Community Monitoring of National Rural Health Mission

in India

Divergent Experiences and Challenges

Bridging ‘demand’ and ‘supply of accountability: RoundtableThe Hague, April 19, 2013

Abhijit DasCHSJ and COPASAH

Introduction to CBM in NRHM• A new coalition Government comes to power in 2004. Coalition

has Left parties support in Parliament and civil society participation in social sector policy think-tank NAC (National Advisory Council)

• National Rural Health Mission introduced by Govt of India as a new delivery mechanism for health services for the poor in 2005 with strong civil society participation

• Community based monitoring introduced both as a component of ‘communitisation’ and accountability

• Government of India entrusts piloting of CBM to civil society groups through an advisory committee AGCA.

• CBM piloted across nine states between 2007 -09. 35 districts – 1620 villages covered through GoI support. Pilot evaluated. GoI says states must include in their own state plans and budgets

Community monitoring after 2009

Continues in the same trend as the pilot in a couple of

states

Continues in a somewhat modified

manner in a couple of

states Has been started in couple of

states

Has stopped after the pilot

After repeated letters/ requests/ instructions

from Government of India

Limited non-Government endorsed processes are there in some states

Has still not started in many states

Two Divergent ExperiencesMaharashtra

• Not a High Focus State but continues CBM from pilot phase

• Strong Civil Society stewardship of CBM ; led and implemented by civil society organisations

• State supports and expands CBM but continually asks for phase out plan

• Improvement of health services clearly documented

• Has also started generating political support at the local level

• Many operational challenges including reduced and delayed funding

• Uttar Pradesh• A High Focus state in NRHM but

excluded from CBM because of poor performance benchmarks

• Civil society led accountability efforts give way to a strong community led accountability process

• Women’s health rights forum (MSAM) of 12,000 women from 200 villages in 10 districts

• Empowerment - Strong local leadership – engagement with public health system – many small gains

• Women leaders enter electoral politics at the local level

Community level challenges• Community

– Apathy/ fatalism – Lack of faith in public services – health world view and past

experiences

• Services– Huge gaps and deficiencies– High levels of privatisation

• Community – authority relationship– Reluctance for ‘complaint’ may need the same providers

service later– Kinship relationships -

Challenges

Maharashtra• Rhetoric vs Intent• Limited to local problems and

local solutions. ‘CBM resistant’ problem

• Seen by managers as a support to administrative oversight of frontline functionaries and better planning

• No redressal mechanism established even after 5 years

Uttar Pradesh• Politically important state –

‘unaccountable’ political leadership;

• Historical donor/external aid management skills

• Deeply entrenched corruption• NGO – State relationship :

NGO beholden-ness• Overall low political

mobilisation of communities – caste politics

An interesting Conundrum

• Enabling conditions met – provision in policy guidelines, official endorsements, standards/procedures/tools, citizen opportunities, facilitating organisations, funds

BUT• Inadequate roll-out after enthusiastic start up• Operational resistances of different nature• Losing interest/energy among communities

without appropriate changes in services

Some thoughts….

• Framing of the issue and focus- – Economic / efficiency - ‘ demand – supply’ (Outcome) or Active

Citizenship/Deepening Democracy - ‘rights- obligation- entitlement’ (Process)

• Intent vs Rhetoric – ‘fashion’ vs political intent.• Different aspirations - Shorthand solutions for fundamental

state failures vs Improved/targetted planning and service delivery vs Accountable public services (Populist/Bureaucratic/Political)

• Governmentality – bureaucratic subversions• Dynamic/changing nature of the actors and their interests –

political compulsion , bureaucratic interests, citizen-leader transitions