Key Learning from Day 1 & Lessons for Scaling up National Consultation on Community Action for Health October , 2014

Day One Proceedings Context setting inaugural Five thematic sessions: -State experiences of Community Based Planning and Monitoring – Bihar, Maharashtra and Tamil Nadu -Role of PRIs: Bihar, Chhattisgarh, West Bengal, -Community action in urban areas: Bangalore, Pune, Vadodara -Grievance redressal: Social Audit, Movement for Right to Food -Perspectives of Development Partners: UNDP, DFID, Packard and BMGF

Scaling up Framework Step 1: Clarity and Understanding on Features of the model/approach; Context, Institutions; Partnerships; Stakeholders Step 2: Establishing Preconditions for Effective Scaling Up: Legitimizing Change, Advocacy, and Constituency Building, Mobilizing Resources Step 3: Implementing at Scale: Modifying and Strengthening Organizations and Institutional rules and regulations; Convergence, and coordinated action; Tracking Performance, Review and feedback; Adaptation; maintaining momentum

Features of Model/Approach No “one” prescription: Nature of “model” to promote the process depends on the context and the issue Approaches to community action: Jaankari; Sunwai; Karwai; Bhagidari; Suraksha; “Tools and traffic lights”- maybe not, but a first step in evolving the process. Phasing of community action facilitates implementation Use of data as a way of triggering debate in the community – and to surface issues to the health system Legal recourse- as in Right to Food; Public Hearings, Score Cards; Citizen Reports; Critical issue: what elements of the model can be embedded in which context- with a vision of scaling up community action- whether the goal is near or distant depends upon a range of factors Outcomes: positive and significant ; but slow in coming- what combination of factors can speed up outcomes? Going to scale- start with simple and standardized approach: keeping the spirit alive- need committed facilitators Facilitation is a parameter for successful outcomes: and is non negotiable - handholding and mentoring of community based platforms NGOs, CBOs, Community Processes support structures, but level of support needed is intensive

Various platforms used to promote community action: Panchayati Raj Institutions, Rogi Kalyan Samities, Village Health, Sanitation, and Nutrition Committees; Self Help Groups ; Civil Society Networks Inclusion – marginalized; CBOs, PRIs, service providers and officials of the public health system. Still preponderantly women: need to engage men Youth – need to go beyond seeing them as being recipients of services but a key stakeholder in community action Realising rights and the business of Governance- needs to be shared by the community Governance may not be the determining factor for support to community action - paradoxically better success in areas where health systems still need strengthening Removing information asymmetry on people's understanding of health rights and entitlements is critical Model- context-institutions: all need tweaking to get best fit Scaling up Community Action- cannot afford model fidelity/exclusion of stakeholders Context, Partnerships

Advocacy/Legitimization Advocacy /dissemination of success and positive outcomes is critical Need to project outcomes on which there is programmatic focus to enable synergy in functioning: increased JSY, increased OPD/IPD attendance; Increased use of RKS funds for patient oriented activities Takes a long time to reach maturity, need to approach it in phases: AGCA/Secretariat: Mechanism for advocacy; cross learning/sharing Important to be certain of adequate, sustained and timely funding support Commitment of 0.5% for social audits: is 1% too much of an ask for monitoring, planning, grievance redressal?

Implementing Community Action at Scale Building on existing systems facilitates scaling up – needs changing mindsets Changing relationships of power and hierarchies- deeply embedded in patient –provider relationship Balance between identifying actions to be taken at local level and those that need systemic action Is the issue one of design or implementation? Can such community action be used to correct design flaws? NGO run versus NGO facilitated: what better enables scaling up in the system? Integrating into existing systems without the provision of additional resource- human and financial – myth Unit of planning: Village level planning versus cluster level planning Urban complexity and heterogeneity- challenge to community action for health

Implementing Community Action at Scale No guarantee that once there is demonstrated success: automatically leads to scaling up Despite sustained advocacy by AGCA supported by centre through / instruments such as conditionality: why has this not yet been scaled up across states: what are the concerns? Inclusion in PIP- and moving from nine to 22 states- what does it take to get to a vibrant process? Why has this not been scaled up: “bits and pieces”, “fits and starts”; Grievance Redressal systems in place: effectiveness questionable; who monitors feedback and action? Need to arrive at an optimum combination of Center, AGCA and state led actions that embed community action in health.

Implementing Community Action at Scale Implementing Community Action: needs independent and autonomous structures – not a substitute for supervision Social audit for MGNREGA proves that this is politically viable Convergence: essential but elusive- better at grassroots; harder up the chain Gram Sabha: one way of enabling this: thematic Gram Sabha: Arogya Gram Sabha

Points to consider for the future National Health Assurance Mission: Social Movement for Health and Health Assurance- necessitates dialogue and action involving the people and the health system Sufficient evidence to demonstrate that it is possible for government to fund community monitoring and accountability processes at scale Community action for health- a process of empowerment not just to the community but supportive prop to those in the health system who want public services to deliver.