Initiative

By the People, for the People

SATHI-CEHAT, has taken a lead in bringing the public back into public health by allowing community members give feedback about the functioning of public health services. Sonal Shukla tells you more

As clichéd as it may sound, it is a very well-known fact that healthcare needs massive re-structuring to reach the grass-root level. On one hand, there are people who just lament and crticise and on the other hand there are people who single-handedly get into action mode and join forces to bring about change. One such NGO, SATHI-CEHAT, which stands for Support for Advocacy and Training to Health Initiatives, falls into the latter bracket. In an attempt to bring accountability in healthcare delivery at the ground level, SATHI is doing outstanding work in the arena of Community-based Monitoring (CBM) programme run under National Rural Health Mission, (NRHM) launched by the UPA Government.

The pilot project is being implemented in nine states in India. In Maharashtra, SATHI-CEHAT is the State Nodal Agency for co-ordinating and anchoring CBM in collaboration with the State Health department. The CBM programme was started in June 2007 and became operational at district level from October 2007.

Call for the Basic Right to Health

It all started with a need to deviate from the standard method of community monitoring of health services where there is miniscule participation of the actual receiver of the healthcare services at the grass root level. "Government normally only has one way of finding out whether the people are getting the services and that is by way of asking its own officials. For example, the secretary will ask the district health officer who in return will ask the Primary Health Centre (PHC) doctors as to whether the services have been given or not. Obviously, the lower officials will tell their seniors that everything is fine. Therefore, this standard method of monitoring is not a very effective method," shares Dr Abhay Shukla, Member of the National Advisory Group for Community Action (AGCA) of NRHM which is facilitating community monitoring.

The sub-group of health professionals from this task group suggested the framework CBM. The new approach of CBM of health services has started turning the tables, with the population at the grass root level being the prime movers and demanding the health services as their right, rather than being at the receiving end. SATHI team members are part of the national level 'Technical Advisory Group' (TAG) constituted to give overall direction and specific technical inputs for facilitation of the CBM pilot project. "SATHI team has played a significant role in preparing prototype of tools for the CBM," shares Dr Anant Phadke, Co-ordinator, SATHI.

Scope of Work

Thane district workshop of community based monitoring programme

The novel concept of CBM and planning has placed community representatives at the centre stage, allowing them to actively and regularly monitor the progress of NRHM interventions in their areas at village, PHC and block levels. "CBM is largely a process where community members assess the health services being given to them. They regularly collect information about it and then communicate this with health officials in order to make improvement in the services in the spirit of accountability and community," shares Dr Shukla. Besides ensuring accountability, it also promotes de-centralised inputs for better planning of health activities, based on the locally relevant priorities and issues identified by the community.

SATHI has been collaborating with many like-minded NGOs and People’s organisations from different parts of Maharashtra to foster health rights of the rural people. The five districts under CBM in the pilot phase are- Nandurbar, Osmanabad, Pune, Thane and Amaravati. The villages are selected on the basis of whether NGOs have local support base where they could mobilise the people in a better way. Today, around 225 villages spread across Maharashtra, with an average population of 1,000 each has been targeted for the CBM programme.

From Village to District

"SATHI team has played a significant role in preparing prototype of tools for the CBM process" - Dr Anant Phadke Co-ordinator SATHI

"The improvements seen are improved attendance of doctors in some PHCs and check on illegal charging of money in some areas" - Dr Abhay Shukla Member National Advisory Group for Community Action

To begin with, CBM involves formation of monitoring and planning committees from village to district level. These tripartite monitoring committees have 30 per cent Panchayati Raj representatives, 20-30 per cent health officials, 20 per cent CBO/ NGO representatives, 15-20 per cent non-official delegates from lower committees and 10 per cent Rogi Kalyan Samiti representatives in block and district committees. In Maharashtra, these committees have been formed in five pilot districts in 225 selected villages and Village Health Community (VHC) orientation is carried out for all 225 villages.

These committees collect information from people in the area on whether they are getting the health services at the village and PHC level. Health services which are supposed to be given at the village level include immunisation, care of pregnant women, health treatment of the minor ailments and so on.

