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Democratic Decentralisation and the Millennium Development Goals for Health : An Analysis of Outcomes for Women in Two South Indian States
Nitya Mohan Journal of Health Management 2009 11: 167 DOI: 10.1177/097206340901100112 The online version of this article can be found at: http://jhm.sagepub.com/content/11/1/167

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Democratic Decentralisation and the Millennium Development Goals for Health: An Analysis of Outcomes for Women in Two South Indian States
Nitya Mohan
In the context of the targets for primary health identied by the MDGs this article evaluates the link between decentralisation and positive outcomes for women and children. Using India as a case study, the article traces the changes in health attainments as a result of decentralisation reforms. The evidence presented, drawn from the experiences of two states, speaks to the relevance of such a link. Despite the heterogeneity of contexts and in implementation, in general democratic decentralisation has enhanced health outcomes for women in the selected village Panchayats. However, the article unearths signicant differences in the impacts of decentralisation between the two states. The variations in outcomes between the two states are found to be linked to the architecture of decentralisation design as well as to non-statutory provisions that can create a process of path-dependency towards achieving MDGs. The article also ags key methodological complexities inherent in the current MDG framework with respect to the actualization of the goals of equity and access to primary health.

In September 2000, 147 heads of nations endorsed the Millennium Development Goals (MDGs) to address the worlds greatest developmental challenges by the year 2015. Half these goals, either directly or indirectly, are concerned with aspects of primary healthcare. These goals include: eradicating extreme poverty and hunger (Goal 1), reducing child mortality (Goal 4), improving maternal health (Goal 5), combating Human Immunodeciency Virus/ Acquired Immune Deciency Syndrome (HIV/AIDS), malaria and other preventable diseases (Goal 6) and environmental sustainability including ensuring sustainable access to safe drinking water (Goal 7).
Journal of Health Management, 11, 1 (2009): 167193 SAGE Publications Los Angeles London New Delhi DOI: 10.1177/097206340901100112

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In the context of developing nations such as India, the public sector is central to the provision of most primary healthcare services relating to the MDGs.1 However, one of the main challenges to attaining the MDGs is the lack of capacity in the public sector to provide these basic services. Public health institutions, especially in rural areas, are neither universal in reach nor adequate in quality. For instance, the government healthcare sector in India has tended to adopt rigid, vertical approaches, which have not been amenable to the needs of their intended beneciaries. This is compounded by structural obstacles to accessing healthcare particularly for poor women, whose utilisation of services has historically been limited due to deep-set biases, lack of acknowledgement of health needs, discriminatory attitudes in diagnosis and low levels of awareness which have negatively inuenced their health-seeking behaviour (Koenig et al. 2000; Sen et al. 2007: 682). This has led to a wide gap between the providers of health services on the one hand and families and communities on the other. One of the principal reasons for the lack of access to health services has been the absence of mechanisms that enable those in need of the services to demand quality services, monitor their availability and supervise their management. Democratic decentralisation is seen as one way of improving equity, management, accountability and responsiveness of government health services through the reform of the public sector. Decentralisation institutionalises opportunities for citizens (particularly the poor and marginalised) to participate in and inuence decision-making and resource allocation, empowering them to become active agents of development (Oates 1972).2 In addition, the opening up of new political spaces at the local level is especially relevant for women who have been traditionally excluded from decisionmaking processes (Manor 1999). With particular reference to the healthcare sector, decentralisation is viewed as an important tool for implementing primary healthcare policies by strengthening patient leverage, responsitivity and enhanced local service delivery (Green 1992). From this perspective, decentralisation is a means of empowering local communities, facilitating multisectoral coordination of activities at the local level, fostering community participation as well as encouraging participatory planning more attuned to local needs (Mills 1994; Taal 1993).3 In economics literature, one of the most commonly cited reasons for advocating health sector decentralisation has been the ability to address variations in preferences across regions or population sub-groups for the
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services that governments provide (Rondinelli et al. 1983). In the absence of cost savings or inter-jurisdictional external effects, decentralisation can improve collective societal welfare by providing a set of health goods and services that are more sensitive to varying local needs than the provision of a homogenous set of services by a central government (Mishra 2005). Decentralisation reforms are thus an important means through which the goals of human development, the main elements of which are articulated through the MDGs, can be achieved (UNDP 2007). However, in the nal analysis, the question of the success of decentralisation will depend on whether equity and access to care, particularly for disadvantaged groups including women has improved.4 This is critical to interpreting progress on overall health outcomes and indeed, to attaining the MDGs. In the specic context of the targets for primary healthcare identied by the MDGs, this article evaluates the link between decentralisation and positive health outcomes for women and children. Using India as a case study, the article traces the changes in health attainments relating to MDG targets for these groups in rural India as a result of decentralisation reforms. An analysis of health outcomes for women in the two southern states should provide salient lessons with respect to the effectiveness of decentralisation in advancing the MDGs. The article is divided into three sections. The rst section briey sets out the background to decentralisation in India and outlines the methodology employed by this article in the outcomes analysis. The next section examines the changes in health attainments for women and children with respect to four selected MDGs, across a 15-year time period. The nal section traces the conditions that facilitate decentralised systems to achieve the MDGs. This section also serves as a conceptual and methodological critique of the current MDG framework with respect to the objective of gender equity.

