People Are Reclaimin

About the English translation

This English booklet is translated from the original Marathi report 'Ata Sarkari Davakhana Hotoy Janatecha' based on processes and experiences of Community based monitoring and planning in Maharashtra. The Marathi booklet was published in 2011, whose title means “The 'Government' clinic is now becoming a 'People's' clinic”.

This qualitative process documentation presents ground realities, experiences and ideas of stakeholders across various districts of Maharashtra involved in the CBMP process. These peoples' voices give an authenticity to the document and make it live and readable. We had received a very positive response to the original book, but due to language constraints it was difficult to take this rich document beyond the Marathi reading public. Hence in order to share these experiences more widely, we decided to translate this Marathi booklet into English for a broader audience. While doing the translation, we deliberately chose to retain the regional flavor of the original while making the content accessible for English readers. We hope this effort will be found useful.

Qualitative Report on Community Based Monitoring and Planning of Health Services in Maharashtra Supported by NHM People are reclaiming the Public health system ... About the English translation

Qualitative Report on Community Based Monitoring and Planning of Health Services in Maharashtra Supported by NHM People are reclaiming the Public health system ... C o n t e n t s 5 What is meant by Community Based Monitoring and Planning (CBMP) of Health Services? Emergence, evolution and implementation of the concept… 15 Innovative methods adopted in the CBMP process 19 Experiences of CBMP in five pilot districts What is this document about? 30 Emerging process of Community based planning An account of a collective process 32 Outcomes of CBMP in numbers to revitalise health services... 39 Selected stories of change 45 Experiences of CBMP implementers he general perception is that nothing can happen smoothly and efficiently in public systems. While people often complain about delays and problems they 53 Representatives from districts speak up... Texperience in Government offices, they exhibit indifference towards this system at the same time. The public health system is no exception to this prevalent sense of 56 Emerging CBMP in eight new districts apathy. Usually people are least concerned about the state of health services, as they consider it to be a government function. Nevertheless, this dissatisfaction, as this 65 State convention on community Accountability of health document presents, can be turned into concern and action. & social services

This document presents the process of implementing 'Community Based Monitoring 68 Generalising & deepening community monitoring through and Planning' (CBMP) in Maharashtra that has been initiated with support from the innovative actions… 'National Rural Health Mission'(NRHM). The CBMP experience shows that people's indifference is waning and 'government' clinics are becoming 'peoples' clinics. This External evaluations : A 'report card' on Community document explains the emergence, scope, impact and future challenges of this innovative 76 Based Monitoring of health services in Maharashtra concept, and also presents views and opinions of various stakeholders, such as a member of National Planning Commission, noted social activists, senior media persons, Health 78 Key issues, challenges and an appeal officials from state and district levels, NGO and CBO activists, village level health functionaries and community members, about CBMP. 83 CBMP of Health services in Maharashtra – Prominent Opinions NRHM, among other things, aims to bring down maternal and child mortality, provide quality health services in rural areas and increase community participation in planning of health services, by taking people's views into account. NRHM is being implemented across the country, while CBMP in Maharashtra started on a pilot basis in five districts – Amravati, Pune, Nandurbar, Thane and Osmanabad and it has expanded in 2010, to additional 8 districts -i.e. Aurangabad, Beed, Chandrapur, Gadchiroli, Kolhapur, Nashik, Raigad, Solapur. CBMP processes and experiences in these districts are covered in this document. We hope that the content and presentation will be a useful resource in scaling up and universalization of this unique concept.

CBMP has instigated a process of change. People identifying gaps within the health system, and then taking initiative to correct them is unprecedented. Through this effort the public health system is becoming accountable. Moreover, government acknowledgment and support makes this entire effort much stronger. Such a remarkable process should be scaled up widely, and we hope this book will contribute towards this goal. 2 3 C o n t e n t s 5 What is meant by Community Based Monitoring and Planning (CBMP) of Health Services? Emergence, evolution and implementation of the concept… 15 Innovative methods adopted in the CBMP process 19 Experiences of CBMP in five pilot districts What is this document about? 30 Emerging process of Community based planning An account of a collective process 32 Outcomes of CBMP in numbers to revitalise health services... 39 Selected stories of change 45 Experiences of CBMP implementers he general perception is that nothing can happen smoothly and efficiently in public systems. While people often complain about delays and problems they 53 Representatives from districts speak up... Texperience in Government offices, they exhibit indifference towards this system at the same time. The public health system is no exception to this prevalent sense of 56 Emerging CBMP in eight new districts apathy. Usually people are least concerned about the state of health services, as they consider it to be a government function. Nevertheless, this dissatisfaction, as this 65 State convention on community Accountability of health document presents, can be turned into concern and action. & social services

'People don't do what you expect, they do what you inspect'

Any system responds to what is directly inspected and monitoring. Regular periodic reporting by the rather than what is expected of it. This management staff and officers in charge at various levels is also rule aptly denotes the human psyche. What applies used to review progress achieved through the work. to people also applies to systems. Community based These two standard methods have often been used monitoring is a method which is used to get to monitor functioning and impact of health beneficiary feedback about a particular service. services. However, the opinions of the people who Community based monitoring enables us to know use these services have not been systematically taken people's feelings and satisfaction levels about the into account so far. CBMP bridges this gap by service and accordingly explore necessary areas for involving community members in the assessment of improvements to satisfy them. services in order to improve them. It is a kind of social audit of public health services, which serves Every system seeks to know whether it functions to facilitate active participation of people who are effectively or not and adopts various methods otherwise indifferent towards the state of affairs in towards this end. One of the prevalent methods is to the health system. appoint an independent agency to undertake review

What are the key elements in implementation of CBMP?

CBMP implementation covers the following; ü This document is about… Initiative of community members to access regular and good quality health services üTaking concrete steps to increase out reach of public health services and disseminating information about schemes and health services meant for community members. Community Based Monitoring and Planning üMonitoring by villagers to ensure availability of local health services. üCollecting information and feedback about available health services from its beneficiaries of Health Services üPresenting key community health issues based on compiled information. üDeliberating upon local issues through public dialogue (Jan Samvad), public hearing or similar methods in order to address and resolve them. Its meaning, emergence, nature, scope, üCommunicating people's opinions to decision makers. effects and outcomes... üIncreasing people's participations at various stages of planning of health services 4 5 An Appropriate Solution to a problem … What is meant by 'Community Based Monitoring and Planning of Health Services'?

'People don't do what you expect, they do what you inspect'

What are the key elements in implementation of CBMP?

CBMP implementation covers the following; ü This document is about… Initiative of community members to access regular and good quality health services üTaking concrete steps to increase out reach of public health services and disseminating information about schemes and health services meant for community members. Community Based Monitoring and Planning üMonitoring by villagers to ensure availability of local health services. üCollecting information and feedback about available health services from its beneficiaries of Health Services üPresenting key community health issues based on compiled information. üDeliberating upon local issues through public dialogue (Jan Samvad), public hearing or similar methods in order to address and resolve them. Its meaning, emergence, nature, scope, üCommunicating people's opinions to decision makers. effects and outcomes... üIncreasing people's participations at various stages of planning of health services 4 5 Community Based Monitoring and Planning Scope of Community Based Monitoring & How did the concept emerge? Planning in Maharashtra

ccording to the directive principles in population. Likewise, it was decided to increase the Indian Constitution, the budgetary provisions for public health. However, Based on approval by NRHM at national level, the process government is responsible to the administration was aware that the desired of CBMP implementation began in all pilot states including A goals would not be reached without effective Maharashtra. The responsibility for implementation was promote public health. However, the health sector in India is plagued with numerous community participation. People's involvement entrusted to civil society organisations. problems. Some of the critical areas of became an essential factor also to monitor concern include inadequate budgetary utilization of funds, especially those meant for SATHI shouldered the responsibility for state level provisions, enervated public health system, marginalized sections. NRHM enhanced the implementation as the state nodal organisation in availability of resources in terms of funds and Maharashtra. proliferation of profit seeking private medical facilities. However, it was equally important to sector, insensitivity of the medical profession have a mechanism in place to ensure that these towards health needs of common people, and resources are utilized properly, effectively and for The process began in five districts on a pilot basis. These poor implementation of services meant for the benefit of all people. How to ensure that are - Amaravati, Nandurbar, Pune, Thane and Osmanabad underprivileged sections. All these critical people are getting quality health services? How to and it has now expanded to additional 8 districts. These are- concerns have been raised often by health assess whether or not they are satisfied with the rights activists. The national campaign service? The government reports alone are Aurangabad, Beed, Chandrapur, Gadchiroli, Kolhapur, platform for health rights – Jan Swasthya insufficient to get a comprehensive picture. In Nashik, Raigad, Solapur.. Abhiyan – has frequently raised these and other this context, the idea of collecting people's concerns at the state and national levels. experiences about health services, as evidence of A District nodal organisation was selected in Upholding the right to health care, JSA has responsiveness of the ser vices, was every district. strongly advocated for improvements in and conceptualized. strengthening of public health system. The With this background, the Health Ministry Three blocks in every district were selected, with a block CBMP process is linked with years of work by established a task force on 'District Health JSA members who have been doing advocacy Planning'. Some of the JSA activists, who were implementing organisation in each. on health rights. part of the task force, urged adoption of community based monitoring. Later their As part of these efforts, in 2004 JSA in The CBMP process was initiated in 3 PHCs and 15 villages suggestions got incorporated in the NRHM in each block. collaboration with National Human Rights framework. Commission organised a series of Public Later the scope of work further expanded. Hearings at regional levels with an aim to The National Advisory Group for Community establish the right to health care. These public Action (AGCA) that was formed as part of Community Based Monitoring & hearings, organised in various parts of the NRHM further explored ways to ensure country, brought forth a range of critical issues community participation. Their deliberations led Planning in pilot districts of Maharashtra now includes... pertaining to the state of public health to formulation of the CBMP framework in its services. Taking serious note of the situation, present form with approval from NRHM. districts blocks PHCs Villages NHRC endorsed the concept of 'Community The actual implementation of Community Based 13 35 118 815 Based Monitoring', as a methodology to Monitoring and Planning of Health Services and is carried out by 25 grassroots NGOs and people's ensure social accountability of health services began in 2007. Total 35 districts from 9 states organisations. Besides this, CBM process is being initiated on and also as a measure to ensure realization of were identified for the pilot phase, including voluntary basis in 10 additional districts by 34 new organisations. people's right to health care. NHRC forwarded Maharashtra where CBMP was initiated in 5 its recommendations to the Health Ministry, districts – Amravati, Nandurbar, Pune, Thane which included community based monitoring. and Osmanabad. All are united by a common objective. Subsequently public health system reforms set As the evolution process indicates, CBMP was Public health officials and health workers, NGOs and people's organisations, in after NRHM was initiated in 2005. NRHM conceived in order to promote elected representatives of local self governing bodies, community members and aimed at bringing down extent of maternal people's right to health care. media personnel all have come onto a common platform for the first time to and child mortality and providing quality discuss health issues, and improve health services. health services to the underprivileged rural 6 7 Community Based Monitoring and Planning Scope of Community Based Monitoring & How did the concept emerge? Planning in Maharashtra ccording to the directive principles in population. Likewise, it was decided to increase the Indian Constitution, the budgetary provisions for public health. However, Based on approval by NRHM at national level, the process government is responsible to the administration was aware that the desired of CBMP implementation began in all pilot states including A goals would not be reached without effective Maharashtra. The responsibility for implementation was promote public health. However, the health sector in India is plagued with numerous community participation. People's involvement entrusted to civil society organisations. problems. Some of the critical areas of became an essential factor also to monitor concern include inadequate budgetary utilization of funds, especially those meant for SATHI shouldered the responsibility for state level provisions, enervated public health system, marginalized sections. NRHM enhanced the implementation as the state nodal organisation in availability of resources in terms of funds and Maharashtra. proliferation of profit seeking private medical facilities. However, it was equally important to sector, insensitivity of the medical profession have a mechanism in place to ensure that these towards health needs of common people, and resources are utilized properly, effectively and for The process began in five districts on a pilot basis. These poor implementation of services meant for the benefit of all people. How to ensure that are - Amaravati, Nandurbar, Pune, Thane and Osmanabad underprivileged sections. All these critical people are getting quality health services? How to and it has now expanded to additional 8 districts. These are- concerns have been raised often by health assess whether or not they are satisfied with the rights activists. The national campaign service? The government reports alone are Aurangabad, Beed, Chandrapur, Gadchiroli, Kolhapur, platform for health rights – Jan Swasthya insufficient to get a comprehensive picture. In Nashik, Raigad, Solapur.. Abhiyan – has frequently raised these and other this context, the idea of collecting people's concerns at the state and national levels. experiences about health services, as evidence of A District nodal organisation was selected in Upholding the right to health care, JSA has responsiveness of the ser vices, was every district. strongly advocated for improvements in and conceptualized. strengthening of public health system. The With this background, the Health Ministry Three blocks in every district were selected, with a block CBMP process is linked with years of work by established a task force on 'District Health JSA members who have been doing advocacy Planning'. Some of the JSA activists, who were implementing organisation in each. on health rights. part of the task force, urged adoption of community based monitoring. Later their As part of these efforts, in 2004 JSA in The CBMP process was initiated in 3 PHCs and 15 villages suggestions got incorporated in the NRHM in each block. collaboration with National Human Rights framework. Commission organised a series of Public Later the scope of work further expanded. Hearings at regional levels with an aim to The National Advisory Group for Community establish the right to health care. These public Action (AGCA) that was formed as part of Community Based Monitoring & hearings, organised in various parts of the NRHM further explored ways to ensure country, brought forth a range of critical issues community participation. Their deliberations led Planning in pilot districts of Maharashtra now includes... pertaining to the state of public health to formulation of the CBMP framework in its services. Taking serious note of the situation, present form with approval from NRHM. districts blocks PHCs Villages NHRC endorsed the concept of 'Community The actual implementation of Community Based 13 35 118 815 Based Monitoring', as a methodology to Monitoring and Planning of Health Services and is carried out by 25 grassroots NGOs and people's ensure social accountability of health services began in 2007. Total 35 districts from 9 states organisations. Besides this, CBM process is being initiated on and also as a measure to ensure realization of were identified for the pilot phase, including voluntary basis in 10 additional districts by 34 new organisations. people's right to health care. NHRC forwarded Maharashtra where CBMP was initiated in 5 its recommendations to the Health Ministry, districts – Amravati, Nandurbar, Pune, Thane which included community based monitoring. and Osmanabad. All are united by a common objective. Subsequently public health system reforms set As the evolution process indicates, CBMP was Public health officials and health workers, NGOs and people's organisations, in after NRHM was initiated in 2005. NRHM conceived in order to promote elected representatives of local self governing bodies, community members and aimed at bringing down extent of maternal people's right to health care. media personnel all have come onto a common platform for the first time to and child mortality and providing quality discuss health issues, and improve health services. health services to the underprivileged rural 6 7 Our mission is to establish people's Right to Health...

Who has been involved in CBMP implementation and where is it being implemented? Pilot phase - 5 districts Community Based Monitoring and Planning From Village level to the State level…

Although the actual process of CBMP started in 2007, the preparatory process was going on at different levels for some time in a collaborative manner involving NRHM, State Health Ministries and voluntary organisations.

A coordinating mechanism is essential if government and NGOs are to work together. Independent forums were formed for the purpose of facilitating the process, specifically in terms of organizing meetings, taking decisions and issuing official orders, to disseminate them and provide overall guidance for Expansion phase - 8 districts the work. Coordinating structures were formed at the national, state as well as district level.

National level State level District level National Advisory Group on State Mentoring District Mentoring Community Action (AGCA) Committee Committee

At the national level, the The state level mentoring committee was formed to A district mentoring committee Advisory Group on Community was formed in all districts where Action has been formed by facilitate the process within the state. The committee members the CBMP process was NRHM to ensure people's implemented. The committee participation in health sector include State Health Officials and persons experienced in has been responsible to take reform processes. Committed review of district level experts who have contributed to public health & community health. processes and their outcomes, public health for many years to issue relevant orders at the were invited to become AGCA district level for the success of members. This group assumed a the project, to have regular 'parental' role to the CBMP at quarterly meetings to review the national level. and plan the process.

8 9 Our mission is to establish people's Right to Health...

Who has been involved in CBMP implementation and where is it being implemented? Pilot phase - 5 districts Community Based Monitoring and Planning From Village level to the State level…

National level State level District level National Advisory Group on State Mentoring District Mentoring Community Action (AGCA) Committee Committee

8 9 Structure and Constituents Proportion of Representation How were the Monitoring and Planning Committees formed? ºÉofÊ¨É iCBMPªÉÉÆSÉÒ ºÉ Æ®CommitteesúSÉxÉÉ ´É ºÉ½þ¦ÉÉMÉÒ PÉ]õEò ºinÉÊ ¨theÉiªÉ ÉCommitteesÆ¨ÉvÉÒ±É |ÉÊiÉÊxÉÊv Éi´ÉÉSÉÆ |É¨ÉÉhÉ Translating a plan on paper into reality is not a simple task. Besides, CBMP was not implemented just at the village level, but at various levels from village to PHC, block and district. The implementation districts were also geographically Proportion of Representation in the State Committees from PHC level and above – and culturally diverse. In spite of these complexities Monitoring a structure that would be commonly applicable was and Planning Representation of elected members of local evolved. Committee government bodies–30% Representation of medical officers – 20 – 30% All stakeholders at various levels were brought District Monitoring Representation of NGOs/CBOs – 15 – 20% together in a phased manner. Village health and Planning Committee Representation of RKS members – 10% committees were expanded first, followed by Block Monitoring formation of PHC level committees. After committees functioned at their respective levels and and Planning Committee In addition, members include heads of health processes were initiated at these levels, block and were engaged in various activities such as back and committees in Zilla Parishad and Panchayat Samiti, District then district level committees were constituted. All forth communication, follow up to get essential PHC Monitoring and Medical Officer and Nodal NGO representative. the committees were connected through a government orders, training of volunteers, Planning Committee Gram Panchayat members, ASHA volunteers, representative structure, which means some conducting village meetings and making field visits. Anganwadi worker, SHG members, representatives of representatives from Village committees were Persistent efforts of various committees, from state Village Health Committee local community groups. members in the PHC committee, similarly PHC to village level, at their respective levels and in committee members were represented in Block coordination with each other, have given required committees and District committee had momentum to the CBMP process. crucial phase in the Time was taken to convince them r e p r e s e n t a t i v e s f r o m representatives from Block committees. All C B M P p r o c e s s i s that existing RKS committees are marginalized communities. f o r m a t i o n o f for guiding implementation, and H o w e v e r , t h e n o d a l o m m u n i t y b a s e d I have specific observations and therefore requires to be A committees. A Government implementing committees by organisations remained firm on monitoring is a good to share from State Mentoring looked at with a positive attitude. Order was necessary to initiate their very nature are unable to do this issue and ensured their Cconcept. It has not just Committee meetings. We need to A number of organisations the process, however it was a independent monitoring as well. participation. been on paper but since last few be careful and conscious in our are involved in this effort. They tough task to get it issued. We After the order was issued, the For effective interlinkages, years we are making efforts to approach. Particularly, the health also need to be cautious about not already had Village Health, process of committee formation some non-government members officials and functionaries in the implement it on the ground. misusing the 'power' that they Nutrition, Water Supply and started. The existing village from each committee were health system should properly There are definitely some changes have been accorded. It should be Sanitation Committees and RKS health committees were mostly included in higher level understand the core of the taking place. People are now kept in mind that monitoring is a committees in place. The inactive to begin with. Hence we committees, to enable posing of process. At first, they might have social responsibility given to these increasingly availing public health question that we were confronted s t a r t e d w i t h awa r e n e s s, problems not being addressed f e l t t h e p r o c e s s t o b e organisations in the public locally, at the higher level. For facilities. The community with was, why these new expansion and activation troublesome, with people interest, for raising relevant i n s t a n c e, V i l l a g e h e a l t h monitoring process is making monitoring and planning programmes. Conscious efforts them aware of their rights and pointing out their faults and problems within the community w e r e m a d e t o e n s u r e committee members in Purandar complaining against them. committees and that too why in steps they need to take to attain and it should not be misused for representation of women, dalit block noticed substandard However, it should be kept in five identified districts? Some their rights. The health system is personal gains. and physically challenged people quality of food provided in some mind that the process is ultimately officials opined that the schools. The problem was not also becoming more responsive Lastly, along with monitoring in the committees. We faced aimed at improving the system we all should be aware of the responsibility of monitoring solved locally, so they raised it at and accountable towards people. opposition in Pune and Thane planning component integral in should be handed over to the d i s t r i c t s i n i n v o l v i n g PHC level and pursued till it got this process. Planning process has already existing RKS committees. resolved. two approaches-first, needs based Training programmes for planning and second, planning by committee members have been Planning only at the the government. Just the latter is Only active members important, including exposure government level never enough. For effective and can bring about visits and dialogue with medical meaningful planning, both officers. If committees are does not suffice … approaches should be combined. change formed without members being Local needs should be prioritized. e f f e c t i ve l y t r a i n e d , t h e The state and district committees committees exist only on paper. -Vikas Kharge, -Dr. Nitin Jadhav However, proper training has will always extend their fullest State Coordinator, Former Mission Director, NRHM, support to facilitate such pro- inculcated awareness and Maharashtra State. CBMP, SATHI, people planning process. State Coordinating Organisation, capabilities among CBMP Pune committee members. 10 11 Structure and Constituents Proportion of Representation How were the Monitoring and Planning Committees formed? ºÉofÊ¨É iCBMPªÉÉÆSÉÒ ºÉ Æ®CommitteesúSÉxÉÉ ´É ºÉ½þ¦ÉÉMÉÒ PÉ]õEò ºinÉÊ ¨theÉiªÉ ÉCommitteesÆ¨ÉvÉÒ±É |ÉÊiÉÊxÉÊv Éi´ÉÉSÉÆ |É¨ÉÉhÉ Translating a plan on paper into reality is not a simple task. Besides, CBMP was not implemented just at the village level, but at various levels from village to PHC, block and district. The implementation districts were also geographically Proportion of Representation in the State Committees from PHC level and above – and culturally diverse. In spite of these complexities Monitoring a structure that would be commonly applicable was and Planning Representation of elected members of local evolved. Committee government bodies–30% Representation of medical officers – 20 – 30% All stakeholders at various levels were brought District Monitoring Representation of NGOs/CBOs – 15 – 20% together in a phased manner. Village health and Planning Committee Representation of RKS members – 10% committees were expanded first, followed by Block Monitoring formation of PHC level committees. After committees functioned at their respective levels and and Planning Committee In addition, members include heads of health processes were initiated at these levels, block and were engaged in various activities such as back and committees in Zilla Parishad and Panchayat Samiti, District then district level committees were constituted. All forth communication, follow up to get essential PHC Monitoring and Medical Officer and Nodal NGO representative. the committees were connected through a government orders, training of volunteers, Planning Committee Gram Panchayat members, ASHA volunteers, representative structure, which means some conducting village meetings and making field visits. Anganwadi worker, SHG members, representatives of representatives from Village committees were Persistent efforts of various committees, from state Village Health Committee local community groups. members in the PHC committee, similarly PHC to village level, at their respective levels and in committee members were represented in Block coordination with each other, have given required committees and District committee had momentum to the CBMP process. crucial phase in the Time was taken to convince them r e p r e s e n t a t i v e s f r o m representatives from Block committees. All C B M P p r o c e s s i s that existing RKS committees are marginalized communities. f o r m a t i o n o f for guiding implementation, and H o w e v e r , t h e n o d a l o m m u n i t y b a s e d I have specific observations and therefore requires to be A committees. A Government implementing committees by organisations remained firm on monitoring is a good to share from State Mentoring looked at with a positive attitude. Order was necessary to initiate their very nature are unable to do this issue and ensured their Cconcept. It has not just Committee meetings. We need to A number of organisations the process, however it was a independent monitoring as well. participation. been on paper but since last few be careful and conscious in our are involved in this effort. They tough task to get it issued. We After the order was issued, the For effective interlinkages, years we are making efforts to approach. Particularly, the health also need to be cautious about not already had Village Health, process of committee formation some non-government members officials and functionaries in the implement it on the ground. misusing the 'power' that they Nutrition, Water Supply and started. The existing village from each committee were health system should properly There are definitely some changes have been accorded. It should be Sanitation Committees and RKS health committees were mostly included in higher level understand the core of the taking place. People are now kept in mind that monitoring is a committees in place. The inactive to begin with. Hence we committees, to enable posing of process. At first, they might have social responsibility given to these increasingly availing public health question that we were confronted s t a r t e d w i t h awa r e n e s s, problems not being addressed f e l t t h e p r o c e s s t o b e organisations in the public locally, at the higher level. For facilities. The community with was, why these new expansion and activation troublesome, with people interest, for raising relevant i n s t a n c e, V i l l a g e h e a l t h monitoring process is making monitoring and planning programmes. Conscious efforts them aware of their rights and pointing out their faults and problems within the community w e r e m a d e t o e n s u r e committee members in Purandar complaining against them. committees and that too why in steps they need to take to attain and it should not be misused for representation of women, dalit block noticed substandard However, it should be kept in five identified districts? Some their rights. The health system is personal gains. and physically challenged people quality of food provided in some mind that the process is ultimately officials opined that the schools. The problem was not also becoming more responsive Lastly, along with monitoring in the committees. We faced aimed at improving the system we all should be aware of the responsibility of monitoring solved locally, so they raised it at and accountable towards people. opposition in Pune and Thane planning component integral in should be handed over to the d i s t r i c t s i n i n v o l v i n g PHC level and pursued till it got this process. Planning process has already existing RKS committees. resolved. two approaches-first, needs based Training programmes for planning and second, planning by committee members have been Planning only at the the government. Just the latter is Only active members important, including exposure government level never enough. For effective and can bring about visits and dialogue with medical meaningful planning, both officers. If committees are does not suffice … approaches should be combined. change formed without members being Local needs should be prioritized. e f f e c t i ve l y t r a i n e d , t h e The state and district committees committees exist only on paper. -Vikas Kharge, -Dr. Nitin Jadhav However, proper training has will always extend their fullest State Coordinator, Former Mission Director, NRHM, support to facilitate such pro- inculcated awareness and Maharashtra State. CBMP, SATHI, people planning process. State Coordinating Organisation, capabilities among CBMP Pune committee members. 10 11 How can ordinary people give their feedback about health services? NRHM clearly delineates health services people are entitled to get at various levels in the health system. Indian Public Health Standards (IPHS) have outlined minimum standards for quality health care. The health system has decided a definite time frame to attain these standards. The government has guaranteed health services at village, block and district levels in various facilities such as Sub-center, PHC and Rural Hospital. Although NRHM has guaranteed health services, it is necessary to check to what extent this commitment is being fulfilled. CBMP provides an opportunity to know whether or not these services are actually available for common people. People often complain about the state of public health services informally. However, such feelings and remarks have little relevance for objective monitoring. Therefore a systematic What exactly are the CBMP committees doing? methodology is adopted in CBMP to get people's objective feedback about the services they get or do not get. Specific issues have been identified for information compilation at every After a variety of efforts the monitoring and planning committees were formed. These level. committees were given specific roles. The process of community based monitoring and planning of health services evolved with a clear methodology as follows. Village Health, Nutrition, Water supply, and Sanitation Committee (VHNWSC) Three key sectors for Monitoring and Planning- l a. Maintaining Village Health Register and reviewing work of health functionaries Availability of Health services guaranteed by the government b. Preparing a village health report card by compiling information about village level lAvailability of resources such as infrastructure, humanpower, medicines health services lUtilization of funds c. Taking initiative to organize health related programmes at the village level d. Visiting PHC and Rural Hospital to get information about the services and to have a For village level health services information on following dialogue with respective medical officers. parameters is collected PHC Monitoring and Planning Committee lMaternal and child health services (Both ante-natal and post-natal care and a. Visiting PHC, preparing a PHC report card by compiling information and addressing immunization) problems identified through this process. Organizing PHC level public hearings. lVillage level disease surveillance services b. Presenting problems indentified through the monitoring process in the RKS meetings. lCurative services at the village level c. Preparing a health plan at the PHC level lAnganwadi (ICDS) services Block Monitoring and Planning Committee lRegularity and quality of services available at PHC and peoples experiences of these a. Visiting RH, preparing a RH report card by compiling information and addressing l problems identified through this process. Organizing block level public hearings. Utilization of village level untied fund provided through NRHM l b. Presenting suggestions in the RKS meetings. Adverse outcomes such as maternal death, infant deaths and denial of health c. Preparing a health plan at the block level services. District Monitoring and Planning Committees For PHC level health services information on following parameters is collected a. Discussing issues related to health services at various levels in the district and pursuing concrete actions. lInfrastructure: Availability and situation of electricity, water supply, toilet b. Organising district level public hearings. facility, labor room, IPD section and situation of laboratory c. Visiting Civil / District and Sub-District Hospitals and reviewing the services therein. lServices: OPD and IPD services, delivery services and referral services d. Presenting suggestions for the health plan at the district level (availability of ambulance) etc. State Monitoring and Planning Committee lHuman resources: Availability of Medical officer, ANM, Pharmacist, Driver a. To discuss and recommend decisions regarding state level unresolved issues, emerging etc. from CBM processes in Districts. lAvailability of essential medicines: Checking whether the essential medicines b. To review and give community based inputs for the state level annual PIP (Project are available in adequate quantity as per the list of essential medicines prepared Implementation Plan). by DHS. c. To communicate initiatives received from the Union Health Ministry concerning various Public health services and to follow up on their implementation. lExit interviews of patients: Information about quality of health services, behavior of health facility staff, illegal charges etc. 12 13 How can ordinary people give their feedback about health services? NRHM clearly delineates health services people are entitled to get at various levels in the health system. Indian Public Health Standards (IPHS) have outlined minimum standards for quality health care. The health system has decided a definite time frame to attain these standards. The government has guaranteed health services at village, block and district levels in various facilities such as Sub-center, PHC and Rural Hospital. Although NRHM has guaranteed health services, it is necessary to check to what extent this commitment is being fulfilled. CBMP provides an opportunity to know whether or not these services are actually available for common people. People often complain about the state of public health services informally. However, such feelings and remarks have little relevance for objective monitoring. Therefore a systematic What exactly are the CBMP committees doing? methodology is adopted in CBMP to get people's objective feedback about the services they get or do not get. Specific issues have been identified for information compilation at every After a variety of efforts the monitoring and planning committees were formed. These level. committees were given specific roles. The process of community based monitoring and planning of health services evolved with a clear methodology as follows. Village Health, Nutrition, Water supply, and Sanitation Committee (VHNWSC) Three key sectors for Monitoring and Planning- l a. Maintaining Village Health Register and reviewing work of health functionaries Availability of Health services guaranteed by the government b. Preparing a village health report card by compiling information about village level lAvailability of resources such as infrastructure, humanpower, medicines health services lUtilization of funds c. Taking initiative to organize health related programmes at the village level d. Visiting PHC and Rural Hospital to get information about the services and to have a For village level health services information on following dialogue with respective medical officers. parameters is collected PHC Monitoring and Planning Committee lMaternal and child health services (Both ante-natal and post-natal care and a. Visiting PHC, preparing a PHC report card by compiling information and addressing immunization) problems identified through this process. Organizing PHC level public hearings. lVillage level disease surveillance services b. Presenting problems indentified through the monitoring process in the RKS meetings. lCurative services at the village level c. Preparing a health plan at the PHC level lAnganwadi (ICDS) services Block Monitoring and Planning Committee lRegularity and quality of services available at PHC and peoples experiences of these a. Visiting RH, preparing a RH report card by compiling information and addressing l problems identified through this process. Organizing block level public hearings. Utilization of village level untied fund provided through NRHM l b. Presenting suggestions in the RKS meetings. Adverse outcomes such as maternal death, infant deaths and denial of health c. Preparing a health plan at the block level services. District Monitoring and Planning Committees For PHC level health services information on following parameters is collected a. Discussing issues related to health services at various levels in the district and pursuing concrete actions. lInfrastructure: Availability and situation of electricity, water supply, toilet b. Organising district level public hearings. facility, labor room, IPD section and situation of laboratory c. Visiting Civil / District and Sub-District Hospitals and reviewing the services therein. lServices: OPD and IPD services, delivery services and referral services d. Presenting suggestions for the health plan at the district level (availability of ambulance) etc. State Monitoring and Planning Committee lHuman resources: Availability of Medical officer, ANM, Pharmacist, Driver a. To discuss and recommend decisions regarding state level unresolved issues, emerging etc. from CBM processes in Districts. lAvailability of essential medicines: Checking whether the essential medicines b. To review and give community based inputs for the state level annual PIP (Project are available in adequate quantity as per the list of essential medicines prepared Implementation Plan). by DHS. c. To communicate initiatives received from the Union Health Ministry concerning various Public health services and to follow up on their implementation. lExit interviews of patients: Information about quality of health services, behavior of health facility staff, illegal charges etc. 12 13 Barometer of people's satisfaction - Health Report Cards Process of Community Based Monitoring and Planning of Health Services was necessary to enable rural who are likely to get excluded p e o p l e t o m o n i t o r due to social or physical government services. We are constraints. generally familiar with report M e m b e r s o f s o c i a l cards of school children. A organisations played a crucial Innovative methods to promote village heatlh report card was role in coordinating the process. people's participation developed on similar lines This facilitated open discussion and villagers were asked to among committees at various in the public health system like- fill it up with necessary levels. Community members details in their community also considered views of meetings. But the village is medical officers and health not a homogenous unit and workers before recording their Public hearings, experience of marginalized remarks in the prescribed color people and those residing in code- red, yellow and green. public dialogue, outskirts or remote hamlets The reports were finalized as can be different from the 'Good', 'Partially satisfactory' or Village Health meetings people living in main village. 'Bad' by calculating the total of In order to get opinion of marks for each category of Village health awareness day, the marginalized groups, services. separate meetings were and An easy to use yet effective tool organised with these groups Involvement of Media Color code ranking for health services : l Red – Serious/Bad, lYellow – Partially Satisfactory, l Green - Good These have helped people to speak up about their health issues Now, and community In 1999-2000 Kashtakari Sanghatana implemented a project titled monitoring 'Empowerment of rural poor for better health' in Dahanu block. With guidance from SATHI we carried out specific activities to increase social now the health services have started gets an accountability of health workers. As part of it, the community openly discussed becoming more responsive official the responsibilities of health workers with them, recorded health workers' village sanction! visits on a specially designed calendar, and also monitored implementation of people's needs... local health programmes. This process got further extended and expanded into a process of community monitoring.

