NRHM

1. Meeting People’s Health Needs NRHM ABRIDGED VERSION 5th September 2009 Community Monitoring & Planning under NRHM National Rural Health Mission Ministry of Health & Family Welfare Government of India

2. Community Monitoring & Planning Why What and How (National level processes) How (State level Processes) Evidence that it works Road Ahead

3. The general direction of Health sector reforms under NRHM is • Away from vertical silos • Towards integrated, decentralized, sector wide initiatives • Towards enabling systems • Quality-Accountability-Equity continuum in reform process should therefore mature beyond merely • “quality of patient care” • “accountability of service provider” • “equity in access to health care”

4. The stakes expand to include: • Quality of health system • Planning (perspective, annual, day to day), policy, managing (Infrastructure, supplies, HR), accounting, monitoring, knowledge management • Accountability of Health System stakeholders • Planners, funders, architects, academics, utility suppliers, regulators. • Equity embedded at several levels • Plans, budgets, technology development & deployment etc • Many components of the reform process are difficult to benchmark in accreditations or certifications.

5. Check Check . Am I on course ??? Review meetings, Field visits SRS of RGI Census, DLHS-III, NSSO, NFHS, Integrated MIS Periodic public reports – JSA, VHAI, etc. Performance audit by CAG External Surveys Concurrent Financial Audit, Financial Audit of SHS/DHS by CAG JRM & CRM ,Missions of programmes – RCH-II, Malaria, RNTCP, Kala Azar, etc. Procurement & civil works audit. Annual State and District Public Reports on Health Assessment by Parliamentary Committees.

6. Community Empowerment has major role in ensuring Quality and Accountability and promoting equity. • Part of over all health sector reform agenda • Both a means and a purpose • Not (only) Community Monitoring but Empowerment • More than grievance redress forum or adverse impact analysis • Covers planning, designing, implementation as well as ongoing concurrent oversight. • Embed in all components of the reforms • Does not have large budgetary footprint. • Protocols are part of the Framework and a restricted implementation phase has been completed with AGCA support.

7. Objectives of Community Monitoring • To provide regular and systematic information about Community needs. • To provide feedback on some indicators and locally developed yardsticks. • To provide feedback on; • Fulfillment of entitlements. • Functioning of various levels of public health system and service providers • To identify gaps and deficiencies in services and level of community satisfaction. • To enable the community and CBOs to become equal partners in planning process. • To increase the community involvement and participation to improve functioning of public health system.

8. Community Monitoring Phase 1

9. States Covered in Phase 1 Rajasthan Orissa Maharashtra Madhya Pradesh Assam Tamil Nadu Karnataka Jharkhand Chhattisgarh

10. Scale of Phase 1 Nine States 38 districts (3-5 districts per state) 114 blocks (three in each district ) 342 PHCs (three in each block. 1710 villages (five revenue villages per PHC).

11. Features of Phase I Green field activity Work of Capital nature : Institutions, Committees, Orientation material, formats, channels of reporting to be developed Advisory Group of Community Action is the operational partner AGCA through Population Foundation of India is vehicle for Start up activities in the initiative. Preparation for basic documentation Handholding the finalisation of G Orders/Resolutions Handholding the formation, orientation and operationalisation of committes Phase 1 funding by MoHFW is to PFI. Funds passed to State Nodal NGOs by PFI. District & Block level funds disbursed by State nodal NGO. Sustenance of CM will be through state PIP

12. Features of Phase I MOHFW has allocated funds to PFI for : Support for preparation of orientation material, Travel of mentoring group members to states State preparatory meetings, workshops, orientation material, travel and meeting expenses. District workshops, expenses for committee formation and orientation Village, PHC and Block levels orientation sessions, travel Travel support to mentoring team from AGCA

13. National level Processes Phase 1

14. Frameworks and Processes Village Health Plan, District Health Plan Entitlements under the JSY Roles and responsibilities of the ASHA Indian Public Health Standards for different facilities like Sub centre, PHC, CHC Concrete Service Guarantees Citizen’s Charter and so on. Block Provider’s Orientation Joint Sharing / Jan Sanwad Village Health and Sanitation Committee Training – Entitlement Awareness and Frameworks Community Sharing Report Cards Community Enquiry- Village and Facility

15. Operational Mechanisms Advisory Group on Community Action NRHM: MoHFW - GoI National Secretariat State MoHFW and Mission Directorate State : CM Mentoring Group State Nodal NGO District Health Society District Nodal NGO Block and PHC Planning and Monitoring Committee Block Nodal NGO Village Health and Sanitation Committee

