1. 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

2. When those with power lack motivation … Then those with motivation must become empowered2

3. 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

4. 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

5. 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

6. 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

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

8. 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

9. 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

10. Village Health Calendar
Report card

11. 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

12. 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

13. 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

14. 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

15. 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

16. Objective positive impact of CBM in improving health services

17. 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

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

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

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

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

22. Increase in deliveries in PHCs covered
by CBM

23. 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

24. 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

25. 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

26. 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

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