Introduction

The study focused on assessing the two frameworks in context of Decentralisation of Health Services in Jhunjhunu District, Rajasthan viz. perceptions of service users and, service providers. Developing country like India faces a big challenge in providing a good quality of life for its citizens. There is undisputable evidence that suggests that economic growth goes hand in hand with the well-being of the nation’s populace. Good health of individuals translates into personal development and economic security, which in turn creates a healthy populace that, is critical for poverty reduction and sustained economic growth.

The efficiency of any healthcare service across the globe is determined by the availability of healthcare providers who can provide quality services, availability of drugs and medicines and cost effectiveness. Over the years, health services in India have been provided mainly by three sectors; the government (public), the private (for profit) and voluntary organizations. Although there has been a higher growth in government infrastructure after Independence, there is still a general expressed disillusionment and confusion regarding its efficacy. The main aim of decentralisation of health care sector is to achieve efficiency with effective management, cost-control and better service of society but it has been observed that the health sector has fallen short of achieving the target. There are several lacunae in the system which are in ardent need of analysis and rectification. It is of utmost importance to understand the problems and preferences of healthcare service users in order to make services more accessible for the users. It is also of vital importance to understand the beliefs and perceptions of service providers to understand the problems and challenges faced by them.

Healthcare is the right of every individual but lack of quality infrastructure, dearth of qualified medical functionaries, and non- access to basic medicines and medical facilities thwarts its reach to 60 per cent of population in India. A majority of 700 million people lives in rural areas where the condition of medical facilities is deplorable. Considering the picture of grim facts there is a dire need of new practices and procedures to ensure that quality and timely healthcare reaches the deprived corners of the Indian villages. Though a lot of policies and programs are being run by the Government but the success and effectiveness of these programs is questionable due to gaps in the implementation.

Due to non-accessibility to public health care and low quality of health care services, a majority of people in India turn to the local private health sector as their first choice of care. If we look at the health landscape of India 92 per cent of health care visits are to private providers of which 70 per cent is urban population. However, private health care is expensive, often unregulated and variable in quality. Besides being unreliable for the illiterate, it is also unaffordable by low income rural folks.

To control the spread of diseases and reduce the growing rates of mortality due to lack of adequate health facilities, special attention needs to be given to the health care in rural areas. The key challenges in the healthcare sector are low quality of care, poor accountability, lack of awareness, and limited access to facilities.

The scope of the study was spread across various defining determinants of perception of healthcare service users and providers. This study focused on assessing the two factors in context of decentralization of Health Services in Jhunjhunu District, Rajasthan viz. perceptions of service users and, service providers. The scope of the study was limited to service providers of Community Health Centre’ (CHC), Primary Health Centre (PHC) and Sub Centre (SC).

Review of Literature

A healthcare system is an institution through which healthcare services have been delivered in any country, which may be explained by the healthcare financing and delivery systems

The harmonisation of healthcare services can be achieved by providing appropriate incentives that are given to healthcare providers and motivating them to improve the health of the people which eventually improves the responsiveness of the system. However, in most conditions the coordination between the healthcare financing and healthcare delivery system is mismatched, which leads to distortions in the healthcare delivery system. Empirical studies on healthcare system over the years have been carried out and came out different policy options and strategies at different conditions. 

The literature review reveals that decentralisation has shown promising results in the direction of local governance and active participation of public.

Bandar Noory et al (2020)3, the research work focused on thorough understanding of perceptions of stakeholders towards decentralization based on their personal experience. The research work was carried out in Khartoum locality. The respondents of the study highlighted that a keen scrutiny of budget allocation for health services would lead to cost recovery fee. The adoption of decentralisation of health services has resulted in change in functioning of health care services. Most of the respondents agreed that present health care system is incapacitated and private sector is prevailing everywhere.

Narayana and Kurup4 (2000) have analysed the decentralization of the health care sector in Kerala and found that the three basic problems of decentralizing the health care sector, namely spill-over effect, role and relevance of a pre-existing body (Hospital Development Committee or HDC), and the level of minimum health care service to be provided by the health care institutions, have not been adequately addressed. The problem of benefit spill over is quite serious with regard to the secondary health care services accessed from the Taluk Head Quarters Hospitals, which have been brought under the Municipal Councils. 

