Reviving Hopes Realising Rights - COPASAH · 2019. 3. 17. · Ms. Moumita Ghosh; CHSJ, New Delhi...

RReevviivviinngg HHooppeess

RReeaalliissiinngg RRiigghhttss

A Report on

the First Phase of Community Monitoring under NRHM

Front.qxp 7/3/2010 12:24 PM Page 1

Contents : Sunita Singh, Abhijit Das, Sona Sharma

Editing : Elisa Parija

Layout & Design : Kishor

Production Coordinator : Moumita Ghosh

Published : June, 2010

Printed at : Design Solution


ii

Preface

The first phase of community monitoring implemented across nine states in 2007 draws its basis from the NRHMFramework for Implementation. The nine states selected for the first phase effort were: Assam, Chhatisgarh,Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Orissa, Rajasthan and Tamil Nadu. In each state, three tofive districts were selected considering the geographical spread, in each district three blocks, in each block threePHCs and in each PHC five villages were selected. The first round of community monitoring process thus coveredover 1600 villages and 300 facilities.

The 18-month process involved capacity building of planning and monitoring committees at different levelsfor conducting enquiry into the functioning of different components of NRHM and the uptake of key services. Itwas an empowering process for the community because it provided community representatives’ knowledge ondifferent entitlements, service standards and service guarantees provided within the NRHM. It also gave anopportunity to discuss the status of health services delivery with healthcare providers and programme managers.

The process of writing the national report and compiling information from across nine states was a dauntingexercise and would not have been possible without due support and guidance from various sources. The detailedprocess documentation and state reports gave us an insight into the efforts, challenges and lessons learned at thestate level. These, and further information provided by the district/state nodal NGOs were the motivation to puttogether information and findings of the states. The state-level findings may not adequately reflect the intensityof the efforts, as the Section was solely dependent on information provided in reports or what was gathered fromdirect feedback. It is meant to give a glimpse of the immediate impact of the effort. There are state reports preparedby the state nodal agencies, which capture further details.

This Report consists of three sections. Section One talks about the overall process adopted, including activitiesundertaken at the National Secretariat level. Section Two draws upon the data and qualitative feedback collatedfrom the states representing state-level findings and changes that took place over a period of time and innovationsthat each state has done. The Third section is based on the review that was done by an external review team.

We hope this Report will provide a comprehensive overview of the extensive process that was carried out innine states. This Report, along with the manuals and materials produced under the first phase will be a usefulresource for states to scale-up their efforts as also for other states to initiate community monitoring keeping in viewthe experiences from the first phase.


iiii

Acknowledgement

We wish to acknowledge our sincere gratitude for all the support, inputs and feedback that we have received.

Firstly, we are grateful to Mr. P.K. Pradhan, Additional Secretary and Mission Director NRHM, Mr. AmarjeetSinha, Joint Secretary, Dr. Tarun Seem, then Director, NRHM, Mr. Ganga Kumar, Deputy Director NRHM and allothers in the Department of Health and Family Welfare, Ministry of Health and Family Welfare, Government ofIndia for their confidence in us and constant support to us through out the first phase and also for disseminatingthe experiences through the national dissemination meeting.

We would like to thank Mr. A R Nanda, Executive Director of Population Foundation of India (PFI) andConvener AGCA, for his excellent guidance and encouragement throughout the process. Without his leadershipand inputs this process would not have been possible.

We would also like to thank Mr. S Ramanathan, Dr Rakhal Gaitonde, Mr. E. Premdas, Dr Abhay Shukla,Dr Narendra Gupta, Dr Ajay Khare, Mr. Govind Madhav, Ms Rehana and Mr. Ajay Srivastava for providing inputsin different sections of the Report, their inputs have been a major source of information and inspiration for thisReport.

Friends and colleagues from different states for providing us valuable information deserve a special mention: Ms. Sanjukta Basa; Secretary; OLAMP OrissaMs. Manorama Dey; Block Coordinator; UNNAYAN Orissa Mr. Ranjit Swain; Director; Chale Chalo Orissa Ms. Tilottama Dash; Programme Coordinator; OMRAH Orissa Mr. Sushil Kumar Pandey; Bastar Samajik Jan Vikas Samiti Chattisgarh Dr. Nitin Jadhav; Saathi Cehat; Maharashtra Mr. Ritesh Laddha; Prayas; Rajasthan

We would also like to acknowledge the support provided by the CHSJ and PFI team in the process of writing andcompiling the Report:Ms. Pratibha D'Mello; CHSJ, New Delhi Ms. Jolly Jose; PFI; New Delhi Ms. Moumita Ghosh; CHSJ, New Delhi Ms. Anita Gulati; CHSJ, New DelhiMs. Jaya Velankar, CHSJ, New Delhi

And finally we would like to express our gratitude to all members of the Advisory Group on CommunityAction, State Mentoring Committees of concerned states and all state nodal organisations and district and blocklevel NGOs. A special thanks to the citizens of India who were engaged in the process of community monitoringacross nine states.


ContentsPreface Acknowledgements Glossary

SSeeccttiioonn II Introduction 3The Process 5National Level Preparatory Phase 6State Implementation Phase 8Material Support 12

SSeeccttiioonn IIII Findings from the States: Some Immediate Outcomes 17

Maharashtra 17Rajasthan 22Jharkhand 24Orissa 27Madhya Pradesh 31Assam 34Chhattisgarh 36Tamilnadu 38Karnataka 43

SSeeccttiioonn IIIIIIReview of Community Monitoring 49

Review Process 49Summary of Findings 49Key Findings on Process 50Key Findings on Program Management 52Gain from Community Monitoring 54Equipped for Scale up - Recommandations 54

RReeffeerreennccee 58

AAnnnneexxuurreessList of Material 62Names of States, Districts and Blocks 64


iivv

Reviving Hopes, Realising Rights

Glossary

AGCA: Advisory Group on Community ActionANM : Auxiliary Nurse MidwifeASHA : Accredited Social Health ActivistAWW : Anganwadi worker

BMO: Block Medical OfficerBP: Blood Pressure BPHC: Block Primary Health CentreBPL: Below Poverty Line

CBM: Community Based MonitoringCBO: Community Based Organization CD: Computer Disc CEHAT: Centre for Enquiry into Health and AlliedThemes CHC: Community Health Centre CHSJ: Centre for Health and Social Justice CINI: Child in Need Institute CM: Community Monitoring CMHO: Chief Medical and Health Officer CMO: Chief Medical Officer CMP: Community Monitoring and Planning CRP: Community Resource Person

DH: District Hospital DHO: District Health Officer

FLW: Front Line Worker

GoI: Government of IndiaGKS: Gaon Kalyan Samiti

JSY: Janani Suraksha Yojana

ICDS: Integrated Child Development Service ID: Identity Card

MDGs: Millennium Development GoalsMO: Medical OfficerMoHFW: Ministry of Health and Family WelfareMPW: Multi Purpose Worker

NFHS: National Family Health SurveyNGO: Non Government OrganisationNHP: National Health PlanNHSRC: National Health Systems Resource Centre NRHM: National Rural Health Mission

OLAMP: Orissa Medical Research and Health ServicesOP: Out Patient OPD: Out Patient Department

PFI: Population Foundation of India PFI-RRC: Population Foundation of India - RegionalResource CentrePHC: Primary Health CentrePIP: Program Implementation Plan PRA: Participatory Rural Appraisal PRI: Panchayati Raj Institution

RCH: Reproductive and Child Health RKS: Rogi Kalyan Samiti RWSS: Rural Water Supply and Sanitation

SC: Schedule CasteSDM: Sub Divisional Magistrate ST : Schedule Tribe SW: Social Worker

TAG: Technical Advisory Group TOT: Training of Trainers

VHC: Village Health CommitteeVHN: Village Health Nurse VHND: Village Health and Nutrition DayVHSC: Village Health and Sanitation Committee


Section - I

Report.qxp 7/3/2010 12:25 PM Page 1

The National Rural Health Mission (NRHM) launchedon April 12, 2005, aims to bring about significantimprovement in healthcare delivery in rural areas ofthe country and in the health status of the people. TheNRHM promises to provide universal access toequitable, affordable and quality healthcare, which isaccountable and at the same time responsive to theneeds of the people, especially those who aremarginalised and live in rural areas.

Key objectives of the Mission are reduction inchild and maternal deaths, population stabilisationand gender and demographic balance. The processesset to achieve the objectives of the Mission will helpaccomplish goals under the National Health Policy(NHP) and the Millennium Development Goals(MDGs).

The NRHM proposes an intensive accountabilityframework through a three-pronged process ofcommunity monitoring, external surveys andstringent internal monitoring. Facility and HouseholdSurvey, NFHS and RCH data would act as the baselinefor the Mission against which the progress would bemeasured.

The adoption of a comprehensive framework forcommunity monitoring and planning at various levelsunder NRHM is an extremely positive development. Itcan place centre-stage community members andbeneficiaries, CBOs and NGOs working withcommunities and Panchayati Raj Institution (PRI)representatives and allow them to actively andregularly monitor the progress of NRHM interventionsin their areas. Besides ensuring accountability, it wouldalso promote decentralised inputs for better planningof health activities based on locally relevant prioritiesand issues identified by community representatives.

This framework is consistent with the 'Right toHealth Care' approach mentioned in the latest NRHMframework document, since it places people at thecentre of the process of regularly assessing whetherhealth rights of the community are being fulfilled. Itcould also be a step towards "Bringing the 'Public' backinto Public health" by allowing community members

and their representatives to directly give feedbackabout the functioning of public health services,including inputs for improved planning of the same.

The Ministry of Health and Family Welfare(MoHFW) has constituted the NRHM Advisory Groupon Community Action (AGCA) with the mandate toprovide guidance for community action under NRHM.To initiate the process of community monitoring asoutlined in the implementation framework, the AGCArecommended the implementation of communitymonitoring in the states with support from theGovernment of India (GoI). Based on the AGCArecommendations, the GoI decided to support a firstphase green field initiative in community monitoringwith active role of AGCA and civil societyorganisations. A partnership between HealthDepartment, community (CBOs and NGOs) and PRIsis envisaged, to realise the objectives of communitymonitoring. Community Monitoring, implemented asa first phase in nine states since 2007, draws its basisfrom the NRHM Framework of Action. PopulationFoundation of India (PFI) and Centre for Health andSocial Justice (CHSJ) were designated the NationalSecretariat for the first phase effort supported by theMoHFW. The nine states selected for the first phaseeffort were: Assam, Chhattisgarh, Jharkhand,Karnataka, Madhya Pradesh, Maharashtra, Orissa,Rajasthan and Tamil Nadu. In each state, three to fivedistricts were selected looking at the geographicalspread, and three blocks were selected from eachdistrict. In each block, three PHCs and in each PHCs,five villages were selected.

Table 1: Geographical Coverage

Particulars Number1 States 9

2 Districts 36

3 Blocks 108

4 PHCs 324

5 Villages 1620

6 VHSC formation 1620

33

First Phase of Community Monitoring under NRHM

Introduction


The objectives of the first phase were:� To set up a common mechanism for

implementing the process of communitymonitoring on a large scale by buildingrelationships between civil society organisations,citizens and government.

� To develop a comprehensive toolkit forimplementing community monitoring, that canbe implemented with local adaptation acrossdifferent socio-cultural contexts (states).

� To demonstrate feasibility of communitymonitoring conducted using commonly developedmechanisms and tools as a method for generatingcommunity-based and community-ownedfeedback, that can be used both for initiating localcorrective action and for triangulation purposesalong with other forms of data.

To realise these objectives, facilitation by civil society,especially NGOs, has been the key element. The NGOswere to mobilise the community and enable aparticipatory process of monitoring by involvingvarious stakeholders. The NGOs were also to represent

the community and be their spokesperson with theHealth Department, as the communities and PRImembers do not have such expertise. This, it waspresumed, would help shift the locus of powergradually from the Heath Department to the people. Itis anticipated that the NGOs would bring inobjectivity to the process, which may be missing if theprocess was anchored by the Health Department. TheNGOs were to have three roles in communitymonitoring:� As members of monitoring committees� As resource groups for capacity building and

facilitation� As agencies helping to carry out independent

collection of informationThe Community Monitoring Project started in April2007 and was completed in March 2009. The entireprocess was divided into three phases - the NationalPreparatory Phase, the State Preparatory Phase and theImplementation Phase. The documentation of theprocess was done concurrently and an external reviewwas done in November - December, 2008.

44



Implementation Mechanism

The AGCA provided oversight and guidanceto the entire process through the NationalSecretariat (PFI & CHSJ). A state nodalagency was identified for each of the ninestates. State nodal agencies identifieddistrict and block nodal agencies in theselected districts and blocks.

Planning and Monitoring Committeeswere to be set up at PHC, block, district andstate levels and at the village level, VillageHealth and Sanitation Committees (VHSC)were to be set up. The process was conceivedas a three-way partnership betweenhealthcare providers and managers of thehealth system, the community (includingCBOs and NGOs) and the PRIs. The tieredmechanism of feedback in the monitoringprocess is illustrated in Figure 1 and 2.

Figure 1: Feedback Mechanism of Different Levels ofCommittees

Figure 2: Feedback Mechanism at Different Levels

Table 2: Nodal NGOs identified for the nine firstphase states

Name of the Name of the State NodalStates NGOs

1 Assam Voluntary HealthAssociation of Assam

2 Jharkhand CINI

3 Rajasthan PRAYAS

4 Tamilnadu Tamil Nadu Science Forum(TNSF)

5 Chhattisgarh State Nodal Consortium(SANDHAN Sansthan,Chattisgarh Voluntary HealthAssociation and PFI-RRC)

6 Karnataka Karuna Trust

7 Madhya Pradesh Madhya Pradesh VigyanSabha

8 Maharashtra SAATHI-CEHAT

9 Orissa KCSD- KIIT

55


The Process

PHC Planning &

Monitoring Committee

Feedback

& Reports

Block Planning &


District Planning &


State Planning &


Village Health &

Sanitation Committee

Ap

pro

pria

te A

ctio

n

& In

terv

en

tion


The Preparatory Phase at the national level includedsetting-up a task group under the aegis of AGCA. Thetask group along with the National Secretariat wasresponsible for developing tools for communitymonitoring, a model curriculum for trainings,materials for trainings and workshops, design andcontent of workshops, awareness and promotionalmaterials and documentation formats. The task groupwas also assigned the responsibility of establishinginitial contact with State Health Secretaries; apprisingthem of the first phase initiative; setting-up the StateCommunity Monitoring and Mentoring Group andidentification of state nodal agencies.

AGCA members were assigned specific states toassist in setting the ball rolling for communitymonitoring in the state.

