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CAH Grievance Redressal Mechanism for The Health Sector in India _ AGCA Monograph 2018 |
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ON FOUNDATIO
Grievance Redressal
Mechanisms
for the health sector in
India
Experiences, learnings and challenges
(COVER)
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Grievance Redressal Mechanisms for the health sector in India
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MONO
GRAPH
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Grievance Redressal Mechanisms for the health sector in India
ACKNOWLEDGEMENTS
This document is a unique resource, which captures experiences, learnings and challenges on grievance redressal mechanisms across
India and South East Asia. It details 6 models from India, which we hope will be useful for policy makers, implementing organisations,
researchers and academics.
At the outset, we sincerely thank Mr Manoj Jhalani, Additional Secretary and Mission Director-National Health Mission; Dr Manohar
Agnani, Joint Secretary-Policy; and Ms Limatula Yaden, Director- National Health Mission, Ministry of Health and Family Welfare
(MoHFW), for their deep commitment to strengthen community action processes and mechanisms for effective redressal of grievances
under the National Health Mission.
We acknowledge the contributions of Advisory Group on Community Action (AGCA) members; Dr Rajani Ved, Executive Director, National
Health Systems Resource Centre (NHSRC); and Mr Nikhil Dey, Founder Member, Mazdoor Kisan Shakti Sangathan (MKSS) for their inputs
and guidance on the study.
We thank Ms Sowmya Kidambi, Director, Society for Social Audit Accountability and Transparency (SSAAT), Department of Rural
Development, Government of Telangana; Mr Sunil Dubey, ICT Director, CM Online, Madhya Pradesh and Mr Mahesh Chandra Chaudhary,
District Collector, Chhindwara, Madhya Pradesh; Dr J Radhakrishnan, Project Director, Tamil Nadu Health Systems Project; Mr Adait
Kumar Pradhan, State Programme Manager and Mr Susanta Nayak, Senior Consultant, Community Processes Resource Centre- Odisha;
Dr Nitin Jadhav, Associate Coordinator, SATHI, Maharashtra; and Ms Rakshita Swamy, MKSS for sparing time to provide valuable insights
and facilitating field visits for documenting the grievance redressal models.
We thank Dr B Subha Sri for the extensive field visits and research study that she undertook to develop the document.
Many officials from the health department, health care providers, project implementers, panchayati raj representatives and community
members shared their insights and field experiences on grievance redressal and our special thanks to all of them.
We are grateful to the Ministry of Health and Family Welfare and John D and Catherine T MacArthur Foundation for supporting the study.
Poonam Muttreja
AGCA Secretariat
Population Foundation of India
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CONTENTS
01 Executive Summary
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02 Chapter 1: Background and Introduction
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03 Chapter 2: Processes for Grievance Redressal
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04 Chapter 3: Structure of Grievance Redressal Mechanisms
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05 Chapter 4: The Context
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06 Chapter 5: Learnings, Challenges and Way Forward
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07 Case Studies of Models on Grievance Redressal
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a. The 104 Health Helpline in Tamil Nadu
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b. Grievance Redress Committees in Amravati District, Maharashtra
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c. The Chief Minister Helpline in Madhya Pradesh
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d. Grievance Redressal through Social Audit of the MGNREGA in
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Andhra Pradesh and Telangana
e. Grievance Redressal Mechanism for ASHA in Odisha
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f. Jawaabdehi Yatra in Rajasthan
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08 Annexure 1: Department of Administrative Reforms and Public Grievances 68
Guidelines for Public Grievance Redress
09 References
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Grievance Redressal Mechanisms for the health sector in India
LIST OF FIGURES AND TABLES
List of Figures
Figure 1:
The proposed organisational framework for Universal Health Coverage
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Figure 2:
Flowchart of Grievance Redress under the Department of Administrative
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Reforms and Public Grievances
Figure 3:
Flowchart of Grievance Redress under the Centralised Public Grievance
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Redress and Monitoring System
Figure 4:
Structure of the 104 helpline, Tamil Nadu
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Figure 5:
Structure of the Grievance Redress Committee, Maharashtra
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Figure 6:
A generic framework for a Grievance Redress mechanism in the health sector
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Figure 7:
The flow of information on 104 Health Helpline, Tamil Nadu
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Figure 8:
Structures of the Chief Minister Helpline, Madhya Pradesh
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Figure 9:
The processes in the Chief Minister Helpline, Madhya Pradesh
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Figure 10:
The Society for Social Audit, Accountability and Transparency Organogram, Andhra Pradesh
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Figure 11:
Structure of the Grievance Redress Mechanism for ASHAs in Odisha
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List of Tables
Table 1:
Accountability Regimes in Public Governance
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Table 2:
Redress Avenues for Citizens
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LIST OF ACRONYMS
AGCA
ANM
ASHA
AWW
CAH
CBMP
CBO
CEDPA
CHMI
CSR
DFID
E-E
EAG
FOGSI
FPF
GOI
HUP
HMIS
IIT
ICDS
ICPD
IDRC
IHMP
IIHMR
IIPS
IRS
IUD
IVRS
KT
MAS
MARD
MCH
MDGs
MIA
MOHFW
MP
Advisory Group on Community Action
Auxiliary Nurse Midwife
Accredited Social Health Activist
Anganwadi Worker
Community Action for Health
Community Based Monitoring and Planning
Community-Based Organisations
Centre for Population and Development
Activities
Community Healthcare Management Initiative
Corporate Social Responsibility
Department for International Development
Education Entertainment
Empowered Action Group
Federation of Obstetric and Gynaecological
Societies of India
Family Planning Foundation
Government of India
Health of the Urban Poor
Health Management Information System
Indian Institute of Technology
Integrated Child Development Scheme
International Conference on Population and
Development
International Development Research Centre
Institute of Health Management, Pachod
International Institute of Health Management
Research
International Institute for Population Sciences
Indian Readership Survey
Intra-Uterine Device
Interactive Voice Response System
Karuna Trust
Mahila Arogya Samiti
Men Against Rape and Discrimination
Mother and Child Health
Millennium Development Goals
Micro Insurance Academy
Ministry of Health and Family Welfare
Madhya Pradesh
MSI
MTP
NGO
NHM
NHSRC
NPP
NRHM
NUHM
PAC
PDS
PFI
PIL
PIP
PMC
PNDT
PPP
PRI
RCH
RKS
RKSK
RTRDC
SEARCH
SEWA
SHG
SHSRC
SUM
TAM
TIP
TRDC
UHND
UN
UNDP
UNFPA
UP
USAID
VHSNC
Management Services International
Medical Termination of Pregnancy
Non-Governmental Organisation
National Health Mission
National Health Systems Resource Centre
National Population Policy
National Rural Health Mission
National Urban Health Mission
Public Accounts Committee
Public Distribution System
Population Foundation of India
Public Interest Litigation
Programme Implementation Plan
Planning and Monitoring Committee
Pre-Natal Diagnostic Techniques
Public Private Partnership
Panchayati Raj Institution
Reproductive and Child Health
Rogi Kalyan Samiti
Rashtriya Kishor Swasthya Karyakram
Regional Training and Resource Development
Centre
Society for Education, Action and Research in
Community Health
Self Employed Women’s Association
Self-Help Group
State Health Systems Resource Centre
Scaling Up Management
Television Audience Measurement
Total Integrated Programme
Training and Resource Development Centre
Urban Health and Nutrition Day
United Nations
United Nations Development Program
United Nations Population Fund
Uttar Pradesh
United States Agency for International
Development
Village Health Sanitation and Nutrition
Committee
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Grievance Redressal Mechanisms for the health sector in India
EXECUTIVE SUMMARY
The National Health Mission (earlier, the National Rural Health Mission) has since 2005 undertaken architectural corrections of the health
system and attempted to improve access to equitable, affordable, accountable and effective primary health care with the stated vision
of providing effective healthcare to the population throughout the country. The NHM has also attempted to introduce several measures to
improve governance of the health system and promote accountability to citizens. However, in spite of efforts at improving accountability,
several studies point out huge gaps in the implementation of the programmes which might not be executed at the ground level in the
way they have been planned and designed.
