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CAH Briefer 2 Social Audits_English |
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Secretariat
Advisory Group on Community Action
COMMUNITY ACTION
FOR HEALTH
Bringing public into public health
Social audits ensure local health services
stay accountable to people: Jharkhand,
Meghalaya and Uttarakhand show the way
Social audit — the process that empowers people, the beneficiaries of any
programme or scheme, to review it — is a powerful tool to promote community’s
awareness, ownership and monitoring of services. In India, social audits began as
a campaign in Rajasthan, with people demanding accountability from their elected
representatives on the expenses incurred for developmental works. This and other
such successful campaigns led to the enactment of the Right to Information Act
(RTI) of 2005 and institutionalisation of social audits for the Mahatma Gandhi
National Employment Guarantee (MGNREG) Act. Twenty-five state governments
have since put in place an independent society — Social Audit Unit (SAU) — under
the Department of Rural Development and Panchayati Raj to conduct social
audits, and expanded SAU’s scope overtime to audit a wide range of schemes
and programmes.
Increased community engagement is a strategic thrust of the Ministry of Health
and Family Welfare, Government of India, to secure the quality, accountability and
effectiveness of public health services. The National Health Policy 2017 stresses
on community-based monitoring and planning (CBMP) to enhance people’s role in
health governance. The National Health Mission (NHM) implementation framework
recommends accountability mechanisms, including participatory community
processes like social audits through Gram Sabhas and Jan Sunwais/Samvads,
to improve programme oversight.
As part of its efforts to bring people’s voice into health delivery and planning, the
Advisory Group on Community Action (AGCA) facilitated state NHMs to partner with
SAUs in Jharkhand, Meghalaya and Uttarakhand for piloting social audits for health.
This brief describes how the social audit pilots increased community awareness and
participation in monitoring local health services.
#2
The learning from social audit pilots can inform the mechanisms to
monitor Ayushman Bharat initiatives to provide comprehensive
primary health care through Health and Wellness Centres (HWCs)
and free health coverage to India’s poor and vulnerable populations
through the landmark Pradhan Mantri Jan Arogya Yojana (PM-JAY).
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SOCIAL AUDIT FOR HEALTH
Three states demonstrate social audit as a mechanism
for community oversight of health services
CONTEXT
NHM conducted the social audit pilots as part of its
Community Action for Health (CAH) strategy, which
places people at the centre of the health system/process
to ensure local health services remain accountable
to people and fulfil their health needs. Population
Foundation of India (PFI), which hosts AGCA, provided
technical assistance to the partnerships between
state NHMs and SAUs for the pilots.
INTERVENTION
The implementation mechanisms and processes for
social audit of health services were common across
the three states, as briefly described below.
A. Preparatory and facilitative processes
1. MoU between NHM and SAU: State NHMs in Jharkhand
and Uttarakhand signed a memorandum
of understanding with the respective SAUs — the SAU
under Jharkhand State Livelihoods Promotion Society
(JSLPS) and the Uttarakhand Social Accountability
and Transparency Agency (USSATA) — to conduct
social audit of health services. NHM provided funds to
the two state SAUs for the exercise. In Meghalaya, the
processes are institutionalised under the state’s unique
legislation, the Meghalaya Community Participation
and Public Services Social Audit Act 2017. Here, the
governing body of the Meghalaya Society for Social
Audit and Transparency (MSSAT) approved the social
audit and used its own resources for the exercise.
2. Development of resource materials and tools: Detailed
technical discussions were conducted at the state level
to develop data collection tools in the context of each
state, involving all concerned programme divisions. The
NHM parameters under the social audit process and
checklists were finalized.
3. Training of district, block and village resource persons:
Resource persons of the SAU in each state were
oriented on communitisation processes, the services
provided at different tiers of health facilities,
community monitoring tools and operational steps in
social audit; trainings were facilitated by NHM with
support from AGCA.
B. Field implementation
4. Awareness building at the community level: The
community was sensitised about the various health
schemes of the government, their health service
entitlements and the monitoring checklist. The
community was mobilised through discussions with
VHSNC members and meetings at the panchayat level.
5. Community monitoring and feedback: The processes
for community monitoring included door-to-door
interactions and verification of beneficiaries; focused
group discussions in the village, including women,
adolescents and the general public, to identify the larger
issues faced in accessing health facilities; personal
interviews with beneficiaries, such as women who
had availed maternity services, to understand their
experience; interviews with doctors to grasp facility-
level challenges; observations and verification of
records available at the facility. Based on these
interactions and observations, village level report
cards were prepared. Village resource persons, mostly
comprising self-help group members and youth, shared
the report card in village meetings to incorporate the
community’s feedback. A wide range of issues were
highlighted from different regions, such as non-
payment of Janani Suraksha Yojana (JSY) incentives
to beneficiaries, denial of health services, practices like
patients being asked to pay unofficial charges, out-of-
pocket expenses on health and lack of staff trained for
providing diagnostic services.
6. Social audits at panchayat, block, district and state
level: The community processes culminated in Jan
Samvads at panchayat/Gram Sabha and block levels
to discuss and resolve the identified issues. Large
numbers from the general public, Village Health
Sanitation and Nutrition Committee (VHSNC)
members, frontline health workers, PRI members,
Block Panchayat Pramukhs (Heads), Medical Officer
In-Charges (MoICs), Block Development Officers,
NGOs and teachers, among others, attended Jan
Samvads at the block level. The identified issues
were discussed and corrective actions taken at
these forums.
