national dissemination meeting community monitoring under
TRANSCRIPT
National Dissemination Meeting
Community monitoring under – National Rural Health Mission (NRHM) June 16, 2010
A Report
Conducted by
Centre for Health and Social Justice
National Rural Health Mission - GOI
Population Foundation Of India
At
India International Center (IIC) 40, Max Muller Marg
Lodhi Estate, New Delhi 110003
Report Prepared By; Sunita Singh and Deepti Morang Edited by; Ms Elisa Parija
Content: Objective of the Meeting Session One: Introducing Community monitoring Session Two: How Community monitoring has Supported Achievement of NRHM Goals Session Three: Empowering Communities to Stimulate Demand and Accountability Session Four: Community monitoring : Partnership Challenges GO- NGO - Community
Annexure: Annexure I - Agenda of meeting Annexure II - List of Participants Annexure III- Power Point Presentations
4
Background of the Meeting Community monitoring (Community Action) has been seen as an important component of both communitisation
processes as well as the monitoring mechanisms of National Rural Health Mission (NRHM). The Advisory Group
on Community Action (AGCA) had been involved in developing the operating methodology for community
monitoring and supported and supervised the implementation of community monitoring across nine states, 35
districts and over 1600 villages during the period 2007 – 09. The entire process was a partnership between
government at all levels and NGOs as facilitating partners. On one hand, nine state-level nodal agencies, district and
block level NGOs worked in partnership with the State Mission Directorate, District Program Management Units
(DPMUs) as well as with Medical Officers and health workers, on the other hand they empowered Village Health
and Sanitation Committees (VHSCs) to conduct community monitoring exercises, prepare village level and facility
level report cards and share them at Jan Samvads (Public Sharing) to identify gaps and plan future action. Changes
have been reported in both the functioning of health facilities, as well as overall uptake and utilisation of public
services through this process. In the year 2010 – 2011, the process of community monitoring was incorporated into
the State Programme Implementation Plans (PIP) of nearly all the states.
A dissemination meeting was organized in order to share the results and process of the first phase of community
monitoring widely among all stakeholders, especially in those states where this process has not implemented yet
and who are responsible for the expanded roll-out and implementation, . The dissemination meeting provided an
opportunity for direct interaction between those who are responsible for implementation (but do not as yet have a
clear knowledge of the implementation process) with those who have been implementing community monitoring
over the last two years. The final report on Community monitoring was distributed along with a short film
depicting the outcome of community monitoring across nine states in the dissemination meeting. The meeting was
hosted by the AGCA National Secretariat PFI (Population Foundation of India) and CHSJ (Centre for Health
and Social Justice).
Objectives of the meeting-
1. To share the implementation process, results and outcomes of community monitoring process with relevant
stakeholders from different states.
2. To enable stakeholders from states that were not part of the first phase to learn about community monitoring
process and from different implementation partners.
3. To share a consolidated report of the community monitoring process that summarises the processes, outcomes,
observations and recommendations of an external review process.
4. To facilitate dialogue and interaction between participants/stakeholders from states where the process has taken
place and states where the process has to take place for sharing resources and lessons learnt. .
6
Session One Introducing Community monitoring
Timings: 10:00 AM – 11:20AM Chair: Mr P.K.Pradhan, Mission Director (NRHM) Co-Chair: Prof Ranjit Roy Chudhary Welcome – Mr A R Nanda, Convenor, AGCA Presenters Community monitoring Processes– Dr Abhijit Das Member AGCA Presentation on Review of First Phase – S. Ramanathan Member Community monitoring Review Team Discussion Closing Remarks by Chairperson __________________________________________________
Welcome by Mr. Nanda: - Convener, AGCA & Representative National Secretariat under NRHM –
Population Foundation of India
Mr. A R Nanda; Executive Director, PFI formally welcomed the participants, resource persons, representatives
from various states, international donor agencies and bilateral and multilateral agencies and members of civil society
to the meeting. He further welcomed and invited Mr. Puneet Kansal, Director NRHM, Dr. Tarun Seem, Head,
Health System Support Unit; PHFI (Public Health Foundation of India) then Mission Director, Mr. S Ramanathan,
member Review Team and Dr. Abhijit Das, member of AGCA and Director CHSJ. He thanked the civil society
organizations, development partners for giving their input time-to-time during the process.
Mr Nanda said that the concept of Community Action/Communitisation is central to the NRHM that was taken up
as part of the communitisation process which has now become “Community Planning and Monitoring.” There are
600, 000 villages in India and we hope that in all these villages the community-led plan for villages will be initiated
and monitored by the community through the VHSCs or with other groups in every village, said Mr Nanda adding
that it would help in realizing the “Health for All” concept in the Indian Health System.
7
Releasing of National Report on Community Monitoring “Reviving Hopes Realising Rights” From left; S Ramanathan, Dr Abhijit Das, Dr Tarun Seem, Mr Puneet Kunsal, Mr Nanda
Community monitoring Processes– Dr Abhijit Das- Member AGCA & Co-secretariat for Community
Monitoring under NRHM (CHSJ)
Dr Abhijit Das said that it is a great opportunity for him as it brings to culmination a two-year long but fulfilling
process of community monitoring. He said that although the National dissemination of the process is delayed, it is
taking place at a very opportune time because the first phase of community monitoring took place in a very limited
sphere. Moreover, the uniqueness of this process was that the entire process was conceived and implemented
through NGO partnership which was a unique partnership between government and civil society organizations.
The community monitoring took place across nine states, 36 districts, 315 PHCs (Primary Health Centres) and 1620
villages and the experiences varied from state to state. He further said that though this is not very large-scale in
comparison to the Country, it is a large-scale collaborative project as it involved at least a hundred partners.
Dr Das said that although community monitoring process was driven from the Centre it was meant to actually
empower the communities in a bottom-up manner. The Advisory Group on Community Action (AGCA) was
involved in conceptualization and provided technical support through the National Secretariat across nine states.
Each of the nine state formed State level Community monitoring and Mentoring groups which comprised of civil
8
society organizations and government departmental representatives who have oversight in that particular state. The
state nodal agency anchored community monitoring in their respective states and adapted the process to the needs
and realities of the state. The adaptation was essential at the state level since nine states represented a variety of
locales in terms of high focus, none high focus and North Eastern states. Speaking on institutional mechanism he
said that there were districts and block implementing organization at the district and block levels which worked with
providers, civil society groups at different level like VHSCs, district and block level monitoring and planning
committees responsible for executing the monitoring process. Dr Das hoped that the process would be taken
forward as provisions existed in various state PIPs and that this process would energize the bottom-up owning of
the health services and demand generation for various improvements that are included within NRHM.
Later, the film “Reviving Hopes Realising Rights” was shown to the participants to develop an understanding of
the process and ground-level realities.
CD cover of Film Reviving Hopes Realising Right
Review of Pilot Phase of Community monitoring - An Overview; Mr. S. Ramanathan – Member Review
Team Community monitoring
Mr. Ramanathan started his presentation by stating that the earlier sessions along with the film provided an
overview of the Community monitoring process in nine states. He informed that he was part of the Team which
reviewed the pilot phase of Community monitoring and though it has been over a year since the review, there have
been several changes, modifications and improvements subsequent to review in the way Community monitoring is
being undertaken in various states. In TamilNadu for instance, it has picked up and now we are looking at more
villages under Community monitoring.
The main objectives of the review were:
• To review whether objectives of community monitoring process were fulfilled in the states.
• To identify key learnings and challenges for each state
• To highlight successful innovations tried out in the states
• To identify lessons for up-scaling
The review was conducted in all the nine states through consultants and NHSRC (reviewed in three states). Apart
from the document review, field visits and various meetings were carried out. The team prepared the state report
and later the state reports were consolidated into a national report. The review looked at institutional mechanism,
processes, program management, relation to the other communitisation process, outcome of the process and
potentiality for sustainability and scaling-up and recommendations. Mr Ramanathan highlighted some key findings
of the review;
1) Significant gain due to community monitoring process; nearly 2000 VHSCs formed either new or recast in
many states. In Tamil Nadu for instance, several VHSCs were recast.
2) Report cards prepared in nearly all the VHSCs
3) Jan Samwads were held and a cycle of monitoring was conducted.
4) Process led to very active engagement with community & Health Department and responses received from
health system too.
5) Passion and commitment evident among stakeholders were very evident. High level of volunteerism and
crusade like approach.
6) Communitisation process of NRHM significantly strengthened due to community monitoring process.
7) Requirement of more support for strengthening communitisation process.
10
8) The process brought community to centre-stage, VHSCs had identity and voice and characterised by equity
principles like strong presence of women and SC/ST in the VHSCs. It created space for negotiation with
Health Department for reaching excluded groups which the film clearly highlights. Significantly, it also led
to better understanding of the community of their entitlements and rights.
9) Jan Samwad (public hearing) was very key process, which lead to the responsiveness of the health
department. It led to an engagement between the community and health department.
10) Better connect between community and frontline service providers. The review found in many places that
community often didn’t know what was the role of the frontline service providers.
11) Better understanding of constraints faced by frontline service providers. In many instances, community
came forward to help frontline providers which are a significant gain as a result of the process.
12) Potential to move people back into the health system.
13) Increased expectations by the community from Health Department
14) Potential to improve health and nutrition outcomes of the people.
Key observation from processes & tools:
1) Community Mobilization: One of the key processes which included village meetings, home visits,
especially among the socially excluded groups. It was a major strategy and there were many innovations.
There were variations across the states the way in which community was involved.
2) Different levels of Committees: The VHSCs formed were significant social capital though they need
major nurturing. Committees that were formed above the village level at the PHC level and CHC level, were
somehow not very active compared to the VHSCs which more robust and active. The involvement of PRI
members and various people at higher level committees were negligible. Even the involvement of Health
Department above the village level committee was very low and there is hardly any review by the PHC and
CHC level committees.
3) Institutional Mechanism: Institutional mechanisms were formed at the national and state level. The major
support came from the central ministry. The National Secretariat AGCA played a significant role and some
states also made additional arrangements to support the process.
4) Report Cards: The community prepared the report cards and it helped them to learn about their
entitlement and rights but the review found that the tools were extremely complex and the review suggests
that tools need to be simplified. In subsequent scale-up process in states like Maharashtra, Rajasthan and
Karnataka tools have been simplified. Repeated visits were required to fill the tools and VHSCs needed
more support to understand the tools, colour codes and rankings. The review found that reporting on
11
equipment and various other issues at PHC level and higher needed more trainings and high level of
knowledge which the community understandably didn’t have. The sharing of report card was very helpful
which lead to village level planning that was an important step as a result of this process.
5) Jan Samvad – It was a major component, which strengthened accountability. It helped in improving
accessibility and quality of health services. Most often, the Health Department responded to the issues
raised during the Jan Samvad. The review finds that the process was led more by the NGOs and not by the
community and the Health Department didn’t seem to be keen to be accountable to the NGOs. Thus, the
review feels that the process gradually need to shift from NGO-led process to community-led process.
There is a need for follow-up action subsequent to the Jan Samvads.
6) Capacity building- Good quality training modules and materials were prepared at the national level. A
large resource pool of trainers have been created which is a major resource. But the review found that since
time was short there was a greater support needed. The team also found that participation of government
functionary in the training was very minimal.
7) Sustainability: The review found that sustainability was a concern as the team found mixed responses from
the state governments. Some of the state governments were keen to implement the process but some
weren’t, some had included it in the PIP and some of them were yet to do. Mr Ramanathan said that at the
time of review some of the non-pilot states were considering to include community monitoring in the PIP
which was an encouraging response.
Mr Ramnatahan also presented the recommendations put forward by the review team which are as follows:
1) The GoI and NGOs should continue to support the process and it should continue to build ownership in
the pilot states and initiate ownership building in new states.
2) The process needs to be anchored in larger communitisation manner in pilot states under existing
institutional arrangement of NRHM.
3) Capacity building of NGOs which were a significant resource through this process should be taken-up
further.
4) Community monitoring need to be linked to village health plans.
5) ASHAs need to get involved in planning and monitoring.
6) Report cards and other tools need to be modified substantially.
7) An incremental approach need to be adopted where issues for monitoring should be enhanced gradually.
The community may not be able to monitor too many issues.
12
8) Jan Samwad should move gradually to a community-led process. During the review, the process was on
ground for seven to eight months only. The review team emphasised that the period of implemantion of the
process need to be considered
Discussion-Question/Answer Session:
Manmohan Sharma-VHA-Punjab- He said that the initiative of Community monitoring under the NRHM varies
from state to state. A state-wise assessment would reveal that states like Orissa and West Bengal would have
different realities from states like Himachal, Punjab and Haryana. Due to the ground level hurdles some states are
lagging behind while in some states Dalits and other marginalized groups utilise services from PHC. . He further
said that people’s involvement in Punjab is very poor in the health programmes as they tend to seek health care
from private sector. He expressed concern at the under-utilization of government health services and said that in
order to tackle such problems we need to look at local realities, socio-culture and environment issues. He expressed
interest to learn about other states’ expriences.
Leuit Goswami - Rural Volunteers Services, Assam – He talked about the problems/ challenges that they faced
during the community monitoring process in Dhemaji District of Assam. The first problem they faced was in
terms of involvement of PRIs because they are engaged in every local level committee and have little time for
community monitoring .
The other challenge was repeated natural calamities as Dhemaji gets flooded and cut-off from the rest of the
districts for four to five months. People tend to migrate or get displaced due to which it is hard to work with the
same people/community.
Vanita Nayak Mukherjee, Program Officer, FORD Foundation, New Delhi - She said that as report cards
are very powerful accountability tools, designing of same is critical to the suucess of the communitisation process.
She raised the following questions:
1) How report cards were designed?
2) Were the communities involved?
3) Was field testing conducted?
4) How to take this process forward?
Dr Anthony, Director, State Health Resource Centre, Chattisgarh - He questioned about the role of VHSCs in
dissemination of monitoring report cards and similarly PHC-level committees and Rogi Kalyan Samitees? He
13
further raised concerns about Jan Samvad organized under the community monitoring process as a one-time affair.