Now, NRHM has supported CBMP. Community members are entrusted with responsibility to monitor performance of the health system. NGOs and people's organisations are also part of this effort. This is a promising process. We have ample evidence to infer that Adivasi communities are far more effective than the government systems in protecting forests. Similarly, now we can say communities are competent in fostering health services.”

- Brian Lobo, Kashtakari Sanghatana, Thane 14 15 Barometer of people's satisfaction - Health Report Cards Process of Community Based Monitoring and Planning of Health Services was necessary to enable rural who are likely to get excluded p e o p l e t o m o n i t o r due to social or physical government services. We are constraints. generally familiar with report M e m b e r s o f s o c i a l cards of school children. A organisations played a crucial Innovative methods to promote village heatlh report card was role in coordinating the process. people's participation developed on similar lines This facilitated open discussion and villagers were asked to among committees at various in the public health system like- fill it up with necessary levels. Community members details in their community also considered views of meetings. But the village is medical officers and health not a homogenous unit and workers before recording their Public hearings, experience of marginalized remarks in the prescribed color people and those residing in code- red, yellow and green. public dialogue, outskirts or remote hamlets The reports were finalized as can be different from the 'Good', 'Partially satisfactory' or Village Health meetings people living in main village. 'Bad' by calculating the total of In order to get opinion of marks for each category of Village health awareness day, the marginalized groups, services. separate meetings were and An easy to use yet effective tool organised with these groups Involvement of Media Color code ranking for health services : l Red – Serious/Bad, lYellow – Partially Satisfactory, l Green - Good These have helped people to speak up about their health issues Now, and community In 1999-2000 Kashtakari Sanghatana implemented a project titled monitoring 'Empowerment of rural poor for better health' in Dahanu block. With guidance from SATHI we carried out specific activities to increase social now the health services have started gets an accountability of health workers. As part of it, the community openly discussed becoming more responsive official the responsibilities of health workers with them, recorded health workers' village sanction! visits on a specially designed calendar, and also monitored implementation of people's needs... local health programmes. This process got further extended and expanded into a process of community monitoring.

- Brian Lobo, Kashtakari Sanghatana, Thane 14 15 Innovative methods Public Hearings

used in the CBMP process Nearly 500 public hearings have been conducted across five districts till March 2012 at various levels such as PHCs, Community Based Monitoring & Planning aims to enable common people to blocks, districts. These hearings are intervene in the health system to ensure social accountability. Various tools that are attended by large numbers of local easy to use and are based on objective principles have been developed for this purpose. c o m mu n i t y m e m b e r s, p e o p l e ' s organisations, NGOs, government officials and prominent persons from the region. In public hearings, community members report their experiences of Health Report Cards health services and denial of care, as well as findings included in the health report cards. The authorities present are then expected to respond to these testimonies, stating how the problems will be addressed. The health report card serves as an assessment tool for the monitoring process. Separate report cards are need at village, Sub-centre PHC and Rural Hospital level. It is a pictorial For all the public hearings dates were decided well in advance, so that enough time is available tool that can be used in a participatory manner. to collect necessary evidence and testimonies. Initially the medical officers did feel offended and some even opposed it, however, soon they realized its long term significance. It can be inferred that public hearings have been well established as a medium of community monitoring in these five districts.

Public Dialogues In the first phase of the CBMP process, during public hearings mostly problem areas were highlighted, and some medical officers and health workers were not satisfied with the process. The origin of problems sometimes lies in policy level issues, and medical functionaries at lower levels cannot do much about such issues. Rather they themselves are unable to work properly because of inadequate resources and infrastructure. Realizing these systemic constraints, now 'Public Dialogue' has evolved as a medium to deepen communication with health service providers, especially to understand their problems and policy matters impinging on the implementation process.

Through the medium of Public Dialogues, community members engage in a discussion with the service providers about ways to address various problems and implement changes. This approach promotes assertive yet constructive dialogue, instead of just confrontation without outcome. 16 17 Innovative methods Public Hearings used in the CBMP process Nearly 500 public hearings have been conducted across five districts till March 2012 at various levels such as PHCs, Community Based Monitoring & Planning aims to enable common people to blocks, districts. These hearings are intervene in the health system to ensure social accountability. Various tools that are attended by large numbers of local easy to use and are based on objective principles have been developed for this purpose. c o m mu n i t y m e m b e r s, p e o p l e ' s organisations, NGOs, government officials and prominent persons from the region. In public hearings, community members report their experiences of Health Report Cards health services and denial of care, as well as findings included in the health report cards. The authorities present are then expected to respond to these testimonies, stating how the problems will be addressed. The health report card serves as an assessment tool for the monitoring process. Separate report cards are need at village, Sub-centre PHC and Rural Hospital level. It is a pictorial For all the public hearings dates were decided well in advance, so that enough time is available tool that can be used in a participatory manner. to collect necessary evidence and testimonies. Initially the medical officers did feel offended and some even opposed it, however, soon they realized its long term significance. It can be inferred that public hearings have been well established as a medium of community monitoring in these five districts.

People in Murbad block further improvised this concept and called all villagers together in the Anganwadi Center on a specific day. People checked the Anganwadi register, verified weight records of children by actually weighing them, What has been assessed the number of women, adolescent girls and children getting nutritious diet from the center. This happening public assessment brought in transparency and in these underlined the significance of these services. People's awareness about local health services has increased five through such programmes, according to the local activists. districts?

These five districts have diverse background characteristics. Some Involvement of Media are predominantly tribal, some have rural areas with minimal tribal Journalists primarily rely on information that becomes population. Each district has a unique geographical and social constitution. available to them, and are always in search of newer sources Yet similar processes were organised in all the five, with a common for this purpose. Their quest for information brought them closer to the committees and organisations involved in goal of improving Health Services. CBMP process, who were able to share facts and ground The perspectives varied between districts but the outcomes were similar : realities with them. This was helpful in getting media coverage regarding health issues. Issues like poor medicine 'With people's action, Health services are beginning availability in public health facilities and inadequacies in providing health services at local level were taken up by the to improve, slowly but surely.' media, and it helped solving the issues to a significant extent. Both the print and television media helped to give visibility to these problems and stressed their importance. We have also started a quarterly newsletter 'Dawandi', which means proclamation or public announcement. This is perhaps the only state level newsletter in the country which is devoted to CBMP processes. The newsletter presents various problems related to health system, while also giving adequate acknowledgment to positive efforts by persons in the system. Thus the newsletter is now read and recognized by common people as well as health functionaries. Interestingly, this newsletter is much in demand in districts even beyond the CBMP districts, especially by the health functionaries. Dawandi has attained popularity among health activists and health workers in just a few years of publication. Other awareness materials on Health rights include wall posters, booklets, poster exhibitions and audio-visual presentations; all of these contribute to building understanding and preparedness of participants for the CBMP process. 18 19 Nandurbar district P+rocÉe®súsÉäM oªfÉ CºoÉmä´mÉÉÆúÉn®itú y± BÉaÉsäEedòÉ vMÉÉoÊn®iútioÉr ingäùJ aÉn®däúJ PÉl anńÉ inÊgxÉ oªfÉÉ HäVÉexaÉl th| ÉSÊeGrvòiªcÉeÉs Chandsaili and Vadgaon. But now villagers in these areas have become Scope of CBMP Blocks : 3 blocks aware about public health services in Nandurbar Shahada, Dhadgaon, Nandurbar These changes are and prefer to use them. As a result district Villages : Total 80 villages private and 'quack' doctors are Primary Health Centers : 16 PHCs invaluable … running out of business. Dr. Rajesh (Bilgaon, Chulwad, Roshmal, Telkhedi, Patil is a very active Medical Officer Mandavi, Son, Kusumwada, Shahana, Wagharde, Aadgaon, Padalda, Sulwada, in Kusumwada, one of the PHCs Mandava, Jangthi, Dekhwad, Natavad) andurbar, which is such people? The public since people were now more involved in the CBMP process. The a predominantly health staff also works in vocal about their health OPD turnout in 2008 was around Nadivasi district, adverse conditions, but they related problems. 900 per month, which is higher fares poorly on all human are so overwhelmed with Although people became compared to other centers, the d e ve l o p m e n t i n d i c e s. 'targets' imposed from above aware, the local association credit goes to Dr. Patil. With Majority of adivasis are that they hardly make efforts of doctors took this as an CBMP the attendance almost marginal far mers and required to reach out to initiative to find fault with doubled to become 1300 – 1800 laborers, due to poverty they people. them. Basically they did not per month by 2010, with people would prefer public health However, a change like the idea of people turning more to the public health f a c i l i t i e s . H o w e v e r , process has begun due to questioning them and system. A competent MO backed misconceptions about the implementation of CBMP. making them answerable. by watchful and aware people led to government health services To begin with people were However, our aim to increased utilization of the facility. and the inadequacies in skeptical about this process. I improve health services was When we earlier checked the government health facilities remember, people hardly clear and we persisted. number of patients given referral are widely prevalent, shared any complaints when G r a d u a l l y t h e ser vices in Wagharde and therefore people turn to the report cards were filled misunderstanding among the Kusumwada PHCs, the numbers 'quack' doctors who have for the first time in villages. doctors also got cleared. So were 34 and 21 respectively. Since proliferated in this area. Later, based on compiled much so that Dr. Dani, MO the issue of people paying out of Most people live in information, we organised a in Shahana PHC, strongly pocket for transportation was taken remote hilly areas and need up in the CBMP process, the public hearing. Gradually urged us to initiate the Some Significant changes to walk upto 10 kilometers to people realized that their real CBMP process in his work number of people receiving reach a main road. Does the experiences are actually area. referral services has increased. We nMedicine stock in public facilities is now displayed on the board. health system reach out to discussed in public meetings, observed that now on an average Therefore everybody has access to the information about CBMP has led to several availability and quantities of medicines at a given point of time. and problems are getting changes. Pimprani, Chirde, 100 patients get referral services addressed. This process from a PHC annually. Earlier nAs a special case, land was allotted to Ohava PHC and construction Langdi, Ghotali are some of has started. encouraged them and made the most remote villages in patients had to spend Rs. 600-900 them examine health towards fuel cost of the vehicle in nPatients now get all medicines from the health facility itself. Out of our areas. Earlier they were stock medicines are purchased from RKS funds. services carefully. Therefore, e v e n d e p r i v e d o f case they get a referral service. Now as compared to the first time, immunization services. Now RKS funds are made available for nBenefits of Janani Suraksha Yojana are now regularly distributed among the genuine beneficiaries. there were more negative n o t o n l y r e g u l a r this. If we assume a modest figure remarks in the second immunization sessions are of 100 referrals per year in these nBehavior of the PHC staff towards patients has improved considerably. round of filling cards organised, but the vacant PHCs, people have saved upon posts are also filled. Practice expenses of Rs. 60,000 to 90,000 in nRegular village level services by ANM and MPW has started and of 'quack' doctors and some a y e a r t o w a r d s r e q u i r e d coverage of immunisation has increased. Ranjana Kanhere, transportation. This is quite nPreviously non-functional Bijari sub center in Dhadgaon block Janarth Adivasi Vikas Sanstha, private practitioners was in full swing in villages like significant. Overall, we are became functional after the pressure exerted though community District Nodal Organisation, convinced about continuing to based monitoring. Nandurbar Rampur, Kansai, Kudawad, pursue this process of change which is indeed, invaluable. l 20 21 Nandurbar district P+rocÉe®súsÉäM oªfÉ CºoÉmä´mÉÉÆúÉn®itú y± BÉaÉsäEedòÉ vMÉÉoÊn®iútioÉr ingäùJ aÉn®däúJ PÉl anńÉ inÊgxÉ oªfÉÉ HäVÉexaÉl th| ÉSÊeGrvòiªcÉeÉs Chandsaili and Vadgaon. But now villagers in these areas have become Scope of CBMP Blocks : 3 blocks aware about public health services in Nandurbar Shahada, Dhadgaon, Nandurbar These changes are and prefer to use them. As a result district Villages : Total 80 villages private and 'quack' doctors are Primary Health Centers : 16 PHCs invaluable … running out of business. Dr. Rajesh (Bilgaon, Chulwad, Roshmal, Telkhedi, Patil is a very active Medical Officer Mandavi, Son, Kusumwada, Shahana, Wagharde, Aadgaon, Padalda, Sulwada, in Kusumwada, one of the PHCs Mandava, Jangthi, Dekhwad, Natavad) andurbar, which is such people? The public since people were now more involved in the CBMP process. The a predominantly health staff also works in vocal about their health OPD turnout in 2008 was around Nadivasi district, adverse conditions, but they related problems. 900 per month, which is higher fares poorly on all human are so overwhelmed with Although people became compared to other centers, the d e ve l o p m e n t i n d i c e s. 'targets' imposed from above aware, the local association credit goes to Dr. Patil. With Majority of adivasis are that they hardly make efforts of doctors took this as an CBMP the attendance almost marginal far mers and required to reach out to initiative to find fault with doubled to become 1300 – 1800 laborers, due to poverty they people. them. Basically they did not per month by 2010, with people would prefer public health However, a change like the idea of people turning more to the public health f a c i l i t i e s . H o w e v e r , process has begun due to questioning them and system. A competent MO backed misconceptions about the implementation of CBMP. making them answerable. by watchful and aware people led to government health services To begin with people were However, our aim to increased utilization of the facility. and the inadequacies in skeptical about this process. I improve health services was When we earlier checked the government health facilities remember, people hardly clear and we persisted. number of patients given referral are widely prevalent, shared any complaints when G r a d u a l l y t h e ser vices in Wagharde and therefore people turn to the report cards were filled misunderstanding among the Kusumwada PHCs, the numbers 'quack' doctors who have for the first time in villages. doctors also got cleared. So were 34 and 21 respectively. Since proliferated in this area. Later, based on compiled much so that Dr. Dani, MO the issue of people paying out of Most people live in information, we organised a in Shahana PHC, strongly pocket for transportation was taken remote hilly areas and need up in the CBMP process, the public hearing. Gradually urged us to initiate the Some Significant changes to walk upto 10 kilometers to people realized that their real CBMP process in his work number of people receiving reach a main road. Does the experiences are actually area. referral services has increased. We nMedicine stock in public facilities is now displayed on the board. health system reach out to discussed in public meetings, observed that now on an average Therefore everybody has access to the information about CBMP has led to several availability and quantities of medicines at a given point of time. and problems are getting changes. Pimprani, Chirde, 100 patients get referral services addressed. This process from a PHC annually. Earlier nAs a special case, land was allotted to Ohava PHC and construction Langdi, Ghotali are some of has started. encouraged them and made the most remote villages in patients had to spend Rs. 600-900 them examine health towards fuel cost of the vehicle in nPatients now get all medicines from the health facility itself. Out of our areas. Earlier they were stock medicines are purchased from RKS funds. services carefully. Therefore, e v e n d e p r i v e d o f case they get a referral service. Now as compared to the first time, immunization services. Now RKS funds are made available for nBenefits of Janani Suraksha Yojana are now regularly distributed among the genuine beneficiaries. there were more negative n o t o n l y r e g u l a r this. If we assume a modest figure remarks in the second immunization sessions are of 100 referrals per year in these nBehavior of the PHC staff towards patients has improved considerably. round of filling cards organised, but the vacant PHCs, people have saved upon posts are also filled. Practice expenses of Rs. 60,000 to 90,000 in nRegular village level services by ANM and MPW has started and of 'quack' doctors and some a y e a r t o w a r d s r e q u i r e d coverage of immunisation has increased. Ranjana Kanhere, transportation. This is quite nPreviously non-functional Bijari sub center in Dhadgaon block Janarth Adivasi Vikas Sanstha, private practitioners was in full swing in villages like significant. Overall, we are became functional after the pressure exerted though community District Nodal Organisation, convinced about continuing to based monitoring. Nandurbar Rampur, Kansai, Kudawad, pursue this process of change which is indeed, invaluable. l 20 21 Amaravati district Process of Community Based Monitoring and Planning of Health Services

employees are usually reluctant Blocks : 4 blocks - Dharni, Chikhaldara, to work in this area and want Scope of CBMP Chandurbajar, Chandur Railway Health Services are an immediate transfer. In fact, in Amaravati p u b l i c h e a l t h wo r ke r s district Villages : Total 90 villages no longer dysfunctional! complained to us about the Primary Health Centers : 14 PHCs District health officer (Dhulghat-Railway, Harisal, Sadrawadi, Bijudhavadi, Kalamkhar, Bairagad, d e m a n d i n g m o n e y f o r Tebrusonda, Semadoh, Asegaon Purna, elghat remains in transfers. We submitted this Karasgaon, Kokarda, Sategaon, focus for two infor mation to higher Padaskhed, Amla-Vishveshwar) reasons; one is the authorities. Investigation was M done by the anti-corruption Melghat Tiger Reserve, the vocal about their problems, changes are evident in health other is the serious problem squad, but it was all 'managed' utilization of public services facilities, for example they do not of malnutrition and child and no action was taken. We has increased and problems close down at noon, some mortality in this area. raised this problem again in the that could be addressed locally provider is present 24x7. People Melghat is a cluster of over State level hearing, which got solved. visiting the health facility at any 320 villages, situated on the created necessary pressure that point of time do not go back finally resulted in transfer of But policy level issues border of Maharashtra and persist. Medical officers shirk without treatment. At least the that corrupt official. In this Madhya Pradesh which is their duties and take another health centers are now open and process, a relationship of trust predominantly populated by posting by paying rupees 5-6 are willing to function round the Korku adivasis. that 'people don't use public we understood the situation has been built between local lakh. The post of the Medical clock. Ever since the Tiger health facilities', hence they comprehensively, our demands health workers, the social Officer is often only filled Project started in 1972, used to close down the health became specific. organisation and community temporarily for 11 months. people in the area are on the facilities by noon. The Initially we faced opposition members. People have become Nevertheless, some positive l verge of being displaced. CBMP process started with by certain health service Living with this insecurity, this kind of background. providers. Prior to one public Some Significant changes they are neither displaced nor T h i s p r o c e s s h a s hearing, the MPW feared that nThe nonfunctional Sub Center falling under Bihali PHC became active after the public hearing. rehabilitated, which has e n h a n c e d o u r o w n people would speak against him, nDhamangaon-gadhi PHC got an ambulance. become an excuse for the understanding. Earlier, in so he tried to lure a few people nThe residential ANMs in Gaurkheda, Kumbhi and Malhar Sub-Centers began staying at the centers. administration to not order to improve health by offering them alcohol. But nHot water facility was started in Dhamngoan-gadhi and Patrot PHCs. develop basic infrastructure. services, we used to demand many more people gathered for n People are asked, 'Why do appointing a pediatrician and the public hearing, and those Health Rights Charter was displayed in a prominent place in Gaurkheda, Kumbhi and Malhar Subcenters. you need amenities when you obstetrician. At that time we who had not taken his nThe number of institutional deliveries went up significantly in Achalpur block. are going to be displaced were 'outsiders' for the 'favor' spoke frankly nAs a special case, a doctor was appointed sometime ago at Sindhi Subcenter that covers around 7000 anyway?' Tar roads are not population. However, people did not benefit since the doctor was irregular and supply of medicines was system. However, with the about their genuine inadequate. Now, as a result of community based monitoring, the medical officer joins duty in time and constructed as tiger foot CBMP process, we became p r o b l e m s . people get required treatment. prints won't be traceable on involved in the system. We Gradually mutual nAs JSY incentive women used to receive only Rs. 500, but now they receive the complete amount of Rs. these roads, hence local n o w a l s o d e m a n d e d trust was developed 700. people have to bear with appointment of pharmacists, with the service nPatients are no longer asked to buy medicines from outside. rough roads. It is very availability of essential providers. nMobile units in Harisal PHC and Nimdari Subcenter have started because of people's initiative. difficult to take a pregnant medicines and provision of Governme nProcess of birth and death registration got regularized in Sadrawadi village after proper coordination woman to hospital for ANMs and their services. As n t among ANM, MPW, ICDS worker and ASHA was established. delivery in timely manner, the nBehavior of the staff to the patients has improved considerably in Dhulghat Railway PHC in Dharni block. roads are so bumpy that she - Bandya Sane nThe Community Monitoring and Planning Committee members in Dharni Block organised a meeting of might deliver on the way. Khoj, private vehicle drivers and made them aware about their important role in making health services accessible Given this context, health District Nodal for people. Now a ready list of drivers is available and patients are able to get a referral on time. workers used to complain Organisation, Amaravati 22 23 Amaravati district Process of Community Based Monitoring and Planning of Health Services

employees are usually reluctant Blocks : 4 blocks - Dharni, Chikhaldara, to work in this area and want Scope of CBMP Chandurbajar, Chandur Railway Health Services are an immediate transfer. In fact, in Amaravati p u b l i c h e a l t h wo r ke r s district Villages : Total 90 villages no longer dysfunctional! complained to us about the Primary Health Centers : 14 PHCs District health officer (Dhulghat-Railway, Harisal, Sadrawadi, Bijudhavadi, Kalamkhar, Bairagad, d e m a n d i n g m o n e y f o r Tebrusonda, Semadoh, Asegaon Purna, elghat remains in transfers. We submitted this Karasgaon, Kokarda, Sategaon, focus for two infor mation to higher Padaskhed, Amla-Vishveshwar) reasons; one is the authorities. Investigation was M done by the anti-corruption Melghat Tiger Reserve, the vocal about their problems, changes are evident in health other is the serious problem squad, but it was all 'managed' utilization of public services facilities, for example they do not of malnutrition and child and no action was taken. We has increased and problems close down at noon, some mortality in this area. raised this problem again in the that could be addressed locally provider is present 24x7. People Melghat is a cluster of over State level hearing, which got solved. visiting the health facility at any 320 villages, situated on the created necessary pressure that point of time do not go back finally resulted in transfer of But policy level issues border of Maharashtra and persist. Medical officers shirk without treatment. At least the that corrupt official. In this Madhya Pradesh which is their duties and take another health centers are now open and process, a relationship of trust predominantly populated by posting by paying rupees 5-6 are willing to function round the Korku adivasis. that 'people don't use public we understood the situation has been built between local lakh. The post of the Medical clock. Ever since the Tiger health facilities', hence they comprehensively, our demands health workers, the social Officer is often only filled Project started in 1972, used to close down the health became specific. organisation and community temporarily for 11 months. people in the area are on the facilities by noon. The Initially we faced opposition members. People have become Nevertheless, some positive l verge of being displaced. CBMP process started with by certain health service Living with this insecurity, this kind of background. providers. Prior to one public Some Significant changes they are neither displaced nor T h i s p r o c e s s h a s hearing, the MPW feared that nThe nonfunctional Sub Center falling under Bihali PHC became active after the public hearing. rehabilitated, which has e n h a n c e d o u r o w n people would speak against him, nDhamangaon-gadhi PHC got an ambulance. become an excuse for the understanding. Earlier, in so he tried to lure a few people nThe residential ANMs in Gaurkheda, Kumbhi and Malhar Sub-Centers began staying at the centers. administration to not order to improve health by offering them alcohol. But nHot water facility was started in Dhamngoan-gadhi and Patrot PHCs. develop basic infrastructure. services, we used to demand many more people gathered for n People are asked, 'Why do appointing a pediatrician and the public hearing, and those Health Rights Charter was displayed in a prominent place in Gaurkheda, Kumbhi and Malhar Subcenters. you need amenities when you obstetrician. At that time we who had not taken his nThe number of institutional deliveries went up significantly in Achalpur block. are going to be displaced were 'outsiders' for the 'favor' spoke frankly nAs a special case, a doctor was appointed sometime ago at Sindhi Subcenter that covers around 7000 anyway?' Tar roads are not population. However, people did not benefit since the doctor was irregular and supply of medicines was system. However, with the about their genuine inadequate. Now, as a result of community based monitoring, the medical officer joins duty in time and constructed as tiger foot CBMP process, we became p r o b l e m s . people get required treatment. prints won't be traceable on involved in the system. We Gradually mutual nAs JSY incentive women used to receive only Rs. 500, but now they receive the complete amount of Rs. these roads, hence local n o w a l s o d e m a n d e d trust was developed 700. people have to bear with appointment of pharmacists, with the service nPatients are no longer asked to buy medicines from outside. rough roads. It is very availability of essential providers. nMobile units in Harisal PHC and Nimdari Subcenter have started because of people's initiative. difficult to take a pregnant medicines and provision of Governme nProcess of birth and death registration got regularized in Sadrawadi village after proper coordination woman to hospital for ANMs and their services. As n t among ANM, MPW, ICDS worker and ASHA was established. delivery in timely manner, the nBehavior of the staff to the patients has improved considerably in Dhulghat Railway PHC in Dharni block. roads are so bumpy that she - Bandya Sane nThe Community Monitoring and Planning Committee members in Dharni Block organised a meeting of might deliver on the way. Khoj, private vehicle drivers and made them aware about their important role in making health services accessible Given this context, health District Nodal for people. Now a ready list of drivers is available and patients are able to get a referral on time. workers used to complain Organisation, Amaravati 22 23 Pune district Process of Community Based Monitoring and Planning of Health Services

Cooperation and dialogue make it possible to achieve our goals Scope lthough Pune is one monitoring. about diarrhea patients, early of CBMP of the developed Initially, elected Panchayat i n t e r v e n t i o n b e c a m e in Pune district Adistricts of the state, it representatives were not possible.” The ANM in Velhe Blocks : 5 blocks has many remote adivasi cooperative and government PHC did not have a proper Velhe, Purandar, Daund, hamlets and villages that are functionaries found this t o i l e t u n i t a n d f a c e d Bhor, Junnar far from the glare of process to be insulting. One of difficulties, particularly in Villages: Total 145 villages development. Majority of the the health officials remarked, monsoon. When the problem Primary Health rural population are compelled “How can the illiterate was presented before the Centers: 15 PHCs to use private health services, villagers do monitoring, when BDO through the CBMP (Velhe, Panshet, Pasli, although they cannot afford even college graduate clerks process, it was constructed Malshiras, Belsar, Parinche, them, because the public are unable to write properly?” within 6 months. Kedgaon, Nandgaon, led to increased participation by PHC building, and got it health services are not working Some found the ter m The CBMP process got a Varvand, Bhogvali, Nasrapur, 'monitoring' objectionable. real boost after the first not only the community but also sanctioned. Regarding space for Jogwadi, Aaptale, Yenere, properly. Due to lack of However, the real purpose is to District level public hearing. by the Panchyat Samiti Sarola Subcenter, the Sarpanch Inglun) facilities, the health workers ensure services, which is The issue of patients being members. The PHC at Belsar announced in the Village health also are also not enthusiastic certainly people's prerogative asked to buy medicines from was running in a small hired committee meeting to give his chairperson of the Health about fulfilling their duties. In as they are the end users. If the outside was discussed in this place since several years. With own plot for construction. The Committee of the Zilla Parishad this context, it was challenging people are not getting services public hearing, and as a result CBMP, the newly elected Grampanchayat at Nhavi and Dr. Sangde, funds became to convince people about their they are entitled to get, they this practice was stopped. In Sar panch Nilesh Jagtap decided to set up a solar lamp at available for repairing of right to health care. It took have a right to know its reasons one villag e the newly followed up the long awaited the Sub-center. Due to efforts Subcenters in Bhatti, Kuran some time to make them from the concerned officers. constructed Sub-center was proposal for construction of b y S a m b h a j i H o l k a r , Khurd and Kodapur. A boat- realize the need to use public When we explained the awaiting formal inauguration based health unit facility was services and to improve them concept of CBMP to service by the local leader, which now made available to Bhutonde t h r o u g h c o m m u n i t y providers, they understood its became functional due to Some Significant changes Subcenter in Jogwadi. Zilla significance and have gradually people's demand. The CBMP nOPD attendance in several PHCs has increased and has even Parishad member Bhausaheb accepted the process. process has enabled people to doubled. Devade assured in one of the We have several positive speak about their problems nHealth Rights Charter is now displayed at all facilities. p u b l i c h e a r i n g s t h a t a stories to share. In some before concerned officers, and nInformation boards about referral services are displayed in all 'suggestion box' will be placed in villages the ANMs now plan t o f e a r l e s s l y p r e s e n t facilities. Aptale and Inglun PHCs in testimonies of malpractices or their village visits with the help nBehavior of the staff has considerably improved in many centers. Junnar. People then demanded of villagers and according to denial of health care in public in the district level public people's convenience. An system. nVacant posts of ANMs and MPWs are now filled up in many places. hearing to have such a box in all ANM in Pariche PHC openly Our consistent efforts led nConsiderable improvement in availability of medicines. PHCs. appreciates initiative of the to an enquiry of health facility nMahur (Parinche-Purandar) Subcenter became functional. The sense of mutual Village health committee: staff in Rural Hospital in cooperation among the nUnder Panshet unit, construction has been started for Ruley “Since they informed me Saswad by an independent Subcenter. villagers, elected representatives and public service providers has committee. The problem of nPatients in Malshiras PHC are no longer given prescriptions to buy Dr. Hemlata Pisal water scarcity in Rural medicines from outside. been enhanced and can be c l a i m e d a s t h e m a j o r District Coordinator, Hospital at Velhe was solved. nRKS funds were sanctioned for Panshet unit in Velhe block. MASUM, Pune As problems were resolved, it achievement of the CBMP process. l 24 25 Pune district Process of Community Based Monitoring and Planning of Health Services

Cooperation and dialogue make it possible to achieve our goals Scope lthough Pune is one monitoring. about diarrhea patients, early of CBMP of the developed Initially, elected Panchayat i n t e r v e n t i o n b e c a m e in Pune district Adistricts of the state, it representatives were not possible.” The ANM in Velhe Blocks : 5 blocks has many remote adivasi cooperative and government PHC did not have a proper Velhe, Purandar, Daund, hamlets and villages that are functionaries found this t o i l e t u n i t a n d f a c e d Bhor, Junnar far from the glare of process to be insulting. One of difficulties, particularly in Villages: Total 145 villages development. Majority of the the health officials remarked, monsoon. When the problem Primary Health rural population are compelled “How can the illiterate was presented before the Centers: 15 PHCs to use private health services, villagers do monitoring, when BDO through the CBMP (Velhe, Panshet, Pasli, although they cannot afford even college graduate clerks process, it was constructed Malshiras, Belsar, Parinche, them, because the public are unable to write properly?” within 6 months. Kedgaon, Nandgaon, led to increased participation by PHC building, and got it health services are not working Some found the ter m The CBMP process got a Varvand, Bhogvali, Nasrapur, 'monitoring' objectionable. real boost after the first not only the community but also sanctioned. Regarding space for Jogwadi, Aaptale, Yenere, properly. Due to lack of However, the real purpose is to District level public hearing. by the Panchyat Samiti Sarola Subcenter, the Sarpanch Inglun) facilities, the health workers ensure services, which is The issue of patients being members. The PHC at Belsar announced in the Village health also are also not enthusiastic certainly people's prerogative asked to buy medicines from was running in a small hired committee meeting to give his chairperson of the Health about fulfilling their duties. In as they are the end users. If the outside was discussed in this place since several years. With own plot for construction. The Committee of the Zilla Parishad this context, it was challenging people are not getting services public hearing, and as a result CBMP, the newly elected Grampanchayat at Nhavi and Dr. Sangde, funds became to convince people about their they are entitled to get, they this practice was stopped. In Sar panch Nilesh Jagtap decided to set up a solar lamp at available for repairing of right to health care. It took have a right to know its reasons one villag e the newly followed up the long awaited the Sub-center. Due to efforts Subcenters in Bhatti, Kuran some time to make them from the concerned officers. constructed Sub-center was proposal for construction of b y S a m b h a j i H o l k a r , Khurd and Kodapur. A boat- realize the need to use public When we explained the awaiting formal inauguration based health unit facility was services and to improve them concept of CBMP to service by the local leader, which now made available to Bhutonde t h r o u g h c o m m u n i t y providers, they understood its became functional due to Some Significant changes Subcenter in Jogwadi. Zilla significance and have gradually people's demand. The CBMP nOPD attendance in several PHCs has increased and has even Parishad member Bhausaheb accepted the process. process has enabled people to doubled. Devade assured in one of the We have several positive speak about their problems nHealth Rights Charter is now displayed at all facilities. p u b l i c h e a r i n g s t h a t a stories to share. In some before concerned officers, and nInformation boards about referral services are displayed in all 'suggestion box' will be placed in villages the ANMs now plan t o f e a r l e s s l y p r e s e n t facilities. Aptale and Inglun PHCs in testimonies of malpractices or their village visits with the help nBehavior of the staff has considerably improved in many centers. Junnar. People then demanded of villagers and according to denial of health care in public in the district level public people's convenience. An system. nVacant posts of ANMs and MPWs are now filled up in many places. hearing to have such a box in all ANM in Pariche PHC openly Our consistent efforts led nConsiderable improvement in availability of medicines. PHCs. appreciates initiative of the to an enquiry of health facility nMahur (Parinche-Purandar) Subcenter became functional. The sense of mutual Village health committee: staff in Rural Hospital in cooperation among the nUnder Panshet unit, construction has been started for Ruley “Since they informed me Saswad by an independent Subcenter. villagers, elected representatives and public service providers has committee. The problem of nPatients in Malshiras PHC are no longer given prescriptions to buy Dr. Hemlata Pisal water scarcity in Rural medicines from outside. been enhanced and can be c l a i m e d a s t h e m a j o r District Coordinator, Hospital at Velhe was solved. nRKS funds were sanctioned for Panshet unit in Velhe block. MASUM, Pune As problems were resolved, it achievement of the CBMP process. l 24 25 Thane district P+rocÉe®súÉsäM oªfÉ CºoÉmä´mÉÉÆ´uÉn®itú y± BÉaÉsäEeòdÉ vMÉÉoÊn®iútioÉr ingäùJ aÉn®däúJ PÉl an´nÉ inÊgxÉ oªfÉÉ HäVÉexaÉl th| ÉSÊeGrvòiªcÉeÉs

People have stepped forward, now is the turn of the Health System...

