Bridging ‘demand’ and ‘supply of accountability: Roundtable
The Hague, April 19, 2013
Community Monitoring of
National Rural Health Mission
in India
Divergent Experiences and
Challenges
Abhijit Das
CHSJ and COPASAH
Introduction to CBM in NRHM
• A new coalition Government comes to power in 2004.
Coalition has Left parties support in Parliament and civil
society participation in social sector policy think-tank NAC
(National Advisory Council)
• National Rural Health Mission introduced by Govt of India
as a new delivery mechanism for health services for the
poor in 2005 with strong civil society participation
• Community based monitoring introduced both as a
component of ‘communitisation’ and accountability
• Government of India entrusts piloting of CBM to civil
society groups through an advisory committee AGCA.
• CBM piloted across nine states between 2007 -09. 35
districts – 1620 villages covered through GoI support. Pilot
evaluated. GoI says states must include in their own state
plans and budgets
Community monitoring after 2009
Continues in the
same trend as the
pilot in a couple of
states
Continues in a
somewhat
modified
manner in a
couple of
states
Limited nonGovernment
endorsed
processes are
there in some
states
After repeated letters/
requests/ instructions
from Government of India
Has still not
started in
many states
Has stopped
after the pilot
Has been started
in couple of
states
Two Divergent Experiences
•
•
•
•
•
•
Maharashtra
Not a High Focus State but
continues CBM from pilot phase
Strong Civil Society stewardship
of CBM ; led and implemented by
civil society organisations
State supports and expands CBM
but continually asks for phase out
plan
Improvement of health services
clearly documented
Has also started generating
political support at the local level
Many operational challenges
including reduced and delayed
funding
•
•
•
•
•
• Uttar Pradesh
A High Focus state in NRHM but
excluded from CBM because of
poor performance benchmarks
Civil society led accountability
efforts give way to a strong
community led accountability
process
Women’s health rights forum
(MSAM) of 12,000 women from
200 villages in 10 districts
Empowerment - Strong local
leadership – engagement with
public health system – many
small gains
Women leaders enter electoral
politics at the local level
Community level challenges
• Community
– Apathy/ fatalism
– Lack of faith in public services – health world view and past
experiences
• Services
– Huge gaps and deficiencies
– High levels of privatisation
• Community – authority relationship
– Reluctance for ‘complaint’ may need the same providers
service later
– Kinship relationships -
Challenges
•
•
•
•
Maharashtra
Rhetoric vs Intent
Limited to local problems
and local solutions. ‘CBM
resistant’ problem
Seen by managers as a
support to administrative
oversight of frontline
functionaries and better
planning
No redressal mechanism
established even after 5
years
•
•
•
•
•
Uttar Pradesh
Politically important state –
‘unaccountable’ political
leadership;
Historical donor/external
aid management skills
Deeply entrenched
corruption
NGO – State relationship :
NGO beholden-ness
Overall low political
mobilisation of
communities – caste politics
An interesting Conundrum
• Enabling conditions met – provision in policy
guidelines, official endorsements,
standards/procedures/tools, citizen
opportunities, facilitating organisations, funds
BUT
• Inadequate roll-out after enthusiastic start up
• Operational resistances of different nature
• Losing interest/energy among communities
without appropriate changes in services
Some thoughts….
• Framing of the issue and focus– Economic / efficiency - ‘ demand – supply’ (Outcome) or
Active Citizenship/Deepening Democracy - ‘rightsobligation- entitlement’ (Process)
• Intent vs Rhetoric – ‘fashion’ vs political intent.
• Different aspirations - Shorthand solutions for
fundamental state failures vs Improved/targetted
planning and service delivery vs Accountable public
services (Populist/Bureaucratic/Political)
• Governmentality – bureaucratic subversions
• Dynamic/changing nature of the actors and their
interests –political compulsion , bureaucratic interests,
citizen-leader transitions