Decentralization of health services in India: barriers and facilitating factors.

BACKGROUND In India, the process of decentralization of health services started taking shape in the mid-1990s. Systemic reforms envisaged delegation of administrative and financial responsibilities at district level for management of health-care institutions in 23 states of India in 1999. Subsequently, some of these reforms became part of the National Rural Health Mission (NRHM) launched in 2005. This study aims to document the process of decentralization in health services with special reference to the barriers and facilitating factors encountered during formulation and implementation of reform policies. METHODS Secondary data were reviewed, health facilities were observed, and semi-structured interviews of the key actors involved in decentralization were carried out in Haryana (India). RESULTS Political and bureaucratic commitment to reforms was found to be the most important facilitating factor. Orientation training on decentralized 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. Significant improvement in the public health infrastructure was observed. From 2004 to 2008, the state government increased the budget of health sector by nearly 60%. Frequent changes in the top administration at the state level hampered the decentralization process. Districts having a dynamic administrative leadership implemented decentralization more effectively than the rest. CONCLUSIONS Decentralization of financial resources has improved the functioning of health services to some extent. Major policy decisions on decentralization of human resource management, increase in financial allocation, and greater involvement of community in decision-making are required.