Background and Methodology

This article evaluates progress in actualising MDGs for women and children as a result of decentralisation reforms. India makes a useful case study for evaluating whether decentralisation does indeed promote improved outcomes as it has a long tradition of emphasising and institutionalising local selfgovernment and grassroots level democracy. In 199293, the Government of India passed a series of constitutional reforms in order to democratise and
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empower a third tier of government at the sub-state level called Panchayati Raj Institutions (PRIs). The reforms mark a transition from a two-tier system of governance (union and state) to a three-tier system, comprising the union, the states and the Panchayats. This three-tier structure of rural local government is based on the principles of democratisation, devolution of powers and resources for planning as well as community involvement in the implementation of development programmes. Healthcare was one of the rst subjects devolved to PRIs in India. Geographically, the article focuses on two southern states in India (Karnataka and Kerala) because they are leading examples of innovation in decentralisation in India, albeit in two very different waysKarnataka was one of the rst states to institute decentralisation and Kerala has arguably been the most comprehensive in its decentralisation programme. Within these geographies, we look at the specic experience of decentralisation in relation to health outcomes for rural women in India. Seven outcome indicators corresponding to four MDGs are evaluated. These goals are: reducing child mortality (Goal 4); improving maternal health (Goal 5); combating preventative diseases (Goal 6) and; ensuring environmental sustainability (Goal 7) (see Box 1). In this study, the assessment of equity in health outcomes focuses on the relative as well as absolute gaps in the health status of women in the postdecentralisation context. By gaps, we mean differences in the health status of a particular sub-section of the population relative to other sections, segregated (wherever possible) on the basis of three specic parameters (geography (rural/ urban),5 religion and caste6). For the purpose of the analysis, the situation is regarded as equitable if there is a reduction in gaps between the parameters of segregation over time. The outcomes analysis is based on secondary data (National Family Health Survey rounds 1, 2 and 3) collected at three periods of time, one prior to decentralisation (199293), and the second and third after decentralisation (199899 and 200405 respectively).7 The comparison between three time periods of health outcomes is expected to help trace changes in the relative health status along a range of parameters of disaggregation against the backdrop of increased PRI involvement in the management and supervision of healthcare. As a caveat, while the article recognises the difculty of establishing a direct and rigorous link between decentralisation and improvements in outcomes and well-being, variations in outcomes observed are likely to be a part of
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Box 1 Selected MDGs, Targets and Indicators Targets Reduce by two-thirds between 1990 and 2015 the under-ve mortality rate Reduce by three-quarters between 1990 and 2015 the maternal mortality ratio Have halted by 2015 and begun to reverse the spread of HIV/AIDS Have halted by 2015 and begun to reverse the incidence of tuberculosis and other major diseases Halve by 2015 the proportion of people without basic sanitation Under-ve mortality rate Infant mortality rate Maternal mortality ratio Proportion of births attended to by skilled health personnel Current contraceptive rate Percentage of population with tuberculosis Indicators

Goals

Goal 4: Reduce child mortality

Goal 5: Improve maternal health

Goal 6: Combat preventative diseases

Goal 7: Ensure environmental sustainability

Proportion of population with access to improved sanitation

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Source: http://www.un.org/millenniumgoals/; Self.

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a changing trend, attributable, at least in some measure, to the changing political and economic context since decentralisation. The point is thus, to examine the trends in the health status of rural women in the two states under study, in the context of decentralisation of healthcare.

Findings
As highlighted in the previous section, this article is specically concerned with health outcomes and utilisation rates across a range of reproductive and child health (RCH) indicators that are under the scope of decentralised governments and where local governments have a direct degree of responsibility. These indicators are now examined.
Child Mortality

With respect to measuring progress on targets for child mortality, two indicators have been used: under-ve mortality rate and infant mortality rate. Under Five Mortality and Infant Mortality8 A comparison of under-ve mortality rates (U5MR) across the three surveys indicates that there has been a substantial decline in mortality in both the states (see Table 1). For instance, in Karnataka the number of under-ve deaths per 1,000 live births decreased from 102 deaths in 199293 (NFHS 1) to 83 deaths in 199899 (NFHS 2) to 55 deaths in 200405 (NFHS 3). In Kerala too, there has been a dramatic decline in U5MR across the surveys. NFHS 1 and NFHS 2 recorded IMRs of 40 and 26 respectively for Kerala. Comparing these estimates with the NFHS 3 estimate of 16 indicates that U5MR declined by 24 deaths per 1,000 live births over the survey period.
Table 1 Under Five Mortality Rate per 1,000 Live Births by State (Figures in brackets indicate percentages) U5MR Karnataka Kerala NFHS 1 102 (10.2%) 40 (4%) NFHS 2 83 (8.3%) 26 (2.6%) NFHS 3 55 (5.5%) 16 (1.6%)

Sources: IIPS 1995 (various reports), IIPS 2000 (various reports), IIPS 2008 (various reports).

