Is the Right to participation in the Health sector being ensured?
Documentation of state wise status of mechanisms forcommunity accountabilityand participatory governance in the Public health system

Today it is widely recognised that in order for Public health servicesto become optimally effective and responsive to people’s needs,various health system inputs are extremely necessary, but are not sufficient. The public health systemmust also be systematically accountable to people, and ordinary people, especially the users of services, need to substantially participate in planning the functioning of this system. Especially since the launching of NRHM in 2005, certain systems for accountability and participation have been mandated in India, however these spaces have often remained on paper, and may or may not have been operationalised on the ground.

To address this important concern, the NRHM framework for implementation document states the following:

NRHM would attempt to transfer funds, functionaries and functions to PRIs. Concerted efforts with the involvement of NGOs and other resource institutions are being made to build capacities of elected representatives and user group members for improved and effective management of the health system. To facilitate local action, the NRHM will provide untied grants at all levels [Village, Gram Panchayat, Block, District, VHSC, SHC, PHC & CHC].

Monitoring committees would be formed at various levels, with participation of PRI representatives, user groups and CBO / NGO representatives to facilitate their inputs in the monitoring planning process, and toenable the community to be involved in broad based review and suggestions for planning. A system of periodic ‘Jan Sunwai’ or ‘Jan Samvad’ at various levels would empower community members to engage in giving direct feedback and suggestions for improvement in Public health services. (p. 30)

Community action is the only guarantee for right to health care- putting community

pressure on health system. (p. 54)

Hence as a part of the NHRC-JSA public hearings on Right to health care, it will be important to concretely assess, in each state, what is the level of implementation of accountability systems, and to what extent is the right to participation being fulfilled. There is a specific session planned on this during each of the public hearings on the first day (related to Public health services), and it will be relevant to present the state wise situation, and to demand much more effective systems for accountability and participation wherever they are inadequate or not operational. For this, the following type of information may be collected and analysed by a group of health activists in each state, who should be conversant with the situation in various districts and at the state level. This is not an exhaustive format, but covers some of the common provisions and mechanisms that are likely to be mandated in most states.

