Results and Cross-Cutting Issues
79
Box 3.1 (continued)
mirror the public service rules. A key difference is that many employees of these hospitals are not civil servants (except some officials on deputation). Rather, they are hired by the facilities. In this respect, often the medical college hospitals under municipal corporations, though not created as autonomous institutions, also mimic some of the attributes of the autonomous institutions as they are selfmanaged and not subject to a statewide transfer policy administered by a state directorate. In general, the autonomous institutions, by virtue of their distinct legal status, have a high degree of decision-making authority on the management of inputs, including human resources, use of resources, financial management, procurement of goods and services, and service mix. Rogi Kalyan Samiti (RKS). The National Rural Health Mission (NRHM), the federal government’s flagship health program, has taken up the mantle of creating and supporting governance bodies for public health facilities called Rogi Kalyan Samiti’s (RKS, patient welfare committees), a nomenclature and concept that was initiated in the state of Madhya Pradesh in the 1990s. The RKSs are registered societies constituted within each public health facility (district hospital, community health center, and primary health center) and receive “untied funds” (grants from the central government without any earmarking of how funds should be spent). In addition, they are empowered to raise their own resources at the facility level. The aim of these committees is to increase participation from people’s representatives and improve the health facility, using its own resources raised from user charges, grants, and other sources. MOHFW sees RKSs as the foundation for broadening decision-making autonomy and fostering management improvements in public hospitals. A recent assessment of 12 RKSs in Madhya Pradesh found that they augmented their revenues from local sources.Though limited in terms of the total budget, these funds were used to address pressing needs (Sadanandan and Shiv Kumar 2006). However, the researchers found no impact of RKSs on management practices, monitoring, or facility utilization.
effect, hospital managers have little decision-making authority over inputs, including hiring, firing, rewarding, or disciplining of staff, while accountabilities for performance are diffuse at best. This model of public hospital service delivery, often referred to as direct management, is known for low efficiency and quality (Preker and Harding 2003; La Forgia and Couttolenc 2008).