Decentralisation and decision space in the health sector, Karnataka, India

Introduction Despite long-term commitment to decentralization in India, progress towards a decentralized form of governance has been rather slow. In Karnataka, despite state compliance with decentralised governance legislation from the mid-1980s, local bodies continue to suffer from inadequate power and resources. Under the National Rural Health Mission (NRHM), decentralization plays an important role in monitoring access to and quality of health services. However, after almost a decade of organized decentralisation in the health sector, its impact is still not clear, nor its ability to enhance participation of individuals/communities. There are very few studies that have tried to assess the impact of decentralization on the provision of health care services and health outcomes. There is also a lack of an analytical framework to empirically analyse its impact. Hence, there is limited evidence on the impact of decentralization on improving delivery of health care services and health outcomes worldwide. In this regard, we undertook a study to ask: 1) does the degree of decentralization under the NRHM correlate strongly with perceived decision space of the officials of the Department of Health and local government representatives at the district level and below? 2) does the capacity of functionaries at different levels of the health system correlate with perceived decision space? 3) does greater perceived decision space by any given functionary lead to better health outcomes? For the purpose of this research, we define decentralisation as a process, which involves shifting of power and responsibilities between tiers of government by way of various fiscal, political, and administrative instruments. We used Bossert’s analytical framework that outlines the concept of decision space, by studying the range of choice that different actors in the health system perceive as being available to them along a series of functional dimensions.