"Under NRHM there are certain guaranteed health services which are supposed to be given. For instance, every PHC should perform normal delivery around-the-clock. Therefore, most of the questions are based on health service guarantees which are promised," says Dr Shukla.

From village level onwards, information is collected by these committees about specific indicators like visits of the various outreach staff of the PHCs, availability of the defined outreach services at the village level and PHC level. Reports cards are prepared at village and PHC levels, which are then publicly displayed.

"When this information collected is displayed as a village health report card on the wall, the villagers grade each service as good, hardly satisfactory or bad. Thereafter, in the village level meetings these cards are shared with the healthcare officials including nurses and doctors and questions are raised to which they have to respond," states Dr Phadke. Similar kind of process is replicated at the PHC level. The questions at the PHC level are slightly different and include questions like whether the doctor is present everyday, whether all medicines are available and is ambulance is readily is available at free of cost or not and so on.

My Country, My Voice

The questionnaire to collect information for the report cards have been prepared at the national level.

'Jan Sunwais' (public hearings) take place in the PHCs after data collection from a focused group discussion in five villages. According to Dr Shukla, the Jan Sunwais/ Jan Samwad in CBM has provided an opportunity for the community to directly dialogue with the relevant officials face-to-face, in presence of an independent panel. People are able to present cases of denial of healthcare and any complaints regarding health services.

This direct accountability has helped to change the power balance between health officials and the people. "This is an ongoing process. Jun Sunwais are organised once or twice in a year. Regular check on whether an improvement is taking place or not is a must, therefore after every three months the report card is to be filled again," shares Dr Phadke.

The CBM programme has thus enabled direct participation of the common person from rural areas through village report card meetings and Jan Sunwais. Large number of village men as well as women have been involved in these processes. Today, the benefits are evident with increased awareness amongst people and Village Health Committee members. The programme has become a tool with people to demand accountability. People have begun to dialogue with health workers and doctors. "With people's initiative, some local improvements are being seen such as increased visits of ANMs to villages, improved attendance of doctors in some PHCs, check on illegal charging of money in some areas," notifies Dr Shukla.

Post Jan Sunwais, officials have definitely become more pro-active. "Regular communication with positive officials within the Health department is an answer," feels Dr Shukla.

Challenges in the Path

Generating awareness at the initial stage was a challenge. Therefore, posters were put up about people's health rights. Local meetings in the village were held to make people aware about their health rights and what health services should they get in their village, at PHC and block levels.

The media also played an active role in making the population aware about the CBM programme. To engage more media in the process, SATHI-CEHAT has been conducting district media workshops in all the districts where media representatives were called and is made aware about the programme, its process and accountability and the role media can play. It has still not been easy for the organisation to make this initiative viable. It has been facing glitches like delayed circulars from the health bureaucracy and cold shoulders from the elected Panchayat representatives on continuous basis.

There were delays in issuing certain circulars by the Government for the formation of PHC, blocks and district level committees. In many cases, prior to the CBM process village health committees were officially formed on paper but when activists actually went to the village, there was no committee. Also, at the initial stage, the response from some health officials was lukewarm as they were not very interested. But gradually, few of the issues were raised and mobilisation took place.

Future Plans

SATHI-CEHAT plans to increase the reach of CBM programme in the existing five districts by adding 45 villages in a block instead of 15. "New seven districts would also be added, hence covering a total of about 1,000 villages. Thus, the number of villages would be multiplied by over four times in the coming year," shares Dr Shukla. Formation of block and district monitoring committees is also underway. During June to September 08, 42 PHC level Jan Sunwais were organised across the five districts.

The coalition of NGOs facilitated by SATHI-CEHAT aims to collectively continue and expand the work as well as deepen it. "We want to monitor the performance of the higher officials also, since monitoring has to extend to the State level. Key issues like availability of essential medicines must be addressed," concludes Dr Shukla.

The CBM programme has surely triggered a process of change at the grass root level where a large number of people have not just become aware of their health rights but also are actively participating and demanding it. Also, the NGOs and people’s organisations now have an official platform and mandate to actually keep a check and to put pressure to make community health a success. It's indeed a win-win situation.

sonal.shukla@expressindia.com