1. Ameerkhan K SOCHARA-CEU On behalf of CAH partners and Makkal Nalavazvu Iyakkam

2. Structure of the presentation Back ground Evolution and context of CAH process Vision and Major strategies Core activities Learnings Major challenges

3. Back ground of CAH evolution in Tamil Nadu Jan Swasthya Abhiyan’s Right to Health care campaign – led to strategies to engage with public health system NRHM – Identified Communitisation as one of the five pillars AGCA – Policy framework to Health program – piloted CAH in 9 states CSO / NGO’s experience – Led to customize the CAH in Tamil Nadu context Tamil Nadu Government – Supported the pilot and funded the expansion phase

4. Evolution and context of the model Piloted from 2007 to 2009 in 225 hamlets with the Government Order of Tamil Nadu. Based on the experience the health system and CSOs jointly wrote a paper on the model and discussed in the state level multi stake holder consultation in 2009. Identified Tamil Nadu specific priorities - The word “CAH” and “Village Health Planning Day” took centre stage. Expanded the process in terms of coverage and process (from 225 to 3800 villages of 446 Panchayats during 2010 – 2012) with financial support from the state.

5. Vision and major strategies To Strengthen the local democracy through improved community participation and to enhance understanding of health and ensuring health for all To develop platform for constructive dialogue between people and health system for the evolution of people centred health policies To build equitable and quality health care accessibility and deliveries in public health system Developed by CSO at the state level consultation based on experiences of pilot phase

6. Major strategies and activities Social Mobilization – democratizing the participation Building critical mass – awareness and in depth trainings – focused on RTH and public health system Community led evidence collection Community led multi stake holder health planning Realizing Health plans through joint action at multiple levels

7. Organogram Following organizational structure was developed based on the experiences of pilot and expansion phase. The model is yet to implement

8. ADVISORY GROUP OF COMMUNITY ACTION FOR HEALTH State Nodal implementation Team State Nodal Organisation State Health Society REPRESENTATIVES FROM EACH GROUP District Nodal Implementation Team District Nodal Org DISTRICT MENTORING COMMITTEE REPRESENTATIVES FROM EACH GROUP Deputy. Directorate of Public Health Block Nodal implementation Team Panchayat Nodal implementation Team Cluster Nodal Org BLOCK FEDERATION COMMITTEE REPRESENTATIVES FROM EACH GROUP VOLUNTEERS (1955) PRI MEMBER S REPRESENTATIVES FROM EACH GROUP PRIMARY HEALTH CENTRES Directorate of Public Health Cluster Coord Pan. Coord BLK. PHC PHC Dt.Coor d Monthly and weekly review participation Monthl y Quarter Monthly Reporting & feedback

9. ACTION / IMPACT AT MULTIPLE LEVEL The process triggered community level action – especially in the health determinants The data created interest and used by many elected representative to involved in direct action – especially by the opposition Policy makers found useful to triangulate and to get nuances from the field

10. Action and outcomes

11. Impact in Peripheral Health Workers service delivery through improvement in Village Health Nurse (VHN) Post Natal Home Visit (42 nd day) in 3700 villages

12. Availability of health care services at village - Percentage of adolescent girls received Iron Folic Acid over two rounds of monitoring in 3700 villages Positive response (%)Negative response (%) Partial response (%)

13. Quality of antenatal care delivery by educating woman on pregnancy related risk factors in 3700 villages Positive response (%)

14. Addressing social determinants of health through village over health water tank cleaning in 3700 villages Negative response (%) Partial response (%)

15. Equitable health development across communities in monthly village over head water tank cleaning in 3700 villages Partial response (%)

16. Reducing the gap between Antenatal Care Availability – Quality – Education Index using informative monitoring tool in 3700 villages

17. Major impact Participatory monitoring and planning process led to collective action and community ownership A platform created for constructive dialogue among multi stake holder – preliminary attempts to balancing the power Created lot of interest and confidence on the public health system – especially in a highly populist policy state The culture of questioning spirit and collective demand was strengthened. At the health system level over the period of time service providers understood the underlying principles and supported the process Created evidences that were not available with health system

18. Emerging Issues Mobilising community and sustaining the community committees at Panchayat level PRI does not have any role / control as it is envisaged in NRHM framework. The overall policy of the state plays major role. Communitization measures almost nil in Tamil Nadu – including un “tied” funds utilisation. Lack of redressal mechanism in public health system impeded the system level changes through CAH process. Lack of trust by the policy makers in community participation in health and in people’s health rights impacted the sustainability.

19. Way forward Long term commitment for communitisation process and adequate support from the government Need to convert community accountability measures as core component of the health system – have to go beyond the mercy of the “good officers” Separating the management of the accountability process from the regular authorities – Autonomous body ! Which works with but outside of the health system Build mechanisms to respond to the need arises from the community action for health process towards first step of building people centered health system.

20. Thank You