Scope of CBMP hane is an adivasi much to reach out to remote shared focused and specific in Thane district dominant district hamlets and villages. Being information that they could situated close to part of a lackadaisical system, benefit from. Blocks : 5 Blocks – T Dahanu, Murbad, Shahapur, Mumbai and its suburbs. The they cannot be blamed Earlier people were aware Mokhada, Javhar district has hilly and forest entirely for poor service of the ANM's visits: that she areas with many remote tribal delivery. They had no sense visits occasionally at the Villages : Total 110 villages hamlets. The population is of accountability since Sarpanch's place, spends started carrying ANC cards and practically impossible. People maintained records of weight raised questions on the basis of Primary Health Centers quite scattered in areas like people were indifferent and some time in ICDS center; : 15 PHCs Mokhada, Dahanu, Palghar, hardly aware of their right to that's all they knew. Through a n d o t h e r c h e c k u p s. such issues identified by them. (Dhundalwadi, Saywan, Shahapur and Murbad, while health care and there was no our information sharing they Sometimes the communication After people realized the Ganjad, Dhasai, Shiroshi, it is dense in parts close to public demand for improving realized what is she actually turned into confrontations. importance of services given Dolkhamb, Vashind, urban areas. Major inequity is public health services. supposed to be doing during H e a l t h f u n c t i o n a r i e s by the health workers, many Takipathar, Khodala, apparent across the district Some blocks in Thane visits, services expected of complained that people are questions were raised. For Vashala, Aase, Sakur, and the health system also district are Scheduled tribe her, ANC check up and its making unnecessary allegations example, in a public hearing it Jamsar, Aina, Tava) reflects this disparity. Private areas which get special funds significance. Now people against them. However, all their was asked that if MPW posts health services are available in for health and other services became more precise in their claims were proved wrong are vacant in many villages, the like ANC check-up and its urban areas and poor people from Tribal Development communication with ANM when the records were assessed existing workers would have importance in ensuring a safe there at least have some Department, but these and other providers, and after as part of the community extra workload. In this case, delivery and healthy baby. Once access to health services by benefits do not reach people. people began to interact, the monitoring process. For how would they be able to people related the significance less qualified doctors, In fact, there are special ANM became responsive and instance, health records provide all the services? of health services to their own compared to their rural a l l o w a n c e s b y t h e particular about her work and showed all pregnant women Moreover, people realized the lives, they began to access counterparts. Villagers have government for health staff records. For instance, she having the same hemoglobin importance of health services services more often and no option except 'quack' working in tribal areas and count and BP, which is demand for services increased. doctors since the public there are additional resources Now community members health system is weak and and provisions like special Some Significant changes and service providers are often inaccessible. In fact, health squads for remote nNow medical officers and staff do not charge for injections. working together to strengthen they need the public services areas. But not much actually nPatients are no longer prescribed to buy medicines from outside. the health system. Changes are the most, but these are often reaches people at ground nBehavior of health facility staff towards patients has generally evident locally, but structural not within easy reach due to l e v e l . U n d e r s u c h improved. problems persist at the higher lack of proper roads and circumstances we initiated nVillage health fund is used for all health needs, which was earlier levels despite repeated follow transportation. Therefore the CBMP and informed people spent only on ICDS center up. Finally, I would like to note health system should reach about their entitlements, in nNow weight records of malnourished children in Murbad block are that while people in Thane people through an efficient p a r t i c u l a r g u a r a n t e e d not manipulated, underreporting of malnutrition has been checked. district now have CBMP as a network of outreach workers. services, outreach services nOPD attendance has increased in all health facilities where tool to improve health services, Prior to initiation of CBMP and provision of funds. We community monitoring is being implemented. this process should be process, the outreach services Indavi Tulpule nFrequency and regularity of village visits by ANMs and MPWs has expanded to other areas of the were quite irregular. Health Van Niketan increased considerably. state, which would certainly workers were not willing (Shramik Mukti Sanghtana), nInstitutional deliveries have increased in all health facilities where make its impact felt more District Nodal community monitoring is being implemented. strongly. Organisation, Thane l 26 27 Thane district P+rocÉe®súÉsäM oªfÉ CºoÉmä´mÉÉÆ´uÉn®itú y± BÉaÉsäEeòdÉ vMÉÉoÊn®iútioÉr ingäùJ aÉn®däúJ PÉl an´nÉ inÊgxÉ oªfÉÉ HäVÉexaÉl th| ÉSÊeGrvòiªcÉeÉs

People have stepped forward, now is the turn of the Health System...

Scope of CBMP hane is an adivasi much to reach out to remote shared focused and specific in Thane district dominant district hamlets and villages. Being information that they could situated close to part of a lackadaisical system, benefit from. Blocks : 5 Blocks – T Dahanu, Murbad, Shahapur, Mumbai and its suburbs. The they cannot be blamed Earlier people were aware Mokhada, Javhar district has hilly and forest entirely for poor service of the ANM's visits: that she areas with many remote tribal delivery. They had no sense visits occasionally at the Villages : Total 110 villages hamlets. The population is of accountability since Sarpanch's place, spends started carrying ANC cards and practically impossible. People maintained records of weight raised questions on the basis of Primary Health Centers quite scattered in areas like people were indifferent and some time in ICDS center; : 15 PHCs Mokhada, Dahanu, Palghar, hardly aware of their right to that's all they knew. Through a n d o t h e r c h e c k u p s. such issues identified by them. (Dhundalwadi, Saywan, Shahapur and Murbad, while health care and there was no our information sharing they Sometimes the communication After people realized the Ganjad, Dhasai, Shiroshi, it is dense in parts close to public demand for improving realized what is she actually turned into confrontations. importance of services given Dolkhamb, Vashind, urban areas. Major inequity is public health services. supposed to be doing during H e a l t h f u n c t i o n a r i e s by the health workers, many Takipathar, Khodala, apparent across the district Some blocks in Thane visits, services expected of complained that people are questions were raised. For Vashala, Aase, Sakur, and the health system also district are Scheduled tribe her, ANC check up and its making unnecessary allegations example, in a public hearing it Jamsar, Aina, Tava) reflects this disparity. Private areas which get special funds significance. Now people against them. However, all their was asked that if MPW posts health services are available in for health and other services became more precise in their claims were proved wrong are vacant in many villages, the like ANC check-up and its urban areas and poor people from Tribal Development communication with ANM when the records were assessed existing workers would have importance in ensuring a safe there at least have some Department, but these and other providers, and after as part of the community extra workload. In this case, delivery and healthy baby. Once access to health services by benefits do not reach people. people began to interact, the monitoring process. For how would they be able to people related the significance less qualified doctors, In fact, there are special ANM became responsive and instance, health records provide all the services? of health services to their own compared to their rural a l l o w a n c e s b y t h e particular about her work and showed all pregnant women Moreover, people realized the lives, they began to access counterparts. Villagers have government for health staff records. For instance, she having the same hemoglobin importance of health services services more often and no option except 'quack' working in tribal areas and count and BP, which is demand for services increased. doctors since the public there are additional resources Now community members health system is weak and and provisions like special Some Significant changes and service providers are often inaccessible. In fact, health squads for remote nNow medical officers and staff do not charge for injections. working together to strengthen they need the public services areas. But not much actually nPatients are no longer prescribed to buy medicines from outside. the health system. Changes are the most, but these are often reaches people at ground nBehavior of health facility staff towards patients has generally evident locally, but structural not within easy reach due to l e v e l . U n d e r s u c h improved. problems persist at the higher lack of proper roads and circumstances we initiated nVillage health fund is used for all health needs, which was earlier levels despite repeated follow transportation. Therefore the CBMP and informed people spent only on ICDS center up. Finally, I would like to note health system should reach about their entitlements, in nNow weight records of malnourished children in Murbad block are that while people in Thane people through an efficient p a r t i c u l a r g u a r a n t e e d not manipulated, underreporting of malnutrition has been checked. district now have CBMP as a network of outreach workers. services, outreach services nOPD attendance has increased in all health facilities where tool to improve health services, Prior to initiation of CBMP and provision of funds. We community monitoring is being implemented. this process should be process, the outreach services Indavi Tulpule nFrequency and regularity of village visits by ANMs and MPWs has expanded to other areas of the were quite irregular. Health Van Niketan increased considerably. state, which would certainly workers were not willing (Shramik Mukti Sanghtana), nInstitutional deliveries have increased in all health facilities where make its impact felt more District Nodal community monitoring is being implemented. strongly. Organisation, Thane l 26 27 Osmanabad district P+rocÉ®esúÉsäM ªoÉf CºoÉmä´ÉmÉÆ´uÉn®iú ty± BÉÉaäEseòdÉv MÉÉoÊ®núitÉo ringäùJ aÉ®ndäúJ PÉ la´nÉn iÊnxgÉ ªoÉfÉ äVHÉexaÉ lth|É SÊGeròvªicÉÉes

Some Significant changes nNumber of village visits by ANMs and MPWs have increased in Local Solutions Kalamb and Osmanabad blocks. to Universal Problems nAppointment of only one medical officer in Ter Rural Hospital was a cause of concern among people and they raised this issue in public hearing. As a result a second doctor has been appointed resulting in increase in IPD admissions. Scope of CBMP in smanabad falls in O s m a n a b a d d i s t r i c t informing that there is high nList of PHC Monitoring and Planning Committee members is Osmanabad district OMarathwada region administration was headed risk. JSY incentives were displayed in all PHCs. which is one of the more by a competent and active delayed without due reasons nHealth Rights Charter has been displayed in prominent areas of b a ck wa r d r e g i o n s o f officer, hence response of in Salgara PHC. In one PHCs, as was decided by PHC level committees Blocks: 1 block M a h a r a s h t r a ; f e u d a l the health system was instance the MO regularly Tulajapur somewhat positive, even came on duty heavily drunk. t r a d i t i o n s a n d c a s t e normal deliveries; the relatives in use. Villages: Total 55 villages though there were many gaps As part of the CBMP hierarchies remain strong had to carry lantern, water and 72 Bharat Vaidyas (village health and problems. Later the process, we highlighted all Primary Health here. Due to traditional bedding with them while workers) of HALO foundation officer was transferred and t h e s e p r o b l e m s w i t h Centers: 6 PHCs cultural practices and gender admitting their patient there. are actively involved in the party leadership within Zilla evidence and testimonies, in (Anadur, Naldurg, Salgara, discrimination, proportion After people pointed out this CBMP process. Our village level Parishad also changed, which public hearings. We also Jalkot, Katgaon, Manglur) of atrocities against women problem through community health activists have also adversely impacted the spirit addressed problems at is also disturbingly high. monitoring, all these necessary become part of village health and situation in the health respective PHC levels, p r o v i s i o n s w e r e m a d e. committees and have a say in the As often experienced, system. however initially we did not Residential quarters for ANMs committee's functioning. We efficiency of the government We used to encounter get desired response. Public were in awful condition in hope, in future CBMP would system depends on the several problems. ANMs and hearings and village meetings Umaraga (Chiwari), Shahapur certainly contribute to make leadership. The system works MPWs did not stay at the Sub h e l p e d i n i n c r e a s i n g and Keshegoan Subcenters, further substantial changes in well when there are sensitive, center. Village visits by awareness among people. efficient officers at the helm, which have now been repaired. the health system in Tuljapur. medical officers remained on Media follow up helped to Due to public pressure, l and it collapses to its prior paper. In PHCs patients were create necessary pressure. As unnecessary referrals and lethargic mode when the asked to buy medicines from a result additional MOs were Dr. Shashikant Ahankari, prescribing medicines for President, HALO Medical c o n c e r n e d o f f i c e r i s outside. Women who went to appointed in three PHCs – purchase have almost stopped. transferred. Naldurg PHC for delivery Andur, Salgara and Naldurg. Foundation, Anadur, Ambulances in all three PHCs Co-Coordinator, W h e n C B M P were unnecessary referred to Itkal Sub center was earlier have been repaired and are now Osmanabad c o m m e n c e d , t h e other facilities, falsely not equipped to handle

28 29 Osmanabad district P+rocÉ®esúÉsäM ªoÉf CºoÉmä´ÉmÉÆ´uÉn®iú ty± BÉÉaäEseòdÉv MÉÉoÊ®núitÉo ringäùJ aÉ®ndäúJ PÉ la´nÉn iÊnxgÉ ªoÉfÉ äVHÉexaÉ lth|É SÊGeròvªicÉÉes

28 29 From 'official based planning' to 'community based planning' in Nasarapur PHC In Nasarapur PHC in Bhor block of Pune district, NRHM flexible funds were being used even without getting sanction by the RKS committee. RKS members revealed that no committee meeting had been called so far, and doctors themselves were taking all the decisions on utilization of funds. Following CBMP orientation programmes Shivaji Konde, President RKS, spoke to doctors and insisted for regular convening of planning meetings by the RKS and circulation of decisions of each meeting to all members. Civil society representatives of the Block Monitoring and Planning committee were invited for the first time to the RKS committee meeting on 12th December 2011 where they actively participated and made several proposals, which led to the RKS committee taking a number of positive decisions for improving the PHC. As a result of these decisions, within a few months the following changes have taken place: There was no board displaying the name of the PHC and it was difficult for any new patient to find the facility which is located in an old building. Now through RKS funds a board has been prepared and put up in a prominent location. The emerging There was a serious problem of water which was pointed out. Now four water tanks have been installed, to process of provide drinking water as well as to other parts of the PHC. The toilets were non functional and cluttered with materials, due to lack of water. Now these have been cleaned up and have become functional. Community In order to make the laboratory more functional, a tank for water storage was purchased, a cupboard and new pipe line for laboratory was installed, making the lab fully functional. Based The post of sanitation worker is vacant in Nasarapur PHC, leading to lack of cleanliness. So the RKS has appointed a worker on contract basis which has led to regular cleaning of the PHC premises. Planning A workshop on role of adolescents in the development of village health was conducted for school children from two villages through the RKS fund. n continuation of the process of representatives as well as RKS members on Community based monitoring, to community based planning were organised Another similar incident is from Velha Rural Ihelp tackle various local and facility at various levels. Frontline health staff, Hospital (RH), where the RKS members, which level issues, promotion of decentralized such as ANMs and MPWs, were also included the BDO, Tehsildar and Private community based planning of health involved in such workshops. Guidelines, a doctors, had never been called for meetings. The services has been initiated in 5 districts poster and a booklet were widely circulated CBMP nodal civil society organisation called a since 2011. It was observed that Hospital on how flexible funds should be used for meeting, inviting all RKS members as well as development committees (Rogi Kalyan genuine patient welfare (Rogi Kalyan). elected representatives like Chairperson and Samitis - RKS) were formed for various Broad based workshops and meetings Deputy Chairperson of the Panchayat Samiti to health centers, however most of the were organised to formulate proposals discuss the need for effective planning. It was the follow up. members were not aware of their based on issues identified in the CBMP reported that almost 60% funds for the financial Similar experiences are now being reported responsibilities and functions, or about process, for inclusion in the annual block year 2011-12 remained unutilized although ten from several CBMP areas. Thus, it is becoming their expected role in deciding about and district level PIPs (Project months had already passed. After learning about evident that through the CBMP process, utilization of flexible funds related to Implementation Plans). This has led to a this, the RKS members listed down key problem information generated through community NRHM. Owing to lack of guidance, even greater level of awareness among various areas and needs in the RH. After taking a round monitoring is now being contributed to enhance the doctors and staff in the health center stakeholders and receptivity of officials of the hospital they prioritized feasible action popular participation in the local health planning were often found to be ill equipped for towards addressing issues emerging from areas, such as setting up an independent room to process. Through this process, the health system proper management of these flexible and community based monitoring, and taking stock medicines, appointment of staff, is also realizing that ordinary people can come untied funds. In this context, workshops up suggestions given by CBMP committee strengthening ambulance service etc. They also up with relevant innovative ideas to improve the for Monitoring and Planning Committee members, exemplified by Nasarapur PHC. asked to include certain proposals in next year's health system. m e m b e r s i n c l u d i n g Pa n c h a y a t PIP and asked the Block Medical Officer to do

30 31 From 'official based planning' to 'community based planning' in Nasarapur PHC In Nasarapur PHC in Bhor block of Pune district, NRHM flexible funds were being used even without getting sanction by the RKS committee. RKS members revealed that no committee meeting had been called so far, and doctors themselves were taking all the decisions on utilization of funds. Following CBMP orientation programmes Shivaji Konde, President RKS, spoke to doctors and insisted for regular convening of planning meetings by the RKS and circulation of decisions of each meeting to all members. Civil society representatives of the Block Monitoring and Planning committee were invited for the first time to the RKS committee meeting on 12th December 2011 where they actively participated and made several proposals, which led to the RKS committee taking a number of positive decisions for improving the PHC. As a result of these decisions, within a few months the following changes have taken place: There was no board displaying the name of the PHC and it was difficult for any new patient to find the facility which is located in an old building. Now through RKS funds a board has been prepared and put up in a prominent location. The emerging There was a serious problem of water which was pointed out. Now four water tanks have been installed, to process of provide drinking water as well as to other parts of the PHC. The toilets were non functional and cluttered with materials, due to lack of water. Now these have been cleaned up and have become functional. Community In order to make the laboratory more functional, a tank for water storage was purchased, a cupboard and new pipe line for laboratory was installed, making the lab fully functional. Based The post of sanitation worker is vacant in Nasarapur PHC, leading to lack of cleanliness. So the RKS has appointed a worker on contract basis which has led to regular cleaning of the PHC premises. Planning A workshop on role of adolescents in the development of village health was conducted for school children from two villages through the RKS fund. n continuation of the process of representatives as well as RKS members on Community based monitoring, to community based planning were organised Another similar incident is from Velha Rural Ihelp tackle various local and facility at various levels. Frontline health staff, Hospital (RH), where the RKS members, which level issues, promotion of decentralized such as ANMs and MPWs, were also included the BDO, Tehsildar and Private community based planning of health involved in such workshops. Guidelines, a doctors, had never been called for meetings. The services has been initiated in 5 districts poster and a booklet were widely circulated CBMP nodal civil society organisation called a since 2011. It was observed that Hospital on how flexible funds should be used for meeting, inviting all RKS members as well as development committees (Rogi Kalyan genuine patient welfare (Rogi Kalyan). elected representatives like Chairperson and Samitis - RKS) were formed for various Broad based workshops and meetings Deputy Chairperson of the Panchayat Samiti to health centers, however most of the were organised to formulate proposals discuss the need for effective planning. It was the follow up. members were not aware of their based on issues identified in the CBMP reported that almost 60% funds for the financial Similar experiences are now being reported responsibilities and functions, or about process, for inclusion in the annual block year 2011-12 remained unutilized although ten from several CBMP areas. Thus, it is becoming their expected role in deciding about and district level PIPs (Project months had already passed. After learning about evident that through the CBMP process, utilization of flexible funds related to Implementation Plans). This has led to a this, the RKS members listed down key problem information generated through community NRHM. Owing to lack of guidance, even greater level of awareness among various areas and needs in the RH. After taking a round monitoring is now being contributed to enhance the doctors and staff in the health center stakeholders and receptivity of officials of the hospital they prioritized feasible action popular participation in the local health planning were often found to be ill equipped for towards addressing issues emerging from areas, such as setting up an independent room to process. Through this process, the health system proper management of these flexible and community based monitoring, and taking stock medicines, appointment of staff, is also realizing that ordinary people can come untied funds. In this context, workshops up suggestions given by CBMP committee strengthening ambulance service etc. They also up with relevant innovative ideas to improve the for Monitoring and Planning Committee members, exemplified by Nasarapur PHC. asked to include certain proposals in next year's health system. m e m b e r s i n c l u d i n g Pa n c h a y a t PIP and asked the Block Medical Officer to do

30 31 ¨ÉÖqùÉ EòÉªÉ, iÉ®...

Thane, Nandurbar, Amaravati, Osmanabad, Pune

Some statistical facts from five districts involved in The tools used for data collection – Community based monitoring and planning of Health Services how is information collected at different levels? Numbers Village level In the village level tool, information is sought about key health services that speak, available at the village level including ANC and PNC services, immunization, treatment of minor ailments and communicable disease control; functioning Graphs of ASHA, use of untied funds available to the village and benefits related to Janani Suraksha Yojana. The information is collected through interviews, which are climbing group discussions and observation. As part of the process of community based monitoring various types of data has been collected. Anganwadi level The impact of this process comes forth through the 'Report cards' produced in the process by the monitoring Services available at the Anganwadi (Village child development and nutrition committees, Health facility records and qualitative information like case studies. centre), frequency and quality of supplementary nutrition provided, nutritional status of children, provision of health services, financial status of A clear conclusion emerges from all this information: self-help groups providing supplementary food and similar information is collected in this tool. Wherever Community based monitoring and planning is underway, Sub-centre level quality of services and people's use of public Information is sought about services being made available (including immunization, ANC and PNC services), availability of medicines, staff health facilities is improving position, utilisation of untied funds available at the sub-centre.

Primary Health Centre level

Information is sought about range of services available in the PHC, round the clock delivery service, laboratory services, surgical services, filled and vacant posts, cleanliness of premises, availability of essential medicines, utilisation of untied funds. Besides direct observation and interviews of staff, exit interviews of patients are also taken.

32 33 ¨ÉÖqùÉ EòÉªÉ, iÉ®...

Thane, Nandurbar, Amaravati, Osmanabad, Pune

Primary Health Centre level

32 33 We can further examine details of improvement in specific village level health services (Graph 2). Rural Hospital (RH) level Services showing significant improvement in CBMP areas are immunisation (65% good in phase 1 to 90% good in phase 4) and Ante-natal care (58% good in phase 1 to 72% good in phase 4).

Information is sought about services available in the RH, round the clock delivery service, Graph 2 : Changes in Village Health Services Rated as 'Good' from Phase I to Phase IV laboratory services, surgical services, filled and vacant posts, availability of essential medicines, utilisation of untied funds. Along with direct observation and interviews of staff, exit interviews of 90 100 Phase I patients are also taken. 90 Phase IV 72 80 64 66 CBMP with people’s participation-has it made a positive impact? 70 58 56 50 The most important parameter of impact of the CBMP process is an improvement in 60 48 people’s experiences of health services. Hence the data collected at the village and PHC level 50 36 36 is most crucial. 40 30 20 What is the story told by data collected at 10 0 Disease Curative ANC Immunisation JSY PHC and village levels, over successive years? Surveillance Services Services The mentioned tools are used to collect data every year at various levels. Based on the data, the services are rated as “good” (marked green), “partly satisfactory” (marked yellow) or “bad” Services in PHCs: Services rated as (marked red). The data shows that the proportion of services rated 'good' has shown a steady ‘Good’ increased from 44% to 75% increase in CBMP areas, while services marked 'bad' have significantly declined over time. The following graphs compare data collected in phase 1 (mid-2008) at time of initiation of CBMP, In CBMP areas there is a similar trend of improvement for services provided at the Primary Health and phase 4 (end 2010 – early 2011). This analysis is based on data from 185 villages and 33 PHCs in Centre level. Overall services rated as 'Good' at PHC level have significantly increased from the five pilot phase districts, where complete data is available across all four rounds. 44% in Round 1, to 75% in Round 4 (Graph 3). Services which were rated as 'Bad' during community monitoring assessments have decreased from 19% to 13%. These ratings are based on assessment by CBM activists by visiting the PHC and conducting direct observation and interviews. It is Village level health services: 'Good' rating significant that when direct community feedback regarding PHC services was sought during village group discussions, there is similar increase in positive ratings over time in CBMP areas (Graph 4). While increased from 50% to 63% community members had rated overall only 32% services as 'Good' in phase 1, the Analysis of information compiled through the village report cards shows an increase in 'Good' experience of provision of PHC services improved dramatically to 79% PHC services rating in successive rounds of community monitoring. In the first round (mid-2008), 50% of the being rated good by phase 4. There is a significant improvement in people's experience of staff services were given 'Good' rating by the community, this increased to 63% in the fourth behavior also in CBMP areas. round (end-2010). Thus there has been a consistent overall improvement in village health services Graph 3 : CBMP Overall rating of Graph 4 : People's perception of about related to the CBMP process. Primary Health Centre services PHC services & behavior rated as Phase I & Phase IV 'Good' from Phase I to Phase IV. Graph 1 : CBMP rating of Village level health services Phase I & Phase IV 75 79 76 80 63 80 80 70 70 70 50 60 60 60 44 47 50 50 38 50 32 40 28 40 40 22 25 30 30 19 30 12 13 13 20 20 20 10 10 10 0 0 0 Bad Partly Good Bad Partly Good Bad Partly Good Bad Partly Good Good rating of Good rating of satisfactory satisfactory satisfactory satisfactory services behavior Phase IV 34 Phase I Phase IV Phase I Phase IV Phase I 35 We can see further details of trends for specific PHC services in Graph 5. Each of these services 110 (such as ambulance facility or availability of lab tests in the PHC) was noted to be having 100 significant deficiencies in CBMP areas at the time of initiation of the process. Due to rigorous 90 101% follow up by CBMP activists and committee members, in synergistic manner with supply side 80 i m p r ove m e n t s f r o m N R H M , 70 Graph 5 : Changes in Primary Health ambulance services rated as 'Good' 60 Centre Services from Phase I to Phase IV have nearly doubled in CBMP areas 50 from 42% to 86%, and availability of 40 48% 100 lab tests in PHCs has also increased, 30 86 83 Phase I 90 Phase IV with 'Good' ratings rising from 47% to 20 71 80 71 61%. When Medical officers do not 10 61 70 reside at the quarters on premises of the 0 50 60 47 42 PHC, delivery of health services beyond Increase in Thane Increase in Thane 50 daytime hours are definitely affected. district PHC deliveries CBM PHCs deliveries 40 This is a contentious issue, and the 30 increase in good ratings from 50% to Between 2007-08 to 2009-10, the average increase in deliveries in PHCs in the entire district was 20 71% is a reflection of relentless 48% whereas the increase in deliveries in CBMP covered PHCs was significantly higher at 101%. 10 community follow-up. 0 It can be concluded that NRHM related improvements have led to some overall increase in Ambulance Round the Clock Availability MO residing in Service Availability Delivery Service of lab test PHC quarters utilization of PHCs in recent years. Further, in areas covered by the CBMP process, synergy between supply side improvements and demand side 'pull' is visible. Increased community Significant increase in utilization of PHC awareness along with additional improvements in services promoted by public dialogue and other accountability processes seem to have induced more people to access PHCs for various types of services : evidence from Thane district care, indicating a movement from private providers to the public health system. Generally there has been some increase in utilization of rural health facilities in most areas after implementation of NRHM. Moreover, there is a significant increase in utilisation of services in CBMP areas. We studied three key utilization indicators: outpatient attendance, inpatient Use of SMS through mobile phones admissions and institutional deliveries for three years – 2007-08, 2008-09 and 2009-10 in Thane to collect and analyse CBMP data SMS district. The trends related to utilization of PHCs covered by CBMP process were analyzed in comparison with the average trends for PHC utilization in the entire district, and it clearly shows Are doctors and nurses actually available round the clock in the PHCs which are greater increase in utilisation of PHCs in CBMP areas. supposed to provide 24x7 services? Are essential medicines available in PHCs, in Between 2007-08 and 2009-10, the average increase in OPD attendance for PHCs in entire adequate quantity? Thane district was 17%, whereas increase in OPD utilization in CBMP covered PHCs was A unique but simple technique was used to collate and analyse community based significantly higher at 34%. Similarly between 2007-08 to 2009-10, the average increase in feedback on such questions- SMS (text messages) sent by ordinary mobile phones. These inpatient admissions for PHCs in the entire district was 50%, whereas the increase in CBMP messages sent by CBMP activists from across the state have been analysed using a simple software, covered PHCs was significantly higher at 73%. which helped to bring out reports of state levels surveys within just a couple of days. A survey to check availability of medicines in PHCs was undertaken in December 2012, which Graph 6 : Increase in Institutional deliveries covered 36 PHCs across 12 districts of Maharashtra. The SMS survey collected information on the 225 availability of 10 most essential medicines, selected from the essential medicines list for the PHCs. 209 Note: 200 Comparative graph Similarly to assess actual round the clock availability of Medical officer and nurses in 24 x 7 175 for Thane district PHCs, a quick survey was conducted by covering 25 PHCs supposed to be providing 24 x 7 services, 175 located across 12 districts of Maharashtra. On 23rd January 2013, a CBMP facilitator / Village health 172 172 of institutional 150 deliveries in 71 committee member visited each selected PHC between 9 pm and midnight and enquired PHCs and 6 about availability of the Medical officer and staff nurse / ANM. It was observed that in 44% 125 116 CBMP PHCs for of the 24x7 PHCs doctor and nurse were both present, or were promptly available on call (categorised as 'Good'); but in 28% PHCs doctors were neither present nor did they come to the 100 three years – 2007- 104 08, 2008-09 and PHC when called, and 12% PHCs were observed to be completely closed in the night. Hence, the 0 2009-10 (monthly situation was found to be 'Unsatisfactory' in 40% of the 24 x 7 PHCs. 2007-08 2008-09 2009-10 average in-facility In this way, the ordinary mobile phone is being used by CBMP activists as a simple but Thane district deliveries per PHC annual 116 175 172 deliveries at PHCs) powerful tool to carry out rapid surveys of the real status of health services in Maharashtra. Thane CBM deliveries 104 172 209 36 per PHC annual 37 We can see further details of trends for specific PHC services in Graph 5. Each of these services 110 (such as ambulance facility or availability of lab tests in the PHC) was noted to be having 100 significant deficiencies in CBMP areas at the time of initiation of the process. Due to rigorous 90 101% follow up by CBMP activists and committee members, in synergistic manner with supply side 80 i m p r ove m e n t s f r o m N R H M , 70 Graph 5 : Changes in Primary Health ambulance services rated as 'Good' 60 Centre Services from Phase I to Phase IV have nearly doubled in CBMP areas 50 from 42% to 86%, and availability of 40 48% 100 lab tests in PHCs has also increased, 30 86 83 Phase I 90 Phase IV with 'Good' ratings rising from 47% to 20 71 80 71 61%. When Medical officers do not 10 61 70 reside at the quarters on premises of the 0 50 60 47 42 PHC, delivery of health services beyond Increase in Thane Increase in Thane 50 daytime hours are definitely affected. district PHC deliveries CBM PHCs deliveries 40 This is a contentious issue, and the 30 increase in good ratings from 50% to Between 2007-08 to 2009-10, the average increase in deliveries in PHCs in the entire district was 20 71% is a reflection of relentless 48% whereas the increase in deliveries in CBMP covered PHCs was significantly higher at 101%. 10 community follow-up. 0 It can be concluded that NRHM related improvements have led to some overall increase in Ambulance Round the Clock Availability MO residing in Service Availability Delivery Service of lab test PHC quarters utilization of PHCs in recent years. Further, in areas covered by the CBMP process, synergy between supply side improvements and demand side 'pull' is visible. Increased community Significant increase in utilization of PHC awareness along with additional improvements in services promoted by public dialogue and other accountability processes seem to have induced more people to access PHCs for various types of services : evidence from Thane district care, indicating a movement from private providers to the public health system. Generally there has been some increase in utilization of rural health facilities in most areas after implementation of NRHM. Moreover, there is a significant increase in utilisation of services in CBMP areas. We studied three key utilization indicators: outpatient attendance, inpatient Use of SMS through mobile phones admissions and institutional deliveries for three years – 2007-08, 2008-09 and 2009-10 in Thane to collect and analyse CBMP data SMS district. The trends related to utilization of PHCs covered by CBMP process were analyzed in comparison with the average trends for PHC utilization in the entire district, and it clearly shows Are doctors and nurses actually available round the clock in the PHCs which are greater increase in utilisation of PHCs in CBMP areas. supposed to provide 24x7 services? Are essential medicines available in PHCs, in Between 2007-08 and 2009-10, the average increase in OPD attendance for PHCs in entire adequate quantity? Thane district was 17%, whereas increase in OPD utilization in CBMP covered PHCs was A unique but simple technique was used to collate and analyse community based significantly higher at 34%. Similarly between 2007-08 to 2009-10, the average increase in feedback on such questions- SMS (text messages) sent by ordinary mobile phones. These inpatient admissions for PHCs in the entire district was 50%, whereas the increase in CBMP messages sent by CBMP activists from across the state have been analysed using a simple software, covered PHCs was significantly higher at 73%. which helped to bring out reports of state levels surveys within just a couple of days. A survey to check availability of medicines in PHCs was undertaken in December 2012, which Graph 6 : Increase in Institutional deliveries covered 36 PHCs across 12 districts of Maharashtra. The SMS survey collected information on the 225 availability of 10 most essential medicines, selected from the essential medicines list for the PHCs. 209 Note: 200 Comparative graph Similarly to assess actual round the clock availability of Medical officer and nurses in 24 x 7 175 for Thane district PHCs, a quick survey was conducted by covering 25 PHCs supposed to be providing 24 x 7 services, 175 located across 12 districts of Maharashtra. On 23rd January 2013, a CBMP facilitator / Village health 172 172 of institutional 150 deliveries in 71 committee member visited each selected PHC between 9 pm and midnight and enquired PHCs and 6 about availability of the Medical officer and staff nurse / ANM. It was observed that in 44% 125 116 CBMP PHCs for of the 24x7 PHCs doctor and nurse were both present, or were promptly available on call (categorised as 'Good'); but in 28% PHCs doctors were neither present nor did they come to the 100 three years – 2007- 104 08, 2008-09 and PHC when called, and 12% PHCs were observed to be completely closed in the night. Hence, the 0 2009-10 (monthly situation was found to be 'Unsatisfactory' in 40% of the 24 x 7 PHCs. 2007-08 2008-09 2009-10 average in-facility In this way, the ordinary mobile phone is being used by CBMP activists as a simple but Thane district deliveries per PHC annual 116 175 172 deliveries at PHCs) powerful tool to carry out rapid surveys of the real status of health services in Maharashtra. Thane CBM deliveries 104 172 209 36 per PHC annual 37 Official reviews and documents take note of CBMP process in Maharashtra