It was recognised right at the outset thatstrategies, especially promotional materials andpresentation of formats, would require adaptationat the state level, given the uniqueness of differentcommunities, varying socio-political situations,local health profile specificities, characteristics ofcivil society organisations involved in themonitoring and the state of public health system.This was critical not only because healthcare needsof the people vary, but also because perceptions ofpeople and their capacities to participate in healthprogrammes also vary. Thus, while the NationalSecretariat developed the general guidelines andmaterials, these were tailored to specific contexts atthe state and district levels.

66


National Level Preparatory Phase

Figure 3: Organogram - Agencies & Committeesat Each Level

Glimpse of material prepared at national level


State Mentoring Group

As a first step to implement the Project at the statelevel, a State Mentoring Group was formed with dueinvolvement of the State Health Department and statelevel voluntary networks. Members of the MentoringGroup included designated representatives from theHealth Department, civil society organizations and insome cases, other related department representativessuch as Public Relation (PR) Department. TheMentoring Group had clearly spelt out responsibilitiesto lead community monitoring in the state during thefirst phase and beyond. In addition, the designatednational AGCA members (as permanent invitees to theState Mentoring Group) provided required impetus tothe effort.

State Nodal Organisation

The State Mentoring Group, in the first meeting itselfidentified one of the state-level organisations byconsensus as the State Nodal NGO to implement thefirst phase. This State Nodal NGO worked under thedirection of the State Mentoring Team withbackstopping support from the National Secretariat.

The State Mentoring Group in coordination withthe State Nodal NGO selected the districts and blocksfor initiating community monitoring. Nodal NGOs fordistrict and block levels were also selected based on aspecific selection criteria initially proposed by theNational Secretariat and modified/accepted at the statelevel by the mentoring group.

National Workshop

To begin with, a three-day National Workshop forTraining of Master Trainers on Community

Monitoring was organised to orient the state nodalagencies and to prepare them to implement thecommunity monitoring process in their respectivestates. The states were asked to nominate four mastertrainers from their respective states, who would workas resource persons and further train people. Theworkshop was used as a platform to share experiencesand develop common working principles.

State-Level Workshop

A State-Level Workshop was subsequently organised bythe State Mentoring Team, State Nodal Organisationand State Health Mission involving all stakeholders(State Mission officials, district health officials. PRIrepresentatives from selected districts, NGO networksand civil society organisations from these districts).Representatives from NRHM, GoI and NationalSecretariat also participated. The activities of the firstphase were shared and the process finalised. Detailedtimetable for district-level meetings, formation andorientation of committees, conducting communitymonitoring and sharing of results at the PHC and blockwas worked out in this two-day state level workshop.

State-Level Training

The State Nodal Organisation under guidance fromthe State Mentoring Team conducted a five-day State-level Training of Trainers. The training was attendedby district-level trainers who were responsible forfacilitating the community monitoring process at thedistrict level and below. The trainers were primarilythe voluntary sector facilitators. However, stateHealth Department officials were also present andinvolved in these workshops, enabling them toactively participate in further such trainings.

77



Activities carried out at the state implementation levelcould be divided into the following phases:� Preparatory phase� Training and workshop phase� Formulation of community monitoring

committee� Monitoring phase� Jan Samvad phase� End phase.

Table 3 : Detail of Activities at the State Level

Phases Activities

Training/ � District workshopworkshop phase � Block facilitators training

� Block providers training � VHSC orientation workshop � Orientation of different level

of committees

Formation of � Village health and Sanitation Community Committee Monitoring � PHC Monitoring andCommittee planning committee

� Block Monitoring andplanning committee

� District monitoring andplanning committee

Monitoring phase � Community Mobilization � Preparation of Village health

profile � Community enquiry � Preparation of report card -

Village, PHC and Block

Jan Samvad Jan Samvad at PHC and Blocklevel

End phase State process documentation andstate review workshop

Once the district and block level facilitatingorganisations were selected and trained at the statelevel, the key activities shifted to the district and blocklevels. The activities at the district and block levelproceeded in the following manner:

Setting the Stage

District processes were facilitated by district-levelorganisations taking responsibility in the first phasealong with district health officials and PRIrepresentatives. A District Mentoring Team (includingrepresentatives of each of the three groups) to facilitatethe community monitoring process was put in place,which facilitated the orientation activities in this andsubsequent stages. In each district, a civil societyorganisation was identified to take responsibility as theDistrict Nodal Organisation. This NGO was assisted byother civil society organisations that would takespecific responsibility in various blocks. The processstarted with a District Level Workshop to share theconcept, identify blocks and PHCs and involve keydistrict health officials, PRI members and civil societyorganisations. For each selected block, the block nodalorganisations took up the responsibility ofcoordinating with the District Nodal NGO.

A Block Facilitator Training was conducted for atleast a four-member Block Community MonitoringFacilitation Team, including at least two NGO/CBOmembers, with at least half the members beingwomen. These Block Facilitation Team members wereresponsible for subsequent committee formation andorientation processes.

88


State Implementation Phase


Figure 4: Organogram of Monitoring & PlanningCommittees

Formation of Committees

During the four months (Aug-Nov 2007), committeeswere formed at village, PHC and block levels in theselected blocks (in that order), along with primaryorientation of their members. Formation ofcommunity monitoring and planning committeesstarted from village committees, PHC, block, andthen district committees. It was important toconstitute the committees from village level upwardsin an inclusive manner - hence a few members fromVHSCs were included in the PHC committee.Similarly, a few PHC committee members wereincluded in the block committee and so on.CBOs/NGOs and Panchayat representatives who hadshown initiative in organising communitymonitoring activities at any level foundrepresentation in the next higher-level committee.Adequate representation of women, dalits andadivasis was ensured in the various committees.

Following committee formation at the peripherallevels, the District Level Committee was also finalisedand became functional in November 2007. In the firstphase, a provisional committee was formed at the statelevel in December 2007. This would be given finalshape only after the next phase of 'ExtendedImplementation' is completed and at least, half of thedistricts of the state have Community MonitoringCommittees in place, which could sendrepresentatives to the State Committee.

Community Mobilisation, Monitoring& Report Card Preparation

A process of raising awareness of community membersregarding their health entitlements and significance ofcommunity monitoring was carried out in all villages,prior to formation/expansion of VHSCs. At least threemeetings in each village were conducted for thispurpose, and the final meeting was expected to be inthe form of an 'official' Gram Sabha where the newVHSC members would be selected andformation/expansion of the VHSC would be declared.Posters related to people's health entitlements underNRHM were put up in the village as part of thisprocess. Innovative strategies for communitymobilisation were adopted by states such as use of folkform (Kala Jaththa), Chinaki (introduction) meetings,padyatras, involving children, youth parliament andsocial mapping etc.

The community monitored the need, coverage,access, quality, effectiveness, behaviour, presence ofhealthcare personnel at service points, possible denialof care and negligence aspects. The monitoring processincluded outreach services, public health facilities andthe referral system. These exercises aggregatedinformation upwards as illustrated in Figure 4. Themonitoring results were also shared at the village level,PHC and block level in the appropriate PRI fora. Someof the broad areas under the NRHM on whichcommunity monitoring was conducted were:� Entitlements under Janani Suraksha Yojna (JSY)� Roles and responsibilities of ASHA� Indian Public Health Standards (IPHS) for

different facilities like Sub-centre, PHC, CHC� Concrete Service Guarantees� Citizen's Charter

In the first phase, indicators for informationcollection at the village level and the PHC level werefinalised, and accordingly tools for monitoring wereformulated at the national level. It was also decidedthat frequency of the monitoring cycle in every villagewould be once in three months i.e. a report card ofvillage would be prepared once every three monthsand submitted to the PHC monitoring committee.However, only one round of data collection wasplanned for the first phase. The exceptions wereKarnataka, Rajasthan and Maharashtra where morethan one round of data collection was done.

In each monitoring cycle at the village level, twogroup discussions were planned. One of these groupdiscussions was with the general community, and onewas exclusively with women. Similarly, at the PHC

99



1100


Figure 5: Issues and Process of CM at different level


level, exit interviews of the OPD patients were to beconducted in each cycle. These group discussions andexit interviews were accompanied by a facility surveyat the PHC and interview of the PHC MO. The blockcoordinators mainly conducted facility surveys andalso exit interviews and interview of MOs.

PHC and block level community monitoringexercises included a public dialogue (Jan Samvad) orpublic hearing (Jan Sunwai) process. Here, individualtestimonies and assessments by local CBOs/NGOswere presented. Individual testimonies were identifiedthrough the adverse outcome recording process. Thesepublic dialogues were moderated by the district andblock facilitation groups in collaboration with PRIrepresentatives and CBOs/NGOs working on healthrights issues.

Monitoring committees reviewed and collatedreports from committees at the unit level below them.The members did not rely on reports but also directlyinteracted in the field and got feedback. Firstly, eachcommittee appointed a small sub-team drawn from itsNGO and PRI representatives who visited a smallsample of units (say one facility or two villages) undertheir purview on a regular basis and directly reviewedthe conditions. This gave the committee a first-handassessment of conditions in their area. For example,the PHC Committee representatives would visit twovillages and conduct group discussions in eachtrimester, selecting different villages by rotation.Similarly, the Block Committee representatives wouldvisit one PHC by rotation in each trimester.

Secondly, monitoring committees at PHC, blockand district level would be involved in six-monthly orannual Jan Samvads or Jan Sunwai at their respectivelevels, where committee members would get directfeedback on the situation, including possiblepresentation of cases of denial of healthcare. Similarly,it is suggested that the State Health Mission couldconduct an annual public meeting open to all civilsociety representatives where the State Mission reportand independent reports would be presented andvarious aspects of design and implementation ofNRHM in the state, including state specific healthschemes, would be reviewed and discussed enablingcorrective action to be taken.

Engaging Media

One of the key strategies in the first phase was toinvolve the media in creating public opinion about theexisting state of the public health system and also topositively influence decision-makers.

Some of the strategies adopted for a wide andeffective media coverage included:1. Appointing a state media consultant: A working

journalist with experience of facilitating mediacoverage of developmental and health issues wasassociated as a consultant with the entire process.This was an innovation which proved quiteeffective in involving senior media persons frommultiple major newspapers, and ensuredcontinuous following-up of involvement of themedia at both state and district level, includingthe electronic media.

2. Appointing and orienting media fellows: Twomedia fellows were designated at the state level tocover the CM (Community Monitoring)activities. These journalists belonged to majordailies with multiple editions in various parts ofthe state to ensure adequate regional as well asstate level coverage. Similarly, a media person atthe block level was assigned to cover and reporton CBM related block activities.

3. State media workshop: In this one-day workshop,media participants were familiarised with theprocess of community monitoring. In some states,this workshop was planned when the communitymonitoring data from villages was alreadyavailable with the state nodal NGO. Preliminaryanalysis of this data was presented in theworkshop. Attempt was made to ensure thatsenior government officials were also present forthis workshop. This helped the media personspresent in the workshop to get official perspectiveon the reported deficiencies from villages and alsoto understand specific issues associated with thequality of healthcare in the states.

1111



1122


One of the important preliminary tasks for theNational Secretariat was to develop communicationmaterial to create awareness on variousentitlements and schemes, service guarantees andprovisions, community participation andframework for community monitoring underNRHM. Seven sets of brochures, six sets of postersand a booklet on Health Entitlements faced weredeveloped. CDs of print-ready version of materialswere sent to each state nodal agency to enable themto modify the materials as per their requirementand print in their state language. These materialswere extensively used during communitymobilisation and orientation of various committeeson their role under NRHM.

In addition to the promotional materials, theNational Secretariat with support from the task groupdeveloped three manuals 1) Manual for Managers, 2)Manual for Training and 3) Manual for Monitoring.These manuals together provide detailed guidelines onhow to plan and implement community monitoringin the state.

A 30-minute documentary film produced towardsthe end of the first phase captured the process,immediate impact of the process in the field, and thelessons learned and challenges faced. The film, bothtraining as well as advocacy tool highlights thepotential of community monitoring as a communityempowerment and democratisation process in thecontext of people's right to health.

Material Support

* copies available at CHSJ.

CD Cover of CM Film


Online Edition

The National Secretariat developed a CommunityMonitoring website (www.nrhmcommunityaction.org) toenable online review of information related tocommunity monitoring. The website contains generalinformation such as definitions and explanations ofcommunity monitoring concepts under NRHM. Thewebsite contains the organogram of communitymonitoring, lists of AGCA members, TAG members,the National Secretariat on community action, broaddescription of Monitoring and Planning Committeesat different levels, and mentoring teams at the stateand district levels. Also included are details of nodalNGOs at the state level, information on the process ofthe Project, name and address of districts and blocksand geographical spread.

The website also has information and documents

related to government orders, progress made and state-specific toolkits. The national toolkit (ManagerManual, Training Manual and Monitoring Manual andother Publications) has been uploaded for widercirculation. State-wise newspaper clippings andphotographs collated on various occasions by the statenodal agencies and during state visits by theprogramme officers have been uploaded as well. Thenational website is linked with state specific webpages. The states have control over these web pagesand are provided with password and user ID so thatthey can upload information as per their requirement.A half-day intensive training was provided to the statetechnical person on how to maintain the web pagesand upload information. The national website islinked with the Health Ministry's NRHM website.

A unique feature of the website is that it enablesaccess to data till the village level. Report cards at

1133


Screen Shot of National CM Website


village, PHC, block and district level can be viewedfor each of the nine states. This enables reviewing the

data not just at the district level but also at the stateand national levels at the click of a button.

SSccrreeeenn SShhoott ooff RReeppoorrtt CCaarrdd GGeenneerraattiioonn PPaaggee

1144


Table 4 - Example of a Village Health Report Cardgenerated by the website

Village Level Report Cards

Village Name Lebeda Year: 2008-09Block Name Muribahal Quarter: IIDistrict Name Bolangir

Sl. Issue Scoreno.1 Maternal Health Guarantees 50

2 Janani Suraksha Yojna 42

3 Child Health 87

4 Disease Surveillance 50

5 Curative Services 96

6 United funds 25

7 Quality of Care 75

8 Community perceptions of ASHA 100

9 ASHA functioning 83

10 Equity Index 100

11 Adverse Outcome or experience reports 100


Section - II


The process of the first phase of CommunityMonitoring (CM) across nine states was implementedfrom March 2007 to March 2009. The monitoringprocess involved capacity building of planning andmonitoring committees at different levels to conductenquiry into the functioning of different componentsof NRHM and uptake of key services. It was anempowering process for the community because itprovided the community representatives knowledge ofdifferent entitlements, services standards and servicesguarantees that are provided within the NRHM. It alsoprovided an opportunity to discuss the status ofservice delivery with health care providers andmanagers.

The geographical coverage and pace of themonitoring process varied from state to state. Whilesome of the states went ahead and completed therequired activities within the set timeframe, othersneeded more time. The districts in the states wereselected considering the geographical spread of thestate. Thus, the number of districts varied from threeto five across nine states.

