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Reviving Hopes
Realising Rights
A Report
on
the First Phase of
Community Monitoring under NRHM
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Contents : Sunita Singh, Abhijit Das, Sona Sharma
Editing : Elisa Parija
Layout & Design : Kishor
Production Coordinator : Moumita Ghosh
Published : June, 2010
Printed at : Design Solution
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i
Preface
The first phase of community monitoring implemented across nine states in 2007 draws its basis from the NRHM
Framework for Implementation. The nine states selected for the first phase effort were: Assam, Chhatisgarh,
Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Orissa, Rajasthan and Tamil Nadu. In each state, three to
five districts were selected considering the geographical spread, in each district three blocks, in each block three
PHCs and in each PHC five villages were selected. The first round of community monitoring process thus covered
over 1600 villages and 300 facilities.
The 18-month process involved capacity building of planning and monitoring committees at different levels
for conducting enquiry into the functioning of different components of NRHM and the uptake of key services. It
was an empowering process for the community because it provided community representatives’ knowledge on
different entitlements, service standards and service guarantees provided within the NRHM. It also gave an
opportunity to discuss the status of health services delivery with healthcare providers and programme managers.
The process of writing the national report and compiling information from across nine states was a daunting
exercise and would not have been possible without due support and guidance from various sources. The detailed
process documentation and state reports gave us an insight into the efforts, challenges and lessons learned at the
state level. These, and further information provided by the district/state nodal NGOs were the motivation to put
together information and findings of the states. The state-level findings may not adequately reflect the intensity
of the efforts, as the Section was solely dependent on information provided in reports or what was gathered from
direct feedback. It is meant to give a glimpse of the immediate impact of the effort. There are state reports prepared
by the state nodal agencies, which capture further details.
This Report consists of three sections. Section One talks about the overall process adopted, including activities
undertaken at the National Secretariat level. Section Two draws upon the data and qualitative feedback collated
from the states representing state-level findings and changes that took place over a period of time and innovations
that each state has done. The Third section is based on the review that was done by an external review team.
We hope this Report will provide a comprehensive overview of the extensive process that was carried out in
nine states. This Report, along with the manuals and materials produced under the first phase will be a useful
resource for states to scale-up their efforts as also for other states to initiate community monitoring keeping in view
the experiences from the first phase.
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ii
Acknowledgement
We wish to acknowledge our sincere gratitude for all the support, inputs and feedback that we have received.
Firstly, we are grateful to Mr. P.K. Pradhan, Additional Secretary and Mission Director NRHM, Mr. Amarjeet
Sinha, Joint Secretary, Dr. Tarun Seem, then Director, NRHM, Mr. Ganga Kumar, Deputy Director NRHM and all
others in the Department of Health and Family Welfare, Ministry of Health and Family Welfare, Government of
India for their confidence in us and constant support to us through out the first phase and also for disseminating
the experiences through the national dissemination meeting.
We would like to thank Mr. A R Nanda, Executive Director of Population Foundation of India (PFI) and
Convener AGCA, for his excellent guidance and encouragement throughout the process. Without his leadership
and inputs this process would not have been possible.
We would also like to thank Mr. S Ramanathan, Dr Rakhal Gaitonde, Mr. E. Premdas, Dr Abhay Shukla,
Dr Narendra Gupta, Dr Ajay Khare, Mr. Govind Madhav, Ms Rehana and Mr. Ajay Srivastava for providing inputs
in different sections of the Report, their inputs have been a major source of information and inspiration for this
Report.
Friends and colleagues from different states for providing us valuable information deserve a special mention:
Ms. Sanjukta Basa; Secretary; OLAMP Orissa
Ms. Manorama Dey; Block Coordinator; UNNAYAN Orissa
Mr. Ranjit Swain; Director; Chale Chalo Orissa
Ms. Tilottama Dash; Programme Coordinator; OMRAH Orissa
Mr. Sushil Kumar Pandey; Bastar Samajik Jan Vikas Samiti Chattisgarh
Dr. Nitin Jadhav; Saathi Cehat; Maharashtra
Mr. Ritesh Laddha; Prayas; Rajasthan
We would also like to acknowledge the support provided by the CHSJ and PFI team in the process of writing and
compiling the Report:
Ms. Pratibha D'Mello; CHSJ, New Delhi
Ms. Jolly Jose; PFI; New Delhi
Ms. Moumita Ghosh; CHSJ, New Delhi
Ms. Anita Gulati; CHSJ, New Delhi
Ms. Jaya Velankar, CHSJ, New Delhi
And finally we would like to express our gratitude to all members of the Advisory Group on Community
Action, State Mentoring Committees of concerned states and all state nodal organisations and district and block
level NGOs. A special thanks to the citizens of India who were engaged in the process of community monitoring
across nine states.
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Contents
Preface
Acknowledgements
Glossary
Section I
Introduction
3
The Process
5
National Level Preparatory Phase
6
State Implementation Phase
8
Material Support
12
Section II
Findings from the States: Some Immediate Outcomes
17
Maharashtra
17
Rajasthan
22
Jharkhand
24
Orissa
27
Madhya Pradesh
31
Assam
34
Chhattisgarh
36
Tamilnadu
38
Karnataka
43
Section III
Review of Community Monitoring
49
Review Process
49
Summary of Findings
49
Key Findings on Process
50
Key Findings on Program Management
52
Gain from Community Monitoring
54
Equipped for Scale up - Recommandations
54
Reference
58
Annexures
List of Material
62
Names of States, Districts and Blocks
64
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Glossary
AGCA: Advisory Group on Community Action
ANM : Auxiliary Nurse Midwife
ASHA : Accredited Social Health Activist
AWW : Anganwadi worker
BMO: Block Medical Officer
BP: Blood Pressure
BPHC: Block Primary Health Centre
BPL: Below Poverty Line
CBM: Community Based Monitoring
CBO: Community Based Organization
CD: Computer Disc
CEHAT: Centre for Enquiry into Health and Allied
Themes
CHC: Community Health Centre
CHSJ: Centre for Health and Social Justice
CINI: Child in Need Institute
CM: Community Monitoring
CMHO: Chief Medical and Health Officer
CMO: Chief Medical Officer
CMP: Community Monitoring and Planning
CRP: Community Resource Person
DH: District Hospital
DHO: District Health Officer
FLW: Front Line Worker
GoI: Government of India
GKS: Gaon Kalyan Samiti
JSY: Janani Suraksha Yojana
ICDS: Integrated Child Development Service
ID: Identity Card
MDGs: Millennium Development Goals
MO: Medical Officer
MoHFW: Ministry of Health and Family Welfare
MPW: Multi Purpose Worker
NFHS: National Family Health Survey
NGO: Non Government Organisation
NHP: National Health Plan
NHSRC: National Health Systems Resource Centre
NRHM: National Rural Health Mission
Reviving Hopes, Realising Rights
OLAMP: Orissa Medical Research and Health Services
OP: Out Patient
OPD: Out Patient Department
PFI: Population Foundation of India
PFI-RRC: Population Foundation of India - Regional
Resource Centre
PHC: Primary Health Centre
PIP: Program Implementation Plan
PRA: Participatory Rural Appraisal
PRI: Panchayati Raj Institution
RCH: Reproductive and Child Health
RKS: Rogi Kalyan Samiti
RWSS: Rural Water Supply and Sanitation
SC: Schedule Caste
SDM: Sub Divisional Magistrate
ST : Schedule Tribe
SW: Social Worker
TAG: Technical Advisory Group
TOT: Training of Trainers
VHC: Village Health Committee
VHN: Village Health Nurse
VHND: Village Health and Nutrition Day
VHSC: Village Health and Sanitation Committee
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Section - I
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Introduction
The National Rural Health Mission (NRHM) launched
on April 12, 2005, aims to bring about significant
improvement in healthcare delivery in rural areas of
the country and in the health status of the people. The
NRHM promises to provide universal access to
equitable, affordable and quality healthcare, which is
accountable and at the same time responsive to the
needs of the people, especially those who are
marginalised and live in rural areas.
Key objectives of the Mission are reduction in
child and maternal deaths, population stabilisation
and gender and demographic balance. The processes
set to achieve the objectives of the Mission will help
accomplish goals under the National Health Policy
(NHP) and the Millennium Development Goals
(MDGs).
The NRHM proposes an intensive accountability
framework through a three-pronged process of
community monitoring, external surveys and
stringent internal monitoring. Facility and Household
Survey, NFHS and RCH data would act as the baseline
for the Mission against which the progress would be
measured.
The adoption of a comprehensive framework for
community monitoring and planning at various levels
under NRHM is an extremely positive development. It
can place centre-stage community members and
beneficiaries, CBOs and NGOs working with
communities and Panchayati Raj Institution (PRI)
representatives and allow them to actively and
regularly monitor the progress of NRHM interventions
in their areas. Besides ensuring accountability, it would
also promote decentralised inputs for better planning
of health activities based on locally relevant priorities
and issues identified by community representatives.
This framework is consistent with the 'Right to
Health Care' approach mentioned in the latest NRHM
framework document, since it places people at the
centre of the process of regularly assessing whether
health rights of the community are being fulfilled. It
could also be a step towards "Bringing the 'Public' back
into Public health" by allowing community members
and their representatives to directly give feedback
about the functioning of public health services,
including inputs for improved planning of the same.
The Ministry of Health and Family Welfare
(MoHFW) has constituted the NRHM Advisory Group
on Community Action (AGCA) with the mandate to
provide guidance for community action under NRHM.
To initiate the process of community monitoring as
outlined in the implementation framework, the AGCA
recommended the implementation of community
monitoring in the states with support from the
Government of India (GoI). Based on the AGCA
recommendations, the GoI decided to support a first
phase green field initiative in community monitoring
with active role of AGCA and civil society
organisations. A partnership between Health
Department, community (CBOs and NGOs) and PRIs
is envisaged, to realise the objectives of community
monitoring. Community Monitoring, implemented as
a first phase in nine states since 2007, draws its basis
from the NRHM Framework of Action. Population
Foundation of India (PFI) and Centre for Health and
Social Justice (CHSJ) were designated the National
Secretariat for the first phase effort supported by the
MoHFW. The nine states selected for the first phase
effort were: Assam, Chhattisgarh, Jharkhand,
Karnataka, Madhya Pradesh, Maharashtra, Orissa,
Rajasthan and Tamil Nadu. In each state, three to five
districts were selected looking at the geographical
spread, and three blocks were selected from each
district. In each block, three PHCs and in each PHCs,
five villages were selected.
Table 1: Geographical Coverage
Particulars
Number
1 States
9
2 Districts
36
3 Blocks
108
4 PHCs
324
5 Villages
1620
6 VHSC formation
1620
First Phase of Community Monitoring under NRHM
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The objectives of the first phase were:
To set up a common mechanism for
implementing the process of community
monitoring on a large scale by building
relationships between civil society organisations,
citizens and government.
To develop a comprehensive toolkit for
implementing community monitoring, that can
be implemented with local adaptation across
different socio-cultural contexts (states).
To demonstrate feasibility of community
monitoring conducted using commonly developed
mechanisms and tools as a method for generating
community-based and community-owned
feedback, that can be used both for initiating local
corrective action and for triangulation purposes
along with other forms of data.
To realise these objectives, facilitation by civil society,
especially NGOs, has been the key element. The NGOs
were to mobilise the community and enable a
participatory process of monitoring by involving
various stakeholders. The NGOs were also to represent
the community and be their spokesperson with the
Health Department, as the communities and PRI
members do not have such expertise. This, it was
presumed, would help shift the locus of power
gradually from the Heath Department to the people. It
is anticipated that the NGOs would bring in
objectivity to the process, which may be missing if the
process was anchored by the Health Department. The
NGOs were to have three roles in community
monitoring:
As members of monitoring committees
As resource groups for capacity building and
facilitation
As agencies helping to carry out independent
collection of information
The Community Monitoring Project started in April
2007 and was completed in March 2009. The entire
process was divided into three phases - the National
Preparatory Phase, the State Preparatory Phase and the
Implementation Phase. The documentation of the
process was done concurrently and an external review
was done in November - December, 2008.
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The Process
Implementation Mechanism
The AGCA provided oversight and guidance
to the entire process through the National
Secretariat (PFI & CHSJ). A state nodal
agency was identified for each of the nine
states. State nodal agencies identified
district and block nodal agencies in the
selected districts and blocks.
Planning and Monitoring Committees
were to be set up at PHC, block, district and
state levels and at the village level, Village
Health and Sanitation Committees (VHSC)
were to be set up. The process was conceived
as a three-way partnership between
healthcare providers and managers of the
health system, the community (including
CBOs and NGOs) and the PRIs. The tiered
mechanism of feedback in the monitoring
process is illustrated in Figure 1 and 2.
Figure 1: Feedback Mechanism of Different Levels of
Committees
State Planning &
Monitoring Committee
District Planning &
Monitoring Committee
Block Pla nning &
Monitoring Committee
PHC Planning &
Monitoring Committee
Village Health &
Sanitation Committee
Feedback
& Reports
Figure 2: Feedback Mechanism at Different Levels
Table 2: Nodal NGOs identified for the nine first
phase states
Name of the
States
1 Assam
Name of the State Nodal
NGOs
Voluntary Health
Association of Assam
2 Jharkhand
CINI
3 Rajasthan
PRAYAS
4 Tamilnadu
Tamil Nadu Science Forum
(TNSF)
5 Chhattisgarh
State Nodal Consortium
(SANDHAN Sansthan,
Chattisgarh Voluntary Health
Association and PFI-RRC)
6 Karnataka
Karuna Trust
7 Madhya Pradesh Madhya Pradesh Vigyan
Sabha
8 Maharashtra
SAATHI-CEHAT
9 Orissa
KCSD- KIIT
First Phase of Community Monitoring under NRHM
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National Level Preparatory Phase
The Preparatory Phase at the national level included
setting-up a task group under the aegis of AGCA. The
task group along with the National Secretariat was
responsible for developing tools for community
monitoring, a model curriculum for trainings,
materials for trainings and workshops, design and
content of workshops, awareness and promotional
materials and documentation formats. The task group
was also assigned the responsibility of establishing
initial contact with State Health Secretaries; apprising
them of the first phase initiative; setting-up the State
Community Monitoring and Mentoring Group and
identification of state nodal agencies.
AGCA members were assigned specific states to
assist in setting the ball rolling for community
monitoring in the state.
Figure 3: Organogram - Agencies & Committees
at Each Level
It was recognised right at the outset that
strategies, especially promotional materials and
presentation of formats, would require adaptation
at the state level, given the uniqueness of different
communities, varying socio-political situations,
local health profile specificities, characteristics of
civil society organisations involved in the
monitoring and the state of public health system.