Although the NHM framework document lists the institution of a grievance redressal mechanism as one of the roles of both the state
and district level Monitoring and Planning Committee, there have been no sustained efforts to put them in place. Thus, when citizens do
not get the benefits of the various programmes, at present, there is no systematic mechanism to respond their needs and address their
grievances. The High Level Expert Group report on Universal Health Coverage in India identifies this as a policy design gap.
This review draws from field visits to five different models of grievance redressal in the health sector (104 health helpline in Tamil Nadu;
Grievance redressal committees in Amravati district, Maharashtra; Chief Minister helpline in Madhya Pradesh; Grievance redressal
mechanism for ASHAs in Odisha; Jawaabdehi Yatra in Rajasthan) and another model such as Social audit of the Mahatma Gandhi Na-
tional Rural Employment Guarantee Act (MGNREGA) across the country. In addition, a literature review was done on grievance redress
mechanisms in the health sector in India and South Asia.
Given the context, a description of various aspects of a grievance redress mechanism is presented along with a brief analysis under the
following headings:
1. Processes for grievance redressal
2. Structures for grievance redressal
3. Role of the context in grievance redressal
Finally, a section on learning’s and challenges drawn from these experiences, and a possible way forward to up-scale grievance redress
mechanisms is included.
Policy and Programme Level Recommendations
Some of the key policy and programme recommendations from this review for consideration are:
l The NHM has over the last couple of years, strengthened efforts to improve grievance redressal systems and been developing citizen
centric services such as Mera Aspatal App and Helplines ( such as 104) to register client feedback and suggestions. These efforts
need to be institutionalised and scaled up across states and districts.
l At present the grievances redressal mechanism under the NHM at the field level is mostly limited to the ASHA component. The scope
of GR should be broadened and made more comprehensive, which encompasses the VHSNC, RKS and community monitoring
components.
l Designated functionary for grievance redressal: There must be an official/functionary (Grievance Redress Officer) tasked with the
responsibility of accepting grievances in all offices at the State, District, Block and Gram Panchayat levels. It is recommended that
designated Grievance Redress Officers be at least one level above and be deemed to have supervisory control on the individual
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designated to deliver goods or render services as per the Citizens Charter.The functionary must also provide dated acknowledgement
receipts for all grievances received to track the grievances are redressed within a stipulated time frame.
l Independent facilitation: In all avenues of grievance redress, citizens, particularly the most marginalized and deprived require
independent facilitation in accessing information about basic entitlements, register grievances and track the progress of redress
of their grievances. For this purpose, Panchayats must be equipped with independent information and facilitation centres run by
volunteers/civil society organisations that can assist citizens in the grievance redress process.
l Time bound action: Grievances registered with the Departments must be redressed within a stipulated time frame. Grievance redress
protocols must also be equipped with provisions for awarding compensation to aggrieved citizens, and penalties to functionaries who
found responsible for wrongdoing and dereliction of duty.
l Independent appellate structures: For the credibility of the grievance redress mechanisms, it is imperative that the appeal against
improper grievance redress should not lie within Departments. It must rest with an independent appellate structure at the district and
state levels which should also be tasked with the responsibility of monitoring the overall compliance of Departments with the laid down
processes of grievance redress.
l Peoples’ participation in monitoring: The Departments must institutionalize an independent social audit mechanism so that citizens
and beneficiaries can audit the physical and financial aspects of the implementation of programmes being run in their names. Social
audits in the health sector in particular, can borrow principles laid down in the Auditing Standards of Social Audit by the Office of the
Comptroller and Auditor General.
l Mandatory pro-active disclosure of information: For any structure of accountability to lend strength and empower citizens, it must
be based on a regime of mandatory pro-active disclosure of information as mandated under Section 4, Right to Information (RTI)
Act. All parameters of financial and physical performance of a programme must be mandatorily disclosed both through online and
offline modes so that people can remain informed about all aspects of the implementation of programmes. Develop an architecture
of mandatory pro-active disclosure of information and records by all Public Departments through a ‘Janta Information System’
comprising online and offline modes. The method of information disclosure accessible to rural and urban citizens is an important
pre-requisite. This system should be real time, transaction based, open and digitized.
l Helplines: A 24 x7 helpline should be initiated at the district and state levels to provide immediate support or response. In addition,
citizens’ charters with details on the minimum service guarantees should be displayed in all health facilities.
l Regular collation and analysis of the grievances are essential, especially at the district and state levels. Senior officials should act on
recurrent trends/ patterns of grievances.
l Wider publicity of health entitlements and grievance redressal mechanisms through traditional and electronic media is essential.
l One percent of the total NHM budget should be earmarked for supporting accountability mechanisms, including community monitoring
and grievance redressal.
l Sensitization of health officials and providers on public engagement, seeking feedback and facilitating grievance redressal is important.
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Grievance Redressal Mechanisms for the health sector in India
CHAPTER 1
BACKGROUND
AND
INTRODUCTION
1.1 Background
The National Health Mission (NHM, earlier the National Rural Health Mission) has since 2005 undertaken architectural corrections of the
health system and attempted to improve access to equitable, affordable, accountable and effective primary health care with the stated
vision of providing effective healthcare to the population throughout the country. Several interventions have been put in place under the
ambit of the NHM and communitization of the health system has been seen as one of the pillars of the Mission.
Nearly three fourth of the population of the country lives in villages. This rural population is spread over more than 10 lakh
habitations of which 60% have a population of less than 1000. If the Mission of Health for All is to succeed, the reform process
would have to touch every village and every health facility. Clearly, it would be possible only when the community is sufficiently
empowered to take leadership in health matters. (1)
Accountability has been seen as an important component of achieving the Right to Health. (2) Accountability has been defined by the
World Bank as “the degree to which governments have to explain or justify what they have done or failed to do”. (3) The two key criteria
of accountability are seen as answerability – the ability to hold a specific actor responsible to provide answers regarding doing or failure
to doing a specific action, and enforceability – the ability to penalise for non performance. (4)
Though the above definition of accountability is one that is oriented to the management approach of “good governance”, there has been
a felt need for articulating accountability as a concept with people at its centre.
The NHM has also attempted to introduce several measures to improve governance of the health system and promote accountability
to citizens. The Framework of Implementation lays stress on driving reforms and accountability, and communtization is seen as a key
strategy to improve accountability.
Community institutions like the Village Health Sanitation and Nutrition Committees (VHSNCs) and Rogi Kalyan Samitis (Patient Welfare
Committees) are expected to monitor the performance of the health facilities on those parameters. Health Monitoring and Planning
Committees would be formed at the PHC, block, district and state levels to ensure regular community based monitoring of activities
at respective levels, along with facilitating relevant inputs for planning. Organisation of periodic public hearings or dialogues would
strengthen the direct accountability of the health system to the community and beneficiaries. (1)
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However, in spite of efforts at improving accountability, several studies, both from the Government and others, point out huge gaps in
implementation, and that programmes might not be implemented at the ground level in the way they have been planned and designed.