The village was the main unit for communitymonitoring. The tools that were developed at thenational level were adapted and modified at the statelevel. The score cards that had 11 parameters to assessthe health situation of the village were based on thetraffic lights. The report cards had three colour codeson the basis of the following parameters:

Green = 75% to 100%Yellow = 50% to 74%Red = 1% to 49%

As described in Section I, the process underwentseveral layers of interventions, which led to enormouslearning, innovations, participation of differentstakeholders, negotiations and challenges. One of theprime objectives of community monitoring was toshow the way for communitisation, which was met byopening doors for dialogues between services providersand community and by reaching a consensus.

Jan Sunwai and sharing of village-level findings ofmonitoring made a great impact on the mindsets ofproviders, which resulted in better service delivery,ratification of the problems and in bringing localhealth providers and community on the sameplatform. The process also enhanced the level ofownership among community members.

This section describes the findings, innovationsand impact of community monitoring that each stateexperienced during the process. It is based on data anddocuments that the state nodal agencies provided,interviews with community organisations andcommunity leaders and case studies shared by districtnodal agencies during the CM process.

MAHARASHTRA

The first phase of community monitoring was carriedout in five districts (Nandurbar, Pune, Amaravati,Osmanabad and Thane) of Maharashtra. The state hasso far completed three rounds of monitoring at village,PHC and rural hospital levels. The first round of datawas collected between July-Aug 2008, the secondround between Mar-Apr 2009 and the third roundbetween Oct-Dec 2009. Though the project ended inMarch 2009, The State collected an additional roundof data during Oct-Dec 2009. The monitoring tookplace in 220 villages, 40 PHCs and 15 blocks. The statehas observed significant improvements in certainservices from July 2008 to Dec 2009, mainly due tocombination of two factors - NRHM 'supply side'inputs and 'demand side' push by CM.

The positive impact of community monitoring inthe state was based on two important aspects:responsiveness of state government officials, adequatesupply of funds and relevant decisions by officials aswell as sustained push by various communities, NGOsand people's organisations. While availability offinance, supportive directions and untied funds fromNRHM give the basic inputs for improvement, the CMprocess provides a matching yet critical 'push from

1177


Findings from the States :Some Immediate Outcomes


below' to help ensure that desired changes are actuallyimplemented.

Village-level Health Services: VisibleImprovements

The village health report cards covered nine key healthservices and these were rated by Village HealthCommittee members as either 'Good' (Green) 'PartlySatisfactory' (Yellow) or 'Bad' (Red). This informationwas collected from 220 villages. Graph 1 shows thetrend of good ratings for these services across fivedistricts in Maharashtra covering three rounds of CM.While 48 per cent of the services were given 'Good'rating in round one, it increased to 61 per cent inround two and further to 66 per cent in round three.Thus, there has been a consistent overall improvementin village health services in the CBM covered villages.

Similarly, Graph no. 2 shows the concurrentreduction in 'Partly Satisfactory' and 'Bad' ratings ofservices in these five districts over three rounds ofCM. Services rated as 'Bad' have reduced from 25per cent in the first round to 14 per cent in the thirdround.

These changes, while generally being in a positivedirection, have varied from district to district. Anaggregate 'Good' evaluation trend for each district overthe three rounds of CM is shown in Graph no. 3. Inthree districts (Amaravati, Pune and Thane) there is a

1188


District Trends over three rounds of CBM

4145

67

35

49

37

55

75

57

81

60 59

6763

85

0

10

20

30

40

50

60

70

80

90

Nandurbar Amaravati Osmanabad Thane Pune

Good evaluation over three rounds of CBM

48

6166

0

10

20

30

40

50

60

70

Round one Round two Round three

Partly satisfactory and Bad evaluations over three rounds of CBM

28

2320

25

1614

0

5

10

15

20

25

30

Round One Round Two Round Three

Graph 3

Graph 2

Graph 1


significant improvement between Round one andRound two, although between Round two and Roundthree the improvement is more gradual. In Nandurbar,ratings remained poor between Round one and Roundtwo, but improved significantly by Round three. Theratings for Osmanabad improved slightly betweenRound one and two, but returned to initial levels byRound three.

Certain health services have shown high andconsistently improving 'Good' ratings across the fiveCBM districts over three phases. At the end of Roundthree, 90 per cent of districts received a rating of 'Good'for immunisation services and 87 per cent of districtsreceived a rating of 'Good' for Anganwadi services. Thefollowing graphs (Graphs 4 and 5) display trends forthese services.

Health Facility Level:Evident Impact

The facility monitoring wasdone keeping four parametersin mind namely, infrastruc-ture, services, personnel andmedicines. From Round one tothree, significant changes havebeen observed in the first twoparameters.

1199


Good evaluation trends over 3 Rounds for

Immunisation services

69 71

90

0

10

20

30

40

50

60

70

80

90

100

Phase 1 Phase 2 Phase 3

Good evaluation trends over 3 Rounds for Anganwadi services

54

75

87

0

10

20

30

40

50

60

70

80

90

100

Phase 1 Phase 2 Phase 3

Trends of Good ratings in PHC over 3 Rounds of CM

64

4236

6257

35

7074

26

0

10

20

30

40

50

60

70

80

PHC Infrastructure PHC Services PHC Personnel

Graph 4 Graph 5

Graph 6


2200


Glimpses of Change

Following are some examples of qualitative improvements, which have resulted from each of these issues beingraised through the CM process. These kinds of improvements have been observed generally in several blocksbeing covered by the CM process. � PHC doctors in one of the districts used to prescribe medicine from private shops. This issue was raised

through CM and subsequently the practice was stopped. Some of the required medicines, which areunavailable, are now purchased from the RKS funds. A suggestion box for patients has been placed in thePHC due to recommendation of PHC Committee.

� Due to efforts of CM, utilisation of the village untied funds for purchasing furniture for Anganwadis insome blocks has stopped. Funds are now used for other ‘more relevant’ health-related activities.

� The laboratory facilities that were not functional in some districts have now started to work twice a week.In one of the blocks a non-functional Sub-centre started to function regularly after the CM process.

� The number of people availing services from certain PHCs, now has increased after the CM process. Insome PHCs, the number of patients availing these services doubled after CM shifted from private to publichealth system.

� Now most of the public health facilities have displayed the "Citizen Health Charter" as well as informationrelated to ambulance services.

� In a significant innovation linked to CM, adolescent representatives (12-17 yrs) in two blocks have beenincluded in the VHSCs so that issues of children and adolescents could be raised and addressed adequatelyin the meetings.

� In one of the adivasi blocks, land has been sanctioned and a new PHC building is now under constructionas a special case. A mobile unit has been started at the Sub-centre level based on demand from thecommunity. A mobile medical unit has also been approved at one of the PHCs.

� Implementation of Janani Suraksha Yojana (JSY) has improved and beneficiaries are getting benefits moreregularly in one of the districts.

� Frequency of visits of ANM and MPWs in villages has improved leading to improved village health servicesin several blocks; there is definite improvement in immunisation coverage in these villages.

� One of the Sub-centres now has a residential medical officer as this centre covers a population of around 7000.� Interaction between local health care providers and community has improved in most of the blocks;

villagers in one area have taken initiative for giving protection to the ANM as her quarter is on theperiphery of the village.

The major role of Jan Sunwais in inducing theseimprovements needs to be emphasised; many of theseissues were raised in such hearings and effectivelyaddressed. As part of the CM process around onehundred Jan Sunwais at PHC and district levels havebeen organised so far in Maharashtra.

Innovations that ‘Made a Difference’

Specially designed, simplified pictorial VHSC toolshave been designed and used particularly in Thane,Nandurbar and Amravati districts keeping in mind theadivasi population and low literacy levels.

Village, PHC and rural hospital report cards havebeen published in a poster format. These large-size posters

are displayed publicly in the village or facility, allowing allvillagers and health functionaries to see the results.

A regular 24-page state-level newsletter inMaharashtra, on community monitoring titled 'Dawandi'(public proclamation) is being published with news items,interviews, photographs, articles, instances and examplesof people's positive and negative experiences at healthfacilities and positive stories of field-level health workerswho have done praiseworthy work.

In the expanded phase, PRI members in manyblocks who had been appointed as panelists during theJan Sunwais have been made members of committeesub-groups to investigate specific health services inPune. This has led to their increased participation.

Arogya Jagruti Diwas has been organised invillages of Thane district with mass participation and


community mobilisation followed by data collectionand report card preparation. Part of the day is also usedto undertake constructive work such as cleaning a well,digging soak pits etc. Such activities create broaderownership of the community monitoring activitybeyond VHSC members.

'Open' trainings in Dahanu and Murbad blocksimply that VHSC trainings are open for not only VHSCmembers but for all other interested communitymember. This has created a facilitative environmentpromoting high social recognition of the programme.

The village health services calendar has been usedin some blocks to inform the community as well asmonitor regular outreach visits of ANMs and MPWs.

'Jahir Arogya Sabhas' were organised at villagelevel in Purandar block with the PHC medical officervisiting each CM village and conducting a village leveldiscussion on improving health services. Panchayatrepresentatives and community members also

participated in the meetings.Active participation of people's organisations

(Sanghatanas) in the entire CM process in Maharashtra isa major highlight of the state. Many of the innovationstook place in areas where such organisations are activebecause some of the earliest experiments in Maharashtraon rights-based mobilisation of community on healthissues had taken place in these areas.

State level review and culmination workshops havebeen organised in November 2008 and April 2010 withparticipation of all concerned PHC Medical Officers,Taluka Medical Officers, DHOs and Civil surgeons orrepresentatives, all block and district nodal NGOs andstate nodal NGO representatives, NRHM Mission Director,state-level NRHM and Directorate of Health Servicesofficials for comprehensive review of issues emergingthrough the CM processes in each district. These majorevents provided a platform for systemic and policy levelissues related to public health system to be discussed.

2211


Testimony of a PHC Doctor during Jan Sunwai - An interesting aspect of the communitymonitoring process

The Amaravati district Jan Sunwai in Oct. 2008 was unusual, because it was the first time in a CM-related publichearing that a PHC MO came to present her own grievance. Her testimony exemplifies the difficulties faced bywell-intentioned and sincere officers in the health bureaucracy.

Dr. Miraj Ali had been working as a PHC MO in Dhamangaon Gadhi for the last one-and-a-half years.People have reported that she has been instrumental in improving the health services of the PHC. This was byno means a small achievement considering the fact that the same PHC was almost dysfunctional before she wasappointed there. She had been staying in the PHC from the day of her appointment and naturally, the numberof OPD patients, especially women patients, had increased significantly.

In the Jan Sunwai around 20 men and women, including one Zilla Parishad representative, travelled allthe way from their village to Amaravati town and strongly protested against her unjustified transfer by the DHO.However, the DHO of Amaravati who was present in the Jan Sunwai was quite dismissive and non-committal.Around 325 people residing in Dhamangaon had signed a petition to reinstate Dr. Ali, and the Zilla Parishadmember from Dhamangaon had also endorsed this demand. This petition was presented in the Jan Sunwai.

What was striking was the way ordinary women from Dhamangaon supported Dr. Ali. CM organisersstill remember a frail looking woman who came to the Sunwai at her own expense and warned the DHO not toplay with the sentiments of the people in Dhamangaon since every house in the village knows about thecontribution and commitment of Dr. Ali.


RAJASTHAN

In the First phase of monitoring four districts werechosen, Alwar, Chittorgarh, Jodhpur and Udaipur inRajasthan. The CM process was carried out in 180villages, 36 PHCs and 12 blocks. Although the processof community monitoring started in the State fromSeptember 2007 but the course of report cardpreparation took place from September 2008.

From Sept 2008 to Nov 2009, the state underwentthree rounds of monitoring and saw a considerableshift in color codes of score cards. The report undersubmission used data from two rounds of communitymonitoring from Sept 2009 and Nov 2009.

Significant Improvements

In a short span of time, the State saw significantchanges and improvements. In districts of Alwar andUdaipur, the process of monitoring not only helped inincreasing the utilisation of vaccination services but

also motivated ASHAs to visit door-to-door for serviceprovision on a regular basis. The process also helped ineffective utilisation of public health services by thecommunity due to which the attendance of patientsincreased. The doctors and other paramedical staffbecame more regular and devoted more time. Thehealth facility eventually became more regular andorganised in terms of services provided.

After the first round of monitoring exercise (Sept2008), 138 villages out of a total 180 villages scoredred, 37 villages were yellow and only five villageswere green. The second round of monitoringexperienced shift in colour score, which was carriedout in Oct 2009. A substantial shift was seen from redto yellow and yellow to green. In the second round,out of 137 villages (which were observed red in thefirst round) 76 villages shifted to yellow colour scoreand 12 villages scored green colour, also showing anincrease from the first phase where only 3 villagesscored green colour. Graph 7, 8, 9 and 10 depict shiftin colour codes during two rounds of CM.

2222


District Alwar

36

1

9

36

0

8

0

5

10

15

20

25

30

35

40

First round Second Round

District Chittorgarh

44

5

1

24

0

16

0

5

10

15

20

25

30

35

40

45

50


District Udaipur

23

4

18

26

2

15

0

5

10

15

20

25

30


10

District Udaipur

23

4

18

26

2

15

0

5

10

15

20

25

30


Graph 7Graph 8

Graph 9 Graph 10


The active involvement of different levels ofcommittees gave leverage to the members to demandbetter and effective services, facilities and human-

power. Some of the changes at the village, PHC andblock level took place due to the hard work of thecommittees.

2233


GGlliimmppsseess ooff CChhaannggee� In Pachla PHC of District Jhodpur, the post of Medical Officer (MO) was vacant for a long time but

due to the efforts of committee members, an MO was appointed.� At Cherai PHC of district Jhodpur, a case of corruption was noticed where one of the nurses was taking

bribe from pregnant women to provide them private quarters. Mismanagement of JSY money was alsoreported. Due to constant pressure from the committee the nurse was transferred.

� At the Bomboli PHC of Udaipur district, there was corruption in disbursement of JSY money tobeneficiaries and BPL card holders faced problems in availing free medicines. With the continuousefforts of committee members these reported problems got solved.

� The committee members ensured ANM’s presence in VHSC meeting.� PHC MOs ensured training of ANMs on the use of BP machine and haemoglobin meter.

Prior to initiation of community monitoring process mostof the VHSCs had already been formed in the State butwhen members of civil society groups enquired about theroles and responsibilities of VHSC members, it was foundthat only the Sarpanch and Anganwadi worker(whotogether are joint signatories for the untied grant) wereaware of these committees and their roles andresponsibilities. Other members who were also part of thecommittees did not have any idea about thecommittee.The feedback of this enquiry was given to theChief Medical Officer (CMO), based on which a specialorder was issued to restructure these committees.Following the restructuring of VHSC, the meetingsconducted at the village level with PRI members helpedevoke increased interest in community monitoring.