He opined that Jan Samvads were sometimes organized with much fanfare with not much of constructive
discussion. Usually they are marked by arguments and accusational thus making it very negative, he said. This leads
to frustration among health staff as the community confrontats and accuses them. He informed that Chattisgarh
now has regular Jan Samwads at the PHC and CHC levels instead of a single annual event done otherwise . It has
helped in initiating a participatory approach where both the community and Health Department make efforts to
address the problems.
Dr. Ajay Khare, Madhya Pradesh Vigyan Sabha, M.P- Dr. Khare also shared his concern with regard to the
involvement of PRI representatives in the Community monitoring process. He said that the State has observed
good PRI engagement at the grassroots level. But PRI participation was not encouraging at the block and janpad
levels because of their prior engagements, interests and priorities. Speaking on the Health Departments’ gains and
interests he said that the BMOs (Block Medical Officers) found this process very useful and they took several
corrective steps on the basis of findings revealed through community monitoring . But at the higher level it became
a burden for providers to fulfill demands of the community. He added that Civil Society Organizations have used
community monitoring as an opportunity to empower communities.
Sudarsan Das, Human Development Foundation (HDF), Orissa - Mr. Das said that PRI representatives
facilitated the Jan Samwad process in several places of Orissa and there was increasing level of PRI participation
too.
Dr Mohanraju, State Health and Family Welfare, -Karnataka - Taking about the method and repercussion of
Jan Samvad, Dr Raju said that the public hearings were only helpful in accusing, responding, raising voices, loosing
temper and getting frustrated. The Karnataka Govt. has taken innovative steps of observing the “Community
Health Day” for every three months, which was done in a few districts last year. But from this year, it would be
observed in all the PHCs every six months. This process could be gradually replace the Jan Samvads. He informed
that the Deputy Commissioner of Karnataka visits the villages and conducts Jan Samwads where not only issues
related to health are raised but other issues are also taken up and concurrently gets resolved.
Dr. Saraswati Swain, AGCA member, Orissa: She responded to Mr. Manmohan Sharma’s question and said that
one has to bear in mind that community action/community monitoring or community empowerment is not an easy
process, especially for those people who are thrown down the line since many decades. We are talking about poor
14
people, Dalits and Tribals whom we had sidelined totally from the society thus we should not expect an immediate
action from these group and shouldn’t expect them to take lead and respond in a mature manner.
Talking about the Punjab health utilization pattern she said since Punjab is a rich state people think that it is better
to go to the private health sector. But looking at public health facilities we find that government facilities all over the
country are not well-equipped and not responsive to the health needs of the people, especially the poor.
Dr.Abhijit Das, Director & AGCA member, CHSJ New Delhi: Talking about the notion of Community
monitoring he said it is seen in the NRHM conceptual framework as a triad process which consist of Health
Management Information System (HMIS), periodic surveys and Community monitoring . He showed concern these
three components were developing on their own and that he is unaware of any triangulation happening at the
Ministry level though it was the original focus. He said that issues of conflict and confrontations were positioned as
a part of planning and monitoring within the rubric of community action. The question is whether the planning
should be done annually or should be done regularly. If the planning is done on a regular manner and in sync with
the village health planning and district PIP then only it would be able to contribute to the overall progress.
Secondly, it should be positioned gradually in a mature manner as there is a part of frustration in the community
due to lack of timely delivery of services and community tends to get docile. He further spoke about governance
issue and said that we were replaying Colonial kind governance where community pleads to the government about
services. Better service delivery will bring down frustration among community which will lead to constructive
engagement of community. Community monitoring is a democratic process of empowerment in which the deprived
slowly becomes competent partner with the service providers. He said that the entire process of community
monitoring was funded only for 11 months and to expect complete success from conception to a mature
engagement between civil society and public service is unrealistic. The entire first phase took 18 months to
complete the activities but unfortunately in many states are not able to continue the activities, but fortunately in
many states it continued and many states has included community monitoring in their PIP. He added that in order
to take the process further one has to keep up faith and perseverance as it had tremendous potential to deal with
problems of privatization and cost of care.
Responding to Vanita’s question whether the Report Cards were field tested and the process of developing the tool
he said that a Technical Advisory Group (TAG) was set-up for developing the tool, which included members of the
AGCA and public health/ community monitoring experts. This was kind of a field test as people brought their
experiences from field to develop such tools. The tool was seen as a template that people could modify and . While
in some states the tools were modified and information edited other states followed the same templates. He said the
15
conceptual part of community monitoring was done voluntarily and rigorous support from technical group would
have been benefited the project.
Dr. Saraswati Swain supported the argument of Dr. Das and said that the first phase was a pilot phase which
should be seen as a large-scale field test.
Dr Later, Dr. Das introduced the national report “Reviewing Hopes Realising Rights” which is divided into three
sections —overall process, state experiences and review of the process.
Mr. Nanda invited Dr. Tarun Seem to give his view on this process. Dr. Seem associated with the NRHM since
the last four years was actively involved with the Community Action group. He completed his tenure with
Government of India as Director of the NRHM.
Dr. Tarun Seem, PHFI, New Delhi - Regarding additional support for Community monitoring he said that
people are keen for more funding and for longer duration. However, this was the closest that Government of India
ever could come to support and initiate an activity for community empowerment and service accountability. He said
that NRHM is an evolving process and it is an outcome of evolution from the Community Need Health
Assessment approach, RCH -1 and 2 which shifted from RCH to health sector reforms that somewhere has the
seed of community empowerment.
Talking about efficient service delivery, he said that it comprises of planning, management, proper implementation
and well-developed infrastructure. When public services are not available, both rich and poor would approach
private health facilities. It is essential to have public hospitals in remote areas and most importantly, with guaranteed
availability of doctors, paramedic and medicines, which people would like to approach when they are sick.
About the significance of Community monitoring he said that the opportunity has been used for grievance redressal
in case of denial of health services to the people. With Community monitoring, NRHM has brought about a very
substantial change in system performance and rights realization. The progress made under community monitoring
across nine states vary as all the states have not moved together- some of the states have made very substantial
improvement in service delivery and incidentally in those very states the monitoring process of AGCA has done
very well too. Speaking on Jan Sunwai/Jan Samvad he said that they are acrimonial and they tend to work best
when the system listens to them, If the system is not concerned people may simply go on accusing without much
16
of a difference. Quoting from news papers which depicted acrimony very quickly turned to self realization where a
doctor said that “if I would not have come to this Jan Samvad, I would have never known about this,”
He further highlighted the importance of community monitoring and said that several issues have emerged from
the process . it is a measurable though sometimes it may be an inefficient and complex tool and may not address all
component failing to capture all good things that states have undertaken, it still has immense merit and needs to be
nurtured. He clarified that community monitoring is a long, gestation period initiative and since social change by
definition takes time, this process would also take time. He emphasized the role of civil society organization and
said that the change has to be lead by the NGOs that play a critical role in Community monitoring /Community
Planning initiative.
Dr. Seem also touched upon the issue of PIP formation and said that PIPs for 2010-11 are proofs of local level
planning. He informed that tools could be changed and Jan Samvads could be replaced with periodic reviews based
on Karnataka model. Within the PIPs internalized, the ethos of allowing the community or forum to demand their
needs, offer their resistance and compensating their gaps has been incorporated in this year PIP. He acknowledged
the support of in participating closely in the PIP building process this year.
Dr Seem raised the following issues & questions
1) Responsibility of monitoring the PIP? Does the AGCA has plans for that?
2) Responsibility of further developing the tools?
3) Mentoring the Committees formed under community monitoring? It has been noted in the past that the
committees at the grassroots level work well but as we go up there seem to be a vacuum in the middle-rung. The
top level state committees and village committees work well but committees at the PHC and CHC level may not
work. How to ensure that the knowledge chain along the system is retained and who would mentor the various
committees?
4) Funding for the mentoring process
Dr. Seem concluded by saying that since he has been closely associated with the community monitoring process, he
is a strong defender of it and seems immense potential to improve the system. We may not like it, we may not
contribute to it but at the end it has a very visible contribution to the system, he said. This is a very robust process
where one has optimism and keep encouraging the grassroots level workers who are the real heroes of the process,
he added.
Mr. Nanda then requested Mr. Puneet Kansal, Mission Director NRHM to speak few words regarding the
process. Mr. Kansal shared his experiences from the field before the NRHM and said that earlier health was the
17
responsibility of PRIs and only few issues, like education, availability of teachers and doctors, drinking water, road
and electricity etc were largely discussed. Community’s involvement was not that strong in raising health issues as
the villagers were unsure about the genuineness of the problem. The involvement of civil society and community in
program implementation has broken this barrier and people are now coming up to ask such questions. Talking
about the Karnataka model, he said that it worked because of good governance as it takes care of issues.
He touched upon the importance of Community monitoring and said that it is a good concept and the NRHM is
committed to the communitisation process upon which the success of NRHM is based. He clarified that
community monitoring is nowhere in conflict with VHSCs and RKSs because they are at different level and
community monitoring is at the most basic level. He also talked about the importance of community awareness
around health entitlements stating that they were the foundation of NRHM and expressed the need to further
strengthen the same consecutively to attain desired results.
In the end, he appreciated the National Report brought out by the National Secretariat Iand said that it would be an
useful tool for strengthening the process. Mr. Nanda extended his thanks to Mr. Puneet Kunsal, Dr Tarun Seem
Mr. Ramanathan for their valuable contribution. .
Session Two How Community monitoring has Supported
Achievement of NRHM Goals Timings: 11:35 to 1:00
Chair : Dr Ramesh Chandra Sagar, MD NRHM, Maharashtra, Co-Chair - Indu Capoor, AGCA member Presenters: Dr. Abhay Shukla; Member AGCA and SATHI-CEHAT - Maharashtra, Increasing accountability among providers and improving access and quality of services – an experience of Maharashtra Dr. Mohanraju, Addl. Director - Project Director (RCH) Karnataka; How Community Monitoring has supported achievement of NRHM goals in Karnataka Mr. Sudarsan Das; HDF and State Mentoring Group member - Orissa – Promoting local level planning by providing flexibility at state and community level; an experience of community monitoring in Orissa Discussion Closing Remarks by Chair
_____________________________________
Dr Ramesh Chandra Sagar welcomed all the presenters and spoke about his experience. He expressed keen interest
in Community monitoring and invited the first presenter for the presentation.
Community based monitoring of Health services in Maharashtra – A process to improve access,
accountability and quality of health services - Dr. Abhay Shukla
Dr. Abhay Shukla started his presentation by introducing the report that the State had brought our recently on the
community monitoring process. He said that his presentation was based on three aspects of the process in
Maharashtra over the last three years and would focus on the changes and innovations taken place in community
monitoring . He said that there were two –ways, one is privatization of health sector and the other is the public
health system which needs to be made functional and accountable. Five districts were taken up in Maharashtra for
the pilot phase: Amravati, Nandurbar, Osmanabad, Pune and Thane. During the fist phase, 15 block-level
committees, 45 PHC-level committees, and 225 Village Health Water Supply, Nutrition and Sanitation Committees
(this committee has broader role than health) had been established.
Dr. Abhay Shukla spoke in detail about various innovations that took place in Maharashtra, the most important
being the pictorial tools. as they The tools developed were developed at the National level were complicated due to
19
which the state developed set of pictorial tools. This innovation took place due to demand for simpler and easily
understandable tools from tribal districts like Thane and Nandurbar as villagers found the centrally developed tools
complicated. Each of the questions were modified and converted into pictures in the pictorial tools. The grading
was done on the basis of 'Full Roti' (means very good), 'Half Roti' (partially satisfactory) and 'No Roti' (very poor).
The innovation helped the state in data collection in a more effective way.
The second innovation was in the report card which was converted into a poster and was put up in several places
in the village so that everybody could participate in report card preparation activities.
The third innovation that the State undertook was in the preparation of Village Health Calendar which was
developed keeping in view regular monitoring visits of ANMs and MPWs in the village on their assigned days. This
was also designed to find out the reason behind their non-functioning.
Another important innovation was around procedure of report card preparation. Report cards were prepared with
collective community efforts in the State and it was not only the mere duty of VHSC members visiting different
parts of the village and conducting group discussions, but that of the entire community.. The process was
completed in a day-long programme called Arogya Jagruti Diwas where people gathered in at a place, cleaned the
village and also constructed a sock pits. After having lunch together the villagers discussed about on important
health issues. The ANM was also invited to participate in the process and finally the report card was prepared.
In addition, another important innovation was Jan Samwad or Jan Sunwai which was one of the most
controversial and also most important aspects of community monitoring . Dr. Shukla said that “I am a very strong
defender of Jan Sunwai, even though it may be uncomfortable for some people.” Talking about the benefits
of Jan Sunwai, he said that there may be acrimony in the first round of Jan Sunwai but it is a forum where ordinary
people can stand-up, speak and demand their rights. The State conducted nearly a total of 100 Jan Sunwais as part
of the community monitoring process. When asked what has brought the changes, people answered that it was Jan
Sunwai. The Jan Sunwais were conducted at PHC and district levels with the intention to address issues at each
level. Each Jan Sunwai was attended by 100-300 people.
State level conventions and review workshop also took a form of innovation. A state level convention was
organized at the beginning of the process which was attended by all stakeholders like officials from PHC, block and
district and civil society organizations. Subsequently, there were two major state-level review workshops, which
20
were attended by more than 200 participants along with state level officials. These workshops provided space and
opportunities to solve issues which could not be resolved at the district level.
Another important innovation was a Marathi newsletter Dawandi, which in Hindi means “Dhin Dhora Peetna.”.
This is a 24-pages newsletter which is published every three months and until now four issues have been brought-
out. The newsletter is very simple and interactive which contains articles of VHSC members and NGOs workers in
addition to interviews of proactive health and grassroots level health workers.
He later talked
about
involvement of media in the process which played a very important role in community monitoring. Nearly 200 news
items were published in the State relating to community monitoring which highlighted health issues and the process
of community monitoring. The articles also talked about the improvements that took place. In this course, one of
the districts under community monitoring published a full newspaper for the district level Jan Sunwai.
Dr Shukla presented indicators of Vellehe block which depicts service improvement across three rounds of
community monitoring. Out of 150 services 2/3 services were improved, he informed.
