How do local participatory governance reforms influence equitable access to health services? The role of Panchayati Raj Institutions in Kerala, India
Lead Research Organisation:
Public Health Foundation of India
Department Name: Research
Abstract
The Public Health Foundation of India, the London School of Hygiene & Tropical Medicine and the National Health Systems Resource Centre (NHSRC) of the Ministry of Health & Family Welfare, Government of India will come together to explore how local participatory governance (LPG) reforms influence equitable access to health services. LPG of social sectors (such as health or education) entails decentralised planning and oversight of services, undertaken through participatory and deliberative processes involving local communities and stakeholders. The salutary impact of LPG on health access is widely acknowledged, however the actual pathways of such change are not well researched, and the role of context in influencing these pathways also remains poorly understood.
This research aims to address these gaps in the knowledge, using the case study of Panchayati Raj Institution (PRI) reforms in Kerala state, India. In India, LPG is synonymous with PRIs - locally elected bodies operating at village, sub-district and district levels with financial and administrative powers over social services including health care. Kerala is an example of extensively implemented PRI reform, and hence offers a best-practices scenario for clear identification of contexts and pathways of influence.
Our conceptual model is informed by global evidence suggesting that LPG reforms have influences on multiple governance arenas, including politics, civil society and public administration. Resultant improvements in political accountability, community empowerment and health system responsiveness can act synergistically to enhance equitable access to health care. These broad putative pathways of influence provide a basic framework for more detailed empirical investigation.
Specific objectives:
1. Explicate the pathways through which institutions of local participatory governance (LPG) influence access to health care for the poor and vulnerable, through a case study of the Panchayati Raj Institution (PRI) local governance system in Kerala state, India
2. Understand the policy context of implementation of Kerala's PRI reforms for LPG in health care
3. Explore and strengthen the application of innovative Health Policy & Systems Research (HPSR) approaches in exploring LPG and its influence on equitable access to health care across different low & middle-income country (LMIC) settings
The study will engage innovative HPSR approaches drawing on the social sciences, including realist enquiry and actor-focused approaches to policy implementation. Qualitative methodology, including in-depth interviews and focus groups conducted in four districts, will help access the lived experiences of involved policy actors (representing PRI committees, service users, civil society and health systems). Data will be analyzed using the "framework" approach for policy research developed by the UK National Centre for Social Research, combining pre-determined and emerging themes.
Data collection strategies will be revised iteratively as the study progresses, an approach that will be fundamental to innovating with HPSR methods. Towards the end of the study, we will convene a workshop to share preliminary findings and develop a larger proposal. The larger proposal will examine the role of LPG mechanisms in facilitating greater access to services in several Indian states and countries in sub-Saharan Africa.
The study emerges from needs expressed by policymakers in India, for deeper understanding of how to support LPG for health, and will fulfill that need. The integral role of NHSRC in the study will facilitate policy uptake of findings. The findings will support accountability and greater citizen participation in decisions that affect them - and ultimately greater access to healthcare for marginalized people, across LMIC settings. The study will also contribute to conceptual innovation and methods in the field of HPSR, and help strengthen UK-India research collaborations.
This research aims to address these gaps in the knowledge, using the case study of Panchayati Raj Institution (PRI) reforms in Kerala state, India. In India, LPG is synonymous with PRIs - locally elected bodies operating at village, sub-district and district levels with financial and administrative powers over social services including health care. Kerala is an example of extensively implemented PRI reform, and hence offers a best-practices scenario for clear identification of contexts and pathways of influence.
Our conceptual model is informed by global evidence suggesting that LPG reforms have influences on multiple governance arenas, including politics, civil society and public administration. Resultant improvements in political accountability, community empowerment and health system responsiveness can act synergistically to enhance equitable access to health care. These broad putative pathways of influence provide a basic framework for more detailed empirical investigation.
Specific objectives:
1. Explicate the pathways through which institutions of local participatory governance (LPG) influence access to health care for the poor and vulnerable, through a case study of the Panchayati Raj Institution (PRI) local governance system in Kerala state, India
2. Understand the policy context of implementation of Kerala's PRI reforms for LPG in health care
3. Explore and strengthen the application of innovative Health Policy & Systems Research (HPSR) approaches in exploring LPG and its influence on equitable access to health care across different low & middle-income country (LMIC) settings
The study will engage innovative HPSR approaches drawing on the social sciences, including realist enquiry and actor-focused approaches to policy implementation. Qualitative methodology, including in-depth interviews and focus groups conducted in four districts, will help access the lived experiences of involved policy actors (representing PRI committees, service users, civil society and health systems). Data will be analyzed using the "framework" approach for policy research developed by the UK National Centre for Social Research, combining pre-determined and emerging themes.
Data collection strategies will be revised iteratively as the study progresses, an approach that will be fundamental to innovating with HPSR methods. Towards the end of the study, we will convene a workshop to share preliminary findings and develop a larger proposal. The larger proposal will examine the role of LPG mechanisms in facilitating greater access to services in several Indian states and countries in sub-Saharan Africa.