Community Ensures Recognition forANM: Benefits From CommunityMonitoring

The community monitoring process in Umed Nagarvillage was initiated in Sept. 2008. The VHSC wasformed through the process of CM and meetings hadbeen held regularly. In Jan Samvad, corruption in JSYscheme in this area was brought to light and it was alsofound that women have to go to CHC Mathaniya fordelivery which is quite far.

Rukhsana Begam, the ANM of Umed Nagar underCHC Mathania in Osian block is a very dynamicmember of VHSC. She has been trained in conductingsafe delivery but due to unavailability of necessary

equipment at Sub-center, deliveries could not beperformed there. The community had raised this issuein the VHSC meeting and had demanded necessaryequipment. Their repeated efforts bore results, whenthe govt. declared it as a model Sub-center and alsogave permission for conducting deliveries. However,they faced another problem of arranging a separateroom and quarter for the ANM. The VHSC againdemanded the same from the Panchayat andsucceeded. Currently, all the deliveries in the area areperformed at this Sub-center and women receive JSYbenefit within a day or two from the delivery.

During the period January-December 2009,Rukhsana conducted 244 deliveries at her Sub-centerwhich is indeed praiseworthy. She resides in the villagewhich makes it easier for her to provide qualitativeservices.

The VHSC has nominated her for ExcellentService Performance Award and she has been rewardedfor her comittment and efficiency at district level onthe occasion of Republic Day.


JHARKHAND

The CM was carried out across three districts ofJharkhand. The process covered 135 villages, 27 PHCsand nine blocks. The CM exercise in the State hasenabled community and community-basedorganisations to monitor demand/need, coverage,

access, quality, effectiveness, behaviour and presenceof healthcare personnel at service points and to tracepossible denial of care and negligence. The Stateunderwent a round of monitoring and for this purposeit undertook a few innovations to make CM effectiveand significant. The graphs (11, 12, & 13) below showsdistrict-wise status:

2244


Dist Palamu

13

1

46

0

4

19

5

18

3

18

8 8

2

11 108

26

39

26

3331

43

30

9

31

0

5

10

15

20

25

30

35

40

45

50

Ma

tern

al H

ea

lth

JSY

Ch

ild H

ea

lth

Dise

ase

Su

rveilla

nce

Cu

rative

Se

rvices

Un

tied

Fu

nd

Qu

ality o

f Ca

re

Co

mm

un

ityp

erce

ptio

ns

Sa

hh

iyafu

nctio

nin

g

Dist Hazaribagh

1 2

10

0

7

1

5

20

8

14

23

19

4

20

5

27

22

18

30

20

16

41

18

39

13

3

18

0

5

10

15

20

25

30

35

40

45

Ma

tern

al H

ea

lth

JSY

Ch

ild H

ea

lth

Dise

ase

Su

rveilla

nce

Cu

rative

Se

rvices

Un

tied

Fu

nd

Qu

ality o

f Ca

re

Co

mm

un

ityp

erce

ptio

ns

Sa

hh

iyafu

nctio

nin

g

Graph 11

Graph 12


Prior to CM, the Village Health CommitteeMembers and Sahiyya ( In Jharkhand ASHAs are calledas sahhiyya) were not well-versed with their role in thecommunity and there was a lack of motivation forparticipation among them.

Breaking the Ice: Orienting CommunityMembers:

The orientation had great impact on the mindset ofmembers; it contributed in grooming VHC membersafter which they were well-informed and sensitised.Members are now more empowered and aware aboutthe purpose of being part of the Committee and theirroles and accountability towards the community. AfterCM, most of the VHCs conduct meetings on a regularbasis and issues related to maternal and child healthand disease control are now being discussed and raisedin the proper forum. Most of the VHCs have developeda sense of ownership for the community and aretaking action to address health issues and advocatingwith health service providers for the same. Sahiyyaearned the community's acknowledgement and anidentity of its own. The community knows about itspresence and purpose in the community.

Regular dialogue with officials at the block,district and state levels during the process has in fact,broken a barrier between the community andgovernment functionaries. Officials in the State anddistrict levels helped in getting cooperation fromgovernment functionaries and are now willing to take

the process forward in the whole State.The most important outcome of this process was

the initiation of dialogue between the community andthe health system. As such the word 'monitoring' or‘nigrani’ was not considered appropriate. Instead, itwas replaced by the word 'Action' and the wordSamwad (dialogue) was used in place of Sunwai(hearing). This was done because the purpose was toensure the quality of services in the State and not findfaults. Moreover, the community and governmenthealth functionaries were part of the process together.

After sharing of report card at the village level,most of the VHCs have prepared the village healthplan based on gaps and have started negotiation withFLWs. The VHCs in some of the blocks are supportingservice providers in VHND.

Following the orientation of Media Fellows,regular news on CM is now being covered, which ishelping in ensuring quality of health services at thevillage level.

Innovative Treatment Bears Fruit

Involvement of a street play group in KKaallaa--JJaatthhtthhaa(theatre-based awareness campaign) was an interestingand innovative initiative. The performance of Kala-Jaththa helped in mobilising and sensitising thecommunity. It has been used successfully in the past inother social programmes like education but it was beingused for the first time on a large-scale within a healthintervention. Training of street play groups ensured that

2255


Dist West Singbhum

1 1 10

10

1

15

2

86

19

2

9

2

6

10

5

3133

20

38

30

38

33

9

24

0

5

10

15

20

25

30

35

40

Ma

tern

al H

ea

lth

JSY

Ch

ild H

ea

lth

Dise

ase

Su

rveilla

nce

Cu

rative

Se

rvices

Un

tied

Fu

nd

Qu

ality o

f Ca

re

Co

mm

un

ityp

erce

ptio

ns

Sa

hh

iyafu

nctio

nin

g

Graph 13


the performance did not lose focus, scripts wereappropriate and right messages were given.

Village Health Register: State has come up withan idea of a village health register to keep records ofproceedings and meetings. Now every VHSC has avillage health register in order to maintain records.

Media plays its Part

Sensitising media on public health issues, especiallymaternal and child health was important to ensuredissemination of such information to sensitisecommunity and to strengthen advocacy with serviceproviders. A Media Fellowship was given to eightmedia persons from Hazaribag, Palamu, WestSingbhum and Ranchi to ensure improvedparticipation of media in sensitising the communityand health service providers about entitlements andfacilities guaranteed under the National Rural HealthMission.

2266


Sample of Village Health Register


ORISSA

The process of community monitoring in Orissa,started in April 2007 in four selected districts-Bolangir,Kendrapara, Mayurbhanj and Nabarangpur. The CMactivity was carried out across 180 villages, 36 PHCsand in 12 blocks of the State. The State underwent around of monitoring and gained vital learning thoughthe process. The success of CM was due to active

participation of districts and blocks in orientationprogrammes, trainings, workshops, planning andreview meetings and individual sharings. The Stateunderwent regular internal planning, review,monitoring of activities, problem solving, learninglessons and incorporating the same in the process forminimising risks and successfully implementating theCM. District wise findings of CM are shown in thegraphs (14, 15, 16 & 17) below.

2277


Dist Bolangir

27

21

38

10

18

0

15

34

30

21

17 17

9

13

20

0

13

10

5

0

3

9

0

24

9

47

19

1

9

21

0

5

10

15

20

25

30

35

40

45

50

MaternalHealth

JSY Child Health DiseaseSurveillance

CurativeServices

Untied Fund Quality ofCare

Communityperceptions

ASHAfunctioning

Equity Index

Dist Nawarangapur

28

5

0 0 0 0 0 0 0

32

14

22

0 0 0 0 0 0 0

8

0

15

42 42 42 42 42 42 42

00

5

10

15

20

25

30

35

40

45

MaternalHealth


CurativeServices



ASHAfunctioning

Equity Index

Graph 14

Graph 15


2288


Dist Mayurbhanj

50

35

49

7

30

3

6

39

44

4

11

15

0

7

15 1513

9

10

3

1415

50

19

4645

16

19

00

10

20

30

40

50

60

MaternalHealth


CurativeServices



ASHAfunctioning

Equity Index

Dist Kendrapara

1

3

9

01

0 0

5 5

15

21

3

9

0

5

1

4

13

10

15

31

19

37

31

36

33

17

29

15

0

5

10

15

20

25

30

35

40

Maternal

Health

JSY Child Health Disease

Surv eillance

Curativ e

Serv ices

Untied Fund Quality of

Care

Community

perceptions

ASHA

functioning

Equity Index

Graph 16

Graph 17


Triggering a Change

The orientation process helped in increasingawareness on different health entitlements of VHSCmembers, which brought about positive changes inperception of the members and resulted in increaseddemand for service facilities.

In addition, the process empowered VHSCmembers to the extent that VHSC members preparedthe health action plan and started working as per theplan even though the VHSC had not received moneyfrom the government.

The process also helped in regularisingdisbursement of JSY funds and facilitated in releasingthe JSY benefits.

The process improved ownership among ANMs,AWWs and ASHAs and increased better coordinationamong them. The CM empowered the ASHAs, as theywitnessed that people at higher level responded totheir grievances and welcomed suggestions fromthem and acted on the information provided bythem.

GGlliimmppsseess ooff CChhaannggeeA contractual doctor appointed in one of the PHCs wasnot visiting the PHC regularly. During the publicsharing meeting, the villagers complained about thisand a new doctor was appointed within three months.

An AWW in one of the PHCs used to charge Rs 50from the women to make JSY cards for them. Acomplaint was filed at the district headquarter afterwhich she stopped taking bribes.

ANMs and AWWs are demanding training due tothe CM process which in turn helps in impartinghealth-related information to the community andalso in providing services.

The CM process in Orissa has sensitised serviceproviders and beneficiaries. The community hasrealised that it is wrong to bribe ANM, ASHA or doctorsfor getting JSY benefits. Most of the women whodelivered in hospital before CM faced harassment inorder to get the JSY benefits. Now due to strongopposition from villagers, the harassment has stoppedand nearly 80 per cent of corruption has been dealt-with by the community at the PHC and CHC level.

Doctors, pharmacists and other staff have nowbecome regular in Badapada PHC due to theirinvolvement in community monitoring process andpublic scrutiny of their performance. Moreimportantly, a friendly and effective relationship hasnow developed among various stakeholders.

The PRI members for the first time realised thatit is their duty to see that villagers get quality healthservice at the Sub-center, PHC and CHC levels.Previously, they were under the impression thatproviding quality health services is only the duty ofdoctors and their involvement is limited only toconstruction of road and digging ponds. Now theyare taking interest in solving problems related tohealth services. They are even lobbying for betterfacilities for doctors and other medical staff likeprovision of quarters, drinking water and bettersanitation facilities.

The score cards helped service providers tounderstand the actual health situation in their areaswhich they tried to improve.

Doctors and medical staff are now graduallybecoming aware that denial of health services can bemade public and disciplinary actions may be taken.They realise that they are accountable for the patients.

Doctors and staff exercise self-restraint in takingmoney from patients after being involved in thecommunity action process.

CChhaannggeess aatt GGaaoonn KKaallyyaann SSaammiittii ((GGKKSS)) lleevveellThe GKS ( in Orissa VHSCs are called GKS) formed andoriented under Community Action are self-managed,self-driven, self-reliant and more effective inaddressing health issues than other GKS. They work asa team with the principle of cooperation, mutualunderstanding and support. They have a sense ofownership for the GKS.

The GKS formed and oriented under communitymonitoring are maintaining proper records of untiedfunds and their utilisation. They maintainappropriate resolution books and accounts and adopta democratic process in deciding actions for whichfunds are to be spent and that it is accountable for.However, in other cases, several irregularities werealso noticed when the GKS was not formed in theright process and had not received adequate training.

CM has provided a good platform to promotehealth rights. The community and committeemembers at various level now understand that healthis their right. So there is effective demand for betterhealth services and at the same time, mutualcooperation between service providers, PRIs,community leaders and other stakeholders.

Some GKS are now preparing their own actionplan in order to plan and spend untied fund money. Itis also involved in raising more funds that has giventhem a leverage to spend on the health of thecommunity.

2299



Reaching Out through Media

The Community Monitoring Media FellowshipProgramme was instituted to provide prospective tomedia journalists with an opportunity for reflection,codification and discussion on specific NRHM issues.The objective of the programme was that this wouldcontribute to strengthening of NRHM programmes by

enhancing capacities at all levels. Central to this, theobjective was to facilitate individual andorganisational learning ( block nodal NGOs, districtnodal NGOs) involved in community action processand by feeding localised knowledge into state,regional and national processes, and vice versa. Mediafellows were selected in each selected district as well asat the state level.

VHSC Resolves Flouride Problems:Ms. Sanjukta Basa, Secretary, OLAMP;Mayurbhanj

Kurkutia village under Kusumbandh PHC hasexcessive fluoride in water and nearly 70 per centpeople suffer from kidney and liver related problems.Although several complaints were made to higherauthorities, nothing much happened. During one ofthe VHSC meetings I called reporters from the

television channel ETV and apprised them about thesituation. Next day the reporters visited the village andsaw the problem themselves. Soon after this, I wrote aletter to the District Collector, Executive EngineerRWSS and CDMO of the district and told them aboutthe fluoride contaminated water and how the villagerswere unable to use the tube well. The District Collectorappointed a health team to investigate the matter. Theteam found that the problem was serious. Afterreceiving the report the Collector gave instructions tothe Executive Engineer RWSS to supply water tankersto the villagers. The district authority is also layingdown a water pipeline to the village. The districtauthority also deactivated the tube wells to preventpeople from using the contaminated water. Thedistrict authorities sprung into action largely due tothe efforts of CM.

Empowered VHSC Tackles Superstition: Ms. Manorama Dey, Block Coordinator,Unnayan Rasgobindpur

The CM has made a great impact on the mindset of thepeople. Training and knowledge imparted under theCM has brought about positive changes in the society.In one of the villages of the block, a small boy wasbitten by a snake after which the family took him tothe local/traditional healer. When the VHSC membersof the village came to know about the incident theyimmediately reached the scene and rushed the boy tothe nearest government hospital. The boy was treatedfor three to four days after which he was discharged.

In another incident, a malaria patient fromvillage was taken to the traditional healer as the familywas very poor and couldn't afford to take the patientto the hospital. The VHSC members upon learningabout the case arranged transport for the patient to betaken to the hospital. They used the RKS fund for thetreatment. They also made the traditional healer tounderstand that serious cases of malaria need to betreated in hospitals. A change in attitude andperception was felt after the process of CM as theCommittee members , with their autonomy anddecision-making power were more empowered.