Although the NHM framework document lists the institution of a grievance redressal mechanism as one of the roles of both the state
and district level Monitoring and Planning Committees, (1) there has been no sustained effort to put them in place. The 6th CRM report
in 2012 notes:
Grievance redressal mechanisms are slow to start up, and only two or three states have functional grievance redressal for peripheral
employees and another two or three for public grievances that linked to assured services and entitlements. Accountability mechanisms
such as separation of Governing Bodies from the Executive Committees, with the former ensuring the accountability of the latter are
weak. Therefore Rogi Kalyan Samitis and District and State Health Societies are able to play the role of coordinated implementation, but
not accountability. (5)
Two years later, in 2014, the 8th CRM also makes similar observations:
Grievance redressal mechanisms are weak across states. In many states, while systems exist, the mechanism to analyse and address
complaints needs strengthening.
In Rajasthan complaints/ suggestion boxes exist but the mechanism to analyse and address the issues is absent, while many states do
not have any complaint/suggestion boxes for the feedback of the patients. Kerala does have suggestion boxes in hospitals for patients
to share their grievances and these are opened once in a month which ensures monitoring. States like Madhya Pradesh, have Samvaad
Setu Yojna, an indigenous scheme for grievance redressal launched by the state. The scheme identifies authorities for grievance
redressal at various levels, from the Principal Secretary and Health Commissioner at the state level to the Chief Medical Health Officer
at the district level. Similarly in Uttar Pradesh, grievance redressal has been established. Committees are formed at District Hospital and
Community Health Centre level facilities for reviewing the complaints. A centralised call centre has been established at the state level
with a toll free no.1800-180-5145. (6)
Thus, when citizens do not get the benefits of various programmes, at present, there is no systematic mechanism to respond their needs
and address their grievances. The High Level Expert Group report on Universal Health Coverage in India identifies this as a policy design
gap and notes:
Grievance redressal is not supported by credible institutional mechanisms that are accessible for the poor, and there is little explication
of corrective and punitive measures.(7)
Similarly, the draft National Health Policy 2015 also points out the need for grievance redressal systems:
The policy would be to increase horizontal accountability, by providing a greater role and participation of local bodies and encouraging
community monitoring and better vertical accountability through better monitoring, grievance redressal systems and programme
evaluation.(8)
Considering the existing scenario, review of Grievance Redressal Mechanisms in the health and other development sectors has been
undertaken. It is hoped that the learnings from this study will help to institute such grievance redress mechanisms at different levels
within the health system.
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Grievance Redressal Mechanisms for the health sector in India
1.2 Objectives of the review
This review was undertaken to answer the following questions:
1. What are the different models/initiatives of grievance redressal in health in terms of
a) Structure
b) Redress process
c) Context in which the grievance redressal mechanisms operate?
2. What are the outcomes of grievance redressal from these models?
3. What are the learnings and challenges from the models that will inform future implementation / scale-up of such grievance
redressal programmes in the health sector?
1.3 Methodology
This review draws from field visits to five different models of grievance redressal in the health sector and another model such as social
audit of MGNREGA across the country. These include –
1.The 104 health helpline in Tamil Nadu
2. Grievance Redressal Committees in Amravati district, Maharashtra
3. The Chief Minister Helpline in Madhya Pradesh
4. Grievance Redressal through the social audit of MGNREGA in Andhra Pradesh and Telangana
5. Grievance Redressal Mechanism for ASHAs in Odisha
6. Jawaabdehi Yatra in Rajasthan
These models were chosen from the different structures they represent for grievance redressal in health and the social sector, and
also for the context that they operate in. The key stakeholders of each of the six grievance redressal mechanism were met with. These
included implementers of the programme, members of grievance redress committees, community representatives, health department
officials, health care providers and Panchayati Raj representatives. Interviews with these stakeholders were guided by the objectives of
the review and evolved organically based on the nature of the model/initiative.
In addition to drawing on experiences of these models for the review, case studies of each of these models have also been presented.
A literature review was also done on grievance redress mechanisms in health in India and South Asia. However, there is very little
literature available in the area except for some reports of the Government of India and some publications from a doctoral work.
1.4 Limitations
The lack of literature in the area of grievance redressal has meant that this review draws largely on the models visited and interviews
held with key stakeholders to draw lessons for possible grievance redress mechanisms in the health sector at different levels. The review
has focused on the use of the different models including helplines and committees. There may be other models. However, the lack of
adequate documentation and literature on them limits the scope of this review. Also, other institutions for grievance redressal, like the
judiciary and independent review mechanisms are outside the scope of this review.
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1.5 Introduction
Governance has been defined as “the exercise of political, economic and administrative authority in the management of a country’s
affairs at all levels and comprises complex mechanisms, processes and institutions through which citizens and groups articulate their
interests, mediate their differences and exercise their legal rights and obligations.” (9) Governance is thought to be a key determinant
of economic growth, social advancement and overall development, as well as for the attainment of the MDGs in low and middle-income
countries. (10)
Governance is the least understood aspect of health systems. Siddiqi’s framework for assessment of governance of health systems
presents the several domains of governance as follows:(10)
l strategic vision
l participation and consensus orientation
l rule of law
l transparency
l responsiveness
l equity and inclusiveness
l effectiveness and efficiency
l accountability
l intelligence and information
l ethics.
Grievance redressal mechanisms can be a form of putting in place several of these domains and thus contribute to the good governance
of the health system. For example, they can be seen as a measure of enforcing accountability, as a means of ensuring transparency, and
as a measure of the responsiveness of the health system.
Grievance redress, accountability and community participation
Accountability mechanisms are an important aspect of governance and a close link has been made out in the literature and in various
programmes between the concepts of community participation and accountability. The NRHM has seen community participation as
one of the means to ensure accountability of the health system to the people. (1) Community participation initiatives, by increasing
citizens’ voice and providing a space for such voice have been seen as improving accountability. However, experience shows that merely
promoting participation does not automatically result in accountability and specific measures have to be put in place if this is to be
achieved.
Similarly, community participation and action programmes have also been seen as one form of grievance redressal mechanism under
the NHM. (1) The Community Action for Health programme guided by the AGCA, provides a platform for public dialogues that facilitate
interactions with health providers and managers and this can enable joint problem solving and corrective action as seen in several
examples from different states where such programmes are in place. (11)
However, while grievance redress mechanisms can be complementary to community action and accountability mechanisms, and their
outcomes can be used for ensuring accountability, they are distinct from them. Thus, a health system needs to invest in both accountability
mechanisms and in grievance redress mechanisms separately and distinctly in order to ensure good governance. Well functioning GR
mechanisms and accountability mechanisms will nevertheless feed into and strengthen each other. On the other hand, each could be
weakened by the absence of the other. In fact, the accountability mechanism will not be completed without a GR mechanism.
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Grievance Redressal Mechanisms for the health sector in India
Governance of health systems, and by extension, grievance redress mechanisms, can be seen from largely two perspectives:
1.The efficiency perspective is largely the framework of health reforms as advocated by international financial institutions
including the World Bank. This sees grievance redressal mechanisms and the accountability they establish as a means to
achieve better health outcome goals of various programmes.
2.The human rights perspective– Health is seen as a basic human right and the governance of health systems as a means
to realise that right. From this perspective, grievance redressal mechanisms would be seen as the basic right of a patient/client
of healthcare services. The human rights perspective need not be necessarily exclusive of efficiency and the desire to achieve
health outcome goals.
Given the importance of GR mechanisms in good governance of health systems, it is indeed surprising that there is very little literature
available on them. Whatever are available talks of GR mechanisms broadly for all public services rather than specifically in the health
sector. This monograph can thus, be seen as filling an important gap of the health policy and programmes.
Literature review
In one of the few pieces of work that look at grievance redress mechanisms in the India in detail, Nicholas Robinson describes the
structure of public service administration, laying emphasis on their hierarchical nature, and focuses on the fact that the onus of provision/
implementation of most public services and programmes is on lower level staff within such hierarchical systems. (12) This can also be
extrapolated to the health system where different health care providers at different hierarchical levels provide specific health services.