Any unresolved issues were presented at the district-
level Jan Samvads organised subsequently. These
Jan Samvads were attended by the general public
and VHSNC members, health facility staff and state
and district NHM officials. Issues were discussed,
corrective actions identified and a clear timeline given
to block and district level officials to address the
issues. A state-level Jan Samvad was also organized
in Jharkhand under the chairmanship of NHM Mission
Director. It was attended by over 250 participants,
including community representatives, Civil Surgeons,
MoICs, district and block personnel, ANMs, ASHAs
and State Nodal Officers from different departments
to address systemic issues. Key policy decisions —
such as CCTV camera installation in all district
hospitals and Community Health Centres (CHCs) and
restrooms for ASHAs in all district hospitals and CHCs
within the next 30 days — were taken at this forum.
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PILOTING SOCIAL AUDIT FOR HEALTH SERVICES
JHARKHAND
• Piloted in 5 districts (450 villages in 20 blocks)
• 151 social auditors trained
• 106 public hearings conducted (80 at panchayat level,
20 at block level, 5 at district level and 1 at state level)
• ~15,000 community members participated in public hearings
Being scaled up to 20 additional blocks in the 5 pilot districts
MEGHALAYA
• Piloted in 11 districts (2,161 villages in 13 blocks)
• 330 social auditors trained
• 1,996 public hearings conducted (1,985 at panchayat level
and 11 at block level)
• ~1,50,000 community members participated in public hearings
UTTARAKHAND
• Piloted in 1 district (3 blocks)
• 40 social auditors trained
• 4 public hearings conducted (3 at block level and 1 at district level)
• ~450 community members participated in public hearings
Being scaled up to 30 blocks across 13 districts
SOCIAL AUDIT
FOR HEALTH
The pilots have
demonstrated how
social audits at the
grassroot level can
deepen democratization
of health services and
bring people’s voice into
health planning
and implementation.
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IMPACT
The pilots in three states have demonstrated the effectiveness
of social audit as a platform to build awareness on health
entitlements, promote ownership by PRIs and enable better
fulfilment of community’s health needs. The social audits
identified gaps and issues and enabled time-bound resolution.
While the immediate result is strengthened local health facilities,
recommendations also travel up to the district and state level,
facilitating evidence-based policy change. The illustration below
represents a few examples from the pilot states, where feedback
from the ground led to corrective actions.
SOCIAL AUDIT FINDINGS PROMPT CORRECTIVE ACTIONS: A FEW EXAMPLES
Jharkhand
Meghalaya
Uttarakhand
ISSUE HIGHLIGHTED BY THE COMMUNITY
Dilapidated condition of primary health centres
(PHCs) and sub-health centres (SHCs)
Irregular VHSNC meetings; some VHSNCs had
not received untied fund for FY2018–19
In some facilities, medicines were being
prescribed on blank paper and patients being
asked to buy medicines from outside
CORRECTIVE ACTIONS
Decision to make budget provision in the
state PIP (FY2020–21) for repair of PHCs and
construction of SHCs
Several VHSNCs had not submitted utilisation
certificates (UCs); ASHAs were asked to submit
the UCs to facilitate release of funds to the
concerned VHSNCs
Facilities instructed to display citizen’s charter
and regularly update an essential drugs list.
District officials have begun making local
procurement, apart from state supplies, to
provide medicines free of cost to patients
LESSONS LEARNED
• Use of independent agencies is critical to objectively
identify the issues at the community level and bring
transparency to the exercise. Engagement of SAUs
with their mandate and experience helped state
NHMs get external feedback on how well the public
health facilities were delivering the intended services.
• Social audit processes should be multi-tiered and
focussed on time-bound actions and decisions,
especially at the district and state level to address
larger systemic issues.
• Community monitoring and audit processes help
build PRI members’ understanding and engagement
on health and can enable leveraging of resources
from Gram Panchayat Development Plans to bolster
health services.
• Social audits provide feedback and deep insights
into community-level issues and aspirations. This
feedback is useful for the health system to make
course corrections through policy decisions. The
insights have an immense potential to shape and
prioritise allocations in the state and district project
implementation plans (PIPs).
THE WAY FORWARD
The imperative for evidence-based health care requires
that planning and implementation remain flexible and
responsive to the real needs of people, an objective
that community monitoring can help achieve.
Encouraging results from Jharkhand, Meghalaya and
Uttarakhand have shown that social audits can help
enhance community participation and monitoring of
health services as well as escalate issues to the
appropriate decision-making level for corrective action.
The positive outcomes have generated confidence in
the state health leadership, resulting in decisions to
scale up social audits for health to 20 additional blocks
in the 5 pilot districts in Jharkhand and 30 additional
blocks across 13 districts in Uttarakhand.
Secretariat
Advisory Group on Community Action
B-28, Qutab Institutional Area, New Delhi – 110016
T: +91 11 43894 100; +91 11 43894 199
www.nrhmcommunityaction.org | www.populationfoundation.in