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Table 2 presents infant mortality rates (IMR) for both the states across time. In both Karnataka and Kerala, the IMR per 1,000 live births declined dramatically from NFHS 1 to NFHS 3. In Karnataka, IMR declined from 75 deaths per 1,000 live births to 43 deaths across the 15-year period, while in Kerala, IMR declined by nearly 50 per cent over the same period. Chart 1 compares IMR and U5MR for India across the three surveys. As the trend in the chart indicates, early childhood mortality rates for India as a whole have also declined over time.
Table 2 Infant Mortality Rate per 1,000 Live Births by State (Figures in brackets indicate percentages) Total IMR Karnataka Kerala NFHS 1 75 (7.5%) 31 (3.1%) NFHS 2 62 (6.2%) 21 (2.1%) NFHS 3 43 (4.3%) 15 (1.5%)

Sources: IIPS 1995 (various reports), IIPS 2000 (various reports), IIPS 2008 (various reports). Chart 1 Early Childhood Mortality Rates across NFHS 1, NFHS 2 and NFHS 3: India

Sources: IIPS 1995 (various reports), IIPS 2000 (various reports), IIPS 2008 (various reports). Note: IMR and U5MR are represented per 1,000 live births.

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Maternal Health

With respect to measuring progress on maternal health, two indicators have been used: maternal mortality ratio and proportion of births attended to by skilled health personnel.9 Maternal Mortality Rate The maternal mortality rates (MMR) for the two states as well as for India as a whole are presented in Table 3.10 Whereas nationally and for Kerala, MMR has been declining over time, in Karnataka progress has been slow. In Karnataka, the MMR increased quite dramatically from 195 deaths per 10,000 live births in 1998 to 266 deaths in 19992001. Although the MMR came down to 228 in 200103, this gure is still higher than the 1997 estimates indicating that progress is tardy. Kerala on the other hand had an MMR of 110 deaths per 10,000 live births (200103), which is half the MMR in Karnataka.
Table 3 Maternal Mortality Rate per 10,000 Live Births: State-wise and India State-wise Maternal Mortality Rate (1997, 1998, 19992001 and 200103) States India Karnataka Kerala 1997 408 195 195 1998 407 195 198 199901 327 266 149 200103 301 228 110

Sources: Ministry of Statistics and Programme Implementation, Government of India; Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India (2001).

Assistance in Delivery With respect to the indicator of assistance in delivery by trained personnel, we see improvements across all parameters of segregation in both the states over time. As Tables 4 and 5 indicate, in Karnataka across all religious and caste groups, the proportion of rural women who were assisted by doctors at the time of delivery increased quite dramatically from NFHS 1 to NFHS 3. For instance, among Hindu women, the proportion of doctor assisted deliveries increased by 125 per cent, while for Muslim women, the corresponding gure was 138 per cent over the 15-year period. Among SC/ST women, the proportion of doctor assisted deliveries went up

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Table 4 Assistance in Delivery by Religion: Rural Karnataka (in per cent) Hindu NFHS 2 28 19 53 100 41 100 58 100 54 100 36 100 44 100 NFHS 3 45 14 NFHS 1 21 22 NFHS 2 23 22 NFHS 3 50 14 NFHS 1 44 13 Muslim Other NFHS 2 46 19 35 100 NFHS 3 68 21 11 100

Karnataka Doctor ANM/Nurse/ Midwife/LHV Other Total

NFHS 1 20 19

60 100

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Sources: IIPS 1995 (Karnataka), IIPS 2000 (Karnataka), IIPS 2008 (Karnataka). Notes: ANM=Auxiliary nurse midwife; LHV= Local health volunteer.

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Table 5 Assistance in Delivery by Caste: Rural Karnataka (in per cent) SC/ST Other

Karnataka Assistance in delivery Doctor ANM/Nurse/Midwife/LHV Other Total

NFHS 1 NFHS 2 NFHS 3 NFHS 1 NFHS 2 NFHS 3 11 13 76 100 17 17 67 100 35 14 51 100 23 21 56 100 32 20 48 100 51 14 35 100

Sources: IIPS 1995 (Karnataka), IIPS 2000 (Karnataka), IIPS 2008 (Karnataka).

from 11 per cent in NFHS 1 to 35 per cent in NFHS 3. Further, gaps between SC/STs and the better-off other castes declined dramatically between NFHS 1 and NFHS 3. Finally, the proportion of assisted deliveries by midwives and nurses declined slightly across the three surveys but these results must be interpreted in light of the sharp increases in assistance by doctors. What is also notable is that the proportion of deliveries that were assisted by untrained personnel (indicated by the category other) declined over the 15-year period across all caste and religious sub-groups. As Tables 6 and 7 indicate, in rural Kerala too, remarkable progress has been made in terms of the increase in the proportion of assisted deliveries by doctors. This is true across all religious and caste sub-groups. For instance, the proportion of deliveries by doctors for Muslim women increased by 62 per cent between NFHS 1 and NFHS 3 and among SC/ST women, the corresponding ratio went up from 63 per cent to 88 per cent. Gaps between Hindus and Muslims as well as SC/STs and other castes also declined substantially between NFHS 1 and 3. Another prominent trend is the reduction in the proportion of deliveries conducted by unqualied personnel. As Table 6 indicates, 17 per cent of Muslim women were assisted by unqualied personnel in NFHS 1. By NFHS 3, this proportion had come down to 0 per cent, indicating the huge strides taken toward safe motherhood strategies in the state.
Preventative diseases

