Social Audit of Health
Services
Improving Family Planning
Services in UP, India
2001 - 2005
Abhijit Das
Centre for Health and Social Justice,
India
Introduction to Presentation
1. What is Social Audit
2. Applying Social Audit to Health related
public programming
3. Example of applying social audit to a
health issue in India
4. Challenges
1. What is social audit
Variety of Audits• Internal Audit – Efficiency, Financial
• Statutory Audit - Financial
• Performance Audit, Compliance Audit
• Environmental Audit
• Social Audit – multiple definitions
Social Audit- Evolving definitions
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A process of measuring and reporting an organisations
social and ethical performance. (Caledonia Centre for
Social Development) ‘mid 1990’s’
A ‘social hearing’ ‘gaze’( Dr Wan Ying Hill –Glasgow
Caledonian University)
A means of collectively probing and understanding
information by citizens ( Amitabh Mukherjee)
A community assessment of public records to evaluate
how well public resources are used and how to improve
performance (OSI-PHW)
The audit of a Programme / Scheme by the community
with active involvement of the primary stake holders and
in collaboration with the Government (MKSS) ‘mid
2000s)
Social Audit : Key Elements
Linked to
• Accountability
• Review of Performance of a Public Programme
• ‘People’s interest’ or ‘Social’ is Central to the
review process
• Review of public documentation of ‘performance’
and ‘expenditure’
• Public ‘data’ and ‘records’ are reviewed by
stakeholders/ non traditional auditors
A Working Definition
• It is the systematic gathering of information about the
social impact of government/public programmes/ service
delivery.
• The information is collected by the users or from the
perspective of the user of services/ affected community.
• The information could relate to the population level
situation, to the level of the delivery of services and to
the experience of the intended beneficiary/user in
receiving or not receiving the services
• The results are shared publicly to reinforce the rights/
entitlements of the users and the responsibilities and
accountability of the providers
• Allows for the empowerment of users and the
improvement in service delivery
Social Audit and Rights Based Approaches
Identifying Gaps
Identifying
Stakeholders
2. Social Audit in Health
Conditions which facilitate
• Guidelines for the provision of services
• Documentation related to the provision of
services
• People’s own experience indicates there is a
problem in service delivery and they are willing
to provide testimonies during public sharing
• An audit team
• An arbitration / hearing mechanism
Steps
• Identification of the problem in the public
programme
• Gathering public documentation
• Reviewing records for fulfillment of
obligations, transparency, accountability..
• Correlating documented evidence with
people’s experience
• Public sharing
• Follow up advocacy
Documentation related to Health
services
• Documents relating to services, standard operating
procedures and quality protocols
• Documents relating to performance – HMIS/ service
statistics, Outcome records, Health survey findings,
• Documents relating to treatment or provision of
service / medical records – Out patient record,
Prescriptions, In patient records, Bed-head tickets,
Laboratory/ Investigation records, Informed Consent
forms, Surgical notes, Discharge records.
( Caution : Ethical issues relating to use of medical
records )
• Fact-finding in case of reported human rights
violations
Verification of records
• Sample surveys to verify the accuracy of
population based health statistics and
HMIS/ service statistics
• Observation and review of records for
compliance of quality standards
• Individual testimonies for verification of
quality compliance (ethical issues)
• Fact finding documentation with back up
medical records
Arbitration/ Hearing Team
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Public Health Experts
Legal Experts
Eminent citizens
Government Functionaries
3. Social Auditing to Improve
Family Planning Services
in Uttar Pradesh, India
A Case Study
Uttar Pradesh - An
Introduction
Most populous state
in the country – 190 mil
Gangetic plain
Rich agricultural land
State with poor sociodemographic
indicators
Strong bastion of
caste based
politics
Politically important
but poor governance
Feudal
hangover
The Problem in Public Programming :
Coercive Population Control Program
with Poor Quality of Care
• Long history of coercive population control
programme in India
• India adopts a Target Free Approach based on
Voluntary and Informed choice through in
National Population Policy
• UP passes a population policy which includes
Targets for different methods
• News papers report that a 13 year old girl has
been forcibly ‘sterilised’ and reported as a 27
year old mother of three children in health facility
records
Our Background
• Network Heathwatch Forum UP (HWFUP)
comprising of public health experts, health
activists, women’s rights activists
• HWFUP had earlier history of working on
issues related to reproductive health and
rights – engaged in post ICPD processes
in India
• HWFUP was committed to securing
reproductive rights for women
Role of Social
Auditing in
our Advocacy
Campaign
Filing a case in
Supreme Court
Sharing results with media
Study of 10 camps
Public Hearing
Fact- finding /Documenting Case-studies
Secondary Data Analysis
Joint Policy Analysis and Opinion Poll .