16. Key Processes and Relevant Materials Manual for Managers – Part 1 Orientation of State Mentoring Group and Nodal NGO Manual for Trainers – Part 2 Manual for Monitoring – Part 3 Orientation of District and Block Nodal NGOs Frameworks for Entitlements under NRHM Brochures for Entitlement education Orientation of Village Health and Sanitation Committee Community Awareness Generation Posters, Media, Kala Jatha

17. Village Level Maternal Health Janani Suraksha Yojana Child Health Disease Surveillance Curative Care Untied Funds Utilisation Quality of Care Community Participation ASHA Functioning PHC Level Infrastructure and Personnel Equipment and Supplies Service Availability Unofficial Charges Quality of Care Functioning of RKS Issues for Community Enquiry

18. Mechanism of Enquiry Group Discussion with Women Maternal Health, Child Health, QoC, ASHA functioning and JSY Interview with Mother who delivered in last 3 months ASHA functioning, United Fund utilisation, Community Participation Interview with ASHA Disease Surveillance, QoC, Untied Fund Utilisation, Community Participation Group Discussion with Community Facility Visit ( PHC/CHC) Infrastructure, Supplies, Personnel Services available Interview with Medical Officer Quality of Care, Unofficial Charges Exit Interview

19. State level processesSome highlights fromRajasthan and Maharashtra 19

20. The first phase of Community Monitoring has been carried out in four districts - Alwar, Chittorgarh, Jodhpur and Udaipur. The coverage summary of the first phase of Community Monitoring of Health services in Rajasthan: No. of Villages 180 (45 in each district) No. of PHC 36 (9 in each district) No. Of Block 12 (3 in each district) No. of Districts 04 (Alwar, Chittorgarh, Jodhpur & Udaipur)

21. VHSCs constitution is completed in all villages. Regular monthly meetings are taking place. Villagers discuss and understand about health & its other determinants i.e. water, sanitation, • PHC and Block level committees, district and state mentoring groups had been established and they meet on regular basis and discuss about problem and to overcome these problem they make their plan on evidence based which is required under NRHM and also it is Decentralization planning. • As Community participating in evaluation of health centers and health service providers through checklists and interviews, it has certainly developed a sense of ownership of health facilities amongst people. • Public Hearings

22. Report card One of monitoring tools to know about the health status of village and services provided at health facilities - it is filled at regular intervals for proper monitoring (every quarter) Finding of report card also shows that communitization of health services have positive impact on health of people.

23. Public Hearing : A tool to know about ground reality Public Hearings so held were the ultimate instances of how issues can be sorted out with mutual dialogues and discussions. These public hearings gave the community members a platform to keep their grievances and problems especially in context of access to health care in front of the service providers and other government officials and policy makers. Service providers and other officials present during the hearing were answerable to the issues so raised right there and then. Public hearings and participation of the community in the evaluation of health services has also come up as an eye opener on many health related aspects. This has certainly made the health care providers realize that they can no more easily bluff the poor and the illiterate and that they would no more keep mum at the injustice. After the Public Hearings and evaluations there have been cases of women getting back their share of Janani Suraksha Yojana amount, deployment of ANM in villages etc.

24. Public Hearing • The following issues emerged during the public hearings: • JSY Payment, • Referral services & insensitive Behaviour of service • provider • Unavailability of vehicle during referral cases • Huge out of pocket Expenditure • Unavailability of medicines • Medicine bill not provided by Medical Shops. • Lack of Quality work (NSV & Tubectomy failure cases etc. & No Compensation to them). • Less involvement of Health Officials in Public Hearing • ASHA Incentive Problem

25. Positive changes • At Chittorgarh District Hospital there was problem of JSY Payment - was raised in each Public Hearing. Due to pressure of it the hospital had to made arrangement for JSY Payment, have ensured JSY payment immediately at the time when mother delivered baby. • In Jodhpur District, the Deputy CM & HO and Block CM & HO had ensured JSY payment after verification of cases. • Regular visits of ANM because of which increase in immunisation has been observed in almost all the villages. • In all 180 intervention villages under community monitoring, separate bank account of VHSC. It gives them recognition and give them authority to use it in manner for betterment of community. • Utilization of Untied Fund as per the community need.

