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Vol. XXIX No. 13, October 16-31, 2019

Efficient governance for better impact of Public Health Services

by A Special Correspondent

NITI Aayog’s annual comparative reviews of states’ performance with respect to education, public health and social progress fill an important void in monitoring public governance. To governments and policy makers, the reviews provide objective, quantitative feedback on specific aspects. The novel feature is that the reviews are not confined to evaluating the scale of infrastructure but, more importantly, its impact. To the public and tax payers, they provide a report on how much and how well the money has been spent. NITI Aayog’s third report for 2017-18 throws light on Tamil Nadu’s efforts at bettering its own performance from year to year, setting benchmarks for other southern states functioning under similar conditions.

The report ranks states on performance. The rank for any given state can be misleading as it depends on performance of other participants. A good performance in itself could show up as a drop in rank when others perform better and, likewise, deterioration in performance could reflect as rise in ranking because others have done even worse. We shall, therefore, go by year-on-year performance on the three major aspects – Input, Outcome and quality of Governance.

The term ‘Input’ refers to physical infrastructure, staffing, equipment etc. for delivery of services. ‘Outcome’ represents the services delivered. Outcome is reflected by the community’s wellness, which is assessed by quantifiable indicators like, say, reduced incidence of TB, longevity, lower school drop outs, lower infant mortality etc. A high performance score on Inputs does not necessarily lead to beneficial Outcomes if the input (infrastructure) is not put to effective use to address the needs of target beneficiaries.

‘Governance’ is the converter of Input into desired Outcome. Governance constitutes supervision, monitoring and accountability. For example, a 50-strong input with 80 per cent governance would yield 40 units of benefit compared to a 100-strong input with 10 per cent governance yielding only 10 units of benefit. Governance has a comprehensive role involving review of infrastructure and process designs for their relevance and effectiveness, making changes to them as necessary, monitoring quantity and quality of services delivered and enforcing accountability. This direct causal relationship between Governance and Outcome is clearly brought out in the NITI review. Wherever Governance score is high, Outcome scores are as high as or higher than Input scores.

Going by the above, Tamil Nadu’s score on Outcomes is lower than that on Inputs or processes, indicating that there is scope for taking fuller advantage from the infrastructure already on the ground. In contrast, Kerala’s score on Outcomes is higher than its score on Inputs. Kerala’s effective Governance is significant when considered in the context of the state’s high literacy. Better Public Services could well be the result of the high literacy level reflecting in greater public awareness of eligibility and ability to demand good service.

In the three-year period ending 2018, Tamil Nadu’s score on Inputs had deteriorated from a score of 74.20 in 2014-15 to 68.92 in 2017-18. It suggests that investment in infrastructure and related needs have not been growing. Outcome scores – that is, the overall score for benefits from the infrastructure – show a drop from 64.04 to 58.90 respectively for the same years. It appears, therefore, that less and less advantage has been derived even from existing infrastructures. More specifically, in terms of final impact, Low Weight at Birth increased steadily from 10.46 per cent in 2014-15 to 13.03 per cent in 2015-16 and to 15.49 per cent in 2017-18. Vacancy of medical officers at PHCs has grown from 7.58 per cent in 2015-16 to 15.06 per cent in 2017-18. The average occupancy of level-3 posts of staff was only 9.98 months in 2017-18 compared to 15.74 months in 2015-16. Frequent transfers and the consequent short duration postings are not conducive to a sense of commitment to the job on hand. This indicates that better management could have yielded higher Outcomes even without additional investment in infrastructure. Of course, there are aspects in the report that the Tamil Nadu Government has commented on – NITI Aayog has taken estimated numbers for indicators like institutional deliveries and immunisation cover as the basis for evaluation; but then, it might be the state’s own fault for delaying the filing of data.

Awareness of available facilities and entitlements and convenient access to them are two major factors that govern how impactful the facilities are to the beneficiary. Awareness that a facility is available is as low as 50 per cent according to one study. People often do not know that they are entitled to free medicines, life-saving drugs, x-ray tests, laboratory tests and ambulance at call. As regards convenience of access, one field study has estimated that only 60 per cent of Primary Health Centres are located within half hour distance. Simple features like the hours of working of health centres are important. For the poor, long distances, hours of waiting and avoidable repeat visits deprive them of their wages for the day thereby increasing the effective cost of the so-called “free” service provided by the government. That could explain under-utilisation of public facilities and increasing preference for private health care.

The Annual Reviews are useful to diagnose design defects of existing infrastructure that hinder higher service standards. Erroneous assumptions of basic data such as those pointed out by the Tamil Nadu Government must be avoided by NITI to maintain credibility of the findings. The results for 2017-18 were made available only in June 2019, that is, after a lapse of 15 months, by when valuable time had gone by without opportunity to make course corrections. In these days of real-time data, efforts should be made by all concerned agencies to get the review ready, say, within six months, if it is to serve the purpose, which is to eradicate deprivation, not just poverty. India’s “income-poor” were 270 million whereas those deprived of basic facilities were more than 364 million.

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