Mak­ing dis­tricts ‘aspire’ for bet­ter health

The As­pi­ra­tional Dis­tricts Pro­gramme aims to del­e­gate pow­ers and in­volve lo­cal com­mu­ni­ties to im­prove health de­liv­ery

The Hindu Business Line - - THINK - URVASHI PRASAD

In­dia has made con­sid­er­able progress on var­i­ous health and nu­tri­tion pa­ram­e­ters, how­ever, sig­nif­i­cant in­ter- and in­tra-State dis­par­i­ties per­sist. For in­stance, while the per­cent­age of in­sti­tu­tional de­liv­er­ies has in­creased from 38.7 per cent in 200506 to 78.9 per cent in 2015-16 at the na­tional level, it varies from 99.9 per cent in Puducherry to 32.8 per cent in Na­ga­land. Sim­i­lar stark dif­fer­ences ex­ist be­tween dis­tricts in the coun­try.

In this con­text, the launch of the As­pi­ra­tional Dis­tricts Pro­gramme (ADP) by the govern­ment is a vi­tal step. One of the key goals of the pro­gramme is to catal­yse a sig­nif­i­cant change in the health and nu­tri­tion sta­tus of 115 “lag­ging” dis­tricts. So, why is this ini­tia­tive likely to suc­ceed where sev­eral oth­ers failed?

States as driv­ers of change

The pro­gramme seeks to in­stil a greater sense of own­er­ship among States by po­si­tion­ing them as change agents re­spon­si­ble for trans­form­ing the se­lected dis­tricts. Cen­tral Prab­hari Of­fi­cers and State Nodal Of­fi­cers have been ap­pointed for pro­vid­ing the nec­es­sary sup­port to Dis­trict Col­lec­tors who are at the heart of this highly am­bi­tious ef­fort.

In ad­di­tion to greater own­er­ship, more pow­ers are also be­ing vested in the dis­trict ad­min­is­tra­tion for fill­ing up va­cant posts in govern­ment fa­cil­i­ties like An­gan­wadi cen­tres. This is a sig­nif­i­cant de­par­ture from the past and the in­tent is clear — those who are clos­est to the ground should be em­pow­ered to take de­ci­sions with­out hav­ing to al­ways wait for or­ders from au­thor­i­ties at higher lev­els.

In fact, there is con­sid­er­able ev­i­dence from the around the world to show that de­volv­ing re­spon­si­bil­i­ties to sub-na­tional and lower lev­els of govern­ment can lead to an in­crease in the util­i­sa­tion of health ser­vices, bet­ter gover­nance of health fa­cil­i­ties in the pub­lic sec­tor as well as a re­duc­tion in ill­ness.

Be­yond govt ac­tion

The per­cep­tion that the govern­ment is the primary ac­tor re­spon­si­ble for In­dia’s trans­for­ma­tion is deeply en­trenched. The ADP aims to change that and make de­vel­op­ment a mass move­ment by in­volv­ing the pri­vate sec­tor, civil so­ci­ety and leg­is­la­tors. In the area of health and nu­tri­tion, for ex­am­ple, Pi­ra­mal Foun­da­tion will be pro­vid­ing sup­port on lead­er­ship de­vel­op­ment, change man­age­ment, tech­nol­ogy in­te­gra­tion and im­ple­ment­ing in­no­va­tive prac­tices. One of the Foun­da­tion’s arms, Pi­ra­mal Swasthya has already un­der­taken a base­line sur­vey of health fa­cil­i­ties in 25 dis­tricts across seven States to iden­tify the gap ar­eas.

The ADP also aims to en­gage lo­cal com­mu­ni­ties ex­ten­sively in the change process as part­ners and mul­ti­pli­ers of health-re­lated ac­tiv­i­ties in­stead of mere tar­gets. This is es­pe­cially im­por­tant in sec­tors like health and nu­tri­tion where im­prove­ments are at least par­tially de­pen­dent on the be­hav­iours and ac­tions of com­mu­ni­ties. The suc­cess of the health and nu­tri­tion ef­fort in sev­eral coun­tries in­clud­ing Thai­land, Peru, Brazil and Zim­babwe has been at­trib­uted at least partly to their abil­ity to in­volve lo­cal com­mu­ni­ties and en­able them to make bet­ter lifestyle choices.