Improved Same Worsened
Disease Surveillance 15 0 0
Curative Services at village level 12 3 0
Adverse Outcomes (ID, MD) 2 13 0
Use of untied funds 14 1 0
ANC 9 6 0
PNC 14 1 0
Immunisation 1 14 0
Anganwadi 9 6 0
PHC Services 12 3 0
PHC staff Behaviour 10 5 0
Total out of 150 98 52 0
These changes were significant in a short span of one-and-half years as most of the services were not very easy to
change. Nearly 48 per cent of services were ‘good ‘ during the first round of community monitoring which went up
to 51 per cent in the second round further improving to 66 per cent in the third round.
The partly satisfactory services declined in the given year. Consequently, the State came up with a new term called
community monitoring sensitive services and community monitoring resistant services as some services respond
rapidly to community monitoring since they were based on local behavioral factors and were open to local change.
He talked about district wise changes that have occurred over the time. The good services were only 49 per cent in
Pune district during the First phase of community monitoring but by the end of Third round it went up to 85 per
cent. The reason behind this rapid and large change was activation of non-functional health facility through the
process.
Jan Sangathan which had strong presence in Thane district made efforts which resulted in better delivery of health
services in the area. During the First round of community monitoring only 35 per cent services were good went up
to 66 per cent during the Third round. Nandurbar was one of the exceptional districts which did see much change
during two the rounds of community monitoring. When enquired it was found that some senior district health
officials had decided not to respond to community monitoring and subsequently the issue was resolved in the State
level facilitation. The Third phase saw a remarkable jump of 60 per cent from 37 per cent in the Second round.
Good rating over 3 Phases
48
6166
0
20
40
60
80
Phase 1 Phase 2 Phase 3
Partly satisfactory and Bad evaluations over
3 phases
14%
20%23%
25%28%
16%
0
5
10
15
20
25
30
Phase 1 Phase 2 Phase 3
District trends of good rating over 3 phases
- Pune
49%
81% 85%
0
20
40
60
80
100
Phase 1 Phase 2 Phase 3
Pune
District trends of good rating over 3
phases - Thane
35%
57% 63%
0
20
40
60
80
100
Phase 1 Phase 2 Phase 3
22
Similarly Amravati which is a tribal district couldn’t see much change in health service delivery due to several
factors. However, four out of five districts witnessed substantial changes in village health services delivery.
Specific services like immunization which is a priority of the Government saw some positive changes. Before
community monitoring, ANMs did not visit villages but through the calendar developed during community
monitoring their movement was monitored which resulted in betterment of their services which went up from 70
per cent to 90 per cent.
Service delivery at the PHC and CHC also improved which resulted in increase in patients in the OPD and IPD.
Due to community monitoring, people shifted from private sector to public sector to some extent. People had no
idea about the Parinche PHC which was covered under community monitoring. They did not know that the PHC
can admit patients and it was almost nonfunctional. But after community monitoring, patient intake went up by 10
times and deliveries started taking place and people got admitted for health problems.
Nandurbar
41 37
60
0
20
40
60
80
Phase 1 Phase 2 Phase 3
District trends of good rating over 3
phases - Amaravati
45%55% 59%
0
20
40
60
80
100
Phase 1 Phase 2 Phase 3
District trends of good rating over 3 phases -
Osmanabad
67% 75% 67%
020406080
100
Phase 1 Phase 2 Phase 3
Some of the qualitative changes taken place in the State are:
• Practices of prescribing medicine from medical shop have reduced.
• Illegal charging and private practice by certain medical officers has reduced. For example, a doctor in Thane
district had put up a donation box in the Centre which was raised in Jan Sunwai and the donation box was
converted into a complaint box.
• Maharashtra was lagging behind in utilization of untied funds which is a very important aspect under
NRHM. It was found in many places that AWW who is a signatory was purchasing furniture, constructing
fences for Anganwadis from the funds. But due to intervention during the community monitoring the
practice was stopped and funds were used for relevant health activities.
• Recording of weights of children have improved and has become more accurate.
• Frequency of ANM and MPW visits to villages has increased which has led to improved village health
services and led to definite improvement in immunization coverage in villages.
• Either the sub-centers or mobile units were closed down or were non-functional in many villages. The issue
was raised in Jan Sunwai which led to better functioning of the Centres.
• JSY beneficiaries are now being paid the rightful amount.
• Citizen’s Health Charter and availability of medicines are now displayed in front of each health centre.
0
100
200
300
2006-7 2007-8 2008-9 2009-10
Parinche PHC IPD - under CBM
Dr. Shukla said “people critiqued community
monitoring by saying that it is not replicable, but we
feel that it can be scaled up in a phase manner.” All
five districts in the State have scaled-up community
monitoring by taking additional blocks and villages.
After the First phase of community monitoring which
was based on common model, each NGO now is
planning on how to take the process in their
respective districts with separate models. Districts
marked pink in the map are from the First phase and
the districts marked green belong to the Second phase
Selection of NGOs across the 8 districts was done through a public advertisement to which more than 450 NGOs
applied. It was decided in one of the state-level workshops that issues that have come out through the community
monitoring process has to be incorporated in the planning process. People’s health planning proposal was given for
23 blocks in year 2010 for preparation of PIP. The State is in process of expanding the ambit of community
monitoring to food security, health care, water supply and nutrition. This has led to possibility of collaboration with
different groups like the Right to Food Campaign and groups working on nutritional issues.
Challenges faced during Community Monitoring:
1. Lack of key systemic improvements. Seven key issues like non-availability of medicine etc were identified
which were not getting resolved. Nearly 2000 people filed petitions to resolve the issue and a note was sent
to the Health Ministry in this regard.
2. Lack of conviction on the part of district health officials which lead to resistance to community monitoring.
With frequent transfers, officials too need regular orientation on community monitoring.
3. Irregular Media strategy. Media is effective in covering vital issues and process but not engaged on a regular
strategic basis.
4. Absence of Formation State monitoring and planning committee. State monitoring and planning committee
needs to be constituted which has been pending as it requires political representation.
25
5. Need for intensified support and timely decisions-making from the State in order to move at a faster pace.
Discussion-Questions/Answer: Indu Capoor, Chetna and AGCA member: Ms. Indu wanted clarification on three issues;
• More about Usmanabad experience
• How nutrition issues were included in community monitoring as it was primarily a health-led
initiative and esp. when anganwadi comes under a different department it might lead to conflict?
• Is community monitoring included in PIP?
In response to these questions Dr. Shukla said:
• Maharashtra is the first state to include community monitoring in PIP 2008 -09. The process
received a support of Rs 2.9 crore from the State Government.
• In response to nutrition being included in community monitoring he said the convergence was
from the below and not from the top. Untied grant of VHSCs are managed by AWW and under
community monitoring one of the indicators was monitoring of AWW functioning. Districts like
Amaravati, Thane and Nandurebar are infamous for malnutrition deaths in Maharashtra. So
organizations working in community monitoring were active on nutritional and food security issues
as well. These organizations were able to raise issues at the local level.
• Talking about Usmanabad situation, he said that to organize a chain of action from National level to
block level is a complex process. All civil society organizations have their own identity and own style
of working so sometime it is very difficult to bring them on one platform.
In response to Dr. Shukla’s question around Untied Grant Mission Director of Maharashtra said that the issues
would be taken care at the directorial level. He also appreciated the Dr. Shukla’s presentation. He added that due to
community monitoring process for the last three years the community now is empowered and facilities are reaching
them though in certain areas there are still no facilities due to lack of infrastructure, communication and non-
availability of providers and it is a to meet those demands. He informed that the Government of India had
increased funding to three times for health but still people approached the private providers as they are getting
better facilities than government centres. The most realistic indicator for the assessment is improvement of health
facilities at the ground/local level. The community indicators include number of deliveries at the facilities in a one
month, number of children immunized in a month, number of ANC check-ups Etc.
26
How Community monitoring has Supported Achievement of NRHM Goals in Karnataka: Dr. Mohanraju
Dr. Mohanraju began his presentation by stating that since the last two-and-half- years in Karnataka positive results
in health has been achieved due to community monitoring. Community monitoring is just in infancy which is
expanding to the districts and the state is serious about the process, he added. He highlighted the following
important features of community monitoring under NRHM;
• It is a key strategy under NRHM
• It helps to ensure reach of services in underserved and unserved areas, poor, women, children and
marginalized sections and reviews functioning of health services
• It promotes community's ownership
• Paves way for community led action
Various committees were formed in Karnataka through community monitoring such as 23020 Village Health and
Sanitation Committees, 2193 PHC Planning and Monitoring committees, 147 Taluk Planning and Monitoring
Committees, 30 District Planning and Monitoring committees and a State Planning and Monitoring committee. He
said that VHSCs perform the following tasks:
� Entitlement awareness on health
� Assessment of major health problems through PRA
� Development of Health Plan on the basis of problems
� Making village-level presentations taking into account achievements, difficulties faced and action taken
� Taking cognizance of denial of care, negligence and other complaints and prompt redressal
� Collecting and collating information from lower levels and reporting to higher level
He later talked about the First phase of community monitoring in Karnataka which took place during 2007-2009
across four districts (Tumkur, Gadag, Chamarajanagar and Raichur). The District NGOs involved in the
implementation process were - AID INDIA in Tumkur, Bharat Gyan Vigyan Samithi (BGVS) in Gadag, Karuna
Trust in Chamarajanagar and CHC (Community Health Cell) in Raichur. The process of community monitoring is
presented in the flow chart below.
Dr. Raju later presented seven parameters to show progress made over three rounds of community monitoring in
the State. The red color bar indicates “None Performance” and the green indicates “Good Performance”. The
parameter related to maternal health guarantees after three rounds of Community monitoring shows that the red
color has come down. Similarly under the JSY, the green color has gone up and red has come down.
Same can be observed for disease Surveillance and child health.
0%
50%
100%
First RoundSecond RoundThird Round
Maternal Health Gaurantees
28
Untied fund was a major area of concern for Karnataka, as during the First round of community monitoring the
red color was higher and green was almost nil. Constant handholding of community and several rounds of
community awareness led to substantial changes in utilization of untied grant.
Similarly, progress around curative services and quality of care could be seen.
The following learnings emerged from the process:
� Appreciation of the community monitoring model toward scalability.
� Coverage of 562 villages by the State instead of 180 villages in the First round of community monitoring.
� Use of Kalajatha (street play) for awareness generation was very effective
� Training meetings called prior to VHSC yielded good results
� Orientation of service providers.
� Inclusion of planning in the community monitoring processes
� Simplification of village health report cards which were complex (specifically the equity index).
� Involvement of other sectors other than health
0%
50%
100%
First RoundSecond RoundThird Round
Untied Fund
0%
50%
100%
First RoundSecond RoundThird Round
Quality of Care
29
He later shared the uniqueness, roles and responsibilities of the Village Heath Planning and Monitoring committee
(VHSCs) which as follows:
� Representatives from Gram Sabha, ANM, MHW, school teachers, AWW, ASHA etc. were part of VHSCs.
� Majority of VHSC members were women, which is an indicator of women empowerment.
� VHSCs involved in preparation of village health plan, village health register and village heath report card.
� Jan Samvads conducted every quarter.
� VHSCs involved in monitoring health programmes and educating and sensitizing community on health
issues.
� VHSC decides on how to use untied funds.
� VHSCs given legal status thus acting like sub-committee on health for GP and accountable to GP.
� VHSCs report to PHC Planning and Monitoring Committee every 3 months.
PHC Planning and Monitoring Committee (PHCPMC)
� It has representatives from all VHPMCs and Gram Panchayat, women representatives from SC/ST, OBC
and general category.
� 11 NGOs/CBOs representatives are included in PHC committees, it has ensured the intersectoral
convergence of all level.
He shared the functions, roles and responsibility of the PHCPMC, Taluka Health Planning and Monitoring
Committees and District Health Planning and Monitoring Committee. Intersectoral convergence was ensured
by including Women and Child Development Department (WCD), Engineering, Education, Rural
Development departments and Panchayat Representative. He outlined the roles and responsibility of District
Monitoring and Planning Committees which are as follows:
� Preparing annual district health plan
� Conducting Jan Samvad once a year
� Establishing intersectoral convergence with other departments
� Sensitizing community on all health issues
� Monitoring progress of Taluk Health Planning and Monitoring Committees.
� Meeting once a month on 3rd Monday
Constituting executive committee with support from DMPC He later added that Community monitoring has been
scaled-up in all districts of Karnataka for the Second round and the State has ensured the capacity building of all
30
NGOs involved in the process. There are 3-4 lakh VHSC members across the State and training of these members
have begun from last three years. The State has allocated around 13.50 crore for this process.
In concluded by sharing significant improvements achieved due to community monitoring initiative such as
improved expenditures and fund utilization. He said that better fund utilization was possible due to
communitization process and now VHSCs, SC, PHC, CHC, TLH and DHs are utilizing funds appropriately and
efficiently.
He informed that there was an increase in institutional deliveries from 64% to 93% in two years. Nearly 29000
ASHAs who were trained are playing an important role in improving women’s health which has led to a fall in
infant and maternal deaths. Number of toilets has also increased in the State under the Total Sanitation Campaign.
He said that nearly four years back Karnataka had a huge morbidity rate related to Malaria which has now come
down and persists only in few backward districts. Citizen Help Desks have been established at the district hospital
to improve services. The State is also observing Community Health Day (an interaction between health providers
and community) since 2008-09, which takes place every six months. This has been expanded to VHSC to PHC and
from 2010 to CHC. He gave a suggestion that the concept of Community Health Day could become an alternative
to Jan Sunwai.
Community based monitoring of health services in Orissa by Mr. Sudershan Das, HDF, Orissa
31
Mr. Sudershan Das said that the goals of NRHM are to promote local initiatives and so he would share his
experience during the First phase of Community monitoring in Orissa.
Odisha's Experience: Coverage
District
Block Block Block
PHC PHC PHC
Village Village Village Village Village
4 districts
12 blocks
36 PHC’s
180 Villages
The State covered four districts, 12 blocks, 36 PHCs and 180 villages under the First phase. The State completed all
stipulated activities on time.
Mr. Das shared some of the experiences and lessons learnt during the implementation of the First phase which are
as follows:
1) Important for service providers and civil society to work hand in hand to make community
monitoring successful .
2) The word ‘monitoring’ has negative connotation due to which health providers were uncomfortable
and thus it was replaced with the word ‘Community Action.’
