Community based monitoring and planning (CBMP) of Health services in Maharashtra, India A framework for making public health services accountable Dr. Abhay Shukla, SATHI, State nodal organisation, CBMP Maharashtra 1 1

When those with power lack motivation … Then those with motivation must become empowered 2

Community based monitoring and planning – an emerging approach for accountability Community members and local activists identify gaps, issues, priorities for change Perspective of people’s health rights and accountability of public services is at the core Challenging the hierarchy of power and moving towards some level of equalization of power

Community monitoring and planning– national first phase States selected for first phase (June 2007 – Mar. 2009) Assam Chhattisgarh Jharkhand Karnataka Madhya Pradesh Maharashtra Orissa Rajasthan Tamil Nadu Maharashtra 112 million population

Scale of community based monitoring (CBM) in Maharashtra Five pilot districts: formation, orientation and activity of 500 Village Health Committees 78 PHC Committees 23 Block Committees 5 District committees From 2011, CBM has now increased from 5 to 13 districts, Expanded to cover 35 blocks and nearly 700 villages

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

Composition of CBM committees Public Health officials Elected representatives – Panchayat members Non-official delegates from lower committees CBO / NGO representatives

Key processes in CBM Capacity building of VHC and monitoring committee members through trainings Monitoring by committee members through data gathering and filling report cards at village, PHC, Rural Hospital levels. Based on report cards, dialogue with health functionaries (Public hearings or mass dialogue) State level conventions and dialogue

Pictorial tools for community monitoring Monitoring booklet forms Village Health Calendar 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

Village Health Calendar Report card

Preparation and display of Report Cards VHC members and block facilitators collect data regarding health services at village, PHC and Rural Hospital level. Report Cards prepared by them after analyzing data collected from community Displayed in poster form in the village, PHC and CHC

Public hearings: a forum for dialogue and accountability Report cards and cases of denial presented. Health officials respond to issues raised by people. Actions ordered regarding services at village, PHC and Rural hospital levels Over 200 Public hearings organised so far at PHC, block and district levels

State newsletter for Community based Monitoring: Dawandi Dawandi - State level Health rights newsletter 24 page quarterly from June 09, eleven issues so far 2000 copies distributed to PHCs, Rural hospitals as well as NGOs, POs and VHCs

Community based planning: Sharing power in the public health system Participation of CBMP representatives in Hospital development committee (HDC) meetings to suggest community health priorities for facility based planning. CBMP committees help develop annual block level plan proposals. Some pro-people shifts in priorities for HDC based planning, leading to improved services

Community based planning Availability of medicines for Diabetes and Hypertension in PHCs addressed and resolved through district planning. Patient oriented utilization of RKS fund – example of Velha RH People oriented utilization of RKS funds – Nasarapur PHC

Objective positive impact of CBM in improving health services

Qualitative improvements in health services in CBM areas Practice of PHCs prescribing medicine from private shops has largely stopped Illegal charging and private practice by certain medical officers has now been checked Frequency of visits of ANM and MPWs in villages has led to improved village health services in many villages Definite improvement in immunisation coverage Certain non-functional sub-centres, mobile units, lab facilities now started functioning

‘Good’ ratings for village level Health services across 220 villages in Maharashtra over 3 phases

‘Bad’ and ‘Partly satisfactory’ ratings for village level Health services across 220 villages

Higher increase in people’s OPD utilisation in PHCs covered by CBM

Higher increase in people’s inpatient utilisation in PHCs covered by CBM

Increase in deliveries in PHCs covered by CBM

Challenges to the CBMP process Health system related - In a few places resistance from medical officers, in some places staff uses it as forum to voice their own problems. Some officials (DHOs, Civil surgeons) tend to resist accountability Major shortages of medicines at all levels due to combination of ineffective procurement and distribution and corruption Shortages of staff due to lack of permanent appointments, poor working conditions, elitist nature of medical education Raise in user fees and moves for privatisation of certain services Resistance to accountability - hierarchical culture and ingrained lack of appreciation of people’s rights and initiative

Broader social relevance of CBMP For the first time, a systematic framework for accountability is being built into the Public health system which is ‘at scale’ and generalisable Community monitoring is much more bottom-up, widespread, decentralised than Lokpal type mechanisms and can improve services, involve people while checking corruption and increasing accountability CBM has the potential to help develop new systems of people-centred governance in the social sector

Some key lessons - 1 External accountability can trigger, complement and strengthen internal accountability processes CBMP can expand the sphere of representative democracy (e.g. M&P Committees), while also activating elected representatives Jan Sunwais / Samvads are a critical forum for accountability and health system change VHSNCs do not automatically become active, rather clear roles and status for members needs to be created and regular mentoring is required CBM is not automatically followed by Community planning; this needs dedicated capacity building, ensuring spaces and role for CSOs in planning processes

Some key lessons - 2 The role of rights oriented CSOs in facilitating the entire CBMP process is absolutely crucial Orientation of providers and officials at various levels is essential for the process to develop in a healthy manner State level events with simultaneous presence of officials from all levels enables effective action At each level, issues under control of officials at that level should be focussed upon, and other issues should be communiciated to higher levels Regular interlinkage and follow up across local, district and state levels enables corrective actions State level ownership and continuous mentoring of the process is extremely important Regular, adequate availability of funds is key to proper implementation of activities

Public systems can get transformed When the public takes initiative to reclaim and change the system!