1. Community Monitoring through Elected Women Representatives in Bihar Dr. Aparajita Gogoi, Executive Director, Centre for Development and Population Activities (CEDPA) India.

2. Project Pahel: Monitoring by Women Elected Representatives o To strengthen the voice, participation, leadership and influence of Elected Women Representatives (EWRs) to bring about social change in areas that affect women particularly family planning/reproductive health (FP/RH) by o Participating effectively in PRI and community meetings o Taking actions to improve reproductive health services o Addressing health and development issues in their constituencies The project is supported by The David Lucile and Packard Foundation

3. Project coverage o Pilot stage of this project (2007) 300 EWRs 2 blocks in Patna district in partnership with PRI Department-(BIPARD) o Scaled up in (Sept. 2010 – March 2015) to 1200 EWRs o 6 blocks across three districts of Aurangabad, Sitamarhi and Muzzafarpur o NGO partners-IDF, Dord and Nirdesh. Currently there are 120,000 women leaders in Bihar

4. Profile of EWRs

5. Project Strategies o Capacity development of EWRs (three day trainings on PRI structures/processes, gender and patriarchy and public health delivery system in the context of MH/FP/RH) and follow up mentoring o Training the EWRs in the use of checklists to monitor services o Supporting them to take planned, concrete actions based on evidence generated by the women themselves on the availability and quality of MH/FP/RH services o Mentoring them through collective forums called Mahila Sabhas (informal women’s councils)

6. Capacity building

7. Monitoring checklists Four checklists (based on Indian Public Health Standards and NRHM guidelines): o Village Health Sanitation and Nutrition Day (VHSND) o Health Sub Centre (HSC) o Primary Health Centre (PHC) o District Hospital (DH) Administered to look at MH/FP/RH services: o Infrastructure o Personnel o Community participation o Availability of equipment, drugs and other supplies o Provision of services o Quality of logistical arrangements

8. Process o Orientation and training on different components of checklists, service provision at various levels, women’s entitlements and the role of stakeholders o Hand holding support by field animator during the visit to the facility o Checklists administered in pairs or groups of 3-4 o Observation and verification against available records before entry in checklist o Debriefing by field animator after facility visit

9. Process o Data analysis and advocacy asks development o Mobilisation by sharing of health data in PRI meetings and Mahila Sabhas, o Convening and regularizing VHSNCs o Convergence meeting with Health officials at district level o Meetings with Health providers for action

10. Findings: VHSND level Supplies Availability Foetal stethoscope8.6% Haemoglobinometer8.8% Urine testing kit11.6% SABLA cards15.9% Vit-A solution with spoon18.5% Counseling protocol chart22.1% Measuring tape23.8% IFA tablets-small/syrup33.0% BP Apparatus38.7% Condoms47.0% Nutrition supplement48.2% Oral pills48.2% Weighing machine-baby55.6% MCH cards61.5% Growth chart67.9% Blank immunization cards72.0% ORS packets76.0% Weighing machine-adults80.0% IFA tablets-large80.5% Disposable syringes94.8% Vaccine carrier with ice packs95.5% Tetanus Toxoid (TT)99.1% Availability of functional supplies Provision of ANC services Duration of VHSND

11. Findings: HSC level Availability of functional supplies SuppliesAvailability DDK9% Sterlizer instrument11% Haemoglobinometer20% Urine Test strips32% Vit-A syrup37% Examination table40% Copper T41% Condoms63% BP apparatus69% Contraceptive pills71% IFA tablets74% Weighing machine83% ORS packets85% Tetanus Toxoid (TT) vaccine88% Disposable syringes91% Provision of ANC services

12. Findings: PHC level Provision of services Provision of facilities/ supplies/equipment

13. Findings: DH level Provision of services

14. District/block Level Convergence Meetings

15. Actions o EWRs supporting ANMs and ASHAs in organizing VHSND o EWRs mobilizing beneficiaries to participate in VHSNDs and visit HSCs for health needs o EWRs working with health workers to ensure equipment, supplies and finding solutions for issues like privacy for ANCs at VHSNDs and HSCs (Source: Quarterly reports)

16. Actions o Irregularity of health workers at Gram Panchayat meetings o Mukhiya asked to add to Panchayat Samiti bi-monthly meeting agenda the need to ask MOIC to ensure regular supply of contraceptives at the HSCs o Urged Mukhiyas to follow up on JSY payments o EWRs met with MLA Sitamarhi to demand for female doctors (Source: Quarterly reports)

17. Results: Convergence meetings emerge as a forum for advocacy and engagement referral transport fund Pramila Devi, a Ward Member from Gorigama Panchayat, raised the issue of non-availability of referral transport fund at the HSC blood bank Raviba Khatoon, Zilla Parishad Member, raised the issue of non- availability of blood at the district Hospital blood bank which was resulting in the patients being referred to other institutions for treatment. She also raised the issue of non-availability of lady doctor at the DH lady doctor Reena Devi, Panchayat Samiti Member, raised the issue of appointment of a lady doctor at PHC Runnisaidpur delivery services monitoring of VHSND Mamta Devi, Up-mukhiya of Chanda Panchayat, raised concerns about the non-availability of delivery services at the HSC. She had also demanded proper monitoring of VHSND site by government officials to ensure quality services EWR voices at convergence meetings:

18. Results: Convergence meetings emerge as a forum for advocacy and engagement equipment To ensure quality health services HSCs in Aurangabad will be provided with appropriate equipment ANMs Two ANMs will be appointed at each HSC in Aurangabad ambulances Two ambulances will be made available at each PHC in Aurangabad district expenditure of the untied funds Civil Surgeon has issued an order to the Medical Officer In-Charge of Dumra and Runnisaidpur PHCs and relevant ANMs, to work with the Pahel local NGO partner, Nirdesh for expenditure of the untied funds Commitments by Health Officials at convergence meetings:

19. Trends o No. of EWRs attending VHSNDs: 21%* (62% are attending an average of 2 VHSND in each quarter o Number of meetings being attended by EWRs: 61%** o Raising FP/RH and Girl’s Edu. issues in meetings: 49%* o No. of EWRs interacting with health providers: 33% * ( 45% of them are meeting with at least 2 health providers in each quarter) * over baseline ** Monthly tracking sheets annual data

20. Challenges and lessons -High levels of illiteracy of EWRs, barriers of patriarchy – are major challenges in participation of EWRs in PRI meetings, demanding accountability and raising their voice (Forums like Mahila Sabha provide women space for sharing and solidarity and helps develop their self- esteem and confidence to take the initiative for change and also develop strategies and implement them as a collective) -Difficult to address the “hard” issues like infrastructure, budgeting processes, appointment of doctors, electricity, running water, etc. -Lack of technical capacity among EWRs to use the checklists requires for support of the project staff to support the filling in of the checklist -Data collection and analysis, and communication of findings takes a substantial time resulting in delay in action

21. Way forward In Bihar, with PFI to propose to GoB for IVR based monitoring checklists Toll free Real time data collection and analysis Audio learning package also accessible to understand the indicators being collected