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Dr. Abhay Shukla Coordinator, SATHI Member, NHM - AGCA 11 People are reclaiming the public health system: Community based monitoring and planning in Maharashtra.

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Presentation on theme: "Dr. Abhay Shukla Coordinator, SATHI Member, NHM - AGCA 11 People are reclaiming the public health system: Community based monitoring and planning in Maharashtra."— Presentation transcript:

1 Dr. Abhay Shukla Coordinator, SATHI Member, NHM - AGCA 11 People are reclaiming the public health system: Community based monitoring and planning in Maharashtra

2 Why are Roman arches still standing 2000 years after they were constructed? The engineers were held directly accountable… they had to stand under the arch when the scaffolding support was first removed after construction. The ‘secret ingredient’ of Roman arches: Accountability

3 Democratising the Public health system – Claiming rights, changing power relations, improving services Need to break through current alienation and unresponsive nature of Public Health services through systematic social action Neither rejecting nor uncritically accepting the existing ‘public’, but rather transforming it through popular action with alliance building and advocacy Community based monitoring and planning as a key intervention to reclaim public health systems: developed in collaboration with PHS but led by network of civil society organisations

4 Transforming a PHC – rolling back private providers: Story of Maligre PHC Maligre PHC in Ajara block of Kolhapur district was very poorly utilised until 2011 and most people in covered villages were unaware of its services With initiation of CBM after first Public hearing the doctor changed; the new doctor is more dynamic and CBM activists organised meetings in all villages to inform people about services at PHC Due to active PHC doctor and community mobilisation by CBM activists, now monthly deliveries have doubled, OPD has significantly increased and three private clinics have closed down The alternative to privatisation is communitisation

5 Transformation in utilisation of Maligre PHC following Community based monitoring and planning 2010-11 (Pre-CBMP) 2013-14 Deliveries8125 Indoor admissions 215857 Outpatient consultations 7,38017,157

6 Community based monitoring and Planning (CBMP) in Maharashtra Covers 13 districts with formation, orientation and activity of multi- stakeholder committees in Over 815 villages 120 PHC areas 35 Blocks Planned expansion in 2014 to now cover more than 1000 villages, across 18 districts

7 Levels of committees for Feedback & Action State Planning & Monitoring Committee District Monitoring & Planning Committee Block Monitoring & Planning Committee PHC Monitoring & Planning Committee Village Health, Water supply, Nutrition and Sanitation Committee

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

9 Key processes in Community monitoring - Maharashtra Data gathering and filling report cards Community awareness programmes Visits by committee members To health facilities Meetings of community based monitoring committees

10 Public hearings (Jan sunwais): a forum for people’s voice and accountability Report cards and cases of denial presented Health officials respond to issues raised by people Actions ordered regarding services at village, PHC and Rural hospital levels Over 450 Public hearings organised so far at PHC, block and district levels

11 Public hearings – a key forum for accountability and engine of change

12 Practice of PHCs prescribing medicine from private shops has largely stopped Illegal charging by certain medical officers has now been checked; challenging corruption Frequency of visits of ANM and MPWs in villages has improved Rude and abusive behaviour stopped Significant improvements in health services in CBM areas Definite improvement in immunisation coverage Non-functional sub-centres, mobile units, lab facilities now started functioning Significant rise in outpatient, inpatient utilisation in CBM areas

13 Significant improvement in PHC services in CBMP areas

14 Increase in deliveries in CBMP covered PHCs compared with district averages

15 Community based planning: Developing sharing of power in the public health system Participation of CBMP representatives in Health facility committee (RKS) meetings to suggest community health priorities CBMP committees develop annual block level PIP proposals. Major pro-people shifts in priorities for RKS based planning in PHCs and CHCs leading to improved services

16 Comparison of total Expenditure by RKSs between 2009-10 and 2011-12: Velha block Facility 2009-10 expenditure 2011-12 expenditure % increase after CBMP PHC Pasli 2,13,0533,42,697 61% PHC Velhe 61,7422,50,294 405% RH Velhe 77,5233,71,223 479%

17 ‘ Reclaiming ’ elected Panchayat representatives Panchayat members now are taking active role and contributing to both community monitoring and planning Major role of Panchayat members in CBMP committees – making surprise visits, ensuring actions Zilla Parishad members have ensured action and funds in some cases Over 75 PRI members participated in State culmination workshop in July 2012 Four ‘Sarpanch melavas’ in 2014

18 Dimensions of democratising and ‘reclaiming’ public health services 1.Promoting forums for direct democracy – Jan sunwais and Arogya Gram Sabhas 2.Expanding representative democracy through multi-stakeholder bodies – monitoring and planning committees 3.Reclaiming representative democracy – activating PRI members to promote health rights 4.Activating ‘internal accountability’ through external accountability processes

19 Community helps to solve problems of health care providers In Bhongowali PHC in Bhor block of Pune district, the doctor was not staying at the PHC. Raised during Jan Sunwai, he complained that he did not have quarters. A CBM committee member offered to arrange a house for him in the village on the spot. Today doctors are regularly staying at the PHC even at night.

20 State level recognition by CBMP process to well performing health care providers

21 Community based monitoring and action for ICDS initiated in 5 districts, 2 cities of Maharashtra

22 Emerging strategies Generalising community monitoring in voluntary mode in various new districts and regions Decision to organise ‘Arogya Gram Sabhas’ in all villages where services can be reviewed, planning decisions can be taken Block level federations, grievance redressal facilitation cells, resource units working with youth ‘Communitisation’ of selected PHCs in tribal areas – based on Nagaland model Need to move from Community monitoring as project to social process mode with demand for generalisation of accountability processes

23 Some broad principles for Health officials concerned with CBMP Partnering, not controlling: CBMP is a shared activity, not entirely driven by officials but rather a joint effort; need to build partnerships with stakeholders ‘outside’ the system Supporting rights based civil society organisations and recognising their contribution ‘Awareness generation’ of officials at various levels is also necessary! Dialogue is essential, though it may sometimes seem to be ‘bitter medicine’! Timely disbursal of necessary funds is essential to continue the process – funds excessively delayed are funds denied! Community based monitoring and planning means sharing power in the health system …


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