Dr. Syeda Hameed, member of National NRHM Fourth Common Review Planning Commission, Mission national report, Dec. 2010 GoI has taken special note of the CBMP The fourth annual review of NRHM, undertaken process in by the Ministry of Health and Family Welfare, Maharashtra. A team Government of India was published in December led by the 2010. This report notes the following points Commission member about CBMP process in Maharashtra. made a four day visit to Maharashtra during 5-8 October 2010 and “Community monitoring has been most successful in Maharashtra and to interacted with a wide some extent in Madhya Pradesh.” range of stakeholders. (Page -7) Based on this visit, in (In section on Community monitoring) “The only positive news is from the report of the team Maharashtra where they hope to increase it from 5 to 13 districts in this year it is observed: and in Madhya Pradesh where civil society involvement has strengthened the process. The main process is of recording community perceptions of received services on 11 indicators and compiling it into a report card which is presented at Jan Sunwai sessions with specific recommendations. The process emphasizes representation of vulnerable and marginalized sections. In Maharashtra, the benefits of this were reflected by significant measurable Selected increases in service utilization and the trend for improvement of PHC and village health services rating scores.” (Page -42) “The CBMP process is a boon for the de- mystification of the NRHM Fourth Common Review Mission, complex schemes that Maharashtra state report are meant to provide Stories The Maharashtra State level report of the NRHM basic health care Fourth Common review mission includes the services to all…. following section: of change Community based monitoring is a “Community based monitoring – an from Community based monitoring promising tool for innovative process for ensuring accountability of health services under NRHM in implementing these Maharashtra and planning in Maharashtra solutions. … The process of CBMP At the core of CBMP is the process of recording must not be looked as and reporting the state of health services in a conflict arising villages, as experienced by community members. In each monitoring cycle, at mechanism but one the village level information is collected about the services at Village, PHC which has the ability to and Rural Hospital (CHC) level through community group discussions with emphasis on participation of women and other marginalized groups… (This is a brief compilation of English summaries of selected stories of change related improve the overall to Community based monitoring and planning under NRHM in Maharashtra; 35 performance of the Specific indicators which are showing improvement are immunization, health system and Anganwadi services, use of untied fund and PHC health services.” such stories have been documented in Marathi in detail and the collection has been bringing in ownership (Page – 24) of the people.” 38 39 Official reviews and documents take note of CBMP process in Maharashtra

Dr. Syeda Hameed, member of National NRHM Fourth Common Review Planning Commission, Mission national report, Dec. 2010 GoI has taken special note of the CBMP The fourth annual review of NRHM, undertaken process in by the Ministry of Health and Family Welfare, Maharashtra. A team Government of India was published in December led by the 2010. This report notes the following points Commission member about CBMP process in Maharashtra. made a four day visit to Maharashtra during 5-8 October 2010 and “Community monitoring has been most successful in Maharashtra and to interacted with a wide some extent in Madhya Pradesh.” range of stakeholders. (Page -7) Based on this visit, in (In section on Community monitoring) “The only positive news is from the report of the team Maharashtra where they hope to increase it from 5 to 13 districts in this year it is observed: and in Madhya Pradesh where civil society involvement has strengthened the process. The main process is of recording community perceptions of received services on 11 indicators and compiling it into a report card which is presented at Jan Sunwai sessions with specific recommendations. The process emphasizes representation of vulnerable and marginalized sections. In Maharashtra, the benefits of this were reflected by significant measurable Selected increases in service utilization and the trend for improvement of PHC and village health services rating scores.” (Page -42) “The CBMP process is a boon for the de- mystification of the NRHM Fourth Common Review Mission, complex schemes that Maharashtra state report are meant to provide Stories The Maharashtra State level report of the NRHM basic health care Fourth Common review mission includes the services to all…. following section: of change Community based monitoring is a “Community based monitoring – an from Community based monitoring promising tool for innovative process for ensuring accountability of health services under NRHM in implementing these Maharashtra and planning in Maharashtra solutions. … The process of CBMP At the core of CBMP is the process of recording must not be looked as and reporting the state of health services in a conflict arising villages, as experienced by community members. In each monitoring cycle, at mechanism but one the village level information is collected about the services at Village, PHC which has the ability to and Rural Hospital (CHC) level through community group discussions with emphasis on participation of women and other marginalized groups… (This is a brief compilation of English summaries of selected stories of change related improve the overall to Community based monitoring and planning under NRHM in Maharashtra; 35 performance of the Specific indicators which are showing improvement are immunization, health system and Anganwadi services, use of untied fund and PHC health services.” such stories have been documented in Marathi in detail and the collection has been bringing in ownership (Page – 24) of the people.” 38 39 1 Call Bells 2 A CBMP installed near each volunteer helps Patient's bed to save a life

Melghat area in Amaravati district is go out of hand, the Public health CBMP is well-known for many public health officials sought urgent help from a problems. Maternal mortality is one volunteer, Someshwar who is actively becoming an of these. In Jyutpani village in Dharni involved in CBMP. As part of this instrument that block, a severely anemic woman went process, he had a good rapport with is being used into labour. The local ANM at the villagers and the family. He by both the sub-center responded immediately, successfully convinced the relatives, community but it was a complicated delivery and that the patient should be shifted to and the public she needed to be shifted to the Rural the higher center. Someshwar, who health hospital. Hours passed but the tribal enjoys confidence of the family, gave providers to woman's relatives were reluctant to a strong assurance to the relatives During a CBMP - Jan sunwai at passed by and removed the saline rebuild shift the patient to nearest Hospital, that the woman would be delivered CBMP is not Ganjad PHC in Thane district, bottle and the IV set. “What if some people's even though she was in grave danger. safely in the Public hospital. She was just a Subhash shared his experience as a patient becomes suddenly serious and confidence in In their own earlier experience none then shifted to the Rural hospital, complaint patient. A few months back, weak and no body is around?” He asked. the public had walked back alive from that examined and given blood and frail with TB he lay on a bed of that making The various participants in the Jan health system. hospital! Worried that the case might delivered safely. PHC with IV saline dripping in to his process. sunwai forum discussed this and came body drop by drop. The bottle Innovative, up with the answer. A mechanically emptied but no one was around to operated simple table bell to be fixed feasible, help. He had no energy to walk beside every bed! (No hassle of Starting sustainable and himself with that Saline bottle in his 3 'Patient electric fitting and availability of simple own hand to the nurses sitting in a electricity). The idea was executed and solutions are different room. Blood in his vein Help Centres' is still functional in Ganjad PHC. emerging from climbed up slowly into the IV set, Now any patient can call the nurse this process. several minutes passed before a nurse at Public health facilities when required. CBMP of Illiterate and poor patients often get mediating person to bridge this gap. health services lost at Public health centers and To fill in the gap, Arogya Sabhapati of hospitals. They do not know whom District level CBMP committee has developed to approach, what do the tests suggested that CBO representatives innovative advised mean, why and what might start patient-help centers in methods treatment is advised, how much Rural hospitals (CHCs). The through which would be the period of stay etc. The Sangathan which is involved in the Public wall of distrust between the patients CBMP in Murbad has started such a health system and Public healthcare-givers process, where activists visit the can partner augments the isolation, fear and hospital on certain days in a week and with CBOs and apprehensions among patients. guide patients, while ensuring that hence with the CBMP activists in Murbad block of they get their entitlements. community. Thane district spotted the need for a 40 41 4 Improving the 6 CBMP Qualityof food given during completes the half-built mid-day meals Sub-centre It's a story known to everyone, even visited block level authorities and As a part of the CBMP process, the though the details might change from complained, but no one responded. The concept PHC monitoring committee in place to place. People in Jamsar In such a scenario, the CBMP process of community Malshiras in Pune district met to village in Thane district required a made a difference! The village level monitoring is discuss various issues. Keeping in Health sub-center. The Sub-center members of CBMP raised the issue now getting mind several complaints from was sanctioned but the 'politically in the Block level monitoring internalised in children of poor quality of food about the substandard nature of the connected' contractor who was committee meetings on repeated the minds of during mid-day meals, a former mid-day meals in the schools, they The CBMP supposed to build the sub-center occasions. This moved the block people, and is Sarpanch from Pisarve village took made a petition to concerned process creates delayed construction which lingered authorities into action. The sub- being used to the lead and suggested monitoring the authorities. Now there is a marked a valuable on and on. A half-raised useless center building got completed and it monitor social mid-day school meals as well. The improvement in the quality of the space for the structure was the outcome! Villagers has become fully functional. Even an services committee members surveyed fifteen mid-day meals being given in these community to additional ANM got posted at this schools in the vicinity, tested the schools. beyond health pursue issues, sub-center and now this is a full meals, and took samples. Convinced services. follow them fledged sub-centre with active up, and make utilisation by people. The ANM Ms. public health Vasawale reports that 'in the last six facilities months, there have been 83 deliveries 5 Treatment functional. in this sub-centre'. for Diabetes and Hypertension at the PHC ! 7 CBMP creates space for innovative uses of A w o r k s h o p w a s conducted at a Malshiras the Village untied fund PHC as part of the CBMP process. Among the participants were Radhabai Informed and inspired through the The VHSC is involved in inspecting and Sushilabai. With very The CBMP CBMP process, the active members quality of drinking water in the village low earnings and with no process is of the VHSC in Degaon in Pune water tank and well, and they have CBMP has family support, they were helping people district have expanded the village used the untied fund for disinfecting successfully not in position to afford to plan for the health committee's mandate beyond the water. They have further used this cost of diabetic medicines, health of the the usual. Through the CBMP fund to organise house-to-house expanded the community, perimeter of even the small cost of Rs. process they realised that anaemia is a chlorination of drinking water. They 20 for every 10 days. Officer took the lead, investigated and is moving serious problem among pregnant even organised an educational visit of available Neither could they afford to spend on beyond 'health women in the village. This led them VHSC members to Pirangut to learn services at the patients, and with the help of a travel to go to nearest government specialist has started a Medical Camp care' to to use the Village untied fund to buy about use of organic fertilizers, PHC beyond Cottage hospital for the same. Based 'health' in a iron 'kadhais' for pregnant women, so vermiculture and kitchen gardens to its traditional once a month in that PHC for on suggestions given by the CBMP Diabetes and Hypertension patients. broader that these expecting mothers would improve nutrition in the village. mandate. committee members, the Medical perspective! get a regular supply of iron in the diet. 42 43 4 Improving the 6 CBMP Qualityof food given during completes the half-built mid-day meals Sub-centre It's a story known to everyone, even visited block level authorities and As a part of the CBMP process, the though the details might change from complained, but no one responded. The concept PHC monitoring committee in place to place. People in Jamsar In such a scenario, the CBMP process of community Malshiras in Pune district met to village in Thane district required a made a difference! The village level monitoring is discuss various issues. Keeping in Health sub-center. The Sub-center members of CBMP raised the issue now getting mind several complaints from was sanctioned but the 'politically in the Block level monitoring internalised in children of poor quality of food about the substandard nature of the connected' contractor who was committee meetings on repeated the minds of during mid-day meals, a former mid-day meals in the schools, they The CBMP supposed to build the sub-center occasions. This moved the block people, and is Sarpanch from Pisarve village took made a petition to concerned process creates delayed construction which lingered authorities into action. The sub- being used to the lead and suggested monitoring the authorities. Now there is a marked a valuable on and on. A half-raised useless center building got completed and it monitor social mid-day school meals as well. The improvement in the quality of the space for the structure was the outcome! Villagers has become fully functional. Even an services committee members surveyed fifteen mid-day meals being given in these community to additional ANM got posted at this schools in the vicinity, tested the schools. beyond health pursue issues, sub-center and now this is a full meals, and took samples. Convinced services. follow them fledged sub-centre with active up, and make utilisation by people. The ANM Ms. public health Vasawale reports that 'in the last six facilities months, there have been 83 deliveries 5 Treatment functional. in this sub-centre'. for Diabetes and Hypertension at the PHC ! 7 CBMP creates space for innovative uses of A w o r k s h o p w a s conducted at a Malshiras the Village untied fund PHC as part of the CBMP process. Among the participants were Radhabai Informed and inspired through the The VHSC is involved in inspecting and Sushilabai. With very The CBMP CBMP process, the active members quality of drinking water in the village low earnings and with no process is of the VHSC in Degaon in Pune water tank and well, and they have CBMP has family support, they were helping people district have expanded the village used the untied fund for disinfecting successfully not in position to afford to plan for the health committee's mandate beyond the water. They have further used this cost of diabetic medicines, health of the the usual. Through the CBMP fund to organise house-to-house expanded the community, perimeter of even the small cost of Rs. process they realised that anaemia is a chlorination of drinking water. They 20 for every 10 days. Officer took the lead, investigated and is moving serious problem among pregnant even organised an educational visit of available Neither could they afford to spend on beyond 'health women in the village. This led them VHSC members to Pirangut to learn services at the patients, and with the help of a travel to go to nearest government specialist has started a Medical Camp care' to to use the Village untied fund to buy about use of organic fertilizers, PHC beyond Cottage hospital for the same. Based 'health' in a iron 'kadhais' for pregnant women, so vermiculture and kitchen gardens to its traditional once a month in that PHC for on suggestions given by the CBMP Diabetes and Hypertension patients. broader that these expecting mothers would improve nutrition in the village. mandate. committee members, the Medical perspective! get a regular supply of iron in the diet. 42 43 Thane, Nandurbar, Amaravati, Osmanabad, Pune 8 Kavita chooses Narratives from key implementers of the Community The PHC for her Delivery based monitoring process in five districts and 'Trupti' is born

The failure of the Public health of PHC due to CBMP, and system in many areas to entitlement to free delivery care. convince even poor people Kavita was convinced that her Let us about its quality of services is delivery should take place at the CBMP is an ongoing tragedy. No PHC and not in a private carry gradually wonder Gopal Sonar, a poor hospital, even though her father winning people landless laborer in Ajara taluka was reluctant. Repeatedly this process back to the of Kolhapur District sold his only assured by Shivaji, the family took Public health buffalo for fifteen thousand rupees, Kavita to the PHC when labor pains forward... system, helping anticipating the expenses that would be began, and she delivered normally at the required for his daughter's first delivery PHC. Gopal was jubilant as he had to them to escape in a private hospital. His daughter pay just five rupees at the PHC for that All those who have shaped 'Community based impoverishment Kavita, during her pregnancy attended delivery, as against the anticipated huge monitoring and planning' processes in the field, the from health some meetings conducted in the village amount expected in a Private hospital. care under CBMP. The local activist Shivaji The newborn girl has been named volunteers of NGOs, people's organisations, state expenditure. briefed her about improved functioning Trupti (meaning 'satisfaction')! health officials, staff of Medical facilities, members of monitoring Based on CBMP processes, 9 committees, members of the state mentoring PRI members committee speak up about their turn around a PHC experiences, expectations, The people of Yesurna village in Sarpanch and other PRI members took Achalpur block of Amaravati were fed initiative and made a written complaint aspirations to carry up with the poor functioning of their to concerned authorities. Two of the PHC. In 2008, a woman in labour came non-functioning staff members were this process forward... to the PHC but there was no stretcher suspended. However the pressure and to take her into the labour room. She persistent monitoring by the CBMP was forced to deliver in the compound empowered local community and PRI CBMP helps in of the PHC and further since there members has ensured that now the highlighting were no facilities to care for the PHC is functioning properly. Due to deficiencies newborn, the baby died. Within a regular monitoring of medicine stocks, requiring month one more patient came with now drugs are available and the correction, and labor pains to the PHC and found a lock ambulance is now functional at the also stimulates on its door, with not a single staff PHC. After presenting this issue in a Jan local PRI member available. She delivered in the Sunwai, now women have started open space outside the PHC building. getting their Janani Suraksha Yojana members to Agitated, villagers forcibly broke the entitlements. The Sarpanch says that become active lock. At this time CBMP processes had “previously our PHC was in a on health just started in the block making people moribund state; now it has come to issues. aware of their entitlements, and the life”. 44 45 Let us use the community Medical officers and other staff monitoring process to help solve members will certainly learn more Making health problems through mutual if they consider 'public' facilities as understanding. This process helps 'peoples' facilities. They should services e x p r e s s i o n o f p e o p l e ' s genuinely try to address problems expectations from the health emerging from the community accessible to system to fulfill its expected tasks, monitoring process. It is the right needy and poor A commitment to establish Rights... hence medical officers should of needy people to get health avoid getting into unnecessary services. people is our disputes. Our ultimate goal is making health Collective efforts of social organisations, The quality of public health services accessible to the poor and goal recognition by the government services should become so good needy. that even the medical officers I have a request for the should be able to urge their organisations involved in relatives to get treatment in these monitoring process. Do not just facilities. go after the health facility staff, but Both the public health system and a l s o i n v o l v e e l e c t e d The selection of activist-partner funds. This will enhance social organisations should strive representatives like Sarpanch, organisations was the most women's status and self- to get maximum participation of members of Panchayat Samiti and crucial part of this monitoring esteem and will also keep a people at various levels. The Zilla Parishad. Do expect the project. On one hand, social and check on the system as and system should recognize the right District Health Officers and Civil political organisations experience when necessary. of organisations to question. In Surgeon to fulfill duties that fall in - Dr. Satish Pawar a dearth of self-motivated, 3. Names and mobile numbers fact, this process is bringing forth their purview, but do not harass Director Health Services, n e w e r a s p e c t s t h a t a r e them for tasks that do not. Be creative activists, however, the of RKS and Village Health Maharashtra Committee members should complementary to our work aware of the limitations of this State Nodal Organisation which if understood, would help process and of the staff. Try to be displayed on boards. The managed to shoulder the tough - Bhim Raskar, us in implementing our various strengthen communication and task of identifying a committed Convener, Mahila Rajsatta Andolan, members should get an activities better. dialogue. l team quite effortlessly. There are Member of CBMP Mentoring identity card, proper training likely to be some gaps in the Committee, Maharashtra. and sufficient funds for their …We also need to think about ways to let people know what actions have been taken, to address the Community monitoring is a step towards reviving the public health system. issues identified by them. Through this process we attempted to assert our rights without getting Community based process has are necessary to improve our entangled in unnecessary blame game with the health system. Some times provided a lens to people to methods that are adopted to we succeeded and some times we did not. But, most importantly, the monitor our work, and we are increase community participation. dialogue process has continued … interested to know their I feel, we are falling short at the observations and responses. level of follow up. We should think process, but the effort has been 1. Observers should be work. Officers usually expect people to of some mechanism to pursue genuine. appointed who would note speak highly about them, but they implementation of decisions. We It is possible to develop a culture - Dr. P. R. Jakkal, should understand that the reality Although health is one of the down and communicate their of commitment, right from the Former Deputy Director, also need to think upon ways to let day-to-day observations Public Health Services may be different. The people people know what actions have topmost concerns of common patient to the Director of health should also have an unbiased about functioning of health been taken to address issues people, health issues often do not services. We would need several approach and should point out identified by them. get due priority on the political facilities. more like minded organisations problems as well as good elements agenda. We need to chalk out a 2. A select team of five members and workers in this process. We Let the people within the system. The process This process should certainly be political strategy so that it gets from among each Village would also require a transparent should serve to present good extended to other areas by deserving attention in electoral SHG Federation should be administration and a visionary become efforts made by the health system. identifying organisations that politics as well. Nevertheless, in formed and oriented to work government, who could further would be competent to facilitate it. as 'Health Animators' to make aware about The list of indicators used in the The officers may or may not Maharashtra, through CBMP we the implementation of this community monitoring process have moved a step forward in the most from Village Funds. concept. CBMP is helping such a welcome it, since many feel they our plans and can be further extended. For are 'put in the dock' during public ensuring due priority to health A g o v e r n m e n t o r d e r social process to take root. instance, a little in-depth necessitating proper publicity hearings. They have to face people issues. corrective monitoring is necessary in the to answer them. Similarly, in public Efforts for further community of provision of village fund hospitals. Some indicators related should be issued, to ensure measures! hearings the attitude of the social monitoring and revival of the to 'people's participation' should organizations should be unbiased appropriate utilization of l health system should include; also be developed. Regular efforts and objective. l 46 47 Let us use the community Medical officers and other staff monitoring process to help solve members will certainly learn more Making health problems through mutual if they consider 'public' facilities as understanding. This process helps 'peoples' facilities. They should services e x p r e s s i o n o f p e o p l e ' s genuinely try to address problems expectations from the health emerging from the community accessible to system to fulfill its expected tasks, monitoring process. It is the right needy and poor A commitment to establish Rights... hence medical officers should of needy people to get health avoid getting into unnecessary services. people is our disputes. Our ultimate goal is making health Collective efforts of social organisations, The quality of public health services accessible to the poor and goal recognition by the government services should become so good needy. that even the medical officers I have a request for the should be able to urge their organisations involved in relatives to get treatment in these monitoring process. Do not just facilities. go after the health facility staff, but Both the public health system and a l s o i n v o l v e e l e c t e d The selection of activist-partner funds. This will enhance social organisations should strive representatives like Sarpanch, organisations was the most women's status and self- to get maximum participation of members of Panchayat Samiti and crucial part of this monitoring esteem and will also keep a people at various levels. The Zilla Parishad. Do expect the project. On one hand, social and check on the system as and system should recognize the right District Health Officers and Civil political organisations experience when necessary. of organisations to question. In Surgeon to fulfill duties that fall in - Dr. Satish Pawar a dearth of self-motivated, 3. Names and mobile numbers fact, this process is bringing forth their purview, but do not harass Director Health Services, n e w e r a s p e c t s t h a t a r e them for tasks that do not. Be creative activists, however, the of RKS and Village Health Maharashtra Committee members should complementary to our work aware of the limitations of this State Nodal Organisation which if understood, would help process and of the staff. Try to be displayed on boards. The managed to shoulder the tough - Bhim Raskar, us in implementing our various strengthen communication and task of identifying a committed Convener, Mahila Rajsatta Andolan, members should get an activities better. dialogue. l team quite effortlessly. There are Member of CBMP Mentoring identity card, proper training likely to be some gaps in the Committee, Maharashtra. and sufficient funds for their …We also need to think about ways to let people know what actions have been taken, to address the Community monitoring is a step towards reviving the public health system. issues identified by them. Through this process we attempted to assert our rights without getting Community based process has are necessary to improve our entangled in unnecessary blame game with the health system. Some times provided a lens to people to methods that are adopted to we succeeded and some times we did not. But, most importantly, the monitor our work, and we are increase community participation. dialogue process has continued … interested to know their I feel, we are falling short at the observations and responses. level of follow up. We should think process, but the effort has been 1. Observers should be work. Officers usually expect people to of some mechanism to pursue genuine. appointed who would note speak highly about them, but they implementation of decisions. We It is possible to develop a culture - Dr. P. R. Jakkal, should understand that the reality Although health is one of the down and communicate their of commitment, right from the Former Deputy Director, also need to think upon ways to let day-to-day observations Public Health Services may be different. The people people know what actions have topmost concerns of common patient to the Director of health should also have an unbiased about functioning of health been taken to address issues people, health issues often do not services. We would need several approach and should point out identified by them. get due priority on the political facilities. more like minded organisations problems as well as good elements agenda. We need to chalk out a 2. A select team of five members and workers in this process. We Let the people within the system. The process This process should certainly be political strategy so that it gets from among each Village would also require a transparent should serve to present good extended to other areas by deserving attention in electoral SHG Federation should be administration and a visionary become efforts made by the health system. identifying organisations that politics as well. Nevertheless, in formed and oriented to work government, who could further would be competent to facilitate it. as 'Health Animators' to make aware about The list of indicators used in the The officers may or may not Maharashtra, through CBMP we the implementation of this community monitoring process have moved a step forward in the most from Village Funds. concept. CBMP is helping such a welcome it, since many feel they our plans and can be further extended. For are 'put in the dock' during public ensuring due priority to health A g o v e r n m e n t o r d e r social process to take root. instance, a little in-depth necessitating proper publicity hearings. They have to face people issues. corrective monitoring is necessary in the to answer them. Similarly, in public Efforts for further community of provision of village fund hospitals. Some indicators related should be issued, to ensure measures! hearings the attitude of the social monitoring and revival of the to 'people's participation' should organizations should be unbiased appropriate utilization of l health system should include; also be developed. Regular efforts and objective. l 46 47 Presenting our The Health System should problems shouldn't Chetan Salve, get accustomed to Activist be interpreted as Narmada Bachao community monitoring Andolan, being 'quarrelsome'! Nandurbar