Narayana and Kurup, studied the impacts of decentralization of the health care sector in Kerala. She enumerated the problems of decentralisation as follows:

• Role and relevance of a pre-existing body

• spill-over effect

• level of minimum health care service

It has been found by the researcher that these issues were not adequately addressed. There is requirement of prompt rectification of problems for decentralization to be successful.

Manoj Kumar Raut, T.V. Sekher (2013)5, the research focused on the implications of decentralisation of healthcare in India. It also studied the association of decentralisation with the prospects of improved healthcare service delivery. It also analyzed the prospect of better utilization of finds in rural areas. The study was conducted in two districts of Vadodara, Gujrat and Khurdha, Odisha.

Robalino et.al, (2001) proposed that the decentralisation had resulted in lower mortality rate by ensuring better healthcare service availability at ground level. The researcher took into account the universally accepted indexes like Infant Mortality Rate, public expenditure share by local government and per capita GDP. The results of the said study has shown that decentralisation has also been successful in ensuring better health services by curbing the magnitude of corruption in poor countries

Chitah and Bossert6 (2001) have studied the decentralization of health systems in Zambia and they have found that decentralization has introduced a measure of performance accountability amongst District Health Management teams and staff.

Gupta and Gumber, (2008)7 have discussed about some initiatives in the health sector, which have led to decentralisation. One reform relates to the collection of user fees, which can be used for non-salary expenditures such as drugs. This has been introduced in Andhra Pradesh, Karnataka, Punjab and West Bengal under the World Bank assisted State Health System Project, which has the provision of varying degrees of local control over their use. This provides them with discretion in expenditures for the welfare of the patient. The other reform is devolution of central responsibilities to the lower levels of government.

Behar and Kumar (2002)8 in their study of decentralisation in Madhya Pradesh have cited attitudinal problems in the bureaucracy and Panchayat functionaries, the caste and gender of the Sarpanch, which dictate the willingness of the bureaucracy to interact with him/ her, capacity of Panchayat functionaries, confusion at all three tiers regarding intra-institutional dynamics as impediments in the process of effective decentralization. 

Bossert et al. (2009) analyses the differences among the officials working at different levels in state and district. 

The researcher also studied the decision space available to these official in prompt execution of their work. The study tried to ascertain the degree of accountability and level of freedom in decision making specifically about the finance related issues in the States of Odisha and Uttar Pradesh.

Khan. (2004). has advocated for development of a mechanism for reinforcing the association between the Panchayat President and Chief Medical Officer.

Kaur M, Prinja S, Singh PK, Kumar R. (2012)9, Political and bureaucratic commitment to reforms was found to be the most important facilitating factor. Orientation training on decentralised administrative structures and performance-based resource distribution were the other important facilitators. Structural changes in administrative procedures led to improvement in the financial management system. Decentralisation of financial resources has improved the functioning of health services to some extent. Major policy decisions on decentralisation of human resource management, increase in financial allocation, and greater involvement of community in decision-making are required.

Research Gap

From the above, it can be seen that studies have been done on implications of decentralization on health services, level of decentralisation, degree of accountability and level of freedom in decision making but no work has been carried out to understand the perceptions of healthcare service user and healthcare service providers in the study area. The present study, therefore, attempts to fill this research gap.

Objectives

1. To assess the existing level of decentralisation of health services in Rajasthan in the study area. 

2. To assess the perceptions of service users regarding decentralisation of health services in Rajasthan in the study area. 

3. To assess the perceptions of service providers regarding decentralisation of health services in Rajasthan in the study area.

4. To explore the opportunities and challenges of decentralisation of healthcare sector.

Methodology

Research Design

The purpose of a research design is to certify that the data acquired enables the researcher to deal with the research problem logically successfully and as explicitly as possible. 

In social sciences research, attaining information related to the research problem usually involve identifying the variety of facts required to test a theory, or to precisely explain and measure implication related to a visible phenomenon.

Hence descriptive research design was selected using survey method as it was found to be the most suitable and pertinent for the purpose. The application of descriptive study was supported by many prominent writers and researchers. (Orodho, 2004; Dane, 2000).