3) Need to involve only those NGOs that are credible, well meaning and self-motivated to take the
community monitoring process in the right direction.
4) Although community and providers disagreed in Jan Samvads in several instances however, the
community and providers came together to solve issues.
5) The preparation of score card was a very difficult process for the community, mainly for people who
were illiterate, semi literate and tribals.
6) There is a need for effective feedback from each level of committees to take the issues forward.
7) Community monitoring is a fantastic tool to ensure communitisation which is the hallmark of
NRHM. The community participated and supported the process at each level in the State.
8) Community monitoring has been used as a platform to resolve issues.
9) Even though community monitoring was a success in the State, the State couldn’t sustain the
process further.
Mr. Das outlined the flexibility provided by the State government to implement the project which are as follows:
1) The Government initially wanted to get all VHSCs in Orissa registered but since it was difficult to do so
they agreed not to do so.
2) Since in rural and tribal communities were unable to understand the word VHSCs, it was changed to
Gaon Kalyan Samiti.
3) As at the local government officials were not comfortable with the word ‘Community monitoring ’ it was
replaced by ‘Community Action.’
4) The formation of Gao Kalyan Samiti was delayed so the State decided to form GKS on a campaign
mode.
5) Issues raised in Jan Samwad were effectively addressed by MOs at PHC and CHC levels.
33
He said that flexibility is desired at all levels starting from village to state level. Based on his experience he made the
following recommendations:
• Need to empower community monitoring committees at different level.
• Community monitoring should not be an auxiliary programme but a formidable component of health
system
• Community monitoring process must be kept away from government domain and the role of govt. should
be that of a facilitator
• It should be made mandatory to have a link between village health plan and district health plan. In other
words, district health plan should be based on village health plan.
• PIP formation should be done with the help of civil society and state mentoring committee inputs.
• There is a need to give clear government orders/instructions to the state mentoring committees in order to
avoid confusion and ambiguity.
• The state needs to follow adequate measures to sensitize government officials on community monitoring
issues.
• PRIs should be integral part of community monitoring process.
• Prompt action and feedback from lower level is required to tackle the issues raised through community
monitoring.
There are some structural level changes that occurred in the state:
• At Village - Gaon Kalyan Samiti
• At GP- GP Swathya Samikhya Samiti
• At Block- Block Swathya Samikhya Samiti (earlier the committee was at the CHC level but now it has been
constituted at the block level)
• At District- Zillay Swathya samikhya Samiti
• At State- Rajya/Orissa Swathya Samikhya Samiti
The Minister of Health and Family Welfare is the Chairperson in the Rajya Sawathya Samikhya Samiti. Proposal has
been submitted in to make an NGO representative as a co-chairperson. PRI members are the Chairpersons of the
Samitis and CSO representative is the Convener at the district, block and GP levels.
Feedback from of different levels of Swathya Samikhya Samiti proposed for next rounds of community
monitoring:
34
Step I- The key health issues would be captured in a Gaon Swathy Patrika at village (GKS) level. The Patrika would
be compiled at the GP level containing health problems related to birth and death in the village during the reporting
period. This would be discussed in GKS meeting and relevant facts captured in the Patrika. (The template of the
Patrika is being prepared)
Step II- The Gaon Swathya Patrika would be compiled at GP level in the “Panchayat Swathya Samikhya Samiti” and
a “Panchayat Swathya Patrika” would be prepared on monthly basis. Only those issues would be taken from each
village which could be easily solved at the GP level. Other issues would be forwarded to the Block Swathya
Samikhya Samiti for their consideration.
Step III- The Panchyat Swathya Patrika would be compiled at Block level by Block Swathya Samikhya Samiti and
Block Swathya Patrika would be prepared. On the basis of GP’s report, necessary action would be taken at this level
and the rest would be forwarded to the district level for corrective measures. This would be done on monthly basis.
Step V- Rajya Swathya Samikhya Samiti (RSSS) would meet once in a quarter to review the District Swathya Patrika
and come up with State Swahthya Patrika. The Health Minister who heads that RSSS would take corrective measures
and instruct the State NRHM to take appropriate action.
He further added that a technical committee has been set-up to work on the indicators. In the First round of
community monitoring there were 11 indicators but it is a felt need to cut down the indicators. The new indicators
would be incorporated in the Sawasth Patrika. Mr. Das said the following undertaken to ensure smooth progress of
community monitoring in the State:
• Details of process being worked out with technical support from AGCA members
• Significant improvement in the Second round of community monitoring framework of
implementation
• State striving to make the community monitoring process simple and community-friendly
Discussion-Questions/Answer:
Vanita Nayak Mukherjee, Program Officer, FORD Foundation, New Delhi: Raising her question to Dr.
Abhay Shukla, Ms. Mukherjee wanted to know how does one attribute the change in the community in Maharashtra
to community monitoring as the civil society organizations involved in community monitoring process in the State
were already strong in social movements and due to their effort the political will and confidence was already there
on ground.. She added that this would help to understand why in some states this process worked so well and why
in others it didn’t. Her second question was about “Helo Foundation” the nodal agency for non-performing district
like Usmanabad. She wanted to know the reason behind non performance as it was a well-know organization.
35
The third question was to Dr. Mohanraju who mentioned about the rise in institutional deliveries. She wanted to
know if there enough infrastructure to cater to the women and how did they deal with infrastructural issues.
The fourth question was to Mr. Das from Orissa, to whom she asked since the State has changed the names from
‘Community monitoring ’ to ‘Community Action’ and to ‘Swathya Samikhya Samiti’, is it just a semantic,
nomenclature and to what extent will it compromise with issues around monitoring or accountability?
Dr. Saraswati Swain, AGCA member, Orissa: Her question was to Dr. Mohanraju around one-child norm which
the State of Karnataka is trying to impose recently. She wanted to know the truth behind it. Her second question
was to Dr. Abhay Shukla about institutional deliveries and post-natal care as women don’t stay in hospital soon after
the delivery. She also showed her concern about extrapolating the data of institutional delivery. She said that women
don’t like to come to the public facilities due to bad behavior of providers and added about the corruption in
institutions where sometimes women send someone else on their behalf to get their name registered and pay around
Rs 400-500 to the doctor to get an institutional delivery certificate. She wanted to know how does one deal with
such cases.
Anurag Chaturvedi PFHI New Delhi: His question was to Dr. Abhay Shukla about the methodologies used in
community monitoring and in village identification.
Pranoti, Packard Foundation, New Delhi: Her question was to Dr. Mohanraju about the sustainability of
community monitoring without an incentive which people believe in.
Dr Ajay Khare, MPVS, Madhya Pradesh: Appreciating Karnataka for taking initiative to cover community
monitoring in the entire State, he expressed his concern about managing the process in the State as it is tedious,
time-consuming and lengthy.
His second comment was on Orissa’s experiences and said that we should not always blame or go against the
government or corner them.
Mr. Govind Madhav, Karuna Trust, Karnataka: He commented on Mr. Sudarsan’s statement that “community
monitoring should be kept away from government domain and move away from health centre to Panchayti Raj
Institutions.” Commenting that most of the PRI representatives functioned as dummies how successful would the
community monitoring process be if handed over to the PRIs. ?
36
Leuit Goswami, Rural Volunteers Services Assam: NRHM has become a figure game now and it is mostly
percentage around institutional delivery, immunization and family planning. What else has been achieved apart
from this?
Laila, UNICEF New Delhi: What is the reason behind increase in institutional deliveries? Is it because of the
informational budget and quality improvement at the facility level? Secondly, is there any link with Community
monitoring Committee improving the facility care?
BK Soam; RRC, NE Guwahati, Assam: Question to Dr. Abhya Shukla - What does ‘Improved’ Immunization
means? Full immunization or part immunization? To Dr Mohanraju - How to measure ‘Improved Maternal
Health” ? When we talk about improved maternal health services, we need to segregate the components.
Responses:
Abhay Shukla: In response he said that in organizations involved in community monitoring process in
Maharashtra have strong backgrounds of working for peoples’ rights. The State has diverse coalition and not all
organizations worked on a rights-based approach. But community monitoring did provide them a space and
through the process they became very active. “Bringing rights to health and bringing health to right – we have tried
to bring ‘Rights’ approach to health NGOs and health to rights-based NGOs.
In response to the credibility of “Helo Medical Foundation” he said that it may not be known outside Maharashtra
but people within the State know that the organization has conducted a range of activities, especially training of
community health workers, community based health insurance etc and added there maybe other issues.
Answering question on institutional delivery he said community monitoring does not look at number of institutional
deliveries directly but looks at the antenatal care, post-natal care and availability of other quality and capacity of
health services to perform normal deliveries. In the community monitoring process incidents have been cited where
women have delivered on the road on the way to institution just to get JSY money. Besides, there are larger issues
that need to be discussed separately. The focus in community monitoring was on the incentive that given to women.
On the issue of selection/identification of villages he said districts like Nandurbar, Amaravarti and Thane in
Maharashtra are the most remote, poor, bad performing and adivasi districts. The village identification was done by
the block nodal NGOs based on the parameter that some community action has taken place.
37
Dr Mohanraju: In response to the question on rise in institutional deliveries in Karnataka he said that the reference
figure of 64 per cent is taken from DLHS 3. The 93 per cent rise in institutional delivery has been achieved through
various means in the State. Following are the initiatives that have been taken by the State to improve institutional
deliveries in the last two years:
1) The State has appointed nearly 49,000 ASHAs they are the big motivators and bring women to PHCs for
deliveries.
2) The State has introduced number of schemes and programmes which benefit women and child health such
as:
a. Manilok kit which contains 19 items helpful for immediate post-natal care
b. Introduction of cash incentive scheme of Rs 1000 for antenatal period and another Rs 1000 for
immediate post-natal period.
c. There are about 974 PHCs working 24x7 and nearly 142 FRUs conducting caesarean deliveries.
In additions to the above parameters, the State is emphasizing on qualitative improvements of institutions which
comprises presence of proper equipment, registered health personnel (doctor, nurse, 24 hrs availability of staff
nurse, trained SBAs for early recognition of complications during pregnancy etc), availability of transport, new born
care etc. He said that these are essential parameters for a quality institutional delivery which GoI also promoted
under the “Family Friendly Health Initiative.”
Regarding two-child norm he said that in the State there are certain districts were sex ratio is very low and the state
is honoring those families with only one girl child wanting to go for sterilization.
In response to the question on Community Health Day he said that besides rapport building, it provides an
opportunity for interaction between the community and service providers. People could debate and ask questions
and raise issues on this forum. Regarding VHCS training he said that in the First round, nearly 4 Lakh VHSC
members got trained across 30 districts of Karnataka and the Second round of capacity building of VHSC will go
along with Community monitoring . He said that components which lead to improved maternal health include
ANC check-ups, PNC check-ups, TT and in case of children – immunization and nutrition in response to the
question on measuring improved maternal health.
Dr Ramesh Chandra Sagar summed up the Session by stating that the Community monitoring programme includes
all stakeholders and the participation of community need to be included in other programmes as well. Talking about
38
condition of tribals he said that there is a need for holistic approach where all services are included and accessible to
all section of society. He appreciated all the NGOs whose effort have contributed in improving the health services.
Session Three Empowering Communities to Stimulate Demand and
Accountability Timings: 2:30- 3:20 PM
Chair- Ms. Indu Capoor Presenters: Narendra Gupta; AGCA member and Prayas Chittorgarh - Nodal Agency for community monitoring in Rajasthan – Community monitoring a tool for Empowering Communities Dr Rakhal Gaitonde; Community Health Cell Extension Unit, Chennai, Society for Community Health Awareness Research and Action; How to use CBM data for district level planning - a process of community empowerment and accountability Dr Ajay Khare; Gyan Vigyan Sabha -MP, State Nodal Agency, TAG member – Experience of Madhya Pradesh Community Based Monitoring. Discussion Closing Remarks by Chair _____________________________________________________________
Dr. Abhijit Das welcomed the presenters and introduced them to the participants.
Community monitoring a tool for Empowering Communities Rajasthan: Dr. Narendra Gupta
Dr. Narendra Gupta started his session by providing a brief history on Community monitoring and Planning
initiatives and health issues in Rajasthan. He positioned that the whole notion of “empowerment of rural poor for
better health” took shape in 1998 and by then health issues were prioritized and community mobilization had
started around health which was done by five organizations at five different places. This triggered Community
monitoring of health services which was further scaled-up.
The Government of Rajasthan took up this model in 2002-03, focusing on equity, accountability and quality of
health services. The main objective was to resolve the dispute between community and health service providers and
the focus was shifted from monitoring to monitoring and planning. Subsequently, Village level Health Committees
and PHC/CHC Planning & Monitoring Committees were formed in Chhoti Sadari block of Pratapgarh district.
He shared the objective and processes of community monitoring in Rajasthan along with detailed information on
various activities undertaken.
The First phase was carried out across 180 villages in four districts of Rajasthan (Alwar, Chittorgarh, Jodhpur and
Udaipur). In the Second phase this intervention was expanded to 225 villages by including a fifth district - Baran.
He shared some of the outcomes/achievements of community monitoring in the State:
40
• Formation of VHSC with proper representation of people.
• Proper utilization of untied funds and separate bank account of VHSC to minimise corruption.
• VHSC manages the untied funds on their own and not managed by ANMs and Sarpanch.
• Training of VHSC for improving the health facilities.
• Village Health Plan formatted to reflect health demands of community which health system can respond.
• Village Health Charters prepared to reflect services provided by service providers to the community.
• Regular meeting of VHSCs members, ASHA and Panch.
• Public hearing at different places helped in understanding health issues and empower the community.
• Public hearing created a platform to discuss health conditions of an area in presence of service providers,
government officials and policy makers.
• Report cards were an important tools to let service providers understand the health status as it displayed the
reality on ground.
Dr. Narendra also mentioned about the data collection process and discussed the positive changes in the field by
using colored pie charts comparing changes taken place in Rajasthan and four districts in a span of one year i.e.
from Sept 08 to November 09. He also spoke about the impact of community monitoring like improved dialogue
between health care frontline workers and the community, improved attendance in the public health services,
greater frequency of visits by ANMs and MPWs, better cooperation by community members and check over illegal
charging by medical officers. He concluded by saying that there is a need for better sustainable partnership and
correlation between the community and health service providers which should be institutionalised at all levels.
