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