This was critical not only because healthcare needs
of the people vary, but also because perceptions of
people and their capacities to participate in health
programmes also vary. Thus, while the National
Secretariat developed the general guidelines and
materials, these were tailored to specific contexts at
the state and district levels.
Glimpse of material prepared at national level
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State Mentoring Group
As a first step to implement the Project at the state
level, a State Mentoring Group was formed with due
involvement of the State Health Department and state
level voluntary networks. Members of the Mentoring
Group included designated representatives from the
Health Department, civil society organizations and in
some cases, other related department representatives
such as Public Relation (PR) Department. The
Mentoring Group had clearly spelt out responsibilities
to lead community monitoring in the state during the
first phase and beyond. In addition, the designated
national AGCA members (as permanent invitees to the
State Mentoring Group) provided required impetus to
the effort.
State Nodal Organisation
The State Mentoring Group, in the first meeting itself
identified one of the state-level organisations by
consensus as the State Nodal NGO to implement the
first phase. This State Nodal NGO worked under the
direction of the State Mentoring Team with
backstopping support from the National Secretariat.
The State Mentoring Group in coordination with
the State Nodal NGO selected the districts and blocks
for initiating community monitoring. Nodal NGOs for
district and block levels were also selected based on a
specific selection criteria initially proposed by the
National Secretariat and modified/accepted at the state
level by the mentoring group.
National Workshop
To begin with, a three-day National Workshop for
Training of Master Trainers on Community
Monitoring was organised to orient the state nodal
agencies and to prepare them to implement the
community monitoring process in their respective
states. The states were asked to nominate four master
trainers from their respective states, who would work
as resource persons and further train people. The
workshop was used as a platform to share experiences
and develop common working principles.
State-Level Workshop
A State-Level Workshop was subsequently organised by
the State Mentoring Team, State Nodal Organisation
and State Health Mission involving all stakeholders
(State Mission officials, district health officials. PRI
representatives from selected districts, NGO networks
and civil society organisations from these districts).
Representatives from NRHM, GoI and National
Secretariat also participated. The activities of the first
phase were shared and the process finalised. Detailed
timetable for district-level meetings, formation and
orientation of committees, conducting community
monitoring and sharing of results at the PHC and block
was worked out in this two-day state level workshop.
State-Level Training
The State Nodal Organisation under guidance from
the State Mentoring Team conducted a five-day State-
level Training of Trainers. The training was attended
by district-level trainers who were responsible for
facilitating the community monitoring process at the
district level and below. The trainers were primarily
the voluntary sector facilitators. However, state
Health Department officials were also present and
involved in these workshops, enabling them to
actively participate in further such trainings.
First Phase of Community Monitoring under NRHM
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State Implementation Phase
Activities carried out at the state implementation level
could be divided into the following phases:
Preparatory phase
Training and workshop phase
Formulation of community monitoring
committee
Monitoring phase
Jan Samvad phase
End phase.
Table 3 : Detail of Activities at the State Level
Phases
Activities
Training/
workshop phase
District workshop
Block facilitators training
Block providers training
VHSC orientation workshop
Orientation of different level
of committees
Formation of
Community
Monitoring
Committee
Village health and Sanitation
Committee
PHC Monitoring and
planning committee
Block Monitoring and
planning committee
District monitoring and
planning committee
Monitoring phase
Community Mobilization
Preparation of Village health
profile
Community enquiry
Preparation of report card -
Village, PHC and Block
Jan Samvad
Jan Samvad at PHC and Block
level
End phase
State process documentation and
state review workshop
Once the district and block level facilitating
organisations were selected and trained at the state
level, the key activities shifted to the district and block
levels. The activities at the district and block level
proceeded in the following manner:
Setting the Stage
District processes were facilitated by district-level
organisations taking responsibility in the first phase
along with district health officials and PRI
representatives. A District Mentoring Team (including
representatives of each of the three groups) to facilitate
the community monitoring process was put in place,
which facilitated the orientation activities in this and
subsequent stages. In each district, a civil society
organisation was identified to take responsibility as the
District Nodal Organisation. This NGO was assisted by
other civil society organisations that would take
specific responsibility in various blocks. The process
started with a District Level Workshop to share the
concept, identify blocks and PHCs and involve key
district health officials, PRI members and civil society
organisations. For each selected block, the block nodal
organisations took up the responsibility of
coordinating with the District Nodal NGO.
A Block Facilitator Training was conducted for at
least a four-member Block Community Monitoring
Facilitation Team, including at least two NGO/CBO
members, with at least half the members being
women. These Block Facilitation Team members were
responsible for subsequent committee formation and
orientation processes.
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Figure 4: Organogram of Monitoring & Planning
Committees
Formation of Committees
During the four months (Aug-Nov 2007), committees
were formed at village, PHC and block levels in the
selected blocks (in that order), along with primary
orientation of their members. Formation of
community monitoring and planning committees
started from village committees, PHC, block, and
then district committees. It was important to
constitute the committees from village level upwards
in an inclusive manner - hence a few members from
VHSCs were included in the PHC committee.
Similarly, a few PHC committee members were
included in the block committee and so on.
CBOs/NGOs and Panchayat representatives who had
shown initiative in organising community
monitoring activities at any level found
representation in the next higher-level committee.
Adequate representation of women, dalits and
adivasis was ensured in the various committees.
Following committee formation at the peripheral
levels, the District Level Committee was also finalised
and became functional in November 2007. In the first
phase, a provisional committee was formed at the state
level in December 2007. This would be given final
shape only after the next phase of 'Extended
Implementation' is completed and at least, half of the
districts of the state have Community Monitoring
Committees in place, which could send
representatives to the State Committee.
Community Mobilisation, Monitoring
& Report Card Preparation
A process of raising awareness of community members
regarding their health entitlements and significance of
community monitoring was carried out in all villages,
prior to formation/expansion of VHSCs. At least three
meetings in each village were conducted for this
purpose, and the final meeting was expected to be in
the form of an 'official' Gram Sabha where the new
VHSC members would be selected and
formation/expansion of the VHSC would be declared.
Posters related to people's health entitlements under
NRHM were put up in the village as part of this
process. Innovative strategies for community
mobilisation were adopted by states such as use of folk
form (Kala Jaththa), Chinaki (introduction) meetings,
padyatras, involving children, youth parliament and
social mapping etc.
The community monitored the need, coverage,
access, quality, effectiveness, behaviour, presence of
healthcare personnel at service points, possible denial
of care and negligence aspects. The monitoring process
included outreach services, public health facilities and
the referral system. These exercises aggregated
information upwards as illustrated in Figure 4. The
monitoring results were also shared at the village level,
PHC and block level in the appropriate PRI fora. Some
of the broad areas under the NRHM on which
community monitoring was conducted were:
Entitlements under Janani Suraksha Yojna (JSY)
Roles and responsibilities of ASHA
Indian Public Health Standards (IPHS) for
different facilities like Sub-centre, PHC, CHC
Concrete Service Guarantees
Citizen's Charter
In the first phase, indicators for information
collection at the village level and the PHC level were
finalised, and accordingly tools for monitoring were
formulated at the national level. It was also decided
that frequency of the monitoring cycle in every village
would be once in three months i.e. a report card of
village would be prepared once every three months
and submitted to the PHC monitoring committee.
However, only one round of data collection was
planned for the first phase. The exceptions were
Karnataka, Rajasthan and Maharashtra where more
than one round of data collection was done.
In each monitoring cycle at the village level, two
group discussions were planned. One of these group
discussions was with the general community, and one
was exclusively with women. Similarly, at the PHC
First Phase of Community Monitoring under NRHM
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Figure 5: Issues and Process of CM at different level
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level, exit interviews of the OPD patients were to be
conducted in each cycle. These group discussions and
exit interviews were accompanied by a facility survey
at the PHC and interview of the PHC MO. The block
coordinators mainly conducted facility surveys and
also exit interviews and interview of MOs.
PHC and block level community monitoring
exercises included a public dialogue (Jan Samvad) or
public hearing (Jan Sunwai) process. Here, individual
testimonies and assessments by local CBOs/NGOs
were presented. Individual testimonies were identified
through the adverse outcome recording process. These
public dialogues were moderated by the district and
block facilitation groups in collaboration with PRI
representatives and CBOs/NGOs working on health
rights issues.
Monitoring committees reviewed and collated
reports from committees at the unit level below them.
The members did not rely on reports but also directly
interacted in the field and got feedback. Firstly, each
committee appointed a small sub-team drawn from its
NGO and PRI representatives who visited a small
sample of units (say one facility or two villages) under
their purview on a regular basis and directly reviewed
the conditions. This gave the committee a first-hand
assessment of conditions in their area. For example,
the PHC Committee representatives would visit two
villages and conduct group discussions in each
trimester, selecting different villages by rotation.
Similarly, the Block Committee representatives would
visit one PHC by rotation in each trimester.
Secondly, monitoring committees at PHC, block
and district level would be involved in six-monthly or
annual Jan Samvads or Jan Sunwai at their respective
levels, where committee members would get direct
feedback on the situation, including possible
presentation of cases of denial of healthcare. Similarly,
it is suggested that the State Health Mission could
conduct an annual public meeting open to all civil
society representatives where the State Mission report
and independent reports would be presented and
various aspects of design and implementation of
NRHM in the state, including state specific health
schemes, would be reviewed and discussed enabling
corrective action to be taken.
Engaging Media
One of the key strategies in the first phase was to
involve the media in creating public opinion about the
existing state of the public health system and also to
positively influence decision-makers.
Some of the strategies adopted for a wide and
effective media coverage included:
1. Appointing a state media consultant: A working
journalist with experience of facilitating media
coverage of developmental and health issues was
associated as a consultant with the entire process.
This was an innovation which proved quite
effective in involving senior media persons from
multiple major newspapers, and ensured
continuous following-up of involvement of the
media at both state and district level, including
the electronic media.
2. Appointing and orienting media fellows: Two
media fellows were designated at the state level to
cover the CM (Community Monitoring)
activities. These journalists belonged to major
dailies with multiple editions in various parts of
the state to ensure adequate regional as well as
state level coverage. Similarly, a media person at
the block level was assigned to cover and report
on CBM related block activities.
3. State media workshop: In this one-day workshop,
media participants were familiarised with the
process of community monitoring. In some states,
this workshop was planned when the community
monitoring data from villages was already
available with the state nodal NGO. Preliminary
analysis of this data was presented in the
workshop. Attempt was made to ensure that
senior government officials were also present for
this workshop. This helped the media persons
present in the workshop to get official perspective
on the reported deficiencies from villages and also
to understand specific issues associated with the
quality of healthcare in the states.
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Material Support
One of the important preliminary tasks for the
National Secretariat was to develop communication
material to create awareness on various
entitlements and schemes, service guarantees and
provisions, community participation and
framework for community monitoring under
NRHM. Seven sets of brochures, six sets of posters
and a booklet on Health Entitlements faced were
developed. CDs of print-ready version of materials
were sent to each state nodal agency to enable them
to modify the materials as per their requirement
and print in their state language. These materials
were extensively used during community
mobilisation and orientation of various committees
on their role under NRHM.
In addition to the promotional materials, the
National Secretariat with support from the task group
developed three manuals 1) Manual for Managers, 2)
Manual for Training and 3) Manual for Monitoring.
These manuals together provide detailed guidelines on
how to plan and implement community monitoring
in the state.
A 30-minute documentary film produced towards
the end of the first phase captured the process,
immediate impact of the process in the field, and the
lessons learned and challenges faced. The film, both
training as well as advocacy tool highlights the
potential of community monitoring as a community
empowerment and democratisation process in the
context of people's right to health.
CD Cover of CM Film
* copies available at CHSJ.
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13
Online Edition
The National Secretariat developed a Community
Monitoring website (www.nrhmcommunityaction.org) to
enable online review of information related to
community monitoring. The website contains general
information such as definitions and explanations of
community monitoring concepts under NRHM. The
website contains the organogram of community
monitoring, lists of AGCA members, TAG members,
the National Secretariat on community action, broad
description of Monitoring and Planning Committees
at different levels, and mentoring teams at the state
and district levels. Also included are details of nodal
NGOs at the state level, information on the process of
the Project, name and address of districts and blocks
and geographical spread.
The website also has information and documents
related to government orders, progress made and state-
specific toolkits. The national toolkit (Manager
Manual, Training Manual and Monitoring Manual and
other Publications) has been uploaded for wider
circulation. State-wise newspaper clippings and
photographs collated on various occasions by the state
nodal agencies and during state visits by the
programme officers have been uploaded as well. The
national website is linked with state specific web
pages. The states have control over these web pages
and are provided with password and user ID so that
they can upload information as per their requirement.
A half-day intensive training was provided to the state
technical person on how to maintain the web pages
and upload information. The national website is
linked with the Health Ministry's NRHM website.
A unique feature of the website is that it enables
access to data till the village level. Report cards at
Screen Shot of National CM Website
First Phase of Community Monitoring under NRHM
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14
village, PHC, block and district level can be viewed
for each of the nine states. This enables reviewing the
data not just at the district level but also at the state
and national levels at the click of a button.
Screen Shot of Report Card Generation Page
Table 4 - Example of a Village Health Report Card
generated by the website
Village Level Report Cards
Village Name
Block Name
District Name
Lebeda
Muribahal
Bolangir
Year: 2008-09
Quarter: II
Sl. Issue
no.
1 Maternal Health Guarantees
2 Janani Suraksha Yojna
3 Child Health
4 Disease Surveillance
5 Curative Services
6 United funds
7 Quality of Care
8 Community perceptions of ASHA
9 ASHA functioning
10 Equity Index
Score
50
42
87
50
96
25
75
100
83
100
11 Adverse Outcome or experience reports 100
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Section - II
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17
Findings from the States :
Some Immediate Outcomes
The process of the first phase of Community
Monitoring (CM) across nine states was implemented
from March 2007 to March 2009. The monitoring
process involved capacity building of planning and
monitoring committees at different levels to conduct
enquiry into the functioning of different components
of NRHM and uptake of key services. It was an
empowering process for the community because it
provided the community representatives knowledge of
different entitlements, services standards and services
guarantees that are provided within the NRHM. It also
provided an opportunity to discuss the status of
service delivery with health care providers and
managers.
The geographical coverage and pace of the
monitoring process varied from state to state. While
some of the states went ahead and completed the
required activities within the set timeframe, others
needed more time. The districts in the states were
selected considering the geographical spread of the
state. Thus, the number of districts varied from three
to five across nine states.
The village was the main unit for community
monitoring. The tools that were developed at the
national level were adapted and modified at the state
level. The score cards that had 11 parameters to assess
the health situation of the village were based on the
traffic lights. The report cards had three colour codes
on the basis of the following parameters:
Green = 75% to 100%
Yellow = 50% to 74%
Red = 1% to 49%
As described in Section I, the process underwent
several layers of interventions, which led to enormous
learning, innovations, participation of different
stakeholders, negotiations and challenges. One of the
prime objectives of community monitoring was to
show the way for communitisation, which was met by
opening doors for dialogues between services providers
and community and by reaching a consensus.