Being an active member, I have been closely watching the CBMP process in regions. Dhadgaon Rural us an opportunity to raise Maharashtra. Although Chandrapur and Gadchiroli districts were initially We are implementing CBMP in Formation of a state a remote area like Dhadgaon in Hospital fails to provide problems and we are going to not included in the CBMP process by the government, we made attempt to specialized services. Owing to make the most of it. level monitoring initiate similar processes in Kurkheda, Korchi, Aarmori and Nagbhid blocks Nandurbar, and hope to equipment break down, lack of Some doctors have political committee is yet in these two districts. empower people though the community monitoring process. electricity or absence of technical connections and therefore are People from village to district levels are coming forward to monitor health awaited. The public However, power dynamics are staff, patients are referred to l e a s t c o n c e r n e d a b o u t services, which has made the system more alert. However formation of a facilities almost 100 kilometers complaints against them. We are health system is still state level monitoring committee is yet awaited. Similarly the public health very complex in far-off, deprived not as transparent as away. The Civil Hospital is also in not personally against any system is still not as transparent as it should be. Health schemes are still not We present our genuine equally poor condition. Health doctor. We are just pursuing the it should be. effectively shared with people. The system has not yet got 'used' to the monitoring process. Nonetheless, we have just begun and it will take some demands - fill up the camps are organised for major right of people to get health time to for better practices to become ingrained. vacant posts, make illnesses such as hernia, heart services in a dignified manner. l posting in remote areas trouble and cancer, however Our objectives are quite clear. We Dr. Satish Gogulwar, mandatory for medical patients do not get required beg to ask - why are the services ‘Amhi Amachya Arogyasathi’, Gadchiroli, Member, students. Presenting treatment. When we point out which government doctors CBMP Mentoring Committee, these problems, we are blamed provide in their own private Maharashtra these problems should for finding faults and causing clinics not available in public not be seen as getting fights among patients and facilities run by them? We into a quarrel. We strive doctors. The adivasi doctors are present our genuine demands - to voice our concerns against us, because they do not fill up the vacant posts, make through the community w a n t u s t o r a i s e a n y posting in remote areas monitoring process, and uncomfortable questions. But we mandatory for medical students. Funds are now do not mean to pick up will not let them have their say so Presenting these problems a fight with the system. easily. Now the community should not be seen as being utilized properly monitoring process has provided quarrelsome. We strive to voice our concerns through the In our area the village untied additional funds if the entire expenditures. Spending of over community monitoring process funds provided through NRHM, untied funds are spent. The Rs. 50,000 was not supported by and do not mean to pick up la were solely spent on the amount of untied funds, rupees proper receipts. The cost of a bed fight with the system. Anganwadi. Malvi is a dominant ten thousand, is not sufficient for was unreasonably quoted as Rs. People have and economically well off local larger villages. Additional funds 10,000. We highlighted these begun to talk about other community, while Korkus are a can be accessed though a problems through a public issues also like ration and water supply socio-economically marginalized Grampanchayat resolution. Our hearing with the help of community in this area. The campaigns helped to build Sarpanch, Deputy Sarpanch and I have been working as a health that 'your' clinics do not have awareness on several such Chairperson of Panchayat Samiti Sarpanch and Aanganwadi activist for past 12 years. required facilities, but now, after worker invariably belong to provisions. and made the concerned medical improved communication, they o f f i c e r p a y b a c k t h e Therefore I am quite familiar Malvis and earlier the untied fund With the help of RKS in the Sub- with all health facility staff. I have say that 'our' clinic should have district hospital, we raised the misappropriated amount. Motiram Thakre, used to get spent on vehicles observed a marked difference in the required facilities. More owned by Sarpanches. r o b l e m o f m a n i p u l a t e d l Activist, the state of health services after importantly, people are also Janarth Adivasi Vikas Sanstha, In the process of community the community monitoring talking about issues like rationing Nandurbar m o n i t o r i n g , w e c r e a t e d As a result of awareness and water supply along with process has started. As a result of What we gain from awareness among village health created among village fund availability through NRHM, health services. committee members. The struggles might be short committee members, they basic facilities and medicine I feel, what we gain from members began to keep a check lived. But what we began to keep a check on struggles might be short lived. on utilization of funds. Now the utilization of village untied availability have improved and achieve from dialogue funds are appropriately used for funds. Now the funds are vacant posts were filled up. But what we achieve from certainly has a longer activities like village cleanliness, appropriately used for activities CBMP has enabled ordinary dialogue certainly has a longer life. As CBMP breast feeding day and health Someshwar Chandurkar, like village cleanliness, breast adivasi women to have an life. As CBMP implementers, we implementers we are awareness campaigns. People did Dharni Block Coordinator, feeding day and health interaction with the doctor and a r e e x p e r i e n c i n g s u c h experiencing such not know that they can get Apeksha Homeo Society, Amaravati awareness campaigns. ANM. Initially they used to say sustainability of outcomes. sustainability of outcomes. 48 l 49 and we made them public every Most importantly, people began A moribund time. In order to improve the to consider the Government Health Center situation, we followed up the matter with all the concerned clinic as their own is returning to life... people such as the District Collector, CEO, BDO and DHO. The situation of Yesurna PHC the fore. They highlighted As a result, the issue became was quite bad when I joined three problems, but came closer to -Shridhar Kale, serious. Two staff members were years ago as a Medical Officer. I health center in the process, which Ex-Sarpanch, suspended. Nevertheless, the has led to considerable changes. Yesurna often saw patients going to private villagers benefited in the process clinics outside the village and felt Today the OPD attendance has Grampanchayat, increased to 50-60 patients daily. Block Achalpur, and problems in Yesurna PHC bad about it. OPD attendance was Amravati barely 10-15 patients per day. We We carried out 56 deliveries last are now addressed promptly. On year. New health workers have behalf of the village health were unable to provide services to hen I took charge as a information. been appointed on contractual W committee, we appealed to women in labour. The post of Dr. Anil Augad, Around the same time an infant basis and our efficiency has Sarpanch, the condition of the villagers to make use of the assistant medical officer was not Medical Officer, Yesurna PHC in our village was very bad. death took place in the premises filled up. We were short of staff increased. PHC, Block Achalpur, public facility and started It is important that people We had a center devoid of any of the health center. The woman and I was somehow managing to Amravati building their awareness. Now consider the government health was in severe pain but there was provide health services to 42 services. I hardly knew what the medicine supply has facility as their own. Since people not even a stretcher available to villages covered by the center. needed to be done to activate it. improved. JSY incentives are are dissatisfied, they pose lift her. In fact, the new born baby Once an unfortunate incident took In the meantime the CBMP properly distributed. An questions. As a Medical Officer, I process was initiated. The village died because the center was ill place. A pregnant woman did not As people pointed out ambulance has been provided. In get necessary services, since the feel, no single person can be held health committee was properly equipped to attend the delivery. the gaps, the problems short, a moribund health center staff was unavailable due to diwali responsible for all the problems. We presented this incidence in Rather than covering up gaps, formed. Workers of Mamata has retuned to life. festival leave. This incidence was in the health system B a h u u d d e s h i y a S a n s t h a the public hearing. Similar l presented in the public hearing. attending to them is more came to the fore. They frequently visited to share incidences repeatedly happened I feel, raising the incident in public important. As per the saying 'Keep highlighted the your critic next to you', having hearing has helped in highlighting problems, but came The issue became serious. Two staff members were suspended. the need for improvements. As someone to point your mistakes helps you improve, which closer to health center Yet ultimately the villagers benefited in the process, and problems in people pointed out gaps, the enhances efficiency. in the process. Yesurna PHC are now addressed promptly. problems in health system came to l Further level monitoring and planning Shripad Konde, committees. strengthening of Velhe Block lWider publicity is necessary to Health services Coordinator, findings highlight identified Rachana Trust, while filling up report cards, is necessary… Pune and also in discussions and d e c i s i o n s i n v a r i o u s In order to further strengthen participation of Gramsevaks, committee meetings from Community based monitoring, BDOs, Sarpanches and other village to district. elected representatives. l we need to focus on following l Medical officers who work to areas- Elected representatives improve the quality of health lBetter coordination among should not dominate or dictate services, work to increase ICDS programme officers the course of community OPD attendance, offer their and Health department at the monitoring, rather they should best service to patients, should block, district and state levels be equal partners in decision be publicly felicitated. making and should take note lConduction of regular lGovernment should accord of views and suggestions by reviews of the community responsibility and authority to other members. monitoring process, presided l Community monitoring over by the CEO Discussion and decisions on committees, to regulate reports of the public hearings lA Government order should private doctors in rural areas. should take place in district be issued to increase l 50 51 and we made them public every Most importantly, people began A moribund time. In order to improve the to consider the Government Health Center situation, we followed up the matter with all the concerned clinic as their own is returning to life... people such as the District Collector, CEO, BDO and DHO. The situation of Yesurna PHC the fore. They highlighted As a result, the issue became was quite bad when I joined three problems, but came closer to -Shridhar Kale, serious. Two staff members were years ago as a Medical Officer. I health center in the process, which Ex-Sarpanch, suspended. Nevertheless, the has led to considerable changes. Yesurna often saw patients going to private villagers benefited in the process clinics outside the village and felt Today the OPD attendance has Grampanchayat, increased to 50-60 patients daily. Block Achalpur, and problems in Yesurna PHC bad about it. OPD attendance was Amravati barely 10-15 patients per day. We We carried out 56 deliveries last are now addressed promptly. On year. New health workers have behalf of the village health were unable to provide services to hen I took charge as a information. been appointed on contractual W committee, we appealed to women in labour. The post of Dr. Anil Augad, Around the same time an infant basis and our efficiency has Sarpanch, the condition of the villagers to make use of the assistant medical officer was not Medical Officer, Yesurna PHC in our village was very bad. death took place in the premises filled up. We were short of staff increased. PHC, Block Achalpur, public facility and started It is important that people We had a center devoid of any of the health center. The woman and I was somehow managing to Amravati building their awareness. Now consider the government health was in severe pain but there was provide health services to 42 services. I hardly knew what the medicine supply has facility as their own. Since people not even a stretcher available to villages covered by the center. needed to be done to activate it. improved. JSY incentives are are dissatisfied, they pose lift her. In fact, the new born baby Once an unfortunate incident took In the meantime the CBMP properly distributed. An questions. As a Medical Officer, I process was initiated. The village died because the center was ill place. A pregnant woman did not As people pointed out ambulance has been provided. In get necessary services, since the feel, no single person can be held health committee was properly equipped to attend the delivery. the gaps, the problems short, a moribund health center staff was unavailable due to diwali responsible for all the problems. We presented this incidence in Rather than covering up gaps, formed. Workers of Mamata has retuned to life. festival leave. This incidence was in the health system B a h u u d d e s h i y a S a n s t h a the public hearing. Similar l presented in the public hearing. attending to them is more came to the fore. They frequently visited to share incidences repeatedly happened I feel, raising the incident in public important. As per the saying 'Keep highlighted the your critic next to you', having hearing has helped in highlighting problems, but came The issue became serious. Two staff members were suspended. the need for improvements. As someone to point your mistakes helps you improve, which closer to health center Yet ultimately the villagers benefited in the process, and problems in people pointed out gaps, the enhances efficiency. in the process. Yesurna PHC are now addressed promptly. problems in health system came to l Further level monitoring and planning Shripad Konde, committees. strengthening of Velhe Block lWider publicity is necessary to Health services Coordinator, findings highlight identified Rachana Trust, while filling up report cards, is necessary… Pune and also in discussions and d e c i s i o n s i n v a r i o u s In order to further strengthen participation of Gramsevaks, committee meetings from Community based monitoring, BDOs, Sarpanches and other village to district. elected representatives. l we need to focus on following l Medical officers who work to areas- Elected representatives improve the quality of health lBetter coordination among should not dominate or dictate services, work to increase ICDS programme officers the course of community OPD attendance, offer their and Health department at the monitoring, rather they should best service to patients, should block, district and state levels be equal partners in decision be publicly felicitated. making and should take note lConduction of regular lGovernment should accord of views and suggestions by reviews of the community responsibility and authority to other members. monitoring process, presided l Community monitoring over by the CEO Discussion and decisions on committees, to regulate reports of the public hearings lA Government order should private doctors in rural areas. should take place in district be issued to increase l 50 51 Thane, Nandurbar, Amaravati, Osmanabad, Pune The issue is that … The CBMP process has highlighted the long ignored issue of 'Public Health System Improvements'. These five districts gave '100 per cent' marks to the The media has responded by giving Community based monitoring and planning process prominent coverage to the process… Voices of diverse stakeholders 1100 1100

We spoke to a wide spectrum of people about this process, we asked them to rate the process Fifty members from monitoring committees, medical officers at PHC, block and district levels, sarpanches, Zilla Parishad members and community members (both men & women), ICDS workers were asked their opinions regarding the process and its future

We are enthused by the opinions of all these stakeholders, Let us hear some of them speak in their own words...

52 53 Thane, Nandurbar, Amaravati, Osmanabad, Pune The issue is that … The CBMP process has highlighted the long ignored issue of 'Public Health System Improvements'. These five districts gave '100 per cent' marks to the The media has responded by giving Community based monitoring and planning process prominent coverage to the process… Voices of diverse stakeholders 1100 1100

We are enthused by the opinions of all these stakeholders, Let us hear some of them speak in their own words...

52 53 Earlier it was hard to get people's support in our efforts against D u e t o Services generally exist only on paper and not in malnutrition. But after CMBP began, villagers come on their own, check C B M , reality. They make hollow promises and do the weight records of children and point out mistakes, if any, to the Aanganwadi particularly public nothing. I am a sanyasi, still I have joined struggle to workers. It is quite significant that people are taking part in rectifying hearings, we come ensure treatment to people in their villages, since I mistakes in the health system. to know about know we will not develop till we speak up. problems at the - Bhaskar Bhoir, grassroots level. ICDS Officer, Block Murbad, District Thane This process is very useful to raise public awareness about NRHM schemes. However, not all Earlier, people paid no attention to us, problems can be dealt at our level. Hence I thinking that we make village visits only to Mutual understanding sense a need for mutual understanding to satisfy our own interests. But now they realized the between medical strengthen communication channels nature of our work and functionaries and people between the social organisations mutual communication and positive approach to and the health system. - Nandram Chote address problems would has increased. Therefore Silore Baba, we also tend to reach out - Rita Gaikwad, Village Rohityakheda, certainly make this process District Programme Coordinator, NRHM, further effective. to as many possible. Now Block Chikhaldara, Villagers we are in a better position District Thane District Amravati to know what they gain think. Specific training and meetings organised for villagers the 'power' - Dr. T. M. Kharat, Block Medical Officer, - Kunda Malusare, ANM, PHC Nasarapur, made them more 'informed' and hence more Block Achalpur, District Amravati Block Bhor, District Pune 'powerful' to address their problems… to tackle Villagers come on their own, and check the weight records health of children and point out mistakes, if any, to Anganwadi The stagnant state health budget in past problems workers. They are contributing to a change in the state of few years reflects the lower priority given health services by stepping forward…. to the health sector by the state government. Now funds are made available through NRHM, however Due to NRHM and CBMP, people became the real question is how would these funds reach the aware about services to be provided by the people. CBMP, which contributes to building people's ANM and MPW. Now we have made a calendar of awareness and gives marginalized sections like adivasi “…Villagers are their work. This has resulted in regular - Yogiraj Prabhune, women a forum to present their problems, can becoming active implementation of health activities. Journalist, provide an effective solution to this question. - Biru Dudhbhate, Pune to ensure delivery Sarpanch, Dhangarwadi, Block Tuljapur, District Osmanabad of health In past, over health facility used to be Solution to people's problems lies with them. closed, but ever since we have Hence, effective work is possible only when we services …” Through the community monitoring formed a committee it remains open due to properly listen to their problems and process, villagers became aware about our monitoring. the solutions suggested by them. various funds being made available under NRHM. People started taking interest in the - Prashant Narnavare, process after benefits reached more - Rusnabai Pawar, Additional District Collector, BDO, people and services improved. Villager, Sulwada, Panchayat Samiti, Block Block Shahada, Chikhaldara, District Amravati - Prabhakar Deshmukh, District Nandurbar Member, Block level Monitoring and Planning Committee, Block Murbad, District Thane 54 55 Earlier it was hard to get people's support in our efforts against D u e t o Services generally exist only on paper and not in malnutrition. But after CMBP began, villagers come on their own, check C B M , reality. They make hollow promises and do the weight records of children and point out mistakes, if any, to the Aanganwadi particularly public nothing. I am a sanyasi, still I have joined struggle to workers. It is quite significant that people are taking part in rectifying hearings, we come ensure treatment to people in their villages, since I mistakes in the health system. to know about know we will not develop till we speak up. problems at the - Bhaskar Bhoir, grassroots level. ICDS Officer, Block Murbad, District Thane This process is very useful to raise public awareness about NRHM schemes. However, not all Earlier, people paid no attention to us, problems can be dealt at our level. Hence I thinking that we make village visits only to Mutual understanding sense a need for mutual understanding to satisfy our own interests. But now they realized the between medical strengthen communication channels nature of our work and functionaries and people between the social organisations mutual communication and positive approach to and the health system. - Nandram Chote address problems would has increased. Therefore Silore Baba, we also tend to reach out - Rita Gaikwad, Village Rohityakheda, certainly make this process District Programme Coordinator, NRHM, further effective. to as many possible. Now Block Chikhaldara, Villagers we are in a better position District Thane District Amravati to know what they gain think. Specific training and meetings organised for villagers the 'power' - Dr. T. M. Kharat, Block Medical Officer, - Kunda Malusare, ANM, PHC Nasarapur, made them more 'informed' and hence more Block Achalpur, District Amravati Block Bhor, District Pune 'powerful' to address their problems… to tackle Villagers come on their own, and check the weight records health of children and point out mistakes, if any, to Anganwadi The stagnant state health budget in past problems workers. They are contributing to a change in the state of few years reflects the lower priority given health services by stepping forward…. to the health sector by the state government. Now funds are made available through NRHM, however Due to NRHM and CBMP, people became the real question is how would these funds reach the aware about services to be provided by the people. CBMP, which contributes to building people's ANM and MPW. Now we have made a calendar of awareness and gives marginalized sections like adivasi “…Villagers are their work. This has resulted in regular - Yogiraj Prabhune, women a forum to present their problems, can becoming active implementation of health activities. Journalist, provide an effective solution to this question. - Biru Dudhbhate, Pune to ensure delivery Sarpanch, Dhangarwadi, Block Tuljapur, District Osmanabad of health In past, over health facility used to be Solution to people's problems lies with them. closed, but ever since we have Hence, effective work is possible only when we services …” Through the community monitoring formed a committee it remains open due to properly listen to their problems and process, villagers became aware about our monitoring. the solutions suggested by them. various funds being made available under NRHM. People started taking interest in the - Prashant Narnavare, process after benefits reached more - Rusnabai Pawar, Additional District Collector, BDO, people and services improved. Villager, Sulwada, Panchayat Samiti, Block Block Shahada, Chikhaldara, District Amravati - Prabhakar Deshmukh, District Nandurbar Member, Block level Monitoring and Planning Committee, Block Murbad, District Thane 54 55 Aurangabad Money charged illegally for providing ambulance service was returned in the Jan sunwai!

It was an example of prompt corrective action, for everyone who had gathered for the Jan District – Aurangabad Sunwai at Manur PHC in Aurangabad district. A woman 1 block – Vaijapur complained that she had brought her grandson to the 3 PHCs- Manur, PHC with a dog bite, who was Gadepimpalgaon, Borsar referred to Aurangabad after g i v i n g s o m e p r i m a r y but the ambulance driver Villages - 25 t r e a t m e n t . T h e P H C demanded money and she had ambulance was made available, to pay. In the Jan sunwai, strong protest emerged on this issue. The District health Emerging officer called the concerned Community based Signposts of change… ambulance driver, and ordered him to return the money taken monitoring and planning in §During the visit of the Monitoring and Planning committee to the woman, there and then members to Borsar PHC, it came to light that neither of the in front of the assembled two Medical Officers there was residing at the PHC premises. people. He also warned all the The committee members brought this to the notice of the staff that if anyone acts Eight New THO, and now both MOs reside at the PHC. similarly in illegal manner, § stern action would be taken The ICU at the Sub district hospital in Vaijapur was shut for and that person would be several years. It got new life after the taluka level Jan samvad terminated. He also gave and has now become functional. instructions to every staff Districts §In Gadhe Pimpalgaon, Boresar and Manur PHCs the required member to be present at their medicines were not being given to patients from the PHC. place of work in time. After the CBMP committee intervened, patients have started It is no wonder that the people getting the necessary medicines. present at the Jan Sunwai have §Honoring the suggestion in a Jan Sunwai that a timetable for regained their faith in public Since March 2011, CBMP processes have been expanded to eight new health services! districts which are spread across various regions of Maharashtra. While village visits by the Sub-centre staff should be displayed at a processes are emerging here, some key facts about the framework of CBMP prominent place, boards with this information have been put processes in these districts are being outlined. As implementation of up in Gadhe Pimpalgaon, Boresar and Manur PHCs. activities moves beyond the initial phase, brief stories reflecting the §Construction work of Sakegaon sub center had been lying emerging changes related to CBMP processes are also included. incomplete since a long period, the work has now progressed due to pressure from the VHSC activated through the CBMP process. §When the VHSC noticed that construction of Nagmathan sub center was being done in sub standard manner, the committee intervened and stopped the poor quality work, and has pressed for standard quality construction. 56 57 Aurangabad Money charged illegally for providing ambulance service was returned in the Jan sunwai!

It was an example of prompt corrective action, for everyone who had gathered for the Jan District – Aurangabad Sunwai at Manur PHC in Aurangabad district. A woman 1 block – Vaijapur complained that she had brought her grandson to the 3 PHCs- Manur, PHC with a dog bite, who was Gadepimpalgaon, Borsar referred to Aurangabad after g i v i n g s o m e p r i m a r y but the ambulance driver Villages - 25 t r e a t m e n t . T h e P H C demanded money and she had ambulance was made available, to pay. In the Jan sunwai, strong protest emerged on this issue. The District health Emerging officer called the concerned Community based Signposts of change… ambulance driver, and ordered him to return the money taken monitoring and planning in §During the visit of the Monitoring and Planning committee to the woman, there and then members to Borsar PHC, it came to light that neither of the in front of the assembled two Medical Officers there was residing at the PHC premises. people. He also warned all the The committee members brought this to the notice of the staff that if anyone acts Eight New THO, and now both MOs reside at the PHC. similarly in illegal manner, § stern action would be taken The ICU at the Sub district hospital in Vaijapur was shut for and that person would be several years. It got new life after the taluka level Jan samvad terminated. He also gave and has now become functional. instructions to every staff Districts §In Gadhe Pimpalgaon, Boresar and Manur PHCs the required member to be present at their medicines were not being given to patients from the PHC. place of work in time. After the CBMP committee intervened, patients have started It is no wonder that the people getting the necessary medicines. present at the Jan Sunwai have §Honoring the suggestion in a Jan Sunwai that a timetable for regained their faith in public Since March 2011, CBMP processes have been expanded to eight new health services! districts which are spread across various regions of Maharashtra. While village visits by the Sub-centre staff should be displayed at a processes are emerging here, some key facts about the framework of CBMP prominent place, boards with this information have been put processes in these districts are being outlined. As implementation of up in Gadhe Pimpalgaon, Boresar and Manur PHCs. activities moves beyond the initial phase, brief stories reflecting the §Construction work of Sakegaon sub center had been lying emerging changes related to CBMP processes are also included. incomplete since a long period, the work has now progressed due to pressure from the VHSC activated through the CBMP process. §When the VHSC noticed that construction of Nagmathan sub center was being done in sub standard manner, the committee intervened and stopped the poor quality work, and has pressed for standard quality construction. 56 57 Beed Chandrapur Eye care services ensured due to Monitoring committee members intervention by ensure that people’s right to free the CBMP committee health care is fulfilled

There was no ophthalmic appointed, but was not visiting been solved at his level; there check-up available in most of most PHCs as expected, was was no need to complain to the the PHCs in Ambejogai taluka, raised in the meetings of the District – Beed state authorities. Members of District – Chandrapur and people had to access the taluka and PHC monitoring the CBMP committee held him private sector and get their and planning committees. A 2 blocks – Ambejogai to his promise, and took a 2 blocks – Chandrapur cataract surgeries done, thus proposal to ensure such visits and Beed delegation to meet him. A team and Varora they ended up spending a lot of by was sent to the district followed up with various money. The issue that an officials, and this issue was also 8 PHCs- Bhavthana, patients in the hospital after a 6 PHCs- Savri, Kosarkar, ophthalmic assistant was raised in the taluka Jan sunwai. Aapegaon, Badrapur, week, and ensured that BPL Nagri, Durgapur, Navgan-Rajuri, patients are now not being Chinchpalli, Tadli A state level video conference Pimpalner, Tadsona, asked to pay any charges, as was organised, where CBMP Ghatnandur, Nalvandi mandated in the rules. villages - 30 activists from various blocks Villages - 40 along with State level health ‘Unsealing’ immunisation A woman from Payli village vaccine. She narrated the officials and District health incident to the village health officials from all CBMP walked with her 4 month old As a result in 2013, a provision baby for immunisation to committee members who has been made at the district districts of Maharashtra discussed and raised the issue – participated. Local civil society Bhatali sub-centre, which is 4 level to ensure that eye testing kms away from the village. The even if there was just one child, by the ophthalmic assistant is activists complained that poor should not the vaccine be people were being charged ANM in the sub-centre refused regularly conducted in to open the seal of the vaccine administered? If the mother Bardapur, Bhavathan and illegally in the Civil hospital, does not return to the health Chandrapur. The Civil surgeon for one child and asked the Apegaon PHCs, as well as in mother to come later, who had centre and the child is deprived Dhanora Rural Hospital. was unhappy and expressed of the vaccine, who would be that the problem would have to walk back home with her About 15-20 patients are baby without receiving the responsible? Chandrapur is a examined in each PHC every forested district where week, and cataract surgeries of transportation is always a referred patients are now also Signposts of change… problem, patients often have to being conducted through the walk several kilometres to Signposts of change… public system. §In Pimpalkhut, Chorgaon, Mamala and Nadgur villages, due to reach a medical facility. The The CBMP process in Beed the CBMP process now Village health committees have committee members along • Since the construction was incomplete, Apegaon PHC was not district has proven to be an eye- become active and have started monitoring various with the local CBMP activists functioning. The CBMP committee ensured that construction opener! expenditures made from untied funds. went and spoke about this to was completed, and the PHC has now started working. § the Medical officer of the The medical staff in various PHCs of Chandrapur block was PHC, who advised the §In the PHCs in Beed district, anti rabies vaccine was not found to behave rudely with patients. After the issue was concerned ANM and from available. Due to persistent follow up by the CBMP raised in a Jan Sunwai, the behavior has improved. then on, not just in Bhatali, but committee, the vaccine was purchased through Rogi Kalyan in all sub-centres, vaccine seals Samiti funds, and has now become available. §ASHAs in various CBMP villages have started getting drug kits after committee members raised this issue. are opened irrespective of §No remuneration was being given to ASHAs for their work on whether there is just one child the day of vaccination. When CBMP committees intervened §After the CBMP committee insisted on this, the list of the for the vaccination or more. on behalf of ASHAs, they have started getting their due drugs available in PHCs has been displayed in a prominent remuneration. place in the PHC. 58 59 Gadchiroli Kolhapur People take action, Strengthened Public health services services become responsive have put a lock on private clinics! Prior to the CBMP process, Kharmat-tola is a small village and they decided to protest at Maligre PHC in Ajara block of under Deolgaon PHC in the mentioned PHC, led by Kolhapur district functioned Kurkheda block of Gadchiroli. Shamrao Kumare, President of poorly, people in Maligre village The CBM process is evolving the Village Health, Water were indifferent to its services, well in the village through Supply, Nutrition and Sanitation District – Gadchiroli District – Kolhapur and those in neighbouring regular activities like meetings, Committee. People confronted villages were not even aware rallies, group discussions and a the six staff members present in 3 blocks – Kurkheda, 3 blocks – Aajara, about this PHC. In the entire series of programmes have the center and demanded to Gadchiroli and Armori CBMP process, villagers gave a Bhudargad and year of 2010-11, only eight created awareness among keep the facility open for good response to these meetings Hatkanangale deliveries took place in the PHC, people on the PHC services they stipulated duration i.e. 8 am to 8 PHCs- Kadholi, and gradually the doctor earned its OPD for the year was 7,380 are entitled to receive. In this noon and 3 to 5 pm. This action Malewada, Deulgaon, the faith of the people. 8 PHCs- Vatangi, and indoor admissions were 215. context, a local news story titled by people inspired by CBM has Porla, Aamirza, Potegaon, The rejuvenation of the PHC Maligre, Uttur, Madilge, Subsequently the CBMP 'Doctors unavailable, patient made a significant impact, now Vadadha, Vairagad and people’s response has been Minche, Bhadole, Saajni, process was initiated and in the returns without treatment' medical officers make regular astounding. In the year 2013-14, Herle first Jan Sunwai, questions were caught the attention of people visits and its overall functioning Villages - 40 the number of deliveries has asked about the efficiency of the increased to 125 (compared to Villages - 40 has also improved. Earlier the medical officer in Maligre PHC; 2010-11, over a fifteen fold moved from private providers to Signposts of change… OPD service was offered only in this pressure led to replacement increase!); number of patients the public facility. Responding the morning, now people can of the apathetic doctor and a admitted has risen to 856 while to an appeal for donation, §Since the demand for regular health check-up of the school avail of these services in both new medical officer being number of patients coming for ordinary villagers collected one children was raised in a Jan sunwai, these are now being carried morning and afternoon sessions appointed. The new medical out patient department has and a half lakh rupees to ensure out in all schools in CBMP areas. and they are enthused by the officer welcomed the CBMP increased massively to 17,157 in colouring and repairs of the constructive changes. process, and CBMP activists this year! The CBMP process § PHC. One individual donated The Sub center at Belgaon had no electricity supply. After two In another instance of change organised his meetings in has helped to establish a channel Rs. 25,000 for a solar water years of follow up by CBMP committee, this Sub-centre has related to CBM, in Kadholi PHC various villages to give people of communication and trust heater, due to which the labour now got its electricity connection. in Kurkheda block, a positive information about the services between people and the public process has been initiated to ward in Maligre PHC now has § offered at PHC. Due to the health facility, and people have In Sonerangi, Engelkheda and Nawargaon, the CBMP address people's complaints hot water for the women coming committee shared the VHSC committee’s accounts related to health services. The for delivery. The labour ward transparently with all the villagers. Subsequently people in Village Health committee has Signposts of change… also has a separate clean toilet, these villages are participating in planning the expenses related set up a 'Health Complaint Box' § and the PHC is now kept spick to the VHSC fund. and has appealed to villagers At Minche PHC, doctors were giving prescriptions to the and span. through public announcements, patients, making them buy medicines from a private pharmacy. The phenomenal improvement §Due to vigilance by the CBMP committees, the health staff are to drop their written complaints The PHC monitoring committee objected and stopped this, of Maligre PHC has proved now residential at the places of their employment. as well as views and suggestions ensuring that all medicines are given from the PHC itself. detrimental for private clinics, §Long overdue construction of Porla PHC finally was in the box. All chits in the box §The Medical officers at Gargoti RH were not staying at the since hardly any patients now completed due to persistent follow up by CBMP committee are collected and discussed in premises. This issue was raised during the Jan sunwai and now prefer to go there. The three members. the village meeting every month they are staying at the hospital premises, making services private clinics in Maligre have to find constructive solutions. available round the clock. now shut down and are locked! §In response to the suggestions given by CBMP committee As an immediate result of this The example of Maligre PHC members in the process of a Jan sunwai, District Health initiative, the health workers §Children coming for treatment to the Pediatrician at Gargoti shows how well functioning officials have issued certain necessary orders for the entire have become more regular in RH were being referred to his private clinic. Due to the issue public health staff and the district. Since this was not being ensured earlier, now orders their village visits. being raised in the Jan Sunwai, now the pediatrician is running CBMP process can complement have been issued making it mandatory for each village to his OPD at the RH regularly, and is treating children free of each other, bringing people back include their ASHA as a member of the VHSC. charge without referring them to his private clinic. to the public health system. 60 61 Gadchiroli Kolhapur People take action, Strengthened Public health services services become responsive have put a lock on private clinics! Prior to the CBMP process, Kharmat-tola is a small village and they decided to protest at Maligre PHC in Ajara block of under Deolgaon PHC in the mentioned PHC, led by Kolhapur district functioned Kurkheda block of Gadchiroli. Shamrao Kumare, President of poorly, people in Maligre village The CBM process is evolving the Village Health, Water were indifferent to its services, well in the village through Supply, Nutrition and Sanitation District – Gadchiroli District – Kolhapur and those in neighbouring regular activities like meetings, Committee. People confronted villages were not even aware rallies, group discussions and a the six staff members present in 3 blocks – Kurkheda, 3 blocks – Aajara, about this PHC. In the entire series of programmes have the center and demanded to Gadchiroli and Armori CBMP process, villagers gave a Bhudargad and year of 2010-11, only eight created awareness among keep the facility open for good response to these meetings Hatkanangale deliveries took place in the PHC, people on the PHC services they stipulated duration i.e. 8 am to 8 PHCs- Kadholi, and gradually the doctor earned its OPD for the year was 7,380 are entitled to receive. In this noon and 3 to 5 pm. This action Malewada, Deulgaon, the faith of the people. 8 PHCs- Vatangi, and indoor admissions were 215. context, a local news story titled by people inspired by CBM has Porla, Aamirza, Potegaon, The rejuvenation of the PHC Maligre, Uttur, Madilge, Subsequently the CBMP 'Doctors unavailable, patient made a significant impact, now Vadadha, Vairagad and people’s response has been Minche, Bhadole, Saajni, process was initiated and in the returns without treatment' medical officers make regular astounding. In the year 2013-14, Herle first Jan Sunwai, questions were caught the attention of people visits and its overall functioning Villages - 40 the number of deliveries has asked about the efficiency of the increased to 125 (compared to Villages - 40 has also improved. Earlier the medical officer in Maligre PHC; 2010-11, over a fifteen fold moved from private providers to Signposts of change… OPD service was offered only in this pressure led to replacement increase!); number of patients the public facility. Responding the morning, now people can of the apathetic doctor and a admitted has risen to 856 while to an appeal for donation, §Since the demand for regular health check-up of the school avail of these services in both new medical officer being number of patients coming for ordinary villagers collected one children was raised in a Jan sunwai, these are now being carried morning and afternoon sessions appointed. The new medical out patient department has and a half lakh rupees to ensure out in all schools in CBMP areas. and they are enthused by the officer welcomed the CBMP increased massively to 17,157 in colouring and repairs of the constructive changes. process, and CBMP activists this year! The CBMP process § PHC. One individual donated The Sub center at Belgaon had no electricity supply. After two In another instance of change organised his meetings in has helped to establish a channel Rs. 25,000 for a solar water years of follow up by CBMP committee, this Sub-centre has related to CBM, in Kadholi PHC various villages to give people of communication and trust heater, due to which the labour now got its electricity connection. in Kurkheda block, a positive information about the services between people and the public process has been initiated to ward in Maligre PHC now has § offered at PHC. Due to the health facility, and people have In Sonerangi, Engelkheda and Nawargaon, the CBMP address people's complaints hot water for the women coming committee shared the VHSC committee’s accounts related to health services. The for delivery. The labour ward transparently with all the villagers. Subsequently people in Village Health committee has Signposts of change… also has a separate clean toilet, these villages are participating in planning the expenses related set up a 'Health Complaint Box' § and the PHC is now kept spick to the VHSC fund. and has appealed to villagers At Minche PHC, doctors were giving prescriptions to the and span. through public announcements, patients, making them buy medicines from a private pharmacy. The phenomenal improvement §Due to vigilance by the CBMP committees, the health staff are to drop their written complaints The PHC monitoring committee objected and stopped this, of Maligre PHC has proved now residential at the places of their employment. as well as views and suggestions ensuring that all medicines are given from the PHC itself. detrimental for private clinics, §Long overdue construction of Porla PHC finally was in the box. All chits in the box §The Medical officers at Gargoti RH were not staying at the since hardly any patients now completed due to persistent follow up by CBMP committee are collected and discussed in premises. This issue was raised during the Jan sunwai and now prefer to go there. The three members. the village meeting every month they are staying at the hospital premises, making services private clinics in Maligre have to find constructive solutions. available round the clock. now shut down and are locked! §In response to the suggestions given by CBMP committee As an immediate result of this The example of Maligre PHC members in the process of a Jan sunwai, District Health initiative, the health workers §Children coming for treatment to the Pediatrician at Gargoti shows how well functioning officials have issued certain necessary orders for the entire have become more regular in RH were being referred to his private clinic. Due to the issue public health staff and the district. Since this was not being ensured earlier, now orders their village visits. being raised in the Jan Sunwai, now the pediatrician is running CBMP process can complement have been issued making it mandatory for each village to his OPD at the RH regularly, and is treating children free of each other, bringing people back include their ASHA as a member of the VHSC. charge without referring them to his private clinic. to the public health system. 60 61 Nashik Raigad A new PHC gets sanctioned due to Flying squad of CBMP persistence of the CBMP committee committee members The block CBMP committee along with civil society For two consecutive years, the now been sanctioned to provide in Karjat discussed many issues members of the CBMP members, in form of a ‘flying much-needed health services in related to PHCs in the block, committee in Tryambakeshwar a deprived area. squad’. block in district Nashik How this process unfolded: including rude behaviour by When the muster in the PHC p e r s i s t e n t l y d e m a n d e d In March 2013, a well- certain medical officers and the was examined there were no District – Raigad construction of PHCs in two attended Jan Sunwai was District – Nashik staff not getting salary since signatures. There was no water areas, to ensure that population organised at Amboli 3 blocks – Igatpuri, last many months. The in toilets, bed sheets were not 3 blocks – Roha, coverage norms are fulfilled and PHC of Tryambak and Peth Chairperson of the Panchayat being provided, although bed- Sudhagad and Karjat people get the necessary health Tryambakeshwar block. The samiti took a decision to visit sheets were stored in the fact that 29 infant deaths had 8 PHCs - Vaitarna, services. The demand was first Kadav PHC unannounced c u p b o a r d . A s h o ck i n g 8 PHCs- Kokban, taken place in the recent past, Kananwadi, Kaluste, raised in Jan Sunwais, and discovery was the presence of Nagothane, Kolad, Pali, stirred all the people who had Amboli, Thanapada, relentless follow up was done at insects in the jar that was used Jambhulpada, Khandas, assembled. The medical officers Shirasgaon, Jogmodi, state level as well as in the to store the glass slides for Ambivali, Kadav pointed to the geographical Kohar Vidhan Sabha (State Assembly). taking blood samples. There As a result, two new PHCs have territory of the block, and brought to notice the fact that Villages - 40 was complete lack of Villages - 45 cleanliness in the PHC. When there is not a single PHC in an this, he said, “the workers do Signposts of change… area stretching over 48 km, the Sabhapati (chairperson) questioned the doctor about not listen to me”. The §Due to a proactive CBMP committee, a shed to provide shelter which currently falls under jurisdiction of the overstretched m o n i t o r i n g c o m m i t t e e for the relatives of patients was erected in Amboli PHC premises. Aboli PHC. Actually given the members also visited the sub- population and geographical Signposts of change… centre and no ANM was found §Due to active follow up by the CBMP committee, the health staff there. Again they got the same at Karashet, Thanapada and Torangan started staying at these Sub area involved, larger number of PHCs are required for this area. § reply from the doctor. centers and their services are now available to people. Due to the Earlier doctors were illegally charging patients for giving Since the majority of infant injections and saline infusions in practically all PHCs in T h e Pa n ch a y a t S a m i t i CBMP process the long pending repairs at Alwand and Take- deaths had taken place in the Sabhapati took the responsible Devgaon Sub-centres were ensured. Sudhagad, Roha and Karjat blocks. The District monitoring same region, the demand committee took strong objection to this and has stopped these staff to task and warned them emerged that additional PHCs §Kanan Wadi PHC was literally non functional; not a single illegal practices in all PHCs in CBMP areas. that such laxity will not be should be sanctioned for this tolerated in the future. delivery was being conducted there, nor was any service being sensitive terrain. The local § given to the pregnant women. When the CBMP process started Lack of cleanliness used to prevail in Pali PHC, and there was The bed sheets are being made Medical officers actively no provision of drinking water for the patients. After the available to all the patients, and the issue was raised, the center became functional, now it’s supported the demand, and the Out-patient department (OPD) has started working. Block monitoring committee raised and followed up these cleanliness of the PHC has Jan Sunwai Panel recommended problems, they have been solved. Now a drinking water filter is the same to the government. d r a s t i c a l l y i m p r o v e d , § available for the patients and cleanliness has improved. At a district level Jan sunwai in Nasik, a woman community health Over the next two years, the arrangements for water supply worker (Accredited Social Health Activist, ASHA) made a are being made through active taluka monitoring and planning §Due to overcrowding and lack of systematic management of complaint of harassment against a male health worker from the committee followed up this efforts of the gram pahchayat. PHC. Based on ongoing CBMP processes, a committee was patient flow in Kadav PHC, the patients as well as the medical matter relentlessly, and the issue officer faced a lot of inconvenience. Members from the block appointed to enquire into the case, comprising of a medical was raised by the local MLA in officer, a representative of the ASHA union, and a woman and PHC monitoring committee have now taken the winter session of the responsibility so that every day, two members work as member of the monitoring and planning committee. Committee Assembly in 2013. The result is members then made visits to the village and received many other that finally two new PHCs have volunteers to organise the examination of patients which has complaints regarding the health worker harassing adolescent girls been sanctioned for Samundi solved this problem. too. On confirming the allegation, a decision was made to and Anjneri areas. §When in a Jan Sunwai, complaint pertaining to irregularity of suspend him immediately. The aggrieved ASHA and many other One more significant impact of attendance of medical officer of Khandas PHC was made, the women were relieved, and frontline health workers realized the the CBMP process! situation changed for the better. power of Jan sunwais for resolving their own issues as well. 62 63 Nashik Raigad A new PHC gets sanctioned due to Flying squad of CBMP persistence of the CBMP committee committee members The block CBMP committee along with civil society For two consecutive years, the now been sanctioned to provide in Karjat discussed many issues members of the CBMP members, in form of a ‘flying much-needed health services in related to PHCs in the block, committee in Tryambakeshwar a deprived area. squad’. block in district Nashik How this process unfolded: including rude behaviour by When the muster in the PHC p e r s i s t e n t l y d e m a n d e d In March 2013, a well- certain medical officers and the was examined there were no District – Raigad construction of PHCs in two attended Jan Sunwai was District – Nashik staff not getting salary since signatures. There was no water areas, to ensure that population organised at Amboli 3 blocks – Igatpuri, last many months. The in toilets, bed sheets were not 3 blocks – Roha, coverage norms are fulfilled and PHC of Tryambak and Peth Chairperson of the Panchayat being provided, although bed- Sudhagad and Karjat people get the necessary health Tryambakeshwar block. The samiti took a decision to visit sheets were stored in the fact that 29 infant deaths had 8 PHCs - Vaitarna, services. The demand was first Kadav PHC unannounced c u p b o a r d . A s h o ck i n g 8 PHCs- Kokban, taken place in the recent past, Kananwadi, Kaluste, raised in Jan Sunwais, and discovery was the presence of Nagothane, Kolad, Pali, stirred all the people who had Amboli, Thanapada, relentless follow up was done at insects in the jar that was used Jambhulpada, Khandas, assembled. The medical officers Shirasgaon, Jogmodi, state level as well as in the to store the glass slides for Ambivali, Kadav pointed to the geographical Kohar Vidhan Sabha (State Assembly). taking blood samples. There As a result, two new PHCs have territory of the block, and brought to notice the fact that Villages - 40 was complete lack of Villages - 45 cleanliness in the PHC. When there is not a single PHC in an this, he said, “the workers do Signposts of change… area stretching over 48 km, the Sabhapati (chairperson) questioned the doctor about not listen to me”. The §Due to a proactive CBMP committee, a shed to provide shelter which currently falls under jurisdiction of the overstretched m o n i t o r i n g c o m m i t t e e for the relatives of patients was erected in Amboli PHC premises. Aboli PHC. Actually given the members also visited the sub- population and geographical Signposts of change… centre and no ANM was found §Due to active follow up by the CBMP committee, the health staff there. Again they got the same at Karashet, Thanapada and Torangan started staying at these Sub area involved, larger number of PHCs are required for this area. § reply from the doctor. centers and their services are now available to people. Due to the Earlier doctors were illegally charging patients for giving Since the majority of infant injections and saline infusions in practically all PHCs in T h e Pa n ch a y a t S a m i t i CBMP process the long pending repairs at Alwand and Take- deaths had taken place in the Sabhapati took the responsible Devgaon Sub-centres were ensured. Sudhagad, Roha and Karjat blocks. The District monitoring same region, the demand committee took strong objection to this and has stopped these staff to task and warned them emerged that additional PHCs §Kanan Wadi PHC was literally non functional; not a single illegal practices in all PHCs in CBMP areas. that such laxity will not be should be sanctioned for this tolerated in the future. delivery was being conducted there, nor was any service being sensitive terrain. The local § given to the pregnant women. When the CBMP process started Lack of cleanliness used to prevail in Pali PHC, and there was The bed sheets are being made Medical officers actively no provision of drinking water for the patients. After the available to all the patients, and the issue was raised, the center became functional, now it’s supported the demand, and the Out-patient department (OPD) has started working. Block monitoring committee raised and followed up these cleanliness of the PHC has Jan Sunwai Panel recommended problems, they have been solved. Now a drinking water filter is the same to the government. d r a s t i c a l l y i m p r o v e d , § available for the patients and cleanliness has improved. At a district level Jan sunwai in Nasik, a woman community health Over the next two years, the arrangements for water supply worker (Accredited Social Health Activist, ASHA) made a are being made through active taluka monitoring and planning §Due to overcrowding and lack of systematic management of complaint of harassment against a male health worker from the committee followed up this efforts of the gram pahchayat. PHC. Based on ongoing CBMP processes, a committee was patient flow in Kadav PHC, the patients as well as the medical matter relentlessly, and the issue officer faced a lot of inconvenience. Members from the block appointed to enquire into the case, comprising of a medical was raised by the local MLA in officer, a representative of the ASHA union, and a woman and PHC monitoring committee have now taken the winter session of the responsibility so that every day, two members work as member of the monitoring and planning committee. Committee Assembly in 2013. The result is members then made visits to the village and received many other that finally two new PHCs have volunteers to organise the examination of patients which has complaints regarding the health worker harassing adolescent girls been sanctioned for Samundi solved this problem. too. On confirming the allegation, a decision was made to and Anjneri areas. §When in a Jan Sunwai, complaint pertaining to irregularity of suspend him immediately. The aggrieved ASHA and many other One more significant impact of attendance of medical officer of Khandas PHC was made, the women were relieved, and frontline health workers realized the the CBMP process! situation changed for the better. power of Jan sunwais for resolving their own issues as well. 62 63 Solapur Memories of Chavdar Tale revived; patients in the Rural hospital finally got drinking water