The study emerges from needs expressed by policymakers in India, for deeper understanding of how to support LPG for health, and will fulfill that need. The integral role of NHSRC in the study will facilitate policy uptake of findings. The findings will support accountability and greater citizen participation in decisions that affect them - and ultimately greater access to healthcare for marginalized people, across LMIC settings. The study will also contribute to conceptual innovation and methods in the field of HPSR, and help strengthen UK-India research collaborations.
Technical Summary
The objectives of the proposed project are as follows:
1. Explicate the pathways through which institutions of local participatory governance (LPG) influence access to health care for the poor and vulnerable, through a case study of the Panchayati Raj Institution (PRI) local governance system in Kerala state, India
2. Understand the policy context of implementation of Kerala's Panchayati Raj Institutional (PRI) reforms for LPG in health care
3. Explore and strengthen the application of innovative Health Policy & Systems Research (HPSR) approaches in exploring LPG and its influence on equitable access to health care across different low and middle-income country settings
The study conceptual model is informed by global evidence suggesting that LPG reforms have influence on multiple governance arenas, including politics, civil society and public administration (Bossert & Beauvais 2002). Resultant improvements in political accountability, community empowerment and health system responsiveness can then lead synergistically to a beneficial effect on equitable access to health care (Kalk & Fleischer 2004, Bossert et al 2003). These broad putative pathways of influence provide a basic framework for more detailed empirical investigation.
The study will engage innovative HPSR approaches drawing from the social sciences, including realist enquiry (Pawson & Tilley 2002) and actor-focused approaches to policy implementation (Barrett & Fudge 1981). Qualitative methodology, including in-depth interviews (estim. n=50) and focus groups (estim. n=8) conducted in four districts, will help access the lived experiences of involved policy actors. Study participants (representing PRI committees, service users, politicians, civil society and health systems) will be selected on maximum variability principles (Silverman 2000). Data will be analyzed using the "framework" approach for policy research developed by the UK National Centre for Social Research (Ritchie & Spencer 1994).
1. Explicate the pathways through which institutions of local participatory governance (LPG) influence access to health care for the poor and vulnerable, through a case study of the Panchayati Raj Institution (PRI) local governance system in Kerala state, India
2. Understand the policy context of implementation of Kerala's Panchayati Raj Institutional (PRI) reforms for LPG in health care
3. Explore and strengthen the application of innovative Health Policy & Systems Research (HPSR) approaches in exploring LPG and its influence on equitable access to health care across different low and middle-income country settings
The study conceptual model is informed by global evidence suggesting that LPG reforms have influence on multiple governance arenas, including politics, civil society and public administration (Bossert & Beauvais 2002). Resultant improvements in political accountability, community empowerment and health system responsiveness can then lead synergistically to a beneficial effect on equitable access to health care (Kalk & Fleischer 2004, Bossert et al 2003). These broad putative pathways of influence provide a basic framework for more detailed empirical investigation.
The study will engage innovative HPSR approaches drawing from the social sciences, including realist enquiry (Pawson & Tilley 2002) and actor-focused approaches to policy implementation (Barrett & Fudge 1981). Qualitative methodology, including in-depth interviews (estim. n=50) and focus groups (estim. n=8) conducted in four districts, will help access the lived experiences of involved policy actors. Study participants (representing PRI committees, service users, politicians, civil society and health systems) will be selected on maximum variability principles (Silverman 2000). Data will be analyzed using the "framework" approach for policy research developed by the UK National Centre for Social Research (Ritchie & Spencer 1994).
Planned Impact
This research will have a positive social impact by supporting accountability and greater citizen participation in the decisions that affect them-and will ultimately support greater access to healthcare for marginalized people. Currently, the relationship between local participatory governance (LPG) and access to health care is not well understood. Through studying Kerala's extensively implemented LPG, we will able to understand how Panchayati Raj Institution (PRI) reforms can support greater political accountability, health system responsiveness and grassroots community empowerment, which in turn facilitate improved and more equitable health care access.
This research will ultimately contribute to building and supporting governance systems that facilitate better access to healthcare for vulnerable people in low- and middle-income countries. Additional beneficiaries of this research, who will mediate the pathway of impact from this research to improved access to healthcare for the most vulnerable, are frontline healthcare workers in the public sector in India, Indian citizens seeking to participate in local governance, elected representatives in the Panchayati Raj system, health policy researchers and policy makers in Kerala, across India and in many international contexts.
Within India, this research will fulfill a need, expressed by government policy-makers, for deeper understandings of how to support LPG for health. The integral involvement of the National Health Systems Resource Centre, the technical support organization for the government's flagship National Health Mission, will amplify the impact of the study. The proposal is developed in direct response to NHSRC's interest in policy that will support health systems decentralization through pre-existing PRI structures. There is particularly acute interest within government, in finding out how Kerala's PRI reforms are influencing healthcare access, so that they these lessons may be transferred to other states through the National Health Mission policy and programmes. We will share our findings from Kerala with representatives from the Ministries of Health & Family Welfare and Panchayati Raj of the Government of India, as well as with key civil society actors working on governance and health issues. Findings will critically inform and guide policy development to strengthen LPG systems and make them more effective.
