Community Monitoring of National Rural Health Mission in India Divergent Experiences and Challenges Bridging ‘demand’ and ‘supply of accountability: Roundtable The Hague, April 19, 2013 Abhijit Das CHSJ and COPASAH

Introduction to CBM in NRHM A new coalition Government comes to power in 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 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 Experiences Maharashtra 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