3300



MADHYA PRADESH

A total of five districts were selected for CM In MadhyaPradesh: Guna, Chindwada, Sidhi, Badwani, and

Bhind. The monitoring was undertaken across 225villages, 41 PHCs and 15 blocks. District wise findingsof CM is shown in the graphs(18, 19, 20 , 21 & 22)below:

3311


Dist Guna

18

26

1619

21

9

23

1720

24

17

13

21

13

20

15 16

119

1210

68

13

4

21

6 6

2

9

0

5

10

15

20

25

30

MaternalHealth

Child Health CurativeServices

Quality ofCare

ASHAfunctioning

Dist Chindwada

18

8

2723

0

15 1520

25 2423

16

510

2

15 1512

5

11

4

21

13 12

43

15 15

611

2

0

5

10

15

20

25

30

35

40

45

50

MaternalHealth


Quality ofCare

ASHAfunctioning

Dist Sidhi

1615

1213

8

0 0

1413 13

1614

1617

12

7

15

13

6

17

13

1617

15

25

38

30

4

22

13

0

5

10

15

20

25

30

35

40

MaternalHealth


Quality ofCare

ASHAfunctioning

Graph 18

Graph 19

Graph 20


3322


GGlliimmppsseess ooff CChhaannggeeThree days of continuous monitoring of the CHC in Pati block was undertaken after the VHSC was orientated Adialogue on effective delivery of health services was initiated with the BMO during the period. The following decisions were taken after the interaction:� Not to prescribe drugs from private medical stores.� Making the ambulance available for all patients.� Starting Janani Express Yojana in the block.� Not charging anything extra from patients.� No charges for BPL card holders for treatment during admission in the hospital.

Dist Badwani

3 36 7

0 2

1013

29

3 5 5

11

3 5

18

2

7

39 3734

27

4238

7

22

4

0

5

10

15

20

25

30

35

40

45

MaternalHealth


Quality ofCare

ASHAfunctioning

Dist Bhind

30

3 3 41 2

6

1818

9 94

8

0

7

23

11

24

3633

3833

44

36

11 13

0

5

10

15

20

25

30

35

40

45

50

MaternalHealth


Quality ofCare

ASHAfunctioning

Doctors posted in PHCs, the CMO and the BMO areappreciative of the demand generated for health

services after community monitoring.

Graph 21

Graph 22


SSuubbssttaannttiiaall CChhaannggee OObbsseerrvveedd iinn AAttttiittuuddee &&BBeehhaavviioouurr ooff PPuubblliicc HHeeaalltthh PPrroovviiddeerrss..

There was no doctor posted at Bhuimad PHC of Sidhidistrict. The compounder, who visited the PHC did notreside at head quarter and was irregular in attendingthe PHC. However, the community members ensuredthat the compounder visits the PHC regularly. DuringJan Samvad it was reported that no vaccination wasbeing conducted in the Bhuimad area. Postcommunity monitoring, the CMHO himself visitedthe PHC for three regular months and monitored thevaccination.

Since it was a malaria endemic area, a malariacheck-up camp was organised after the Jan Samvad inwhich more than 1000 patients were examined andtreated. Medicine stock was also increased as existingsupply of medicines was inadequate.

Baigas are a primitive tribal group who have notreceived BPL cards on the basis of which they couldavail various entitlements and benefits under the DeenDayal Antyodaya Upchar Yojana Card and receivetreatment up to Rs 20,000. The matter was brought tothe notice of of health officials and it immediatelyinstructed to issue BPL cards along with the DeenDayal Antyodaya Upchar Yojna cards also to theBaigas. As a result the tribe members were successful ingetting the said cards. .

The doctor posted in the PHC said during theJan Samvad that he could not reside in the headquarter due to non-availability of quarter in thePHC. The villagers discussed the issue during thehearing and took the initiative of arranging a housefor the doctor.

In Guna District, the CMHO is highly motivated afterthe community monitoring programme. He hasattended all the district level trainings and visitedBlock and PHC committees. He has also released theVHSC untied fund and given the responsibility to PHCCommittees for supporting them.

IImmpprroovviinngg CClliieenntt--PPrroovviiddeerr IInntteerraaccttiioonn

Gaildubba village, Chhindwara- villagers reportedabout the ANM not visiting the village to BMO whichresulted in regular visits of the ANM. They are alsoundertaking other sanitation related activities in thevillage after discussing it in VHSC meetings likecleaning of wells before rainy season etc.

Markadhana village, Chhindwara-villagers put upthe ANM visit chart in the Anganwadi centre andmonitored the same. They reported to BMO that ANMwas irregular. An action was taken against her. In thisvillage also, sanitation activities were undertaken asdecided during the VHSC meeting.

Palwat village Badwani - After the delivery of aVHSC member's wife in the government hospital thenurse refused to vaccinate the newborn baby andprepare the card as she was not given moneydemanded by her for the services. Villagers placedtheir complaint to the BMO and as a result she cameto the village to vaccinate the child and prepared thecard.

Ubad garh village, Badwani: The ANM was notcoming regularly to the village. In order to monitorANM performance, VHSC members gave BMO a list ofwomen who didn't received ANC and children whowere not vaccinated. The BMO instructed the ANM tovisit the villages regularly and meet VHSC members.She responded positively and her visits became morefrequent and regular.

Kandara, Limbi, Berwada, Gudi villages, Badwanithe ANM was not regular in these villages. The VHSCtook the initiative and wrote to the BMO after whichthe ANM has started visiting the villages regularly. Incase of absence, she informs the same to ASHA orVHSC members. This step taken by her enabled themembers to communicate her visit plans to thevillagers and save them from inconvenience.

A total of 220 ASHAs in Gohad Block, Bhinddistrict have formed the AHSA Adhikar Samiti foraddressing their problems. They submittedmemorandum to the SDM, CMHO for timely release ofJSY incentives, which is released regularly now.

3333



ASSAM

For the first phase of the community monitoring threedistricts Chirang, Dhemajee and Kamrup Rural werechosen in the state. The monitoring was carried out

across 135 villages, 27 PHCs and 9 blocks. The stateunderwent one round of monitoring. District wisefindings of CM is shown in the graphs (23, 24 & 25)below:

3344


Dist Kamrup Rural

21

9

15

22

45

95

44

23

32 30

10

0

25

10

014

0

13

0

11

30

00

5

10

15

20

25

30

35

40

45

50

MaternalHealth


Quality ofCare

Dist Chirang

1 0 0 03

0 0

4 4

9

15

7

14

1

6

1 1 0

4

8

12

21

14

27

19

27 27

1

15

4

0

5

10

15

20

25

30

MaternalHealth


Quality ofCare

ASHAfunctioning

Dist Dhemaji

3 69

07

0 0

25

12

28

19 1723

3

12

3 2

20

7 8

38 37

28

57

41

57 58

14

39

5

0

10

20

30

40

50

60

70

MaternalHealth


Quality ofCare

ASHAfunctioning

Graph 23

Graph 24

Graph 25


Community monitoring processes have startedempowering people in the state. After the process ofCM was initiated in the state, people have startedspeaking out what they like and what they do not. Dueto initiatives taken up in the process, people are nowaware about their health rights, what has to be donewhen there is a denial of services which is violation oftheir health rights. The process has made communityaware about how best they could cooperate with thehealth service providers.

Another significant achievement is that after theinitial progress of CM in three districts , the stateNRHM has proposed to integrate the process in twomore districts and has included in the state PIP.

Desired changes have taken place

After the first phase of CM positive changes have beenseen in the community as well as in the functioning ofthe Sub-centre at Ratanpur under Jonai BPHC inDhemaji District .

The Community now feels that having goodhealth is their right and assured service guaranteeshould be in place. The people of Ratanpur now canaccess health services at the newly constructed, well-equipped Sub centre, which earlier was in a dilapidatedcondition. The community monitors working of SW,MPW, reports to MO and looks after cleanliness of theSub-centres.

As shared by Mr Nirmal Doley (Ward Member)President, VHSC; Ms Premolota Pegu (ASHA worker)Secretary, VHSC; and Mr. Nava Deori, CommunityMember - the Community has come to know aboutthe responsibilities of ASHA as well as ANM which hasimproved registration of the pregnant women. Theuntied fund of the VHSC has now been used moreappropriately, e.g. cleanliness of the village, awarenessgeneration programme on Malaria, Diahorrea,Nutrition Public Health and Sanitation.

Increase in registration of birth and death has alsobeen seen. Village Health and Nutrition Day is nowobserved in the villages with active participation of theASHA, AWW, ANM and villagers.

People now have easy access to modern FamilyPlanning Methods (FPM) (Oral Contraceptive Pills andCondoms) Iron Folic Acid tablets from the ASHA andthey now don't hesitate to ask and enquire about theFPM in meetings and women also take part in this kindof discussion. Women are now more concernedabout their health which is a positive sign for thecommunity.

What is more encouraging to note is that thoughthe process is still at a nascent stage, it has not onlyenhanced the accountability of service providers butalso kindled the sense of ownership amongst peoplewhich is undoubtedly a core essence of communitymonitoring process.

3355



CHHATTISGARH

The state of Chhattisgarh undertook three districts forCM. The CM activity was done across 115 villages, 27

PHCs and nine blocks. The state underwent a round ofmonitoring. District wise findings of CM is shown inthe graphs (26, 27 & 28) below.

3366


Dist Baster

18

12

16

36

0 0

19

30

0

24

1011

18

9

0

22

10

15

0

4

17

22

11

0

45

23

16

0

45

2

0

5

10

15

20

25

30

35

40

45

50

MaternalHealth


Quality ofCare

Mitanin functioning

Dist Kawardha

7

1

11

17

01

8

22

0

21

7

19

11

0

3

21

8

0

2

22

0

2

30

36

10

30

0

5

10

15

20

25

30

35

40

MaternalHealth


CurativeServices


Communityperceptionsof Mitanin

Mitanin functioning

Graph 26

Graph 27


VHSC members take charge of health

Bastar Samajik Jan Vikas Samiti, Darva Bastar

This incident occurred nearly 15 days after theformation of VHSC in Bispur village under CM. It wasrevealed during one of the meetings that adequate andsufficient medicines were not available at the Sub-centre. Several community members also spoke aboutthe irregularity of hospital staff. The meeting wasattended by all health workers and health departmentstaff. Soon after the meeting, the VHSC memberscontinued to monitor the health related problems inthe village due to which the situation improved. Thestock of medicine at the Sub-centre increased andimportance was given to hygiene and sanitation issuesin the village. The areas around boring wells werethoroughly cleaned. The VHSC members in fourvillages through their proactive approach not onlyenhanced the quality of health services in the villages

but raised awareness on CM in the community.

Community Monitoring helped in gettinghuman resource and infrastructure

A meeting was organised at the PHC in Koleng villageunder CM. While reviewing the health delivery statusfrom the rural community members, it was found thatthere was a great need of a lady ANM, lady doctor andalso of ambulance service. When asked whether thecommunity members were paying any sort of bribe tohealth personnel or if the doctor was being irregular inhis visit, the villagers replied in the negative. They saidthat they have never paid money to health officialsand that they were quite happy with the performanceof the existing doctor, Dr Sharma, who had beenvisiting the Centre regularly and treating people well.Now efforts are being made through the VHSCmembers to appoint lady health staff at the Centre andalso to acquire an ambulance for the PHC.

3377


Dist Koriya

8

12 12

28

0 0

12

15

0

12

30

1312

8

0

22

18

0 0

32

1516

4

40

23

10

0

40

00

5

10

15

20

25

30

35

40

45

MaternalHealth


Quality ofCare

Mitanin functioning

Graph 28


TAMIL NADU

CM in the State has been effectively on ground forabout 18 months. For the first phase, the State chosefive districts: Dharmapuri, Kanyakumari, Perambalur,Thiruvallur and Vellore. The monitoring was carriedout in 225 villages, 45 PHCs, and in 15 blocks.

The CM process in the State has set in motionefforts to bring the community to the centre-stage inhealth delivery. The VHSCs have given voice andvisibility to the community and thereafter people have

a better sense of their entitlements and hence theirexpectation from the public health system hasincreased. They have also begun to understand theconstraints of the Health Department, especially thoseof the frontline workers. It has not only enabled abetter linkage between the community and the HealthDepartment but also enhanced accountability of theDepartment in engaging with the community and inresponding to the community.District wise findings of CBM is shown in the graphs(29, 30, 31, 32 & 33) below.

3388


Dist Kanyakumari

25

3

16

13

26

17

41

18

12

23

26

15

21

42

30

6 6

4

7

00

5

10

15

20

25

30

35

40

45

Maternal Health JSY Child Health DiseaseSurveillance

CurativeServices

Untied Fund Quality of Care

Dist Dharmapuri

15

46

1

6

01

23

9

28

3

11

0

18

7

32

11

41

28

45

26

0

5

10

15

20

25

30

35

40

45

50

Maternal Health JSY Child Health Disease Curative Untied Fund Quality of Care

Graph 29

Graph 30


3399


Dist Vellore

11

7

53

76

2

19

5

25

11

17

9

4

15

33

15

31

21

30

39

0

5

10

15

20

25

30

35

40

45


CurativeServices


Dist Perembalur

12

1

7

10 0 0

24

3

22

1

42

1

9

41

16

41 4143

44

0

5

10

15

20

25

30

35

40

45

50


CurativeServices


Graph 31

Graph 32


Glimpses of positive changes

In the State, the changes brought about after the firstphase activities can be classified at a systemic andcommunity level.

Meeting Demands from an EnlightenedCommunity:

The members of VHSC in one of the districts played aproactive role, thanks to the orientation and trainingprovided to them. The training helped them to accesshealth care services as per their needs and they felt therequirement of a sub-centre in their village. Theycollected all relevant information from the facilitatorsand the local health staff after which they approachedthe appropriate health authorities and followed-up onthe issue till the sub-center was actually establishedmuch to the surprise and joy of the villagers. Thisinfused the VHSC members with a huge amount ofconfidence.

It was only after the orientation and training ofcommunity members and VHSC members in one ofthe blocks that they realized that all services of VillageHealth Nurse (the ANM is called VHN in Tamil Nadu)should be available free of cost. In their particular area,which is very remote, the VHN was actually staying inthe village. She was treating simple illnesses at thevillage level by giving injections and tablets wherevernecessary, but she was charging for these services. The

VHSC members discussed this with her. Shementioned that the medicines she was using werebought from the market and that she was merelycharging the market price. The VHSC members thenapproached the MO who then called the VHN andexplained to her that people are better aware now andthat she should change her old practice. The VHNsubsequently stopped charging for her services. Shealso stopped stocking injections and medicines boughtfrom the market. Despite these positive outcomes,however, some people feel the VHN has now stoppedproviding health services especially during emergencysituations which is a loss.

Ensuring Rights

Despite the fact that there are no user fees for out-patient services in Tamil Nadu, one of the PHCs wascharging a small amount for registration and makingthe Out-patient (OP) ticket. During the orientationand training sessions when the VHSC members weretold that this was not a standard practice and thatthey were entitled to free services, they decided to dosomething about it. The VHSC members approachedthe MO and raised the issue pointing out that theywere well aware now of the illegality of this fee. TheMO immediately took steps to make sure that nomoney was collected from the patients for what issupposed to be a free service.

