1. SOCIAL AUDIT of Maternal Health Services in Uttaranchal AN EFFECTIVE MECHANISM FOR MONITORING HEALTH SERVICE PROVISION

2. Background to the Social Audit Our experiences and studies show- There is high maternal mortality in the area; existing health services are of poor quality and poorly accessible for women There is no community monitoring or state accountability: low information about what Government health programmes are meant to provide Panchayats have low interest in women’s health issues (never on the meeting agenda)

3. Objectives of Social Audit To carry out a community based audit of the state maternal health services in Uttaranchal towards…

4. Social Audit towards … Creating a demand for maternal health services from the community Increasing responsiveness to community needs in health providers and managers

5. Principles of Social Audit To take permission from the state health department To maintain confidentiality of all sources of information To cross-check and verify all information To ensure informed consent to any information that is made public To ensure that no punitive action is taken as a result of the audit To ask all actors for their suggestions to solve the problems

6. Scope of Social Audit Area – 2 blocks in two districts of Uttaranchal state Within each block, - 10 villages - 2 Sub-Centres - 1 PHC TEAM: Included Panchayat members, women’s group leaders and NGO staff

7. Steps of the Social Audit – Preparations (July 04) We obtained accurate information about available maternal health services and facilities from the government Capacity building of team through training programme, field visit and PHC visit Developing Social Audit tools, field testing Taking permission from district CMO Taking permission of village Panchayats

8. Steps of the Social Audit – Information gathering by team Conducting interviews and observations in 2 PHCs Conducting interviews and observations in 4 ANM Sub-centres Conducting group discussions in 20 villages Documenting 17 case studies of maternal deaths and experiences of family planning services in RCH camps

9. Steps of the Social Audit - Sharing Collated findings and shared with audit team for internal checking Shared with community in 20 villages for consent Shared separately with CMOs, MOICs and ANMs for consent Printed the Audit Report in Hindi

10. Sharing of Audit findings Shared with the community, media and Panchayat leaders in a Public Gathering (March 2005)

11. Outcomes of the Social Audit – Gaps Emerging No one document defining what services women are entitled to Lack of material or staff for health education and public awareness Information given only regarding female sterilization No involvement of Panchayats in maternal health activities

12. Gaps contd. Lack of women doctors in PHCs/CHCs – poor system of referral in emergencies Very limited range of services despite ‘RCH camps’ Lack of essential equipment in Sub centres for ante-natal check-ups, delivery and post-partum care; gaps in supply and maintenance/ repair

13. Outcomes of the Social Audit – Success with service providers Health department supported entire audit process – for the first time ‘reminded of their responsibility by the community’ The PHC has 3 doctors including a woman doctor who goes to the villages; deliveries are conducted and there are curtains – referral is through a written slip

14. Success with service providers … ANM’s community level work has improved, gives more information about health programmes She comes when called home for deliveries and does not charge money for home deliveries, also stopped giving the injections to speed up labour ANM has better relations with women’s group, keeps up contact, attends meetings The ANMs are staying in the SCs with community support, women help her during immunization camps ANMs provide improved ANC and cover remote villages now

15. Outcomes of the Social Audit – Success with community Panchayats at village and block level are actively involved in the issue of maternal health services Women have created a pressure so that Panchayats are now taking up health issues as an agenda in meetings Women are now clear about their entitlements when they seek health services Women’s groups monitor the quality of care in RCH camps

16. Future Community Action Formation of a group with Panchayat representatives, women leaders, government health managers to take the audit process forward

17. Some challenges It is not easy for an NGO to facilitate an audit process while maintaining a relationship with the government It is not easy to create a relationship with the Panchayat leaders on a ‘women’s issue’ The informants were hesitant to provide accurate information about the actual state of maternal health services

18. More challenges … Making the audit report was difficult – to maintain accuracy while not alienating the health providers - to ensure that the audit report was accepted by all stakeholders The public sharing of the audit report had to be only fact-based, not fault- finding or accusation

19. Conclusion The experience shows it is possible to ~ Impartially audit quality of maternal health services with the cooperation of the health department and the community Make Panchayats actively involved in maternal health and make them a ‘voice’ that demands accountability from the health system Change the client-provider relationship to empower even non-literate rural dalit women users to exercise their rights in health services

20. Recommendation for 11 th Five Year Plan The effective implementation of NRHM in rural areas depends on – The monitoring of services by community user groups at the point of service delivery Shared quality parameters for both users and providers The informed demand created among users: empowerment of users to negotiate for quality services

21. Institutionalizing Social Audit in 11 th Five Year Plan Both public and private service provider institutions must go through regular social audit The Social Audit must be carried out with full participation of community /users, Panchayats, the service providers and administrative officials The Audit has to be facilitated by an NGO which has a good rapport with the community and the Panchayats

22. Costs of Social Audit For the NGO to facilitate the Social Audit in 2 districts in 2 blocks (1 PHC, 2 Sub-Centres and 10 villages) cost was Rs 2 lakhs. This includes preparation, training, audit activities, sharings and publication of audit report This does not cover the NGO’s costs of building rapport with the Panchayats and community women for the previous three years

23. Acknowledgements Community members of Nainital and Udham Singh Nagar districts Government of Uttaranchal Health Department Audit team members, other NGOs who helped with the process SAHAYOG and MacArthur Foundation for resources

24. ~ Thank You Sunita Shahi, PRAYAS Nainital Uttaranchal