Repli­cat­ing best prac­tices

No spe­cific fi­nan­cial al­lo­ca­tion has been made for this pro­gramme. In­stead, the in­tent is to con­verge the multiple schemes of the Cen­tral and State gov­ern­ments and chan­nelise the funds for this pro­gramme. In­vest­ing ad­di­tional re­sources is of­ten not the so­lu­tion. It is about spend­ing the money more smartly for achiev­ing bet­ter out­comes.

An Em­pow­ered Com­mit­tee has been no­ti­fied un­der the con­venor­ship of the CEO of NITI Aayog for en­sur­ing con­ver­gence and ad­dress­ing the spe­cific con­cerns brought out by Prab­hari Of­fi­cers. Such an ap­proach is es­pe­cially crit­i­cal in the ar­eas of health and nu­tri­tion which have multiple and in­ter­re­lated de­ter­mi­nants in­clud­ing ac­cess to safe drink­ing wa­ter and san­i­ta­tion, gen­der equity as well as ed­u­ca­tional sta­tus, among oth­ers.

The ADP will also em­pha­sise the scal­ing up of in­no­va­tive and im­pact­ful ser­vice de­liv­ery ap­proaches across States. Sev­eral States and dis­tricts have adopted in­no­va­tive ap­proaches for home-based coun­selling and track­ing of preg­nant and lac­tat­ing mothers as well as chil­dren un­der three years. Su­poshan vol­un­teers were as­signed in Ch­hat­tis­garh to look after a group of un­der­nour­ished chil­dren at the com­mu­nity-level. Sim­i­larly, in Bi­har, fe­male vol­un­teers were given the re­spon­si­bil­ity of coun­selling and link­ing fam­i­lies with the In­te­grated Child De­vel­op­ment Ser­vices pro­gramme and re­lated health ser­vices.

In the ab­sence of a clear mech­a­nism for shar­ing such prac­tices, their im­ple­men­ta­tion has re­mained lim­ited to a par­tic­u­lar State or even to a few dis­tricts within the State.

Real-time data mon­i­tor­ing

We have been lack­ing a com­pre­hen­sive data sys­tem that can pro­vide in­for­ma­tion about health The last mile

and nu­tri­tion in­di­ca­tors on a reg­u­lar ba­sis. The pe­ri­od­ic­ity, con­tent and cov­er­age of the cur­rent Na­tional Fam­ily Health Sur­vey and Na­tional Sam­ple Sur­vey Organisation house­hold sur­veys on health seek­ing be­hav­iour has left a lot to be de­sired, mak­ing it dif­fi­cult to iden­tify the spe­cific gap ar­eas for which pol­icy in­ter­ven­tions are re­quired.

Un­der this pro­gramme, key per­for­mance in­di­ca­tors have been iden­ti­fied on which progress will be mon­i­tored on a real-time ba­sis. This will en­able govern­ment of­fi­cials to make the req­ui­site course cor­rec­tions in pro­gramme im­ple­men­ta­tion. It will also spur com­pe­ti­tion among dis­tricts by al­low­ing them to reg­u­larly as­sess their po­si­tion visà-vis other as­pi­ra­tional dis­tricts as well as the best dis­trict in the coun­try.

A base­line rank­ing of all as­pi­ra­tional dis­tricts has been re­leased re­cently by NITI Aayog based on pub­lished data of 49 in­di­ca­tors. Go­ing for­ward, the dis­tricts will be ranked on the ba­sis of im­prove­ments from the base­line and this in­for­ma­tion will be made avail­able in the pub­lic do­main. This could also be the first step to­wards as­sess­ing the per­for­mance of civil ser­vants on the ba­sis of data-driven per­for­mance met­rics. For young of­fi­cers like Dis­trict Col­lec­tors it will also serve as an in­cen­tive to go be­yond their call of duty as they will be able to show tan­gi­ble re­sults dur­ing their ten­ure it­self.

The ADP has un­doubt­edly changed the de­vel­op­ment nar­ra­tive by re­fer­ring to these dis­tricts as as­pi­ra­tional in­stead of back­ward. By en­sur­ing that no dis­trict in the coun­try lags be­hind, the pro­gramme can pro­vide much needed mo­men­tum to In­dia’s quest for dra­mat­i­cally im­prov­ing its po­si­tion in the UNDP’s Hu­man De­vel­op­ment In­dex (cur­rently ranked 131 out of 188 na­tions) as well as achiev­ing its com­mit­ments un­der the Sus­tain­able De­vel­op­ment Goals.

The writer is Pub­lic Pol­icy Spe­cial­ist, Of­fice of Vice-Chair­man, NITI Aayog. The views ex­pressed are per­sonal.

Health de­liv­ery

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