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Improving Health System and Strengthening NRHM through
Community Action Experiences, Lessons Learnt, Challenges and Way
Forward
Advisory Group on Community Action (AGCA)
Secretariat Population Foundation of India
September 11, 2012
Outline
1. The accountability framework under NRHM
2. Community action under NRHM - experiences
and gains
3. Scaling up community action in next phase of
NRHM and way forward
Accountability Framework under NRHM
A three pronged process: • community based monitoring,
• external surveys and
• routine program monitoring
Communitization of the health institutions • Prominent display of information on funds received,
medicines in stock, health right entitlements
Public reports on Health at the State and district levels to report progress to the community
Community Action in NRHM
• Mechanism to improve accountability and enable better delivery of services
– Builds community awareness on health entitlements
– Provides a platform for community feedback and dialogue with service providers
– Initiates corrective action and planning with community engagement
– Leads to improved coverage and accessibility of health services
In essence brings ‘public’ back into public health
Advisory Group on Community Action (AGCA)
Group of civil society experts constituted by the
MOHFW in 2005 with Population Foundation of India (PFI) as the Secretariat
Mandate :
Advise on developing community partnership and ownership for the Mission
Provide feedback based on ground realities, to inform policy decisions
Develop new models of Community Action and recommend for further adoption/extension to the national / state governments
First phase of Community Monitoring ( 2007-09)
9 States, 36 districts, 1620 villages
• Assam
• Chhattisgarh
• Jharkhand
• Karnataka
• Madhya Pradesh
• Maharashtra
• Orissa
• Rajasthan
• Tamil Nadu
Rajasthan
Gujarat
Maharashtra
Karnataka
Tamil
Nadu
Andhra
Pradesh
Madhya
Pradesh
Uttar
Pradesh
Uttaranchal
Orissa
Chhattisgarh
W Bengal
Bihar
Jharkhand
Assam Nagaland
Manipur
Community action under NRHM - experiences and gains
Story of change - Maharashtra
Outcomes of Community Action
In Jamshet village, Thane district, construction of a
sub-center was incomplete for over two years
Village health committee members discussed the issue in a series of Gram Sabha meetings and in Block monitoring committee meetings
A Large group of community members went to the sub-centre to ‘complete’ the construction through ‘Shramdaan’
The sub-center building got completed and is fully functional
Improvement in PHC services and utilisation, Maharashtra , 4 districts
0
10
20
30
40
50
Increase in ThaneCBMP PHCs OPD
Increase in Thane district PHCs OPD
0
10
20
30
40
50
17%
34%
4438
19
75
12.5 12.50
10
20
30
40
50
60
70
80
Round I Round IV
Improvement in PHC services from Round I to Round IV
Good Satisfactory Bad0
20
40
60
80
100
120
District PHC average CBM PHCs
48
101
Increase in deliveries in Thane from 2007-08 to 2009-10
0
10
20
30
40
50
Increase in ThaneCBMP PHCs OPD
Increase in Thane district PHCs OPD
0
10
20
30
40
50
17%
34%
Outcomes- Village health services in Rajasthan
(Sep 2008-Oct 2009)
36
1
9
36
0
8
0
5
10
15
20
25
30
35
40
First round Second Round
District Alwar
44
5
1
24
0
16
0
5
10
15
20
25
30
35
40
45
50
First round Second Round
District Chittorgarh
23
4
18
26
2
15
0
5
10
15
20
25
30
First round Second Round
District Jodhpur
23
4
18
26
2
15
0
5
10
15
20
25
30
First round Second Round
District Udaipur
Poor
Average
Good
Nu
mb
er
of
Vil
lag
es
Stories of Change: Tamil Nadu
In Mothakal Panchayat, Vellore, during the health planning exercise the Mobile Medical Unit route was redrawn to include one remote hamlet
Laligam PHC in Dharmapuri district did not have water supply. The Panchayat President made sure that water connection was provided immediately.