This article utilises two indicators to measure progress on preventative diseases: current contraceptive use11 and proportion of population suffering from tuberculosis.
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Table 6 Assistance in Delivery by Religion: Rural Kerala (in per cent) Hindu NFHS 2 94 3 3 100 94 5 1 100 60 24 17 100 87 3 11 100 97 2 0 100 92 5 3 100 NFHS 3 NFHS 1 NFHS 2 NFHS 3 NFHS 1 Muslim Other NFHS 2 96 3 2 100 NFHS 3 96 4 0 100

Kerala 84 10 6 100

NFHS 1

Doctor ANM/Nurse/Midwife/LHV Other Total

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Sources: IIPS 1995 (Kerala), IIPS 2000 (Kerala), IIPS 2008 (Kerala).

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Table 7 Assistance in Delivery by Caste: Rural Kerala (in per cent) SC/ST Other NFHS 3 88 8 4 100 NFHS 1 77 10 13 100 NFHS 2 92 2 6 100 NFHS 3 97 3 0 100

Kerala Doctor ANM/Nurse/Midwife/ LHV Other Total

NFHS 1 63 21 16 100

NFHS 2 82 8 10 100

Sources: IIPS 1995 (Kerala), IIPS 2000 (Kerala), IIPS 2008 (Kerala).

Current Contraceptive Use An important indicator of the reproductive health of women is the use of contraception. What is remarkable is that the three rounds of NFHS data indicate that dramatic improvements in contraception rates (modern method, any method) have been achieved in both the states (Tables 8, 9, 10, 11). The proportion of women not using any contraception also declined in the two states across the different parameters of segregation. It is noteworthy that across SC/ST households in Karnataka, the proportion of households using modern forms of contraception increased from 43 per cent (NFHS 1) to 65 per cent (NFHS 3). Gaps between disadvantaged SC/ST households and other households using modern forms of contraception also dramatically decreased between the survey periods indicating greater equity in outreach services (Table 9). With respect to religion as the parameter of segregation, we nd that the gaps between Hindu and Muslim households using modern contraception have also declined (Table 8). In Kerala, the gures for any contraceptive use among SC/ST households increased marginally from 73 per cent (NFHS 1) to 75 per cent (NFHS 3) (Table 11). What is interesting in the Kerala case is that the proportion of women from the disadvantaged SC/ST castes that used contraception was higher than more advantaged other castes, agging the success of targeted family planning programmes. Consequently, gaps in equity among caste groups in the post-decentralisation period are positively biased towards SC/STs. Given that 67 per cent of rural users in Kerala obtain their contraceptives from the public health sector (NFHS 2 Kerala), the high rates of contraception indicates that needs for family planning services are being met effectively by the network of PHCs, sub-centres and medical staff in conjunction with PRIs.
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Table 8 Current Contraceptive Use by Religion: Rural Karnataka (in per cent) Hindu NFHS 2 59 58 1 41 100 66 66 1 34 100 34 33 1 66 100 42 42 1 58 100 56 56 1 44 100 NFHS 3 NFHS 1 NFHS 2 NFHS 3 Muslim NFHS 1 45 42 3 55 100 Other NFHS 2 54 51 3 46 100 NFHS 3 59 58 2 41 100

Karnataka

NFHS 1

Any method Any modern method Any traditional method Not using any method Total

49 48 1 51 100

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Sources: IIPS 1995 (Karnataka), IIPS 2000 (Karnataka), IIPS 2008 (Karnataka).

Table 9 Current Contraceptive Use by Caste: Rural Karnataka (in per cent) SC/ST NFHS 1 43 43 1 57 100 52 51 1 48 100 66 65 1 34 100 49 47 1 51 100 NFHS 2 NFHS 3 NFHS 1 Other NFHS 2 59 58 1 41 100 NFHS 3 65 65 1 35 100

Karnataka

Any method Any modern method Any traditional method Not using any method Total

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Sources: IIPS 1995 (Kerala), IIPS 2000 (Kerala), IIPS 2008 (Kerala).

Table 10 Current Contraceptive Use by Religion: Rural Kerala (in per cent) Hindu NFHS 2 72 65 7 28 100 75 65 10 25 100 36 31 6 64 100 47 41 6 53 100 53 44 9 47 100 NFHS 3 NFHS 1 NFHS 2 NFHS 3 Muslim NFHS 1 71 59 12 29 100 Other NFHS 2 72 61 12 28 100 NFHS 3 78 58 20 22 100

Kerala

NFHS 1

Any method Any modern method Any traditional method Not using any method Total

71 63 8 29 100

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Sources: IIPS 1995 (Kerala), IIPS 2000 (Kerala), IIPS 2008 (Kerala).

