Health Sector Reforms Workshop
SIHFW, Jaipur
June 18, 2008
Community Based Planning & Monitoring of Health Services
Dr. Narendra Gupta*
Backdrop:
Health sector reform has been going on in India from the time Bhore Committee gave its recommendations in 1948 to ensure universality of health services to all the people of the country. Since then, many committees and national health policies of 1983 and 2002 have been formulated. Guided by these policies, various measures have been taken to contain the health problems through disease specific national health programs, increasing medical human resource deployment and area specific outreach planning. This has led to reduction in infectious diseases morbidity, disability, premature mortality and also the fertility. However, the health gains had been asymmetrical and as a result we find different kind of health scenarios. While certain but small section of Indian population has attained health and demographic transition, but still a large part of the country especially from northern states and within these states those who experience inequities on account of their social, economical and geographical locations are struggling to move towards health & demographic goals.
In order to make one more determined impact for improvement of people’s health, the Govt. of India has launched the National Rural Health Mission (NRHM) in the year 2005 with special focus on EAG and north eastern states. The mission seeks to significantly increase public health spending and guarantee health care services through architectural corrections in the health care delivery system.
The health outcomes and goals listed in the mission document are very precise and comprehensive with definite time frame of seven years. The mission has explicitly synthesized a framework of bottom up planning mechanism of health services delivery with strong elements of community ownership in order to evolve transparent, responsive and need based systems with very clear pro poor focus. The intent of the mission is very apparent from the core strategy wherein it is mentioned that it will promote community ownership and decentralized planning from village to district level through participatory processes by strengthening evidence based effective monitoring and evaluation.
Context:
Geo-physically, Rajasthan is poorly endowed state with arduous terrains. Most parts of it lack in water and energy availability which are the main components to spur economic growth both in agriculture and manufacturing in any region. Per capita income of the state is quite low and owing to general insufficiency of infrastructure and natural resources the growth of gross domestic product is also far less in comparison to other states. This has led to very little investment from private and corporate enterprises not only in core but also in social sector. Low per capita income with tardy growth in GDP makes it imperative on the public system to be as efficient as possible to provide quality services in education, health and other social welfare services to its people because the private and other forms of systems are either absent or are of inferior quality. Therefore, it is all the more imperative on the State to gear itself to deliver these services efficiently and with quality through highest possible use of the available resources. The state should also mobilize funds from as many sources as possible as there is a tremendous need to improve the quality of services offered through public systems in Rajasthan especially in the area of health.
Health is a function of number of determinants more important amongst them is food, housing, water & sanitation, safe employment and freedom from risky behaviors & habits. In order to have final impact on the health of people, it is essential that these determinants are met, besides establishment of a good quality accessible basic health services. A broad analysis shows that there are wide disparities as far as access to health care is concerned. These disparities are on the basis of place of residence, income, gender, social category. The challenge is to move towards health transition by strengthening public health services. National Rural Health Mission provides tremendous opportunity to ensure health care to all in the state of Rajasthan. NRHM provides space for number of need based modifications for assured health services. One amongst them is the adoption of community based planning, review and implementation of primary health services. Community monitoring is consistent with the approach of decentralized planning based on local priorities and guarantee of health services as illustrated in NRHM operational guidelines. This also provides strength to establish people’s right to health.
Concept:
Though the non-communicable diseases are rising, but still the overwhelming burden of diseases in India is from communicable diseases caused owing to inadequate access to basic requirements of healthy life. Most of these ailments are preventable or manageable at primary levels of health care. Amongst host of causal factors, one important cause is inability to access quality services and community’s role in managing them.The essential concept of community based monitoring is to evolve forums of interactions between health services providers and the community at all levels of primary health care delivery to facilitate quality services. It is being envisaged that constitution of such standing forums willcreate space forregular input of community in shaping, planning and executing health services based on specific requirements at different institutions of health care delivery. Such an approach also provides a platform for convergent action through elimination of discontent and miscommunication amongst all stake holders.
Community Monitoring entails formation of planning and monitoring committees at the level of village, PHC and block.Each of these committees would have representation from service providers, panchayati raj institutions, community and civil society organizations.Mentoring groups are to be formed to support these committees at district, state and national level. This is still an evolving concept and currently it is piloted in 9 states of India (Assam, Chattisgarh, Jharkhand, Karnataka, M.P., Maharashtra, Orissa, Rajasthan, and Tamilnadu). In each state 3-5 districts have been chosen depending on the number of districts. Three blocks in each district, three PHCs in each block and five villages in each PHC have been chosen for this phase.