Accountability regimes for public services
Robinson further explicates that these staff of various public services is governed by three different forms of accountability regimes:
(12, 13)
l Administrative – where the accountability is to superior officers higher up in the hierarchical system and is judged by a set
of rules and regulations
l Political – where accountability is to politicians at different levels and is judged by what is considered for politically
acceptable
l Legal – where gaps in service provision can be challenged in a court of law.
The different facets of these three accountability regimes are detailed in Table 1.
Table 1: Accountability regimes in public governance (12)
Accountable to whom?
By what standards?
Administrative
Superior officials
Administrative rules
Through what process?
Managerial
With what effects?
Penalisation
Political
Politicians
Political acceptability of
behaviour
Political power over bureau-
cracy
Informal penalisation like
transfer
Legal
Courts
Law
Litigation
Penalisation, for example
fines
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Redressal avenues for citizens
Given that public servants are governed by these different accountability regimes, they also serve as different avenues for redressal
when a citizen feels he/she has been denied services. For example, a citizen can approach an administrative superior with a complaint
regarding services provided by the particular departmental staff, go to his elected representative for help with redressing a gap in service,
or go to court for legal action against a public servant/department for failure to provide services. However, each of these avenues differs
in key areas, like the ease of access, its impartiality, its power to remedy and its cost as detailed in Table 2.
Table 2: Redress avenues for citizens (12)
Access
Impartiality towards complainant
Impartiality towards local administration
Power to remedy
Cost to government to create
Political Redress Legal Redress Administrative Redress
High
Low
Middle
Low
High
Middle
Middle
High
Low
Low
Middle
High
Low
Middle
High (if new forum)
Low (if pre-existing)
In addition to these, there are some forms of grievance redress that explore innovative means to improve the process of redressal.
These include:
l Regular fixed-day open house meetings with the public for grievance redressal by senior administrative officers like
the District Collector, Minister and the Chief Minister. These have been instituted in many states and help citizens access
redress through facilitation by senior bureaucrats and politicians. However, not many outcomes have been reported on this in
literature. (12,13)
l Independent review mechanisms like the National Human Rights Commission (NHRC), National Commission for Women
also act as fora for grievance redress. For example, the Jan Swasthya Abhiyan has conducted a series of public hearings on
denial of the right to health under the aegis of NHRC in 2003-04 and again in 2015. (14)
l Independent authorities like the Lokpal have been suggested as ombudspersons in certain sectors to address grievances,
particularly corruption. However, there is not much literature on this. A study from Karnataka reports on how one particular
Lokayukta along with the Vigilance Director of Health was able to expose systemic corruption in public health, but since there
was no political commitment to the process, the results could not be sustained beyond his tenure. (15)
As stated earlier, this monograph focuses on administrative mechanisms for grievance redressal within the public health system, and
thus, these independent review mechanisms are beyond its scope.
Key attributes of grievance redressal mechanisms
In order to study various models of grievance redressal, this monograph reviewed the literature on grievance redress and accountability
to identify critical features that a GR mechanism for the health sector must possess. These features have then been used subsequently
in the description of the various models reviewed, and also in understanding learnings and challenges.
Some reviews have looked at what the key attributes of a good grievance redress mechanism should be. These include:
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Grievance Redressal Mechanisms for the health sector in India
l Effectiveness - its ability to provide redress
l Efficiency – its ability to provide redress in a timely and cost effective manner
l Credibility – the trust reposed in it by the citizens it is supposed to serve. (16)
These have been seen as essential attributes in any grievance redress mechanism to enable it to be functional in a meaningful and
relevant manner.
As mentioned earlier, it is equally important to define a social accountability framework based on its conceptualization and articulation
by citizens in general and affected communities in particular.
A group of young Dalit activists from Bhilwara District, Rajasthan put forward the following as the components of a social accountability
framework which places their rights at the centre of the discourse. The following were defined as the minimum principles of people
centred social accountability framework:
• Information (Jaankari): The process of seeking accountability begins with having access to information. In order to enable and
empower citizens- individually and collectively, to effectively perform the function of monitoring the implementation of interventions
rolled out in their names, various conditions need to be fulfilled. These include a widespread understanding of the entitlements,
prescribed time frames, who’s responsible for what, prescribed standards and rates, decision making processes, possibility for
appeal, complaint or grievance redressal, and reasonably expected outputs and outcomes.
• Acknowledgement (Sunwai): Once made aware of all the benefits and norms of services that the citizen is entitled to, he/she
should have the right to define his/her grievances, submit it to the concerned authority and get an official acknowledgement of it.
In essence, citizens’ petitions to Government in the form of complaints, suggestions, grievances should be acknowledged by the
State through institutionalized norms.
• Time bound action (Karywahi): Once grievances are submitted and acknowledged, there must be standard operating protocols
provide for redressals within a stipulated time frame. The citizen and/or beneficiary should be aware of the time frame within which
his/her grievance is redressed /responded to.
• Participation (Bhagidari): Most often, processes of enquiry and investigation to identify the cause of the grievance are internal
departmental processes and are therefore, represented by the interests of the administration. A process of enquiry into a grievance
should necessarily include the views of the complainant and the official against whom the complaint is made. Therefore, systematic
processes need to be introduced in the redressal process that can incorporate the views and feedback of the complainant on
record.
• Protection (Suraksha): Grievance redress protocols should attribute the highest importance to give protection to complainants.
Complainants should be given the status of whistleblowers and they and their immediate family should be protected from any form
and manner of violence and intimidation by vested interests.
• Peoples’ Collective Public Platform (Janta ka Manch): To balance the highly skewed equation of power between the administration
and the people, in favour of the people- the role of public collective platforms cannot be ignored. Such public platforms enable
citizens as a collective, to interface with the administration in their immediate surrounding (instead of a Government office) to file
grievances, seek the status of redress of those grievances and confirm/corroborate the administrative version of the cause of
complaint which plays a significant role in empowering citizens.
The framework and its components is a reflection of how living realities can contribute to theoretical constructs and make them both
substantive and meaningful.
However, the health sector is unique in many ways and this has implications for a GR mechanism in this sector.
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• A person seeking health care is often in a distressful situation, and any grievance in this situation adds to the distress. The high
out-of-pocket expenditure also adds to the distress leading in many cases to impoverishment.
• Health and health care are often highly mystified and the common person usually lacks the technical knowledge to help him/her
make logical decisions in a distressful situation.
• There are huge power hierarchies between a common person and health care providers and health authorities.
These above factors give rise to a fear of not being treated if any grievance is voiced aloud and lead to an inability to negotiate for
better treatment or addressing of any grievance at the point of seeking care.
Grievance redress in the health sector – different levels of
response needed
As many issues about grievances arising while seeking health care, it is not enough for a grievance redress mechanism in the health
sector to provide redressals only. Rather, there need to be three levels of response to a grievance by the public health system.
1. Immediate response – Given that the person with a grievance in the health sector may be facing a life and death situation,
the lack of immediate response could have grave consequences. This level is crucial and would involve setting in motion
timely actions to respond to the immediate need of a person seeking health care and facing a problem with it.
2. Redress – this would be another level of grievance redressal that would involve an analysis of the facts and actual redressal.
The redress could be in several forms, including provision of services, financial compensation, or even an apology for lack or
denial of services.
3. Systemic feedback and learning – this level would put in systemic changes based on learnings from the public grievances
so that such grievances do not recur in the future.
In addition, an ideal GR mechanism needs to have a facilitator who will help bridge the power hierarchy between the complainant and
the health system, and negotiate for a timely response and redress.