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Table 11 Current Contraceptive Use by Caste: Rural Kerala (in per cent) SC/ST Other NFHS 3 NFHS 1 75 61 68 52 7 8 25 100 40 100 NFHS 2 62 54 8 38 100 NFHS 3 67 56 12 33 100

Kerala Any method Any modern method Any traditional method Not using any method Total

NFHS 1 73 69 5 27 100

NFHS 2 74 69 6 26 100

Sources: IIPS 1995 (Kerala), IIPS 2000 (Kerala), IIPS 2008 (Kerala).

While examining the data by religion we note that there have been sharp increases in the use of any method of contraception among different religious sub-groups (Table10). This trend is particularly visible among Muslim women. More crucially, gaps in equity between Hindu and Muslim households using any contraception declined sharply between NFHS 1 and NFHS 3, which is indicative of a positive trend. Tuberculosis Using NFHS data, the experience of morbidity in terms of preventable diseases such as tuberculosis (TB) has been presented in Table 12. Due to the small size of the NFHS sample and the difculties in disaggregation, only state-wise data is presented here. We note that a higher proportion of women in Kerala have TB relative to women in Karnataka. However, in both the states there has been a decline in TB prevalence rates from NFHS 1 to NFHS 3, which is indicative of a positive trend.
Table 12 Prevalence of Tuberculosis by State across Surveys (in per cent) Tuberculosis Karnataka Kerala NFHS 1 1 6 NFHS 2 3 5 NFHS 3 1 3

Sources: IIPS 1995 (various reports), IIPS 2000 (various reports), IIPS 2008 (various reports).

Environmental Sustainability

To evaluate progress on environmental sustainability, this section probes the level of basic sanitary facilities in the two states. The provision of sanitation is
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directly within the realm of Panchayat responsibility in India. Improvements in water sources and sanitation facilities are critical as they have a signicant inuence on the health of household members, especially children (NFHS 2, Karnataka).12 Lack of access to facilities is a particular problem for girls and women because of issues of privacy and safety. Sanitation As indicated by the NFHS data for Karnataka, there has been a marked increase in the percentage of households with improved toilet facilities between the three rounds for all parameters of segregation (Tables 13 and 14).13 Conversely, there were also reductions in the proportion of households with non-improved facilities across all groups between NFHS 1 and 3. Among Muslims, the change in the proportion of households having improved toilets was remarkablefrom 12 per cent households in NFHS 1 to 35 per cent in NFHS 3 (Table 13). Considering the data by caste, the proportion of SC/ST households with improved sanitation increased from 2 per cent to 10 per cent (Table 14). However, differences within caste and religious sub-clusters were very high, indicating variations in equity between different groups in Karnataka. The NFHS data also highlights the great strides that have been made in Kerala in terms of construction of sanitary facilities (Tables 15 and 16). Across all religion and caste groups, there has been a substantial increased in improved facilities. For instance, among caste groups, the proportion of SC/ ST households with improved facilities doubled between NFHS 1 and 3. Further, gaps in equity in terms of proportion of households possessing own pucca toilets narrowed among caste and religious sub-categories. We also nd strictly decreasing proportions of households with non-improved facilities across all parameters between the three rounds.

Conclusion
Within the context of womens empowerment, engagement through local governments is the rst step towards greater democratisation and consequently towards transformative outcomes for vulnerable communities. A comparison of secondary data over time indicates that decentralisation of public healthcare responsibilities to local governments in India has resulted in augmenting health (and health-related) outcomes for rural women. An observation clearly discernible from the data is a reduction in inequity over
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Table 13 Household Sanitation Facilities by Religion: Karnataka (in per cent) Hindu NFHS 3 19 81 0 100 NFHS 1 12 88 0 100 NFHS 2 8 92 0 100 NFHS 3 35 65 0 100 NFHS 1 33 67 0 100 Muslim Other NFHS 2 52 48 0 100 NFHS 3 44 56 0 100

Karnataka Improved Non-improved Other

NFHS 1 6 94 0 100

NFHS 2 12 88 0 100

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Sources: IIPS 1995 (Karnataka), IIPS 2000 (Karnataka), IIPS 2008 (Karnataka).

Table 14 Household Sanitation Facilities by Caste: Karnataka (in per cent) SC/ST NFHS 2 5 95 0 100 NFHS 3 10 90 0 100 NFHS 1 8 92 0 100 Other NFHS 2 16 84 0 100 NFHS 3 24 76 0 100

Karnataka Improved Non-improved Other

NFHS 1 2 98 0 100

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Sources: IIPS 1995 (Karnataka), IIPS 2000 (Karnataka), IIPS 2008 (Karnataka).

