen as a vehicle to ensure that preventive and promotive interventions reach the vulnerable and marginalized through expanding outreach and linking with local governance institutions. PRIs are seen as critical to the planning, implementation, and monitoring of the NHM. Implementation of the NHM in achieving its outcomes is significantly dependent on well functioning gram, block and district level panchayats. At the District level a District Health Mission will coordinate NHM functions. Key to NHM success are: intersectoral convergence, community ownership steered through village level health committees at the level of the Gram Panchayat, and a well functioning public sector health system with support from the private sector.
  4.1.2 ASHA, (Accredited Social Health Activist), the mechanism to strengthen village level service delivery, will be a local resident and selected by the Gram Panchayat or the Village Health Committee. She will be supported in her work by the AWW, school teacher, community based organizations, such as SHGs, and the VHC. Her role would be to facilitate care seeking and serve as a depot holder for a package of basic medicines. She will be reimbursed by the panchayat on a performance based remuneration plan. The Village Health Committee (VHC) will form the link between the Gram Panchayat and the community, and will ensure that the health plan is in harmony with the overall local plan.
4.2 Empowerment of Panchayats through and the assured availability of adequate funds , clear articulation of functions, and transfer of requisite functionaries to carry out such functions
  4.2.1 State legislatures have been behindhand in framing laws that endow Panchayats with power and authority to enable their functioning. It has largely been a matter of political will in each state and is governed by different legislations, despite the central mandate. While PRI are mandated to carry out health activities, they are not backed by the necessary policy/legal framework, authority or fiscal commitments. Many centrally sponsored schemes and others are implemented outside the purview of the panchayats, thus keeping them out of the loop and undermining their credibility. Issues of political patronage hamper functioning.
    4.2.1.1 Funds transfer to PRI for effective functioning of health services. Transfer of funds to PRI is a critical must before they can be expected to play a meaningful role in HFW activities. While several states have taken steps complete financial devolution commensurate with functions still has a long way to go. With financial devolution other processes such as fiscal management, systems training and appropriate checks and balances will need to be introduced.
    4.2.1.2 Clear articulation of functions of PRI at various levels: In areas where little devolution of power or funds has taken place, PRI representatives and particularly women lack clarity on their roles in development functions, including health. Line department staff have to recognize that PRI carry the mandate of the people.
  4.2.2 Transfer of functionaries with commensurate authority and accountability guidelines. PRIs are expected to undertake monitoring of functionaries, particularly of line departments such as health and family welfare for increased accountability and improved functioning, without any authority over them. Transfer of functionaries is critical to ensure adequate functioning, monitoring, and accountability. Safeguards must be in place to protect against intimidation, wrongful harassment, and corruption.
4.3 Enlisting NGO support in building capacity among PRI members to effectively handle development related functions.
  4.3.1 Capacity building of PRI is required in thematic areas and leadership skills, negotiating, monitoring, ability to withstand patronage and political interference. Capacity building processes need to be tailored to literacy levels, sex and circumstances of PRI members.
  4.3.2 Joint orientation and sensitization meetings between PRI and health and medical professionals could help to bridge the gap in education and social strata. Developing Citizen Charter of Rights and Codes of conduct also lay down guidelines for boundaries of operation and accountability.
  4.3.3 NGOs could be involved in PRI strengthening in a variety of ways, including: consciousness raising, provision of technical advice, support in participatory planning, capacity building and facilitating monitoring processes, such as community and social audits to improve accountability.
4.4 Repealing penalties and disincentives such as the two child norm, which violate individual rights and discriminate against womens participation in panchayats.
  4.4.1 Several states include disincentives in their population policies. The most draconian is that which bars people who have more than two children from holding office. Such policies are anti- women, threaten to undo the good of a decades work in enabling women to participate in political processes and violate womens freedom and individual rights. They feed son preference actions such as sex selective abortions, pushing down an already unfavorable sex ratio. There are cases of women being abandoned, the third child given away or disowned, and consequent denial of the childs rights.
  4.4.2 Policies and laws such as this need to be repealed or they might have serious negative consequences for women and society at large. Population stabilization is a function of womens empowerment, access to high quality RH services and equal participation of men. PRIs should be encouraged to support these interventions to further promote improved health.

Conclusion

There are enough portents to suggest that PRI engagement in improving key health indicators will become a reality. However in order to expedite the process and to make it more effective, consideration of key issues related to empowerment of panchayats through funds, human resources and capacity are critical. PRI engagement is perhaps the only existing mechanism to achieve large-scale community participation and reach the marginalized and vulnerable, particularly women, children, and the poor. Locating NHM functions within the gram panchayat and implementing it through a village health committee/gram Sabha will facilitate the process and make health for all an achievable reality.