  1. Status of community based monitoring and planningmechanisms
  • Is there any defined framework by the State Health department / State Health Missionfor implementation of Community based monitoring and planning / Community action for health processes? Please describe it in brief.
  • What is the present scale and purview of this framework (names and number of districts and blocks covered, number and types of committees formed as part of this process)
  • If yes, what is the scale of funds allocated under the Programme Implementation Plan (PIP) of State Health Mission/ State government’s own budget during 2015-16, for such Community based monitoring and planning activities?
  • At what level and in which form are Civil society organizations involved in Community based monitoring and planning / Community action for health processes, as part of NHM or State Health Department processes in your state?
  • Which CSO(s) are involved in facilitation of CBMP processes at state level? (provide names if possible)
  • Is there any defined regular mechanism/space for conducting mass eventsfor accountability such as public dialogue (like Jan sunwai or Jan samvad), involving community members and Health providers? How many Jan sunwais / Jan samvads have been organised since the initiation of the process in the state, and during the last year (2014-15)?
  • What are the institutional mechanisms such as monitoring and planning committees, involving various stakeholders such as PRI members, CBOs and NGOs, community representatives and Health officials, to ensure participatory inputs for improving public health services, and ensuring that they respond to people’s needs?
  • What is the status of state level structures to mentor CBMP processes and to ensure action on issues that have not be resolved at lower levels (e.g. State mentoring committee / State AGCA / State monitoring and planning committee)? Have these committees been formed with adequate civil society participation, as mentioned in the NRHM framework for implementation? Are these bodies regularly functional?
  • How are these mechanisms functioning? In the opinion of the group, to what extent is the objective of ensuring accountability and popular participation being achieved in practice? What have been challenges and lessons?
  • In what form is participation of village communities, PRI members and CSOs encouraged and ensured during the process of preparing the Programme Implementation Plans (PIPs) at block, district and state levels? Is this adequate to ensure reflection of community priorities in the health planning process, or does it need to be made more participatory? Examples may be given if possible.
  • What kind of resistance and challenges are faced by civil society organisationsduring the implementation of such participatory processes like CBMP? Are adequate funds and administrative support made available in regular and timely manner for these processes? Concrete experiences and examples may be given if possible.
  • Are there anypositive impacts seen in improving public health service delivery due to CBMP / CAH or similar processes? Concrete experiences and examples may be given if possible.
  • What needs to be done to make CBMP / CAH or similar community accountability and participation processes more effective in the state?
  • What kind of documentation is maintained for CBMP/CAH processes, and by whom? How is information about this process disseminated? Is there any website or webpage dedicated to making information about this processavailable in the public domain?
  1. Status of grievance redressal mechanisms in the Public Health system
  • Is there any defined framework by the state government for redressal of grievances related to Public Health services, raised by individualsor community groups?
  • Briefly describe the structure, level and operational framework of grievance redressal mechanisms which havebeen established by Public Health System. Is this currently effective in addressing grievances of ordinary people? Concrete experiences and examples may be given if possible.
  • Is there any institutional space for involving various community based stakeholders such as PRI members, CSOs and community groups in the Grievance redressal structure?
  • Are the Grievance redressal mechanisms widely publicized, and are communities aware about these mechanisms established by the public health system?
  • How are records kept on grievance redressal over time? Who maintains this? Where is this information available/ is it reported or published periodically?
  1. Status of functioning of Village Health, Sanitation and Nutrition committees (VHSNCs) and usage of village level untied funds
  • Has the VHSNC (Village Health, Sanitation and Nutrition committee)been constituted in each village? In your experience, are meetings of these committees regularly organised? Has training been given to members of these committees to ensure that they are aware of their roles and responsibilities?
  • Is there adequate representation of women and persons from SCand ST background, as members in the existing VHSN Committees?
  • In which month of the last financial year (2014-15), were the untied funds received bythe VHSNCs?
  • In your experience, how are decisions actually taken regarding expenditure by VHSNCs? Do you think this is appropriate to address community needs and priorities?
  • Are there any mechanisms / spaces for community members to participate in decision making related to VHSNC untied funds?
  • Were the accounts for the funds received by the committee in the last year, presented in the Gram Sabha or Village meeting?
  • What kind of documentation is maintained of VHSNC meetings? Are VHSNC members able to examine the records and review utilization of funds over various years?
  1. Status of functioning of RKS / Hospital Development Committees and usage of related flexible funds
  • Has an RKS / Hospital Development Committee been constituted in each relevantPublic Health Facility (PHC, CHC, SDH, DH etc)?
  • Describe the membership of the RKS – who are the members, when and how were they selected. In your understanding and experience, is the current membership of RKS representative of various community groups, including marginalised sections?
  • What is the process for selection of RKS members? Does this process involve participation of various community based stakeholders?
  • What is the mechanism for community members to know about RKS meetings and expenses related to RKS funds?
  • Is there any mechanism for local CSOs to participate in decision making process related to utilization of RKS funds?
  • Is there any institutional mechanism/space for raising and resolving community based health needs/demands through RKS funds?
  • Is there any mechanism for ensuring accessibility of the documents and records related to RKS funds expenditures for a given year? What about over time?
  • In which month of the last financial year (2014-15), were the untied funds received by RKS Committees? Is the flow of funds from State NHM to RKSs timely and as per norms?
  • Taking a few RKS as examples, which are the major components on which RKS funds were utilized in the last financial year (2014-15)? Are there examples of either inappropriate spending, or genuinely addressing community needs through the RKS funds? (During the larger study on services and facilities available at sample PHCs / CHCs, the RKS of these institutions could also be studied).

How to collect and document this information

In order to collect information related to present status of such accountability and participation processes, the above questions can be answered by organising state level or regional level discussion within the state, among activists of several organisationswho are involved in community health activities, from several different districts / regions across the state. The list of questions may be circulated beforehand to various activists, so that they can come to the meeting with relevant information from their area.

Activists from various districts may come for the meeting, after collecting basic information related to status of functioning of VHNSCs in some villages in their respective areas, based on these questions. Similarly information related to status of functioning of RKS may be collected from a sample of RKS from various blocks / districts. Specific information regarding RKS in any area may be collected organising group discussions with a few RKS members, especiallynon-official members, in a sample of a few Health institutions in a block.

This should be combined with accessing of relevant information at state level, related to Community action for Health component in the State PIP, status of Grievance redressal cells etc.

Some states may have established significant participation mechanisms (such as decentralised planning by Panchayats in Kerala) that are beyond this format. In such situations, relevant points focusing on any positive impacts, as well as how these mechanisms need to be made more effective, can be noted down by organising state level discussion among activists with direct experience of these processes.

To the maximum extent possible, instead of giving general opinions, attempt should be made to give concrete examples, data or information about the status of these accountability and participation mechanisms in the state, along with specific recommendations about how they need to be strengthened.