Table 15 Household Sanitation Facilities by Religion: Kerala (in Per cent) Muslim NFHS 3 93 7 0 100 68 33 0 100 83 17 0 100 98 2 0 100 NFHS 1 NFHS 2 NFHS 3 NFHS 1 71 29 0 100 Other NFHS 2 86 14 0 100 NFHS 3 94 5 1 100

Hindu 76 24 0 100

Kerala

NFHS 1

NFHS 2

Improved Non-improved Other

60 40 0 100

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Sources: IIPS 1995 (Kerala), IIPS 2000 (Kerala), IIPS 2008 (Kerala).

Democratic Decentralisation and the Millennium Development Goals

Table 16 Household Sanitation Facilities by Caste: Kerala (in per cent) SC/ST Kerala Improved Non-improved Other NFHS 1 44 55 0 100 NFHS 2 68 32 0 100 NFHS 3 83 17 0 100 NFHS 1 66 35 0 100 Other NFHS 2 81 19 0 100

187

NFHS 3 96 4 0 100

Sources: IIPS 1995 (Kerala), IIPS 2000 (Kerala), IIPS 2008 (Kerala).

a majority of selected indicators for both Kerala and Karnataka. Further, the data indicates that the proportion of households suffering from preventative illnesses such as tuberculosis as well as household attainments of RCH care including maternal and child mortality rates, contraceptive use and safe deliveries have increased between the survey periods across all the parameters of segregation. There have also been substantial improvements in trends in health infrastructure particularly in terms of sanitation at the village level as a result of decentralisation across both states. However, despite the success of decentralisation reforms, there is much ground to be covered in terms of achieving MDG targets by 2015. This is very obvious in the case of Karnataka. For instance, U5MR in Karnataka decreased by 46 per cent between 199293 and 200405 but by 2015, it must reduce by 67 per cent. On the other hand in Kerala, U5MR has declined substantially by 60 per cent since 199293. MMR in Karnataka increased dramatically by 17 per cent between 1997 and 2003. However, by 2015, it must reduce by nearly 75 per cent. In Kerala, MMR declined by 44 per cent in the same period. Finally, the 7th MDG requires that by 2015 the proportion of people without basic sanitation should be halved. While progress has been made in this direction in both the states, the data indicates that in Karnataka there is still a long way to go to realise this target. Thus, a striking paradox that emerges from the data is that Kerala performs much better in terms of achieving MDG targets than Karnataka. This is surprising in light of Karnatakas institutional experience vis--vis decentralisation.14 Yet, decentralisation has had a more muted effect on womens health outcomes in Karnataka than in Kerala. How can we explain the differential impacts in the two states?

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The Kerala model of decentralisation indicates that the success of such reforms is linked to both the architecture of the decentralisation design (institutional mechanisms and other features of design) as well as to nonstatutory provisions such as a vibrant civil society, levels of literacy and awareness that create a sustainable process of path-dependency towards emancipatory opportunities for women. We now turn our attention briey to these factors.
The Kerala Model

As the experience of decentralisation in Kerala suggests, the effective design of decentralised systems is a necessary prerequisite for the success of such systems. In order to render decentralisation more effective, consideration of key factors relating to the empowerment of Panchayats are critical. These factors include a greater degree of nancial and administrative decentralisation to the local level along with a concomitant strengthening of channels of accountability and transparency in local government functioning. Such factors are essential to sustain positive outcomes from decentralisation, provide safeguards for the marginalised and lead to improved outcomes. In Karnataka, many of these factors are as yet inchoate. Keralas success with decentralisation has also been abetted by the interaction of a multiplicity of enabling social factors. One of the salient features of Keralas development experience is the role of education. The success of the literacy movement and the states active interest in promoting universal access was instrumental in spreading education throughout Kerala and ensuring gender parity in school enrolments. The spread of education catalysed an increased level of social consciousness in society. This resulted through public demand and supply, in wider access to and awareness of healthcare among the population.15 Other landmarks in the development history of Kerala include powerful caste and social reform movements in the early 20th century, radical land reforms, the vast public distribution of food networks as well as a host of social security and welfare measures. This commitment has paid off in dramatic and lasting improvements in the quality of life for its rural people (Dreze and Sen 1995). This has bestowed a measure of economic freedom, especially among socially marginalised communities and has led to an enhancement in their overall well-being.

