People are reclaiming the public health system:

Community based monitoring and planning in Maharashtra

Dr. Abhay Shukla Coordinator, SATHI Member, NHM - AGCA

Why are Roman arches still standing 2000 years after they were constructed?

The engineers were held directly accountable… they had to stand under the arch when the scaffolding support was first removed after construction.

Democratising the Public health system – Claiming rights, changing power relations, improving services

• Need to

break through current alienation and unresponsive nature of Public Health services

through systematic social action • Neither rejecting nor uncritically accepting the existing ‘public’, but rather

transforming it through popular action

with alliance building and advocacy •

Community based monitoring and planning

as a key intervention to reclaim public health systems: developed in collaboration with PHS but led by network of civil society organisations

Transforming a PHC – rolling back private providers:

Story of Maligre PHC

• Maligre PHC in Ajara block of Kolhapur district was very poorly utilised until 2011 and most people in covered villages were unaware of its services • With initiation of CBM after first Public hearing the doctor changed; the new doctor is more dynamic and CBM activists organised meetings in all villages to inform people about services at PHC • Due to active PHC doctor and community mobilisation by CBM activists, now monthly deliveries have doubled, OPD has significantly increased and

three private clinics have closed down

Transformation in utilisation of Maligre PHC following Community based monitoring and planning Deliveries Indoor admissions Outpatient consultations 2010-11 (Pre-CBMP)

8 215 7,380

2013-14

125 857 17,157

Community based monitoring and Planning (CBMP) in Maharashtra

• • •

Covers 13 districts with formation, orientation and activity of multi stakeholder committees in Over 815 villages 120 PHC areas 35 Blocks

Planned expansion in 2014 to now cover more than 1000 villages, across 18 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

Composition of CBMP committees

Elected representatives – Panchayat members Public Health officials CBO / NGO representatives Representatives from lower committees and community members

Key processes in Community monitoring - Maharashtra

Community awareness programmes Data gathering and filling report cards Visits by committee members To health facilities Meetings of community based monitoring committees

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 450 Public hearings organised so far

at PHC, block and district levels

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

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

has improved of ANM and MPWs in villages

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

Significant improvement in PHC services in CBMP areas

Improvement in PHC services from Round I to Round IV

30 20 10 0 80 70 60 50 40

75 44 38 19

Round I Good Satisfactory

12.5 12.5

Round IV Bad

Increase in deliveries in CBMP covered PHCs compared with district averages

120 100 80 60 101% 40 48% 20 0 Increase in Thane district PHC deliveries Increase in Thane CBM PHCs deliveries

Community based planning:

Developing sharing of power in 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 2009-10 and 2011-12: Velha block Facility PHC Pasli PHC Velhe RH Velhe Analysis of expenditure RH Velha 2011-12: 2011-12 % increase expenditure expenditure after CBMP

2,13,053 not linked with CbMP

3,42,697 61% 405%

41% 77,523 linked with CbMP

3,71,223

59%

479%

‘

Reclaiming

’

elected 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, ensuring actions • Zilla Parishad members have ensured action and funds in some cases • Over 75 PRI members participated in State culmination workshop in July 2012 • Four ‘Sarpanch melavas’ in 2014

Dimensions of democratising and ‘reclaiming’ public health services

1. Promoting forums for direct democracy

– Jan sunwais and Arogya Gram Sabhas

2. Expanding representative democracy

through multi-stakeholder bodies – monitoring and planning committees

3. Reclaiming representative democracy

– activating PRI members to promote health rights

4.

Activating ‘internal accountability ’

through external accountability processes

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

Community based monitoring and action for ICDS initiated in 5 districts, 2 cities of Maharashtra

Emerging strategies

• Generalising

community monitoring in voluntary mode

in various new districts and regions • Decision to organise

‘Arogya Gram Sabhas’ in all villages

where services can be reviewed, planning decisions can be taken • Block level

federations

,

grievance redressal facilitation cells

,

resource units

working with youth • ‘

Communitisation’ of selected PHCs

in tribal areas – based on Nagaland model • Need to

move from Community monitoring as project to social process mode

with demand for generalisation of accountability processes

Some broad principles for Health officials concerned with CBMP

•

Partnering, not controlling:

CBMP is a shared activity, not entirely driven by officials but rather a joint effort; need to build partnerships with stakeholders ‘outside’ the system • •

Supporting rights based civil society organisations and recognising their contribution ‘Awareness generation’ of officials at various levels

is also necessary!

•

Dialogue is essential,

though it may sometimes seem to be

‘bitter medicine’!

•

Timely disbursal of necessary funds

continue the process – is essential to

funds excessively delayed are funds denied!

• Community based monitoring and planning means

sharing power in the health system …