In Indian history, 20th March The memory of this historic 1927 is a significant day. On that event was revived when at day Dr. Ambedkar drank a sip of Akkalkot Rural hospital, a Jan District – Solapur water from the water tank Sunwai began on 22rd March ‘Chavdar Talé’ at Mahad (which 2013, two days after the 1 blocks – Akkalkot was until then banned for historical event completed its ‘untouchables’), and thus 86th anniversary. Now the issue 4 PHCs- Chapalgaon, initiated the movement to of lack of drinking water for Jeur, Shirval, Vagdari State liberate Dalits. The date is poor patients in Rural Hospital commemorated as freedom day Akkalkot had become a burning Villages - 40 on for Dalits. issue. Yes, there was a water tank Convention at the hospital, but it contained Superintendent, Rural Hospital Community Accountability of no water! There was a water filter started blaming the people, but it was kept locked and was alleging that people do not use reserved only for the medical the water filter properly. Health & staff! The hospital had no Whatever might be the reasons, drinking water for the patients, the fundamental right of getting Social Services who had to make their own drinking water in the hospital arrangements to satisfy this was being violated, and the State level convention on involved wide ranging interest groups, from basic need. When the issue was officials had no remorse! After 'Community Accountability of academicians and activists to elected raised in the Jan Sunwai, the people strongly pressed for this Health & Social Services' was Panchayat members. issue in the Jan Sunwai, the A Superintendent had to declare organised on 22nd and 23rd November 2011 Signposts of change… that within a few days at Tata Institute of Social Sciences, Mumbai, The wide range of positive experiences arrangement would be made to which was an occasion for CBMP emerging from CBMP being implemented as provide drinking water to the organisations to share their work experiences part of the National Rural Health Mission in §A complaint came up in a Jan Sunwai that women who had patients. He assured that soon and insights with nearly 300 delegates coming Maharashtra since 2007 formed a key delivered were not being given their due benefit under the the water tank would be filled from more than 23 districts of Maharashtra. reference point during the two-day Janani Suraksha Yojana scheme. After probing it was revealed and taps would be fitted, making Co-organised by People's Health Movement- deliberations. In the inaugural programme, that many poor women had no bank accounts. After the Jan water available to patients. Now Maharashtra (known as Jan Arogya Abhiyan, representatives from about 30 different Sunwai, the health staff members helped many women to water has become available to all state unit of PHM-India), Centre for Rights CBMP blocks presented posters sharing open their bank accounts, so that they started getting the funds the patients in the hospital! and Governance, School for Rural briefly the key positive changes brought due to them. Development, Tata Institute of Social about, linked with their efforts. §There were no quarters at Jeur and Karjal PHCs, so the Sciences and organisations implementing medical officers were not staying in the village to offer service Community Based Monitoring of health The main speakers in the inaugural session at night. Due to the CBMP process, the quarters were built and services in Maharashtra, the convention were Prof. Yesudian, Dean, Department of now the medical officers live in the village and provide services around the clock. §The day when vaccination is given, is called Health day. In 15 villages covered under CBMP in Akkalkot block, on this day, all villagers were made aware of the jobs and responsibilities of various staffs in the health department. 64 65

State Convention on Community Accountability of Health & Social Services

State level convention on involved wide ranging interest groups, from 'Community Accountability of academicians and activists to elected AHealth & Social Services' was Panchayat members. organised on 22nd and 23rd November 2011 at Tata Institute of Social Sciences, Mumbai, The wide range of positive experiences which was an occasion for CBMP emerging from CBMP being implemented as organisations to share their work experiences part of the National Rural Health Mission in and insights with nearly 300 delegates coming Maharashtra since 2007 formed a key from more than 23 districts of Maharashtra. reference point during the two-day Co-organised by People's Health Movement- deliberations. In the inaugural programme, Maharashtra (known as Jan Arogya Abhiyan, representatives from about 30 different state unit of PHM-India), Centre for Rights CBMP blocks presented posters sharing and Governance, School for Rural briefly the key positive changes brought Development, Tata Institute of Social about, linked with their efforts. Sciences and organisations implementing Community Based Monitoring of health The main speakers in the inaugural session services in Maharashtra, the convention were Prof. Yesudian, Dean, Department of

65 Solapur Memories of Chavdar Tale revived; patients in the Rural hospital finally got drinking water

State Convention on Community Accountability of Health & Social Services

65 Health System Studies, TISS; Admiral Vishnu how issues like caste based differentials in of NREGA. greater accountability of the administrative Bhagwat, Retd. Chief of Naval Staff; Abhijit delivery of services often need to be kept in system. Nikhil emphasised that we need to Das, Member of NRHM Advisory Group for mind while doing community based planning As a keynote speaker, Medha Patkar spoke about develop models of 'people friendly information Community Action; Rakhal Gaitonde, State combined with monitoring. the significance of community involvement in display' for various social services, and the need coordinator – Community monitoring and all public services and stressed the need for to implement grievance redressal systems from planning, NRHM Tamil Nadu; and Abhay Over twenty PRI members from various decentralization and devolution of power in the District level upwards. Shukla, Coordinator- SATHI, State nodal districts recounted their experiences of how order to have accountable public systems. She agency for Community Based Monitoring and the CBMP process has led to positive local stressed the importance of empowered and In the concluding session, representatives from Planning, Maharashtra. impacts, in a session specially devoted to informed communities taking decisions about various networks such as Right to Food explore the role and future involvement of issues concerning them. campaign – Maharashtra, Bal Hakka Abhiyan, Abhay Shukla noted the significant positive Panchayat members in the CBMP process. The subsequent discussions were in parallel Movement for Peace and Justice, Wada Na Todo impacts of CBMP in form of improved They stressed the need for giving space to sessions where activists working on urban Abhiyan, Shoshit Jan Andolan and Jan Arogya presence of doctors and staff, check on local community based processes, to plan for health, water supply, public distribution system, Abhiyan discussed about possible further corruption and increased utilization of PHCs. effective use of untied funds based on ICDS and primary education discussed their activities to promote accountability of social He emphasized the need to take up people's priorities. The session with experiences of working for social rights and the sector services. Finally a set of resolutions Community monitoring not just as a project representatives of Health sector employees possibilities of community accountability demanding further development and widening but as a social process across the state, such as Maharashtra Government Medical systems in the above contexts. These sessions of Community Based Monitoring and expanding this within the health sector and officers association, State Nurses federation, highlighted the importance of having dialogue accountability of health services were adopted. working to strengthen similar accountability ASHA union and other Health sector with political representatives at various levels; processes for other social services. He noted employee unions, brought forth the need to provision of CBMP in urban areas; wider use of Overall the State convention enabled sharing of that CBMP is emerging as a strong bottom-up combine their struggles for better working accountability tools like complaint boxes and the effective approach of Community Based complement to 'Jan Lokpal' type conditions for staff with delivery of setting up of grievance redressal systems with Monitoring & Planning of health services with a accountability mechanisms, and CBMP can improved health services for people. prompt remedial action. large and diverse audience, this has taken help in checking corruption with people's forward the emerging discourse on active involvement. Abhijit Das, while The opening plenary on the second day was In the next plenary session Aruna Roy and accountability of public services, and has appreciating the efforts by civil society chaired by senior activist and academician Nikhil De from Mazdoor Kisan Shakti furthered the debate on how to develop such organizations in implementing CBMP in an Pradip Prabhu, Dean of School for Rural Sangathan (MKSS) in Rajasthan spoke about mechanisms for various services in the social effective way in the state of Maharashtra, Development, TISS. Sowmya Kidambi, their experiences in using the Right to sector. stressed the need for key insights generated Director of Society for Social Audit, Information Act and the Social Audit process to here to be replicated in other states. He Accountability and Transparency, shared enable people to demand their rights and ensure pointed out that the CBMP process was experiences of coordinating the social audit originally initiated on a pilot basis in nine process of NREGA in Andhra Pradesh. She states of the country, however only in a few mentioned that the key to an accountable states like Maharashtra has it continued in an public system is a clean and transparent effective way. Presenting key issues faced information system and shared her during CBMP execution in Tamil Nadu, experience of training more than one lakh Rakhal Gaitonde shared experiences about young people for the process of social audit

66 67 Health System Studies, TISS; Admiral Vishnu how issues like caste based differentials in of NREGA. greater accountability of the administrative Bhagwat, Retd. Chief of Naval Staff; Abhijit delivery of services often need to be kept in system. Nikhil emphasised that we need to Das, Member of NRHM Advisory Group for mind while doing community based planning As a keynote speaker, Medha Patkar spoke about develop models of 'people friendly information Community Action; Rakhal Gaitonde, State combined with monitoring. the significance of community involvement in display' for various social services, and the need coordinator – Community monitoring and all public services and stressed the need for to implement grievance redressal systems from planning, NRHM Tamil Nadu; and Abhay Over twenty PRI members from various decentralization and devolution of power in the District level upwards. Shukla, Coordinator- SATHI, State nodal districts recounted their experiences of how order to have accountable public systems. She agency for Community Based Monitoring and the CBMP process has led to positive local stressed the importance of empowered and In the concluding session, representatives from Planning, Maharashtra. impacts, in a session specially devoted to informed communities taking decisions about various networks such as Right to Food explore the role and future involvement of issues concerning them. campaign – Maharashtra, Bal Hakka Abhiyan, Abhay Shukla noted the significant positive Panchayat members in the CBMP process. The subsequent discussions were in parallel Movement for Peace and Justice, Wada Na Todo impacts of CBMP in form of improved They stressed the need for giving space to sessions where activists working on urban Abhiyan, Shoshit Jan Andolan and Jan Arogya presence of doctors and staff, check on local community based processes, to plan for health, water supply, public distribution system, Abhiyan discussed about possible further corruption and increased utilization of PHCs. effective use of untied funds based on ICDS and primary education discussed their activities to promote accountability of social He emphasized the need to take up people's priorities. The session with experiences of working for social rights and the sector services. Finally a set of resolutions Community monitoring not just as a project representatives of Health sector employees possibilities of community accountability demanding further development and widening but as a social process across the state, such as Maharashtra Government Medical systems in the above contexts. These sessions of Community Based Monitoring and expanding this within the health sector and officers association, State Nurses federation, highlighted the importance of having dialogue accountability of health services were adopted. working to strengthen similar accountability ASHA union and other Health sector with political representatives at various levels; processes for other social services. He noted employee unions, brought forth the need to provision of CBMP in urban areas; wider use of Overall the State convention enabled sharing of that CBMP is emerging as a strong bottom-up combine their struggles for better working accountability tools like complaint boxes and the effective approach of Community Based complement to 'Jan Lokpal' type conditions for staff with delivery of setting up of grievance redressal systems with Monitoring & Planning of health services with a accountability mechanisms, and CBMP can improved health services for people. prompt remedial action. large and diverse audience, this has taken help in checking corruption with people's forward the emerging discourse on active involvement. Abhijit Das, while The opening plenary on the second day was In the next plenary session Aruna Roy and accountability of public services, and has appreciating the efforts by civil society chaired by senior activist and academician Nikhil De from Mazdoor Kisan Shakti furthered the debate on how to develop such organizations in implementing CBMP in an Pradip Prabhu, Dean of School for Rural Sangathan (MKSS) in Rajasthan spoke about mechanisms for various services in the social effective way in the state of Maharashtra, Development, TISS. Sowmya Kidambi, their experiences in using the Right to sector. stressed the need for key insights generated Director of Society for Social Audit, Information Act and the Social Audit process to here to be replicated in other states. He Accountability and Transparency, shared enable people to demand their rights and ensure pointed out that the CBMP process was experiences of coordinating the social audit originally initiated on a pilot basis in nine process of NREGA in Andhra Pradesh. She states of the country, however only in a few mentioned that the key to an accountable states like Maharashtra has it continued in an public system is a clean and transparent effective way. Presenting key issues faced information system and shared her during CBMP execution in Tamil Nadu, experience of training more than one lakh Rakhal Gaitonde shared experiences about young people for the process of social audit

66 67 Community based Monitoring and Planning of Health Services

Generalising Generalising CBM through action & deepening beyond the project mode

Presently about 25 CSOs and mass community organisations are involved in implementing CBMP in 13 districts monitoring of the state. The initiative of these CSOs in implementing CBMP through effectively in these districts in an intensive project mode has been very important to demonstrate the innovative feasibility of this process. However it has been felt that CBMP based on community accountability and participation is a core principle which needs to actions… expand beyond these 13 districts, and needs to be expanded in a less intensive manner moving beyond the project mode, in many more areas. 2007 to 2009: CBM process initiated on pilot basis in 5 districts The process began when SATHI and CBMP and some activity related support. 2010 to 2012: expansion to partner organisations conducted regional level In January 2014, an advertisement was 13 districts of Maharashtra workshops, where several new NGOs and mass published by NRHM across Maharashtra in a 2013-2014: expansion to another organisations showed interest in undertaking leading state level newspaper, inviting 8 districts beyond project mode... this process on a voluntary basis in their areas. interested organisations to express interest Given this demonstrated interest, it was regarding taking up CBMP in their areas on a Along with quantitative expansion, efforts are underway for proposed that Regional Resource Persons voluntary basis. Despite a relatively short qualitative development of community action through (RRPs) would work with new organisations to deadline, 121 applications were received from develop CBMP activities in a lower intensity across the state. SATHI as the State nodal NGO innovative activities like organising conventions of Panchayat mode in various new districts, and this was set up a scrutiny committee to screen these representatives to strengthen and widen the CBMP process, included in the State supplementary PIP (2013- based on certain defined criteria, especially developing community based planning of health services, 14). After sanctioning of the supplementary experience of community health work, and expanding the community monitoring approach beyond health PIP in September 2013, five persons with conducting mass programmes or rights based care to cover ICDS services, to establish CBMP as an effective requisite field experience were selected from and accountability oriented activities on any strategy to ensure pro-people governance of social services ... different geographical regions of Maharashtra, social issue. Based on these criteria, 34 new to work as RRPs. They were assigned the task of organisations were short-listed and four identifying rights based CSOs in their respective regional workshops were conducted to orient areas, who could take up CBMP activities in a these organisations during January and voluntary manner, based on technical guidance February 2014.

68 69 Community based Monitoring and Planning of Health Services

Generalising Generalising CBM through action & deepening beyond the project mode

68 69 The Regional resource persons have co-ordinated and then, the responsibilities were distributed and with these newly involved organisations and have within three days both PHCs were thoroughly cleaned up provided guidance to enable them to conduct health . The self help group volunteers Conventions with Panchayat rights activities and preparation for Jan samwads. ascertained the fact and reported back to the District These organisations are drawn from 8 new Health Officer, who visited the PHCs and some MP members to strengthen districts covering 16 blocks t CB (where CBMP has not villages around and ensured full rectification. This is Wan yet been implemented); in each block, data has been one more example of what community based We the CBMP process collected from at least 3 PHCs and 15 villages. Since monitoring of health services can achieve, and what the regular CBMP tool for data collection was quite it means when we say, ‘people should reclaim public Local elected representatives - Panchayat Raj about the poor condition of health services in their detailed, it was made concise for this exercise, so that services’. Institution (PRI) members are important area and expressed the desire to start CBMP in their Karanja it covered basic services in the PHC. With Another Jan sunwai was conducted in stakeholders in the community based monitoring block. taluka of Washim district appropriate training and guidance from SATHI, by the CSO ‘Manoday’ process, and have been instrumental in resolving In all the conventions, the people’s representatives these organisations have prepared report cards which has a large network of self-help groups, many local level issues. To increase and sustain expressed that they find the process of CBMP which are displayed on large flex posters during the resulting in a large mobilization, with participation their involvement, district level conventions with Fourteen such Jan samvads in new useful for monitoring of health services at the local Jan samvads. of about 500 women and 100 men. The Panchayat members were conducted in Beed, level. Especially when they face some technical areas have been organised during Feb.-March organization was not sure that women would speak Amaravati, Pune and Aurangabad during January problems, they find the involvement of NGOs 2014, a couple of such Jan samvads in such new up at the Jan sunwai, as they had earlier shown and February 2014. These ‘melavas’ were attended useful. They also appreciated the fact that due to the areas are described as a sample here. hesitation, however women decided to voice their by Zilla Parishad members, Panchayat samiti CBMP process, people are now becoming aware Jan Samwad at Sangamner, District grievances, and finally so many of them wanted to members, Sarpanches and Gram about health care as their right. Ahmadnagar panchayat members from across : Lok Panchayat, a local NGO which speak that some testimonies were curtailed due to Beed Some of the demands that the villages in the districts – has been working on watershed development took time constraints. One specific case of denial was have emerged from each convention had up the responsibility of collecting data related to regarding a small boy who was referred to Amaravati the conventions, about 60 to 100 functioning of three PHCs in Sangamner block in but the vehicle was not provided by the PHC, hence are that CBMP elected District Ahmadnagar. The NGO organised a Jan they had to take a private vehicle and spent Rs. 800. should representatives. Samwad (Public Dialogue) at Sangamner where It was decided that the expense must be reimbursed be expanded more than 250 villagers participated along with the and the THO assured the funds from the RKS. Most The Pune to Taluka Health Officer (THO). Many issues of other complaints were about the MPW and ANMs convention, other blocks, concern were raised by villagers like ANM and not visiting the villages, and the THO promised that held on 17 and that the MPW not visiting villages regularly, ASHAs not disciplinary action would be taken against them. It February 2014, Aurangabad state getting trained as expected, and denial of transport was also decided that the Advance Tour Programme was attended by administratio facility for delivery. But the most forcefully raised of the ANMs would be displayed so villagers were members of the n should assist issue was the filthy nature of two PHCs, to the aware about these, and contact numbers of the Zilla Parishad in resolving the extent that hardly anyone was visiting them for THO would also be displayed so the villagers could (from various structural and treatment; villagers came with the photographs of contact him if required. political parties), the policy issues such as these PHCs. One of the panelists was a local One of the highlights of this expansion of CBMP in DHO and Sarpanches of inadequate staff and newspaper reporter, who published a news item the new districts in voluntary mode is that organisations villages, Gram Panchayat supply of medicines, that have next day with the heading - “The PHCs are dirty, and with very diverse profiles have joined in the process, members and members of various repeatedly come up during the process. the cleaning staff does not heed orders by officials.’” and are raising issues forcefully even in new areas committees involved in CBMP. The DHO spoke Another concrete demand has been that members The medical officer shared the published news with with not much earlier background of such about the many problems which they had of the district monitoring committees should be the staff responsible, which initiated change. There accountability activities. managed to solve with help of CBMP, and also included in the State monitoring and planning asked that any remaining obstacles should be committee. reported to him and other concerned officials. A letter has been drafted on behalf of the PRIs in In the Aurangabad convention, held on 22 February each district, stating that they would like expansion 2014, the Sarpanch of Nagmathane spoke about the of CBMP in their respective areas, and demanding changes that had taken in the village health services support for the same from the state machinery. As due to CBMP. He also reiterated that the best way to part of the conventions, the PRIs members have keep a check on the health services, is for us to been signing such letters, which are being sent to the monitor them ourselves. A Sarpanch from Paithan Health Minister and the Chief Minister. 70 taluka (currently not covered by CBMP) lamented 71 The Regional resource persons have co-ordinated and then, the responsibilities were distributed and with these newly involved organisations and have within three days both PHCs were thoroughly cleaned up provided guidance to enable them to conduct health . The self help group volunteers Conventions with Panchayat rights activities and preparation for Jan samwads. ascertained the fact and reported back to the District These organisations are drawn from 8 new Health Officer, who visited the PHCs and some MP members to strengthen districts covering 16 blocks t CB (where CBMP has not villages around and ensured full rectification. This is Wan yet been implemented); in each block, data has been one more example of what community based We the CBMP process collected from at least 3 PHCs and 15 villages. Since monitoring of health services can achieve, and what the regular CBMP tool for data collection was quite it means when we say, ‘people should reclaim public Local elected representatives - Panchayat Raj about the poor condition of health services in their detailed, it was made concise for this exercise, so that services’. Institution (PRI) members are important area and expressed the desire to start CBMP in their Karanja it covered basic services in the PHC. With Another Jan sunwai was conducted in stakeholders in the community based monitoring block. taluka of Washim district appropriate training and guidance from SATHI, by the CSO ‘Manoday’ process, and have been instrumental in resolving In all the conventions, the people’s representatives these organisations have prepared report cards which has a large network of self-help groups, many local level issues. To increase and sustain expressed that they find the process of CBMP which are displayed on large flex posters during the resulting in a large mobilization, with participation their involvement, district level conventions with Fourteen such Jan samvads in new useful for monitoring of health services at the local Jan samvads. of about 500 women and 100 men. The Panchayat members were conducted in Beed, level. Especially when they face some technical areas have been organised during Feb.-March organization was not sure that women would speak Amaravati, Pune and Aurangabad during January problems, they find the involvement of NGOs 2014, a couple of such Jan samvads in such new up at the Jan sunwai, as they had earlier shown and February 2014. These ‘melavas’ were attended useful. They also appreciated the fact that due to the areas are described as a sample here. hesitation, however women decided to voice their by Zilla Parishad members, Panchayat samiti CBMP process, people are now becoming aware Jan Samwad at Sangamner, District grievances, and finally so many of them wanted to members, Sarpanches and Gram about health care as their right. Ahmadnagar panchayat members from across : Lok Panchayat, a local NGO which speak that some testimonies were curtailed due to Beed Some of the demands that the villages in the districts – has been working on watershed development took time constraints. One specific case of denial was have emerged from each convention had up the responsibility of collecting data related to regarding a small boy who was referred to Amaravati the conventions, about 60 to 100 functioning of three PHCs in Sangamner block in but the vehicle was not provided by the PHC, hence are that CBMP elected District Ahmadnagar. The NGO organised a Jan they had to take a private vehicle and spent Rs. 800. should representatives. Samwad (Public Dialogue) at Sangamner where It was decided that the expense must be reimbursed be expanded more than 250 villagers participated along with the and the THO assured the funds from the RKS. Most The Pune to Taluka Health Officer (THO). Many issues of other complaints were about the MPW and ANMs convention, other blocks, concern were raised by villagers like ANM and not visiting the villages, and the THO promised that held on 17 and that the MPW not visiting villages regularly, ASHAs not disciplinary action would be taken against them. It February 2014, Aurangabad state getting trained as expected, and denial of transport was also decided that the Advance Tour Programme was attended by administratio facility for delivery. But the most forcefully raised of the ANMs would be displayed so villagers were members of the n should assist issue was the filthy nature of two PHCs, to the aware about these, and contact numbers of the Zilla Parishad in resolving the extent that hardly anyone was visiting them for THO would also be displayed so the villagers could (from various structural and treatment; villagers came with the photographs of contact him if required. political parties), the policy issues such as these PHCs. One of the panelists was a local One of the highlights of this expansion of CBMP in DHO and Sarpanches of inadequate staff and newspaper reporter, who published a news item the new districts in voluntary mode is that organisations villages, Gram Panchayat supply of medicines, that have next day with the heading - “The PHCs are dirty, and with very diverse profiles have joined in the process, members and members of various repeatedly come up during the process. the cleaning staff does not heed orders by officials.’” and are raising issues forcefully even in new areas committees involved in CBMP. The DHO spoke Another concrete demand has been that members The medical officer shared the published news with with not much earlier background of such about the many problems which they had of the district monitoring committees should be the staff responsible, which initiated change. There accountability activities. managed to solve with help of CBMP, and also included in the State monitoring and planning asked that any remaining obstacles should be committee. reported to him and other concerned officials. A letter has been drafted on behalf of the PRIs in In the Aurangabad convention, held on 22 February each district, stating that they would like expansion 2014, the Sarpanch of Nagmathane spoke about the of CBMP in their respective areas, and demanding changes that had taken in the village health services support for the same from the state machinery. As due to CBMP. He also reiterated that the best way to part of the conventions, the PRIs members have keep a check on the health services, is for us to been signing such letters, which are being sent to the monitor them ourselves. A Sarpanch from Paithan Health Minister and the Chief Minister. 70 taluka (currently not covered by CBMP) lamented 71 Taking CBMP further – Plans for deepening communitization of Health Services