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Thus, Keralas steady progress towards MDG targets can be interpreted to be a result of the state having given higher priority to the development of social services in response to organised public demand. All of these conditions provided a fertile setting for the institutionalisation of decentralisation that the state undertook in the 1990s. In this sense, public action and social mobilisation have ensured path dependency towards increased political participation and improved developmental outcomes in Kerala. This has led to an environment that has fostered citizenship opportunities for disadvantaged groups, particularly women.16 With specic reference to healthcare, an increase in participation has resulted in improved needs assessment, increased accountability of personnel and enhanced access and quality of healthcare in Kerala. Indeed, Keralas relative success in decentralisation bears out the importance of social mobilisation and womens education as catalysts for path dependency and key strategies for achieving strategic improvements in well-being for women. It is worth acknowledging that these factors (particularly womens literacy) are recognised as contributing to improved health and well-being in the MDGs in the goals for womens equality and universal primary education. However, lessons from the Kerala model of decentralisation underscore several important points and serve as a critique of the MDG framework. First, gender equity is derived from both political and social spheres. Womens effective citizenship is a combination of political rights as well as enabling social conditions that facilitate participation in the public sphere (YuvalDavis 1997). Because womens responsibilities are traditionally perceived as lying in the private sphere (family and caring roles) and mens gender roles as being related to decision-making in the public domain, women are often excluded from the realm of public activity. This public/private divide, based on the classical theories of the social contract, contributes to relationships of inequality and difference between women and men. None of the MDGs really address the issue of womens citizenship and effective participation. While Goal 3 ags the proportion of sets held by women in national government, the indicators do not acknowledge the importance of womens participation and decision-making rights in the multiple contexts of the household, the community and the state. What the Kerala model also highlights is the importance of integrated gender-responsive policies that explicitly target excluded communities and serve to reduce gender and class based disparities in society. In this sense,

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gender equality is not just a goal in its own right but is central to achieving all other goals (UNDP 2003). Yet, of the eight MDGs, only the 3rd and 5th goals refer directly to women and (indirectly) to gender relations. Given that the MDGs are mutually reinforcing, it is critical to make the gender dimension more explicit in the targets and indicators of the MDGs. Not addressing the gender issue in an integrated manner is one of the main weaknesses of the MDG framework. Third, under the MDG framework there is an overwhelming emphasis on the achievement of targets. However in the process, it is quite easy to lose sight of the main objectives. For instance, one of the indicators under Goal 5 (maternal health) is the proportion of deliveries undertaken by trained birth attendants. Yet, the quality of that care matters as much as the proportion of assisted deliveries. Thus, achieving the MDGs is not simply about tracking progress but is inextricably linked to developing sensitive and sustainable approaches to accomplishing the goals. Finally, it is important to acknowledge the role of gender relations at all levels (household, community, state) in inuencing the achievement of targets. Gender relations may be perceived to be largely socially imposed as opposed to being biologically determined. In India (and indeed in many parts of the world), these relations sustain and reproduce a hierarchy where women are subordinate to men. For gender equity to take root, development policies must be cognisant of the ideologies and exclusions underpinning gender relations in society. Such policies must be both gender responsive and gender sensitive as the Kerala experience has taught us.

Notes
1. For instance, it has been estimated that 90 per cent of immunisations and 60 per cent of prenatal care is publicly provided in India (IIPS 2000). Further, deprived sections of the population like poor women are highly reliant on public health services in rural areas where private services are either unavailable or are unaffordable. 2. There are two main discourses underpinning decentralisationthe empowerment and efciency frameworks. The empowerment discourse posits that decentralisation offers an enabling context to empower citizens by institutionalising processes that catalyse collective action, agency and social change (Pateman 1970; UNDP 2004). This in turn leads to broader emancipatory impacts for citizens in terms of the realisation of outcomes for their well-being. Another rationale is the neo-liberal efciency argument (Bird 1999). According to this argument, decentralisation is a means to minimise wasteful spending and encourage scal efciency, facilitating cost-recovery through mechanisms such as privatisation. Since

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3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

the MDGs are directly relevant to issues of equity and empowerment, this article anchors its analysis in the empowerment framework. Some non-country specic studies draw attention to the potential advantages of decentralised health systems, including improved accountability and logistic systems as well as a greater degree of resource efciency (Bossert 1998; Jimnez and Smith 2005). This is particularly relevant for certain services (for instance reproductive and child healthcare) where gender bias at the local level can create allocational inefciencies that result in worsening gender outcomes. As a caveat, analysing health inequities through a gender lens is problematic. This is because unlike inequalities in education, health has a physiological basis or at least biological referents. However, more often than not, social determinants are more instrumental in aggravating gender based health asymmetries than physiological factors. This article takes the view that inequities in health are for the most part, socially produced, rather than biologically given. Thus, they can be ameliorated by changes in the power structures underpinning societal relations. Although the data is segregated according to geography, only rural data is shown. The rural bias is justied in that over 70 per cent of Indian citizens (and voters) reside in rural India. This article does not consider the parameter of class in its analysis. Although this is a critical dimension, class-wise data could not be obtained from NFHS 1 and hence comparison over time was not possible. However, in the Indian context, caste hierarchies are pervasive and the caste groups at the lower end of the hierarchy (denoted as Scheduled Castes and Tribes, i.e., SC/STs) suffer from severe social and economic discrimination. Thus, the category of caste can be taken to approximately reect class differences. At the outset, it must be said that these surveys were designed to present state and nationallevel estimates of demographic trends and were not specically meant to provide information on utilisation and health outcomes. However, because they represent a continuum of information across a 15-year period, these sources were used. For both IMR and U5MR, data could not be disaggregated by caste, religion or geography due to the small size of the sample in both the states. Hence, only state-wise and national estimates for these two indicators have been presented. These two specic indicators have been selected because they are interlinked. Indeed, the proportion of births attended to by trained personnel has a direct implication on maternal mortality rates. Again for MMR, data could not be disaggregated by caste, religion or geography due to the small size of the sample in both the states. Hence, only state-wise and national estimates for this indicator have been presented. The indicator current contraceptive use has been employed as an approximate indicator of HIV knowledge and safe-sex practices in this article. NFHS 3 is the rst national survey in India to provide HIV estimates through testing. Since this was not done in NFHS 1 and 2, the results from round 3 cannot be compared with the earlier rounds. It is estimated that the poor quality of water and sanitation resources accounts for about 10 per cent of the disease burden in developing countries (Government of Karnataka 2001). Improved toilet facilities include facilities with a ush/ pour ush connected to a sewer system, septic tank or pit latrine, a ventilated latrine, a biogas latrine and a twin pit, composting toilet. If a household has any of these types of facilities but shares them with other

