Improving Health System and Strengthening NRHM through

Community Action Experiences, Lessons Learnt, Challenges and Way

Forward

AGCA Secretariat

Population Foundation of IndiaDecember 24, 2013

Outline

1. The accountability framework under NRHM

2. Community action under NRHM – process,

experiences and gains

3. Challenges

4. Way forward – status of implementation in

states

Community Action in NRHM

• Mechanisms to improve accountability and enable better delivery of services– Builds community awareness on health entitlements– Provides a platform for community feedback and

dialogue with service providers– Initiates corrective action and planning with

community engagement

Leads to improved coverage and accessibility of health services

In essence brings ‘public’ back into public health

Accountability Framework under NRHM

• A three pronged process: • community based monitoring, • external surveys and • routine program monitoring

– Communitization of the health institutions• Prominent display of information on funds received,

medicines in stock, health right entitlements

– Public reports on Health at the State and district levels to report progress to the community

Advisory Group on Community Action (AGCA)

• Group of civil society experts constituted by the MOHFW in 2005 with Population Foundation of India (PFI) as the Secretariat

• Mandate :– Advise on developing community partnership and

ownership for the Mission– Provide feedback based on ground realities, to

inform policy decisions– Develop new models of Community Action and

recommend for further adoption to the national / state governments

CAH - Immediate Outcomes

Community Based Planning and Monitoring (CBPM)programme in Bihar - India

First phase of Community Monitoring (2007-09)

9 States, 36 districts, 1620 villages

• Assam• Chhattisgarh• Jharkhand• Karnataka • Madhya Pradesh• Maharashtra• Orissa• Rajasthan• Tamil Nadu

Rajasthan

Gujarat

Maharashtra

Karnataka

TamilNadu

AndhraPradesh

MadhyaPradesh

UttarPradesh

Uttaranchal

Orissa

Chhattisgarh

W Bengal

Bihar

Jharkhand

Assam Nagaland

Manipur

Process1. Education and awareness :• Community awareness on health entitlements • Training of Village Health Sanitation and Nutrition Committees

(VHSNC) and Rogi Kalyan Samities (RKS) members• Display of Citizen’s charter and service guarantees

2. Monitoring and information sharing• Collection of information and sharing of report cards, community

experiences of health services• Multi stakeholder Monitoring and Planning Committees at

PHC, Block and District levels

3. Public dialogue• Periodic public dialogue (Jan Samvad) - Engagement with

providers based on community evidence

Community action under NRHM - experiences and gains

Five Tangible benefits: 1. Construction work completed2. Improvements in status of delivery of health

services3. Enhanced trust and improved interaction 4. Community based inputs in planning and action5. Reduction in out of pocket expenditure

1. Construction of Sub-Centre completedStory of change - Maharashtra• In Jamshet village, Thane district,

construction of a sub-center was incomplete for over two years

• Village health committee members discussed the issue in a series of Gram Sabha meetings and in Block monitoring committee meetings

• A large group of community members went to the sub-centre to ‘complete’ the construction through ‘Shramdaan’

• The sub-center building got completed and is fully functional

2. Performance of health services improves -Rajasthan

(Sep 2008-Oct 2009)

Poor

Average

Good

Key outcomes

3. Enhanced trust and improved interaction between provider and community– Improvement in service delivery - ANC, PNC, immunization, – Responsiveness of provider to community needs– Improved provider attitude and behavior

4. Community based inputs in planning and action – Active involvement of PRI members in planning and

functioning of health facilities– Appropriate planning and utilization of untied funds at VHSC,

PHC and CHC

Key outcomes5. Reduction in out of pocket expenditure – Reducing demands for informal payments – Ensuring timely and full payments of Janani Surksha Yojana – Significant reduction on outside prescription

Key challenges• Capacity constraints to institutionalize and scale

up community monitoring• Allocation of adequate resources• Mechanisms to address systemic gaps emerging

from CBMP process and feeding into the planning process

- vacancies/ posting, procurement and distribution of drugs and supplies, training of health functionaries

• Institutionalizing minimum service guarantees, grievance redressal mechanisms

Implementation status

• Scaled up - Maharashtra, Tamil Nadu, Jharkhand, Chhattisgarh

• Modified – Karnataka, Chhattisgarh • Re/Initiated – Odisha, Rajasthan, Assam and Bihar• In FY 2013-14, 15 States / UTs CAH component has

been approved• AGCA has provided support to Assam, Jammu and

Kashmir, Maharashtra, Madhya Pradesh and Uttar Pradesh in developing their state PIP

Way forward – Role of AGCA

Technical Support proposal approved by GOINational level • Revise CAH tools and share with states for adoption • Development of RKS guideline and training manual (in

consultation with NHSRC and MoHFW) • Report on review of approaches/models on grievance

redressal • Processes developed for selection of NGOs to support

implementation of CAH

Way forward – Role of AGCA

State Level• Support constitution and orientation of State

AGCAs • Development of state plans – visioning for scale

up• Orientation of Nodal Officers and state

institutions - SHRC, ARC, RRC, SIRD etc • Regular mentoring and review

Thank You