Jan Sunwai and sharing of village-level findings of
monitoring made a great impact on the mindsets of
providers, which resulted in better service delivery,
ratification of the problems and in bringing local
health providers and community on the same
platform. The process also enhanced the level of
ownership among community members.
This section describes the findings, innovations
and impact of community monitoring that each state
experienced during the process. It is based on data and
documents that the state nodal agencies provided,
interviews with community organisations and
community leaders and case studies shared by district
nodal agencies during the CM process.
MAHARASHTRA
The first phase of community monitoring was carried
out in five districts (Nandurbar, Pune, Amaravati,
Osmanabad and Thane) of Maharashtra. The state has
so far completed three rounds of monitoring at village,
PHC and rural hospital levels. The first round of data
was collected between July-Aug 2008, the second
round between Mar-Apr 2009 and the third round
between Oct-Dec 2009. Though the project ended in
March 2009, The State collected an additional round
of data during Oct-Dec 2009. The monitoring took
place in 220 villages, 40 PHCs and 15 blocks. The state
has observed significant improvements in certain
services from July 2008 to Dec 2009, mainly due to
combination of two factors - NRHM 'supply side'
inputs and 'demand side' push by CM.
The positive impact of community monitoring in
the state was based on two important aspects:
responsiveness of state government officials, adequate
supply of funds and relevant decisions by officials as
well as sustained push by various communities, NGOs
and people's organisations. While availability of
finance, supportive directions and untied funds from
NRHM give the basic inputs for improvement, the CM
process provides a matching yet critical 'push from
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18
below' to help ensure that desired changes are actually
implemented.
70
Village-level Health Services: Visible 60
Improvements
50
40
30
The village health report cards covered nine key health
20
services and these were rated by Village Health
10
Committee members as either 'Good' (Green) 'Partly
0
Satisfactory' (Yellow) or 'Bad' (Red). This information
was collected from 220 villages. Graph 1 shows the
trend of good ratings for these services across five
districts in Maharashtra covering three rounds of CM.
While 48 per cent of the services were given 'Good'
rating in round one, it increased to 61 per cent in
round two and further to 66 per cent in round three.
Thus, there has been a consistent overall improvement
in village health services in the CBM covered villages.
Similarly, Graph no. 2 shows the concurrent
30
reduction in 'Partly Satisfactory' and 'Bad' ratings of
25
services in these five districts over three rounds of 20
CM. Services rated as 'Bad' have reduced from 25 15
per cent in the first round to 14 per cent in the third 10
round.
5
These changes, while generally being in a positive
0
direction, have varied from district to district. An
aggregate 'Good' evaluation trend for each district over
the three rounds of CM is shown in Graph no. 3. In
three districts (Amaravati, Pune and Thane) there is a
Good evaluation over three rounds of CBM
66
61
48
Round one
Round two
Round three
Graph 1
Partly satisfactory and Bad evaluations over three
rounds of CBM
28
25
23
16
20
14
Round One
Round Two
Round Three
Graph 2
90
80
70
60
60
50
41
37
40
30
20
10
0
Nandurbar
District Trends over three rounds of CBM
59
55
45
75
67
67
63
57
35
Amaravati
Osmanabad
Thane
Reviving Hopes, Realising Rights
85
81
49
Pune
Graph 3
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19
significant improvement between Round one and
Round two, although between Round two and Round
three the improvement is more gradual. In Nandurbar,
ratings remained poor between Round one and Round
two, but improved significantly by Round three. The
ratings for Osmanabad improved slightly between
Round one and two, but returned to initial levels by
Round three.
Certain health services have shown high and
consistently improving 'Good' ratings across the five
CBM districts over three phases. At the end of Round
three, 90 per cent of districts received a rating of 'Good'
for immunisation services and 87 per cent of districts
received a rating of 'Good' for Anganwadi services. The
following graphs (Graphs 4 and 5) display trends for
these services.
Good evaluation trends over 3 Rounds for
Immunisation services
100
90
80
70
69
60
50
40
30
20
10
0
Phase 1
71
Phase 2
90
Phase 3
Good evaluation trends over 3 Rounds for Anganwadi services
100
90
80
70
60
54
50
40
30
20
10
0
Phase 1
75
Phase 2
87
Phase 3
Graph 4
Graph 5
Health Facility Level:
Evident Impact
The facility monitoring was
done keeping four parameters
in mind namely, infrastruc-
ture, services, personnel and
medicines. From Round one to
three, significant changes have
been observed in the first two
parameters.
Trends of Good ratings in PHC over 3 Rounds of CM
80
70
70
64 62
60
50
40
30
20
10
0
PHC Infrastructure
74
57
42
PHC Services
36 35
26
PHC Personnel
Graph 6
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20
Glimpses of Change
Following are some examples of qualitative improvements, which have resulted from each of these issues being
raised through the CM process. These kinds of improvements have been observed generally in several blocks
being covered by the CM process.
PHC doctors in one of the districts used to prescribe medicine from private shops. This issue was raised
through CM and subsequently the practice was stopped. Some of the required medicines, which are
unavailable, are now purchased from the RKS funds. A suggestion box for patients has been placed in the
PHC due to recommendation of PHC Committee.
Due to efforts of CM, utilisation of the village untied funds for purchasing furniture for Anganwadis in
some blocks has stopped. Funds are now used for other ‘more relevant’ health-related activities.
The laboratory facilities that were not functional in some districts have now started to work twice a week.
In one of the blocks a non-functional Sub-centre started to function regularly after the CM process.
The number of people availing services from certain PHCs, now has increased after the CM process. In
some PHCs, the number of patients availing these services doubled after CM shifted from private to public
health system.
Now most of the public health facilities have displayed the "Citizen Health Charter" as well as information
related to ambulance services.
In a significant innovation linked to CM, adolescent representatives (12-17 yrs) in two blocks have been
included in the VHSCs so that issues of children and adolescents could be raised and addressed adequately
in the meetings.
In one of the adivasi blocks, land has been sanctioned and a new PHC building is now under construction
as a special case. A mobile unit has been started at the Sub-centre level based on demand from the
community. A mobile medical unit has also been approved at one of the PHCs.
Implementation of Janani Suraksha Yojana (JSY) has improved and beneficiaries are getting benefits more
regularly in one of the districts.
Frequency of visits of ANM and MPWs in villages has improved leading to improved village health services
in several blocks; there is definite improvement in immunisation coverage in these villages.
One of the Sub-centres now has a residential medical officer as this centre covers a population of around 7000.
Interaction between local health care providers and community has improved in most of the blocks;
villagers in one area have taken initiative for giving protection to the ANM as her quarter is on the
periphery of the village.
The major role of Jan Sunwais in inducing these
improvements needs to be emphasised; many of these
issues were raised in such hearings and effectively
addressed. As part of the CM process around one
hundred Jan Sunwais at PHC and district levels have
been organised so far in Maharashtra.
Innovations that ‘Made a Difference’
Specially designed, simplified pictorial VHSC tools
have been designed and used particularly in Thane,
Nandurbar and Amravati districts keeping in mind the
adivasi population and low literacy levels.
Village, PHC and rural hospital report cards have
been published in a poster format. These large-size posters
are displayed publicly in the village or facility, allowing all
villagers and health functionaries to see the results.
A regular 24-page state-level newsletter in
Maharashtra, on community monitoring titled 'Dawandi'
(public proclamation) is being published with news items,
interviews, photographs, articles, instances and examples
of people's positive and negative experiences at health
facilities and positive stories of field-level health workers
who have done praiseworthy work.
In the expanded phase, PRI members in many
blocks who had been appointed as panelists during the
Jan Sunwais have been made members of committee
sub-groups to investigate specific health services in
Pune. This has led to their increased participation.
Arogya Jagruti Diwas has been organised in
villages of Thane district with mass participation and
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21
community mobilisation followed by data collection
and report card preparation. Part of the day is also used
to undertake constructive work such as cleaning a well,
digging soak pits etc. Such activities create broader
ownership of the community monitoring activity
beyond VHSC members.
'Open' trainings in Dahanu and Murbad blocks
imply that VHSC trainings are open for not only VHSC
members but for all other interested community
member. This has created a facilitative environment
promoting high social recognition of the programme.
The village health services calendar has been used
in some blocks to inform the community as well as
monitor regular outreach visits of ANMs and MPWs.
'Jahir Arogya Sabhas' were organised at village
level in Purandar block with the PHC medical officer
visiting each CM village and conducting a village level
discussion on improving health services. Panchayat
representatives and community members also
participated in the meetings.
Active participation of people's organisations
(Sanghatanas) in the entire CM process in Maharashtra is
a major highlight of the state. Many of the innovations
took place in areas where such organisations are active
because some of the earliest experiments in Maharashtra
on rights-based mobilisation of community on health
issues had taken place in these areas.
State level review and culmination workshops have
been organised in November 2008 and April 2010 with
participation of all concerned PHC Medical Officers,
Taluka Medical Officers, DHOs and Civil surgeons or
representatives, all block and district nodal NGOs and
state nodal NGO representatives, NRHM Mission Director,
state-level NRHM and Directorate of Health Services
officials for comprehensive review of issues emerging
through the CM processes in each district. These major
events provided a platform for systemic and policy level
issues related to public health system to be discussed.
Testimony of a PHC Doctor during Jan Sunwai - An interesting aspect of the community
monitoring process
The Amaravati district Jan Sunwai in Oct. 2008 was unusual, because it was the first time in a CM-related public
hearing that a PHC MO came to present her own grievance. Her testimony exemplifies the difficulties faced by
well-intentioned and sincere officers in the health bureaucracy.
Dr. Miraj Ali had been working as a PHC MO in Dhamangaon Gadhi for the last one-and-a-half years.
People have reported that she has been instrumental in improving the health services of the PHC. This was by
no means a small achievement considering the fact that the same PHC was almost dysfunctional before she was
appointed there. She had been staying in the PHC from the day of her appointment and naturally, the number
of OPD patients, especially women patients, had increased significantly.
In the Jan Sunwai around 20 men and women, including one Zilla Parishad representative, travelled all
the way from their village to Amaravati town and strongly protested against her unjustified transfer by the DHO.
However, the DHO of Amaravati who was present in the Jan Sunwai was quite dismissive and non-committal.
Around 325 people residing in Dhamangaon had signed a petition to reinstate Dr. Ali, and the Zilla Parishad
member from Dhamangaon had also endorsed this demand. This petition was presented in the Jan Sunwai.
What was striking was the way ordinary women from Dhamangaon supported Dr. Ali. CM organisers
still remember a frail looking woman who came to the Sunwai at her own expense and warned the DHO not to
play with the sentiments of the people in Dhamangaon since every house in the village knows about the
contribution and commitment of Dr. Ali.
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RAJASTHAN
In the First phase of monitoring four districts were
chosen, Alwar, Chittorgarh, Jodhpur and Udaipur in
Rajasthan. The CM process was carried out in 180
villages, 36 PHCs and 12 blocks. Although the process
of community monitoring started in the State from
September 2007 but the course of report card
preparation took place from September 2008.
From Sept 2008 to Nov 2009, the state underwent
three rounds of monitoring and saw a considerable
shift in color codes of score cards. The report under
submission used data from two rounds of community
monitoring from Sept 2009 and Nov 2009.
Significant Improvements
In a short span of time, the State saw significant
changes and improvements. In districts of Alwar and
Udaipur, the process of monitoring not only helped in
increasing the utilisation of vaccination services but
District Alwar
40
36
36
35
30
25
20
15
10
9
5
0
0
First round
50
45
44
40
35
30
25
20
15
10
5
1
0
0
First round
8
1
Second Round
Graph 7
District Chittorgarh
24
16
5
Second Round
Graph 9
Reviving Hopes, Realising Rights
also motivated ASHAs to visit door-to-door for service
provision on a regular basis. The process also helped in
effective utilisation of public health services by the
community due to which the attendance of patients
increased. The doctors and other paramedical staff
became more regular and devoted more time. The
health facility eventually became more regular and
organised in terms of services provided.
After the first round of monitoring exercise (Sept
2008), 138 villages out of a total 180 villages scored
red, 37 villages were yellow and only five villages
were green. The second round of monitoring
experienced shift in colour score, which was carried
out in Oct 2009. A substantial shift was seen from red
to yellow and yellow to green. In the second round,
out of 137 villages (which were observed red in the
first round) 76 villages shifted to yellow colour score
and 12 villages scored green colour, also showing an
increase from the first phase where only 3 villages
scored green colour. Graph 7, 8, 9 and 10 depict shift
in colour codes during two rounds of CM.
30
25
23
20
18
15
District Udaipur
26
10
15
10
5
2
0
First round
30
25
23
20
18
15
4
Second Round
Graph 8
District Udaipur
26
15
10
5
2
0
First round
4
Second Round
Graph 10
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The active involvement of different levels of
committees gave leverage to the members to demand
better and effective services, facilities and human-
power. Some of the changes at the village, PHC and
block level took place due to the hard work of the
committees.
Glimpses of Change
In Pachla PHC of District Jhodpur, the post of Medical Officer (MO) was vacant for a long time but
due to the efforts of committee members, an MO was appointed.
At Cherai PHC of district Jhodpur, a case of corruption was noticed where one of the nurses was taking
bribe from pregnant women to provide them private quarters. Mismanagement of JSY money was also
reported. Due to constant pressure from the committee the nurse was transferred.
At the Bomboli PHC of Udaipur district, there was corruption in disbursement of JSY money to
beneficiaries and BPL card holders faced problems in availing free medicines. With the continuous
efforts of committee members these reported problems got solved.
The committee members ensured ANM’s presence in VHSC meeting.
PHC MOs ensured training of ANMs on the use of BP machine and haemoglobin meter.
Prior to initiation of community monitoring process most
of the VHSCs had already been formed in the State but
when members of civil society groups enquired about the
roles and responsibilities of VHSC members, it was found
that only the Sarpanch and Anganwadi worker(who
together are joint signatories for the untied grant) were
aware of these committees and their roles and
responsibilities. Other members who were also part of the
committees did not have any idea about the
committee.The feedback of this enquiry was given to the
Chief Medical Officer (CMO), based on which a special
order was issued to restructure these committees.
Following the restructuring of VHSC, the meetings
conducted at the village level with PRI members helped
evoke increased interest in community monitoring.
