1. An experience from implementing Decentralized Health Planning (DHP) process in Maharashtra
A process of conversion of people’s demand into budget proposals (PIP)
Presented by Dr. Nitin Jadhav
SATHI- Support for Advocacy and Training to Health Initiatives

2. Expansion in 2015 now leading to coverage across 19 districts
Community based monitoring and Planning (CBMP) in Maharashtra – 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

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

4. Conceptual Framework: Process of Feedback & Action
State Planning & Monitoring Committee
District Planning & Monitoring Committee
Appropriate Action
& Intervention
Block Planning & Monitoring Committee
Feedback
& Reports
PHC Planning & Monitoring Committee
Village Health and Sanitation Committee

5. Composition of CBMP committees
Public
Health
officials
Elected
representatives –
Panchayat
members
Representatives
from lower
committees and
community members
CBO /
NGO
representatives 5

6. Community Based Monitoring and Planning of Health services in Maharashtra
Data gathering and
filling report cards
Community awareness
programmes
Community awareness
programs
Data gathering and
filling report cards
Constitution of Monitoring and Planning Committees at various levels
Public Hearings – Jan Sunwais
Building upon mandate and space of CBMP process, various innovations have been developed.

7. 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

8. 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

9. Public hearings (Jan sunwais): a forum for people’s voice 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 550 Public hearings organized so far at PHC, block and district levels

10. Public hearings – a key forum for accountability and engine of change

11. Significant improvements in health services in CBM areas
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
Definite improvement in immunisation coverage
Non-functional sub-centres, mobile units, lab facilities now started functioning
Significant rise in outpatient, inpatient utilisation in CBM areas

12. Markedly better services in CBM PHCs compared to non-CBM PHCs

13. Current status of decentralized planning - how participatory is process for......
? Village untied funds, Sub-centre untied funds
? Rogi Kalyan Samitis – at PHCs, Rural hospitals
? Block level health planning and District health plans
Mostly top-down planning with very little input from communities or grassroots organisations continues

14. Questioning some assumptions
Current form of involvement of Panchayats is adequate to carry out people-based planning.
Filling up of pre-designed state level formats, adding local figures is a form of decentralised planning.
Village health plans can be prepared mainly based on efforts of peripheral public health staff (ANMs, MPWs)

15. Questioning some assumptions
Planning for untied funds / RKS funds = decentralised planning
People in communities can participate in health planning just by providing the formal space
Need for large scale awareness building, fostering active representation with help of grassroots organisations, participatory processes and dialogue, supportive resources, positive responses from local officials.

16. Decentralized Health Planning process in Maharahstra

17. Challenges and Lesson learnt....
If Community engagement is to be increased in a real sense, we have to give them concrete activity and mandate to take decisions. Such spaces could be useful to ensure community engagement.
Building consenses among various stakeholders especially in the community is huge task.
The multi-stakeholder bodies are essential and effective especially in the context of decision making and creating pressure group for execution.
As Health Planning is complex process where multi-stakeholders are involved, the role of Civil Society Organizations is very crucial and important especially in the context of facilitation and coordination.
Some concrete and prompt actions from higher and local health officials are very helpful in maintaining motivation of various stakeholders.
In order to ensure participation and cooperation of field level Health officials, the mandate at least in the form orders should be given from higher level officials to field level staff.

18. Key learnings and lessons from previous experiences related to DHP
Community level processes are crucial and most essential component of DHP.
It is team work with involvement of various stakeholders such as community, Health providers & officials, RRI and CSOs.
For moving towards sustainability, DHP processes should be linked with existing structures and processes of NHM/Public Health System.
The role of NHM officials especially DPM, DAM at district level and SPM/SAM at state level is crucial and central in DHP, as they are an expert in the preparation of PIP.

19. Obstacles faced while working in context of PIP-
The government’s process of preparing the PIP is completed in very less time. Besides there are very few spaces in this PIP for community to present their health needs and for them to be incorporated in the PIP.
The current PIP framework is complicated and limited and it needs to be modified.
The local Health officers and providers do not have the clarity about the importance of preparing the PIP.

