Improving Health System and
Strengthening NRHM through
Community Action
Experiences, Lessons Learnt, Challenges and Way
Forward
AGCA Secretariat
Population Foundation of India
December 24, 2013
Outline
1. The accountability framework under NRHM
2. Community action under NRHM – process,
experiences and gains
3. Challenges
4. Way forward – status of implementation in states
Community Action in NRHM
• Mechanisms to improve accountability and
enable better delivery of services
– Builds community awareness on health entitlements
– Provides a platform for community feedback and
dialogue with service providers
– Initiates corrective action and planning with
community engagement
Leads to improved coverage and accessibility of
health services
In essence brings ‘public’ back into public health
Accountability Framework
under NRHM
• A three pronged process:
•
•
•
community based monitoring,
external surveys and
routine program monitoring
– Communitization of the health institutions
• Prominent display of information on funds received,
medicines in stock, health right entitlements
– Public reports on Health at the State and district
levels to report progress to the community
Advisory Group on
Community Action (AGCA)
• Group of civil society experts constituted by the
MOHFW in 2005 with Population Foundation of India
(PFI) as the Secretariat
• Mandate :
– Advise on developing community partnership and
ownership for the Mission
– Provide feedback based on ground realities, to
inform policy decisions
– Develop new models of Community Action and
recommend for further adoption to the national /
state governments
CAH - Immediate Outcomes
Community Based
Planning and
Monitoring
(CBPM)
programme in
Bihar - India
First phase of Community Monitoring
(2007-09)
9 States, 36 districts, 1620 villages
•
•
•
•
•
•
•
•
•
Assam
Chhattisgarh
Jharkhand
Karnataka
Madhya Pradesh
Maharashtra
Orissa
Rajasthan
Tamil Nadu
Uttaranchal
Uttar
Pradesh
Rajasthan
Assam
Nagaland
Bihar
Manipur
Jharkhand
Gujarat
Madhya
Pradesh
W Bengal
Chhattisgarh
Orissa
Maharashtra
Andhra
Pradesh
Karnataka
Tamil
Nadu
Process
1. Education and awareness :
• Community awareness on health entitlements
• Training of Village Health Sanitation and Nutrition Committees
(VHSNC) and Rogi Kalyan Samities (RKS) members
• Display of Citizen’s charter and service guarantees
2. Monitoring and information sharing
•
Collection of information and sharing of report cards,
community experiences of health services
• Multi stakeholder Monitoring and Planning Committees at
PHC, Block and District levels
3. Public dialogue
•
Periodic public dialogue (Jan Samvad) - Engagement with
providers based on community evidence
Community action under NRHM experiences and gains
Five Tangible benefits:
1. Construction work completed
2. Improvements in status of delivery of health
services
3. Enhanced trust and improved interaction
4. Community based inputs in planning and action
5. Reduction in out of pocket expenditure
1. Construction of Sub-Centre completed
Story of change - Maharashtra
• In Jamshet village, Thane district,
construction of a sub-center was incomplete
for over two years
• Village health committee members discussed
the issue in a series of Gram Sabha meetings
and in Block monitoring committee meetings
• A large group of community members went
to the sub-centre to ‘complete’ the
construction through ‘Shramdaan’
• The sub-center building got completed and is
fully functional
2. Performance of health services improves Rajasthan
(Sep 2008-Oct 2009)
District Alwar
40
36
District Chittorgarh
36
50
35
45
30
40
44
35
25
30
20
10
5
0
Number of Villages
15
24
25
20
9
16
15
8
10
0
5
5
1
1
0
0
First round
Second Round
First round
District Jodhpur
30
Second Round
District Udaipur
26
30
26
25
25
20
20
23
23
18
18
15
15
15
15
Poor
Average
10
10
5
4
5
4
2
2
0
0
First round
First round
Second Round
Second Round
Good
Key outcomes
3. Enhanced trust and improved interaction between
provider and community
– Improvement in service delivery - ANC, PNC, immunization,
– Responsiveness of provider to community needs
– Improved provider attitude and behavior
4. Community based inputs in planning and action
– Active involvement of PRI members in planning and
functioning of health facilities
– Appropriate planning and utilization of untied funds at VHSC,
PHC and CHC
Key outcomes
5. Reduction in out of pocket expenditure
– Reducing demands for informal payments
– Ensuring timely and full payments of Janani Surksha Yojana
– Significant reduction on outside prescription
Key challenges
• Capacity constraints to institutionalize and scale
up community monitoring
• Allocation of adequate resources
• Mechanisms to address systemic gaps emerging
from CBMP process and feeding into the planning
process
- vacancies/ posting, procurement and distribution of drugs
and supplies, training of health functionaries
• Institutionalizing minimum service guarantees,
grievance redressal mechanisms
Implementation status
• Scaled up - Maharashtra, Tamil Nadu, Jharkhand,
Chhattisgarh
• Modified – Karnataka, Chhattisgarh
• Re/Initiated – Odisha, Rajasthan, Assam and Bihar
• In FY 2013-14, 15 States / UTs CAH component has
been approved
• AGCA has provided support to Assam, Jammu and
Kashmir, Maharashtra, Madhya Pradesh and Uttar
Pradesh in developing their state PIP
Way forward – Role of AGCA
Technical Support proposal approved by GOI
National level
• Revise CAH tools and share with states for adoption
• Development of RKS guideline and training manual (in
consultation with NHSRC and MoHFW)
• Report on review of approaches/models on grievance
redressal
• Processes developed for selection of NGOs to support
implementation of CAH
Way forward – Role of AGCA
State Level
• Support constitution and orientation of State
AGCAs
• Development of state plans – visioning for scale
up
• Orientation of Nodal Officers and state
institutions - SHRC, ARC, RRC, SIRD etc
• Regular mentoring and review
Thank You