Current situation of public grievance redressal in India
Over recent years, there is a recognition of the importance of grievance redressal and institutionalisation of its mechanisms. A 2010
compilation of guidelines for grievance redress by the Department of Administrative Reforms and Public Grievances, Ministry of
Personnel, Public Grievances and Pensions, Government of India states in its foreword: (17)
One of the biggest concerns facing the Government of India is how to make the public service delivery system more citizen-centric.
An essential pre-requisite for this is to have a robust public grievance redress and monitoring mechanism, particularly in
Government agencies that have a large public interface.
Several official bodies have also stated the primacy of grievance redress mechanisms. The Second Administrative Reforms Commission
in its 12 Report entitled “Citizen Centric Administration The Heart of Governance” in Chapter 7 paragraph 7.2.2 has stated as
follows: (18)
The basic principle of a grievance redressal system is that if the promised level of service delivery is not achieved or if a right of a citizen
is not honoured, then the citizen should be able to take recourse to a mechanism to have the grievance redressed. This mechanism
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Grievance Redressal Mechanisms for the health sector in India
should be well publicized, easy to use, prompt and above all, citizens must have faith that they will get justice from it.
Similarly, the Parliamentary Standing Committee on Personnel, Public Grievances, Law and Justice, in their Twenty-Fifth Report has
observed: (17)
The Committee is of the view that generally, people are not aware that a system of redressal exists in many of the Government
departments and its subordinate offices where they are required to visit. The Committee, therefore, recommends that wide publicity
through national, regional and local media, as well as through electronic media to create awareness regarding the redressal mechanism
among people is the need of the day, particularly for the weaker sections of the society, women and those challenged with handicaps
and also the people living in remote areas.
The Committee also recommends that grievance-handling system should be accessible, simple, quick, fair, responsive and effective.
It is not uncommon to hear from people complaining against harassment, waste of time, repeated visits to offices etc. The Committee,
therefore, recommends that every Ministry / Department in the Union / State Government UTs should have a dynamic public grievance
redressal mechanism in place with a special focus on the information delivery system. The Committee further feels that the language
and the content of various application/ complaint forms should be user-friendly, and should be widely available in various outlets, like
post offices, on websites for downloading etc.
The Committee is of the view that time limits should be fixed for approval or rejection of the application on the basis of well publicized
and uniformly applied criteria. Also, redressal should be done within a reasonable time period as prescribed for each stage of redressal
without indulging in lengthy technicalities of the procedure. The Committee, therefore, recommends that due attention should be given
to timely redressal of grievances lodged. It is also of the considered view that officers responsible for delay should be made accountable
and suitable action taken against them.
The High Level Expert Group report on Universal Health Coverage for India states: (7)
Grievance redressal in the context of health services is a fundamental regulatory function, which is currently not supported by a credible
community-friendly mechanism. Even where limited redressal mechanisms exist in the context of some hospitals or services, there is
little a explication of appropriate measures for adjudicating disputes, compensating plaintiffs, disciplinary action, or feedback to the
health services to enable the correction. A systematic and responsive grievance redressal and information mechanism are essential to
ensure that citizens can access knowledge of their health entitlements, and are enabled to claim them.
The report then proceeds to provide specific recommendations for instituting a grievance redressal mechanism in the health sector:
We recommend the introduction of a systematic and responsive grievance redressal and information mechanism for citizens to access
knowledge of and claim their health entitlements. Such a mechanism is urgently required at the block headquarters to deal with
confidential complaints and grievances about public and private health services in a particular block. Procedures for corrective measures
should be clearly enunciated at each level, with defined parameters for grievance investigation, feedback loop, corrective process, no-
fault compensation and grievance escalation. Responsibilities of health department officials should be defined in relation to Grievance
Redressal Officers and vice versa, supported by sufficient and clear directives and guidelines or orders, as applicable. This should be
linked, at the district level, with an Ombudsperson who functions under the aegis of a National Health Regulatory and Development
Authority. Serious grievances and unresolved cases should be referred to the Ombudsperson.We recommend the setting up of Jan
Sahayata Kendras (People’s Facilitation Centres) that should be co-located with the office for grievance redressal in order to locally
provide people with information services. But the two should function independently. The Jan Sahayata Kendra should conduct periodic
public hearings, and operate a telephone helpline. Wherever possible, these should be managed by local CBOs, MBPs or women’s or
farmers’ groups, trade unions and cooperative societies.
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Figure 1: Proposed organisational framework for Universal Health Coverage (7)
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Grievance Redressal Mechanisms for the health sector in India
Nodal agencies for Grievance Redress
Two nodal agencies have been set up by the Government of India to primarily handle grievances:
l The Department of Administrative Reforms and Public Grievances (DARPG), Ministry of Personnel, Public Grievances and Pensions
l The Directorate of Public Grievances, Cabinet Secretariat
The Department of Administrative Reforms and Public Grievances, Government of India has laid out guidelines for setting up of public
grievance redress cells for public services under all government departments. (17) These, as put up on the National Health Portal
website, are described in Annexure 1.
Figure 2: Flowchart of grievance redress under the Department of Administrative Reforms and Public Grievances (17)
Receipt of a Grievance in DARPG
Assessment of the Grievance by Public Grievance Officer
of DARPG to take up with Ministry /Department concerned
Action Report
Ministry/Department concerned receives and the Director
of Public Grievances makes assessment
Case forwarded to No
Sub. Orgn./Attached
Does it pertain
to Ministry/
Yes
Case taken up
within office for
office
&AsecRntietopnotrat ken
Department itself
redress
Case can further be forwarded to Field
units
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The Public Grievances Division is responsible for issuing policy guidelines coordinating and monitoring of issues regarding
redress of public grievances and staff grievances in general and for the central government in particular. A web based
Centralized Public Grievance Redress and Monitoring System (CPGRAMS) has been designed and implemented in all the
Ministries / Departments of Government of India. A customized software with local language interface has also been designed
for the state governments. This software is called CPGRAMS - States. The state module of CPGRAMS has been implemented
in 9 States/Union Territory namely Haryana, Odisha, Rajasthan, Puducherry, Meghalaya, Mizoram, Uttarakhand, Jharkhand
and Punjab.
The Department of Administrative Reforms and System generated unique complaint registration number and Public Grievances
(DARPG) with the technical support of NIC PG PORTAL, empowering the citizens to lodge their grievances/complaints online
from anywhere anytime and also enabling the Government Departments to take redress action within a prescribed time
limit. It has two interfaces, (a) Public Lodging of manual grievances with the facility of uploading a scanned document, and
(b) CPGRAMS for Ministry/Departments/ Organisations to facilitate Redress and Monitoring process by Directors of Public
Grievances/PGO. This is a single Window system introduced in Ministries/Departments /Grievance Organisations in June
2007 and made mandatorily applicable. CPGRAMS is a web-enabled single window system, providing online access to
citizens to raise their grievances and to the nodal Public Grievance Officers in Government Departments to take prompt
action for redress under intimation to the petitioners.
Highlights and facilities for Citizens/Government Departments
l Online receipt of grievances by Government Departments
l SMS alert to Public Grievance Officers
l Online forwarding of Grievances to multiple sub-ordinate offices
l Grievance lodging and monitoring system for citizens
l Speedy redress and effective monitoring of grievances
l Uploading of action taken/disposal reports concerning each
l Forwarding of reminders/clarifications for the grievances lodged earlier
l Query based reports and system generated correspondence letters
l Feedback of complainant regarding disposal of grievance
Reference: http://pgportal.gov.in
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Grievance Redressal Mechanisms for the health sector in India
Figure 3: Flowchart of grievance redress under the Centralised Public Grievance Redress and Monitoring System
Citizen
DARPG
PG Portal
DPG
President’s Sectt.