The study employs framework between two constructs which delineates SPs and SUs. It also explains the phenomena of people’s participation as Service Users of Health Care services at Grass-root level.

Study Population

Population comprises of all the units to be studied for the purpose of research and have equal likelihood to be included for the study. Study population comprises of health care administrators at district level and block level and professionals like doctors, nurses, local community leaders and service users like patient or client visiting at CHC’s and PHC’s in selected district of Rajasthan state.

Sampling

Sampling is the process of selecting respondents from the population which possess the similar traits that of the general population so that the findings could be generalised. Sample is considered a representative of entire population. Non-probability convenience sampling method was used as all units in the universe can’t be listed. It also allows quick collection of data. Every care had been taken to keep the sample unbiased and thorough representative of the population. 

Sampling designs have been used to select participants which were more likely to be representative of the population in order to get best suited answer to the research questions posed. The focus of the study is to develop and gather in-depth information. Therefore, in light of these factors, this study used a convenient sampling strategy that integrated quantitative and qualitative approaches.

The study focuses only on Jhunjhunu District, Rajasthan in order to analyse the healthcare delivery system at decentralized level and suggest policy options. The service providers and Service users are selected from the mentioned areas with a specific focus to keep the sample unbiased by employing non-probability convenience sampling.

Sample Size

a. For health-care Service Users: 

• The literature associated with decentralisation of healthcare sector was thoroughly studied and analysed to find out the most apt sample size for the purpose of study.

• The required sample size is determined by using sample size formula as the population using decentralised healthcare facilities is indefinite and large one:

• As the required sample size is 385 respondents, 450 questionnaires were sent to the respondents out of which 390 questionnaires were found to be reliable, complete and relevant to the study.

So the sample size taken for study is 390 with respect to service users (SUs).

a. For health-care Service Providers: 

For the purpose of healthcare service providers, the sample size taken on the basis of research review was kept at 150 service providers for the purpose of study.

Research Tools

Comprehensively designed Questionnaire was applied to obtain data from the respondents. Semi structured interviews and focused group discussions were also employed for obtaining data in order to decide the variables under study.

Pilot Study

It was conducted on 60 respondents and the responses were tested for reliability using Cronbach Alpha. Cronbach's alpha is a measure of computation and assessment for scale reliability. The Cronbach’s alpha value equivalent to 0.7 or more could be considered to be reliable and hence suitable for further analysis. The calculated value was found to be greater than 0.7 symbolizing its suitability for further data collection and analysis.

Variables

a Independent Variables 

i. Demographic Variables: Income, gender, occupation, age, marital status, education.

ii. Healthcare Service attributes

b Dependent Variables

Perceptions of Healthcare service users and service providers.

Tool Used For Analysis

The statistical tools applied for analysis of data included descriptive statistics, cross tabulation, arithmetic mean, Percentage, standard deviation, and Variance etc. The statistical method used for testing hypothesis like chi-square test which was used for testing first hypothesis, Kruskal-Wallis test, Man-Whitney test used for testing second hypothesis, Multiple Linear Regression used for testing hypothesis.

Hypotheses 

H01 : There is no significant difference in healthcare service-user’s perception with respect to demographics of consumers.

H11 : There is a significant difference in healthcare service-user’s perception with respect to demographics of consumers.

H02 : There is no significant association between healthcare service attributes and user’s perception.

H12 : There is a significant association between healthcare service attributes and user’s perception.

H03 : There is no significant impact of healthcare service attributes on the perception of healthcare service providers.

H13 : There is a significant impact of healthcare service attributes on the perception of healthcare service providers.

Sources of Data

Both the secondary and primary data sources are used.

Primary data: Both structured and semi-structured questionnaire method was used to collect the primary data. 

Secondary Data: The secondary data collected from the literature available, textbooks, online journals, reports, thesis and Research Papers.

Delimitations of the study

i. Among 33 districts of Rajasthan State, the study is confined only to Jhunjhunu District of Rajasthan state considering its inadequate public health infrastructure, worst Child Sex Ratio in the State despite highest rank in HDI (Human Development Index) and having highest male literacy in the State. 

ii. The study is limited to participants viz. service users and health care administrators at district level and block level and the professionals like doctors, nurses and local community leaders as service providers at CHC’s and PHC’s of selected district. 

iii. The study’s purview is limited to healthcare services only and for year 2019-20.