How to use community monitoring data for district level planning - A process of community empowerment and accountability-Tamil Nadu- Non high focus state - Dr.Rakhal Gaitunde Dr. Rakhal started his session by mentioning that their notable experience related to COMMUNITY
MONITORING was negotiating and building up relationship with the public health system. His presentation
focused on following: points:
• Community level processes
• Feedback of collected data - To communities and to the health system
• Type of data generated and potential uses for both community and the system
Community Process:
He said that gains made through community monitoring is impressive, given the time and the intensive effort
required for these tasks. The spirit, enthusiasm, volunteerism, commitment and passion that went into the process
are commendable. community monitoring is a multi-level process and the stakeholders, including the NGOs,
worked a hard for building a conducive environment. The process actually took place because of the enthusiasm
among people, animators and field workers. For the first time, they got to know their rights and the duties of the
service provisions. A key initiative in the State was to involve the VHN Association in the process.
Community monitoring found that there is lack of knowledge among communities with regard to various services
thus there is a need to look at micro level issues. In order to create awareness various awareness building process
were initiated like padyatras, film shows, trainings, exhibitions, -posters, photos, pamphlet distribution etc. VHSC
training was one of the components of the process. A large number of contact groups were formed and contact
sessions were held.
Data Collection:
The data collection process reflected that a large number of meetings took place at variety of settings and people
were keen to know about various services. There were a large number of training sessions for adolescent girls and
SHG members. Data collection in Tamil Nadu included several meetings with individual families and for the first
time, field workers also started to see the complexities involved in health services ranging from transport,
infrastructure, delays etc. Monitoring health had given them access to health services. The data collection exercise
helped to understand both problems faced by the field workers as well as community members. Data was collected
from 212 villages through report cards and feedback was provided to the community including health service
providers and answers were sought from the govt. officials. Meetings were held in the premises of the PHCs to
discuss issues reflected in the data. These meetings culminated into district meeting where report cards were
discussed at length. In these meetings it was made sure not to target frontline workers and mover beyond this.
Communitization process: Community monitoring has set in motion to bring the community at centre-stage in health delivery. VHSCs have
given voice and visibility to the community. Through this process communities now have a better sense of their
entitlements and hence their expectation from public health system has increased. It has enabled a better connect
between the community and the Health Department leading to better accountability. Relationships were developed
with the department and it began to engage the community and to respond to its requests.
42
Report Cards:
He shared templates of report cards, which were initially complicated but once filled were very informative. Village
health report cards formed points of departure for a large number of discussions at the systemic and community
level and this was one of the major achievements in Tamil Nadu. The most significant aspect was the interaction of
community with officials, doctors, VHSC members and Deputy Directors. There were numerous instances where
decision to make changes was made during public hearing which led to a lot of confidence building among the
community. People started perceiving that system is responsive to their need.
He presented the block level report cards reflecting the equity index which was very informative in nature where
names of villages, services provided and social composition was given. The district report cards reflected that
despite existing infrastructure how services were not reaching the people.
He concluded his presentation by saying that community monitoring was not only for the empowerment of the
people but that the data could be used to strengthen the system, get into triangulation, district and PHC level
review, micro planning, quality review mostly in ownership and accountability of the community etc.
Block PHC Village Disease Surveillanc
e
Curative Services
VHSC & Fund
Child Care
Adolescent & School
Prog
Maternal Guarantees
Dr Muthulakshmi & JSY Scheme
Adverse Outcome
Infrastructure Materials Instruments Services
Agestheeswaram Kottaram Perumalpuram 70 75 60 68 83 91 31 6 69 70 93 78
Agestheeswaram Kottaram Achenkullam 60 88 70 76 83 87 50 0 54 80 93 78 Agestheeswaram Kottaram Arumugapuram 40 100 80 72 83 90 50 0 54 70 93 78
Agestheeswaram Kottaram Puthugramam 80 88 40 64 83 100 35 0 69 70 93 78
Agestheeswaram Kottaram Vavathurai 60 88 30 76 100 88 13 0 77 70 93 78
Agestheeswaram Agestheeswaram Chinnamuttom 70 75 50 68 50 80 2 12 15 80 93 78
Agestheeswaram Agestheeswaram Arockia Puram 60 63 40 60 83 87 18 24 77 100 93 78
Agestheeswaram Agestheeswaram Kovalam 90 50 80 76 67 87 23 50 62 100 93 78
Agestheeswaram Agestheeswaram Punnaiadi 40 25 40 96 67 90 44 20 69 100 93 78
Agestheeswaram Agestheeswaram Thenthamari Kullam 80 63 60 92 50 88 42 0 62 70 93 78 Agestheeswaram Azhapapuram Vadakuthamari kullam 60 63 60 96 100 95 50 0 85 70 93 78
Agestheeswaram Azhapapuram Swamithoppu 80 25 60 96 67 93 28 20 54 80 93 78
Agestheeswaram Azhapapuram Marrunkure 80 75 70 76 100 88 65 52 77 90 93 78
Agestheeswaram Azhapapuram Athiyadi 80 75 70 68 100 87 75 30 77 90 93 89
Agestheeswaram Azhapapuram Mylady 80 100 60 76 83 87 81 70 85 90 93 78
Kurunthencodu Kurunthencodu Madathattuvillai 60 75 100 60 67 41 6 60 31 80 71 44
Kurunthencodu Kurunthencodu VillukuriR.C Stret 60 88 100 56 67 64 25 0 62 80 57 56
Kurunthencodu Kurunthencodu Veeravillai 60 88 100 56 33 83 13 0 92 100 86 100
Kurunthencodu Kurunthencodu Chunkankadai 60 75 100 60 83 61 21 0 62 70 86 78
Kurunthencodu Kurunthencodu Ellanthavillai 70 88 100 84 67 7 13 0 77 70 86 67 Kurunthencodu Vellichanthai Thumpavillai 100 75 100 76 100 67 38 0 62 80 86 78
Kurunthencodu Vellichanthai Thirunainar Kurichi 60 88 90 76 67 60 33 0 77 80 86 89 Kurunthencodu Vellichanthai Ramanaathapuram 70 88 100 72 67 72 22 0 85 100 86 78
Kurunthencodu Vellichanthai Kattuvillai 80 75 80 84 67 72 25 0 54 80 71 67
Kurunthencodu Vellichanthai Kadeatti 60 100 100 72 50 78 13 30 92 100 93 78
Kurunthencodu Muttom Thonnimukku 80 100 100 92 100 63 38 0 31 70 71 78 Kurunthencodu Muttom Periyavillai 50 75 80 64 67 65 22 0 69 80 86 78
Kurunthencodu Muttom Chakapathu 90 50 70 60 67 80 50 0 69 70 79 67
Kurunthencodu Muttom MealaKodimunai 80 100 100 52 100 55 20 0 54 70 71 78 Kurunthencodu Muttom Reethapuram Colony 70 100 80 84 100 80 38 0 54 70 86 78
Killiyoor Nattalam Kodumkullam 70 63 80 64 83 72 63 0 69 90 79 89
Killiyoor Nattalam Edavillagam 20 75 40 63 73 84 38 0 92 100 86 78
Killiyoor Nattalam Payanam 70 63 70 44 83 69 63 0 77 90 79 80
Killiyoor Nattalam Midalam 50 50 60 40 83 82 45 0 92 100 71 78
Killiyoor Nattalam Kuttiparavillai 50 50 50 60 83 78 78 0 92 100 86 89
Killiyoor Keelkulam Elluvillai 50 50 70 48 83 78 45 0 92 100 86 89
Killiyoor Keelkulam Puthenthurai 30 50 50 56 83 56 46 0 92 100 71 89
Killiyoor Keelkulam Enayam 30 50 50 56 84 56 45 0 92 100 71 89 Killiyoor Keelkulam Udavillai 50 88 30 40 67 70 73 0 100 100 65 67
Killiyoor Keelkulam Aienivillai 70 52 48 56 83 69 60 0 79 90 80 76
Killiyoor Killiyoor Kattuvillai 50 50 60 64 83 53 58 0 92 100 71 78
Killiyoor Killiyoor Paramen Konam Street 50 50 60 48 83 82 52 0 92 100 86 78
Killiyoor Killiyoor kottettikadai 20 75 10 40 83 73 27 0 93 100 100 88 Killiyoor Killiyoor Kattavillai 50 40 50 56 83 87 50 0 85 100 79 78
Killiyoor Killiyoor Kannanvillai 30 27 60 77 83 67 48 0 93 100 100 88
43
Experience of Madhya Pradesh Community Based Monitoring- Madhya Pradesh – Dr. Ajay Khare
Dr. Ajay Khare said the focus of his presentation would be mainly on empowerment of community for stimulating
demand and the response of the system. The selection of districts was done keeping demographic profile like
SC/ST population, literacy rate and sex ratio in mind.
Process of empowerment:
1) Selection of block facilitator and training
2) Formation of VHSC, PHC, CHC and District Planning and Monitoring Committee
3) Entitlements awareness
4) Community enquiry and report card preparation
5) Script writing and media workshop
6) Preparation of equity Index
7) Sharing of report cards in village
8) Conducting Jan Samvad
9) Distribution of IEC material- poster and pamphlets
10) Involvement of PRI members and other civil society organizations
He further said that Jan Sunwai was the most critical component of community monitoring .
Village Report Card: He presented the cumulative report which showed that the number of red villages were high
in comparison to green villages.
Issue No of Villages Green No of Villages Yellow No of Villages Red
Maternal Health Guarantees 58 77 90
Janani Suraksha Yojna 52 55 118
Child Health 63 64 98
Disease Surveillance 68 44 113
Curative Services 63 61 101
Untied funds 10 27 188
Quality of Care 42 58 125
44
Community perceptions of
ASHA 67 77 35
ASHA functioning 76 25 85
Equity Index 109 58 41
The functioning of ANMs was also comparatively better. The equity index was surprisingly good as MP is mostly a
backward area where distribution of services are equal for every sections of society. The problem of caste as a
barrier was not found in the State. He also mentioned about the untied funds and the inability of managing the
same.
Sub-Centre Report Card: He presented the sub-centre report card and said that the sub-centre which is the lowest
unit and an important component of community monitoring has bad service delivery. The sub- centre report card
highlighted that the status of the infrastructure and personnel, equipment and supplies were not up to the mark
whereas the CHCs and the PHCs were in a better condition.
It was seen that various committees played an important role with regard to awareness on entitlements and
displayed the list of medicines available in the health centres. The VHSCs also prepared informative list reflecting
the status. Trainings were also conducted to communicate properly and give information. Jan Samvads were held in
many places.
Demands by Community: The demands raised by the communities were related to regular vaccination which was
low due to irregular visits by ANMs and unavailability of vaccines. The need was felt for better co-ordination
among the Dai, Asha and Anganwadi worker for smooth functioning. In addition, there were other related to:
• Availability of medical and paramedical staff at the centre
State cumulative Sub Center Report cards
10
28
10
33
2855
57
4335
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Infrastructure and
Personnel
Equipment and
Supplies
Service Availability
< 50 %
51-75 %
76-100 %
45
• Hand pump and construction of boundary wall - Guhisar PHC of Bhind District.
• Availability of ambulance.
• Availability of essential medicines
Awareness regarding rights and health entailment: He also spoke on awareness regarding rights and
entitlements where specific issues came up like complaints against charging money. He cited an example where a
person spent Rs 20,000 for delivery, which was supposed to be conducted free of cost. Many prompt responses
were also made and BPL cards were also issued to the Baiga tribe who had no access to BPL cards earlier. Many
more positive steps were taken by the Health Department including CMO’s visit to the field, regular visits of ANM,
starting of Janani Express in Pati, Badwani.
He mentioned that the process of empowerment of community has to be a continuous process and the first phase
of community monitoring has created a space for community participation and demand generation. The future
strategy is to ensure sustained community-led action for strengthening health services
He concluded by saying that the challenge is to forward and enhance community based monitoring of health
services in MP to empower community and increase accountability.
Discussion: Questions/Answer
Dr Dhananjay, SATHI CEHAT, Pune: He raised question about ASHAs’ compensation on a monthly basis for
attending meeting at PHC. The other question was on legislation related to private practice of medical officers.
He cited the example of Maharashtra were ASHAs are compensated on a monthly basis and the Block Medical
Officer controls the private practice of medical officers.
Ajay, CINI, Jharkhand: He question was on untied funds and accompanying problems as ASHA and the Panch
managed the funds. The community is not empowered enough to raise any questions to these functionaries.
The different presentations were based on different states and highlighted lot of differing experiences in terms of
governing the system, internalizing the NRHM. Tamil Nadu has done a good job and is anticipating third
generation reforms. Secondly, are we part of the PIP preparation process, if it can be solved and be a part of the
PIP and can be solved at the district plan refresher. Same is the case with Rajasthan as they have information about
infrastructure services of in the field which have been triangulated against the MIS that particular sub-centre, PHC,
46
CHC has been sending out. This would give immediate information like in MP, 118 villages were catalogued which
were not performing well and the immediate need was to start triangulation at that level in which the data has been
collected and then participating at the district plan process and initiating remedial action. In Maharashtra, sometimes
Jan Sunwais turn into rhetorical nare baji which do not lead to any programme improvement. The triangulation done
at that level to overcome the shortcomings should be done at the data collection level. In the original theme of
community monitoring , that was in fact one of the mandatory activity. The issues of improvement of the health
status should be set up along with timelines for the completion of the activities and the person responsible for the
same has to be identified like- who documented the Jan Sunwai, who followed it and what was the follow up action
and impact of the same. It was seen that almost in all the states of the country, the MIS was mostly number based.
It would have been of added value if community based monitoring could have given at least some basic themes
which could be triangulated.
No one seems to raise the issue at the state level regarding postings of the doctors, training, multi scaling, cadre
response, redefining the job profile of the ANMs, procurement, logistics, management, immunization and vaccine .
This need to be addressed. If there is connectivity from the VHSCs to the state level, the issues of the state level can
also be raised. Most of the solutions lie at the district and the state level. As a consequence of the successful
implementation of the first phase, the second phase need to be more mature.