Community Ensures Recognition for
ANM: Benefits From Community
Monitoring
The community monitoring process in Umed Nagar
village was initiated in Sept. 2008. The VHSC was
formed through the process of CM and meetings had
been held regularly. In Jan Samvad, corruption in JSY
scheme in this area was brought to light and it was also
found that women have to go to CHC Mathaniya for
delivery which is quite far.
Rukhsana Begam, the ANM of Umed Nagar under
CHC Mathania in Osian block is a very dynamic
member of VHSC. She has been trained in conducting
safe delivery but due to unavailability of necessary
equipment at Sub-center, deliveries could not be
performed there. The community had raised this issue
in the VHSC meeting and had demanded necessary
equipment. Their repeated efforts bore results, when
the govt. declared it as a model Sub-center and also
gave permission for conducting deliveries. However,
they faced another problem of arranging a separate
room and quarter for the ANM. The VHSC again
demanded the same from the Panchayat and
succeeded. Currently, all the deliveries in the area are
performed at this Sub-center and women receive JSY
benefit within a day or two from the delivery.
During the period January-December 2009,
Rukhsana conducted 244 deliveries at her Sub-center
which is indeed praiseworthy. She resides in the village
which makes it easier for her to provide qualitative
services.
The VHSC has nominated her for Excellent
Service Performance Award and she has been rewarded
for her comittment and efficiency at district level on
the occasion of Republic Day.
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JHARKHAND
The CM was carried out across three districts of
Jharkhand. The process covered 135 villages, 27 PHCs
and nine blocks. The CM exercise in the State has
enabled community and community-based
organisations to monitor demand/need, coverage,
access, quality, effectiveness, behaviour and presence
of healthcare personnel at service points and to trace
possible denial of care and negligence. The State
underwent a round of monitoring and for this purpose
it undertook a few innovations to make CM effective
and significant. The graphs (11, 12, & 13) below shows
district-wise status:
50
45
40
35
30
26
25
20
18
15
10
5
1
0
39
26
18
33
1
Dist Palamu
43
33
31
30
8
4
8
6
2
0
11
4
19
10 9
31
8
5
Graph 11
45
40
35
30
30
25
20
15
14
10
5
1
0
23
20
19
16
10
2
Dist Hazaribagh
41
39
4
0
20
18
7
5
1
27
22
20
13
5
3
18 18
8
Reviving Hopes, Realising Rights
Graph 12
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25
40
35
31
30
25
20
15
10
8
5
1
0
33
19 20
6
1
1
Dist West Singbhum
38
38
33
30
2
0
9
1
2
0
6
1
15
10 9
24
5
2
Prior to CM, the Village Health Committee
Members and Sahiyya ( In Jharkhand ASHAs are called
as sahhiyya) were not well-versed with their role in the
community and there was a lack of motivation for
participation among them.
Breaking the Ice: Orienting Community
Members:
The orientation had great impact on the mindset of
members; it contributed in grooming VHC members
after which they were well-informed and sensitised.
Members are now more empowered and aware about
the purpose of being part of the Committee and their
roles and accountability towards the community. After
CM, most of the VHCs conduct meetings on a regular
basis and issues related to maternal and child health
and disease control are now being discussed and raised
in the proper forum. Most of the VHCs have developed
a sense of ownership for the community and are
taking action to address health issues and advocating
with health service providers for the same. Sahiyya
earned the community's acknowledgement and an
identity of its own. The community knows about its
presence and purpose in the community.
Regular dialogue with officials at the block,
district and state levels during the process has in fact,
broken a barrier between the community and
government functionaries. Officials in the State and
district levels helped in getting cooperation from
government functionaries and are now willing to take
Graph 13
the process forward in the whole State.
The most important outcome of this process was
the initiation of dialogue between the community and
the health system. As such the word 'monitoring' or
‘nigrani’ was not considered appropriate. Instead, it
was replaced by the word 'Action' and the word
Samwad (dialogue) was used in place of Sunwai
(hearing). This was done because the purpose was to
ensure the quality of services in the State and not find
faults. Moreover, the community and government
health functionaries were part of the process together.
After sharing of report card at the village level,
most of the VHCs have prepared the village health
plan based on gaps and have started negotiation with
FLWs. The VHCs in some of the blocks are supporting
service providers in VHND.
Following the orientation of Media Fellows,
regular news on CM is now being covered, which is
helping in ensuring quality of health services at the
village level.
Innovative Treatment Bears Fruit
Involvement of a street play group in Kala-Jaththa
(theatre-based awareness campaign) was an interesting
and innovative initiative. The performance of Kala-
Jaththa helped in mobilising and sensitising the
community. It has been used successfully in the past in
other social programmes like education but it was being
used for the first time on a large-scale within a health
intervention. Training of street play groups ensured that
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Media plays its Part
Sensitising media on public health issues, especially
maternal and child health was important to ensure
dissemination of such information to sensitise
community and to strengthen advocacy with service
providers. A Media Fellowship was given to eight
media persons from Hazaribag, Palamu, West
Singbhum and Ranchi to ensure improved
participation of media in sensitising the community
and health service providers about entitlements and
facilities guaranteed under the National Rural Health
Mission.
the performance did not lose focus, scripts were
appropriate and right messages were given.
Village Health Register: State has come up with
an idea of a village health register to keep records of
proceedings and meetings. Now every VHSC has a
village health register in order to maintain records.
Sample of Village Health Register
Reviving Hopes, Realising Rights
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4.4 Page 34 |
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27
ORISSA
The process of community monitoring in Orissa,
started in April 2007 in four selected districts-Bolangir,
Kendrapara, Mayurbhanj and Nabarangpur. The CM
activity was carried out across 180 villages, 36 PHCs
and in 12 blocks of the State. The State underwent a
round of monitoring and gained vital learning though
the process. The success of CM was due to active
participation of districts and blocks in orientation
programmes, trainings, workshops, planning and
review meetings and individual sharings. The State
underwent regular internal planning, review,
monitoring of activities, problem solving, learning
lessons and incorporating the same in the process for
minimising risks and successfully implementating the
CM. District wise findings of CM are shown in the
graphs (14, 15, 16 & 17) below.
Dist Bolangir
50
47
45
40
38
35
30
27
25
20
17
15
10
5
3
0
Maternal
Health
34
30
21
17
9
24
20
18
13
10
9
9
19
15
13
10
21 21
9
5
1
0
00
0
JSY
Child Health Disease
Curative Untied Fund Quality of Community ASHA Equity Index
Surveillance Services
Care perceptions functioning
Graph 14
Dist Nawarangapur
45
42
42
42
42
42
42
42
40
35
32
30 28
25
20
15
14
22
15
10
5
0
0
Maternal
Health
5
JSY
8
00
00
00
Child Health Disease
Curative
Surveillance Services
00
00
Untied Fund Quality of
Care
00
00
0
Community
ASHA
Equity Index
perceptions functioning
Graph 15
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4.5 Page 35 |
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28
60
50
50
49
40
35
30
Dist Mayurbhanj
50
30
46
45
44
39
20
11
10
3
0
Maternal
Health
15 14
15
19
15
15
13
19
16
77
0
6
3
9
4
1
00
JSY
Child Health Disease
Curative Untied Fund Quality of Community
ASHA
Equity Index
Surveillance Services
Care
perceptions functioning
Graph 16
Dist Kendrapara
40
37
36
35
31
30
33
31
29
25
21
20
19
15
15
17
13
15 15
10
99
5
1
0
Maternal
Health
33
JSY
5
5
5
4
1
00
1
0
0
1
0
Child Health Disease
Surv eillance
Curativ e
Serv ices
Untied Fund
Quality of
Care
Community
perceptions
ASHA
functioning
Equity Index
Graph 17
Reviving Hopes, Realising Rights
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4.6 Page 36 |
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29
Triggering a Change
The orientation process helped in increasing
awareness on different health entitlements of VHSC
members, which brought about positive changes in
perception of the members and resulted in increased
demand for service facilities.
In addition, the process empowered VHSC
members to the extent that VHSC members prepared
the health action plan and started working as per the
plan even though the VHSC had not received money
from the government.
The process also helped in regularising
disbursement of JSY funds and facilitated in releasing
the JSY benefits.
The process improved ownership among ANMs,
AWWs and ASHAs and increased better coordination
among them. The CM empowered the ASHAs, as they
witnessed that people at higher level responded to
their grievances and welcomed suggestions from
them and acted on the information provided by
them.
Glimpses of Change
A contractual doctor appointed in one of the PHCs was
not visiting the PHC regularly. During the public
sharing meeting, the villagers complained about this
and a new doctor was appointed within three months.
An AWW in one of the PHCs used to charge Rs 50
from the women to make JSY cards for them. A
complaint was filed at the district headquarter after
which she stopped taking bribes.
ANMs and AWWs are demanding training due to
the CM process which in turn helps in imparting
health-related information to the community and
also in providing services.
The CM process in Orissa has sensitised service
providers and beneficiaries. The community has
realised that it is wrong to bribe ANM, ASHA or doctors
for getting JSY benefits. Most of the women who
delivered in hospital before CM faced harassment in
order to get the JSY benefits. Now due to strong
opposition from villagers, the harassment has stopped
and nearly 80 per cent of corruption has been dealt-
with by the community at the PHC and CHC level.
Doctors, pharmacists and other staff have now
become regular in Badapada PHC due to their
involvement in community monitoring process and
public scrutiny of their performance. More
importantly, a friendly and effective relationship has
now developed among various stakeholders.
The PRI members for the first time realised that
it is their duty to see that villagers get quality health
service at the Sub-center, PHC and CHC levels.
Previously, they were under the impression that
providing quality health services is only the duty of
doctors and their involvement is limited only to
construction of road and digging ponds. Now they
are taking interest in solving problems related to
health services. They are even lobbying for better
facilities for doctors and other medical staff like
provision of quarters, drinking water and better
sanitation facilities.
The score cards helped service providers to
understand the actual health situation in their areas
which they tried to improve.
Doctors and medical staff are now gradually
becoming aware that denial of health services can be
made public and disciplinary actions may be taken.
They realise that they are accountable for the patients.
Doctors and staff exercise self-restraint in taking
money from patients after being involved in the
community action process.
Changes at Gaon Kalyan Samiti (GKS) level
The GKS ( in Orissa VHSCs are called GKS) formed and
oriented under Community Action are self-managed,
self-driven, self-reliant and more effective in
addressing health issues than other GKS. They work as
a team with the principle of cooperation, mutual
understanding and support. They have a sense of
ownership for the GKS.
The GKS formed and oriented under community
monitoring are maintaining proper records of untied
funds and their utilisation. They maintain
appropriate resolution books and accounts and adopt
a democratic process in deciding actions for which
funds are to be spent and that it is accountable for.
However, in other cases, several irregularities were
also noticed when the GKS was not formed in the
right process and had not received adequate training.
CM has provided a good platform to promote
health rights. The community and committee
members at various level now understand that health
is their right. So there is effective demand for better
health services and at the same time, mutual
cooperation between service providers, PRIs,
community leaders and other stakeholders.
Some GKS are now preparing their own action
plan in order to plan and spend untied fund money. It
is also involved in raising more funds that has given
them a leverage to spend on the health of the
community.
First Phase of Community Monitoring under NRHM
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4.7 Page 37 |
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30
Reaching Out through Media
The Community Monitoring Media Fellowship
Programme was instituted to provide prospective to
media journalists with an opportunity for reflection,
codification and discussion on specific NRHM issues.
The objective of the programme was that this would
contribute to strengthening of NRHM programmes by
enhancing capacities at all levels. Central to this, the
objective was to facilitate individual and
organisational learning ( block nodal NGOs, district
nodal NGOs) involved in community action process
and by feeding localised knowledge into state,
regional and national processes, and vice versa. Media
fellows were selected in each selected district as well as
at the state level.
VHSC Resolves Flouride Problems:
Ms. Sanjukta Basa, Secretary, OLAMP;
Mayurbhanj
Kurkutia village under Kusumbandh PHC has
excessive fluoride in water and nearly 70 per cent
people suffer from kidney and liver related problems.
Although several complaints were made to higher
authorities, nothing much happened. During one of
the VHSC meetings I called reporters from the
television channel ETV and apprised them about the
situation. Next day the reporters visited the village and
saw the problem themselves. Soon after this, I wrote a
letter to the District Collector, Executive Engineer
RWSS and CDMO of the district and told them about
the fluoride contaminated water and how the villagers
were unable to use the tube well. The District Collector
appointed a health team to investigate the matter. The
team found that the problem was serious. After
receiving the report the Collector gave instructions to
the Executive Engineer RWSS to supply water tankers
to the villagers. The district authority is also laying
down a water pipeline to the village. The district
authority also deactivated the tube wells to prevent
people from using the contaminated water. The
district authorities sprung into action largely due to
the efforts of CM.
Empowered VHSC Tackles Superstition:
Ms. Manorama Dey, Block Coordinator,
Unnayan Rasgobindpur
The CM has made a great impact on the mindset of the
people. Training and knowledge imparted under the
CM has brought about positive changes in the society.
In one of the villages of the block, a small boy was
bitten by a snake after which the family took him to
the local/traditional healer. When the VHSC members
of the village came to know about the incident they
immediately reached the scene and rushed the boy to
the nearest government hospital. The boy was treated
for three to four days after which he was discharged.
In another incident, a malaria patient from
village was taken to the traditional healer as the family
was very poor and couldn't afford to take the patient
to the hospital. The VHSC members upon learning
about the case arranged transport for the patient to be
taken to the hospital. They used the RKS fund for the
treatment. They also made the traditional healer to
understand that serious cases of malaria need to be
treated in hospitals. A change in attitude and
perception was felt after the process of CM as the
Committee members , with their autonomy and
decision-making power were more empowered.
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31
MADHYA PRADESH
A total of five districts were selected for CM In Madhya
Pradesh: Guna, Chindwada, Sidhi, Badwani, and
Bhind. The monitoring was undertaken across 225
villages, 41 PHCs and 15 blocks. District wise findings
of CM is shown in the graphs(18, 19, 20 , 21 & 22)
below:
Dist Guna
30
25
20 1817
15
10
10
5
26
13
6
21
16
8
19
2120
1313
4
21
15
23
16
9
6
17
11
6
20
9
2
24
12
9
0
Maternal
Health
Child Health
Curative
Services
Quality of
Care
ASHA
functioning
Graph 18
Dist Chindwada
50
45
40
35
30
23
25
18
20
15
10
4
5
0
Maternal
Health
21
16
8
27
13
5
23
1012
Child Health
43
25
24
20
151515 151515
12
11
11
6
5
02
2
Curative
Services
Quality of
Care
ASHA
f unc tioning
Dist Sidhi
40
35
30
25
20
16 16
15
13
10
5
0
Maternal
Health
15
16
14
17
16
12
17
15
13
Child Health
25
12
8
Curative
Services
38
30
7
0
15
0
14
13
4
22
13
6
17
13
13
Quality of
Care
ASHA
f unc tioning
Graph 19
Graph 20
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4.9 Page 39 |
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32
Dist Badwani
45
39
40
35
30
25
20
15
10
33
5
0
Maternal
Health
42
37
34
27
11
35
65
7
Child Health
3
0
Curative
Services
38
29
22
18
13
10
5
2
7
7
2
4
Quality of
Care
ASHA
f unc tioning
Graph 21
Dist Bhind
50
45
40
35
30
24
25
18
20
15
10
3
5
0
Maternal
Health
36
38
33
9
9
3
34
0
Child Health
33
8
4
Curative
Services
44
36
7
10
2
Quality of
Care
23
11
6
18
1113
ASHA
f unc tioning
Graph 22
Glimpses of Change
Three days of continuous monitoring of the CHC in Pati block was undertaken after the VHSC was orientated A
dialogue on effective delivery of health services was initiated with the BMO during the period.