While engaging with community based monitoring provision for self-governance in Fifth Schedule processes, there has been a discussion about how areas. At least half of the members on the health health services should be brought under control by councils will be women. The State Government the community. Communitisation of health services shall delegate the powers to Health councils for being implemented in Nagaland is a relevant planning the functioning of Health providers and Expanding CBM beyond health services - example, and the possibility of implementing such Health institutions at various levels. This delegation a process on a pilot basis in Maharashtra is being will be done with detailed training of the members Community based monitoring explored based on a decision taken with of the village committee together with the health involvement of the Health Minister in the State functionaries. The Arogya Gram Sabha (see below) & action for ICDS Monitoring and Planning Committee meeting in and councils will also be empowered to take certain December 2013. Communitisation is based on three decisions and actions, based on people’s priorities. specific principles – Trust, Train and Transfer. There Given the positive experiences of CBMP of Health Nagpur and Mumbai. 15 villages from each block in Another decision taken in the State Monitoring and services in Maharashtra, in mid-2013 it was rural areas i.e. total 75 villages from 5 blocks, and 39 are naturally major differences between Nagaland Planning Committee relates to organising annual and Maharashtra, and these will need to be taken proposed to the State Women & Child urban clusters from Nagpur and Mumbai cities have special ‘Gram Sabhas’ (Village Assemblies) to Development (WCD) department that applying the been involved. into account while implementing the process, which discuss health issues. To ensure participatory inputs will be implemented on a pilot basis in three CBMP principle of community monitoring to ICDS Following are some of the activities that have been for planning related to the Village untied funds, and services might help make implementation of the districts (Gadchiroli, Nandurbar and Thane) with to enable people to discuss and monitor delivery of carried out as part of this initiative : primarily adivasi population, at village, sub-centre scheme more responsive to community needs and pThe existing Village Health Sanitation and health services in their area it has been decided that more effective. ‘Community Based Monitoring and and PHC level. It is proposed to expand and annual ‘Arogya Gram Sabhas’ would be organised in Nutrition Committees were linked to the reconstitute the existing Monitoring and Planning Action’ (CBMA) related to ICDS has been initiated Mother’s committees, and these were activated all villages of the state, to enable people to discuss on a pilot basis since mid 2013, in 5 rural blocks and committees, to create Block Health Councils, which and decide on health issues. and oriented for community action to improve will implement the process, keeping in mind 2 urban areas, which includes selected rural areas in the Anganwadi. (AW or child development and Amaravati (2 blocks), Nandurbar, Gadchiroli, and nutrition centre) 72 Pune (one block each) and selected urban areas of 73 pBased on experiences of monitoring children. The first Jan samvad on nutrition rights was electricity, fans etc. and in some places the owners of Anganwadis in brief manner as part of CBMP Some of the positive impacts of the CBMA conducted at Panshet in Velhe block, Pune district the premises did not permit putting up charts, of health services, a detailed Anganwadi process so far include : on 19 December 2013. From all fifteen villages boards etc. monitoring tool has been prepared covering around 60 to 70 people participated in this Jan pSignificantly improved awareness among In Shivajinagar area of Chembur block of Mumbai, infrastructure, quality of food, difficulties faced Samwad. Several issues were raised- inadequate community members and VHSNC members there was a problem of non availability of drinking by the Anganwadi Worker (AWW) etc. Two space for AW, lack of acceptability of Take Home about the entitlements under ICDS. For water in Anganwadis. The committee discussed the rounds of data collection have been completed Ration (THR) received at AW, unavailability of example, in Gadchiroli district, following issue in their meeting and appealed to the with this tool. drinking water. People disclosed that they take the initiation of CBMA, the VHNSC members community members living next to each anganwadi p THR packets just to please AWW, but because it is A detailed survey of utilisation and community approached the District collector with the to help. Now community members have agreed to found inedible they feed this to their cattle. The experiences regarding Take home ration (THR) demand of replacement of bad quality rice provide drinking water to all the children in several demand for supplying appropriate locally cooked for under-3 children was conducted, critical grains supplied to AWs in Kurkheda Block. This anganwadis in the area, thus solving this problem. food for under-3 children instead of commercial results highlighting the serious problems with has led to replacement of bad quality rice with Overall, community based monitoring and planning THR packets has been raised in this context. The packaged THR have been published in the form good quality rice grains. is gradually becoming accepted in Maharashtra as a of a policy brief which has been widely covered panellists also explained that malnutrition was not pIn Dhadgaon block of Nandurbar district, a powerful approach for improving public health and by the State level media. merely for the anganwadis to resolve, it was the detailed meeting with the Ration shop owner nutrition related services, leading to steps towards pCommunity level meetings were conducted and responsibility of the entire village. A resolution was generalisation as well as deepening of the process. has led to ensuring regular and good quality passed that each and every village would contribute need to address the systemic and community awareness on nutrition issues was food grains to all the Anganwadis. Now there is undertaken through innovative processes like Kala 10% of the village level tax collected to improve the structural issues identified through community pIn Velhe block of Pune district, due to CBMA, Jatha, demonstration of pictorial stories etc. There AW. monitoring. now regular practical demonstrations are being Provided there is effective resolution was also a focus on identifying forms of community Similar Jan sunwais were also conducted in Mumbai organised by the Anganwadi worker, to educate st of state level policy issues, more effective response and household action, which could help to improve on 1 March and Nagpur on 5th March 2014. One mothers about methods for preparing from officials at various levels, and institutionalised nutrition. of the issues which was raised in the urban areas was medium to long term support for this process from nutritious foods for children. Minor repairs of that ICDS gives an allowance of only Rs. 750 for Certain innovative initiatives have emerged in several Anganwadis which were pending have public systems, CBMP would be able to achieve its the process so far : rent of space for anganwadi, which is quite full potential to establish people's health rights, and now been carried out due to community insufficient, since only very small premises are p‘Bal Hakk Gat’ (Child rights groups) have been intervention. to make health and other social services accountable available in this amount. Besides this, spaces and responsive to people, who would be able to formed in Kurkheda block in Gadchiroli and pIn Mumbai city, the community of available are sometimes not equipped with Velhe block in Pune, where local high school Bainganwadi, Govandi area was not even aware reclaim these through organised community action. children are actively involved in Anganwadi of the scheduled timings for opening and monitoring. closing of any Anganwadi. With awareness pIn Gadchiroli district, a local ritual called drive linked with the CBMA process, the ‘Chatavani’ was used for creating awareness community got to know about the scheduled programme in the community, where a timings. When the community observed that nutritionist was invited for providing the timings were not being observed by the information related to how to prepare AWW, it kept a close vigilance proactively and nutritious food items with the help of available noted timings of actual opening and closing for local food items. a particular anganwadi. This pressure worked pIn Velhe block, on the occasion of Raksha- and now all anganwadis are run punctually. bandhan, members of the Bal Hakka gat tied In all CBMA areas, mothers groups have been threads on the wrists of the government properly formed, these groups have become well officials working in ICDS. This was their unique oriented and are quite active in engaging with the way of appealing to these authorities to protect Anganwadis. As a result, in many places quality and children of the village from malnourishment. regularity of supplementary food in Anganwadis On 15th August the children tied the threads to has improved. a series of block level ‘Jan samvads’ (Public other political leaders and PRI members who Now Dialogues) visited the villages. From the donation collected to improve Anganwadis in all these from politicians; children bought some quality areas has been initiated. food items for the malnourished/ low weight 74 75 pBased on experiences of monitoring children. The first Jan samvad on nutrition rights was electricity, fans etc. and in some places the owners of Anganwadis in brief manner as part of CBMP Some of the positive impacts of the CBMA conducted at Panshet in Velhe block, Pune district the premises did not permit putting up charts, of health services, a detailed Anganwadi process so far include : on 19 December 2013. From all fifteen villages boards etc. monitoring tool has been prepared covering around 60 to 70 people participated in this Jan pSignificantly improved awareness among In Shivajinagar area of Chembur block of Mumbai, infrastructure, quality of food, difficulties faced Samwad. Several issues were raised- inadequate community members and VHSNC members there was a problem of non availability of drinking by the Anganwadi Worker (AWW) etc. Two space for AW, lack of acceptability of Take Home about the entitlements under ICDS. For water in Anganwadis. The committee discussed the rounds of data collection have been completed Ration (THR) received at AW, unavailability of example, in Gadchiroli district, following issue in their meeting and appealed to the with this tool. drinking water. People disclosed that they take the initiation of CBMA, the VHNSC members community members living next to each anganwadi p THR packets just to please AWW, but because it is A detailed survey of utilisation and community approached the District collector with the to help. Now community members have agreed to found inedible they feed this to their cattle. The experiences regarding Take home ration (THR) demand of replacement of bad quality rice provide drinking water to all the children in several demand for supplying appropriate locally cooked for under-3 children was conducted, critical grains supplied to AWs in Kurkheda Block. This anganwadis in the area, thus solving this problem. food for under-3 children instead of commercial results highlighting the serious problems with has led to replacement of bad quality rice with Overall, community based monitoring and planning THR packets has been raised in this context. The packaged THR have been published in the form good quality rice grains. is gradually becoming accepted in Maharashtra as a of a policy brief which has been widely covered panellists also explained that malnutrition was not pIn Dhadgaon block of Nandurbar district, a powerful approach for improving public health and by the State level media. merely for the anganwadis to resolve, it was the detailed meeting with the Ration shop owner nutrition related services, leading to steps towards pCommunity level meetings were conducted and responsibility of the entire village. A resolution was generalisation as well as deepening of the process. has led to ensuring regular and good quality passed that each and every village would contribute need to address the systemic and community awareness on nutrition issues was food grains to all the Anganwadis. Now there is undertaken through innovative processes like Kala 10% of the village level tax collected to improve the structural issues identified through community pIn Velhe block of Pune district, due to CBMA, Jatha, demonstration of pictorial stories etc. There AW. monitoring. now regular practical demonstrations are being Provided there is effective resolution was also a focus on identifying forms of community Similar Jan sunwais were also conducted in Mumbai organised by the Anganwadi worker, to educate st of state level policy issues, more effective response and household action, which could help to improve on 1 March and Nagpur on 5th March 2014. One mothers about methods for preparing from officials at various levels, and institutionalised nutrition. of the issues which was raised in the urban areas was medium to long term support for this process from nutritious foods for children. Minor repairs of that ICDS gives an allowance of only Rs. 750 for Certain innovative initiatives have emerged in several Anganwadis which were pending have public systems, CBMP would be able to achieve its the process so far : rent of space for anganwadi, which is quite full potential to establish people's health rights, and now been carried out due to community insufficient, since only very small premises are p‘Bal Hakk Gat’ (Child rights groups) have been intervention. to make health and other social services accountable available in this amount. Besides this, spaces and responsive to people, who would be able to formed in Kurkheda block in Gadchiroli and pIn Mumbai city, the community of available are sometimes not equipped with Velhe block in Pune, where local high school Bainganwadi, Govandi area was not even aware reclaim these through organised community action. children are actively involved in Anganwadi of the scheduled timings for opening and monitoring. closing of any Anganwadi. With awareness pIn Gadchiroli district, a local ritual called drive linked with the CBMA process, the ‘Chatavani’ was used for creating awareness community got to know about the scheduled programme in the community, where a timings. When the community observed that nutritionist was invited for providing the timings were not being observed by the information related to how to prepare AWW, it kept a close vigilance proactively and nutritious food items with the help of available noted timings of actual opening and closing for local food items. a particular anganwadi. This pressure worked pIn Velhe block, on the occasion of Raksha- and now all anganwadis are run punctually. bandhan, members of the Bal Hakka gat tied In all CBMA areas, mothers groups have been threads on the wrists of the government properly formed, these groups have become well officials working in ICDS. This was their unique oriented and are quite active in engaging with the way of appealing to these authorities to protect Anganwadis. As a result, in many places quality and children of the village from malnourishment. regularity of supplementary food in Anganwadis On 15th August the children tied the threads to has improved. a series of block level ‘Jan samvads’ (Public other political leaders and PRI members who Now Dialogues) visited the villages. From the donation collected to improve Anganwadis in all these from politicians; children bought some quality areas has been initiated. food items for the malnourished/ low weight 74 75 However, where addressing the grievance Community involvement, though present, needs requires intervention at higher levels, there are to increase substantially to ensure sustainability instances when effective response from higher of the process. officials is lacking and the issue remains It has been discussed that the process of attaining unresolved. It is noted that this could lead to de- sustainability will take time. Withdrawal of Civil motivation of the community and NGOs. society organisations in absence of an effective An important aspect of the CBMP process has alternative to lead the process may be counter- been the involvement of multiple stakeholders, productive, since CBMP is a complex process especially the PRI members. An example of this which involves mobilisation, local advocacy and noted in one of the evaluations, is the proactive capacity building of community members and role of Chairperson, Zilla Parishad, Mokhada, representatives in various committees. Increased External evaluations : Thane: role of PRI members is also an essential “In one block, the chairperson of ZP who is the member of component of the sustainability process. A 'report card' on the district level monitoring committee has asked people to Along with regular and adequate flow of funds, contact him on his personal number if they face any ensuring ongoing training and capacity building Community Based Monitoring of difficulties in accessing services. He receives many such calls of members of various committees (many of health services in Maharashtra and resolves the problems.” whom, especially PRI members, change Evaluation report by Renu Khanna periodically due to elections) has been noted as an As part of both the evaluations, health officials at important challenge. What two recent external evaluations (2013) collection for needs assessment and various levels were also interviewed. Despite a Following are some recommendations made have to say about the CBMP process, its identification of gaps in the health services. This few points of resentment, an important by the two evaluations : parameter of the effectiveness of the process is impact and challenges has created a system of accountability and pSufficient and timely resources for the that it has been lauded by several health officials at To objectively assess the Community Based introduced the crucial element of people’s process should be available, based on participation. various levels. Monitoring process in Maharashtra and ascertain systematic timelines suggested by AGCA its relevance, effectiveness and impact on health Both evaluations also indicate that the process “The CBM concept was good for the health services at pCommunity based planning component services, two evaluation studies have been has shown an impact through resolution of different levels. It ensures that the difficulties/issues of should be given more importance in the conducted in 2013. One was undertaken by the complaints, better availability of services and people would get resolved at each level and NGOs bring out coming phase. SHSRC (State Health Systems Resource Centre) better behaviour of staff with patients. Due to the valuable points which could bring positive changes in the p Maharashtra with involvement of consultant increased awareness and training of members of system” (District govt official, Osmanabad) Communication between community/ NGOs and government officials should be organizations Pravara Institute of Medical various level committees, the utilization of SHSRC evaluation report Sciences (PIMS), Loni and Gramin Samasya untied funds has improved. Jan sunwais too have improved. “The significant aspect of CBM was the public hearing Mukti Trust (GSMT), Yavatmal. The other study proved to be crucial tools which provide a pState level processes should be strengthened. was done by senior evaluator Ms. Renu Khanna platform for interface between community and and public dialogue which serves as base for resolving the public issues, CBM process made availability of physical pA systematic programme is required for (who was one of the lead evaluators in the healthcare providers, and several issues raised in sensitization of the health system to issues national evaluation of CBMP pilot phase in the Jan sunwais have been resolved by concerned infrastructure (Belsar PHC) and manpower to render of power, democratic functioning 2009), under the guidance of the NRHM- authorities. Some of the changes brought about quality health services. There was a change in trend accountability and professional ethics, to Advisory Group on Community Action. in the CBMP villages have also been extended to (increase) of OPD patients visit and institutional deliveries” (Block govt official, Pune) ensure responsiveness of the system. Samples for both evaluations were selected from broader areas. the pilot phase districts- Amaravati, Nandurbar, To quote an example from Shahada, Nandurbar, SHSRC evaluation report References Osmanabad, Pune and Thane. The evaluations Challenges : "A mother reported to one of the CBMP committee Khanna, R. and Pradhan, A. 2013. Evaluation of the process of used both qualitative and quantitative data members that the ANM is asking bribe to give the JSY Sustainability remains one of the major community based monitoring and planning of health services collection with multiple tools like interviews, benefits. After verifying facts of this situation, the issue challenges for the CBMP process. Both in Maharashtra. Evaluation carried out under guidance of FGDs etc. was raised in the Jansunwai. Medical Officer very evaluations indicate that the role played by the NRHM-Advisory Group on Community Action (AGCA). The two evaluations indicate that overall most of promptly took action and assured to clear all issues related CSOs and NGOs in the process is crucial and Pune, India: SATHI. the structures envisaged in the CBMP process to JSY. Because of this even in non CBM PHCs and they are mostly the driving force behind the State Health System Resource Centre (SHSRC). 2013. have been set up, and are functioning as per their villages this matter was solved." Evaluation of community based monitoring and planning of success of the process. Where CBMP has shown health care services under National Rural Health Mission, mandate. The CBMP process has led to SHSRC evaluation report results, it has significantly been due to the pro- Maharashtra. Pune, India: SHSRC. development of mechanisms for periodic data active role played by the NGOs/CSOs. 76 77 However, where addressing the grievance Community involvement, though present, needs requires intervention at higher levels, there are to increase substantially to ensure sustainability instances when effective response from higher of the process. officials is lacking and the issue remains It has been discussed that the process of attaining unresolved. It is noted that this could lead to de- sustainability will take time. Withdrawal of Civil motivation of the community and NGOs. society organisations in absence of an effective An important aspect of the CBMP process has alternative to lead the process may be counter- been the involvement of multiple stakeholders, productive, since CBMP is a complex process especially the PRI members. An example of this which involves mobilisation, local advocacy and noted in one of the evaluations, is the proactive capacity building of community members and role of Chairperson, Zilla Parishad, Mokhada, representatives in various committees. Increased External evaluations : Thane: role of PRI members is also an essential “In one block, the chairperson of ZP who is the member of component of the sustainability process. A 'report card' on the district level monitoring committee has asked people to Along with regular and adequate flow of funds, contact him on his personal number if they face any ensuring ongoing training and capacity building Community Based Monitoring of difficulties in accessing services. He receives many such calls of members of various committees (many of health services in Maharashtra and resolves the problems.” whom, especially PRI members, change Evaluation report by Renu Khanna periodically due to elections) has been noted as an As part of both the evaluations, health officials at important challenge. What two recent external evaluations (2013) collection for needs assessment and various levels were also interviewed. Despite a Following are some recommendations made have to say about the CBMP process, its identification of gaps in the health services. This few points of resentment, an important by the two evaluations : parameter of the effectiveness of the process is impact and challenges has created a system of accountability and pSufficient and timely resources for the that it has been lauded by several health officials at To objectively assess the Community Based introduced the crucial element of people’s process should be available, based on participation. various levels. Monitoring process in Maharashtra and ascertain systematic timelines suggested by AGCA its relevance, effectiveness and impact on health Both evaluations also indicate that the process “The CBM concept was good for the health services at pCommunity based planning component services, two evaluation studies have been has shown an impact through resolution of different levels. It ensures that the difficulties/issues of should be given more importance in the conducted in 2013. One was undertaken by the complaints, better availability of services and people would get resolved at each level and NGOs bring out coming phase. SHSRC (State Health Systems Resource Centre) better behaviour of staff with patients. Due to the valuable points which could bring positive changes in the p Maharashtra with involvement of consultant increased awareness and training of members of system” (District govt official, Osmanabad) Communication between community/ NGOs and government officials should be organizations Pravara Institute of Medical various level committees, the utilization of SHSRC evaluation report Sciences (PIMS), Loni and Gramin Samasya untied funds has improved. Jan sunwais too have improved. “The significant aspect of CBM was the public hearing Mukti Trust (GSMT), Yavatmal. The other study proved to be crucial tools which provide a pState level processes should be strengthened. was done by senior evaluator Ms. Renu Khanna platform for interface between community and and public dialogue which serves as base for resolving the public issues, CBM process made availability of physical pA systematic programme is required for (who was one of the lead evaluators in the healthcare providers, and several issues raised in sensitization of the health system to issues national evaluation of CBMP pilot phase in the Jan sunwais have been resolved by concerned infrastructure (Belsar PHC) and manpower to render of power, democratic functioning 2009), under the guidance of the NRHM- authorities. Some of the changes brought about quality health services. There was a change in trend accountability and professional ethics, to Advisory Group on Community Action. in the CBMP villages have also been extended to (increase) of OPD patients visit and institutional deliveries” (Block govt official, Pune) ensure responsiveness of the system. Samples for both evaluations were selected from broader areas. the pilot phase districts- Amaravati, Nandurbar, To quote an example from Shahada, Nandurbar, SHSRC evaluation report References Osmanabad, Pune and Thane. The evaluations Challenges : "A mother reported to one of the CBMP committee Khanna, R. and Pradhan, A. 2013. Evaluation of the process of used both qualitative and quantitative data members that the ANM is asking bribe to give the JSY Sustainability remains one of the major community based monitoring and planning of health services collection with multiple tools like interviews, benefits. After verifying facts of this situation, the issue challenges for the CBMP process. Both in Maharashtra. Evaluation carried out under guidance of FGDs etc. was raised in the Jansunwai. Medical Officer very evaluations indicate that the role played by the NRHM-Advisory Group on Community Action (AGCA). The two evaluations indicate that overall most of promptly took action and assured to clear all issues related CSOs and NGOs in the process is crucial and Pune, India: SATHI. the structures envisaged in the CBMP process to JSY. Because of this even in non CBM PHCs and they are mostly the driving force behind the State Health System Resource Centre (SHSRC). 2013. have been set up, and are functioning as per their villages this matter was solved." Evaluation of community based monitoring and planning of success of the process. Where CBMP has shown health care services under National Rural Health Mission, mandate. The CBMP process has led to SHSRC evaluation report results, it has significantly been due to the pro- Maharashtra. Pune, India: SHSRC. development of mechanisms for periodic data active role played by the NGOs/CSOs. 76 77 Thane, Nandurbar, Amaravati, Osmanabad, Pune What did we achieve through this process of community Community based monitoring and planning : based monitoring and planning of health services? Learning from findings Key Points, of external observers! Any live social process is an evolving, dynamic entity, which cannot be judged in terms of any 'final outcome'. Ongoing events constitute successive links in an open ended process. But it is Challenges our experience that if we are able to see the visible tip of an iceberg, a much larger invisible what two process can be extrapolated from what is visible. In this context, let us have a look at and external observers, the international developmental organisation ‘Oxfam’ and a Member of the Planning commission of India, have observed during field visits to an Appeal observe the CBMP process in Maharashtra. During October 2010, Member of Planning Commission Dr. Syeda Hameed accompanied by Senior Adviser (Health) Dr. N.K. Sethi observed CBMP processes in Maharashtra by visiting villages, tribal hamlets, Public Health centres and hospitals in two districts, and had To, opinions, observations and consultations with diverse stakeholders. These are some of the Panchayati raj institution members, recommendations expressed in the Planning commission Member's report. community members, Principally Community-based Monitoring involves drawing in, activating, NGOs & CBOs, Health officials and staff motivating, capacity building and allowing the community and its representatives e.g. community-based organizations (CBOs), people's movements, voluntary organizations and Panchayat representatives, to directly give feedback about the functioning of public health services. CBM strives to develop synergy and We have moved ahead, but do not claim that we partnership between the public health service providers and community to enable have been able to radically improve health better delivery and utilization of health services. It is critical to develop clear spaces for communities to participate in all aspects of the health system including policy services. making, planning, and implementation and holding the system accountable. But if we all join our efforts then certainly the The CBM process is a boon for the de-mystification of the complex schemes that are meant to provide basic health care services to all. Also, in a few areas it was 'Government' clinics will become 'Peoples' clinics. observed that CBM process not only benefits the community but also addresses difficulties faced by the service providers (doctors, other health functionaries), and tries to bring out solutions for them. The tribal population, as observed is quite proactive and would reap significant voice if the process of CBM is strengthened institutionally especially in these remote areas. However, this cannot be done unless there is a commitment and deeper understanding among the service providers / government machinery of the benefits that CBM would have on the overall process. 'Jan sunwais' are periodically organized with mass participation at primary health centers and at the district level, where this information and cases of denial of health

78 79 Thane, Nandurbar, Amaravati, Osmanabad, Pune What did we achieve through this process of community Community based monitoring and planning : based monitoring and planning of health services? Learning from findings Key Points, of external observers! Any live social process is an evolving, dynamic entity, which cannot be judged in terms of any 'final outcome'. Ongoing events constitute successive links in an open ended process. But it is Challenges our experience that if we are able to see the visible tip of an iceberg, a much larger invisible what two process can be extrapolated from what is visible. In this context, let us have a look at and external observers, the international developmental organisation ‘Oxfam’ and a Member of the Planning commission of India, have observed during field visits to an Appeal observe the CBMP process in Maharashtra. During October 2010, Member of Planning Commission Dr. Syeda Hameed accompanied by Senior Adviser (Health) Dr. N.K. Sethi observed CBMP processes in Maharashtra by visiting villages, tribal hamlets, Public Health centres and hospitals in two districts, and had To, opinions, observations and consultations with diverse stakeholders. These are some of the Panchayati raj institution members, recommendations expressed in the Planning commission Member's report. community members, Principally Community-based Monitoring involves drawing in, activating, NGOs & CBOs, Health officials and staff motivating, capacity building and allowing the community and its representatives e.g. community-based organizations (CBOs), people's movements, voluntary organizations and Panchayat representatives, to directly give feedback about the functioning of public health services. CBM strives to develop synergy and We have moved ahead, but do not claim that we partnership between the public health service providers and community to enable have been able to radically improve health better delivery and utilization of health services. It is critical to develop clear spaces for communities to participate in all aspects of the health system including policy services. making, planning, and implementation and holding the system accountable. But if we all join our efforts then certainly the The CBM process is a boon for the de-mystification of the complex schemes that are meant to provide basic health care services to all. Also, in a few areas it was 'Government' clinics will become 'Peoples' clinics. observed that CBM process not only benefits the community but also addresses difficulties faced by the service providers (doctors, other health functionaries), and tries to bring out solutions for them. The tribal population, as observed is quite proactive and would reap significant voice if the process of CBM is strengthened institutionally especially in these remote areas. However, this cannot be done unless there is a commitment and deeper understanding among the service providers / government machinery of the benefits that CBM would have on the overall process. 'Jan sunwais' are periodically organized with mass participation at primary health centers and at the district level, where this information and cases of denial of health

78 79 care are presented. … Over a period of time, centres also acquired new facilities, such as along with civil society organizations, village and ambulances and hot water, resulting in an The real challenge is how to deepen and generalise block level Panchayat members are also showing increase in the number of visits and childbirths in increasing interest in this process. Lack of hospital. Such changes indicate a synergy the process, while making it sustainable… accountability and monitoring of public health between the NRHM ‘top-down’ push and the CBM services especially in remote areas can also be ‘bottom-up’ pull. … As the pages of this booklet show, development of community based monitoring and made effective through CBM not only in health In Oxfam interviews in Maharashtra state, planning of health services in Maharashtra over the last seven years has been an exciting schemes but in other schemes like education, community members confirmed significant and unfolding journey. Though we have made some significant advances, the journey is public distribution systems, mid-day meals etc. improvements in the attitudes of medical staff just beginning. This can be done on a pilot basis to begin with and towards patients, following the requirement to to see the impact in terms of Community based monitoring and planning is not just “one more project”, but is a key respond to patient queries and complaints, and improvement at the village community emerging social approach to transforming governance. Large scale public services are listen to patients’ suggested solutions. Public level and above. delivered by systems controlled at state or national levels, yet are supposed to be promises to tackle problems have allowed accountable and responsive to ordinary people in diverse, remote villages. Here CBMP is Oxfam International has published a community members to undertake consistent and one of the measures which can help ensure that such services indeed meet people's needs. policy brief ‘Held to Account’, for which the broad-based follow-up. … Since people are currently placed on the periphery of public systems despite being their researcher Cecile Unternaehrer from Belgium The role of grassroots organizations was crucial formal 'owners', CBMP is an approach which can begin to ensure that people as the real investigated the CBMP process in Maharashtra in to the CBM’s success. NGOs brought local 'owners' begin to assert their central role. In this context, CBMP deserves much more 2012. This researcher visited various villages, expertise that complemented the top-down development, and there are frontiers along which further advances need to be made. approach of official bodies, and directly mobilized talked with a diverse range of stakeholders expansion of CBMP to further districts, blocks and villages community participation. Over time, their role is One front is in including Panchayat members and NRHM likely to shift as communities become more Maharashtra. Recently through promoting voluntary action, the scope of Community officials, based on which the following empowered, and elected representatives monitoring has been expanded beyond 13 districts to new blocks in 8 districts, which will 1 observations have been made in the policy brief : strengthen their involvement. Activists foresee lead to such broadening; however, such expansion must further continue. The CBMP communities taking up the baton and becoming The districts of Maharashtra state approach is also relevant for urban areas, and should be actively promoted as a component initiators of change – not simply where CBM was implemented saw of the Urban health mission. For expansion, there is need to identify appropriate civil beneficiaries of it – for example in significant improvements in health society organisations, to facilitate the process, also continued support from NRHM at planning and budgeting processes. service delivery: medical staff were state and national levels for such expansion is essential. present more regularly in the health centre or These are significant observations and combine community monitoring with community based Another cutting edge is to hospital, vacant staff positions were more readily recommendations from external observers. It is planning. It is not sufficient for communities and local activists to point out the filled, and outreach staff visited villages more evident that certain issues and gaps in Public frequently and according to a pre-determined problems; this process needs to flow into collectively working out and suggesting Health services are being addressed and calendar. Medicine stocks and budgets were appropriate solutions, for asserting people's priorities in the planning process. From displayed in health facilities, limiting the potential improvements are taking place through CBMP. village health planning, to planning for health facilities like PHCs and CHCs, and moving for illegal charges and mismanagement. But we would like to add that many issues remain on to Block and District health planning, there is tremendous need and scope to expand The most noticeable change has been the unresolved, and in many of these situations, this area of work. extending the CBMP approach to other social services. increased levels of trust in public health services, decisions are required to be taken at systemic or A third frontline is Those with many more people using their services and policy level for their resolution. In the influence problems which afflict public health services – limited accountability, provider's lack of purchasing medicines through health facility zone of CBMP, civil society activists are taking responsiveness, gap between official provisions and people's experience of pharmacies, rather than from private ones. the lead along with Panchayat representatives and services – are shared by other social services like Anganwadis, PDS, water Several dysfunctional sub-centres and PHCs community members for making Public health supply, education etc. which are also crucial for people's health. Hence it is have become operational again. Some health services accountable; this influence is strong at proposed that in areas where CBMP of health services is underway, local and block levels but becomes weaker at community monitoring of other social services should also be initiated on District and State levels. As is expected in any a pilot basis. As mentioned in this report, one step in this direction has dynamic change process, with development and been made by initiating Community based monitoring and action for ICDS services. 'Multi-sectoral' community monitoring would require expansion, the challenges and frontiers for change also expand, and these need to be addressed through continuously evolving Dr. Abhay Shukla, strategies. Coordinator, SATHI, State Nodal Organisation, CBMP. Member, NHM Advisory Group for Community Action 1: Oxfam briefing paper 'Held to Account' available at: http://www.oxfam.org/en/policy/held-account 80 81 care are presented. … Over a period of time, centres also acquired new facilities, such as along with civil society organizations, village and ambulances and hot water, resulting in an The real challenge is how to deepen and generalise block level Panchayat members are also showing increase in the number of visits and childbirths in increasing interest in this process. Lack of hospital. Such changes indicate a synergy the process, while making it sustainable… accountability and monitoring of public health between the NRHM ‘top-down’ push and the CBM services especially in remote areas can also be ‘bottom-up’ pull. … As the pages of this booklet show, development of community based monitoring and made effective through CBM not only in health In Oxfam interviews in Maharashtra state, planning of health services in Maharashtra over the last seven years has been an exciting schemes but in other schemes like education, community members confirmed significant and unfolding journey. Though we have made some significant advances, the journey is public distribution systems, mid-day meals etc. improvements in the attitudes of medical staff just beginning. This can be done on a pilot basis to begin with and towards patients, following the requirement to to see the impact in terms of Community based monitoring and planning is not just “one more project”, but is a key respond to patient queries and complaints, and improvement at the village community emerging social approach to transforming governance. Large scale public services are listen to patients’ suggested solutions. Public level and above. delivered by systems controlled at state or national levels, yet are supposed to be promises to tackle problems have allowed accountable and responsive to ordinary people in diverse, remote villages. Here CBMP is Oxfam International has published a community members to undertake consistent and one of the measures which can help ensure that such services indeed meet people's needs. policy brief ‘Held to Account’, for which the broad-based follow-up. … Since people are currently placed on the periphery of public systems despite being their researcher Cecile Unternaehrer from Belgium The role of grassroots organizations was crucial formal 'owners', CBMP is an approach which can begin to ensure that people as the real investigated the CBMP process in Maharashtra in to the CBM’s success. NGOs brought local 'owners' begin to assert their central role. In this context, CBMP deserves much more 2012. This researcher visited various villages, expertise that complemented the top-down development, and there are frontiers along which further advances need to be made. approach of official bodies, and directly mobilized talked with a diverse range of stakeholders expansion of CBMP to further districts, blocks and villages community participation. Over time, their role is One front is in including Panchayat members and NRHM likely to shift as communities become more Maharashtra. Recently through promoting voluntary action, the scope of Community officials, based on which the following empowered, and elected representatives monitoring has been expanded beyond 13 districts to new blocks in 8 districts, which will 1 observations have been made in the policy brief : strengthen their involvement. Activists foresee lead to such broadening; however, such expansion must further continue. The CBMP communities taking up the baton and becoming The districts of Maharashtra state approach is also relevant for urban areas, and should be actively promoted as a component initiators of change – not simply where CBM was implemented saw of the Urban health mission. For expansion, there is need to identify appropriate civil beneficiaries of it – for example in significant improvements in health society organisations, to facilitate the process, also continued support from NRHM at planning and budgeting processes. service delivery: medical staff were state and national levels for such expansion is essential. present more regularly in the health centre or These are significant observations and combine community monitoring with community based Another cutting edge is to hospital, vacant staff positions were more readily recommendations from external observers. It is planning. It is not sufficient for communities and local activists to point out the filled, and outreach staff visited villages more evident that certain issues and gaps in Public frequently and according to a pre-determined problems; this process needs to flow into collectively working out and suggesting Health services are being addressed and calendar. Medicine stocks and budgets were appropriate solutions, for asserting people's priorities in the planning process. From displayed in health facilities, limiting the potential improvements are taking place through CBMP. village health planning, to planning for health facilities like PHCs and CHCs, and moving for illegal charges and mismanagement. But we would like to add that many issues remain on to Block and District health planning, there is tremendous need and scope to expand The most noticeable change has been the unresolved, and in many of these situations, this area of work. extending the CBMP approach to other social services. increased levels of trust in public health services, decisions are required to be taken at systemic or A third frontline is Those with many more people using their services and policy level for their resolution. In the influence problems which afflict public health services – limited accountability, provider's lack of purchasing medicines through health facility zone of CBMP, civil society activists are taking responsiveness, gap between official provisions and people's experience of pharmacies, rather than from private ones. the lead along with Panchayat representatives and services – are shared by other social services like Anganwadis, PDS, water Several dysfunctional sub-centres and PHCs community members for making Public health supply, education etc. which are also crucial for people's health. Hence it is have become operational again. Some health services accountable; this influence is strong at proposed that in areas where CBMP of health services is underway, local and block levels but becomes weaker at community monitoring of other social services should also be initiated on District and State levels. As is expected in any a pilot basis. As mentioned in this report, one step in this direction has dynamic change process, with development and been made by initiating Community based monitoring and action for ICDS services. 'Multi-sectoral' community monitoring would require expansion, the challenges and frontiers for change also expand, and these need to be addressed through continuously evolving Dr. Abhay Shukla, strategies. Coordinator, SATHI, State Nodal Organisation, CBMP. Member, NHM Advisory Group for Community Action 1: Oxfam briefing paper 'Held to Account' available at: http://www.oxfam.org/en/policy/held-account 80 81 Who can 'monitor' those active support from various government departments. Moving forward on all these frontiers requires continued, deepened support from who are doing monitoring? the Government, especially the National Health Mission, in terms of resources, facilitating orders and positive participation at all levels, complemented by providing space to facilitating organisations and community based committees. Obviously, those whose social contributions are Such support could provide the conditions in which ordinary people, the real protagonists of this process, would move ahead to take charge of the public unquestioned, those who are shaping the direction of services which belong to them, and take forward community monitoring and society. planning which must become a people's movement. We placed the process of Community based Challenges in the CBMP process monitoring and planning of health services before some of these socially eminent personalities and asked Any process as multi-dimensional and complex as CBMP, involving diverse their opinion about the process. These well known stakeholders and seeking to significantly change an established system through 'creative conflict' is bound to face many challenges; a few of these are mentioned personalities have expressed their opinions about this here. Firstly, although health services in CBMP areas have improved in some

