People are reclaiming the public
health system:
Community based monitoring and
planning in Maharashtra
Dr. Abhay Shukla
Coordinator, SATHI
Member, NHM - AGCA
1
Why are Roman arches still standing
2000 years after they were constructed?
The engineers were held directly accountable… they
had to stand under the arch when the scaffolding
support was first removed after construction.
Democratising the Public health system
– Claiming rights, changing power
relations, improving services
• Need to break through current alienation and
unresponsive nature of Public Health services
through systematic social action
• Neither rejecting nor uncritically accepting the
existing ‘public’, but rather transforming it through
popular action with alliance building and advocacy
• Community based monitoring and planning as a
key intervention to reclaim public health systems:
developed in collaboration with PHS but led by network
of civil society organisations
Transforming a PHC – rolling back private
providers: Story of Maligre PHC
• Maligre PHC in Ajara block of
Kolhapur district was very poorly
utilised until 2011 and most people in
covered villages were unaware of its
services
• With initiation of CBM after first Public
hearing the doctor changed; the new
doctor is more dynamic and CBM
activists organised meetings in all
villages to inform people about
services at PHC
• Due to active PHC doctor and
community mobilisation by CBM
activists, now monthly deliveries have
doubled, OPD has significantly
increased and three private clinics
have closed down
Transformation in utilisation of Maligre PHC
following Community based monitoring and
planning
Deliveries
Indoor
admissions
Outpatient
consultations
2010-11
(Pre-CBMP)
8
2013-14
215
857
7,380
17,157
125
Community based monitoring
and Planning (CBMP) in
Maharashtra
Covers 13 districts
with formation,
orientation and
activity of multistakeholder
committees in
• Over 815 villages
• 120 PHC areas
• 35 Blocks
Planned expansion in 2014 to now cover more
than 1000 villages, across 18 districts
Levels of committees for
Feedback & Action
State Planning &
Monitoring
Committee
District Monitoring
& Planning
Committee
Block Monitoring &
Planning Committee
PHC Monitoring &
Planning Committee
Village Health, Water
supply, Nutrition and
Sanitation Committee
Composition of CBMP committees
Elected
representatives –
Panchayat
members
CBO /
NGO
representatives
Public
Health
officials
Representatives
from lower
committees and
community members
Key processes in Community
monitoring - Maharashtra
Community awareness
programmes
Visits by committee members
To health facilities
Data gathering and
filling report cards
Meetings of community based
monitoring committees
Public hearings (Jan sunwais): a forum
for people’s voice and accountability
• Report cards and cases of
denial presented
• Health officials respond to
issues raised by people
• Actions ordered regarding
services at village, PHC
and Rural hospital levels
• Over 450 Public hearings
organised so far at PHC,
block and district levels
Public hearings – a key forum for
accountability and engine of change
Significant improvements in
health services in CBM areas
• Practice of PHCs prescribing medicine from
private shops has largely stopped
• Illegal charging by certain medical officers has now
been checked; challenging corruption
• Frequency of visits of ANM and MPWs in villages
has improved
• Rude and abusive behaviour stopped
• Definite improvement in
immunisation coverage
• Non-functional sub-centres,
mobile units, lab facilities now
started functioning
Significant rise in outpatient, inpatient utilisation in CBM areas
Significant improvement in
PHC services in CBMP areas
Improvement in PHC services from Round I to Round IV
80
70
75
60
50
40
30
44
38
20
19
10
12.5 12.5
0
Round I
Good
Round IV
Satisfactory
Bad
Increase in deliveries in CBMP covered PHCs
compared with district averages
120
100
80
101%
60
40
48%
20
0
Increase in Thane district
PHC deliveries
Increase in Thane CBM
PHCs deliveries
Community based planning:
Developing sharing of power in the public
health system
• Participation of CBMP
representatives in Health
facility committee (RKS)
meetings to suggest
community health priorities
• CBMP committees develop
annual block level PIP
proposals.
• Major pro-people shifts in
priorities for RKS based
planning in PHCs and CHCs
leading to improved services
Comparison of total Expenditure by RKSs
between 2009-10 and 2011-12: Velha block
Analysis of expenditure RH Velha 2011-12:
of items with CbMP2011-12
Process suggestions
Facility linkage2009-10
% increase
expenditure expenditure
PHC
Pasli
PHC
Velhe
RH
Velhe
Expenditure
2,13,053
not linked
with CbMP
61,742
process
41%
77,523
after CBMP
3,42,697
61%
Expenditure
2,50,294
linked with
CbMP
3,71,223
process
59%
405%
479%
‘Reclaiming’ elected
Panchayat representatives
• Panchayat members now are taking
active role and contributing to both
community monitoring and planning
• Major role of Panchayat members in
CBMP committees – making surprise
visits, ensuring actions
• Zilla Parishad members have ensured
action and funds in some cases
• Over 75 PRI members participated in
State culmination workshop in July
2012
• Four ‘Sarpanch melavas’ in 2014
Dimensions of democratising and
‘reclaiming’ public health services
1. Promoting forums for direct democracy –
Jan sunwais and Arogya Gram Sabhas
2. Expanding representative democracy
through multi-stakeholder bodies – monitoring
and planning committees
3. Reclaiming representative democracy –
activating PRI members to promote health
rights
4. Activating ‘internal accountability’ through
external accountability processes
Community helps to solve problems
of health care providers
In Bhongowali PHC in Bhor block of Pune
district, the doctor was not staying at the
PHC. Raised during Jan Sunwai, he
complained that he did not have quarters. A
CBM committee member offered to arrange a
house for him in the village on the spot.
Today doctors are
regularly staying at the
PHC even at night.
State level recognition by CBMP process
to well performing health care providers
Community based monitoring and action for ICDS
initiated in 5 districts, 2 cities of Maharashtra
Emerging strategies
• Generalising community monitoring in voluntary
mode in various new districts and regions
• Decision to organise ‘Arogya Gram Sabhas’ in all
villages where services can be reviewed, planning
decisions can be taken
• Block level federations, grievance redressal
facilitation cells, resource units working with youth
• ‘Communitisation’ of selected PHCs in tribal areas
– based on Nagaland model
• Need to move from Community monitoring as
project to social process mode with demand for
generalisation of accountability processes
Some broad principles for
Health officials concerned with CBMP
• Partnering, not controlling: CBMP is a shared activity, not
entirely driven by officials but rather a joint effort; need to
build partnerships with stakeholders ‘outside’ the system
• Supporting rights based civil society organisations and
recognising their contribution
• ‘Awareness generation’ of officials at various levels is
also necessary!
• Dialogue is essential, though it may sometimes seem to
be ‘bitter medicine’!
• Timely disbursal of necessary funds is essential to
continue the process – funds excessively delayed are funds
denied!
• Community based monitoring and planning means sharing
power in the health system …