4400


Dist Thiruvallur

13

9

12

6

11

10

16

10

7

12

6

9

15

8

7

14

6

18

10

5

6

0

2

4

6

8

10

12

14

16

18

20


CurativeServices

Untied Fund Quality of Care Graph 33


During the public hearing in one district, thepeople raised the issue that in one of the PHCs therewas lack of privacy especially for women patients. TheDeputy Director immediately ordered that simplepartitions be purchased and installed so that privacyfor women patients during simple procedures andwhile taking injections is maintained. This was greatlywelcomed by the people in that area.

Long-term Impact through SystemicChanges

Besides these motivating examples of local changebrought about during the pilot phase, some of themost significant changes have also been brought aboutat the systemic level. � It is for the first time that the Health Department

officials and the people met as part of a systemicmechanism and discussed issues from people'spoint of view. This led to a huge positive feelingamong the people.

� One of the major benefits of the process was thatpeople recognised the various constraints whichfront-line health staff have to face during thecourse of their work. This occured thanks to thefact that the people, now as committee members, raised various issues regarding serviceavailability and quality directly with frontlineworkers for the first instance. This gave them achance to understand various issues from thesystemic point of view. Similarly, the systembegan to appreciate the needs and priorities ofpeople and gaps in the system as perceived bypeople, thanks to these discussions.

� Thanks to the various changes brought about inthe health system and to the CM process;especially public hearings and face-to-facemeetings of senior health officials with thepeople, community members have now begun toperceive the health system as being responsive. Itwas felt that this was the first step towards fullownership of the healthcare system by thepeople.

� As per the Tamil Nadu Government rules, theVHSC consists of 5 members - three of whom(VHN, AWW and Health Inspector) aregovernment staff. It was pointed out at thebeginning of the Project that to function as apeople's committee there had to be greatercommunity representation in the committee.

However, it was only after demonstrating thefeasibility of formation of such committeesduring the first phase and continued interactionwith higher officials, that there was a consensusthat there needs to be a change in thecomposition. As a first step, a larger group ofpeople at the village level will receive orientationand training in the ongoing VHSC traininginitiative by the government.

� The potential role of civil society groups in thefield of health is being increasingly recognised.Both state and district level officials of the publichealth system are more open to interaction withcivil society-based groups.

� One of the major outputs from the process hasbeen the publication and release of a documententitled "Community Monitoring and PlanningFirst Phase in Tamil Nadu: A Joint LearningProcess." This was co-authored by MissionDirector, State Rural Health Mission, Director ofPublic Health and Preventive Medicine andrepresentatives of civil society of the State MentoringCommittee of the first phase. This paper was acollation of various discussions between thegovernment and civil society groups on varioussteps/stages and dimensions of the first phase. Thispaper was released as a background paper during thestate-level dissemination workshop. It formed thebasis for discussion during a half-day session wherevarious stakeholders, including Deputy Directors,Medical Officers, village health nurses, NGOdirectors, academics, and project facilitatorsdiscussed it. The participants came up with furtherrecommendations for each of the issues raised anddiscussed in the joint paper. This comprehensivedocument forms the basis of the next phase of theproject.

� Due to the CM process, the visit of VHN hasbecome regular. Many instances of denial wherepeople were asked to buy syringes have now beenresolved. The duty roster, timings and mobilenumbers of the VHN are now displayed on wallsof the health facility.

� One of the PHCs of Tiruvellore district used to beoften closed and it had no proper transportaccess. Following the CM, the PHC is now openand the MO visits the PHC regularly.

� The VHNs are now aware about the availability ofuntied funds and request for allocation from theMOs. The process of empowerment of VHNs isalso believed to be happening.

4411



Innovative Alliances

One of the interesting initiations that the Stateundertook was to involve VHN associations in the CMprocess. The involvement with the VHN Associationhelped to allay their fears about the process as theyinitially perceived the process as a fault-findinginitiative. The President of the VHN Associationparticipated in the state-level meeting, and extendedher support to the process.

Children and youth parliament were organised tomobilise the elders in a district. The church too, playeda role in mobilisation in certain villages. The NursingCollege in the district was roped in to spreadinformation about NRHM and CM.

Folk media and handbills were also used forspreading awareness and mobilisation. These handbills

provide details of the functioning of Sub-centers andthe services provided in them; facilities in a PHC andservices provided in a PHC; details of duty time ofdoctors, nurses and VHNs, other staff, and the citizen'scharter. This is one of the major outputs of the process.The presence of volunteers from the literacymovement - Valar Kalvi Thittam (ContinuingEducation Programme) is a significant strength in afew districts. They helped to mobilise the communityin many villages. In fact, these volunteers took thelead in preparing score cards in villages where theywere present.

Another small but significant initiativeundertaken in Dharmapuri district was issuing of IDcards for VHSC Members so as to ensure that they arerecognised and accepted by the Health Department.

4422



KARNATAKA

For the first phase of CM in Karnataka, four districtswere selected with a target to cover 180 villages acrossthe State. Karnataka was included in the CM processquite late but it managed to form 562 VHSC which wasway above the original target of 180 across fourdistricts. The State gradually increased the number ofvillages as it undertook rounds of monitoring. TheState underwent three rounds of monitoring over a sixmonths period and witnessed significant changes.Four districts, 52 PHCs and 12 blocks were taken forthis process.

Visible Difference

Analysis of the score cards shows that the perceptionof community members on various health and healthservice parameters has changed. All the parametersover the project period show differential degree ofprogress (red signs decrease while yellow and greensigns increase). Round wise findings of CBM is shownin the graphs (34, 35, 36, 37, 38 & 39) below.

4433


Untied Fund

4

2940

23

47 51

108

59

44

0

20

40

60

80

100

120

First Round Second Round Third Round

Curative Services

2534

46

6672 76

88

73

57

0102030405060708090

100


Disease Surveillance

3342

555565

58

91

7266

0102030405060708090

100


Janani Surakhsha Yojana

7382

9080 77

64

2620

25

0102030405060708090

100


Child Health

79

10390

5665 64

44

11

25

0

20

40

60

80

100

120


Maternal Health Gurantee

7382

9080 77

64

2620

25

0102030405060708090

100


Graph 34

Graph 35 Graph 39

Graph 38

Graph 37

Graph 36


Glimpses of Change

Jan Samvads resulted in action being taken in someareas - such as use of untied funds at PHC and SC levelfor repairs of infrastructure and equipment or postingof health personnel in some cases.

The process has also resulted in more accuratereporting of deaths. For instance, in the last sixmonths, in one Taluka alone, the VHSC processidentified six infant deaths and one maternal death,which were not picked up by the system earlier.

The State Government took strong ownership ofthe programme and worked in close partnership withcivil society organisations. State Mentoring andMonitoring group (SMMG) included key officers fromthe state Health Department and the NGOs thatshared a common vision and commitment. TheSMMG facilitated coordination at state and districtlevels and significantly influenced the outcomes.

A common focus across districts on the high levelof investment in village processes including threemember CRP team to (i) mobilise community, (ii) formVHSC, (iii) train VHSC members and (iv) facilitatescore card filling - have resulted in strong VHSCs.

The CM process worked as an agent to bringtogether ICDS and AWW and helped them performbetter in the absence of ASHAs (Karnatka has noprovision of ASHA). In some of the CBM villages,convergence between health and ICDS was furtherstrengthened as the AWW took a leadership role as aco-convener, and in many instances she served as thede facto convener.

Innovative Deviations

Karnataka chose to make two significant deviationsfrom the national design. One was to expand theprocess to "planning and monitoring" instead of just"monitoring." Thus, the initiative in Karnataka isreferred to as Community Planning and Monitoring ofHealth Systems (CPHMS).

The second was in terms of geographic coverage.The departure from national guidelines of coveringfive villages in each PHC area to attempt universalcoverage of all villages in the PHC area resulted in 80-100 per cent coverage of villages under each PHC.

Kala Jaththa as a prelude/precursor to VHSCformation served to mobilise communities andfacilitated acceptance of marginalised groups bygeneral community. Kala Jaththa performances also

facilitated acceptance of marginalised groups by thegeneral population.

The state undertook the Participatory RuralAppraisal (PRA) techniques to mobilize community,the method was used for formation of VHSCs anddeveloping village action plan.

Another initiative that resulted in highcommunity acceptance of the process was a series ofmeetings held with different caste groups prior to theVHSC training. Appointing ten Community ResourcePersons (CRP) at Taluka level to create VHSC was acritical measure in achieving scale with quality. TheCRP invested substantial time in working with allsections of the community in these areas (where

4444



casteism is high) to ensure appropriate representationon VHSC.

In all districts of first phase, the districtcoordinator networked with the local media toenable periodic articles in the regional languagepress about the process and ensuring coverage inthe Jan Samvad. This yielded results, particularlythe publicity in regional language newspapers.

However, the coverage varied across the districts. Several variations from national guidelines in

capacity building process strengthened it. Also, theState organised a district level TOT for nodal NGOsrather than one common state level TOT in order toprovide more focused and high level mentoring andsupport to the district NGOs.

4455


A Transformed PHC

AA SSuucccceessss ssttoorryy bbyy CCoommmmuunniittyy HHeeaalltthh CCeellll,, BBaannggaalloorree -- NNooddaall OOrrggaanniissaattiioonn ffoorr RRaaiicchhuurr DDiissttrriicctt -- Gunjalli is a village situated at a distance of 22 km from Raichur district headquarters, covering a

population of 35,000 in 20 villages within its jurisdiction.Before the CM, it was a very low-performing PHC with less than 40 per cent immunisation coverage.

Though VHSCs were formed the members did not know about their roles and responsibilities, with zeroutilisation of untied funds. Most of the deliveries were taking place at home. After the intensive process of CMtraining, Jan Sunwais and follow-up during the CM process, the atmosphere in the PHC and in the villages takenfor CM was transformed.

Activated VHSCs: Ten VHSCs were revitalised and started functioning. The village health plans madeincluded addressing health and hygiene issues. In the villages, Unradoddi and Gunjalli, the area around borewells did not have any drain and hence was dirty due to accumulation of waste water causing unhealthyatmosphere for school children. The VHSC had soak pits dug (filled with coal and sand) and the place wascovered with granite stones. Another VHSC cleaned gutters in these villages, with the help of women Self HelpGroups. This added to the cleanliness of the villages. Though NRHM started in 2005, till the CM in 2008, theamount under JSY was not distributed at all. At the Jan Samvad, 189 women were given their dues for the firsttime. The disbursement of JSY started then is now happening regularly. � The PHC untied fund was not utilised at all till 2008. During the CM, in the months of Jan-Feb 2009 the

PHC building was painted and renovated, filtered drinking water unit was installed, the hitherto unusabletoilets were repaired and were tiled, a TV was installed for patients to watch in the waiting area. Patientsand pregnant women had to sit on the floor or stand in the waiting area. So, chairs (20) were made availableat the reception. The area around the PHC, which was earlier filled with waste and bushes got cleaned anda compound wall was erected around the PHC. The loads of red soil around the PHC not only helped infilling all the uneven places, but also enhanced the look of healthy atmosphere giving it a new and cleanlook.

� Though the PHC was declared 24 x 7 functioning PHC in 2006 itself, it had only one staff nurse and adoctor. With the pressure of people and the influence of Jan Samvad two more nurses were posted. Thisresulted in the increase in immunisation coverage to 80 per cent from the earlier 40 per cent.

� Institutional delivery saw a rise even up to 35 deliveries a month. On an average, about 25 deliveries havebeen conducted every month during and after the CM.

Dr. Anil Kumar, the Medical Officer, was extremely cooperative with the process. In the entire process, theinvolvement and participation of people around the villages has significantly increased. "Due to people'sinvolvement and doctor's cooperation we saw a transformation in this PHC", say Shivram Reddy andTarakeshwari of Roovari (NGO) who were involved in the process of CM.


Section - III


4499


Review of Community Monitoring

The first phase of the community monitoring processwas implemented in nine states of India. The processwent through several challenges and invited bothadmiration and critique. The AGCA wanted toconduct a rapid assessment/review of the first phase ofCM to identify key achievements and challenges tomake recommendations for further scaling up. TheAGCA suggested that the review must be conducted ina participatory manner, and must be steered by athree-member team in each state. The review wasproposed for all the nine states to assess, if theobjectives of community monitoring were fulfilled toidentify key learnings and challenges and to highlightsuccessful innovations. This section has been drawnfrom the National Review Report (Coordinated andwritten by S. Ramanathan) submitted by the reviewteam. The review was undertaken with the followingobjectives: � To assess whether the objectives of community

monitoring process were fulfilled in the state � To identify key learning and challenges for each

state� To highlight successful innovations tried out in

the state

Methodology - Ensuring Field Rigor:

The review was conducted by external consultants(Dr. Ashok Dyalchand in Maharashtra and Rajasthan,Ms. Rajani Ved in Karnataka, Mr. S. Ramanathan inOrissa and Tamil Nadu, and Ms. Renu Khanna inMadhya Pradesh) along with representatives from theNational Secretariat and State Mentoring Groups. TheNational Health Systems Resource Centre (NHSRC)undertook the review in three states (Assam,Chattisgarh and Jharkhand). The field visit in each state was for six days. As one ofthe objectives of the review was to identify lessons forscaling -up, a middling district was identified to learnwhat worked and what did not. Three days were spentin the field and three days at the state level. The first

two days at the state level were spent oninterviewing/meeting government officials, membersof the State Mentoring Group, state Nodal NGO, NGOrepresentatives from other districts, mediarepresentatives and development partners. In the fieldinterviews were held with MO, ANM/VHN, ASHAs,AWWs, Sarpanch and representatives of NGOs at thedistrict, block and village levels, and group discussionswere organised with members of various committees.The final day of the review was spent on presentingpreliminary findings of the review and filling gaps, ifany.

The review covered wide range of issues likenational and local context of the state, institutionalarrangements such as different levels of committeesand mentoring team, the process of CM in the stateincluding selection criteria for nodal NGOs andcapacity building, monitoring and reporting, andengagement with media and linkages with otherprocesses of communitisation.

Ready for Roll-out - Summary ofFindings:

In period of 18 months, only one cycle of monitoringwas done. Hence, the review team felt that it was tooearly to assess the outcomes of the process. However,there had been significant gains. The gains include:� Preparation of national and state level resource

materials.� Formation of over 2000 VHSCs in nine states� Preparation of report cards in all VHSCs� Organising Jan Samvads/Jan Sunwai� Completion of one cycle of monitoring

The gains are reflective of the commitment andpassion of all stakeholders - GOI, state governments,NGOs and communities. The crusader approach andthe spirit of volunteerism are abundantly evident inthe way community monitoring was implemented inthe nine states. The review does indicate that with theimplementation of community monitoring, thepromise of communitisation articulated in the NRHM


5500


Framework is beginning to be fulfilled. Therefore, it isimperative that the first phase is expanded forthwithand sustained to ensure that this promise is realised.