Dr. Jyoti Ranjan, Rajasthan Health System Resource Centre: He said that there is need to carry out
triangulation of information of grassroots level data with HMIS. Such triangulation of information would provide
possibility of auditing the HIMS data, recognize the gaps, and better implementation of HIMS data in all the states.
Responses: Dr. Khare questioned at whose interest is triangulation of data done as the community does not
require it and it is only for the Programme Managers and the system providers. There is not much need to emphasis
on triangulation when we talk of community. It was seen in MP that whenever funds were stopped, activities related
to funds were also stopped and the officials never made any effort to get involved in any activity. The need for
active and repeated involvement of officials is needed.
Indu Cappor: Everyone has been raising the issue of Jan Samvad and the backlash thereafter. We are leaving the
community more disempowered if we NGOs are not staying long enough with them after the Jan Samvads.
Question was also raised on the response towards the break-up of equity index on the basis of indicators and
population.
47
The idea of triangulation at the community level was to initiate a process of self-appraisal. The issue of
mismanagement of untied funds can be addressed by facilitating the equity oriented concept. The break -up of the
equity index can be understood if we check the increasing gaps between different classes and castes which are
evident in the NHFS data.
In case of Tamil Nadu, it was seen that there are multiple expectations form a single person. The district official is
of the opinion that community monitoring can be successful if the attendance of the Out Patient Department
increases whereas the fact remains that attendance would increase only if the infrastructure of the OPD improves.
Expectation at each level is divergent, so negotiation is required which would be a very lengthy process and cannot
be put within any time frame.
Session Four Community monitoring : Partnership Challenges GO :
NGO: Community Timings: 3:40 – 5:30 PM
Chair: Dr. Tarun Seem – PHFI, New Delhi Co-Chair – Dr. Thelma Naraynan, CHC; Bangalore Presenters Yogiraj Prabhune; Media Expert and Shashikant Gaikwad PRI representative PRI member - Maharashtra Sashi Tyagi GRAVIS and Sohanlal Kchawa VHSC Member - Rajasthan Dr Ramveer Singh CMO Guna, Arti Pandey Media Fellow - Madhya Pradesh Mr. Vanamiyalan Community Trainer Tamil Nadu Discussion Closing Remarks by Chair & Co-Chair Vote of Thanks: Dr. Abhijit Das, CHSJ ______________________________________________________________
Experience sharing from different stakeholders: During this session different stakeholders shared their experiences
of Community monitoring and challenges and learnings that they gathered from the process. The sharing was done
by; media expert from Maharashtra, Ward Punch from Rajasthan, from Madhya Pradesh – Media fellow and MO,
Maharashtra – Mr. Yogiraj Prabhune; Media Expert and Mr. Shashikant Gaikwad PRI representative
Mr. Yogitraj Prabhunne, Senior Reporter of a local newspaper spoke about the status of NRHM in Maharashtra and
the impact of NRHM on the media. He stated that earlier the NRHM infrastructure was in place but development
was not taking place properly. It was only implemented at the national level and there was no work done at the
ground level. The introduction of NRHM brought back life in the health service. Health services could not reach
the people as their voices could not be heard and there were very few institutional deliveries in the tribal areas of
Nandurbar and Amravati,. This was also one of the reasons for Maharashtra lagging behind states like Rajasthan
and Tamil Nadu. The community based monitoring process was a positive initiative but the officials took it in a
negative way. He cited the example of Salware block in Pune where corruption in health services was a common
practice but this has been reduced with the efforts of community monitoring. A survey was also conducted in this
regard with the help of SAATHI and questionnaires were distributed in 23 districts hospitals for a comparative
study. News articles were also published on this. The Aurangabad bench of the Bombay High Court took suo moto
cognizance of denial of health services. He also highlighted that monitoring was a good component and outcome of
49
community monitoring as it was reaching the people. He also stated that a state- level Jan Sunwai was held in
Mumbai in the month of April.
Mr. Shashikant Gaikwad stated that earlier people raised issues on services related to water supply, electricity etc.
They were not aware about their health rights and were silent on it. People are now aware about their health rights
due to constant interaction as a result of community monitoring. They started realizing the significance of health
services and started questioning the service providers and discussed issues related to health indicators like hygiene,
sanitation, immunization etc. Questions were raised on issues like availability of medicines in the health centers,
working of MPWs, ASHAs and medical officers.
The meetings were also attended by the medical staff, including doctors, which was a positive sign. He said that
earlier the people were hesitant to visit the government hospitals due to non -availability of medical facilities and
absence of doctors. They preferred visiting the private hospitals but now, the situation has changed. Information on
medicine stock was given, sonography operator was appointed and Anganwadi started functioning effectively.
Quality and regularity of nutrition was ensured which helped in improving the health status of children. All this has
been possible due to the level of awareness generation amongst the community. The community monitoring also
ensured timely immunization. As a result of the Jan Sunwais, many issues raised at the lower levels were taken up at
the district level instantly. There was also a suggestion to provide online information of all medical stores and
medicines available. It was seen that the participation of the PRIs leads to increased capacity building of the entire
process.
Rajasthan – Mr. Sohanlal, member of VHSC and Ms. Sashi Tyagi, -Ward Panch GRAVIS
Mr. Sohanlal, member of VHSC, Kachakhedi village told that the VHSC in his village was formed with the help of
an NGO. He stated that the untied fund of Rs 10,000 was used for improving sanitation in the village. Earlier, the
doctor in the PHC charged an amount of Rs 500 for delivery but with the VHSC’s efforts this practice was stopped.
Shashi Tyagi of Kachakhedi village said that Jan Sunwais were a positive step forward as they were based on
authentic information. In the first Jan Sunwai, eight women came forward to reveal how they were charged a certain
amount during their deliveries and did not receive the JSY amount for institutional delivery. The VHSC took up this
issue and confronted the doctor who was very annoyed at this and threatened to resign. But the people were
determined and after 15 days 36 JSY cheques were cleared by the Deputy CMHO in the second Jan Sunwai and
50
private practice was also banned. She also cited the example of a another PHC which was not functioning properly
and how the issue was raised in the Jan Sunwai by the people. The district officials who had earlier committed their
presence for the meeting did not turn up and subsequently the community locked the PHC and the CMHO was
forced to address the people. This resulted in the smooth functioning of the PHC and CHC thereafter. The untied
funds were also utilised properly. As a result of community monitoring, trained dais replaced by ASHAs under
NRHM were institutionalised.
She also narrated her experience of the Jan Sunwai held by Prayas, an NGO. The Jan Sunwai raised the issue of
compensating dais who accompanied women for delivery in the PHCs. As a result, it was decided that an amount of
Rs 200 would be paid to the dais who accompany women during pregnancies. Another result of the community
monitoring was that VHSCs started displaying the list of available medicines in the health centres. It was seen that
Jan Sunwai contributed greatly to the improvement of health services at the village level.
She emphasized the need for Jan Samvads at the government level so that sensitivity is created at the government
level. She also expressed concerned at the unspent funds under NRHM.
Smt. Shashi Tyagi clarified that the Rs 200 amount paid to the dais was paid by the government. Increased
participation of the PRIs and their positive contribution to the smooth functioning of health services was also
discussed.
Madhya Pradesh – Dr. Ramveer Singh, CMO Guna; Ms. Arti Pandey, Media Fellow
Dr. Ramveer shared some significant changes that occurred due to community monitoring process such as
information on untied funds, their right utilization, increased awareness of community on health issues. He also
stated that as a result of community monitoring, there was increase in immunization, proper functioning of blood
banks and rise in malaria health camps catering to around 1000 people etc. Communities faced several problems
like irregular visits of ANMs, especially in tribal areas, communication problem, caste-based discriminations etc
before the community monitoring.
Ms. Arti Pandey, Media Fellow from MP shared her experience form the Media Workshop conducted by the
NGOs. She said that earlier, the media was ignorant about NRHM provisions, defined role of ANMs, ASHAs,
Anganwadi workers , untied funds and their utilization etc. The Media Workshop helped the media in
understanding about NRHM and they were keen to see the report cards and highlight issues mentioned in the
51
report cards. She also shared her experience during the Vidhan Sabha election when malaria became an epidemic
but was not highlighted by the state-level media and their focus was on malnutrition as the CMHO kept focusing on
malnutrition. She also mentioned how maximum members of a particular family were victims of malaria in Guha
block of Bhind district. The media and VHSC members were able to shift the priority towards malaria successfully.
The media representatives were of the opinion that if the VHSCs were functioning smoothly and contributing to
the improvement of health services then the VHSCs should be strengthened through frequent trainings and media
can also play a positive role in it. It was also shared in the Workshop that there was instant follow-up and in
Chindwara district and action taken on issues raised by the media at the district level. They also highlighted various
problems faced at the grassroots level by ASHAs and ANMs. The VHSSC representatives wanted to know that
when the media was not involved since its inception why are they being involved at this stage.
It was seen that there was no coordination between ASHA and the VHSC. But co-ordination between the two
strengthened as a result of community monitoring. Moreover, ASHA is seen as a leader at the field level and is
usually under pressure from higher officials, villagers and her own family. The role of ASHAs must be appreciated if
there is an increase in the number of institutional deliveries. A strong support system must be created for ASHAs,
especially in the health centres of hilly areas. She concluded by saying that media should be considered as one of the
stakeholders in the community monitoring process.
Tamil Nadu – Mr. Vanamiyalan, Community Trainer
Mr. Vanamiyalan said that initially people’s response towards community monitoring was not very positive and they
were not keen to be a part of the process, but slowly people with bad experiences came forward and started
participating in the process. He stated that earlier, people did not recognise government health facility as a centre
for quality services, but now due to positive effect of community monitoring there is a growing faith is public health
system. Medical officers did not give proper explanation to people about their medical conditions and also did not
prescribe proper medicines and so the people were forced to consult private doctors. Moreover, medical staff were
not available in the government health centers and there was inadequate facilities. People visiting health centers
were suggested to buy disposable needles. It was a practice in most of the villages. The untied funds were also not
being utilised properly. He said that corruption was rampant, especially in the Maternity Benefit Scheme. People
became aware of their health rights and started availing the Rs 6000 amount of under the Maternity Benefit Scheme
which resulted in increased institutional deliveries as a result of community monitoring. He also shared several
52
positive outcomes such as ban on user fee (except X-ray, MRI and USG) but it was seen that many PHCs still
charged money. The efforts of community monitoring resulted in increased visits to OPD and less corruption in
Maternity Benefit Scheme.
Assam - Mr. Zahir Abbas, NGO coordinator, NRHM Assam
Mr. Abbas shared his experience of NRHM as he has been associated with NRHM since its inception. He stated
about the positive changes as a result of community monitoring which resulted in manifold demands by the
community. He observed that during 2005-06, the number of institutional deliveries was 1.5 lakh which increased to
4 lakh in the 2009. Moreover, the demand for institutional deliveries also increased Earlier, there were not many
VHSCs in Assam but now it is seen that 26, 000 VHSCs have been formed and VHSCs have been trained. The
NRHM was in an infant stage in 2007 and health facilities were minimal in the State in rural areas. Now the
situation has changed and there is an increased demand of health services leading to improved infrastructure at all
levels. The health centres have started displaying the list of JSY beneficiaries. Citizen Charter and drugs lists are
displayed on the board in the sub-centers and the PHCs. He mentioned that this year they would ensure that
VHSCs also get involved with ASHAs in organising Village Health and Nutrition Days.
He also stated a few drawbacks of community monitoring like presence of too many communities and groups like
the Planning and Monitoring Committee etc. It has also been seen that some community members were members
of two committees due to which their roles and responsibilities were not well-defined. He also stated that there was
lack of ownership and ignorance on the part of state officials at times.
Gajen, The Ant, Assam: The community monitoring process helped in awareness generation of communities on
their health rights. New villages were included in the Second phase. He also mentioned that the report was prepared
in Bodo language. Adding to this Ms. Ruchira of AVHA clarified that the report was prepared in Bodo language for
local level only and not for the state level. She also mentioned that there was confusion regarding the functioning of
the PHCs and it various committees. The problem faced by ASHA was that she had no company during
institutional deliveries. Moreover, the beneficiaries faced many problems while availing the JSY. All these problems
were raised in the NRHM meeting leading to subsequent reviews.
Discussions- Question/Answer
Mr. Ajay from Jharkhand spoke about the concept of community monitoring, its outcome activities leading to
better understanding of community action amongst common people. The process contributed towards the
awareness generation of the community. The problems faced by communities were solved during the Jan Sunwais
where report cards of each village was presented and main issues taken up. There was more red color in the report
cards initially because frontline workers were also unaware of their roles. It was seen that health facilities were not
functioning properly and corruption was one of the major issues. Gradually, the situation changed as the
communities tried to solve various issues and facilitated and supported the ANMs and Sahiyas to carry out their
work effectively.
Dr. Thelma concluded that the Session was enriching as different experiences were shared by people at the cutting
edge – BMOs, VHSCs, MOs, PRIs etc. He said that there must be a system to support and mentor community
monitoring activities at the National Secretariat level so that it becomes easier for the stakeholders to contribute.
He also felt that agencies like the RHC in Guwahati, SHRC in Chattisgarh could support and mentor the work done
by these stakeholders. He also stated that states like Assam and Jharkhand require additional support where the
presence of health services is minimal.
It was stated that the community monitoring process was earlier not that strong and the most important
stakeholders in the health system are the people and the communities. It was through NRHM that one got an
opportunity to hear the voices and issues within NRHM. One of the important step taken by community
monitoring is asking question whether one was able to reach 20% of the people under NRHM of the total
population of 6 lakh villages. The main role is to take this step forward. It is also seen that the process has not been
functioning smoothly the way it should have been. The experiences shared highlight the various problems faced by
health personnel including the ASHAs and the stakeholders and there is a need to be accountable and taking this
forward in a positive way.
The Dissemination Workshop concluded with a Vote of Thanks by Dr. Abhijit Das of CHSJ.