PMO
CPGRAMS
Ministry/Department/
State Government
DoPPW
In addition to the processes outlined above, it is important to acknowledge certain interventions that have been institutionalized/are in
the process of being institutionalized for strengthening grievance redress in the implementation of social sector schemes:
a. Auditing Standards of Social Audit, MGNREGA: Though the legal mandate for facilitating social audits as a means of securing greater
transparency and accountability in the implementation of MGNREGA was established in 2011, the Office of the Comptroller and Auditor
General (CAG) defined detailed auditing standards for social audit in 2016. The Standards lay out details for operationalising provisions
for accessing and verification of information, presentation of findings and evidence to a collective body and time bound follow up
on grievances identified during the audit. Adherence to the standards of social audit as laid down by the O/o the C&AG will result in
further strengthening grievance redress protocols under the MGNREGA. They can also be incorporated into social audits of other public
programmes.
b. Public Grievance Redress Act, Bihar: In addition to the Right to Public Service Delivery Act, the Government of Bihar has passed the
Public Grievance Redress Act in 2015 which gives citizens the right to register grievances with dedicated Grievance Redress Officers.
The Act also mandates an independent appellate structure at the district level along with Information and Facilitation Centers at the
block level.
c. Right to Hearing Act, Rajasthan: The Right to Hearing Act, 2012 applicable in Rajasthan, provides a platform for setting up of an
institutional structure capable of accepting and redressing grievances, that is both standardized, and having a legal sanctity. It does by
giving a legal mandate for setting up of single window facilities in every Gram Panchayat to receive grievances of any nature; facilitates
a collective hearing of grievances by providing a physical interface between Line Department officials and all complainants in a common
place, requiring a time bound written response for each grievance submitted by a complainant and mandatory pro-active disclosure of
information.
d. Rajasthan Sampark, Rajasthan: A single window web portal was developed to register and track grievances. This software necessitate
interoperability of registering and tracking grievances across all Departments by providing a unique ID to every grievance. Redressal of
grievances is subject to time frames crossing of which results in an automatic escalation of complaints.
e. Right of Citizens for Time Bound Delivery of Goods and Services and Redress of their Grievances Bill, 2011: The Bill attempted to put
in place a legislative framework to ensure that the (i) citizen secures his/her legitimate entitlement; and
(ii) activate action against officials for not carrying out their stated obligations. It also aimed to:
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• Build a comprehensive awareness of entitlements, functions and obligations of functionaries in each Public Department, through
the formation of Citizens Charter that will be duly notified and justified.
• Facilitate and assist citizens in the filing of their grievances by providing them with multiple modes of registering grievances- by
mandating the setting up of Grievance Redressal Officers (GROs) in every public office to assist and acknowledge all grievances
received and the constitution of an Information and Facilitation Centre.
• Time Bound redressal of grievances.
• Ensure that majority of the grievances are redressed at the district level by setting up of an independent designated authority.
It is responsible for investigating the appeals addressed to it, in case the complainant not satisfied with the action taken by the
concerned Grievance Redress Officer (GRO).
• Develop an Independent appellate structure to hear complaints in an objective and non-partisan manner.
• Levy penalty on erring officials.
• Award compensation to those aggrieved, as a reparative measure.
The Bill passed by the Lok Sabha and Parliamentary Standing Committee in 2011 eventually lapsed because of not being passed by
the Rajya Sabha within the stipulated time frame.
Challenges
However, in spite of these guidelines and recent interventions, a study by the Indian Institute of Public Administration in 2008 listed the
following challenges in the existing grievance redress mechanisms (16):
l The DARPG, while laying down policy guidelines for grievance redress mechanisms, does not engage in substantive redress of
grievances by itself. This is largely left to local departments concerned with the grievance.
l There were wide variations between ministries and departments in their commitment towards implementation of, and capacity to
provide grievance redress.
l The centralised public grievance redress mechanism instituted by DARPG had not been implemented uniformly by most
departments.
l The existing mechanisms in most cases lacked effectiveness, efficiency and credibility.
In addition to the factors listed here, some of the other factors that could have led to the failure of GR mechanisms, could be systemic.
These include hierarchical systems with a very little devolution of power to communities, underfunding and lack of community
participation.
In recent times, grievance redress has been recognised as an important component of good governance. In line with the overall move
in public systems to increasingly involve the community, and with more use of hybrid structures, different states have tried to innovate
in providing grievance redress mechanisms. The three forms of grievances – administrative, political and legal that Robinson describes
– are seen to have within them inherent challenges, these mechanisms are often a mixture of the distinct forms of grievance redres-
sal, which often combine administrative and political redress. The models documented in this review also fall under this category.
How this review is structured
This review describes six different models of grievance redress and attempts to understand learnings and challenges from them. In
the following sections, descriptions of various aspects of a grievance redress mechanism are presented along with a brief analysis.
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Grievance Redressal Mechanisms for the health sector in India
Following a brief description of these models, the sections are organised as follows:
1. Processes for grievance redressal – describing the various steps and processes involved in the redressal of a grievance
2. Structures for grievance redressal – describing the various structures and spaces that need to be set up for an effective and
efficient GR mechanism
3. Role of the context in grievance redressal
Each section also highlights case studies from the field visits to describe and reiterate the points made in the review. Finally, a section
on ways forward drawn from these experiences and possible future steps to up-scale grievance redress mechanisms is included.
Short description of the models documented
1. The 104 health helpline, Tamil Nadu
The 104 health helpline run by the Government of Tamil Nadu, offers services related to health advice, health information, counseling and
service grievance redress. The operation of this helpline has been outsourced under a Public Private Partnership mode to Gram Vikas
Kosh - Emergency Management and Research Institute (GVK EMRI), which runs the helpline. The Tamil Nadu Health Systems Project
(TNHSP) offers technical support to the helpline. One Service Improvement Officer (SIO), who is an administrative officer retired from the
government service in the health department and with experience in the structure and functioning of the public health system, receives
grievances and facilitates their resolutions. When a call is received regarding complaints regarding service delivery, the call is forwarded
to the SIO, who speaks directly to the caller and understands the details of the grievance. Based on the nature of the grievance, he then
contacts the concerned authority with power to resolve the issue real time. In case the grievance is still not resolved, the SIO escalates
the call along with a pre-determined hierarchy based on the nature of the complaint and the specific directorate it concerns. The SIO
also forwards reports of grievances received each day regarding specific directorates to the concerned Director with a copy to TNHSP
for further actions wherever necessary.
2. Grievance redress committees in Amravati district, Maharashtra
The community monitoring and planning process that has been ongoing in Maharashtra since 2007 has brought about the realisation
that with increased awareness of rights, there is a need for a grievance redress mechanism to address issues and grievances arising
both from citizens and out of the monitoring process. The civil society organisations facilitating the process in the Community Based
Monitoring and Planning districts have also facilitated the formation of grievance redress committees. The GR mechanism, while distinct
from the community accountability mechanism under the NHM, acts complementary to it. One such committee, the Block level Takrar
Nivaran Samiti or Grievance Redress Committee in Dharani block, Amravati district was formed in 2015. Its membership consists of
multiple stakeholders including health care providers, block level health officials, elected representatives, and representatives from
both the civil society and the media. The Takrar Nivaran Samiti meets once every three to four months to discuss grievances and take
decisions to address them. It receives grievances from both the community and health care providers while also taking cognizance of
issues arising out of the community monitoring process. Once a grievance is received, it is discussed by the committee at its regular
meetings. The presence of different stakeholders in the committee helps resolution of issues during discussions with contribution from
the different members.