Building stakeholdership
Centrality of Evidence
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Review of Evidence
Total no. of live birth -5million/yr
Target for sterilisation 600,000/yr and increasing
annually
Achievement – 3 -400,000/yr
Failed sterilisation/reconception – 5% or 12,000 15000/yr
Complication – upto 50%
Death from sterilisation – not counted but reported in
papers
Over-reporting on other methods – upto 20times ( CuT)
No of maternal deaths – 40,000 (approx)
Unsafe delivery 3- 4 million.
Sources of Information
• National Family Health Survey
• State Family Planning Service Statistics
(HMIS)
• Studies conducted by state research
organisations
• Hospital/ Sterilisation Camp records
• Verification – Fact finding Cases and
Camps
Verifying Users Experiences :
Documenting Case- Studies
Over 100 case-studies collected
• Women who had died in childbirth after the
child was conceived after sterilisation
• Women who had died during sterilisation
and the team had left the woman
unattended and disappeared
• Women who had infections/complications
which was not treated in the public sector
and ended costing large sums of money
Verifying Compliance of Quality
Standards
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Ten Sterilisation Camps were studied using
government mandated quality benchmarks
Doctors were often not informed about quality
parameters
Doctors not following infection prevention
procedures
Doctors not following recommended surgical
procedures
Women not treated with dignity
Women not provided options for informed choice
Publicly Sharing the results
• Public hearing / Jan Sunwai – face to face
sharing of affected people (testimonies)
with a set of subject matter and human
rights experts, media persons and
government functionaries
• Sharing results with bureaucrats and
programme managers
• Sharing results over the media – in our
case we had a Parliamentary enquiry over
poor quality of services
Conducting Social Audit
Primarily Conducted by facilitating organisation/s
which possess skills documentation and advocacy
Preparations
• Knowledge of
government
policy/programme
provisions
• Ability to conduct
documentation / studies
• Strong alliance with
Affected
groups/Community
Helpful conditions
• Need for service/ change
explicitly acknowledged
• Availability of some
Standard operating
procedures and quality
parameters concerned
with the service at hand
• Some relationship with
provider which will enable
them to participate in
sharing processes
Results of our Campaign
• Supreme Court orders relating to compliance of
quality standards and compensations applicable
to the entire country
• Introduction of Family Planning Insurance
Scheme for paying compensation to all cases of
failure/re-conception, complications and deaths
• Setting up Quality Assurance committees at all
districts in the country which now cover all
aspects of health service delivery (NRHM)
• The benefits of these two mechanisms apply to
over 5 million women undergoing sterilisation
every year
4. Lessons and Challenges
• Our initial arguments on coercion using the
ICPD PoA and the National Population Policy as
benchmark was not successful in getting a
response from the state family planning
programme. However advocacy based on this
benchmark was successful in stopping a
proposed legislation “UP Population Control
Act/Bill”
• There was lack of political will at the state level
so most of our achievements were at the central
level
• We had to sustain our advocacy beyond social
audit and move to litigation
Challenges (contd.)
• When we found that coercion was not a very sustainable
framework for argument we added the dimension of
quality. We had ‘discovered’ quality parameters during
our review of documentation.
• We face criticism from some quarters that the Supreme
Court guidelines have reduced access to sterilisation
services in places
• Population Control mindset continues be widespread
with the Supreme Court upholding another population
control law relating to 2 child norm in 2002. Among
bureaucracy there is concern about inadequate practice
of family planning and a temptation to re-introduce family
planning targets.
Thank you
Acknowledgements : All members of Healthwatch Forum, Uttar Pradesh
and members of SAHAYOG and CHSJ