The committee to be called as Village Health & Sanitation Committee (VHSC) to be formed at every revenue village level is the first such forum. This is the first but very important unit of operation and interaction. This committee is different than a standing committee on health formed at panchayat comprised of panchayat members only. A VHSC would typically have about 12 persons as members drawn from different strata of village, panchayat representative, and other social sector functionaries’ viz. aganwari worker, Dai, teacher and ASHA as the member secretary. VHSC essentially would first develop village health planby rapid assessment of the burden of diseases, identification of foci of higher morbidities in the village, treatment seeking pattern of different segments of society and health care expenditure for commonly occurring diseases. It will also do mapping of the available resources in village from standpoint of health. The assessment would provide data for building health intervention plan for targeted reduction in morbidities, disabilities and premature mortalities mostly owing to childhood diseases or maternal complications. The implementation plan would try to be consistent with national goals. Another important task of the VHSC is to monitor the health services to be offered at village level which are: early registration of pregnant women, complete periodical ante-natal check-ups with appropriate counseling & education, arrangements for transport for institutional delivery, post-natal caresupport, immunization to infants, treatment of minor ailments & regular periodic medication to chronic patients besides sanitation related activities. VHSC would also keep track of the maternal and childhood deaths, ensure verbal autopsies of such deaths. This committee ought to meet once every month to discuss about the health scenario of the village and to review the progress of the village health implementation. Untied fund of Rs. 10,000/- is being provided to every VHSC to be used for implementation of health plan. The VHSC would leverage funds from other government schemes for implementation of health plan and use untied fund in case of finding no other source of funding. The VHSC would rigorously oversee how the work of village level functionaries viz. ANM visits, aganwari worker and ASHA carrying out their activities.For this it would develop report cards, interview schedules, calendars, registers and other formats. Report prepared through VHSC would be used to provide feedback to health functionaries.
The next level is the constitution of PHC Planning & Monitoring Committee(PPMC) at each PHC. Membership of this committee is drawn from service providers, representatives from VHSCs (from 20% of VHSCs on rotation) and panchayats with local civil society organization as member secretary. The committee essentially would collate the village health plans to formulate a PHC level health plan for implementation and looks at the reports sent by VHSCs in terms of health functionaries performance, implementation of village health plans and any special activity. The PPMC would review the services offered from PHC: outpatient, drug availability, laboratory investigations, deliveries and disbursement of JSY, inpatient etc. It would examine whether services offered are consistent with Indian Public Health Standards (IPHS) and health care is guaranteed as entitlements. It would track maternal & childhood deaths based on reports of VHSCs. The committee would formulate tools in the form of report cards, interview schedules and other formats to collect information. The collected and collated information will be placed before the committee to seek direction for appropriate action to further improve services. Committee members would participate in activities and special campaigns.
The committee constituted at the block level would be consistent with CHC. It would be termed as Block Health Planning & Monitoring Committee (BHPMC). This committee would have members drawn from service providers, representatives of VHSCs and PPMCs, representative of panchayts. A local civil society organization will serve as its member secretary. The block CM & HO will be the convener of this committee and it will be chaired by the Pradhan of Panchayat Samiti. The task for the committee is to draw up block health plan through collation of PHC plans and review its implementation. The committee will also review IPHS compatibility of health services offered from CHC and visit other health institutions – PHCs & sub centres. It will provide feed to block health team based on review and also send its report to district mentoring group to be finally converted into district planning & monitoring committee.
Role of district and state mentoring groups for community monitoring of health services is to provide continuing support to the committees in capacity building and discharging their functions. These groups ensure that these committees are properly constituted; they meet regularly and transact their mandates in letter and spirit.
NRHM has recognised an important role of voluntary organizations in the community monitoring framework in the form of hand holding, capacity building and carrying the secretarial role so that functions of these are not marred into bureaucratic procedures. Therefore, the positions of member secretaries in all committees except VHSCs have been assigned to local voluntary groups. This provides a unique opportunity to draw on strengths of all possible agencies in promoting health agenda. In their first role, organizations working in close, regular contact with communities on health related issues, especially from a rights-based perspective, would be able to present in various monitoring committees the community concerns, experiences and suggestions regarding improving public health system functioning. In their second role, organizations with experience of capacity building could conduct orientation of committee members about the process of community based monitoring including the roles of members. All three types of members – Panchayat representatives, civil society organizations and health system functionaries would benefit from such capacity building. In their third role, NGOs and CBOs could contribute to the collection of information relevant to the monitoring process at all levels – from the village to state level. There will be strong element of community mobilization in these processes.
Other significant activities to be carried out to strengthen community based planning & monitoring is by holding public hearings/dialogues periodically at PHCs, blocks and districts. Public hearings/dialogues are very powerful tool to know people’s perception about health services. These events should showcase both good practices and adverse outcomes in the form of individual/group testimonies before a panel of distinguished speakers. Objectives of these hearings/dialogues would be to identify systemic problems, inconsistencies in delivering quality health care and what ought to be done to rectify them.
*Author is a member of the Advisory Group on Community Action, NRHM, New Delhi. He primarily works with Prayas, Chittorgarh State nodal organization for community monitoring in Rajasthan. The framework is also available at
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