RTI for better services in the health sector.

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CITIZEN'S RIGHT TO INFORMATION ABOUTTHE PUBLIC HEALTH MANAGEMENT IN INDIA Sri Dhirendra Krishna - Retired IA & AS, India.INTRODUCTION1. Government is committed to increase the expenditure on public health from 0.9% of GDP to 2-3 % of G.D.P. by 2012. Such growth implies improved schemes of Public Health Management and an exponential increase in related activities during the 11th. Five-Year Plan. Financial Management Systems also have to improve, to cope with basic requirements of effective utilization of resources earmarked for improving public health in India. Over the years a paradoxical situation has emerged where although the country suffers from inadequate public health facility, implementing agencies are unable to utilize the budget allocations. This problem has to be effectively resolved, if we have to reach the higher level of expenditure on public health.

2. Some of the major issues of public concern regarding qualitative improvement of public health administration are summarized below: • 57% children are borne in India without medical support. • Quality of public health system, which covers only 20% of the population, is very poor. Private health care is expensive and in many families this leads to debt-trap. • Although the per-capita expenditure on public health (Rs. 200 per year) is about the lowest in the world, health departments cannot spend entire budget allocation and there are savings. • Capacity-building to reach expenditure level of 2-3% of GDP from 0.9% of GDP is a major issue of concern. This would involve long-term projects, during the 11th Plan. As public health is a State Subject, long-term commitment from State Governments is essential to meet the goal of reaching 2-3% of GDP by 2012.• Another issue of concern is to ensure that the increase

in expenditure on public health results in qualitative improvements. Effective control measures to avoid waste of public money are essential, while planning almost three-fold increase in expenditure on public health in the 11th. Plan. SYSTEMIC CORRECTIONS IN THE HEALTH CARE SYSTEM FOR EFFECTIVE UTILISATION OF INCREASED FINANCIAL OUTLAYS3. Several policy directions are likely to lead to improvement in financial management of the health sector: • Structural changes and institutional strengthening at Centre, State and District levels, flowing from the National Rural Health Mission launched in April 2005: such as decentralization, transparency, amalgamation of multifarious schemes at the implementation level, result orientation, administrative commitment to reforms and public participation.• Advent of "Outcome Budget" indicates a shift of focus from expenditure to outcome. Apart from laying "outcome

Budget" document to Parliament and State legislatures, this also implies greater stress on outcome, in the internal control and appraisal systems.• E-governance initiatives by the Government of India and State Governments, which would result in a quantum jump in the use of Information Communication Technology (ICT). Government is committed to provide wide spread computer connectivity under the National e-Governance Plan (NeGP). This would also facilitate flow on information regarding financial and operational performance between the implementing agencies and monitoring agencies at the Central and State level.4. Implementation of the Right To Information Act 2005 would enforce greater public accountability. It will also result in greater citizen's involvement in governance, by enabling them to raise issues of concern with the public authorities. This development has a special significance in public health

management, as highly decentralized public health professionals will have to meet public demands and the citizens empowered by the Right To Information Act 2005 would question them.5. There is close conceptual synergy in aforesaid directions, which are likely to result in far-reaching changes. They are likely to enforce service orientation in public health management. Public health related activities of the Central and State Governments would have to meet higher public expectations. Officials at the cutting edge level would face greater accountability to the beneficiaries and would have to satisfy their "clients." They have to be prepared for greater transparency in their operations and financial managements. 6. Citizens can use Right To Information Act to question any activities and therefore officials at all levels would have to be prepared for this paradigm shift. RTI Act confers democratic

privileges to the citizens to pose questions to public authorities at all levels. In practice, public health authorities at the cutting edge level and implementing agencies are likely to be directly questioned by the citizens regarding implementation of policies and programs of the Government. In short, apart from accountability to their seniors, officers handling Government policies and programs relating to public health may face greater direct accountability to the citizens who derive benefits of public health expenditure by the Government. The questions raised by the citizens could be a more intensive form of "audit" than the issues raised by C & AG or Internal Auditors as the citizens may use RTI Act to question the outcome. Citizens who raise issues under RTI Act may be better conversant with the ground realities; as a result there will be greater public accountability down the line. 7. The solution to

problems in financial management of the health sector should be found in procedural changes, in view of aforesaid developments as these are leading to unprecedented increase in public accountability, use of ICT can change the systems regarding flow of operational as well as financial information and transparency in working would lead to greater public participation in health care management. Greater degree of public accountability would arise from Right To Information Act 2005 may lead to public debate on issues of public interest, such as the issues enumerated in Para 2 above. Traditionally, C & AG and Internal Audit largely comments upon procedural issues; questions raised by public under the RTI Act may result in raising issues relating to outcome of the activities. CHANGES IN PUBLIC HEALTH MANAGEMENT SYSTEM, WITH THE ADVENT OF RIGHT TO INFORMATION ACT 20058. RTI Act 2005 imposes several new

obligations on the Central and State Governments. Authorities and Societies at Centre, State and District Level, created under the National Rural Health Mission are also governed by the Right To information Act 2005. Similarly, authorities under RCH II program and Disease Control Programme are also covered under the RTI Act. Thereby citizens can access all accounting, operational and administrative records at Central, State, District, Block or Village levels. It is essential to improve the record keeping at all levels. 9. According to Section 4 (1) (a): "Every public authority shall maintain all its records duly catalogued and indexed in a manner and form which facilitates the right to information under this Act and ensure that all records that are appropriate to be computerized are, within a reasonable time subject to availability of resources, computerized and connected through a network all over the country