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households, it has a non-improved facility. This category also includes households without any facility (NFHS 3). 14. Local self-governance has had a long history in Karnataka and the states experience with respect to decentralisation and Panchayati Raj reforms has been signicant (Nataraj and Anantpur 2004). 15. Scholars concur that one of the most important factors behind Keralas remarkable performance in reducing fertility is the high level of female education (Bhat and Rajan 1990). 16. Besides mandating a one-third reservation of seats for women, the planning process in Kerala also provides for a Womens Component Plan comprising 10 per cent of the local governments budget.

References
Bhat, P.N.M. and S.I. Rajan (1990). Demographic transition in Kerala revisited. Economic and Political Weekly, 25(35/36), 195780. Bird, R. (1999). Rethinking sub national taxes: A new look at tax assignment. IMF Working Paper WP/99/165. Washington D.C. International Monetary Fund. Bossert, T. (1998). Analyzing the decentralization of health systems in developing countries: Decision Space, Innovation and Performance. Social Science and Medicine, 47(10), 151327. Dreze, J. and A. Sen (1995). India: Economic development and social opportunity. New Delhi: Oxford University Press. Government of India. (2001). Final report of the task force on health and family welfare. Bangalore, Government of Karnataka. Green, A. (1992). An introduction to health planning in developing countries. Oxford: Oxford University Press. Indian Institute for Population Sciences (IIPS) (2000). National family health survey summary, Karnataka, Kerala 198899. Mumbai: Indian Institute for Population Sciences. (2008)a. National family health survey summary, India 199899. Mumbai, Indian Institute for Population Sciences. (2008)b. National family health survey summary, Karnataka 199899. Mumbai, Indian Institute for Population Sciences. (2008)c. National family health survey summary, Kerala 199899. Mumbai, Indian Institute for Population Sciences. Jimnez, D. and P. Smith (2005). Decentralisation of healthcare and its impact on health outcomes. York: Health Economics Data Group, University of York. Koenig, M., G. Foo and K. Joshi (2000). Quality of care within the Indian family welfare programme: A review of recent evidence. Studies in Family Planning, 31(1), 118. Manor, J. (1999). The political economy of democratic decentralization. Washington D.C.: World Bank. Mills, A. (1994). Decentralization and accountability in the health sector from an international perspective: What are the choices? Public administration and development, 14, 28192.

Journal of Health Management, 11, 1 (2009): 167193

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193

Mishra, U.S. (2005). Understanding health inequity in decentralized health systems of Kerala State, India (mimeo). Boston. Nataraj, V.K. and K. Anantpur (2004). Delegation to devolution: Karnataka. Chennai: Madras Institute of Development Studies. Oates. W.E. (1972). Fiscal federalism. New York: Harcourt Brace Jovanivich. Pateman, C. (1970). Participation and democratic theory. Cambridge, M.A.: Cambridge University Press. Rondinelli, D., J. R. Nellis and G.S.Cheema (1983). Decentralization in developing countries: A review of recent experience. Washington, D.C.: World Bank. Sen, G., A. Iyer and A. George (2007). Systematic hierarchies and systematic failures: Gender and health inequities in Koppal district. Economic and Political Weekly, XLII(8), 68290. Taal, H. (1993). Decentralization and community participation for improving access to basic services: An empirical approach. Florence: UNICEF. UNDP (2003). Human development report. New York: United Nations. (2004). Decentralized governance for development. New York: United Nations. (2007). Improving local service delivery for the MDGs in Asia: Pilot of methodology for support to national policy and MDG strategies. Available at http://regional centrebangkok.undp.or.th/practices/governance/decentralization/documents/ WorkshopReport.pdf (Accessed on 20 November 2007). UNDP, Millenium Development Goals. Available at http://www.un.org/millenniumgoals/ (Accessed on 20 November 2007). Yuval-Davis, N. (1997). Gender and nation. London, Thousand Oaks and New Delhi, Sage Publications.

Nitya Mohan is Director, Nand and Jeet Khemka Foundation. E-mail:n.khemka@khemkaf oundation.org

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