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3. The Chief Minister helpline in Madhya Pradesh
The CM helpline in Madhya Pradesh is a one-stop helpline where a citizen can lodge a complaint about any government department. The
helpline provides information on over 400 government schemes across 56 departments, registers complaints and provides a platform
for citizens’ suggestions. The operation of this helpline has been outsourced under a public private partnership mode and an officer in
the grade of Under-Secretary has been appointed as Director of the helpline. The helpline is run through a call centre that has been
provided a toll free number, 181, and is functional every day from 7 AM to 11 PM. One of the key features of the system is that it is
completely paperless. In preparation for the launching of the helpline, a mapping of different levels of officers in each department was
done and these officers have been graded as belonging to different levels to facilitate addressing of grievances in a hierarchical fashion.
In addition, nodal officers have been appointed in each department to monitor redress of grievances concerned with that department.
The whole grievance redress process has been brought under the ambit of the Public Services Guarantee Act that provides a legislative
framework for the process. Key features of this helpline are the automatic time bound escalation system and transparency through a
website displaying progress on the redress of any grievance.
4. Grievance redressal through social audit of the MGNREGA in Andhra Pradesh and Telangana
The erstwhile Andhra Pradesh (now Andhra Pradesh and Telangana) government institutionalised a process of social audit of the
MGNREGA for the past several years. The Society for Social Audit, Accountability and Transparency (SSAAT), an independent society
under the Department of Rural Development, has a unique structure of being a public sector society but being headed and staffed
by persons belonging to the civil society. SSAAT conducts regular social audits of social sector programmes primarily the MGNREGA
through youth volunteers. The audit involves house to house and worksite verification of official records with the help of grassroot social
auditor. The audit report is shared with the Gram Sabha and at a public hearing, which serves as a space for grievance redress. The
Vigilance wing separately deals with serious cases of lapses/frauds.
5. Grievance redressal mechanism for ASHAs in Odisha
The ASHA grievance redress mechanism in Odisha was set up with the objective of providing an easily accessible mechanism to
ASHAs for timely resolution of their grievances. The ASHA facilitator serves as the first person in direct contact with the ASHAs who also
contribute to the redressal of the grievance. The issues that are beyond the scope of the ASHA facilitator, or are common to many ASHAs
in the region, are raised at sector level meetings. A structured format is used for noting the grievances, which is subsequently submitted
to the block health administration on a monthly basis. Apart from this, grievance redress committees are constituted at the block and
the district levels. The Block ASHA Grievance Redressal Committee is constituted with health care providers, health managers, NGO
representatives and ASHA representatives as members. The committee meets on a monthly basis to discuss the grievances redressed by
the ASHA facilitators and the Sector-in-charge and discuss any unresolved cases. Similarly, the district level committee has the District
Collector, Chief District Medical Officer (CDMO), health care providers and NGO representatives as members.
6. Jawaabdehi Yatra in Rajasthan
Beginning in December 2015, a 100-day long “Jawaabdehi Yatra” travelled to each one of the 33 districts in the State of Rajasthan.
The Yatra was organised by the Soochna Evam Rozgaar Abhiyaan (SR Abhiyaan) consisting of activists from roughly 150 organisations.
The Yatra was undertaken with the objective of interacting with citizens and inform them of their entitlements under public health
programmes and register grievances that they were facing in accessing basic services. The Yatra spent an average of three days in
each District with nukkad sabhas, block level meetings, seminars and workshops, RTI and accountability clinics, street theatre, songs,
distribution of pamphlets, grievance redress camps and melas, followed up by discussions and meetings with the administration in every
District. In the Yatra, a total of 9,297 grievances were lodged by people facing difficulties in accessing their entitlements/basic services.
The Yatra culminated with a draft legal framework for ensuring accountability in public service delivery as articulated by citizens,
beneficiaries and peoples’ movements who participated in the Yatra.
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Grievance Redressal Mechanisms for the health sector in India
CHAPTER 2
PROCESSES FOR
GRIEVANCE
REDRESSAL
As described in the introductory chapter, the National Health Mission envisages the setting up of accountability mechanisms through one
of its pillars, communitisation. Community Action for Health programmes in states like Tamil Nadu and Maharashtra have incorporated
elements of grievance redressal in their programmes as described in the subsequent chapters. Public dialogues as part of Community
Action for Health programmes in states like Maharashtra and Bihar, guided by the Advisory Group on Community Action (AGCA), have
also acted as fora for grievance redress. (11) However, before we analyse the effectiveness of these programmes, we need to understand
the different processes that make up grievance redressal.
In this chapter, the different processes towards redressing a grievance are detailed out.
Grievance redressal – The steps
For a grievance to be redressed, several step-wise actions have to take place, which are as follows:
1.
Recognising and framing the grievance
2.
Registering the grievance
3.
Redress of complaint
Each of these steps has several sub-steps and is described in detail below:
Recognising and framing the grievance
The first step in the grievance redress is the grievance to be recognised and framed in the mind of the aggrieved citizen as a grievance.
It happens only when the grievance redress mechanism can be set in motion.
It is well known that there are several gaps in the implementation of public services. However, very often, citizens accept this as a given
and do not register a complaint. A citizen has to be aware and acknowledge that he/she has been denied a service. It is necessary to
have a sense of awareness of his/her rights or entitlements to frame a grievance from a citizen’s rights perspective and thus, it is
necessary for grievance redress mechanisms to be embedded within the programmes that actively promote rights awareness.
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In different models of grievance redress mechanisms, this step has been addressed differently and through different actors.
• In initiatives where civil society organisations have been involved in facilitating the setting up of grievance redress
mechanisms, the role of promoting awareness of rights/entitlements among the community has been performed by them.
This could be through specific programmes that promote knowledge about government schemes and entitlements. It
could also be through community monitoring or social audits of public services that identify gaps in service delivery and
frame them as grievance from a rights perspective. The models like Maharashtra where the GR mechanism is linked to the
community action for health programme, and Andhra Pradesh where the grievance redress mechanism is situated within
a social audit of a government programme’s process.
• In state sponsored initiatives, for eg. the helplines in Tamil Nadu (TN) and Madhya Pradesh (MP), specific efforts need to
be put in to introduce rights awareness among citizens. The helplines in TN and MP also have a component that provides
information on various state sponsored schemes and helps citizens to understand their entitlements.
Registration officers at both these helplines are trained to provide such information. They are provided with material that
will support them in their job. In addition, in both states, wide publicity has been provided to the grievance redress helpline,
and the framing of grievances as a citizen’s right. Citizen charters and legal frameworks have also been put in to support
this.
It is important to note that awareness promotion must be from a rights perspective, where the citizen learns to see public services,
including health and health care, as a basic human right. If the GR mechanism is complimentary on the ground to a community action
initiative, as in the models in Maharashtra or Andhra Pradesh, the rights perspective is already imbued within the programme. This
makes it easier for a citizen to articulate a gap in service as actually a grievance, rather than as an administrative failure.
At the same time, it is important to ensure that the articulation of a grievance is bottom up and not top down. For example, one of the
most limiting features of the Right to Public Service Delivery Acts operational in states today is the process by which the scope of the
grievance is defined by the administration and communicated to citizens, by way of ‘notified services’, instead of it being the other way
round.
The important step of recognizing a gap in service as a grievance can only be taken by a well informed citizen. This is influenced and
enabled by several factors - educational level, access to information, place of residence etc. An interesting example is from the 104
helpline in Tamil Nadu. In the first year of its launch, most users have been from the urban/peri-urban areas of the state, signifying how
access to information, which is important for citizens to make use of a GR mechanism. Similarly, in Madhya Pradesh, most users of the
GR helpline have been from geographical regions that are known for being well informed and assertive in claiming rights.
