Transcript Community Action in NRHM

Improving Health System and
Strengthening NRHM through
Community Action
Experiences, Lessons Learnt, Challenges and Way
Forward
Advisory Group on Community Action (AGCA)
September 11, 2012
Outline
1. The accountability framework under NRHM
2. Community action under NRHM - experiences
and gains
3. Scaling up community action in next phase of
NRHM and way forward
Accountability Framework under NRHM
– A three pronged process:
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community based monitoring,
external surveys and
routine program monitoring
– Communitization of the health institutions
• Prominent display of information on funds received,
medicines in stock, health right entitlements
– Public reports on Health at the State and district
levels to report progress to the community
Community Action in NRHM
• Mechanism to improve accountability and enable
better delivery of services
– Builds community awareness on health entitlements
– Provides a platform for community feedback and
dialogue with service providers
– Initiates corrective action and planning with
community engagement
– Leads to improved coverage and accessibility of health
services
In essence brings ‘public’ back into public health
Advisory Group on Community Action (AGCA)
• Group of civil society experts constituted by the
MOHFW in 2005 with Population Foundation of India
(PFI) as the Secretariat
• Mandate :
– Advise on developing community partnership and
ownership for the Mission
– Provide feedback based on ground realities, to
inform policy decisions
– Develop new models of Community Action and
recommend for further adoption/extension to the
national / state governments
First phase of Community Monitoring
( 2007-09)
9 States, 36 districts, 1620 villages
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Assam
Chhattisgarh
Jharkhand
Karnataka
Madhya Pradesh
Maharashtra
Orissa
Rajasthan
Tamil Nadu
Uttaranchal
Uttar
Pradesh
Rajasthan
Assam
Nagaland
Bihar
Manipur
Jharkhand
Gujarat
Madhya
Pradesh
W Bengal
Chhattisgarh
Orissa
Maharashtra
Andhra
Pradesh
Karnataka
Tamil
Nadu
Community action under NRHM experiences and gains
Story of change - Maharashtra
Outcomes of Community Action
• In Jamshet village, Thane district, construction of a
sub-center was incomplete for over two years
• Village health committee members discussed the
issue in a series of Gram Sabha meetings and in Block
monitoring committee meetings
• A Large group of community members went to the
sub-centre to ‘complete’ the construction through
‘Shramdaan’
• The sub-center building got completed and is fully
functional
Improvement in PHC services and utilisation,
Maharashtra , 4 districts
Improvement in PHC services from Round I to Round IV
50
50
40
40
30
30
80
20
70
10
75
60
10
0
Increase in Thane
district PHCs OPD
40
30
20
17%
0
50
44
34%
Increase in Thane
CBMP PHCs OPD
Increase in deliveries in Thane from 200708 to 2009-10
38
20
120
19
10
100
12.5 12.5
0
80
101
60
Round I
Good
Round IV
Satisfactory
Bad
40
48
20
0
District PHC average
CBM PHCs
Outcomes- Village health services in Rajasthan
(Sep 2008-Oct 2009)
District Alwar
40
36
District Chittorgarh
36
50
35
45
30
40
44
35
25
30
Number of Villages
20
24
25
20
15
9
10
8
16
15
10
5
0
5
5
1
0
1
0
0
First round
Second Round
District Jodhpur
First round
30
Second Round
District Udaipur
26
30
26
25
25
20
20
23
23
18
18
15
15
15
15
Poor
Average
10
10
5
4
5
4
2
2
0
0
First round
First round
Second Round
Second Round
Good
Stories of Change: Tamil Nadu
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In Mothakal Panchayat, Vellore, during the health planning
exercise the Mobile Medical Unit route was redrawn to
include one remote hamlet
Laligam PHC in Dharmapuri district did not have water supply.
The Panchayat President made sure that water connection
was provided immediately.
Outcomes -Experiences from states
• Enhanced trust and improved interaction between
provider and community
– Improvement in service delivery - ANC, PNC, immunization,
– Responsiveness of provider to community needs
– Improved provider attitude and behavior
• Community based inputs in planning and action
– Active involvement of PRI members in planning and
functioning of health facilities
– Local and need based planning, special groups / remote areas
– Appropriate planning and utilization of untied funds at VHSC,
PHC and CHC
Outcomes…
• Reduction in out of pocket expenditure
– Reducing demands for informal payments
– Ensuring timely and full payments of Janani Surksha Yojana
– Significant reduction on outside prescription
How did this happen?
