Making districts ‘aspire’ for better health
The Aspirational Districts Programme aims to delegate powers and involve local communities to improve health delivery
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.