An experience from implementing Decentralized Health Planning (DHP) process in Maharashtra

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. NitinJadhav SATHI- Support for Advocacy and Training to Health Initiatives

Community based monitoring and Planning (CBMP) in Maharashtra – 2007 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

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

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

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

Community Based Monitoring and Planning of Health services in Maharashtra Community awareness programmes Data gathering and filling report cards 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.

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

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

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

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 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

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

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

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)

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.

Decentralized Health Planning process in Maharahstra

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.

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.

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.

Step- 1:Community mobilization foridentification of community needs 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 Activity 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

Step-3: Compilation, categorization and prioritization of community needs Proposed stakeholders Joint meeting between RKS committee and Monitoring & Planning committee in each selected PHC and RH • Members of RKS committee • Members of Monitoring & Planning committee • Medical Officer and staff of PHC • RH superintendent and staff of RH level Activity • 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

Step- 5 :Compilation of community needs at block level and development of budget proposal based on prioritized community needs Proposed stakeholders Block level workshop for various stakeholders. • 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 Activity • 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.

Step- 8:Finalization of budget proposal at district level 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 Activity • 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

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

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

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

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.....

Participatory Audit and Planning of RKS- Process developed in selected health facilities of Thane, Nandurbar and Raigad since 2014. 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 2015-16.- Jointly facilitated by Block nodal NGOs and District RKS coordinators.

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.

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.

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.

Thank you!!!!

An experience from implementing Decentralized Health Planning (DHP) process in Maharashtra