*******************************
54
Annexure I Agenda
Community monitoring in NRHM National Dissemination Meeting
June 16, 2010 S/L Time Detail
1 9:30 – 10:00 Registration 2 10:00 – 11:20
10:00 – 10.10 10:10 – 10:30 10:30 – 10:45 10:45 – 11:10 11:10 – 11:20
Session One: Introducing Community monitoring Chair: Mr P.K.Pradhan, Mission Director (NRHM) Co-Chair: Prof Ranjit Roy Chudhary Welcome – Mr A R Nanda, Convenor, AGCA Presentation on Community monitoring Processes– Dr Abhijit Das Member AGCA Presentation on Review of First Phase – S. Ramanathan Discussion Closing Remarks by Chairperson
3 11.20 to 11.35 Tea
4 11:35 to 1:00 11:35 – 12:20 12:20 – 12:45 12:45 – 1:00
Session Two: How Community monitoring has Supported Achievement of NRHM Goals Chair : Dr Ramesh Chandra Sagar, MD NRHM, Maharashtra, Co-Chair - Indu Capoor AGCA member Presentation from three states Maharashtra: Dr Abhay Shukla; Increasing accountability among providers and improving access and quality of services – an experience of Maharashtra Karnataka:Dr. Mohanraju, Addl. Director - Project Director (RCH) Karnataka; How Community Monitoring has supported achievement of NRHM goals in Karnataka Orissa: Mr Sudarsan Das; HDF – Promoting Local level planning by providing flexibility at state and community level; an experience of community monitoring in Orissa
Discussion Closing Remarks by Chair
5 1:00 to 2:00 Lunch
6 2:00 to 3:20 2:00 – 2:45
Session Three: Empowering Communities to Stimulate Demand and Accountability Chair : Mr Pravin Srivastava; Co-Chair- Ms. Indu Capoor Presentation from three states Rajasthan: Dr Narendra Gupta – Community monitoring a tool for Empowering Communities
55
2:45-3:10 3:10 – 3:25
Tamil Nadu: Dr Rakhal Gaitonde - How to use COMMUNITY MONITORING data for district level planning - a process of community empowerment and accountability Madhya Pradesh; Dr Ajay Khare – Experience of Madhya Pradesh Community Based Monitoring. Discussion Closing Remarks by Chair & Co-Chair
7 3.25 – 3.40 Tea 8 3:40 to 5:30
3:40 – 4:40 4:40 – 5:05 5:05 – 5:20 5:20 – 5:30
Session Four: Community monitoring : Partnership Challenges GO : NGO: Community Chair : Dr Tarun Seem ( PHFI) Co-Chair – Dr. Abhay Shukla Presentation from different stakeholder : Maharashtra – Yogiraj Prabhune; Media and Shashikant Gaikwad PRI representative PRI member Rajasthan – Sashi Tyagi GRAVIS and Sohanlal Kchawa VHSC Member Madhya Pradesh – Dr Ramveer Singh COMMUNITY MONITORING O Guna, Arti Pandey; Media Fellow Tamil Nadu – Mr. Vanamiyalan; Community Trainer Discussion Closing Remarks by Chair & Co-Chair Vote of Thanks: Dr. Abhijit Das, CHSJ
56
Annexure II
National Dissemination Meeting on 16th July –List of Participants
S. No
Name Organizations and Designation Contact Details Email
1 Mr Yogiraja Trabune, Media Sakal Newspaper, Maharashtra 9881099086
2 Mr Gajen Brahma The Ant 9957576037
3 Mr Satyavrat PFI 9971721383
4 Mr Matish PFI 9334188208
5 Dr Vanita Mukherjee Ford Foundation 24619441
6 Mr Sudarshan Das HDF - Orirsa 9437020225
7 Mr Shashi Kant Gaikward
VHSC, BPMC and PRI Member, Maharashtra
9096479951
8 Ms Jyotika Baruah VHAA Guwahati 9864044568
9 Mr Akai Minz State Program Coordinator- VSRC 9430330208 [email protected]
10 Mr Ajit Kumar CINI 9708572883
11 Dr. Shanti G 11-26851088
12 Ms Pranoti Packard Foundation 11- 41435468
13 Ms Sunita Anand CEDPA 11- 47488888 [email protected]
14 M Chartterjee World Bank 11- 41479133 [email protected]
15 Ms Mamta Kohli DFID [email protected]
16 Dr. Jyoti Ranjan HSRC Rajasthan [email protected]
17 Dr. Reena Bhatia VHAP [email protected]
18 Dr. Garima Pathak PHFI Garima.pathak@
57
19 Ms Devika Biswas BVHA Bihar Voluntry Health Association, LCT Ghat Manippura Patna -80001
[email protected], [email protected]
20 Ms Sarita Gupta Gravis Jodhpur 458,Milk Men Colony Pal Roa, Jodhpur Rajasthan
21 Dr Antony K.R State Health Resource Centre Chhattisgarh
SHRC Directore Kolilabadi Raipur -492001
22 Mr Man Mohan Sharma VHAP Chandigarh Voluntary Health Association of Punjab
23 Mr S. Ramanathan 3F, Shantniketan Chennai [email protected]
24 Mr Luit Goswami RVC RVC Village
25 Dr. dhananjay SATHI Flat No 3& 4 Aan E - Terase Kithrud Pune
26 Dr. Rakhal Gaitonde CHC No. 31 Prakanam st T. Nagar Chennai-17
27 Dr. Nitin Jadhav SATHI Flat No 3& 4 Aan E - Terase Kithrud Pune
28 Dr. Ajay Kumar Khare MPVS MPVS Bopal ajaykhar
29 Mr Puneet Kansal Director NRHM - MOHFW House 308 -D Nirman Bhawan
30 Dr. Ahay Shukla Coordinator – SATHI CEHAT Flat No.3 & 4, Aman E Terrace, Dahanukar Colony, Plot no. 140, Kothrud,Pune - 411 029, INDIA Ph.No. +91-20-25451413/ 25452325 Telefax- +91-20-25451413
31 Ms Madhavi PHFI 011-46046000 [email protected]
32 Dr Tarun Seem Head, Health System Support Unit - PHFI
986884411 [email protected]
33 Dr. Arundhati Mishra Additional Director – PFI [email protected]
34 Dr Saraswati Swain NIAHRD 0671-344203 [email protected]
35 Mr Billy Stewart DFID 9873660184 billy-stewart@dfid.
58
36 Ms Sudipta Mukhopadhyay
CEDPA India 9811926079
37 Mr S.Kaushik USAID 9811100263 [email protected] 38 Mr. Rameshchandra
Sagar MD NRHM Maharahtra 9867172972
39 Mr Ritesh ladha Prayas Chittorgarh 9461178475 [email protected]
40 Mr Sohan Lal Prayas – Rajesthan
41 Mr Narayam Sevake Head Society Udaipur 9001990719
42 Ms Seema Gupta VHAI 9868541655 [email protected]
43 Ms Shashi GRSVIS 0291-27855317
44 Dr. Shyam World Bank 011-41479184 [email protected]
45 Dr Thelma Naryan Community Health Cell, Bangalore, 9341257911 [email protected]
46 Mr.Govind Madhav Karuna Trust 0 9449599568 16+A Main 4th (T) Block Jayanagar Banglore -41
47 Mr. K.K Panchal Community Health Gandhinagar 9099075157 [email protected], [email protected]
48 Mr Ajay Srivastava CINI JHK Ashok Nagar Ranchi. 09431794215
49 Mr T. Vanamayilan TNSF T. Vanamayikam Areattamkudisai Munjur Pat Post Vellore District
50 Mr A.R Nanda Executive Director - PFI B-28 Qutub Institutional Area New Dlehi
51 Dr. Mohan Raju Addl. Director - Project Director (RCH) Karnataka Health & FW Karnataka
52 Ms Ragini Mishra Gram Sudhar Samiti Sidhi (M.P) 07882-251385 [email protected]
53 Mr B. Mohanthi RDI
54 Dr Homberg UNICEF New Delhi [email protected]
55 Ms. Zahir Abbas Mazumdar
NGO Coordinator - NRHM, Assam 9435074406 [email protected]
59
56 Mr Mohanmad Ahsan CEDPA 97171584847 [email protected]
57 Dr. Narender Gupta Prayas Chittorgarh 9414110328
58 Dr Kumudha Aruldas Population Council New Delhi - 986823962 [email protected]
59 Ms Smita Srinivasn SAGE B-1/I-1, MCIA Malkan Road smita.srinivasan@sage 60
A. M. Mir J & K Voluntary Health & Development Association
9419002734 voluntary health @gmail.com
61 Mr Briaj Kanti Shome Community Mobilization Expert – RRC NE
Regional Resource Centre (RRC-NE) Assam Medical Council Bhawan Six Mile, Khanapara, Guwahati-22 9435172953 [email protected]
62 Dr. J.Das RAC Guwahati Md NRHM Assam Guwahti -22 [email protected]
63 Mr JP Sharma UPVHA
5/459, Viram Khand Gomti Nagar, Lucknow . 09839180521 [email protected]
64 Dr. Duresh Kumar 9412321566
65 Ms Indu Capoor CHETNA
66 Mr Sant Kumar Mahato SATHI
183, Sukhvilas Colony Behind the Court Dist. Barwani (M.P) [email protected]
66 Dr. Umesh Singh CHC BMO, Kusmi Dist. Sidhi 9425477817, 09425331939
67 Ms Aarti Pandey JSA BPL MP Mg -5, Ram Complex II 34 Govind Garden Bhopal [email protected]
68 Mr Anuraag Ch PHFI
4,Vasant Kunj Insttutional Area ISID Complex – New Delhi [email protected]
60
69 Ms Reema Bhatia Delhi University Delhi University [email protected]
70 Mr Lauladhy UNICEF UNICEF llochring@unicef
71 Dr. Abhijit Das Director – CHSJ
Centre for Health & Social Justice Basement of Young Women's Hostel No. 2 (Near Bank of India) Avenue 21, G Block, Saket New Delhi-110017 Ph: 91-11-26535203, 26536163, 26511425 Telefax: 26536041 [email protected]
72 Ms Tulsi Manimuthu Administrative Assistant - CHSJ - Do - [email protected]
73 Ms Pratibha D Mello Program Officer – CHSJ - Do - [email protected]
74 Ms Gursimran Kaur Intern - CHSJ - Do -
75 Ms Moumita Ghosh Program Officer – CHSJ - Do - [email protected]
76 Ms Shelley Shaha Program Manager – CHSJ - Do - [email protected]
77 Ms Archana Program Manager – CHSJ - Do - [email protected]
78 Ms Sunita Singh Program Manager – CHSJ 9873482235
- Do - [email protected]
79 Ms Anita Gulati Admin Officer - CHSJ - Do - [email protected]
80 Mr Ishu Office Assistant - CHSJ - Do -
PARTICIPANTS FROM PRESS
1 Anjali IANS 9654242095 [email protected]
2 Abhay N Jha NE 9818018049
3 Ruby Kr ETV News 9313293125 [email protected]
4 Palesh Singh The Pioner 98689668591 [email protected]
61
Annexure III Session One: Introducing Community monitoring S. Ramanathan - Presentation on Review of First Phase Slide 1
Review of Pilot Phase of
Community Monitoring - An Overview
June 16, 2010
New Delhi
Slide 2
NRHM- Community
Monitoring• NRHM – is to bring about fundamental changes
in the delivery of health care.
• One of key elements of NRHM is its emphasis on accountability.
• “communitisation” – a process where the “community is …empowered to take leadership in health matters”.
• “process of communtisation of the health institutions itself would bring in accountability”.
• Community monitoring, as a part of the communitisation process is an approach to enable accountability
Slide 3
Overview of Review
Process
Slide 4
Objectives of Review
• To review whether objectives of
community monitoring process were fulfilled in the states.
• To identify key learning & challenges
for each state
• To highlight successful innovations
that were tried out in the states
• To identify lessons for up scaling
62
Slide 5
Review Process
• Review done in all 9 states, thru consultants & NHSRC
• Document review, field visits & meetings
• Draft report from each state, consolidated into national report
Slide 6
Review Addressed
• Institutional Mechanisms
• Process
• Programme Management
• Relation to other communitisationprocess
• Gains made
• Potential Outcomes
• Potential for sustainability & scaling up
• Recommendations for scaling up
Slide 7
Overview of Review
• Some salient points, from the review, esp. on the process, is highlighted in this
presentation.
Slide 8
Summary Observations
Slide 9
Overview
• CM in place since August 2007.
• Review observed that significant gains were made.
– Over 2000 VHSCs formed in 9 states, Report
cards prepared, Jan Samwads held & one
cycle of monitoring done
• Importantly, process enabled active
engagement with community & health dept.
Slide 10
Overview
• Reflective of commitment & passion of all stakeholders- GOI, state Govts, NGOs &
communities
• Spirit of volunteerism, a crusader
approach among all stakeholders
abundantly evident
• Imp. communitsation process of NRHM
being strengthened, more support required
though,
63
Slide 11
Significant Gains.
• Given short implementation time & one cycle of monitoring, Review didn’t assess outcomes.
• However, significant outputs observed.
• CM Process had
• Brought community centre-stage
• Provided VHSCs: identity & voice for community
• Enabled greater presence of women, SCs & STs in VHSCs.
• Opened space for community to negotiate with health department
• Enabled reaching the excluded
• Facilitated a better understanding by the community of their entitlements & rights.
Slide 12
Review Observed…
• Perception that health department is responsive is increasing.
• Process for improving accountability.
• Better connect between community & front line providers, in some instances.
• Has increased expectations by the community from health department
• Has potential to move people back to public health facilities.
• Potential for improving health & nutrition outcomes.
Slide 13
Key observations on
process & tools of CM
Slide 14
Community Mobilisation
• Community mobilisation received high attention.
• Village meetings, home visits specially among socially excluded groups, major strategy – equity perspective
• Innovations such as- kalajatha, hand bills, children’s parliament
• Community at centre-stage, voice & visibility for them
• Variations across states.
Slide 15
Institutional Arrangements
• VHSCs- significant social capital, however, need nurturing
• Committees above village level formed but not active compared to VHSCs.
• No review by mentoring teams at PHC, block & district levels.
Slide 16
Institutional Mechanisms
• GOI/MOHFW supportive
• National AGCA – mentoring & partial
implementation
• National Secretariat provided technical
support
• State & sub-state arrangements, formed
as per national guidelines
• Few states had additional arrangements
(state resource team) to provide support
64
Slide 17
Report Cards
• Tool helped community to learn about entitlements & rights.
• Tool was complex- Took substantial time
even for NGOs to internalise.
• Needs time to fill tool. Repeated visits to households often became necessary.
