Dr. Abhay Shukla, Member, National Health Mission - AGCA 11 Community based monitoring and planning (CBMP) of Health services in Maharashtra: Bridging the gap between Health services and communities to promote people’s health

When the powerless begin to speak, and the powerful begin to listen, Its an unbeatable combination for positive change.

Supply side inputs by NHM- resources for implementation of Health Services Demand side inputs through community action - Independent regular feedback, demand generation, community initiative Major improvements in delivery of Health Services

Community based monitoring and Planning (CBMP) in Maharashtra – 2007 to 2016 Covers 14 districts with formation, orientation and activity of multi- stakeholder committees in Nearly 1000 villages 140 PHC areas 40 Blocks Expansion in 2015 now leading to coverage across 19 districts

Levels of committees for Feedback & Action State Planning & Monitoring Committee District Monitoring & Planning Committee Block Monitoring & Planning Committee PHC Monitoring & Planning Committee Village Health, Water supply, Nutrition and Sanitation Committee Elected Reps PRI Public Health officials CBO / NGO reps Reps from lower level and community

Village level data collection on Health services through group discussion

People-friendly tools for community monitoring Monitoring booklet forms Interview format for MO PHC / CHC Actual medicine stock taking at PHC/CHC Format for Exit interview (PHC / CHC) Documentation of testimony of denial of health care

Preparation of Village Health Report Cards VHC members and block facilitators collect data regarding health services at village, Sub- centre, PHC and Rural Hospital levels. Report Cards prepared by them after analyzing data collected from community Displayed in poster form in the village and PHC

Filling report cards

Visits to Health facilities – PHCs, Rural hospitals to gather information

Use of SMS through mobile phones to collect & analyse CBMP data Survey to check availability of medicines in 36 PHCs across 12 districts Survey conducted to assess actual round the clock availability of Medical officer and nurses in 24 x 7 PHCs, by covering 25 PHCs providing 24 x 7 services, and 24 non-24x7 PHCs located across 12 districts Survey to assess quality of laboratory services available at PHCs, an SMS based survey was undertaken in 123 PHCs across Maharashtra

Public hearings (Jan sunwais / Jan samvads): a forum for people’s voice and accountability Report cards and cases of denial of health care presented Health officials respond to issues raised by people Actions ordered regarding services at village, PHC and Rural hospital levels Over 500 Public hearings organised so far at PHC, block and district levels

Community helps to solve problems of health care providers In Bhongowali PHC in Bhor block of Pune district, the doctor was not staying at the PHC. Raised during Jan Sunwai, he complained that he did not have quarters. A CBM committee member offered to arrange a house for him in the village on the spot. Today doctors are regularly staying at the PHC even at night.

State level recognition by CBMP process to well performing health care providers

‘Reclaiming ’ Panchayat representatives Panchayat members now are taking active role and contributing to both community monitoring and planning Major role of Panchayat members in CBMP committees – making surprise visits, Zilla Parishad members have ensured action and funds in Over 75 PRI members participated in State culmination workshop in July 2012, ‘Sarpanch melavas’ in 2014 State level PRI convention in March 2016

Practice of PHCs prescribing medicine from private shops has largely stopped Illegal charging by certain medical officers has now been checked; challenging corruption Frequency of visits of ANM and MPWs in villages has improved Rude and abusive behaviour stopped Significant improvements in health services in CBMP areas Definite improvement in immunisation coverage Non-functional sub-centres, mobile units, lab facilities now started functioning Significant rise in outpatient, inpatient utilisation in CBMP areas

Matched profile of Infrastructure and Medical officers in both sets of PHCs

Significantly better services in CBMP PHCs compared to non-CBMP PHCs

Community based planning: People’s priorities inform the public health system Participation of CBMP representatives in Health facility committee (RKS) meetings to suggest community health priorities CBMP committees develop annual block level PIP proposals. Major pro-people shifts in priorities for RKS based planning in PHCs and CHCs leading to improved services

Comparison of total Expenditure by RKSs between and : Velha block Facility expenditure expenditure % increase after CBMP PHC Pasli 2,13,0533,42,697 61% PHC Velhe 61,7422,50, % RH Velhe 77,5233,71, %

Present status - activities by CBMP organizations during April 15 – Jan 16 continued through their own resources More than 365 Community awareness and mobilization programs at village level conducted through CSO resources. More than 100 PHC level Monitoring and Planning Committee meetings on voluntary basis. without funds from State NHM. More than 40 District level Review and Planning meetings conducted by implementing CSOs on their own.

Emerging innovations towards sustainability and scaling up Federations of VHSNCs and community monitoring committees – solving various issues beyond health care (Pune) Grievance redressal facilitation cells – resolving issues locally (Amaravati) Training of youth volunteers in large numbers to reach out to many new villages, sparking off community action (Dhadgaon, Purandar) Social audit of RKS leading to improved and more community oriented utilisation Decentralised, participatory planning for developing block and district PIPs Organising ‘Arogya Gram Sabhas’ in all villages

Promoting voluntary action- strategy for scaling up CBMP Need to move from Community monitoring as project to social process mode towards wide generalization Advertisement published across Maharashtra in Jan inviting organisations to implement CBM in voluntary manner -121 organisations applied; 34 selected - regional workshops organised to build capacity Simplified and concise tool developed for rapid, low intensity survey at village and PHC levels – data collection followed by block level Jan samvads in 30 blocks Example - Lok panchayat in Ahmadnagar district with self-help groups organised Jan samvad with over 250 people, where filthy situation of two PHCs was raised with photos - led to complete cleaning of both PHCs within 2 days

Some broad suggestions for Health officials concerned with CAH / CBMP Partnering, not controlling: CAH should not be entirely driven by officials but rather a joint effort; need for partnerships with stakeholders ‘outside’ the system who are for improvements Supporting rights based civil society organisations and recognising their value ‘Awareness generation’ of officials and staff at various levels is also necessary! Dialogue is essential, though it may sometimes seem to be ‘bitter medicine’! Timely disbursal of necessary funds is essential to continue the process – funds excessively delayed are funds denied! Community based planning means sharing power - moving from a ‘bureaucratic’ to ‘democratic’ health system!

The Public health system can get revitalized - When we make this system democratic and participatory!