20. Step- 1: Community mobilization for identification of community needs
Activity
Proposed stakeholders
Meetings with VHNSC and community with participation of active community members, marginalised people and women
VHNSC committee
Community especially marginalized community groups and women
Output/Outcome-
- Adequate understanding among community about DHP processes and proposed intervention
-List of identified community needs
Minimum 5 prioritized needs about
Village and sub centre level health services
PHC related health services
RH/SDH related health services
Minimum 5 prioritized needs about
Village and sub centre level health services
PHC related health services
RH/SDH related health services

21. Step-3: Compilation, categorization and prioritization of community needs
Proposed stakeholders
Activity
Members of RKS committee
Members of Monitoring & Planning committee
Medical Officer and staff of PHC
RH superintendent and staff of RH level
Joint meeting between RKS committee and Monitoring & Planning committee in each selected PHC and RH
Output/Outcome
List of categorized and priorities community needs
Issues which can be resolved through dialogue or through CBMP.
Issues which require budget/funds (RKS or PIP).
Systemic or policy level issues which can be resolved at state or district level.
Catogorization

22. Proposed stakeholders
Step- 5 : Compilation of community needs at block level and development of budget proposal based on prioritized community needs
Proposed stakeholders
Activity
Chairperson and active, interested members of RKS committee from each selected PHC and RH
THO office and block accountant
Medical officers and RH superintendent
District NHM cell especially DPM, DAM
Block level workshop for various stakeholders.
Output/Outcome-
List of prioritized community based budget proposals
At least one meeting of various stakeholders at block level for scrutinizing and finalizing key issues  
- To orient and understand about DHP to RKS committee
- To discuss and finalize action plan related to community needs which can be resolved through PIP budget.

23. Step- 8: Finalization of budget proposal at district level
Activity
Proposed stakeholders
Multi-stakholder district level meeting including DPDC/District Monitoring and Planning committee
Members of District Planning and Developemnt Committee
DHO and CS
DPM and DAM
Output/Outcome-
Develop understanding how community can be converted into budget proposals
Copies of developed budget proposals in each selected intervention block.  
- To srcutinize and give final approval to devloped budget proposals
- To discuss and develop plan of action for intervening in the next year’s PIP preparatiom process

24. Proposed stakeholders
Step- 9 : State level review of included community needs based proposals in district PIP
Activity
State AGCA meeting for reviewing Budget proposals and addressing policy and systemic level issues
Proposed stakeholders
MD, NHM, Maharashtra
Members of State Mentoring Committee
NHM senior officials
SPM and SAM
Representatives of SHSRC
CBMP implementing State nodal organization
Output/Outcome
-Copies of approved community based budget proposals
-Ensure inclusion of developed budget proposals in each intervention districts.  

25. Participatory Audit and Planning for ensuring Community-oriented utilization of RKS funds25 25

26. Key findings of study conducted by SHSRC, showing status of RKS fund expenditure in Maharashtra

27. Key gaps and issues related to RKS identified and raised through CBMP process
Funds are not being used as per community needs, and there is little transparency in their usage
Health officials dominate the decision making for planning as compared to other committee members.
Lack of awareness and information among committee members about their roles and responsibilities.
Irregularities in record keeping related to the expenditure of funds as well as functioning of RKS
Through the Participatory Audit and Planning process, an attempt was made to overcome all these gaps.....

28. Participatory Audit and Planning of RKS - Process developed in selected health facilities of Thane, Nandurbar and Raigad since In each block, 2 PHCs and 1 RH / SDH were involved, covering 9 health care institutions. - Based on positive impacts of the process, PAP was up-scaled to cover 26 CBMP blocks, involving 65 PHCs during Jointly facilitated by Block nodal NGOs and District RKS coordinators.

29. Key steps in Participatory Audit and Planning
PHC level CBMP committee (incl. PRI members) developed and displayed a poster on details of expenditure of RKS funds in previous year; analyzed to figure out the heads which had incurred maximum spending.
Joint meeting between RKS members and Monitoring and Planning Committee members in the premises of Health Institution where key findings from posters were shared.

30. Key steps in Participatory Audit and Planning
Examination of financial documents and records related to RKS was followed by physical verification of items purchased through RKS funds.
Based on findings and observations, planning was done for next year’s RKS fund usage.
Issues such as inappropriate record keeping, irregularity in RKS meetings, mismanagement of RKS funds were raised and discussed.
- Based on these issues and prioritising patients needs, planning for current year’s RKS funds has been done.

31. Example of PAP findings and changes: CHC Dhadgaon, Nandurbar
A fridge and cooler for CHC were purchased last year but were in staff quarters at the time of the visit. RMO of the DH with the team said these items should be immediately brought into the hospital, and this was done.
Curtains were purchased from the RKS funds, but put up only in the doctors’ cabin. The doors of other wards like General Ward, Women’s ward, did not have any curtains. Now curtains have been purchased and put on doors of all wards
Based on discussion, the current year RKS funds were used for fixing nets on all windows to protect inmates from mosquitoes.
The water tanks of the hospital had lot of leakage so these were replaced using the current year RKS funds.

32. Thank you!!!!