• Most VHSC members understand colour codes but unable to explain tool or how
ranking is derived.
Slide 18
Report Cards
• Reporting on equipment in health facilities need higher level of knowledge & training.
• Sharing report cards in villages helpful.
• Aggregation of village report cards largely
not done.
Slide 19
Jan Samwad
• Access & quality improved post Jan Samwad
• Post Jan Samwad, community perceives health department as being responsive.
• Empowering: community aware of entitlements & rights.
• NGOs seen as leading the process
• Health Officials do not want to be seen as being accountable to NGOs.
• Post Jan Samwad follow up & action taken to be informed to community
Slide 20
Capacity building
• Quality training materials & modules prepared at national level & adapted at state level.
• Resource pool of trainers created- a major resource- to be nurtured & upgraded.
• Transmission loss in cascade training
• More on-job support, supportive supervision & handholding would have helped.
• No significant participation of government functionaries in trainings.
Slide 21
Potential for sustainability & scaling
up
• Review observed that
• Sustainability was in question, given mixed response from state Govt’s
• Some states have included in PIP, others yet to do.
• Non Pilot states considering inclusion in PIP
Slide 22
Recommendations • Review recommended:
• Continued support from GOI
• Continue to build ownership in existing states.
• Initiate ownership building in new states.
• Anchor process in larger communitisationprocess & in existing institutional arrangement in health department
• NGOs at all levels to be involved as resource centres- technical support, capacity building, monitoring & documentation
• Link community monitoring to village health plans
• Involve ASHA- to help in planning & monitoring
65
Slide 23
Recommendations
• Review recommended that • Need for substantial simplification of process &
tools & local adaptation• Suggest an incremental approach. Increase
issues for monitoring gradually.
• Jan Samwad- to become gradually a community led process to enable community involvement & accountability.
• Need longer time frame for fruition
• Pilot supported largely by volunteerism- while up scaling realistic HR requirement to be done
• Need for adequate finances to realise NRHM promise of communitisation.
Slide 24
Thank You.
66
Session Two: How Community monitoring has Supported Achievement of NRHM Goals Presenters Dr Abhay Shukla: Increasing accountability among providers and improving access and quality of services – an experience of Maharashtra Dr Dr. Mohanraju: How Community Monitoring has supported achievement of NRHM goals in Karnataka Mr Sudarsan Das: Promoting Local level planning by providing flexibility at state and community level; an experience of community monitoring in Orissa
Presentation 1 Slide 1
Community based monitoring of
Health services in Maharashtra –
A process to improve access, accountability and quality of
health services
Dr. Abhay Shukla,
SATHI-CEHAT, Pune
and NRHM - AGCA
Slide 2
For addressing the crisis of the public health system …
the alternative to privatisationis communitisation
Slide 3
I. Some key innovations in the CBM
process in Maharashtra
II. Impact of CBM in improving access
and accountability of services – to meet
NRHM goals
III. Emerging directions – expansion,
community based planning, integration with other social services
Slide 4
Scale of first phase communitymonitoring in Maharashtra
• 225 Village Health, water supply, nutrition and sanitation committees
• 45 PHC Committees
• 15 Block Committees
• 5 District committees
Five pilot districts: Amaravati, Nandurbar, Osmanabad,
Pune, Thane
Slide 5
I. Some key innovations which have increased effectiveness of
the CBM process in Maharashtra
Slide 6
Pictorial tools for monitoring
Village tool includes -
• Information from Village
group discussions
• Interviews of beneficiaries
• Interview of MO PHC / CHC
• Exit interviews (PHC / CHC)
• Documentation of testimony
of denial of health care
67
Slide 7
Village HealthReport card –poster format
Slide 8
8
Village Health Calendar
Slide 9
Arogya Jagruti Divas• Arogya Jagruti Divas (Health
Awareness Day) organised in villages
by Kashtakari Sanghatana and Shramik
Mukti Sanghatana
• Discussions with groups of people and
health functionaries (ANM, MPW,
Anganwadi Sevika)
• Collection of information for report
cards
• Involving people in collective
activities like cleaning the village,
making of soak pits and cleaning of
wellsFilling of report cards
on Arogya Divas
Slide 10
Jan Sunwais at district level• About 90 Jan Sunwais
organised at PHC level during June – Sept. 2008 and then in Nov.-Dec. 2009
• 5 District level Jan Sunwais / Jan Samvadconducted during October 2008 and again in March - April 2010
• 80 to 250 people present in each District Jan Sunwai.
• Nearly 100 Jan sunwaisorganised till now
under CBM
Slide 11
State level conventions and review workshops
• State level convention organised in Mar. 2008 with participation of PHC, block, district and state level stakeholders for orientation
• First state review workshop in Nov. 2008 with participation of Union Health Ministry and PHC to state level stakeholders > 100 participants
• Second state review workshop in Apr. 2010 with all levels of stakeholders, health employee associations ~ 200 participants
Slide 12
State newsletter for Community Based
Monitoring in Maharashtra
• Dawandi! -‘ArogyaHakkansathicheMukhpatra’
• 24 page quarterly from June – Aug. 09, four issues so far
• 1500 copies distributed to PHCs, Rural hospitals as well as NGOs, POs and VHSCs
68
Slide 13
Over 200 news items published in various
newspapers so far – key role of media
Slide 14
II. Impact of CBM in improving access
and accountability of services –
to meet NRHM goals
Slide 15
NRHM has provided increased
funds, flexibility, enabling conditions…
CBM has complemented these with
community level ‘push’ to ensure that intended changes are
implemented
Slide 16
Change after six months of monitoring
October 2008 April 2009
Slide 17
05298Total out of 150
0510PHC staff Behaviour
0312PHC Services
069Anganwadi
0141Immunisation
0114PNC
069ANC
0114Use of untied funds
0132Adverse Outcomes (ID, MD)
0312
Curative Services at village
level
0015Disease Surveillance
WorsenedSameImproved
Velhe Block, Pune: Change in services in Village health report cards from Oct. 08 to Apr. 09
Slide 18
Overall trend of ‘Good’ ratings for village level Health services across 220 villages in Maharashtra
Good rating over 3 Phases
48
6166
0
20
40
60
80
Phase 1 Phase 2 Phase 3
• Disease Surveillance
• Curative Services
at village level• Use of untied
funds• ANC
• PNC
• Immunisation• Anganwadi• PHC Services
• PHC staff behaviour
69
Slide 19
Overall trend of ‘Bad’ and ‘Partly satisfactory’ratings for village level Health services across 220
villages in Maharashtra
Partly satisfactory and Bad evaluations over
3 phases
14%
20%23%
25%28%
16%
0
5
10
15
20
25
30
Phase 1 Phase 2 Phase 3
Slide 20
District wise trend of ‘Good’ ratings for village level Health services over 3 phases of CBM
District trends of good rating over 3 phases
- Pune
49%
81% 85%
0
20
40
60
80
100
Phase 1 Phase 2 Phase 3
Pune
District trends of good rating over 3
phases - Thane
35%
57% 63%
0
20
40
60
80
100
Phase 1 Phase 2 Phase 3
Slide 21
District wise trend of ‘Good’ ratings for village level
Health services over 3 phases of CBM
Nandurbar
41 37
60
0
20
40
60
80
Phase 1 Phase 2 Phase 3
Slide 22
District trends of good rating over 3 phases -
Osmanabad
67% 75% 67%
020406080
100
Phase 1 Phase 2 Phase 3
District wise trend of ‘Good’ ratings for village level Health services over 3 phases of CBM
District trends of good rating over 3
phases - Amaravati
45%55% 59%
0
20
40
60
80
100
Phase 1 Phase 2 Phase 3
Slide 23
Good evaluation trends over 3 P has es
for Immunis ation s ervic es
6971
90
50
60
70
80
90
100
P has e 1 P has e 2 P has e 3
Slide 24
Good evaluation trends over 3 P has es for
Ang anwadi s ervic es
54
75
87
40
50
60
70
80
90
100
P has e 1 P has e 2 P has e 3
70
Slide 25
0
200
400
600
2006-7 2007-8 2008-9 2009-10
Valhe PHC IPD - non CBM
0
100
200
300
2006-7 2007-8 2008-9 2009-10
Parinche PHC IPD - under CBM
Slide 26
Qualitative improvements
• Practice of prescribing medicine from private shops has largely stopped, some required medicines now from RKS
• Illegal charging and private practice by certain medical officers has now stopped.
• Utilization of untied funds for purchasing furniture, fences for Anganwadis has stopped and funds are used for other more relevant health related activities.
• Based on more accurate recording, there is now no discrepancy between Anganwadi records and independently taken weights of malnourished children.
Slide 27
Qualitative improvements
• Frequency of visits of ANM and MPWs in villages has led to improved village health services in many villages; there is definite improvement in immunisation coverage in these villages.
• Certain sub-centres and mobile units which were not working have now started functioning
• JSY beneficiaries are now being paid the rightful amount after being raised in the CBM process
• Boards regarding Citizen’s health charter and availability of medicines have been displayed
Slide 28
III. Emerging directions –
expansion, community based planning,
integration with other social services
Slide 29
Expansion of community monitoring process in 5 districts
One block nodal NGO selects 10 additional villages in each of the
existing PHCs
New Blocks selected by 2 block nodal NGOsThane5
Two block nodal NGOs select option of 3 new PHCs each in
existing blocks
New Block selected by one block nodal NGONandurbar4
Each block nodal NGO selects 10 additional villages in all the
existing PHCsOsmanabad3
One block nodal NGO selects option of 3 new PHCs in existing
block
New Blocks selected by 2 block nodal NGOsAmaravati2
New Blocks selected by each block nodal NGOPune1
Options selected for expansionDistrictSr.
No.
Increase from 15 to 23 blocks, fro
m 225 to 510 villages
Slide 30
Expansion to eight new districts
Gadchiroli, Chandrapur, Raigad, Kolhapur,
Nashik, Solapur, Aurangabad, Beed
Selection of district and block nodal
NGOs completed in
all districts
71
Slide 31
Moving ahead from monitoring to planning
• Now process of Community health planning being initiated in 225 villages of 5 districts
• Issues, priorities identified during monitoring would be basis for planning
• Jan sunwais to be enlarged into ‘People’s health planning conventions’
• Development of ‘Block people’s health planning proposals’ to feed into PIPs
Slide 32
Can CBM be broadened to monitor food
security, nutritional services, water supply?
• Can existing over 500 ‘Village health, sanitation, water supply, nutrition committees’ now also monitor some aspects of food security, water supply and more intensive monitoring of anganwadis?
• Can existing other networks help in providing orientation, resource persons, materials for such activity?
• Is there a possibility of proposing an integrated process to monitor various social services –leading to ‘integration from below’?
Slide 33
Challenges
• Lack of key systemic improvements may lead to
frustration among people
• District health officials not fully convinced – need
regular orientation
• Need to somewhat modify media strategy
• State monitoring and planning committee
formation long pending
• With positive background, need for intensified
support, timely decisions from State level
Slide 34
Without people, no major change is possible.
With people’s action, no change is impossible.
72
Presentation 2 Slide 1
1
By Dr. By Dr. By Dr. By Dr. MohanrajuMohanrajuMohanrajuMohanraju,,,,
Addl. Director Addl. Director Addl. Director Addl. Director ---- Project Director (RCH)Project Director (RCH)Project Director (RCH)Project Director (RCH)1
HOW COMMUNITY MONITORING
HAS SUPPORTED ACHIEVEMENT
OF
NRHM GOALS IN KARNATAKA
BY
Slide 2
2
Community Monitoring : -� Key strategy under NRHM
� Purpose -
-ensure reach of services in underserved and un
served areas; poor; women-children and
marginalized sections.
-Review working of health-care services.
� Promotes community's ownership.
� Paves way for community led action.
2
Slide 3
Mechanism� Village Health and Sanitation committees
-23020
� PHC Planning and Monitoring committees
-2193
� Taluk planning and Monitoring committees (Block)-147
� District planning and Monitoring committees
-30
� State planning and Monitoring committee.3
Slide 4
-Functions of planning and Monitoring
committees -
� Public awareness about their entitlements in health.
� Assessment of major health problems by PRA
� Develop Health plan prioritizing problems
� Present progress made (achievements. difficulties faced, action taken.etc.,) at village level.
� Take cognizance of care-denial, neglect and other complaints and prompt redressal.
� Collect and collate information from lower levels and report to higher level.
4
Slide 5
PILOTING in Karnataka(2007-2009)� 4 districts- Tumkur, Gadag, Chamarajanagar and
Raichur
(3 taluks in each district, 2PHCs in each taluk, and 5 villages from each PHC)
� District NGOs-Tumkur –AID INDIA
-Gadag-BGVS
(Bharat gyan vigyan samithi)
-Chamarajanagar-Karuna trust
-Raichur-CHC.
(community health cell) 5
Slide 6
6
73
Slide 7
0%
50%
100%
First RoundSecond RoundThird Round
Maternal Health Gaurantees
Fallout of Pilot project
Slide 8
Fallout of Pilot project - contd.
Slide 9
0%
50%
100%
First RoundSecond RoundThird Round
Untied Fund0%
50%
100%
First RoundSecond RoundThird Round
Quality of Care
Fallout of Pilot project - contd.
Slide 10
Learnings� Scalability of the model well appreciated
� Covered 562 villages against 180 scheduled
� Use of Kalajatha ( street play) and meetings prior to VHSC training yielded good results.
� Orientation of service providers is very important .
� Community processes extended behind community monitoring by involving planning also.
� Village report cards to made simpler
� Involvement of sectors other than health is crucial to attainment of total health
Slide 11
Village Heath Planning and Monitoring
committee
�Representatives from Gramasabha, ANM, MHW, school teachers, AWW, ASHA etc.,.
�Majority are women;ASHA member secretary
� Prepares village health plan, village health register and village heath report.
�Conducts Jansamvad once in a quarter
�Monitors all health care programmes in the village
� Educates and sensitizes community on health matters
11
Slide 12
Village Heath Planning and
Monitoring committee(contd.)
�Decides on using untied funds
� Sub committee on health for GP
�Collects donations in cash/kind
�Meets every month on first Monday afternoon.
�Accountable to gramapanchayat
�Reports to PHC planning and monitoring committee every 3 months.
12