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Trained VHSC and RKS
Community awareness on health entitlements
Display of Citizen’s charter and service guarantees
Collection of information and sharing of report
cards reflecting community experiences of health
services ; based on this development of village
health plans
• Active multi stakeholder Monitoring and Planning
Committees at PHC, Block and District levels
• Engagement with providers based on community
evidence – periodic public dialogue (Jan Samvad)
Participatory committees for
Feedback & Action
District Monitoring
& Planning
Committee
Block Monitoring
& Planning
Committee
PHC Monitoring &
Planning
Committee
Village Health
Committee
Feedback & Reports
State Planning &
Monitoring
Committee
Composition of
Community Based
Planning and Monitoring
(CBMP) committees
• Public Health Officials
• Delegates from
previous level
committees
• Elected
representatives
• CBO/NGO
representatives
Members of Community filling the report card
Community level sharing of health report cards
Panchayat level planning meeting
Review of community report cards
A public dialogue (Jan Samwad) in progress
A public dialogue(Jan Samwad) in progress
Challenges at state level
• Capacity constraints to institutionalize and scale
up CBMP
• Delayed fund flow, tedious reporting
requirements , interruption of activities
• Mechanisms to address systemic gaps emerging
from CBMP process and feeding into the planning
process
- vacancies/ posting, procurement and distribution of drugs
and supplies, training of health functionaries
• Institutionalizing minimum service guarantees,
grievance redressal mechanisms
Way Forward
Promoting Community Action
A Proposed Road Map for States
• Orientation of Program Managers/Designated Nodal
Officers
• Development of three year state level plans
• Identification of Nodal Agencies to facilitate
implementation in new states
• Strengthening capacities of PRI members and VHSNCs
• Reconstitute/strengthen RKS for better facility
management
• Inputs from CBMP for developing the district PIPs
• Institutionalise and publicise grievance redressal
mechanism
– Display of Citizen’s charter, minimum service guarantees and
mechanisms for corrective action
– Ombudsperson/ombudsman
Pre requisites for Scaling Up
• Adaptation of the model without losing
effectiveness
• State capacities to implement CBMP
• Presence and capacity of NGOs/ CBOs
• Building upon existing structures: ASHA, VHSNC,
PRI (SIRD & other training mechanisms)
• Grievance redressal mechanisms
• Adequacy and sustainability of funding
• Flexibility in administration rules and regulations
• Ownership at all levels
Engagement of PRI’s in NRHM
• In some areas, as members of VHSNC, PRI
members are mostly engaged at the
village/panchayat level only:
- Organize/ support health camps, mobilize women for
services in VHND
- Monitor health services and plan use of village untied funds.
• Uneven progress in engaging PRI under NRHM
- Lack of institutional modalities and clear guidelines on
participation from Ministry of Rural Development
-Variable capacity to take on planning and monitoring functions
- Cognizance of the role of PRI in the health system
Some measures to strengthen PRI
engagement
• Define and strengthen role of PRIs in monitoring
and supporting NRHM implementation
• Build capacity of PRI members on health and its
social determinants
– in training curriculum of (SIRD)
– review of current state curriculum and incorporating
changes with inputs from AGCA
• Facilitation of village health plans by PRIs and
endorsement through the Gram/Ward Sabha
Some measures to strengthen PRI
engagement
• Mentoring on participatory planning,
monitoring, including social audits (like NREGA
Social Audit Cell in Andhra Pradesh)
• Inclusion of PRI members in Rogi Kalyan
Samities and District Health Society/ Health
Mission
• Motivating Gram Panchayats - NRHM Awards
for best performing Panchayats
Proposed Role of AGCA
• Develop guidelines and training materials
• Develop communication material
• Strengthen capacities of State nodal officers and
institutions
• Support in designing grievance redressal mechanism
• Periodic review of progress on community action
• Undertake rapid assessment on status of community
action- Functioning of VHSC, RKS, Grievance
Redressal etc
Thank You