26. Innovative community monitoring processes in Maharashtra

27. Innovation in community mobilisation -Arogya Jagruti Divas Arogya Jagruti Divas (Health Awareness Day) organised in all CBM villages of Dahanu taluka by Kashtakari Sanghatana Hundreds of people involved in collective activities like cleaning the village, making of soak pits and cleaning of wells Interviews, data collection and filling of village health report card carried out with involvement of large numbers of community members

28. Pictorial information collection tool for less educated communities

29. Jahir Arogya Sabhas In Pune district, instead of PHC level Jan Sunwai - ‘Jahir Arogya Sabhas’ involving MO PHC, Sarpanch and villagers conducted in several villages

30. Impact of Community based monitoring 30

31. What is the evidence that Community monitoring can lead to Health service improvements? Comparing report cards from the start of monitoring process, with report cards after some period of monitoring and dialogue. Changes shown here are not solely due to CBM – but CBM works in synergy with, and boosts ongoing Health system strengthening

32. Maharashtra

33. Before: Aug – Sep 08 Change between two rounds After: Apr 09 • Amaravati • Thane Improved or maintained good Remained partly satisfactory Remained poor Deteriorated

34. Rajasthan

35. Karnataka

36. Tamil Nadu • Increase in awareness of people regarding services available in Public health system; in Kanniyakumari and Tiruvalur districts has increased people’s usage of public health services • People have become more aware of the problems faced by frontline workers, has led to people coming forward with actions to support their work • The Process has led the people to perceive the government as being responsive where interactions have taken place • More face to face contact between the people and the government officials, leading to less adversarial relationships.

37. Overall key changes due to Community monitoring • Improved dialogue between frontline Health care providers and community • Improved attendance at public health facilities in some areas • Greater frequency of visits by ANMs, MPWs to villages and better cooperation from community • Check on illegal charging, irregularities in JSY payments • More responsive attitude of PHC doctors and staff, improved services in many areas • Mutual suspicion, lack of understanding has been replaced by better understanding of problems of Health care providers and positive interaction

38. Challenges • Need for more commitment from health departments of some existing states e.g. Jharkhand, M.P., Orissa – as well as new states • Building and sustaining motivation of community for health improvement. Consolidation of functional partnership/coalition between community and public health system. • Frequent indifferent attitude & lack of transparency in health care delivery. • Integration and institutionalization of community monitoring. • Formation of national action plan on community based planning and monitoring in health care.

39. State Ownership of Community monitoring

40. In some states Community Monitoring has been specifically approved under NRHM Flexipool chapter in the RoP for 2009-10 : • Chhattisgarh Rs.23.87 lakh • Chandigarh Rs.1 crore • Gujarat Rs. 65.38 lakh • Maharashtra Rs. 2.44 crore • Tamil Nadu Rs. 1.27 crore • Uttar Pradesh Rs. 20 lakh

41. In following states Community monitoring is approved both in RCH II chapter (Para A 8.3) as well as NRHM Flexipool Chapter in the RoP for 2009-10: Jharkhand Under RCH Flexipool Rs. 48 lakh for NGO Programme and Rs. 2 lakh under MFP for state workshop and ToT. Orissa Under RCH Flexipool Rs. 3.95 crore for NGO Programme & Under MFP, Rs.52.08 lakh for CM Rajasthan Under RCH Flexipool Rs. 5.27 crore for NGO Programme and Rs 1 crore under NRHM Flexipool for CM. Andhra Pradesh Under RCH Flexipool Rs. 2.00 crore for NGO and Under MFP Rs. 50 lakh West Bengal Under RCH Flexipool Rs. 7.40 crore for NGO Programme and Rs. 1.21 crore under NRHM Flexipool for the same activity

42. In following states, under RCH Flexipool, para A 8.3, (Which deals with NGO involvement, mainly MNGO/SNGO) various amounts have been approved for NGO Programme (including ASHA mentoring, 5th module training & Community Monitoring) in the RoP for 2009-10 • Delhi Rs. 1.20 crore • Goa Rs. 16 lakh • Himachal Pradesh Rs. 1.92 crore • Jammu & Kashmir Rs. 68.3 lakh • Karnataka Rs. 3.80 crore • Madhya Pradesh Rs. 2.70 crore • Punjab Rs. 1.25 crore • In following states the activity of Community Monitoring is not provided for (except under general guidelines) in the RoP for 2009-10 : • Bihar, Haryana, Kerala, Uttarakhand, Andaman & Nicobar, Daman Diu, Dadra & NH and Lakshadweep.

43. Press Clippings and IEC material 43

44. THANK YOUweb : mohfw.nic.in\nrhm.htmemail : healthmission@nic.in