The following decisions were taken after the interaction:
Not to prescribe drugs from private medical stores.
Making the ambulance available for all patients.
Starting Janani Express Yojana in the block.
Not charging anything extra from patients.
No charges for BPL card holders for treatment during admission in the hospital.
Doctors posted in PHCs, the CMO and the BMO are
appreciative of the demand generated for health
services after community monitoring.
Reviving Hopes, Realising Rights
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4.10 Page 40 |
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33
Substantial Change Observed in Attitude &
Behaviour of Public Health Providers.
There was no doctor posted at Bhuimad PHC of Sidhi
district. The compounder, who visited the PHC did not
reside at head quarter and was irregular in attending
the PHC. However, the community members ensured
that the compounder visits the PHC regularly. During
Jan Samvad it was reported that no vaccination was
being conducted in the Bhuimad area. Post
community monitoring, the CMHO himself visited
the PHC for three regular months and monitored the
vaccination.
Since it was a malaria endemic area, a malaria
check-up camp was organised after the Jan Samvad in
which more than 1000 patients were examined and
treated. Medicine stock was also increased as existing
supply of medicines was inadequate.
Baigas are a primitive tribal group who have not
received BPL cards on the basis of which they could
avail various entitlements and benefits under the Deen
Dayal Antyodaya Upchar Yojana Card and receive
treatment up to Rs 20,000. The matter was brought to
the notice of of health officials and it immediately
instructed to issue BPL cards along with the Deen
Dayal Antyodaya Upchar Yojna cards also to the
Baigas. As a result the tribe members were successful in
getting the said cards. .
The doctor posted in the PHC said during the
Jan Samvad that he could not reside in the head
quarter due to non-availability of quarter in the
PHC. The villagers discussed the issue during the
hearing and took the initiative of arranging a house
for the doctor.
In Guna District, the CMHO is highly motivated after
the community monitoring programme. He has
attended all the district level trainings and visited
Block and PHC committees. He has also released the
VHSC untied fund and given the responsibility to PHC
Committees for supporting them.
Improving Client-Provider Interaction
Gaildubba village, Chhindwara- villagers reported
about the ANM not visiting the village to BMO which
resulted in regular visits of the ANM. They are also
undertaking other sanitation related activities in the
village after discussing it in VHSC meetings like
cleaning of wells before rainy season etc.
Markadhana village, Chhindwara-villagers put up
the ANM visit chart in the Anganwadi centre and
monitored the same. They reported to BMO that ANM
was irregular. An action was taken against her. In this
village also, sanitation activities were undertaken as
decided during the VHSC meeting.
Palwat village Badwani - After the delivery of a
VHSC member's wife in the government hospital the
nurse refused to vaccinate the newborn baby and
prepare the card as she was not given money
demanded by her for the services. Villagers placed
their complaint to the BMO and as a result she came
to the village to vaccinate the child and prepared the
card.
Ubad garh village, Badwani: The ANM was not
coming regularly to the village. In order to monitor
ANM performance, VHSC members gave BMO a list of
women who didn't received ANC and children who
were not vaccinated. The BMO instructed the ANM to
visit the villages regularly and meet VHSC members.
She responded positively and her visits became more
frequent and regular.
Kandara, Limbi, Berwada, Gudi villages, Badwani
the ANM was not regular in these villages. The VHSC
took the initiative and wrote to the BMO after which
the ANM has started visiting the villages regularly. In
case of absence, she informs the same to ASHA or
VHSC members. This step taken by her enabled the
members to communicate her visit plans to the
villagers and save them from inconvenience.
A total of 220 ASHAs in Gohad Block, Bhind
district have formed the AHSA Adhikar Samiti for
addressing their problems. They submitted
memorandum to the SDM, CMHO for timely release of
JSY incentives, which is released regularly now.
First Phase of Community Monitoring under NRHM
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5.1 Page 41 |
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34
ASSAM
For the first phase of the community monitoring three
districts Chirang, Dhemajee and Kamrup Rural were
chosen in the state. The monitoring was carried out
across 135 villages, 27 PHCs and 9 blocks. The state
underwent one round of monitoring. District wise
findings of CM is shown in the graphs (23, 24 & 25)
below:
Dist Chirang
30
27
27 27
25
20
15
15
12
21
1414
10
7
5
1
0
0
Maternal
Health
0
01
Child Health
19
6
3
01
Curative
Services
15
98
4
44
4
01
01
Quality of
Care
ASHA
f unc tioning
Graph 23
Dist Dhemaji
70
57
57 58
60
50
38 37
40
28
30
23
19 17
20
10 3
6
9
3
0
0
Maternal
Health
Child Health
41
12
7
03
Curative
Services
39
25
28
20
14 12
02
7
85
Quality of
Care
ASHA
f unc tioning
Graph 24
Dist Kamrup Rural
50
45
44
45
40
35
32
30
30
25 2123
22
30
25
20
15
13
15
9
10
9 11 10
10
4
5
1
0
5
00
00
0
Maternal
Health
Child Health
Curative
Services
Quality of
Care
Reviving Hopes, Realising Rights
Graph 25
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5.2 Page 42 |
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35
Community monitoring processes have started
empowering people in the state. After the process of
CM was initiated in the state, people have started
speaking out what they like and what they do not. Due
to initiatives taken up in the process, people are now
aware about their health rights, what has to be done
when there is a denial of services which is violation of
their health rights. The process has made community
aware about how best they could cooperate with the
health service providers.
Another significant achievement is that after the
initial progress of CM in three districts , the state
NRHM has proposed to integrate the process in two
more districts and has included in the state PIP.
Desired changes have taken place
After the first phase of CM positive changes have been
seen in the community as well as in the functioning of
the Sub-centre at Ratanpur under Jonai BPHC in
Dhemaji District .
The Community now feels that having good
health is their right and assured service guarantee
should be in place. The people of Ratanpur now can
access health services at the newly constructed, well-
equipped Sub centre, which earlier was in a dilapidated
condition. The community monitors working of SW,
MPW, reports to MO and looks after cleanliness of the
Sub-centres.
As shared by Mr Nirmal Doley (Ward Member)
President, VHSC; Ms Premolota Pegu (ASHA worker)
Secretary, VHSC; and Mr. Nava Deori, Community
Member - the Community has come to know about
the responsibilities of ASHA as well as ANM which has
improved registration of the pregnant women. The
untied fund of the VHSC has now been used more
appropriately, e.g. cleanliness of the village, awareness
generation programme on Malaria, Diahorrea,
Nutrition Public Health and Sanitation.
Increase in registration of birth and death has also
been seen. Village Health and Nutrition Day is now
observed in the villages with active participation of the
ASHA, AWW, ANM and villagers.
People now have easy access to modern Family
Planning Methods (FPM) (Oral Contraceptive Pills and
Condoms) Iron Folic Acid tablets from the ASHA and
they now don't hesitate to ask and enquire about the
FPM in meetings and women also take part in this kind
of discussion. Women are now more concerned
about their health which is a positive sign for the
community.
What is more encouraging to note is that though
the process is still at a nascent stage, it has not only
enhanced the accountability of service providers but
also kindled the sense of ownership amongst people
which is undoubtedly a core essence of community
monitoring process.
First Phase of Community Monitoring under NRHM
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5.3 Page 43 |
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36
CHHATTISGARH
The state of Chhattisgarh undertook three districts for
CM. The CM activity was done across 115 villages, 27
PHCs and nine blocks. The state underwent a round of
monitoring. District wise findings of CM is shown in
the graphs (26, 27 & 28) below.
Dist Baster
50
45
45
45
40
36
35
30
30
25
22
20 18 17
18
16
15
10
1211
10
11
9
2223
24
19
16
15
10
5
0
Maternal
Health
Child Health
0 00
0
Curative
Services
Quality of
Care
0 00
Mitanin
functioning
4
2
Graph 26
Dist Kawardha
40
36
35
30
30
30
25
21
20
15
10
7
5
2
0
Maternal
Health
22
19
17
22
21
11
11
7
8
8
1
JSY
3
2
1
0
00
1
0
00
Child Health Disease
Surveillance
Curative
Services
Untied Fund
Quality of
Care
Community Mitanin
perceptions functioning
of Mitanin
Graph 27
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5.4 Page 44 |
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37
Dist Koriya
45
40
40
40
35
30
30
28
25
20
15
10 8
15
13
12
16
1212
5
2
0
Maternal
Health
Child Health
2223
18
15
12
12
10
8
4
00
0
3
00 00
0
Curative
Services
Quality of
Care
Mitanin
functioning
Graph 28
VHSC members take charge of health
Bastar Samajik Jan Vikas Samiti, Darva Bastar
This incident occurred nearly 15 days after the
formation of VHSC in Bispur village under CM. It was
revealed during one of the meetings that adequate and
sufficient medicines were not available at the Sub-
centre. Several community members also spoke about
the irregularity of hospital staff. The meeting was
attended by all health workers and health department
staff. Soon after the meeting, the VHSC members
continued to monitor the health related problems in
the village due to which the situation improved. The
stock of medicine at the Sub-centre increased and
importance was given to hygiene and sanitation issues
in the village. The areas around boring wells were
thoroughly cleaned. The VHSC members in four
villages through their proactive approach not only
enhanced the quality of health services in the villages
but raised awareness on CM in the community.
Community Monitoring helped in getting
human resource and infrastructure
A meeting was organised at the PHC in Koleng village
under CM. While reviewing the health delivery status
from the rural community members, it was found that
there was a great need of a lady ANM, lady doctor and
also of ambulance service. When asked whether the
community members were paying any sort of bribe to
health personnel or if the doctor was being irregular in
his visit, the villagers replied in the negative. They said
that they have never paid money to health officials
and that they were quite happy with the performance
of the existing doctor, Dr Sharma, who had been
visiting the Centre regularly and treating people well.
Now efforts are being made through the VHSC
members to appoint lady health staff at the Centre and
also to acquire an ambulance for the PHC.
First Phase of Community Monitoring under NRHM
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5.5 Page 45 |
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38
TAMIL NADU
CM in the State has been effectively on ground for
about 18 months. For the first phase, the State chose
five districts: Dharmapuri, Kanyakumari, Perambalur,
Thiruvallur and Vellore. The monitoring was carried
out in 225 villages, 45 PHCs, and in 15 blocks.
The CM process in the State has set in motion
efforts to bring the community to the centre-stage in
health delivery. The VHSCs have given voice and
visibility to the community and thereafter people have
a better sense of their entitlements and hence their
expectation from the public health system has
increased. They have also begun to understand the
constraints of the Health Department, especially those
of the frontline workers. It has not only enabled a
better linkage between the community and the Health
Department but also enhanced accountability of the
Department in engaging with the community and in
responding to the community.
District wise findings of CBM is shown in the graphs
(29, 30, 31, 32 & 33) below.
45
Dist Kanyakumari
41
40
35
30
25
25
30
23
26
26
20
18
15
12
10
5
2
0
Maternal Health
3
JSY
16
13
6
6
15
4
Child Health
Disease
Surveillance
Curative
Services
Dist Dharmapuri
21
17
7
4
0
Untied Fund Quality of Care
50
45
40
35
30
25
23
20
15
15
10
7
5
32
28
9
4
11
6
0
Maternal Health
JSY
Child Health
41
3
1
Disease
45
28
26
18
11
6
Curative
00
1
Untied Fund Quality of Care
Reviving Hopes, Realising Rights
Graph 29
Graph 30
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|
5.6 Page 46 |
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39
Dist Vellore
45
40
39
35
33
31
30
25
25
20
19
15
15
11
10
5
7
5
15
11
5
3
0
Maternal Health
JSY
Child Health
Disease
Surveillance
21
17
7
Curative
Services
30
9
6
4
2
Untied Fund Quality of Care
Graph 31
Dist Perembalur
50
45
41
40
44
43
41
41
35
30
25
24
20
15
12
10
9
5
0
Maternal Health
3
1
JSY
22
16
7
11
Child Health
Disease
Surveillance
4
0
Curative
Services
2
0
01
Untied Fund Quality of Care
Graph 32
First Phase of Community Monitoring under NRHM
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40
20
18
16
14
13
12
10
10
8
7
6
4
14
9
7
Dist Thiruvallur
18
12 12
6
66
11
10
9
15
10
5
16
8
6
2
0
Maternal Health
JSY
Child Health
Disease
Surveillance
Curative
Services
Untied Fund Quality of Care
Graph 33
Glimpses of positive changes
In the State, the changes brought about after the first
phase activities can be classified at a systemic and
community level.
Meeting Demands from an Enlightened
Community:
The members of VHSC in one of the districts played a
proactive role, thanks to the orientation and training
provided to them. The training helped them to access
health care services as per their needs and they felt the
requirement of a sub-centre in their village. They
collected all relevant information from the facilitators
and the local health staff after which they approached
the appropriate health authorities and followed-up on
the issue till the sub-center was actually established
much to the surprise and joy of the villagers. This
infused the VHSC members with a huge amount of
confidence.
It was only after the orientation and training of
community members and VHSC members in one of
the blocks that they realized that all services of Village
Health Nurse (the ANM is called VHN in Tamil Nadu)
should be available free of cost. In their particular area,
which is very remote, the VHN was actually staying in
the village. She was treating simple illnesses at the
village level by giving injections and tablets wherever
necessary, but she was charging for these services. The
VHSC members discussed this with her. She
mentioned that the medicines she was using were
bought from the market and that she was merely
charging the market price. The VHSC members then
approached the MO who then called the VHN and
explained to her that people are better aware now and
that she should change her old practice. The VHN
subsequently stopped charging for her services. She
also stopped stocking injections and medicines bought
from the market. Despite these positive outcomes,
however, some people feel the VHN has now stopped
providing health services especially during emergency
situations which is a loss.