Findings and Conclusions

• The average population covered under SCs, PHCs and CHCs is comparatively less than the average of population covered in Rajasthan.

• Total Percentage of Villages having Sub-centres within Villages in Jhunjhunu (57.5) is higher than average percentage of Rajasthan(47.3).

• ANM residing in Sub Centre quarter in Jhunjhunu is remarkably lower than Rajasthan

• Majority of healthcare service user were aware about the health-centers in Jhunjhunu District, Rajasthan

• Majority of healthcare service user were of the opinion that Participation of Service Providers can improve the Performance of health-centers.

• A significant percentage of service Users were well aware about health-centers in Jhunjhunu District, Rajasthan.

• Most of the respondents considered their experiences at registration desk of health-centers, good or satisfactory.

• Most of the respondents considered the facilities to minimize the queue length at waiting room of clinics as inadequate.

• Only a small number of respondents considered the services provided by Doctors and paramedical staff as excellent.

• More than 80 per cent of respondents expressed their displeasure over the availability of ambulance.

• Most of the respondents were of the opinion that cost charge to the patient in OPD was reasonable.

• Most of the respondents considered the overall quality of health care centers as average.

• Most respondents agreed that nurses checked the vitals properly before the visit of doctor.

• A big majority of respondents showed a deep dissatisfaction over proper sanitary facilities, which include bathrooms available in health centers.

• Majority of respondents were not completely satisfied with the environment of health-center.

• Most of the healthcare providers asserted that hospital has issued health card in reducing the expenditure on health services.

• Most of the service providers asserted that there is requirement of better coordination between the concerned authorities.

• Most of the service providers vouched for efficient use of technology for better dissemination of information and timely feedback.

• Most of the service providers felt the need of better working environment.

Hypotheses testing

First Hypothesis H11 is partially accepted as it was found that there is a significant difference in health care service user's perception across gender and income, but the perception does not differ significantly across age, education and occupation.

Second Hypothesis H12 is completely accepted as all attributes of healthcare services found to have significant relationship with perception of service users.

Third hypothesis H13 is also accepted because all the attributes of healthcare services found to have positive impact on perception of healthcare service providers.

• This study tries to understand and measure the level of health system decentralisation and the perception of the community towards decentralization of health services and the participation of the PRIs members. 

The major findings and conclusions of research are as follows:

• Need to focus on awareness: The discussions with the PRI members and health officials reveal that there is a need to focus on the awareness of PRI members about their roles and responsibilities.

• Positive perception about decentralisation of health-care services: Both the service users and service providers are of the opinion that the decentralisation of health care system has resulted in better availability of health facilities at grass root level.

• Demographic variables are insignificant: Demographic factors like age, gender etc. not significant in effecting perception of service users.

• Quality of healthcare services: Quality of services and attitude of doctors and staff are most important factors impacting perception of service users.

• National Rural Health Mission (NRHM) provided a boost to decentralization of health care services:  This study also reveals that the process of empowering the local self-governments in decentralized health planning and program implementation had a boost under the National Rural Health Mission/ National Health Mission (NHM).

• More involvement of Panchayati Raj Institutions: PRIs are getting more involved in health planning and health service delivery.

• Need of more awareness among PRI members: The discussions with the PRI members and health officials reveal that there is a need to focus on the awareness of PRI members about their roles and responsibilities. Many elected representatives were unaware of their powers to improve the health facilities in their villages.

• Decentralisation of health system had a significant impact: It was observed that the health system decentralization has a positive impact on health services delivery at the grassroots level.

• Need of better coordination: It is observed there are many administrative problems at the ground level, which create difficulty in better coordination between the health department and PRIs. Wherever, local, informed and educated leadership was actively involved, a qualitative change can be seen in the functioning of rural health care services.

• Deficiencies of health-care system in Jhunjhunu: The study found from the trend analysis of health infrastructure in Jhunjhunu district that there are healthcare infrastructure deficiencies in the Jhunjhunu district. The number of PHCs has been significantly increased from 1995 to 2010, which implies that the Government of Rajasthan has made valuable efforts in creating sufficient number of PHCs and thereby reducing the ratio of medical institutions and the people. However, in case of sub-centers, it shows only a marginal increase which does not guarantee that the SCs serve in the decentralized areas of Jhunjhunu district.