There had been rapid acceleration in theimplementation of the community monitoring in thelast six months of the first phase; building upon thestrong preparatory phase of the Project. During thereview, it was found that a few states had begun theprocess to include it in the Annual State ProgramImplementation Plan (PIP) for the year 2009-10.Karnataka had committed Rs 25 crores forimplementation in the next year. Maharashtra, Orissa,Rajasthan, and Tamil Nadu had initiated steps forinclusion of community monitoring. Other states arein process to do so.

Key Findings on the Process

Selection process:

The criteria for the selection of the districts variedacross states. The presence of civil societyorganizations and regional representation were someof the considerations in the choice of districts andblocks within them. The NGOs did the first -levelidentification of districts. The selection of the districtswas discussed with the State Governments and inalmost all the states, the Government modified theselection.

In nearly all the states, Government largely didnot interfere in the selection of district and blocknodal NGOs at any level. They accepted the choicemade by the state nodal NGOs.

Community Mobilisation

This is one of the key processes which received highlevel of attention from the NGOs. Village Committeeswere aIready existing in some states and these werereconstituted, given the national guidelines for theVHSCs. In other states, fresh committees were formed.It involved getting the requisite permission/ordersissued by the Health Department forrecasting/formation; organising village meetings for theformation; identifying members for the Committee;building their capacity; and ensuring that the meetingsof the VHSCs are held. This took considerable time andeffort from all the NGOs involved in the process.

Village meetings coupled with home visits tosocially excluded groups, especially Dalit hamlets andwomen, was the major strategy in almost all the states.

This process helped in inclusion of marginalisedgroups and in enabling equity. In Madhya Pradesh andOrissa, emphasis was placed on having an SC/ST PRIrepresentative as the head of the VHSCs. Meetingswere also organised with Sarpanch and other localleaders, in nearly all the states. On an average, aboutthree to five meetings were held in villages in all thestates to mobilise the community and to identifymembers for the VHSC. Posters prepared at thenational level were adapted and used for mobilisation.

In many states, getting Government Order (GO)issued for formation of VHSCs proved time-consuming. In Orissa, the guidelines for VHSCformation kept changing. While this reflects anevolution in the process of forming them, constantchanges reduced the project period available formobilisation and the process was hurried through. Inone block in Rajasthan, it was observed that themobilisation depended on political affiliation - theRuling Party representatives were not keen on formingVHSCs or in convening the meetings, whereas therepresentatives from the Opposition Party were verykeen. Communal divide is said to have hinderedmobilisation in parts of Rajasthan.

Committee Formation

VHSCs: The VHSCs were reconstituted in Tamil Naduand in few villages of Madhya Pradesh, where VHSCsalready existed. They were reconstituted, given theNRHM guidelines. In the remaining states, newcommittees were formed. In Madhya Pradesh, thereconstituted VHSCs were approved by the Panchayatsin the Gram Sabha. This was also done in two districtsof Tamil Nadu. In Maharashtra, Gram Sabhas couldnot be convened in all villages; hence, VHSCs wereformed by convening small group meetings.

The VHSCs reflect a significant social capitaland they have to be nurtured to strengthencommunitisation in NRHM. While the communitymobilisation and the formation of VHSCs hasincreased knowledge about entitlements and rightsin the community, it is still limited. There is a needfor more orientation and strengthening of theVHSCs.

It was observed in Orissa that womenoutnumbered men in almost all the VHSCs. On anaverage, the ratio of women to men representationwas 3:1. Many see participation of women asadvantageous as this is expected to lead to a betterhealth status in the household. However, from theinteractions with the women during the review, it


emerged that they did not have much freedom todecide on any issue. Any decision taken by themneeded the approval of men. In Tamil Nadu too, menrarely attended the meetings.

Committees above village level : All the committeesabove the village level - in PHCs, block and districtswere formed in all the states. In Jharkhand, a Sub-centre Planning and Monitoring Committee too wasformed. In Maharashtra, district monitoringcommittees were formed earlier when Jan ArogyaAbhiyan initiated monitoring in few districts. Thecomposition of these committees was modified basedon national guidelines.

However, unlike the VHSCs, these bodies are notvibrant due to shortage of time for providing trainingand supervision of functioning of the committees. Thecommittees at each higher level are to prepare acumulative card of the reports from below, along witha facility report card at their level. However, this hardlyhappens largely due to the complexreporting format,which is not easily understood even by many of theNGO facilitators. There is hardly any review of theprocess by the Mentoring Teams at the district, blockand PHC level.

In almost all states, there is no significantparticipation of health officials in the formation ofcommittes above village level. Even the PRIrepresentatives rarely participate. The objective ofbringing together the Health Department, civilsociety and PRI representatives to mentor andsupport the process is not realised. It is importantthat Health Department convenes these committees.This is essential to ensure that these are not seen asNGO committees.

The review felt a need for orienting and buildingcapacity of the members of these various committeesabove the village level.

Report Card Preparation

Village Report Cards: The process for preparation ofReport Cards is uniform across all states. The NGOfacilitators mostly prepare the report cards. The VHSCmembers find the preparation of the report cards verycomplex. The review also indicates that even NGOfacilitators found the report card preparation processand tool to be difficult. For e.g. there is confusion inmarking, especially on marking negative responses. InTamil Nadu, the NGO facilitators took nearly threemonths to internalise the tools. Sharing village report cards: In Tamil Nadu and

Maharashtra, the report cards are displayed and sharedin village meetings. The sharing of the report cardsgenerate discussions about how to make the red toamber and amber to green, paving the way for villagehealth plans. No significant details of sharing thereport cards with the community are available fromother states. In our view, the community should beaware of the output of the process.

In almost all the states, some officials of theHealth Department are aware of the score cards but theknowledge of score cards overall within theDepartment is still limited.

Tool for preparing report card: The tool helps inincreasing awareness of the communities on theirentitlements and rights. However, two indicators thatreceive greater attention from the community inalmost all the states are attendance of service providersand provision of JSY.

One key issue that emerges from the review is theneed for simplification of the tool as the current tool iscomplex. This view emerges from all the states.

To ensure that the communities have a controlover the process, the review suggests an incrementalapproach. To begin with, there should be fewindicators. For instance, initially the communitymonitoring could be limited to mortality indicators.The issues to be monitored should be graduallyincreased, as the community gains experience and thehealth system becomes responsive to the process.

Triangulation of data: There are some concernswhether the tool will facilitate triangulation. In nostate triangulation appears to have been done.There is a view that the data collected throughcommunity monitoring is not comparable with theinformation collected through routine HealthManagement Information System (HMIS). There arealso concerns that the data is subjective and reflectsperceptions. Hence, there is some resistance fromthe Health Department in accepting the data. Toensure that the triangulation occurs, the tool has tobe modified in consultation with the HealthDepartment and mechanisms to enabletriangulation put in place.

Jan Samvad/ Jan Sunwai

Jan Samvad is an important process for sharing thereport cards. The objective of Jan Samvads was tocreate a common understanding of key health issuesamong the community; to review the current

5511



implementation and to prepare action plans forimproving NRHM implementation. The Samvad is alsoan opportunity for dialogue between the communityand the Health Department.

The Report Cards were the basis for Jan Samvad.In some instances, case studies were prepared andshared in the Jan Samvad. The process of Jan Samvadwas intense in terms of mobilising communities andservice providers.

Jan Samvad benifited in many ways. It raisedexpectations of community and led changes. Thereare instances of change that happened subsequent toa Samvad. There are reports, of few Medical Officersbeing changed, visits of front line workers becomingregular, drugs and syringes being given to thepeople, JSY money being paid to the beneficiaries,and instances of money deducted from JSY beingpaid back to the community. The availability ofuntied funds has enabled the Health Department toaddress few of the needs articulated in the Samvads.Consequently, community in such instances havebegun to perceive the Health Department asresponsive. More importantly, the process isempowering the community as it has made themaware of their entitlements and their rights ascitizens.

However, the Samvads, have also raised the ire ofservice providers, in some instances. In Rajasthan, theissues raised in the Jan Samvad led to conflict betweenthe community and service providers at the lowerlevels. In Chattisgarh, a Medical Officer said that JanSamvads should also highlight the conditionsprevalent in the facilities - lack of water, equipment,schooling and quarters for the staff and not just issuesof service denial. Following Jan Samvad inMaharashtra there was opposition from field workersand resistance at the block and district levels. Serviceproviders observe that Report Cards and Jan Samvadsdo not highlight the efforts by the health workers.They only highlight service gaps, deficiencies anddenial of rights and entitlements.

It is important that the protocol on Jan Samvad isfollowed and there is adequate preparation for it. It isalso important to ensure that the Health Departmentis a partner in the process and not an adversary . TheSamvad should not become a forum for conflict withthe Health Department . It would be helpful to discussthe issues with the Health Department before theSamvad is organised. Also, as originally conceived, theobjective of the Samvad, should be more towardsplanning rather than only highlighting denial ofservices.

Engaging the Media

Engaging the media is an important activity incommunity monitoring. However, the manner inwhich media is engaged varies across states. In fewstates, there were media workshops were held both atthe district and state level; in many states mediafellowships were given to select journalists at state anddistrict level; and in some, the media merely coveredthe events. In Maharashtra, a State Media Consultantis also appointed. The media workshops helped toorient the media on covering health issues.

Media has played an important role inhighlighting community monitoring and being itsadvocate in some instances. Reports were written innational newspapers such as 'The Hindu' (The Times ofIndia) and in local dailies.

However, in several instance the media tended tosensationalise the issues. They disproportionatelyhighlighted issues of denial and weaknesses in theHealth Department pointed out during the JanSamvads. Following the media highlight, there is asense of fear, resistance and an increase in theadversarial position from the Health Department.

While recognizing the media as an important ally,the review emphasizes the need to explore further howmedia could be involved in community monitoring.

Key Findings on ProgrammeManagement

Capacity Building

The National Secretariat prepared good trainingmaterials to enable training and orientation. Thetraining materials detail the issue of rights andentitlements, the process of community mobilizationand committee formation and preparation of reportcards. These are translated and adapted at the statelevel. No significant changes are made in trainingmaterials in any state. The Secretariat has also preparedelaborate guidelines for organizing trainings. Theseguidelines were modified in few states.

The capacity building was done in a cascadingmanner in almost all the states, following the patternrecommended by the National Secretariat. In almostall states, besides classroom teaching, field visits wereorganised to provide hands-on training in fillingreport cards and in mobilisation.

The first phase has created a resource pool oftrainers at the state and sub-state levels. This resource

5522



pool should be nurtured and upgraded. However, there is transmission loss in the cascade

training. Many VHSC members are unable to recall theissues discussed during the training. VHSC membersand some NGO facilitators, said that while issuesseemed clear during the training they were unable torecall them later. Many felt the need for more trainingon preparing the score card as it is complicated.

There was no significant participation of healthofficials in the trainings. This is despite the efforts offew states to break the training to phases to ensuretheir participation. The health officials cited otherresponsibilities as the reason for non-participation.One of the main learnings from the first phase is thatcapacity building of the health officials fromconceptualization to details of community monitoringand action is as important as capacity building ofcommunity and civil society groups.

A more regular process of orientation on-jobsupport and supportive supervision and handholdingcould have helped the process. In Karnataka, besidesthe training, a very high degree of on-job support andhandholding is provided by the district NGOs. Thishad a significant impact on the implementation. Thehandholding by district facilitators is also evident inBolangir district of Orissa. Few members of the StateMentoring Team in Tamil Nadu backstop the processin a significant manner. Whereas places where suchcontinued on-job support is provided, it has made adifference in implementation.

Relationships and Convergence

Relation with the Health Department: The relationwith the Health Department varies across states. Whilethere is a better ownership of the process in Karnataka,Maharashtra and Rajasthan at the state level, there waslack of ownership in states like Madhya Pradesh andAssam. The remaining states fall between these twolevels. In Karnataka, Maharashtra and Rajasthan, thestate officials participate in all the state mentoringcommittee meetings. The relation at the state level alsovaries depending on who is at the helm.

The Health Department in many states appearuncomfortable with the term "monitoring." The term“nigrani” was not well accepted as the officials felt thatthe purpose of community monitoring is to ensurequality service rather than finding faults. They felt thatthe process is more of an action than monitoring.They renamed the process as community action.Karnataka decided to amplify the process to includeplanning as well.

While the acceptance at the state level was mixed,the acceptance at sub-state levels in almost all states waslow. In Orissa and Tamil Nadu, the health officials lowerdown often refused to acknowledge letters issued by stateofficials. They provide support only if there is a directionfrom the district officials. In Karnataka also, where therewas a high level of acceptance at the state level, it doesnot translate into any effective cooperation at the sub-state levels. In Maharashtra, NGOs had to depend onadministrative orders from higher authorities to enforceattendance at meetings at lower levels. Despite the highacceptance at the state level in Rajasthan, the relationbetween NGOs and health providers was adversarial inthe PHCs visited for the review.

The review felt that it was important to overcomethis and engage the Health Department as a partner inthe process. It is important to ensure that the healthofficials do not feel intimidated or threatened andperceive the VHSCs and NGOs as adversaries. Toenable the acceptance it may be helpful if datagenerated by the community monitoring is used inplanning, implementing, improving services,concurrent monitoring, rather than merely to findfault. It is important that the threat perception isremoved and the link between planning andmonitoring is established. This has been done in a fewstates and this needs to be done in other states as well.

Relation with ICDS: At the village level, there isconvergence in many states as AWW are a part of theVHSC. In Karnataka, AWW take on the leadership rolein the VHSC. In Orissa, AWW being senior to ASHA,take a lead in the VHSC activities. In Orissa andRajasthan, ICDS is represented in the state MentoringCommittee. No significant issues of relation with ICDSemerged from any state.

Relation with PRIs: This is one of the weakest links inalmost all states. In Maharashtra, the PRIs areindifferent to the process. Their non-involvement hasan impact on community mobilisation and inidentification of persons as members of the VHSCs. InKarnataka, the PRIs are yet to be engaged in theprocess. Although the PRI members largely head theVHSC in Orissa, they rarely turned up for themeetings. However, the participation of PRIs in Orissaas compared to other states appears to be better.

Relation between NGOs: Majority of the NGOsinvolved in the pilot phase in most of states are a partof other networks. Most work together on rights-basedissues. Many are affiliated to the Jan Swasthya

5533



Abhiyan. Their membership in a pre-existing networkand a shared value and commitment helps tosmoothen the process of working together. Hence,there is harmony between the NGOs involved incommunity monitoring. Some however, are new tothis arrangement. Decisions are taken in aparticipatory manner in most states, which help tostrengthen the collective. The formation of network ofNGOs on community monitoring is an importantoutput too. The network could be a source of supportwhen the process is scaled-up in the respective states.