Ensuring Rights
Despite the fact that there are no user fees for out-
patient services in Tamil Nadu, one of the PHCs was
charging a small amount for registration and making
the Out-patient (OP) ticket. During the orientation
and training sessions when the VHSC members were
told that this was not a standard practice and that
they were entitled to free services, they decided to do
something about it. The VHSC members approached
the MO and raised the issue pointing out that they
were well aware now of the illegality of this fee. The
MO immediately took steps to make sure that no
money was collected from the patients for what is
supposed to be a free service.
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During the public hearing in one district, the
people raised the issue that in one of the PHCs there
was lack of privacy especially for women patients. The
Deputy Director immediately ordered that simple
partitions be purchased and installed so that privacy
for women patients during simple procedures and
while taking injections is maintained. This was greatly
welcomed by the people in that area.
Long-term Impact through Systemic
Changes
Besides these motivating examples of local change
brought about during the pilot phase, some of the
most significant changes have also been brought about
at the systemic level.
It is for the first time that the Health Department
officials and the people met as part of a systemic
mechanism and discussed issues from people's
point of view. This led to a huge positive feeling
among the people.
One of the major benefits of the process was that
people recognised the various constraints which
front-line health staff have to face during the
course of their work. This occured thanks to the
fact that the people, now as committee members
, raised various issues regarding service
availability and quality directly with frontline
workers for the first instance. This gave them a
chance to understand various issues from the
systemic point of view. Similarly, the system
began to appreciate the needs and priorities of
people and gaps in the system as perceived by
people, thanks to these discussions.
Thanks to the various changes brought about in
the health system and to the CM process;
especially public hearings and face-to-face
meetings of senior health officials with the
people, community members have now begun to
perceive the health system as being responsive. It
was felt that this was the first step towards full
ownership of the healthcare system by the
people.
As per the Tamil Nadu Government rules, the
VHSC consists of 5 members - three of whom
(VHN, AWW and Health Inspector) are
government staff. It was pointed out at the
beginning of the Project that to function as a
people's committee there had to be greater
community representation in the committee.
However, it was only after demonstrating the
feasibility of formation of such committees
during the first phase and continued interaction
with higher officials, that there was a consensus
that there needs to be a change in the
composition. As a first step, a larger group of
people at the village level will receive orientation
and training in the ongoing VHSC training
initiative by the government.
The potential role of civil society groups in the
field of health is being increasingly recognised.
Both state and district level officials of the public
health system are more open to interaction with
civil society-based groups.
One of the major outputs from the process has
been the publication and release of a document
entitled "Community Monitoring and Planning
First Phase in Tamil Nadu: A Joint Learning
Process." This was co-authored by Mission
Director, State Rural Health Mission, Director of
Public Health and Preventive Medicine and
representatives of civil society of the State Mentoring
Committee of the first phase. This paper was a
collation of various discussions between the
government and civil society groups on various
steps/stages and dimensions of the first phase. This
paper was released as a background paper during the
state-level dissemination workshop. It formed the
basis for discussion during a half-day session where
various stakeholders, including Deputy Directors,
Medical Officers, village health nurses, NGO
directors, academics, and project facilitators
discussed it. The participants came up with further
recommendations for each of the issues raised and
discussed in the joint paper. This comprehensive
document forms the basis of the next phase of the
project.
Due to the CM process, the visit of VHN has
become regular. Many instances of denial where
people were asked to buy syringes have now been
resolved. The duty roster, timings and mobile
numbers of the VHN are now displayed on walls
of the health facility.
One of the PHCs of Tiruvellore district used to be
often closed and it had no proper transport
access. Following the CM, the PHC is now open
and the MO visits the PHC regularly.
The VHNs are now aware about the availability of
untied funds and request for allocation from the
MOs. The process of empowerment of VHNs is
also believed to be happening.
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Innovative Alliances
One of the interesting initiations that the State
undertook was to involve VHN associations in the CM
process. The involvement with the VHN Association
helped to allay their fears about the process as they
initially perceived the process as a fault-finding
initiative. The President of the VHN Association
participated in the state-level meeting, and extended
her support to the process.
Children and youth parliament were organised to
mobilise the elders in a district. The church too, played
a role in mobilisation in certain villages. The Nursing
College in the district was roped in to spread
information about NRHM and CM.
Folk media and handbills were also used for
spreading awareness and mobilisation. These handbills
provide details of the functioning of Sub-centers and
the services provided in them; facilities in a PHC and
services provided in a PHC; details of duty time of
doctors, nurses and VHNs, other staff, and the citizen's
charter. This is one of the major outputs of the process.
The presence of volunteers from the literacy
movement - Valar Kalvi Thittam (Continuing
Education Programme) is a significant strength in a
few districts. They helped to mobilise the community
in many villages. In fact, these volunteers took the
lead in preparing score cards in villages where they
were present.
Another small but significant initiative
undertaken in Dharmapuri district was issuing of ID
cards for VHSC Members so as to ensure that they are
recognised and accepted by the Health Department.
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KARNATAKA
For the first phase of CM in Karnataka, four districts
were selected with a target to cover 180 villages across
the State. Karnataka was included in the CM process
quite late but it managed to form 562 VHSC which was
way above the original target of 180 across four
districts. The State gradually increased the number of
villages as it undertook rounds of monitoring. The
State underwent three rounds of monitoring over a six
months period and witnessed significant changes.
Four districts, 52 PHCs and 12 blocks were taken for
this process.
Visible Difference
Analysis of the score cards shows that the perception
of community members on various health and health
service parameters has changed. All the parameters
over the project period show differential degree of
progress (red signs decrease while yellow and green
signs increase). Round wise findings of CBM is shown
in the graphs (34, 35, 36, 37, 38 & 39) below.
Untied Fund
120
108
100
80
60
40
23
20
4
0
First Round
59
47
29
Second Round
Curative Services
100
88
90
80
70
66
60
50
40
30
25
20
10
0
First Round
72 73
34
Second Round
51
40
44
Third Round
Graph 34
76
57
46
Third Round
Graph 35
Disease Surveillance
100
91
90
80
70
60
55
50
40
33
30
20
10
0
First Round
72
65
42
Second Round
66
55 58
Third Round
Graph 36
Janani Surakhsha Yojana
100
90
80
80
73
70
60
50
40
30
26
20
10
0
First Round
82
77
20
Second Round
90
64
25
Third Round
Graph 37
120
100
79
80
60
56
44
40
20
0
First Round
Child Health
103
65
11
Second Round
90
64
25
Third Round
Graph 38
Maternal Health Gurantee
100
90
80
80
73
70
60
50
40
30
26
20
10
0
First Round
82
77
20
Second Round
90
64
25
Third Round
Graph 39
First Phase of Community Monitoring under NRHM
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Glimpses of Change
Jan Samvads resulted in action being taken in some
areas - such as use of untied funds at PHC and SC level
for repairs of infrastructure and equipment or posting
of health personnel in some cases.
The process has also resulted in more accurate
reporting of deaths. For instance, in the last six
months, in one Taluka alone, the VHSC process
identified six infant deaths and one maternal death,
which were not picked up by the system earlier.
The State Government took strong ownership of
the programme and worked in close partnership with
civil society organisations. State Mentoring and
Monitoring group (SMMG) included key officers from
the state Health Department and the NGOs that
shared a common vision and commitment. The
SMMG facilitated coordination at state and district
levels and significantly influenced the outcomes.
A common focus across districts on the high level
of investment in village processes including three
member CRP team to (i) mobilise community, (ii) form
VHSC, (iii) train VHSC members and (iv) facilitate
score card filling - have resulted in strong VHSCs.
The CM process worked as an agent to bring
together ICDS and AWW and helped them perform
better in the absence of ASHAs (Karnatka has no
provision of ASHA). In some of the CBM villages,
convergence between health and ICDS was further
strengthened as the AWW took a leadership role as a
co-convener, and in many instances she served as the
de facto convener.
facilitated acceptance of marginalised groups by the
general population.
The state undertook the Participatory Rural
Appraisal (PRA) techniques to mobilize community,
the method was used for formation of VHSCs and
developing village action plan.
Another initiative that resulted in high
community acceptance of the process was a series of
meetings held with different caste groups prior to the
VHSC training. Appointing ten Community Resource
Persons (CRP) at Taluka level to create VHSC was a
critical measure in achieving scale with quality. The
CRP invested substantial time in working with all
sections of the community in these areas (where
Innovative Deviations
Karnataka chose to make two significant deviations
from the national design. One was to expand the
process to "planning and monitoring" instead of just
"monitoring." Thus, the initiative in Karnataka is
referred to as Community Planning and Monitoring of
Health Systems (CPHMS).
The second was in terms of geographic coverage.
The departure from national guidelines of covering
five villages in each PHC area to attempt universal
coverage of all villages in the PHC area resulted in 80-
100 per cent coverage of villages under each PHC.
Kala Jaththa as a prelude/precursor to VHSC
formation served to mobilise communities and
facilitated acceptance of marginalised groups by
general community. Kala Jaththa performances also
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45
casteism is high) to ensure appropriate representation
on VHSC.
In all districts of first phase, the district
coordinator networked with the local media to
enable periodic articles in the regional language
press about the process and ensuring coverage in
the Jan Samvad. This yielded results, particularly
the publicity in regional language newspapers.
However, the coverage varied across the districts.
Several variations from national guidelines in
capacity building process strengthened it. Also, the
State organised a district level TOT for nodal NGOs
rather than one common state level TOT in order to
provide more focused and high level mentoring and
support to the district NGOs.
A Transformed PHC
A Success story by Community Health Cell, Bangalore - Nodal Organisation for Raichur District -
Gunjalli is a village situated at a distance of 22 km from Raichur district headquarters, covering a
population of 35,000 in 20 villages within its jurisdiction.
Before the CM, it was a very low-performing PHC with less than 40 per cent immunisation coverage.
Though VHSCs were formed the members did not know about their roles and responsibilities, with zero
utilisation of untied funds. Most of the deliveries were taking place at home. After the intensive process of CM
training, Jan Sunwais and follow-up during the CM process, the atmosphere in the PHC and in the villages taken
for CM was transformed.
Activated VHSCs: Ten VHSCs were revitalised and started functioning. The village health plans made
included addressing health and hygiene issues. In the villages, Unradoddi and Gunjalli, the area around bore
wells did not have any drain and hence was dirty due to accumulation of waste water causing unhealthy
atmosphere for school children. The VHSC had soak pits dug (filled with coal and sand) and the place was
covered with granite stones. Another VHSC cleaned gutters in these villages, with the help of women Self Help
Groups. This added to the cleanliness of the villages. Though NRHM started in 2005, till the CM in 2008, the
amount under JSY was not distributed at all. At the Jan Samvad, 189 women were given their dues for the first
time. The disbursement of JSY started then is now happening regularly.
The PHC untied fund was not utilised at all till 2008. During the CM, in the months of Jan-Feb 2009 the
PHC building was painted and renovated, filtered drinking water unit was installed, the hitherto unusable
toilets were repaired and were tiled, a TV was installed for patients to watch in the waiting area. Patients
and pregnant women had to sit on the floor or stand in the waiting area. So, chairs (20) were made available
at the reception. The area around the PHC, which was earlier filled with waste and bushes got cleaned and
a compound wall was erected around the PHC. The loads of red soil around the PHC not only helped in
filling all the uneven places, but also enhanced the look of healthy atmosphere giving it a new and clean
look.
Though the PHC was declared 24 x 7 functioning PHC in 2006 itself, it had only one staff nurse and a
doctor. With the pressure of people and the influence of Jan Samvad two more nurses were posted. This
resulted in the increase in immunisation coverage to 80 per cent from the earlier 40 per cent.
Institutional delivery saw a rise even up to 35 deliveries a month. On an average, about 25 deliveries have
been conducted every month during and after the CM.
Dr. Anil Kumar, the Medical Officer, was extremely cooperative with the process. In the entire process, the
involvement and participation of people around the villages has significantly increased. "Due to people's
involvement and doctor's cooperation we saw a transformation in this PHC", say Shivram Reddy and
Tarakeshwari of Roovari (NGO) who were involved in the process of CM.
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Section - III
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Review of Community Monitoring
The first phase of the community monitoring process
was implemented in nine states of India. The process
went through several challenges and invited both
admiration and critique. The AGCA wanted to
conduct a rapid assessment/review of the first phase of
CM to identify key achievements and challenges to
make recommendations for further scaling up. The
AGCA suggested that the review must be conducted in
a participatory manner, and must be steered by a
three-member team in each state. The review was
proposed for all the nine states to assess, if the
objectives of community monitoring were fulfilled to
identify key learnings and challenges and to highlight
successful innovations. This section has been drawn
from the National Review Report (Coordinated and
written by S. Ramanathan) submitted by the review
team.
The review was undertaken with the following
objectives:
To assess whether the objectives of community
monitoring process were fulfilled in the state
To identify key learning and challenges for each
state
To highlight successful innovations tried out in
the state
Methodology - Ensuring Field Rigor:
The review was conducted by external consultants
(Dr. Ashok Dyalchand in Maharashtra and Rajasthan,
Ms. Rajani Ved in Karnataka, Mr. S. Ramanathan in
Orissa and Tamil Nadu, and Ms. Renu Khanna in
Madhya Pradesh) along with representatives from the
National Secretariat and State Mentoring Groups. The
National Health Systems Resource Centre (NHSRC)
undertook the review in three states (Assam,
Chattisgarh and Jharkhand).
The field visit in each state was for six days. As one of
the objectives of the review was to identify lessons for
scaling -up, a middling district was identified to learn
what worked and what did not. Three days were spent
in the field and three days at the state level. The first
two days at the state level were spent on
interviewing/meeting government officials, members
of the State Mentoring Group, state Nodal NGO, NGO
representatives from other districts, media
representatives and development partners. In the field
interviews were held with MO, ANM/VHN, ASHAs,
AWWs, Sarpanch and representatives of NGOs at the
district, block and village levels, and group discussions
were organised with members of various committees.
The final day of the review was spent on presenting
preliminary findings of the review and filling gaps, if
any.
The review covered wide range of issues like
national and local context of the state, institutional
arrangements such as different levels of committees
and mentoring team, the process of CM in the state
including selection criteria for nodal NGOs and
capacity building, monitoring and reporting, and
engagement with media and linkages with other
processes of communitisation.
Ready for Roll-out - Summary of
Findings:
In period of 18 months, only one cycle of monitoring
was done. Hence, the review team felt that it was too
early to assess the outcomes of the process. However,
there had been significant gains. The gains include:
Preparation of national and state level resource
materials.
