Decentralization in India: Two Sides of the Coin

One of the key issues discussed at HSR2014 was the issue of improving community health worker (CHW) performance in the context of decentralized health systems.

Decentralization in India: Two Sides of the Coin

By Shreelata Rao Seshadri, Professor, Azim Premji University, Bangalore, India

Within the overall theme of people-centered health systems, one of the key issues discussed at the recent Global Symposium on Health Systems Research was the issue of improving community health worker (CHW) performance in the context of decentralized health systems. This issue is particularly relevant to India, where decentralization in the health sector has been a critical strategy to transform health system functioning and substantially improve health outcomes. Decentralization has followed two distinct paths: (i) politically, it has been through elected representatives at the state, district and village levels; and (ii) programmatic devolution has taken place from the state to the district level, and finally down to the CHW in each village. However, despite an enabling legal framework, India continues to struggle with making decentralization/devolution an effective vehicle for people-centered, responsive health systems (1, 2, 3). The question is: what is the potential for CHWs to engage with elected representatives at the village level to contribute to agreed common goals? Ongoing research on decentralization and decision space conducted in Karnataka, India reveals the following:

  • Differing measures of success: CHWs are very closely aligned to their program objectives, and see their role as fulfilling measurable program outputs. The elected representatives, on the other hand, see the delivery of highly visible basic amenities such as drinking water and sanitation are seen as more politically valuable.
  • Unequal power: CHWs are and indeed perceive themselves to be the lowest rung in the ladder of power in the health sector. They are not empowered to take independent action even in the case of emergencies, and have few expectations of support from the elected representatives. Elected representatives, on the other hand, see themselves in the “drivers’ seat” and decide if and when they will offer their help and support to the CHWs.
  • Gender: CHWs are usually young women, easily dominated by older, male elected representatives. Even with regard to serious operational issues, they are reluctant to raise them, with a sense that it would be impertinent for them to do so.
  • Poor capacity of CHWs, which further shifts the balance of power in favour of the elected representatives. Their technical expertise is poor; and they are poorly oriented to the community they serve.

There are spaces where open dialogue between CHWs and elected representatives is possible: (i) in times of crisis, they have worked together to respond to urgent community needs, such as malaria spraying; (ii) sometimes programmes mandate such collaboration. For example, CHWs were required to conduct the beneficiary survey for implementation of the household toilet scheme; and (iii) village level bodies have been set up for joint decision-making by CHWs and elected representatives, which need to be fully activated with capacity building and funds.

Effective decentralization is not only about delegating “funds, functions and functionaries;”(4)  it is also about recognizing community needs and responding to those needs effectively and in full measure. Currently, the voice of the community is drowned out in the sea of lowered expectations.


  1. Chakraborthy P, L Chakraborthy, S Mitra, S Bose, A Mukherjee. Decetralization in Education and Health Service Delivery: Evidence from India. National Institute of Public Finance and Policy, New Delhi; 2011.
  2. Mahal, A., Srivastava, V., & Sanan, D. (2000). Decentralization and public sector delivery of health and education services: The Indian experience (No. 20). ZEF discussion papers on development policy
  3.  Varatharajan, D., Thankappan, R., & Jayapalan, S. (2004). Assessing the performance of primary health centres under decentralized government in Kerala, India. Health Policy and Planning, 19(1), 41-51.
  4. Report of the Task Force on Panchayati Raj Institutions. Planning Commission, New Delhi; December 2001.

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