Outcomes -Experiences from states
Enhanced trust and improved interaction between provider and community
Improvement in service delivery - ANC, PNC, immunization,
Responsiveness of provider to community needs
Improved provider attitude and behavior
Community based inputs in planning and action Active involvement of PRI members in planning and
functioning of health facilities
Local and need based planning, special groups / remote areas
Appropriate planning and utilization of untied funds at VHSC, PHC and CHC
Outcomes…
Reduction in out of pocket expenditure Reducing demands for informal payments
Ensuring timely and full payments of Janani Surksha Yojana
Significant reduction on outside prescription
How did this happen? Trained VHSC and RKS
Community awareness on health entitlements
Display of Citizen’s charter and service guarantees
Collection of information and sharing of report cards reflecting community experiences of health services ; based on this development of village health plans
Active multi stakeholder Monitoring and Planning Committees at PHC, Block and District levels
Engagement with providers based on community evidence – periodic public dialogue (Jan Samvad)
Participatory committees for Feedback & Action
State Planning & Monitoring Committee
District Monitoring & Planning Committee
Block Monitoring & Planning Committee
PHC Monitoring & Planning
Committee
Village Health Committee
Composition of
Community Based
Planning and Monitoring
(CBMP) committees
Feed
back &
Rep
ort
s
• Public Health Officials • Delegates from previous level committees • Elected representatives • CBO/NGO representatives
Members of Community filling the report card
Community level sharing of health report cards
Panchayat level planning meeting
Review of community report cards
A public dialogue (Jan Samwad) in progress
A public dialogue(Jan Samwad) in progress
Challenges at state level
• Capacity constraints to institutionalize and scale up CBMP
• Delayed fund flow, tedious reporting requirements , interruption of activities
• Mechanisms to address systemic gaps emerging from CBMP process and feeding into the planning process
- vacancies/ posting, procurement and distribution of drugs and supplies, training of health functionaries
• Institutionalizing minimum service guarantees, grievance redressal mechanisms
Way Forward
Promoting Community Action A Proposed Road Map for States
• Orientation of Program Managers/Designated Nodal Officers
• Development of three year state level plans • Identification of Nodal Agencies to facilitate
implementation in new states • Strengthening capacities of PRI members and VHSNCs • Reconstitute/strengthen RKS for better facility
management • Inputs from CBMP for developing the district PIPs • Institutionalise and publicise grievance redressal
mechanism – Display of Citizen’s charter, minimum service guarantees and
mechanisms for corrective action – Ombudsperson/ombudsman
Pre requisites for Scaling Up
• Adaptation of the model without losing effectiveness
• State capacities to implement CBMP
• Presence and capacity of NGOs/ CBOs
• Building upon existing structures: ASHA, VHSNC, PRI (SIRD & other training mechanisms)
• Grievance redressal mechanisms
• Adequacy and sustainability of funding
• Flexibility in administration rules and regulations
• Ownership at all levels
Engagement of PRI’s in NRHM
In some areas, as members of VHSNC, PRI members are mostly engaged at the village/panchayat level only: - Organize/ support health camps, mobilize women for
services in VHND
- Monitor health services and plan use of village untied funds.
Uneven progress in engaging PRI under NRHM - Lack of institutional modalities and clear guidelines on
participation from Ministry of Rural Development
-Variable capacity to take on planning and monitoring functions
- Cognizance of the role of PRI in the health system
Some measures to strengthen PRI engagement
Define and strengthen role of PRIs in monitoring and supporting NRHM implementation
Build capacity of PRI members on health and its social determinants
in training curriculum of (SIRD) review of current state curriculum and incorporating
changes with inputs from AGCA
Facilitation of village health plans by PRIs and endorsement through the Gram/Ward Sabha
Some measures to strengthen PRI engagement
Mentoring on participatory planning, monitoring, including social audits (like NREGA
Social Audit Cell in Andhra Pradesh)
Inclusion of PRI members in Rogi Kalyan Samities and District Health Society/ Health Mission
Motivating Gram Panchayats - NRHM Awards for best performing Panchayats
Proposed Role of AGCA
Develop guidelines and training materials
Develop communication material
Strengthen capacities of State nodal officers and institutions
Support in designing grievance redressal mechanism
Periodic review of progress on community action
Undertake rapid assessment on status of community action- Functioning of VHSC, RKS, Grievance Redressal etc
Thank You
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