Formation of over 2000 VHSCs in nine states
Preparation of report cards in all VHSCs
Organising Jan Samvads/Jan Sunwai
Completion of one cycle of monitoring
The gains are reflective of the commitment and
passion of all stakeholders - GOI, state governments,
NGOs and communities. The crusader approach and
the spirit of volunteerism are abundantly evident in
the way community monitoring was implemented in
the nine states. The review does indicate that with the
implementation of community monitoring, the
promise of communitisation articulated in the NRHM
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Framework is beginning to be fulfilled. Therefore, it is
imperative that the first phase is expanded forthwith
and sustained to ensure that this promise is realised.
There had been rapid acceleration in the
implementation of the community monitoring in the
last six months of the first phase; building upon the
strong preparatory phase of the Project. During the
review, it was found that a few states had begun the
process to include it in the Annual State Program
Implementation Plan (PIP) for the year 2009-10.
Karnataka had committed Rs 25 crores for
implementation in the next year. Maharashtra, Orissa,
Rajasthan, and Tamil Nadu had initiated steps for
inclusion of community monitoring. Other states are
in process to do so.
Key Findings on the Process
Selection process:
The criteria for the selection of the districts varied
across states. The presence of civil society
organizations and regional representation were some
of the considerations in the choice of districts and
blocks within them. The NGOs did the first -level
identification of districts. The selection of the districts
was discussed with the State Governments and in
almost all the states, the Government modified the
selection.
In nearly all the states, Government largely did
not interfere in the selection of district and block
nodal NGOs at any level. They accepted the choice
made by the state nodal NGOs.
Community Mobilisation
This is one of the key processes which received high
level of attention from the NGOs. Village Committees
were aIready existing in some states and these were
reconstituted, given the national guidelines for the
VHSCs. In other states, fresh committees were formed.
It involved getting the requisite permission/orders
issued by the Health Department for
recasting/formation; organising village meetings for the
formation; identifying members for the Committee;
building their capacity; and ensuring that the meetings
of the VHSCs are held. This took considerable time and
effort from all the NGOs involved in the process.
Village meetings coupled with home visits to
socially excluded groups, especially Dalit hamlets and
women, was the major strategy in almost all the states.
This process helped in inclusion of marginalised
groups and in enabling equity. In Madhya Pradesh and
Orissa, emphasis was placed on having an SC/ST PRI
representative as the head of the VHSCs. Meetings
were also organised with Sarpanch and other local
leaders, in nearly all the states. On an average, about
three to five meetings were held in villages in all the
states to mobilise the community and to identify
members for the VHSC. Posters prepared at the
national level were adapted and used for mobilisation.
In many states, getting Government Order (GO)
issued for formation of VHSCs proved time-
consuming. In Orissa, the guidelines for VHSC
formation kept changing. While this reflects an
evolution in the process of forming them, constant
changes reduced the project period available for
mobilisation and the process was hurried through. In
one block in Rajasthan, it was observed that the
mobilisation depended on political affiliation - the
Ruling Party representatives were not keen on forming
VHSCs or in convening the meetings, whereas the
representatives from the Opposition Party were very
keen. Communal divide is said to have hindered
mobilisation in parts of Rajasthan.
Committee Formation
VHSCs: The VHSCs were reconstituted in Tamil Nadu
and in few villages of Madhya Pradesh, where VHSCs
already existed. They were reconstituted, given the
NRHM guidelines. In the remaining states, new
committees were formed. In Madhya Pradesh, the
reconstituted VHSCs were approved by the Panchayats
in the Gram Sabha. This was also done in two districts
of Tamil Nadu. In Maharashtra, Gram Sabhas could
not be convened in all villages; hence, VHSCs were
formed by convening small group meetings.
The VHSCs reflect a significant social capital
and they have to be nurtured to strengthen
communitisation in NRHM. While the community
mobilisation and the formation of VHSCs has
increased knowledge about entitlements and rights
in the community, it is still limited. There is a need
for more orientation and strengthening of the
VHSCs.
It was observed in Orissa that women
outnumbered men in almost all the VHSCs. On an
average, the ratio of women to men representation
was 3:1. Many see participation of women as
advantageous as this is expected to lead to a better
health status in the household. However, from the
interactions with the women during the review, it
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51
emerged that they did not have much freedom to
decide on any issue. Any decision taken by them
needed the approval of men. In Tamil Nadu too, men
rarely attended the meetings.
Committees above village level : All the committees
above the village level - in PHCs, block and districts
were formed in all the states. In Jharkhand, a Sub-
centre Planning and Monitoring Committee too was
formed. In Maharashtra, district monitoring
committees were formed earlier when Jan Arogya
Abhiyan initiated monitoring in few districts. The
composition of these committees was modified based
on national guidelines.
However, unlike the VHSCs, these bodies are not
vibrant due to shortage of time for providing training
and supervision of functioning of the committees. The
committees at each higher level are to prepare a
cumulative card of the reports from below, along with
a facility report card at their level. However, this hardly
happens largely due to the complexreporting format,
which is not easily understood even by many of the
NGO facilitators. There is hardly any review of the
process by the Mentoring Teams at the district, block
and PHC level.
In almost all states, there is no significant
participation of health officials in the formation of
committes above village level. Even the PRI
representatives rarely participate. The objective of
bringing together the Health Department, civil
society and PRI representatives to mentor and
support the process is not realised. It is important
that Health Department convenes these committees.
This is essential to ensure that these are not seen as
NGO committees.
The review felt a need for orienting and building
capacity of the members of these various committees
above the village level.
Report Card Preparation
Village Report Cards: The process for preparation of
Report Cards is uniform across all states. The NGO
facilitators mostly prepare the report cards. The VHSC
members find the preparation of the report cards very
complex. The review also indicates that even NGO
facilitators found the report card preparation process
and tool to be difficult. For e.g. there is confusion in
marking, especially on marking negative responses. In
Tamil Nadu, the NGO facilitators took nearly three
months to internalise the tools.
Sharing village report cards: In Tamil Nadu and
Maharashtra, the report cards are displayed and shared
in village meetings. The sharing of the report cards
generate discussions about how to make the red to
amber and amber to green, paving the way for village
health plans. No significant details of sharing the
report cards with the community are available from
other states. In our view, the community should be
aware of the output of the process.
In almost all the states, some officials of the
Health Department are aware of the score cards but the
knowledge of score cards overall within the
Department is still limited.
Tool for preparing report card: The tool helps in
increasing awareness of the communities on their
entitlements and rights. However, two indicators that
receive greater attention from the community in
almost all the states are attendance of service providers
and provision of JSY.
One key issue that emerges from the review is the
need for simplification of the tool as the current tool is
complex. This view emerges from all the states.
To ensure that the communities have a control
over the process, the review suggests an incremental
approach. To begin with, there should be few
indicators. For instance, initially the community
monitoring could be limited to mortality indicators.
The issues to be monitored should be gradually
increased, as the community gains experience and the
health system becomes responsive to the process.
Triangulation of data: There are some concerns
whether the tool will facilitate triangulation. In no
state triangulation appears to have been done.
There is a view that the data collected through
community monitoring is not comparable with the
information collected through routine Health
Management Information System (HMIS). There are
also concerns that the data is subjective and reflects
perceptions. Hence, there is some resistance from
the Health Department in accepting the data. To
ensure that the triangulation occurs, the tool has to
be modified in consultation with the Health
Department and mechanisms to enable
triangulation put in place.
Jan Samvad/ Jan Sunwai
Jan Samvad is an important process for sharing the
report cards. The objective of Jan Samvads was to
create a common understanding of key health issues
among the community; to review the current
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implementation and to prepare action plans for
improving NRHM implementation. The Samvad is also
an opportunity for dialogue between the community
and the Health Department.
The Report Cards were the basis for Jan Samvad.
In some instances, case studies were prepared and
shared in the Jan Samvad. The process of Jan Samvad
was intense in terms of mobilising communities and
service providers.
Jan Samvad benifited in many ways. It raised
expectations of community and led changes. There
are instances of change that happened subsequent to
a Samvad. There are reports, of few Medical Officers
being changed, visits of front line workers becoming
regular, drugs and syringes being given to the
people, JSY money being paid to the beneficiaries,
and instances of money deducted from JSY being
paid back to the community. The availability of
untied funds has enabled the Health Department to
address few of the needs articulated in the Samvads.
Consequently, community in such instances have
begun to perceive the Health Department as
responsive. More importantly, the process is
empowering the community as it has made them
aware of their entitlements and their rights as
citizens.
However, the Samvads, have also raised the ire of
service providers, in some instances. In Rajasthan, the
issues raised in the Jan Samvad led to conflict between
the community and service providers at the lower
levels. In Chattisgarh, a Medical Officer said that Jan
Samvads should also highlight the conditions
prevalent in the facilities - lack of water, equipment,
schooling and quarters for the staff and not just issues
of service denial. Following Jan Samvad in
Maharashtra there was opposition from field workers
and resistance at the block and district levels. Service
providers observe that Report Cards and Jan Samvads
do not highlight the efforts by the health workers.
They only highlight service gaps, deficiencies and
denial of rights and entitlements.
It is important that the protocol on Jan Samvad is
followed and there is adequate preparation for it. It is
also important to ensure that the Health Department
is a partner in the process and not an adversary . The
Samvad should not become a forum for conflict with
the Health Department . It would be helpful to discuss
the issues with the Health Department before the
Samvad is organised. Also, as originally conceived, the
objective of the Samvad, should be more towards
planning rather than only highlighting denial of
services.
Engaging the Media
Engaging the media is an important activity in
community monitoring. However, the manner in
which media is engaged varies across states. In few
states, there were media workshops were held both at
the district and state level; in many states media
fellowships were given to select journalists at state and
district level; and in some, the media merely covered
the events. In Maharashtra, a State Media Consultant
is also appointed. The media workshops helped to
orient the media on covering health issues.
Media has played an important role in
highlighting community monitoring and being its
advocate in some instances. Reports were written in
national newspapers such as 'The Hindu' (The Times of
India) and in local dailies.
However, in several instance the media tended to
sensationalise the issues. They disproportionately
highlighted issues of denial and weaknesses in the
Health Department pointed out during the Jan
Samvads. Following the media highlight, there is a
sense of fear, resistance and an increase in the
adversarial position from the Health Department.
While recognizing the media as an important ally,
the review emphasizes the need to explore further how
media could be involved in community monitoring.
Key Findings on Programme
Management
Capacity Building
The National Secretariat prepared good training
materials to enable training and orientation. The
training materials detail the issue of rights and
entitlements, the process of community mobilization
and committee formation and preparation of report
cards. These are translated and adapted at the state
level. No significant changes are made in training
materials in any state. The Secretariat has also prepared
elaborate guidelines for organizing trainings. These
guidelines were modified in few states.
The capacity building was done in a cascading
manner in almost all the states, following the pattern
recommended by the National Secretariat. In almost
all states, besides classroom teaching, field visits were
organised to provide hands-on training in filling
report cards and in mobilisation.
The first phase has created a resource pool of
trainers at the state and sub-state levels. This resource
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pool should be nurtured and upgraded.
However, there is transmission loss in the cascade
training. Many VHSC members are unable to recall the
issues discussed during the training. VHSC members
and some NGO facilitators, said that while issues
seemed clear during the training they were unable to
recall them later. Many felt the need for more training
on preparing the score card as it is complicated.
There was no significant participation of health
officials in the trainings. This is despite the efforts of
few states to break the training to phases to ensure
their participation. The health officials cited other
responsibilities as the reason for non-participation.
One of the main learnings from the first phase is that
capacity building of the health officials from
conceptualization to details of community monitoring
and action is as important as capacity building of
community and civil society groups.
A more regular process of orientation on-job
support and supportive supervision and handholding
could have helped the process. In Karnataka, besides
the training, a very high degree of on-job support and
handholding is provided by the district NGOs. This
had a significant impact on the implementation. The
handholding by district facilitators is also evident in
Bolangir district of Orissa. Few members of the State
Mentoring Team in Tamil Nadu backstop the process
in a significant manner. Whereas places where such
continued on-job support is provided, it has made a
difference in implementation.
Relationships and Convergence
Relation with the Health Department: The relation
with the Health Department varies across states. While
there is a better ownership of the process in Karnataka,
Maharashtra and Rajasthan at the state level, there was
lack of ownership in states like Madhya Pradesh and
Assam. The remaining states fall between these two
levels. In Karnataka, Maharashtra and Rajasthan, the
state officials participate in all the state mentoring
committee meetings. The relation at the state level also
varies depending on who is at the helm.
The Health Department in many states appear
uncomfortable with the term "monitoring." The term
“nigrani” was not well accepted as the officials felt that
the purpose of community monitoring is to ensure
quality service rather than finding faults. They felt that
the process is more of an action than monitoring.
They renamed the process as community action.
Karnataka decided to amplify the process to include
planning as well.
While the acceptance at the state level was mixed,
the acceptance at sub-state levels in almost all states was
low. In Orissa and Tamil Nadu, the health officials lower
down often refused to acknowledge letters issued by state
officials. They provide support only if there is a direction
from the district officials. In Karnataka also, where there
was a high level of acceptance at the state level, it does
not translate into any effective cooperation at the sub-
state levels. In Maharashtra, NGOs had to depend on
administrative orders from higher authorities to enforce
attendance at meetings at lower levels. Despite the high
acceptance at the state level in Rajasthan, the relation
between NGOs and health providers was adversarial in
the PHCs visited for the review.
The review felt that it was important to overcome
this and engage the Health Department as a partner in
the process. It is important to ensure that the health
officials do not feel intimidated or threatened and
perceive the VHSCs and NGOs as adversaries. To
enable the acceptance it may be helpful if data
generated by the community monitoring is used in
planning, implementing, improving services,
concurrent monitoring, rather than merely to find
fault. It is important that the threat perception is
removed and the link between planning and
monitoring is established. This has been done in a few
states and this needs to be done in other states as well.
Relation with ICDS: At the village level, there is
convergence in many states as AWW are a part of the
VHSC. In Karnataka, AWW take on the leadership role
in the VHSC. In Orissa, AWW being senior to ASHA,
take a lead in the VHSC activities. In Orissa and
Rajasthan, ICDS is represented in the state Mentoring
Committee. No significant issues of relation with ICDS
emerged from any state.
Relation with PRIs: This is one of the weakest links in
almost all states. In Maharashtra, the PRIs are
indifferent to the process. Their non-involvement has
an impact on community mobilisation and in
identification of persons as members of the VHSCs. In
Karnataka, the PRIs are yet to be engaged in the
process. Although the PRI members largely head the
VHSC in Orissa, they rarely turned up for the
meetings. However, the participation of PRIs in Orissa
as compared to other states appears to be better.