• The health sector in Jhunjhunu district has been designed and organised primarily at three levels Viz. District, Block and village or peripheral levels. 

• Gap in user’s expectations and existing facilities in health centers: People expect better services, infrastructure, sanitation and test facilities. This is the serious concern of the public health delivery system at the decentralised level of Jhunjhunu district, Rajasthan.

• Need of improvement in quality of services in Primary Health Centers: It is important to note that large numbers of SCs are converted into the PHCs in order to fulfill the norms of the establishment of PHCs. 

• This led a situation where there are sufficient numbers of the PHCs according to the population norms but the quality of the PHCs is not up to the mark.

• Rural-Urban Drive: The results from the major health indicators like CDR, CBR and IMR are quite impressive at the territory level when compared to national level. However, the variations of health indicators across the rural-urban divides and regional levels are still significant. It implies that health indicators across rural-urban divides have marked declining trends but the gap has not been narrowing down in the Jhunjhunu district.

• The analysis infers that the health centers at the decentralized levels are not fully efficient in the territory, which is due to technical problems and ineffective allocative system of resources of the hospitals. There is an ardent need for improvement.

Suggestions and Policy Recommendations

Decentralisation and primary health care (PHC) approach is closely associated with principles of equity, community participation and inter-sectoral collaboration. It can be developed to achieve the target of “Health for all” and “Universal Health Coverage.” The study had extensively analysed the various factors influencing the perception of service users and service providers. Based on inferences drawn from current research following suggestions and recommendations can be made. 

• The discussions with the PRI members and health officials reveal that there is a need to focus on the awareness of PRI members about their roles and responsibilities.

• There is a need to institutionalize the regular joint meetings of health workers and PRIs for better coordination and successful implementation of health programs.

• There is also a need for more clarity about the roles and responsibilities required of the PRIs in the supervision of health services.

• There is an ardent need of involvement of local leadership to facilitate better coordination between the health department and PRIs.

• Standardisation of hospitals and improvement in quality of healthcare services need to be attended immediately in the territory. Due to the intangible nature of service, the quality of service delivering process is what determines customers’ impression about the service provider.

• There is a requirement of provision of better facilities to service providers. They also need a better conducive environment to work.

• The service provider should focus to address the problem areas as cited by the service users in the current study. There should be an effective mechanism to resolve grievances.

References

1. Rural Health Care System in India; 2012. Ministry of Health and Family Welfare, Government of India, New Delhi.

2. Health Vision 2025, Government of Rajasthan, Department of Medical Education

3. Bandar Noory, Sara A. Hassanain, Benedikte Victoria Lindskog, Asma Elsony & Gunnar AkselBjune, Exploring the consequences of decentralisation: has privatization of health services been the perceived effect of decentralization in Khartoum locality, Sudan? BMC Health Services Research volume 20, Article number: 669 (2020)

4. Narayana and Kurup, 2000, Decentralisation of the Health Care Sector in Kerala: Some Issues, 2000, IDEAS/RePEc

5. Manoj Kumar Raut, T. S. Shekhar Decentralization of Health Care Systems: Findings from Odisha and Gujarat, India, Journal of Health Management, Volume: 15 issue: 2, page(s): 235-251  https://doi.org/10.1177/0972063413489007

6. Thomas Bossert, Mukosha Bona Chitah, Diana Bowser Decentralization in Zambia: resource allocation and district performance, Health Policy Plan; 18(4):357-69, doi: 10.1093/heapol/czg044.

7. Devendra b Gupta, Anil Gumber 2008, External Assistance To The Health Sector And Its Contributions: Problems And Prognosis Researchgate.net

8. Behar, A., & Kumar, Y. (2002). Decentralisation in Madhya Pradesh, India: from Panchayati Raj to Gram Swaraj (1995 to 2001).

9. Kaur M, Prinja S, Singh PK, Kumar R. Decentralization of health services in India: barriers and facilitating factors. WHO South-East Asia J Public Health 2012; 94-104.