Improving Health System and Strengthening NRHM through Community

Improving Health System and Strengthening NRHM through Community Action Experiences, Lessons Learnt, Challenges and Way Forward Advisory Group on Community Action (AGCA) September 11, 2012

Outline 1. The accountability framework under NRHM 2. Community action under NRHM - experiences and gains 3. Scaling up community action in next phase of NRHM and way forward

Accountability Framework under NRHM – A three pronged process: • • • community based monitoring, external surveys and routine program monitoring – Communitization of the health institutions • Prominent display of information on funds received, medicines in stock, health right entitlements – Public reports on Health at the State and district levels to report progress to the community

Community Action in NRHM • Mechanism to improve accountability and enable better delivery of services – Builds community awareness on health entitlements – Provides a platform for community feedback and dialogue with service providers – Initiates corrective action and planning with community engagement – Leads to improved coverage and accessibility of health services In essence brings ‘public’ back into public health

Advisory Group on Community Action (AGCA) • Group of civil society experts constituted by the MOHFW in 2005 with Population Foundation of India (PFI) as the Secretariat • Mandate : – Advise on developing community partnership and ownership for the Mission – Provide feedback based on ground realities, to inform policy decisions – Develop new models of Community Action and recommend for further adoption/extension to the national / state governments

First phase of Community Monitoring ( 2007 -09) 9 States, 36 districts, 1620 villages • • • Assam Chhattisgarh Jharkhand Karnataka Madhya Pradesh Maharashtra Orissa Rajasthan Tamil Nadu Uttaranchal Uttar Pradesh Rajasthan Assam Bihar Nagaland Manipur Jharkhand Gujarat Madhya Pradesh W Bengal Chhattisgarh Orissa Maharashtra Andhra Pradesh Karnataka Tamil Nadu

Community action under NRHM experiences and gains

Story of change - Maharashtra Outcomes of Community Action • In Jamshet village, Thane district, construction of a sub-center was incomplete for over two years • Village health committee members discussed the issue in a series of Gram Sabha meetings and in Block monitoring committee meetings • A Large group of community members went to the sub-centre to ‘complete’ the construction through ‘Shramdaan’ • The sub-center building got completed and is fully functional

Improvement in PHC services and utilisation, Maharashtra , 4 districts Increase in deliveries in Thane from 200708 to 2009 -10 120 100 80 60 40 101 20 0 48 District PHC average CBM PHCs

Outcomes- Village health services in Rajasthan (Sep 2008 -Oct 2009) District Alwar 40 36 36 50 35 45 30 40 35 25 30 20 Number of Villages District Chittorgarh 44 24 25 15 20 9 10 8 16 15 10 5 0 1 5 5 0 1 0 0 First round District Jodhpur 30 25 20 Second Round 26 First round 30 25 23 20 18 15 15 Second Round District Udaipur 26 23 18 15 15 10 10 5 4 2 2 0 0 First round Second Round Poor Average Good

Stories of Change: Tamil Nadu In Mothakal Panchayat, Vellore, during the health planning exercise the Mobile Medical Unit route was redrawn to include one remote hamlet Laligam PHC in Dharmapuri district did not have water supply. The Panchayat President made sure that water connection was provided immediately.

Outcomes -Experiences from states • Enhanced trust and improved interaction between provider and community – Improvement in service delivery - ANC, PNC, immunization, – Responsiveness of provider to community needs – Improved provider attitude and behavior • Community based inputs in planning and action – Active involvement of PRI members in planning and functioning of health facilities – Local and need based planning, special groups / remote areas – Appropriate planning and utilization of untied funds at VHSC, PHC and CHC

Outcomes… • Reduction in out of pocket expenditure – Reducing demands for informal payments – Ensuring timely and full payments of Janani Surksha Yojana – Significant reduction on outside prescription

How did this happen? Trained VHSC and RKS Community awareness on health entitlements Display of Citizen’s charter and service guarantees Collection of information and sharing of report cards reflecting community experiences of health services ; based on this development of village health plans • Active multi stakeholder Monitoring and Planning Committees at PHC, Block and District levels • Engagement with providers based on community evidence – periodic public dialogue (Jan Samvad) • •

State Planning & Monitoring Committee District Monitoring & Planning Committee Block Monitoring & Planning Committee PHC Monitoring & Planning Committee Village Health Committee Feedback & Reports Appropriate Action & Intervention Participatory committees for Feedback & Action Composition of Community Based Planning and Monitoring (CBMP) committees • Public Health Officials • Delegates from previous level committees • Elected representatives • CBO/NGO representatives

Members of Community filling the report card

Community level sharing of health report cards

Panchayat level planning meeting

Review of community report cards

A public dialogue (Jan Samwad) in progress

A public dialogue(Jan Samwad) in progress

Challenges at state level • Capacity constraints to institutionalize and scale up CBMP • Delayed fund flow, tedious reporting requirements , interruption of activities • Mechanisms to address systemic gaps emerging from CBMP process and feeding into the planning process - vacancies/ posting, procurement and distribution of drugs and supplies, training of health functionaries • Institutionalizing minimum service guarantees, grievance redressal mechanisms

Way Forward

Promoting Community Action A Proposed Road Map for States • Orientation of Program Managers/Designated Nodal Officers • Development of three year state level plans • Identification of Nodal Agencies to facilitate implementation in new states • Strengthening capacities of PRI members and VHSNCs • Reconstitute/strengthen RKS for better facility management • Inputs from CBMP for developing the district PIPs • Institutionalise and publicise grievance redressal mechanism – Display of Citizen’s charter, minimum service guarantees and mechanisms for corrective action – Ombudsperson/ombudsman

Pre requisites for Scaling Up • Adaptation of the model without losing effectiveness • State capacities to implement CBMP • Presence and capacity of NGOs/ CBOs • Building upon existing structures: ASHA, VHSNC, PRI (SIRD & other training mechanisms) • Grievance redressal mechanisms • Adequacy and sustainability of funding • Flexibility in administration rules and regulations • Ownership at all levels

Engagement of PRI’s in NRHM • In some areas, as members of VHSNC, PRI members are mostly engaged at the village/panchayat level only: - Organize/ support health camps, mobilize women for services in VHND - Monitor health services and plan use of village untied funds. • Uneven progress in engaging PRI under NRHM - Lack of institutional modalities and clear guidelines on participation from Ministry of Rural Development -Variable capacity to take on planning and monitoring functions - Cognizance of the role of PRI in the health system

Some measures to strengthen PRI engagement • Define and strengthen role of PRIs in monitoring and supporting NRHM implementation • Build capacity of PRI members on health and its social determinants – in training curriculum of (SIRD) – review of current state curriculum and incorporating changes with inputs from AGCA • Facilitation of village health plans by PRIs and endorsement through the Gram/Ward Sabha

Some measures to strengthen PRI engagement • Mentoring on participatory planning, monitoring, including social audits (like NREGA Social Audit Cell in Andhra Pradesh) • Inclusion of PRI members in Rogi Kalyan Samities and District Health Society/ Health Mission • Motivating Gram Panchayats - NRHM Awards for best performing Panchayats

Proposed Role of AGCA • Develop guidelines and training materials • Develop communication material • Strengthen capacities of State nodal officers and institutions • Support in designing grievance redressal mechanism • Periodic review of progress on community action • Undertake rapid assessment on status of community action- Functioning of VHSC, RKS, Grievance Redressal etc

Thank You