respects, much more improvement is required, which is mostly dependent on process. The gist of their responses is… systemic and policy level factors, e.g. ensuring adequate staff including specialist doctors, and overhauling the system for medicine procurement. If required changes at policy level do not take place, then further improvements would slow down leading to frustration among people involved in the process. positive involvement of health officials at various levels Next, the in the CBMP process is not always assured, and certain officials tend to restrict their “This process is important. participation, resist accountability and even delay decisions, which retard the process. There is need for strong ownership and regular orientation of officials, It is in the broader interests and ensuring that key official decisions related to CBMP are taken in a timely tendency among some officials to reduce the role of manner. Further, there is a of society. civil society organisations in facilitating the CBMP process – which does not recognise the key role that CSOs have played in developing community awareness Promote it and develop it.” and skills, fostering mobilization, organising dialogue, as well as guiding data collection and analysis. It is unrealistic to expect that ordinary people who have been traditionally completely on the margins of the health system will be able to automatically challenge and hold accountable this large and complex system, without certain forms of organisation and capacity building. Hence the crucial role of CSOs in CBMP needs to be positively recognised, even though this role should be modified and may reduce over a period of time. Finally there is a 'frontier' which is also a challenge. This consists in Community based monitoring and planning being able to move from a project to movement mode , and being increasingly taken up by ordinary people themselves. CBMP is a complex activity, which initially requires some knowledge- based and social facilitation by civil society organisations. However, over a period of time, aware and organised people themselves will need to take up major initiative, while CSOs move into supportive roles, enabling wider generalisation and sustainability of the process. How this can develop in a movement mode with a large degree of voluntary initiative is a core challenge that we must address. 82 83 Who can 'monitor' those active support from various government departments. Moving forward on all these frontiers requires continued, deepened support from who are doing monitoring? the Government, especially the National Health Mission, in terms of resources, facilitating orders and positive participation at all levels, complemented by providing space to facilitating organisations and community based committees. Obviously, those whose social contributions are Such support could provide the conditions in which ordinary people, the real protagonists of this process, would move ahead to take charge of the public unquestioned, those who are shaping the direction of services which belong to them, and take forward community monitoring and society. planning which must become a people's movement. We placed the process of Community based Challenges in the CBMP process monitoring and planning of health services before some of these socially eminent personalities and asked Any process as multi-dimensional and complex as CBMP, involving diverse their opinion about the process. These well known stakeholders and seeking to significantly change an established system through 'creative conflict' is bound to face many challenges; a few of these are mentioned personalities have expressed their opinions about this here. Firstly, although health services in CBMP areas have improved in some respects, much more improvement is required, which is mostly dependent on process. The gist of their responses is… systemic and policy level factors, e.g. ensuring adequate staff including specialist doctors, and overhauling the system for medicine procurement. If required changes at policy level do not take place, then further improvements would slow down leading to frustration among people involved in the process. positive involvement of health officials at various levels Next, the in the CBMP process is not always assured, and certain officials tend to restrict their “This process is important. participation, resist accountability and even delay decisions, which retard the process. There is need for strong ownership and regular orientation of officials, It is in the broader interests and ensuring that key official decisions related to CBMP are taken in a timely tendency among some officials to reduce the role of manner. Further, there is a of society. civil society organisations in facilitating the CBMP process – which does not recognise the key role that CSOs have played in developing community awareness Promote it and develop it.” and skills, fostering mobilization, organising dialogue, as well as guiding data collection and analysis. It is unrealistic to expect that ordinary people who have been traditionally completely on the margins of the health system will be able to automatically challenge and hold accountable this large and complex system, without certain forms of organisation and capacity building. Hence the crucial role of CSOs in CBMP needs to be positively recognised, even though this role should be modified and may reduce over a period of time. Finally there is a 'frontier' which is also a challenge. This consists in Community based monitoring and planning being able to move from a project to movement mode , and being increasingly taken up by ordinary people themselves. CBMP is a complex activity, which initially requires some knowledge- based and social facilitation by civil society organisations. However, over a period of time, aware and organised people themselves will need to take up major initiative, while CSOs move into supportive roles, enabling wider generalisation and sustainability of the process. How this can develop in a movement mode with a large degree of voluntary initiative is a core challenge that we must address. 82 83 Dr. Syeda Hameed Dr. Tarun Seem Former Member, Planning Commission , Govt. of India Former Director, Ministry of Health and Family Welfare

An opportunity to take development This is a role model for other states… to the most marginalized he health sector reform agenda, long overdue in our country has found a robust vehicle under the mandate and framework for implementation of NRHM. Comprehensive, he biggest problem we encounter is inadequate implementation. The schemes architectural corrections in all aspects of Public Health have accelerated the journey of which are very well conceptualised at higher level by the Government of India are T public systems towards Universal Health Care. often not implemented appropriately at grassroots level. The schemes are well T The reforms under NRHM are steered by Govt. of India in partnership with the states, and the designed but are not found efficacious as they should be at the ground level. Hence there is a lot of dissatisfaction about health programs all around. state of Maharashtra has been a front runner in several strategies like disease surveillance, community monitoring etc. So, what I found useful in the CBMP program is that the most disempowered people – The selection of the state nodal NGO under the CBM initiative was through a rigorous, the tribal population has actually started monitoring the program. They sit in a public decentralized process and Maharashtra was fortunate to have the services of SATHI-CEHAT forum to speak and express themselves, they discuss their issues with health officials and available for this task. The active involvement of leaders of SATHI in the Advisory Group on the local health officials have actually started responding to them. Community Action at National level facilitated rapid and accurate internalization of CBM ethos amongst state level stakeholders. Close follow up and concerted, affirmative efforts at field level People are now able to express themselves and get themselves heard at 'Jan sunvais' by SATHI allowed the state to complete the first phase rapidly. While the scale up took some regarding health services and nutrition schemes like Anganwadi services. I feel all of this time, the difficult task of including the initiative into the state annual PIP was accomplished is very important. before any other state in the country.

In our country there is lot of diversity, there are different needs in different areas. A During the state workshop on CBMP, I witnessed vociferous, activist voices challenging the uniform framework may not be sufficient and if we want to implement any scheme senior most state officials level regarding service deficits, incidents of denial of service, medicine effectively at ground level, we need to involve the availability etc. The mature nature of the discourse left me with a profound sense of hope for the community in planning in a major way. There must be process, as well as appreciation towards the participants for negotiating with a dialogue with people about the planning process. In perspective of affirmative action and not fault finding. community based monitoring in Maharashtra, this NGO engagements have always been integral part of Government kind of environment is being created. policies and programs in the social sector. However, NGO participation has been placed at a much higher level under NRHM. We always talk about 'inclusive growth', a process in The manuals and tools kits necessary for operationalising and scaling which all sections will be benefited. If everyone is to up the close engagement of NGOs under NRHM were developed be included in the developmental process, then I feel under the CBMP initiative. The first phase of the process, initiated by that Community monitoring is an effective medium. Government of India in nine states showed varied uptake and The CBMP process in Maharashtra has shown the progress. The rapid setting up of institutional framework of CBMP in potential of bringing together all stakeholders on a Maharashtra was mainly due to the robust, customized tool kits common platform for change. developed by the state unit. The questionnaires and pictorial analysis charts adopted by the state were found useful by other states also. The learning from this has helped accelerate the implementation of the initiative in other states and has served as a role model.

84 85 Dr. Syeda Hameed Dr. Tarun Seem Former Member, Planning Commission , Govt. of India Former Director, Ministry of Health and Family Welfare

84 85 Anna Hazare úMedha Patkar Noted Social Leader Ralegan Siddhi, District Ahmednagar Senior Social Activist

If 'Self-government' is to become 'Good governance', then power should be in people's hands Community monitoring - a people-centred step Community Monitoring process: towards empowerment and democratization An effective tool for good governance

ersonal and public health contribute to the well being of society as a whole, as well feel the Community monitoring process initiated as part of NRHM in over 500 villages in 5 towards its growth and prosperity. The real test of Government lies not in ratifying districts in Maharashtra is very important. Participation of elected representatives and Pinternational covenants, but in satisfying fundamental health needs of its citizens. Every community members, who are actual users of these services, is shaping it as a people's citizen should get to live in a clean, peaceful environment and should have access to timely, I adequate and affordable health care. Among others, people who are disadvantaged as a result of process. The success of this process is indicated by the increased utilization of services wherever it has been initiated. physical conditions or social, economic and political policies should be primary beneficiaries of government programmes. These include adivasi communities, marginalized dalits, unorganized Swami Vivekananda and Mahatma Gandhi's thoughts that, 'It is useless to share knowledge with a workers, women and children in all oppressed sections. It is imperative for policy makers and starving person,' still stand true. Therefore we developed a self-sufficient village like Ralegan Siddhi. activists to promote 'universal health care' that covers disadvantaged sections on a priority basis. Starvation damages health that ultimately impacts a person's ability to do productive work. Therefore while developing an ideal village, society and nation we must ensure that nobody Community monitoring is contributing not only towards decentralization of health programmes remains deprived of required health care. It is positive to see that new health policies are instituted in India, but it is also a pro-people step towards empowerment and democratization. Efforts by through NRHM for strengthening the health system. various organisations and people's movements to ensure involvement of local communities for effective implementation of national programme are certainly noteworthy and its results are As part of of this new process, people from village to state level are doing assessments of health services through public hearings and report cards, which is helping in increasing accountability of promising. SATHI is well experienced to facilitate this process, and while working with them we health service providers towards people. This process is also addressing corruption within the have experienced that adivasi women and youth from the work area of Narmada Bachao health system and demanding fair utilization of public funds. In order to get information from the Aandolan from Satpura ranges in Nandurbar district are becoming confident and competent to medical officers, people can now use of Right to Information Act. However, they are getting assess public health services. needed information even without using the Act. I consider this as an We came across cases of rampant corruption in our efforts impact of decade long struggle for RTI in Maharashtra. of monitoring and social audit of various government Government staff receive their salaries from taxes collected from programmes in Dhadgaon and Akkalkuva blocks in citizens. Hence people should keep a check on public servants so that Nandurbar. However, we also got whole hearted support of they do not evade their responsibilities or join hands with corrupt genuine doctors and government officers. In order to politicians and criminals. The CBMP process is helping this cause and convert the Community monitoring process into a 'health should be extended to all districts in the state, and to other sectors like campaign', the government should support mass education, food security and employment. I hope that the government organisations who are working in remote and difficult areas will extend full support to achieve this expansion. on a largely voluntary basis. This would ensure that this is a I always insist that everyone should respond to their social 'healthy' movement, otherwise the programme will remain responsibilities along with their personal commitments. We will set an only on paper. example of good governance if people from all across the country get In case, the central and state governments withdraw support engaged in community monitoring processes to ensure proper from this programme, as social organisations we should implementation of programmes for health, education, food and come together and express our commitment to effectively employment. Moreover, this participatory process would be an continue this process. important step in strengthening democratic principles and moving forward from 'self government' to 'good governance'. 86 87 Anna Hazare úMedha Patkar Noted Social Leader Ralegan Siddhi, District Ahmednagar Senior Social Activist

ersonal and public health contribute to the well being of society as a whole, as well feel the Community monitoring process initiated as part of NRHM in over 500 villages in 5 towards its growth and prosperity. The real test of Government lies not in ratifying districts in Maharashtra is very important. Participation of elected representatives and Pinternational covenants, but in satisfying fundamental health needs of its citizens. Every community members, who are actual users of these services, is shaping it as a people's citizen should get to live in a clean, peaceful environment and should have access to timely, I adequate and affordable health care. Among others, people who are disadvantaged as a result of process. The success of this process is indicated by the increased utilization of services wherever it has been initiated. physical conditions or social, economic and political policies should be primary beneficiaries of government programmes. These include adivasi communities, marginalized dalits, unorganized Swami Vivekananda and Mahatma Gandhi's thoughts that, 'It is useless to share knowledge with a workers, women and children in all oppressed sections. It is imperative for policy makers and starving person,' still stand true. Therefore we developed a self-sufficient village like Ralegan Siddhi. activists to promote 'universal health care' that covers disadvantaged sections on a priority basis. Starvation damages health that ultimately impacts a person's ability to do productive work. Therefore while developing an ideal village, society and nation we must ensure that nobody Community monitoring is contributing not only towards decentralization of health programmes remains deprived of required health care. It is positive to see that new health policies are instituted in India, but it is also a pro-people step towards empowerment and democratization. Efforts by through NRHM for strengthening the health system. various organisations and people's movements to ensure involvement of local communities for effective implementation of national programme are certainly noteworthy and its results are As part of of this new process, people from village to state level are doing assessments of health services through public hearings and report cards, which is helping in increasing accountability of promising. SATHI is well experienced to facilitate this process, and while working with them we health service providers towards people. This process is also addressing corruption within the have experienced that adivasi women and youth from the work area of Narmada Bachao health system and demanding fair utilization of public funds. In order to get information from the Aandolan from Satpura ranges in Nandurbar district are becoming confident and competent to medical officers, people can now use of Right to Information Act. However, they are getting assess public health services. needed information even without using the Act. I consider this as an We came across cases of rampant corruption in our efforts impact of decade long struggle for RTI in Maharashtra. of monitoring and social audit of various government Government staff receive their salaries from taxes collected from programmes in Dhadgaon and Akkalkuva blocks in citizens. Hence people should keep a check on public servants so that Nandurbar. However, we also got whole hearted support of they do not evade their responsibilities or join hands with corrupt genuine doctors and government officers. In order to politicians and criminals. The CBMP process is helping this cause and convert the Community monitoring process into a 'health should be extended to all districts in the state, and to other sectors like campaign', the government should support mass education, food security and employment. I hope that the government organisations who are working in remote and difficult areas will extend full support to achieve this expansion. on a largely voluntary basis. This would ensure that this is a I always insist that everyone should respond to their social 'healthy' movement, otherwise the programme will remain responsibilities along with their personal commitments. We will set an only on paper. example of good governance if people from all across the country get In case, the central and state governments withdraw support engaged in community monitoring processes to ensure proper from this programme, as social organisations we should implementation of programmes for health, education, food and come together and express our commitment to effectively employment. Moreover, this participatory process would be an continue this process. important step in strengthening democratic principles and moving forward from 'self government' to 'good governance'. 86 87 Dr. Prakash Amte Adv. Eknath Awad Winner of Magsaysay Award President, Manavi Hakka Abhiyan, Senior Leader Lok Biradari Prakalpa, Hemalkasa, Gadchiroli of Dalit and Human Rights Movement

An auspicious beginning to ensure A space for Dalits to demand their rights people's health and well being

divasi people from a radius of around 200 kilometers visit the Lok Biradari Clinic for ccording to Census of India in 2001, 35.4% of the Scheduled Caste rural population was treatment. There are no proper roads and therefore no regular transport; people often below poverty line. What would be the nature of health care these poor dalits would be Awalk upto 60 kilometers to reach the clinic. Daily OPD attendance goes up to 150-200 Agetting, especially when caste hierarchies are still intact in villages? Dalits who got and 35-40 patients are admitted in the clinic at any given point of time. Our experience shows that educated were able to stand firmly on their own, however, those who are poor and landless have to people respond if you are able to win their trust. Our health and education programmes in face discrimination and humiliation. I have observed that upper caste women, who are actually Hemalkasa became successful because we developed them by taking into consideration adivasi appointed as sevikas to clean up the anganwadi centres, are reluctant to clean up in dalit areas. living and were respectful of their lifestyles. Arajkheda village has a militant group of dalits who are associated with our Jameen Adhikar Andolan. The SHG in Dalit area got the contract to cook food for children in the Anganwadi. The Government also has a network of health services. We come across Sub centers and However upper caste mothers did not let their children eat this food, because it was cooked by Anganwadi centers in remotest villages, however alongside these problems like malnourishment, dalit women. Finally the dalit women discontinued the contract so that children do not suffer. maternal and infant deaths also persist. There is no sure system to provide people timely treatment for most common diseases. Lack of good dialogue between the health service providers and National level statistics on health status of dalit communities speaks for itself. Infant mortality is adivasi communities is one of the major reasons for ineffectiveness of public health services. 83 per 1000 live birth for SCs, whereas it is 61.8 among open category. Child mortality is 119.3 for SCs and 82.6 for open category. These figures clearly indicate inaccessibility of adequate health NRHM aims at minimizing maternal and infant mortality and providing quality health services in services in dalit areas. In my district Beed, over 4 lakh sugarcane cutting workers migrate every rural remote areas. At the same time, adopting 'community monitoring' as a tool to facilitate year. These people are predominantly from dalit and nomadic tribe communities. Nobody cares change is equally significant. Community monitoring is a promising process which is bringing for health needs of these migrant workers. Motivated by Dr. Babasaheb Ambedkar's appeal to together elected representatives, NGO workers and community members from village level to educate children, poor worker parents toil day after day; dalit women get delivered in fields quickly state level, to dialogue with the health system and improve health services. This promotes to return to work. Who cares whether or not these mothers were collective responsibility to change the state of health services, registered in hospitals, or their babies got immunized? which is a very important aspect, according to me. As people would start monitoring availability and quality of services, In this context, I tried to understand the significance of the utilization of public services would automatically increase. community monitoring process. Workers involved in this process have interacted with all villagers, including dalit areas. Of the five districts under CBMP in Maharashtra, three districts - Through group discussions they have checked the state of health Thane, Nandurbar and Amravati have hilly areas with majority services everywhere and looked at disparities within villages. Out adivasi populations. Community monitoring experiences in these of the group discussions in five villages, in one discussion with districts show significant increase in OPD turnover, noteworthy upper caste community and in two discussions in dalit areas 'Bad' progress in medicine availability and efforts for institutional rating was recorded for services. I think, in this process dalits have deliveries. These changes would culminate in ensuring people's a space to express their views about health services and they are health and well being. I hope that the process would lead to using it fearlessly. Dalit communities are militant and assertive strengthening dialogue between the health services and local about their rights, which makes an impact if the environment is people. conducive. I support Community monitoring since I perceive its potential to create an enabling environment for Dalits. I extend best wishes to this process from my end, as well as from our Lok Biradari project! 88 89 Dr. Prakash Amte Adv. Eknath Awad Winner of Magsaysay Award President, Manavi Hakka Abhiyan, Senior Leader Lok Biradari Prakalpa, Hemalkasa, Gadchiroli of Dalit and Human Rights Movement

An auspicious beginning to ensure A space for Dalits to demand their rights people's health and well being divasi people from a radius of around 200 kilometers visit the Lok Biradari Clinic for ccording to Census of India in 2001, 35.4% of the Scheduled Caste rural population was treatment. There are no proper roads and therefore no regular transport; people often below poverty line. What would be the nature of health care these poor dalits would be Awalk upto 60 kilometers to reach the clinic. Daily OPD attendance goes up to 150-200 Agetting, especially when caste hierarchies are still intact in villages? Dalits who got and 35-40 patients are admitted in the clinic at any given point of time. Our experience shows that educated were able to stand firmly on their own, however, those who are poor and landless have to people respond if you are able to win their trust. Our health and education programmes in face discrimination and humiliation. I have observed that upper caste women, who are actually Hemalkasa became successful because we developed them by taking into consideration adivasi appointed as sevikas to clean up the anganwadi centres, are reluctant to clean up in dalit areas. living and were respectful of their lifestyles. Arajkheda village has a militant group of dalits who are associated with our Jameen Adhikar Andolan. The SHG in Dalit area got the contract to cook food for children in the Anganwadi. The Government also has a network of health services. We come across Sub centers and However upper caste mothers did not let their children eat this food, because it was cooked by Anganwadi centers in remotest villages, however alongside these problems like malnourishment, dalit women. Finally the dalit women discontinued the contract so that children do not suffer. maternal and infant deaths also persist. There is no sure system to provide people timely treatment for most common diseases. Lack of good dialogue between the health service providers and National level statistics on health status of dalit communities speaks for itself. Infant mortality is adivasi communities is one of the major reasons for ineffectiveness of public health services. 83 per 1000 live birth for SCs, whereas it is 61.8 among open category. Child mortality is 119.3 for SCs and 82.6 for open category. These figures clearly indicate inaccessibility of adequate health NRHM aims at minimizing maternal and infant mortality and providing quality health services in services in dalit areas. In my district Beed, over 4 lakh sugarcane cutting workers migrate every rural remote areas. At the same time, adopting 'community monitoring' as a tool to facilitate year. These people are predominantly from dalit and nomadic tribe communities. Nobody cares change is equally significant. Community monitoring is a promising process which is bringing for health needs of these migrant workers. Motivated by Dr. Babasaheb Ambedkar's appeal to together elected representatives, NGO workers and community members from village level to educate children, poor worker parents toil day after day; dalit women get delivered in fields quickly state level, to dialogue with the health system and improve health services. This promotes to return to work. Who cares whether or not these mothers were collective responsibility to change the state of health services, registered in hospitals, or their babies got immunized? which is a very important aspect, according to me. As people would start monitoring availability and quality of services, In this context, I tried to understand the significance of the utilization of public services would automatically increase. community monitoring process. Workers involved in this process have interacted with all villagers, including dalit areas. Of the five districts under CBMP in Maharashtra, three districts - Through group discussions they have checked the state of health Thane, Nandurbar and Amravati have hilly areas with majority services everywhere and looked at disparities within villages. Out adivasi populations. Community monitoring experiences in these of the group discussions in five villages, in one discussion with districts show significant increase in OPD turnover, noteworthy upper caste community and in two discussions in dalit areas 'Bad' progress in medicine availability and efforts for institutional rating was recorded for services. I think, in this process dalits have deliveries. These changes would culminate in ensuring people's a space to express their views about health services and they are health and well being. I hope that the process would lead to using it fearlessly. Dalit communities are militant and assertive strengthening dialogue between the health services and local about their rights, which makes an impact if the environment is people. conducive. I support Community monitoring since I perceive its potential to create an enabling environment for Dalits. I extend best wishes to this process from my end, as well as from our Lok Biradari project! 88 89 Vidya Bal Sada Dumbre Senior Women's Rights Activist Senior Editor

An opportunity for rural sisters to promote a A process to bring issues to the forefront, and 'Healthy' Political Process to inspire people's confidence in change

n the women's rights movement, we have continuously posed questions about the system and beliefs, which I feel provoked people to think beyond conventional patterns. This Welfare State is primarily responsible to provide adequate health services to people. process of raising questions is significant because it propagates positive ideas and Accordingly the government has evolved a well knit health system through PHCs and I other facilities. However, dominance of market forces and corresponding withdrawal of progressive thoughts. Community monitoring to me is a similar process. While reading the A newsletter, I realized that it goes beyond raising questions and stating problems. There is also a government from fundamental social sectors like health, education and employment have recognition of well meaning efforts by public health workers who are given due respect. weakened these public systems. Consistent decline in budgets for these social sectors indicates that Government health staff are also burdened with other worries apart from looking after patients, the state has become subservient to the market. For the past ten-fifteen years 'growth rate' has and they also suffer from policy impediments. However, Community monitoring envisions a become the only obsession, as if it is master key to all pressing problems plaguing the country. process where the service providers and patients come together to improve the health system. It is Even our Prime Minister admits social contradictions existing today and hence asserts the need for quite akin to our idea of involving men along with women in the women's movement to root out 'development with a human face.' The title of the report published last year by 'Survival patriarchy. International' aptly describes the present phenomena as 'Growth Can Kill'. The majority of the I am happy that ground level problems such as lack of women doctors, gynecologists in rural poor in our country would agree with it, while surviving on the edge despite the country boasting areas, are coming to the fore through this process. The way setting up of women's police cells its two-digit growth rate. A strong political will and conscious attempts to building stakes of made women more at ease to express their problems, involvement of women doctors would common people in the process would lead to minimize social imbalances. change the way the health system functions. Women's health issues will get duly recognized in the In this context, the Community monitoring process that is initiated as part of NRHM is effective planning process. and useful. It will take some time to make its broader impact visible, but the newsletter 'Dawandi' In India, the average life span of women is less compared to their counterparts in rest of the clearly gives glimpse of positive outcomes of this process. As evident in Community monitoring, world. Women's diet and health needs get neglected due to their secondary status and therefore it is possible to bring about changes in rural areas by awareness building and systematic advocacy malnutrition and anemia is seriously rampant among women. India stands second in terms of of people's interests. Public hearings are building people's confidence to raise their problems on maternal mortality in the world. Only 42% deliveries in rural areas are undertaken by skilled birth public platforms before concerned officers and to seek solutions. The newly entered force of attendants. According to the UNDP report of 1997, 88% pregnant women in 15-49 years age young public servants is more sensitive about their responsibilities towards people. Rather than group suffered from anemia. It means that a large section of women face high risk pregnancies. depending on organisations who are interested in getting projects for their survival, it would be Government is planning programmes to change this grim scenario and it is better if people become self-reliant to support community processes and I am sure their efforts heartening that people are taking initiative to ensure these are effectively would lead to change the state of health system. implemented. I am told that people speak fearlessly in public hearings and I really Most newspapers today primarily cater to urban readers with 'infotainment'. Such appreciate their initiative. I am very optimistic about this process where community processes do not fit in their priorities, and it is unlikely that they would take people assemble in forums they themselves have evolved to discuss ways proper cognizance of this process. Therefore all involved in Community monitoring out of their problems. need to be assertive and smart enough to draw deserving media attention towards In Maharashtra, we have initiatives like Mahila Rajsatta Aandolan, which people's initiatives. Rather than focusing on media coverage of occasional advocates exercise of political power for the benefit of people at the programmes, ensuring involvement of a prominent newspaper in respective village level. Community monitoring is also a kind of power in people's districts as 'media partner' would help to keep the issue on agenda. In fact, knowing hands. Fifty percent reservations for women in Grampanchayat will that a newsletter like 'Dawandi' devoted to health rights is being published since facilitate women's participation in decision making. Women should past one year was itself a 'news' for me. Reaching out to a large section of people get due space in this process to present their problems. I give my who are not aware of this process, like myself, is a big challenge before the initiators best wishes to this process and expect this opportunity will of this work. My best wishes to them. enable rural women to further a 'healthy' political process and explore positive solutions to their health problems. 90 91 Vidya Bal Sada Dumbre Senior Women's Rights Activist Senior Editor

An opportunity for rural sisters to promote a A process to bring issues to the forefront, and 'Healthy' Political Process to inspire people's confidence in change n the women's rights movement, we have continuously posed questions about the system and beliefs, which I feel provoked people to think beyond conventional patterns. This Welfare State is primarily responsible to provide adequate health services to people. process of raising questions is significant because it propagates positive ideas and Accordingly the government has evolved a well knit health system through PHCs and I other facilities. However, dominance of market forces and corresponding withdrawal of progressive thoughts. Community monitoring to me is a similar process. While reading the A newsletter, I realized that it goes beyond raising questions and stating problems. There is also a government from fundamental social sectors like health, education and employment have recognition of well meaning efforts by public health workers who are given due respect. weakened these public systems. Consistent decline in budgets for these social sectors indicates that Government health staff are also burdened with other worries apart from looking after patients, the state has become subservient to the market. For the past ten-fifteen years 'growth rate' has and they also suffer from policy impediments. However, Community monitoring envisions a become the only obsession, as if it is master key to all pressing problems plaguing the country. process where the service providers and patients come together to improve the health system. It is Even our Prime Minister admits social contradictions existing today and hence asserts the need for quite akin to our idea of involving men along with women in the women's movement to root out 'development with a human face.' The title of the report published last year by 'Survival patriarchy. International' aptly describes the present phenomena as 'Growth Can Kill'. The majority of the I am happy that ground level problems such as lack of women doctors, gynecologists in rural poor in our country would agree with it, while surviving on the edge despite the country boasting areas, are coming to the fore through this process. The way setting up of women's police cells its two-digit growth rate. A strong political will and conscious attempts to building stakes of made women more at ease to express their problems, involvement of women doctors would common people in the process would lead to minimize social imbalances. change the way the health system functions. Women's health issues will get duly recognized in the In this context, the Community monitoring process that is initiated as part of NRHM is effective planning process. and useful. It will take some time to make its broader impact visible, but the newsletter 'Dawandi' In India, the average life span of women is less compared to their counterparts in rest of the clearly gives glimpse of positive outcomes of this process. As evident in Community monitoring, world. Women's diet and health needs get neglected due to their secondary status and therefore it is possible to bring about changes in rural areas by awareness building and systematic advocacy malnutrition and anemia is seriously rampant among women. India stands second in terms of of people's interests. Public hearings are building people's confidence to raise their problems on maternal mortality in the world. Only 42% deliveries in rural areas are undertaken by skilled birth public platforms before concerned officers and to seek solutions. The newly entered force of attendants. According to the UNDP report of 1997, 88% pregnant women in 15-49 years age young public servants is more sensitive about their responsibilities towards people. Rather than group suffered from anemia. It means that a large section of women face high risk pregnancies. depending on organisations who are interested in getting projects for their survival, it would be Government is planning programmes to change this grim scenario and it is better if people become self-reliant to support community processes and I am sure their efforts heartening that people are taking initiative to ensure these are effectively would lead to change the state of health system. implemented. I am told that people speak fearlessly in public hearings and I really Most newspapers today primarily cater to urban readers with 'infotainment'. Such appreciate their initiative. I am very optimistic about this process where community processes do not fit in their priorities, and it is unlikely that they would take people assemble in forums they themselves have evolved to discuss ways proper cognizance of this process. Therefore all involved in Community monitoring out of their problems. need to be assertive and smart enough to draw deserving media attention towards In Maharashtra, we have initiatives like Mahila Rajsatta Aandolan, which people's initiatives. Rather than focusing on media coverage of occasional advocates exercise of political power for the benefit of people at the programmes, ensuring involvement of a prominent newspaper in respective village level. Community monitoring is also a kind of power in people's districts as 'media partner' would help to keep the issue on agenda. In fact, knowing hands. Fifty percent reservations for women in Grampanchayat will that a newsletter like 'Dawandi' devoted to health rights is being published since facilitate women's participation in decision making. Women should past one year was itself a 'news' for me. Reaching out to a large section of people get due space in this process to present their problems. I give my who are not aware of this process, like myself, is a big challenge before the initiators best wishes to this process and expect this opportunity will of this work. My best wishes to them. enable rural women to further a 'healthy' political process and explore positive solutions to their health problems. 90 91

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