on different systems, so that access to such records is facilitated. " 10. Implementation of aforesaid provision of RTI Act would not only facilitate the access to information by the citizens, it would also simplify the access to information from the implementing agencies by the Health and Family Welfare Departments at Centre and State Headquarters. While implementing aforesaid provision of RTI Act, accounting and reporting systems should be computerized, so that administrative reporting of financial and operational. 11. Section 4(2) of the RTI Act requires every public authority to take steps to provide information of public interest to the citizens at regular intervals through various means of communication, including internet, so that public has minimum resort to the use of RTI Act, to obtain information. Accordingly, authorities have to identify the activities of public interest being performed under

their domain and evolve effective mechanism for disclosing the information. The practical application of this enactment has to gradually evolve and it has to improve over the years as public appetite for information regarding health sector becomes more pronounced. CITIZENS RIGHT TO QUESTION THE PUBLIC HEALTH PROGRAMS EMPOWERED BY RIGHT TO INFORMATION ACT. 12. RTI Act enables citizens to raise issues regarding efficiency and performance of public health programs. Experience in practical application of RTI Act shows the citizens have already started raising searching questions regarding performance of public authorities in several field. Authorities at all level of public health administration should be prepared to answer searching questions. Ideally, it may be preferable to suo-moto disclose the relevant information regarding public health on web sites, to avoid citizen's resort to the RTI Act. Few

indicative areas are where citizens can use RTI Act to question public health programs are summarized below. • Government's has committed that increase of expenditure on public health from 0.9% of GDP to 2-3% during the next five years. How is this being translated into practice in District / Block / Village?• What is the commitment of State Governments regarding increase in their budget on Public health during 11th.Plan? What are the instructions by State Governments to District level authorities regarding planning to reach this level by 2012?• What are the shortcomings in healthcare services and what is being done to improve? How are these activities reflected in the Budget/ Plan documents?• What are the shortcomings in basic reproductive and child health services? What is the trend of Infant Mortality Rate and Maternal Mortality Rate at District/ Block / Village level? What are the plans

for improvements in the 11th? Plan under the RCH schemes? • How is the National Population Policy and National Population Policy being implemented at the District / Block / Village level? Are financial allocations adequate to meet the targets?• What are the physical targets and progress regarding creating cadre of ASHA in the District / Block /Village levels? Are financial provisions and administrative arrangements adequate to meet these objectives? • What are the plans for improving hospitals in the District? Is there any long term planning that is reflected in annual budgets and 11th. Plan? • What is the progress in decentralization of public health administration to the District level? What are the guidelines framed by State Government? • What are the instructions by Central and State Governments regarding "inter-sectoral convergence" at the District level? How is this reflected in

budget and planning documents? • What is the Government policy regarding private sector participation in improving public health? What are the plans for involving Panchayati Raj Institutions and Non-Government Organizations at District / Block? Village level? What are the terms and condition for public-private- partnership? Is there adequate budget provisions or this purpose? • Have Integrated District Societies/ Hospital Management Societies been formed? What is the Constitution, etc. of these Societies? Who are the Members and State Public Information Officer of these Societies? Do the State budget/plans reflect devolution of funds to these societies? Minutes of meeting of these societies and the action plan formulated by them may be kindly disclosed. • What are the administrative linkages for the implementation of RCH II and NRHM, at District / Block / Village level? How are the centrally sponsored

Disease Control Programs linked with NRHM? • What are the contingency plans for meeting the disaster situations and epidemics? How are the citizens being prepared for such contingencies and how are the citizens involved in preventive measures? Is there adequate financial provision to meet such contingencies?• What would existing institutions like AIMS, etc expend their activities during the next five years? Institutions are required to plan their expansion, in line with overall policy regarding increase in public health expenditure from 0.9% to the level of 2-3% of GDP in the next five years. Have the existing institutions formulated their development plans for next five years? What are the plans for establishing new Institutions of research, training and medical treatment during the 11 th. Plan? Plan? Plan?SUGGESTIONS FOR THE NGOs WORKING IN HEALTH SECTOR 1. In a vast country like India, public

health programs would be largely managed by Central and State Governments. Private sector steps in to earn profit in commercially viable fields. NGOs supplement the Government initiatives in public health, depending upon the financial resources they can raise and the social service by volunteers.2. In a highly decentralized set-up, it is not easy for the Government to control their far-flung administrative units. Inefficiency and corruption is common in a complex situation, where it is difficult to exercise effective administrative control.3. Efficient and effective use of public money by grass root authorities dealing with public health is a matter of serious public concern. RTI Act enables the citizens to demand better services.4. NGOs and public-spirited- citizens can raise issues of concern with public health authorities at the grass root. They can demand copy of public records and raise issues at

political level and with higher administrative authorities, where inefficiency, waste of public money and corruption is visible to them, as the beneficiary of Government sponsored public health programs.5. Public pressure for demanding better services from the Government would have to be a sustained process. This requires educating the volunteers working in the health sector regarding RTI Act. They may need help them in drafting RTI applications. "I am, and have been for years a confirmed anti-vaccinationist. I have not the least doubt in my mind that vaccination is a filthy process that is harmful in the end" - Mahatma Gandhi (Koren Publications Inc.)

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