The benefits of this research will be extended beyond the specific country context in which it is undertaken. Lessons from Kerala can also be applied to other low and middle-income country (LMIC) settings to support better access to healthcare through LPG. By explicating pathways of influence of LPG on access to quality health services, we will contribute to the knowledge around how LPG can contribute to health outcomes, and facilitate thinking and action on LPG policy in diverse country settings. The Principal Investigator (KS) and lead investigator from the LSHTM (JH) are co-convenors of SHaPeS, a thematic group of the Health Systems Global society that focuses on sharing and developing social science innovations in HPSR. We plan to engage the SHaPeS membership in active discussion and dissemination of study findings - the membership spans 50-plus countries, and as such presents an effective medium for disseminating knowledge. As elaborated in the communications plan, we also plan to produce peer-reviewed publications for high-impact academic journals.
This research will ultimately contribute to building and supporting governance systems that facilitate better access to healthcare for vulnerable people in low- and middle-income countries. Additional beneficiaries of this research, who will mediate the pathway of impact from this research to improved access to healthcare for the most vulnerable, are frontline healthcare workers in the public sector in India, Indian citizens seeking to participate in local governance, elected representatives in the Panchayati Raj system, health policy researchers and policy makers in Kerala, across India and in many international contexts.
Within India, this research will fulfill a need, expressed by government policy-makers, for deeper understandings of how to support LPG for health. The integral involvement of the National Health Systems Resource Centre, the technical support organization for the government's flagship National Health Mission, will amplify the impact of the study. The proposal is developed in direct response to NHSRC's interest in policy that will support health systems decentralization through pre-existing PRI structures. There is particularly acute interest within government, in finding out how Kerala's PRI reforms are influencing healthcare access, so that they these lessons may be transferred to other states through the National Health Mission policy and programmes. We will share our findings from Kerala with representatives from the Ministries of Health & Family Welfare and Panchayati Raj of the Government of India, as well as with key civil society actors working on governance and health issues. Findings will critically inform and guide policy development to strengthen LPG systems and make them more effective.
The benefits of this research will be extended beyond the specific country context in which it is undertaken. Lessons from Kerala can also be applied to other low and middle-income country (LMIC) settings to support better access to healthcare through LPG. By explicating pathways of influence of LPG on access to quality health services, we will contribute to the knowledge around how LPG can contribute to health outcomes, and facilitate thinking and action on LPG policy in diverse country settings. The Principal Investigator (KS) and lead investigator from the LSHTM (JH) are co-convenors of SHaPeS, a thematic group of the Health Systems Global society that focuses on sharing and developing social science innovations in HPSR. We plan to engage the SHaPeS membership in active discussion and dissemination of study findings - the membership spans 50-plus countries, and as such presents an effective medium for disseminating knowledge. As elaborated in the communications plan, we also plan to produce peer-reviewed publications for high-impact academic journals.
| Description | Dissemination meeting at Vancouver on the sidelines of the Health Systems Global Symposium in Vancouver. |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | A dissemination activity was organised on the sidelines of the Health Systems Global Symposium in Vancouver with an objective to share the methodology and preliminary findings from the study. The idea was also to showcase to the research community how to go about using Health Policy and Systems research (HPSR) methods to research such areas as local participatory governance (LPG) and its influences on health. Another activity was to evolve a Research framework for studying pathways of influences of LPG on health which could be applicable to varied contexts. Some preliminary inputs were collected on this and further discussions are going on |
| Year(s) Of Engagement Activity | 2016 |
| Description | Paper presentation at the 3rd International Conference on Public Policy (ICPP3) June 28-30, 2017 - Singapore |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | Nearly 60 people attended the paper presentation by a team member Ms. Shinjini Mondal titled "How do local participatory governance reforms influence equitable access to health services? The role of Panchayat Raj Institutions(PRI) in Kerala, India" at the 3rd International Conference on Public Policy (ICPP3) June 28-30, 2017 - Singapore. This was an international audience and the paper was well received followed by discussions. There were also further follow-up with researchers on the methodology used for the study. |
| Year(s) Of Engagement Activity | 2017 |
| Description | Poster presentation at the Health Systems Global Symposium in Vancouver |
| Form Of Engagement Activity | Participation in an activity, workshop or similar |
| Part Of Official Scheme? | No |
| Geographic Reach | International |
| Primary Audience | Professional Practitioners |
| Results and Impact | An abstract submitted titled 'Power and politics of the health professionals in decentralised and devolved local participatory governance: a study of Panchayats and health services in Kerala, India' was submitted to the Fourth Symposium of the Health Systems Global at Vancouver. The abstract was selected to be presented as a poster during the Symposium in November 2016. The lead investigator participated in the Symposium and presented the poster to the participating policymakers, researchers, students and other members of the Health Systems Global community. There was willingness expressed by other researchers from LMIC countries to collaborate for further research in this area. Another abstract from the same project 'How Institutionalized Local Participatory Governance Facilitated Emergence of New Platforms for Community Participation in Health Care. A case study from Kerala, India" also got selected for an e-poster at the symposium but could not be presented due to some logistical reasons. |
| Year(s) Of Engagement Activity | 2016 |