Short Term Gains

The gains are impressive, despite the shortimplementation time. The most significant gain fromcommunity monitoring is the active engagementbetween the community and the Health Department.It is enabling the community to be in centre-stage andmaking them a significant stakeholder in themanagement of public health system. It isempowering too, as the VHSCs have given a sense ofidentity and voice to community. Given the projectduration, the work done on formation of variousinstitutional arrangements to facilitate communitymonitoring across the nine states is commendable.The VHSCs and various committees above the villagelevel reflect a significant social capital and they shouldbe strengthened, nurtured and sustained to contributeto the communitisation process in NRHM.

Community mobilisation is a key element ofcommunity monitoring and it received high level ofattention from the NGOs. The communitymobilisation, the VHSCs, the monitoring tool, thereport cards, the Jan Samvads, which are the variouselements of the community mobilisation process, haveincreased knowledge about entitlements and rights inthe community. Consequently, as mentioned above,the process is empowering. Changes have beeneffected in many instances following a Jan Samvadand this has led to the perception that the HealthDepartment is responsive and accountable. This hasthe potential to move the community, back to theunder/unutilised public health facilities; leading to animprovement in health and nutrition outcomes.

Gains on Gaps

There have been gains from an equity perspective too.Community monitoring has involved the excluded

and the marginal groups in the process. There was anaffirmative approach to ensure that the Dalits, the STand the women were involved. Steps were taken, inmany states to ensure that women, Dalit and STmembers headed the VHSCs. This is an important gainfrom the process.

Community monitoring has also enabled a betterconnect between front line service providers and thecommunity, in some instances. The community hasbegun to appreciate the constraints of front lineproviders. There are instances where, the communityhas begun to address some of the constraints faced byfront line workers.

Equipped for scale-up

The sharing of report cards in the villages, besidesempowering the community, is also paving the wayfor the next stage - the village level plans. This wouldfacilitate a need-based village-level planning anddeepen the process of decentralisation - a key objectiveof the NRHM.

Various institutional arrangements have beenformed at the national, state and sub-state levels toimplement community monitoring. Thesearrangements reflect a significant social capital andshould be utilised as technical resource agencies whenthe process is scaled-up in the country. Qualitytraining materials and modules have been prepared atnational level and adapted at state levels. There is alsoa sizeable resource pool of trainers that has beencreated by the process. These will facilitate a smoothroll out when the process is scaled-up.

Key Recommendations

� The Review Team strongly recommendscontinued support from the MoHFW for theprocess. The process still needs significantnurturing and direction from MoHFW. There is aneed for technical and financial support to ensurethat the process continues to be implemented inthe first phase states as well as initiated in otherstates.

� To ensure this, there is a need to build ownershipof the process by the respective StateGovernments. The process of building ownershipshould continue in the first phase states and theprocess should to be initiated in the remainingstates. The AGCA with support from MoHFW and

5544



various NGOs, who were a part of the first phaseshould enable this. As a start, the reviewrecommends a dissemination meeting of the firstphase experience and exposure visits by teamsfrom Health Departments of different states. Thecapacity building of Health Departmentpersonnel for communitisation and communitymonitoring has to be a key result area.

� Community monitoring should be anchoredwithin the larger communitisation process of theNRHM; and within an existing arrangement inthe Health Department. This is essential to ensureacceptance of the process by the health officialsand to ensure that the process is scaled-up.However, while the implementation role isanchored in an existing arrangement in theHealth Department, the oversight role should bekept separate. The oversight committee atdifferent levels should have representatives ofgovernment and civil society.

� The Review Team recommends that communitymonitoring be linked to village level planning.Monitoring, after all, is a post-facto exercise. Inaddition, community may monitor a programmethat is top-driven and framed, without a concernfor their needs. Community ought to have acontrol over what is implemented too. To enablethe link between planning and monitoring, it isrecommended that ASHA be involved in theprocess. ASHA could assess the health needs andthe VHSCs prepare a health plan based on thoseneeds. This could be incorporated as a part of thedistrict plan by due process. On a monthly basis,ASHA will report to the VHSC if the health needsare being addressed. This process will enableplanning, implementation and monitoring too. Itcould also facilitate triangulation of data. If afterthis collaborative effort, there are still gaps inservice provision and denial of services, it couldbe resolved in Jan Samvads held at regularintervals. The Review Team believes that that thisstrategy could be replicated and likely to be moreacceptable to health providers, administratorsand policy makers.

� The NGOs, who are part of the first phase atvarious levels, should be involved as resource

centres and provide technical support to theprocess - in developing training materials, trainingVHSCs and health officials, on-site support for theVHSCs, monitoring and in process documentation.Community monitoring, when scaled-up, shouldinvolve mother NGOs SHGs, women Panchayatmembers' collectives and PRIs. Efforts should bemade to strengthen the role of PRIs incollaboration with Rural DevelopmentDepartment.

� It is essential to ensure that both the process andtools for monitoring are simple and adapted tolocal needs. Hence, it is recommended that theprocesses and the tools followed in the pilotphase be simplified. The review also recommendsan incremental approach. To begin with,monitoring be done with few indicators andgradually expanded to both build the capacity ofthe community and acceptance by the HealthDepartment. Initially, monitoring could belimited to mortality and this could be linked withplanning. Gradually, other indicators could beadded.

� The Jan Samvad is currently seen as being led bythe NGOs. It is important that the processgradually becomes a community led process. Thisis important to ensure community involvementand accountability of the Health Department.

� The process, when up-scaled, should not belimited to a one-year cycle in the manner inwhich the pilot phase was done. The processneeds significant nurturing. It should besupported for a minimum of three years to ensurethat the institutional arrangements are functionaland mature before a decision is taken torestructure or revamp the process.

� The first phase has been largely supported byvolunteerism on the part of NGOs. This may notoccur when the process is scaled -up. Hence, it isimportant that a realistic assessment of thehuman resource requirement is done andbudgeted for.

� The review recommends that adequate budgetarysupport be provided for community monitoringto realize the promise of communitization, underNRHM.

5555



5566


Innovations in the Process

Selection� Format to screen NGOs and field visits to assess NGO capacity in Orissa � A three-member committee headed by Director, RCH to identify NGOs in Rajasthan

Community Mobilisation� Use of folk form Kala Jaththa in Karnataka, Jharkhand and Orissa� Padyatras in Rajasthan� Chinaki (introduction) meetings in Assam� Organising meetings in Dalit hamlets and separate meetings with women groups in many states � Use of children and youth parliament to mobilise adults in Tamil Nadu� Appointment of 10 Community Resource Persons per taluk in Karnataka for mobilisation� Use of PRA, social mapping and community mapping to prepare health profile in Rajasthan and Karnataka � Involving VHN Association in Tamil Nadu� Organisation of conventions and mass participation in districts and state level in Maharashtra

VHSCs� Provision of ID card to all VHSC members in a district in Tamil Nadu to ensure their recognition by Health

Department � Approval from Gram Sabha for the reconstituted VHSCs in Tamil Nadu and Madhya Pradesh to secure their

tenure � Ensuring that SC/ST PRI representatives head the VHSCs in few states to ensure equity

Report Cards and Tool� Pictorial tools for tribal regions of Maharashtra� Tool, a reference document on rights and entitlements published as a booklet in Tamil Nadu� Sharing of Village Report Cards in Tamil Nadu and Maharashtra in villages, ensuring accountability and

enabling the next step in preparing village plans.


5577


References:

1. A Pilot Project of Community Based Monitoring of Health Services under NRHM in Chhattisgarh- ProgressReport by state nodal agency

2. Community Based Monitoring of Health Services under NRHM in Jharkhand- A Report by the State NodalAgency; 2008

3. Community Monitoring of Health Services under NRHM in Orissa; Activity Report- Prepared by StateAdvisory Group on Community Action (SAGCA), Bhubaneshwar

4. Community Planning and Monitoring of Health Services -Karnataka Experience; H. Sudarshan UpendraBhojani Govind Madhav N. Prabha On behalf of, State Mentoring Monitoring Group & State Nodal NGO;2009

5. Community Monitoring website; wwww.nrhmcommunityaction.org

6. Madhya Pradesh final Community Monitoring State Report - By Madhya Pradesh Vigyan Sabha & SATHICEHAT

7. National Rural Health Mission Framework of Implementation; Ministry of Health and Family Welfare GOI

8. Rajasthan State Report by Prayas, Rajasthan

9. Report on First Phase of Community Based Monitoring of Health Services under NRHM in Maharashtra;Dr. Dhananjay Kakde with inputs from other SATHI-CEHAT team members and District nodal NGOsPublished by SATHI CEHAT; December 2008

10. Review of the Community Monitoring Activities in Chirang District of Assam; Prepared by Regional ResourceCentre for North Eastern States Ministry of Health & Family Welfare, GOI, Guwahati, Assam; December 2008

11. Review of Community Monitoring in Tamil Nadu: State Report; S Ramanathan; 2009

12. Review of Pilot Phase of Community Monitoring: National Report; S Ramanathan; 2009



Annexures


6611


Annexure I: List of Materials

SS//NN PPaarrttiiccuullaarr LLaanngguuaaggee DDeessccrriippttiioonn

BBrroocchhuurree

1 Apne adhikar janiye Hindi Services given by ASHAs, JSY scheme, ANMs,PHCs and Sub Centers under NRHM.

2 What is Community based English What is first phase of Community monitoring, monitoring process of community monitoring, initiating

community monitoring, role of civil societyorganizations in community monitoring,activities within community monitoring andtimeline of activities.

3 What is Community based monitoring Hindi Translated from English version.

4 What is Gram Swasthya Samiti (VHSC) Hindi What is the VHSC, members of VHSCs, role andresponsibilities of VHSC and untied funds.

5 Swasthya evam Poshan Diwas Hindi About Health and nutrition day, preparation(Health and Nutrition Day) before organizing the day, facility available,

suggestions, information and referral.

6 Prathmic Swasthya Kendra (Primary Hindi Services availabile at PHC.Health Center)

7 Upkendra ko milne wali mukta Hindi How to utilize untied fund at the sub centre, va anudan rashi dos and donts of untied fund.

PPoosstteerr

1 Upkendra (Untied fund and Sub Centre) Hindi Utilization of untied fund money.

2 Garbhawati Stri ko Milne Wali Suvidha Hindi Facilities for pregnant women, right to health ( Free services for pregnant women) care.

3 Gram Swasthya va Swachhata Samiti Hindi VHSC’s role and responsibility(Village health and Sanitation Committee)

4 Janani Suraksha Yojana Hindi JSY scheme and benefits

5 Prathmic Swasthya Kendra Se Hindi Concrete service guarantee at PHC level.Milne Wali Suvidhayen?

6 Samudayik Nigraani Hindi What is community monitoring andcomponent of community monitoring


6622


EEnnttiittlleemmeenntt kkiitt

1 Community Entitlement English Introduction to NRHM, service guarantees and Hindi scheme and provision under NRHM,

community participation in NRHM, andFramework for community monitoring.

MMaannuuaallss

1 Managers Manual English Introduction of NRHM, CommunityMonitoring under NRHM, first phase ofcommunity monitoring, implementation offirst phase of CM, Organizational responsibility.

2 Training Manual English How to conduct - state level, state managers'orientation, district level, and block providers'workshop. How to train different levels ofcommittees.

3 Monitoring Manual English What are health rights, health systems in India,communitisation of health services, what iscommunity monitoring, introduction toNRHM, frameworks for community monitoringin NRHM, mobilizing community andformation of VHSCs, conducting communitymonitoring at the village and facility level,compiling village and facility level score card,sharing the results and conducting Jan Samvad.


6633


AAnnnneexxuurree IIII:: NNaammee ooff SSttaatteess,, DDiissttrriiccttss aanndd BBlloocckkss

SS//NN NNaammee ooff tthhee ssttaattee NNaammee ooff DDiissttrriicctt NNaammee ooff BBlloocckkss 1 Assam Chirang Sidli

BorobazarDhemaji Jonai

SissiborgaonDhemajiBordoloni

Kamrup Rural RangiaKamalpurBoko

2 Chhattisgarh Baster Tokapal BadekilepalDarbha

Kawardha KawardhaBoldaShaspur (Lohara)

Koriya KhadgwanManendargarhJanakpur

3 Jharkhand Palamu PatanChainpurLesliganj

West Singbhum ChakradharpurManoharpurTonto

Hazaribag ChurchuKatkamsandiIchak

4 Karnatka Gadag GadagRonaMundaragi

Chamarajnagar KollegalYelandurC.R.Nagar

Tumkur GubbiMadhugiriPavagada

Raichur RaichurDevadurgaManvi

5 Madhy Pradesh Guna GunaRaghogarhBamouri

Chindwada TamiaParasiyaJunnardev

Sidhi SidhiMacholiKusmi


6644


Badwani PatiBansemalBadwani

Bhind BhindGohadMehgaon

6 Maharashtra Amaravati DharniChikhaldaraAchalpur

Nandurbar AkkalkuwaDhadgaonShahada

Osmanabad OsmanabadTuljapurKalam

Pune VelhePurandarKhed

Thane DahanuJawharMurbad

7 Orissa Bolangir LoisinghaMuribahalPatnagarh

Kendrapara PatamundaiRajnagarDerabisi

Mayurbhanj RasgobindpurBahaldaBangiriposi

Nawarangapur NawarangpurTentulikhuntiRaighar

8 Rajasthan Jodhpur LuniMandorOsiyan

Chittorgarh BhainsroagarhChittorgarhKapasan

Udaipur KotdaGogundaSarada

Alwar LaxmangarhUmrainRamgarh

9 Tamil Nadu Dharmapuri HarurNallampalli Kariyamangalam

Kanyakumari Agasteeswaram Kuruthancode Killiyoor


6655


Perambalur Perambalur Andimadam Tirumanur

Thiruvallur Gumidipoondi Meenjur Poonamalli

Vellore Kandhili Pernampet Kaniyampadi


Population Foundation of India (PFI)B-28, Qutab Institutional AreaNew Delhi - 110 016Phone: +91-11- 43894100 Fax: 91-11-43894199E-mail: [email protected]: www.popfound.org

Centre for Health and Social Justice (CHSJ)D-63, Basement, Saket, New Delhi-110017Phone: +91-11-46150604, 26535203, 26536163, 40517478, 26511425Telefax: +91-11-26536041E-mail: [email protected]: www.chsj.org

Reviving Hopes Realising Rights - COPASAH · 2019. 3. 17. · Ms. Moumita Ghosh; CHSJ, New Delhi...

Documents

Transcript of Reviving Hopes Realising Rights - COPASAH · 2019. 3. 17. · Ms. Moumita Ghosh; CHSJ, New Delhi...