Relation between NGOs: Majority of the NGOs
involved in the pilot phase in most of states are a part
of other networks. Most work together on rights-based
issues. Many are affiliated to the Jan Swasthya
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Abhiyan. Their membership in a pre-existing network
and a shared value and commitment helps to
smoothen the process of working together. Hence,
there is harmony between the NGOs involved in
community monitoring. Some however, are new to
this arrangement. Decisions are taken in a
participatory manner in most states, which help to
strengthen the collective. The formation of network of
NGOs on community monitoring is an important
output too. The network could be a source of support
when the process is scaled-up in the respective states.
Short Term Gains
The gains are impressive, despite the short
implementation time. The most significant gain from
community monitoring is the active engagement
between the community and the Health Department.
It is enabling the community to be in centre-stage and
making them a significant stakeholder in the
management of public health system. It is
empowering too, as the VHSCs have given a sense of
identity and voice to community. Given the project
duration, the work done on formation of various
institutional arrangements to facilitate community
monitoring across the nine states is commendable.
The VHSCs and various committees above the village
level reflect a significant social capital and they should
be strengthened, nurtured and sustained to contribute
to the communitisation process in NRHM.
Community mobilisation is a key element of
community monitoring and it received high level of
attention from the NGOs. The community
mobilisation, the VHSCs, the monitoring tool, the
report cards, the Jan Samvads, which are the various
elements of the community mobilisation process, have
increased knowledge about entitlements and rights in
the community. Consequently, as mentioned above,
the process is empowering. Changes have been
effected in many instances following a Jan Samvad
and this has led to the perception that the Health
Department is responsive and accountable. This has
the potential to move the community, back to the
under/unutilised public health facilities; leading to an
improvement in health and nutrition outcomes.
Gains on Gaps
There have been gains from an equity perspective too.
Community monitoring has involved the excluded
and the marginal groups in the process. There was an
affirmative approach to ensure that the Dalits, the ST
and the women were involved. Steps were taken, in
many states to ensure that women, Dalit and ST
members headed the VHSCs. This is an important gain
from the process.
Community monitoring has also enabled a better
connect between front line service providers and the
community, in some instances. The community has
begun to appreciate the constraints of front line
providers. There are instances where, the community
has begun to address some of the constraints faced by
front line workers.
Equipped for scale-up
The sharing of report cards in the villages, besides
empowering the community, is also paving the way
for the next stage - the village level plans. This would
facilitate a need-based village-level planning and
deepen the process of decentralisation - a key objective
of the NRHM.
Various institutional arrangements have been
formed at the national, state and sub-state levels to
implement community monitoring. These
arrangements reflect a significant social capital and
should be utilised as technical resource agencies when
the process is scaled-up in the country. Quality
training materials and modules have been prepared at
national level and adapted at state levels. There is also
a sizeable resource pool of trainers that has been
created by the process. These will facilitate a smooth
roll out when the process is scaled-up.
Key Recommendations
The Review Team strongly recommends
continued support from the MoHFW for the
process. The process still needs significant
nurturing and direction from MoHFW. There is a
need for technical and financial support to ensure
that the process continues to be implemented in
the first phase states as well as initiated in other
states.
To ensure this, there is a need to build ownership
of the process by the respective State
Governments. The process of building ownership
should continue in the first phase states and the
process should to be initiated in the remaining
states. The AGCA with support from MoHFW and
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various NGOs, who were a part of the first phase
should enable this. As a start, the review
recommends a dissemination meeting of the first
phase experience and exposure visits by teams
from Health Departments of different states. The
capacity building of Health Department
personnel for communitisation and community
monitoring has to be a key result area.
Community monitoring should be anchored
within the larger communitisation process of the
NRHM; and within an existing arrangement in
the Health Department. This is essential to ensure
acceptance of the process by the health officials
and to ensure that the process is scaled-up.
However, while the implementation role is
anchored in an existing arrangement in the
Health Department, the oversight role should be
kept separate. The oversight committee at
different levels should have representatives of
government and civil society.
The Review Team recommends that community
monitoring be linked to village level planning.
Monitoring, after all, is a post-facto exercise. In
addition, community may monitor a programme
that is top-driven and framed, without a concern
for their needs. Community ought to have a
control over what is implemented too. To enable
the link between planning and monitoring, it is
recommended that ASHA be involved in the
process. ASHA could assess the health needs and
the VHSCs prepare a health plan based on those
needs. This could be incorporated as a part of the
district plan by due process. On a monthly basis,
ASHA will report to the VHSC if the health needs
are being addressed. This process will enable
planning, implementation and monitoring too. It
could also facilitate triangulation of data. If after
this collaborative effort, there are still gaps in
service provision and denial of services, it could
be resolved in Jan Samvads held at regular
intervals. The Review Team believes that that this
strategy could be replicated and likely to be more
acceptable to health providers, administrators
and policy makers.
The NGOs, who are part of the first phase at
various levels, should be involved as resource
centres and provide technical support to the
process - in developing training materials, training
VHSCs and health officials, on-site support for the
VHSCs, monitoring and in process documentation.
Community monitoring, when scaled-up, should
involve mother NGOs SHGs, women Panchayat
members' collectives and PRIs. Efforts should be
made to strengthen the role of PRIs in
collaboration with Rural Development
Department.
It is essential to ensure that both the process and
tools for monitoring are simple and adapted to
local needs. Hence, it is recommended that the
processes and the tools followed in the pilot
phase be simplified. The review also recommends
an incremental approach. To begin with,
monitoring be done with few indicators and
gradually expanded to both build the capacity of
the community and acceptance by the Health
Department. Initially, monitoring could be
limited to mortality and this could be linked with
planning. Gradually, other indicators could be
added.
The Jan Samvad is currently seen as being led by
the NGOs. It is important that the process
gradually becomes a community led process. This
is important to ensure community involvement
and accountability of the Health Department.
The process, when up-scaled, should not be
limited to a one-year cycle in the manner in
which the pilot phase was done. The process
needs significant nurturing. It should be
supported for a minimum of three years to ensure
that the institutional arrangements are functional
and mature before a decision is taken to
restructure or revamp the process.
The first phase has been largely supported by
volunteerism on the part of NGOs. This may not
occur when the process is scaled -up. Hence, it is
important that a realistic assessment of the
human resource requirement is done and
budgeted for.
The review recommends that adequate budgetary
support be provided for community monitoring
to realize the promise of communitization, under
NRHM.
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Innovations in the Process
Selection
Format to screen NGOs and field visits to assess NGO capacity in Orissa
A three-member committee headed by Director, RCH to identify NGOs in Rajasthan
Community Mobilisation
Use of folk form Kala Jaththa in Karnataka, Jharkhand and Orissa
Padyatras in Rajasthan
Chinaki (introduction) meetings in Assam
Organising meetings in Dalit hamlets and separate meetings with women groups in many states
Use of children and youth parliament to mobilise adults in Tamil Nadu
Appointment of 10 Community Resource Persons per taluk in Karnataka for mobilisation
Use of PRA, social mapping and community mapping to prepare health profile in Rajasthan and Karnataka
Involving VHN Association in Tamil Nadu
Organisation of conventions and mass participation in districts and state level in Maharashtra
VHSCs
Provision of ID card to all VHSC members in a district in Tamil Nadu to ensure their recognition by Health
Department
Approval from Gram Sabha for the reconstituted VHSCs in Tamil Nadu and Madhya Pradesh to secure their
tenure
Ensuring that SC/ST PRI representatives head the VHSCs in few states to ensure equity
Report Cards and Tool
Pictorial tools for tribal regions of Maharashtra
Tool, a reference document on rights and entitlements published as a booklet in Tamil Nadu
Sharing of Village Report Cards in Tamil Nadu and Maharashtra in villages, ensuring accountability and
enabling the next step in preparing village plans.
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References:
1. A Pilot Project of Community Based Monitoring of Health Services under NRHM in Chhattisgarh- Progress
Report by state nodal agency
2. Community Based Monitoring of Health Services under NRHM in Jharkhand- A Report by the State Nodal
Agency; 2008
3. Community Monitoring of Health Services under NRHM in Orissa; Activity Report- Prepared by State
Advisory Group on Community Action (SAGCA), Bhubaneshwar
4. Community Planning and Monitoring of Health Services -Karnataka Experience; H. Sudarshan Upendra
Bhojani Govind Madhav N. Prabha On behalf of, State Mentoring Monitoring Group & State Nodal NGO;
2009
5. Community Monitoring website; wwww.nrhmcommunityaction.org
6. Madhya Pradesh final Community Monitoring State Report - By Madhya Pradesh Vigyan Sabha & SATHI
CEHAT
7. National Rural Health Mission Framework of Implementation; Ministry of Health and Family Welfare GOI
8. Rajasthan State Report by Prayas, Rajasthan
9. Report on First Phase of Community Based Monitoring of Health Services under NRHM in Maharashtra;
Dr. Dhananjay Kakde with inputs from other SATHI-CEHAT team members and District nodal NGOs
Published by SATHI CEHAT; December 2008
10. Review of the Community Monitoring Activities in Chirang District of Assam; Prepared by Regional Resource
Centre for North Eastern States Ministry of Health & Family Welfare, GOI, Guwahati, Assam; December 2008
11. Review of Community Monitoring in Tamil Nadu: State Report; S Ramanathan; 2009
12. Review of Pilot Phase of Community Monitoring: National Report; S Ramanathan; 2009
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Annexures
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Annexure I: List of Materials
S/N Particular
Language Description
Brochure
1 Apne adhikar janiye
Hindi
Services given by ASHAs, JSY scheme, ANMs,
PHCs and Sub Centers under NRHM.
2 What is Community based
monitoring
English
What is first phase of Community monitoring,
process of community monitoring, initiating
community monitoring, role of civil society
organizations in community monitoring,
activities within community monitoring and
timeline of activities.
3
What is Community based monitoring
Hindi
Translated from English version.
4
What is Gram Swasthya Samiti (VHSC)
Hindi
What is the VHSC, members of VHSCs, role and
responsibilities of VHSC and untied funds.
5 Swasthya evam Poshan Diwas
(Health and Nutrition Day)
Hindi
About Health and nutrition day, preparation
before organizing the day, facility available,
suggestions, information and referral.
6 Prathmic Swasthya Kendra (Primary
Health Center)
Hindi
Services availabile at PHC.
7 Upkendra ko milne wali mukta
va anudan rashi
Hindi
How to utilize untied fund at the sub centre,
dos and donts of untied fund.
Poster
1 Upkendra (Untied fund and Sub Centre) Hindi
Utilization of untied fund money.
2 Garbhawati Stri ko Milne Wali Suvidha Hindi
( Free services for pregnant women)
Facilities for pregnant women, right to health
care.
3 Gram Swasthya va Swachhata Samiti
Hindi
(Village health and Sanitation Committee)
VHSC’s role and responsibility
4 Janani Suraksha Yojana
Hindi
JSY scheme and benefits
5 Prathmic Swasthya Kendra Se
Milne Wali Suvidhayen?
Hindi
Concrete service guarantee at PHC level.
6 Samudayik Nigraani
Hindi
What is community monitoring and
component of community monitoring
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Entitlement kit
1 Community Entitlement
Manuals
1 Managers Manual
2 Training Manual
3 Monitoring Manual
English Introduction to NRHM, service guarantees
and Hindi scheme and provision under NRHM,
community participation in NRHM, and
Framework for community monitoring.
English
English
English
Introduction of NRHM, Community
Monitoring under NRHM, first phase of
community monitoring, implementation of
first phase of CM, Organizational responsibility.
How to conduct - state level, state managers'
orientation, district level, and block providers'
workshop. How to train different levels of
committees.
What are health rights, health systems in India,
communitisation of health services, what is
community monitoring, introduction to
NRHM, frameworks for community monitoring
in NRHM, mobilizing community and
formation of VHSCs, conducting community
monitoring at the village and facility level,
compiling village and facility level score card,
sharing the results and conducting Jan Samvad.
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Annexure II: Name of States, Districts and Blocks
S/N
Name of the state
1
Assam
2
Chhattisgarh
3
Jharkhand
4
Karnatka
5
Madhy Pradesh
Name of District
Chirang
Dhemaji
Kamrup Rural
Baster
Kawardha
Koriya
Palamu
West Singbhum
Hazaribag
Gadag
Chamarajnagar
Tumkur
Raichur
Guna
Chindwada
Sidhi
Name of Blocks
Sidli
Borobazar
Jonai
Sissiborgaon
Dhemaji
Bordoloni
Rangia
Kamalpur
Boko
Tokapal
Badekilepal
Darbha
Kawardha
Bolda
Shaspur (Lohara)
Khadgwan
Manendargarh
Janakpur
Patan
Chainpur
Lesliganj
Chakradharpur
Manoharpur
Tonto
Churchu
Katkamsandi
Ichak
Gadag
Rona
Mundaragi
Kollegal
Yelandur
C.R.Nagar
Gubbi
Madhugiri
Pavagada
Raichur
Devadurga
Manvi
Guna
Raghogarh
Bamouri
Tamia
Parasiya
Junnardev
Sidhi
Macholi
Kusmi
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6
Maharashtra
7
Orissa
8
Rajasthan
9
Tamil Nadu
Reviving Hopes, Realising Rights
Badwani
Bhind
Amaravati
Nandurbar
Osmanabad
Pune
Thane
Bolangir
Kendrapara
Mayurbhanj
Nawarangapur
Jodhpur
Chittorgarh
Udaipur
Alwar
Dharmapuri
Kanyakumari
Pati
Bansemal
Badwani
Bhind
Gohad
Mehgaon
Dharni
Chikhaldara
Achalpur
Akkalkuwa
Dhadgaon
Shahada
Osmanabad
Tuljapur
Kalam
Velhe
Purandar
Khed
Dahanu
Jawhar
Murbad
Loisingha
Muribahal
Patnagarh
Patamundai
Rajnagar
Derabisi
Rasgobindpur
Bahalda
Bangiriposi
Nawarangpur
Tentulikhunti
Raighar
Luni
Mandor
Osiyan
Bhainsroagarh
Chittorgarh
Kapasan
Kotda
Gogunda
Sarada
Laxmangarh
Umrain
Ramgarh
Harur
Nallampalli
Kariyamangalam
Agasteeswaram
Kuruthancode
Killiyoor
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Perambalur
Thiruvallur
Vellore
65
Perambalur
Andimadam
Tirumanur
Gumidipoondi
Meenjur
Poonamalli
Kandhili
Pernampet
Kaniyampadi
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Centre for Health and Social Justice (CHSJ)
D-63, Basement, Saket, New Delhi-110017
Phone: +91-11-46150604, 26535203, 26536163,
40517478, 26511425
Telefax: +91-11-26536041
E-mail: chsj@chsj.org
Website: www.chsj.org
Population Foundation of India (PFI)
B-28, Qutab Institutional Area
New Delhi - 110 016
Phone: +91-11- 43894100
Fax: 91-11-43894199
E-mail: popfound@sify.com
Website: www.popfound.org