Registering the grievance
Once the grievance is recognized, the next step would be to register the grievance with the appropriate forum to initiate redress.
Traditionally, as described in the background section, this can be done with different mechanisms or actors, each with different levels
of access and impact.
1.
With the administrative mechanism
2.
With politicians
3.
With the judicial mechanism
The grievance redress models described in this monograph have explored different mechanisms, which make registering a grievance
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Grievance Redressal Mechanisms for the health sector in India
easier for a citizen, and different models provide different modalities for this.
• This could be done through-
o the complainant can directly go to a designated centre for registering complaints or
o mediation to register the complaint through an elected representative, like a PRI member or politician or through civil
society members who then take up its registration at the appropriate forum.
• In models where monitoring or audits raise grievances, organisations facilitating the monitoring process can also facilitate
registering the grievances in an appropriate forum including committees, public hearings or helplines.
• In other initiatives where the citizen has to directly contact the grievance redress mechanism like helplines. Complainants can use
a mobile phone to call a designated call centre which then registers the complaint on their behalf. Websites can also be used for
this, and also to follow up on already registered complaints.
These different modalities to register a complaint have implications for access to the grievance redressal mechanism itself. Traditionally,
GR mechanisms require that a complaint is made through a physical visit to a complaint centre. This means several direct and indirect
costs for the complainant. Thus, only those who have adequate resources - finance, time etc - to meet these costs, will be able to register
a grievance. This would also require the citizen to be able to negotiate power hierarchies within the administrative set up to register the
grievance.
In order to circumvent these issues and to increase access, grievance redress mechanisms have put in specific measures in some cases.
The Madhya Pradesh government has set up Lok Seva Kendras (Public Service Centres) in every block, which serves as single window
centres where applications for specified public services can be made and received within a specified time frame.
Lok Seva Kendra, Madhya Pradesh
As part of its administrative reforms to improve public sector governance, the MP government has appointed persons retired
from the administrative services as Lok Seva Managers in each district. In addition, each block has a Lok Seva Kendra that
serves as a one stop centre for citizens to approach for delivery of services.
The Lok Seva Kendra in Chhindwara block of Chhindwara district is located in the premises of the District Magistrate. It is
being run by a private agency to whom it has been contracted out under a Public Private Partnership model. A list of entitled
services under the Public Services Act is displayed prominently outside the Kendra along with a maximum time frame. Any
citizen can apply for any of these services at the Kendra by paying a fee of Rs 30 and is immediately provided an electronically
generated receipt which serves as evidence of having made the application. He/she also gets an SMS on the mobile phone
with details of the application and again when the requisite service, for example, a certificate would be ready. He/she can then
collect the certificate from the same Lok Seva Kendra.
If the service is delayed, a fine of Rs 250 per day is charged from the concerned government personnel. Sixty per cent of the
fine goes to the beneficiary.
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While the GR mechanisms reviewed here have explored alternative means of registering a grievance, these also have implications for
access. For example, registering of a complaint through technological devices like a mobile phone automatically requires access to a
phone and to a mobile network. This has implications for those persons who do not have financial resources for the same or live in areas
where there is limited access.
Similarly, access can also be restricted by financial means. Where the specified helpline number is not toll free, as in Tamil Nadu, the
cost of the call could also influence access to the helpline. Similarly, in Madhya Pradesh, a service fee is charged for access to the Lok
Seva Kendra. While this could be seen as a very small amount, it nevertheless could be a restricting factor for those to whom even this
amount may be significant.
In modalities where GR mechanisms are embedded in the community, as in the use of committees or public hearings, access to
these mechanisms would be influenced by various axes of social marginalisation, like caste, class, gender. Where rights based civil
society organisations have facilitated the process of monitoring public services and grievance redress, as in Maharashtra, Bihar and
Andhra Pradesh, they have put in specific efforts to ensure that committees formed for the purpose, have representations from these
marginalised sections and that they have access to the GR mechanism.
Thus, it is seen that access to GR mechanisms can be affected by several factors including geography, technology, finance and social
status. Any GR mechanism must make a special effort to ensure that all these factors are addressed. For example, GR helpline calls
could be made toll free, no service fee charged for registering grievances, and civil society organisations be involved to ensure that
persons from marginalised sections are adequately represented on GR committees and have equitable access to GR mechanisms,
It is important to bear in mind that despite the best efforts, institutionalized modes of grievance redress can be corrupted or blocked.
Multiple modes and routes must therefore, be introduced in order to inhibit the difficulty of citizens to register and track their grievances.
Redressal of complaint
Once a complaint is registered, the next step would be the actual process of redressal. This pans out differently in different initiatives
based on how the structure of the redress mechanism is organised.
As seen earlier, a grievance redress mechanism must be effective, efficient as well as credible. In addition, in the health sector, three
levels of response to a grievance are necessary.
1.
Immediate response
2.
Redressal
3.
Systemic feedback
In this section, the monograph draws on the models reviewed to understand the three levels of response and also to learn how a GR
mechanism can be effective and efficient.
Immediate response
An immediate response mechanism is essential to provide immediate relief to the complainant who may be in a situation where he/
she is not able to access health care. The lack of an immediate response in such a case may actually lead to loss of life or morbidity.
Therefore, such immediate response mechanisms are essential. The GR committees in Maharashtra and the helpline in Tamil Nadu
provide for such immediate relief as shown in the following case studies.
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Saving women’s lives – Grievance redress in Maharashtra
The block level Takrar Nivaran Samithi in Dharani block of Amravati District in Maharashtra has served as a forum for
addressing grievances. Both citizens and health care providers approach the Samithi in case of an emergency medical
situation where there is difficulty in either procuring or providing services. Several lives of women and children have been
saved because of this immediate response mechanism that the committee has been able to provide.
One such instance is that of a woman whose life was saved after she developed eclampsia. She had been diagnosed with
pre-eclampsia during the ante-natal period, had delivered and had been discharged. On the fifth day, she developed seizures
at home, a life threatening condition. Because of traditional beliefs that her tribal community held about seizures, her family
refused to bring her to the sub-district hospital for treatment in spite of repeated requests by the local ANM and the PHC
medical officer.
In desperation, the PHC medical officer called the block level grievance redress committee members. Subsequently, a team
of doctors from the sub-district hospital, Dharani travelled to her home. After an hour of discussion with the family, they were
able to give her a dose of Magnesium Sulphate injection (the standard treatment for eclampsia) at her home itself. They then
negotiated with the family to bring her to the facility, where they could start treatment with modern medicine, while the family
could continue to perform their traditional customs even in the hospital. The woman was then brought to the sub-district
hospital and was well by the next morning.
Another instance of such immediate response is when a pregnant woman attending the sub district hospital, was found to
have a very low haemoglobin level. The doctors referred her to Amravati District Hospital, about four hours away across a ghat
road. However, since the community has a very low opinion of the quality of care provided at the district hospital, the woman
and her husband refused to go. Who would take care of the other children at home that they wanted to know. In desperation,
the doctors at the sub district hospital called members of the Grievance Redressal Committee. These members convinced the
family to take the woman to the district hospital while simultaneously making arrangements in the community for the care of
the other children and ensuring they were fed. Not stopping with this, one of the members, the Sabhapati of the Panchayat
Samiti, also followed up with the Civil Surgeon at the District Hospital regularly to ensure the woman received adequate care.
Real time grievance redress in Tamil Nadu
The 104 helpline in Tamil Nadu is being run by a private agency (GUK-EMRI) under a public private partnership mode. An
officer retired from the health administration department of the government has been appointed as Service Improvement
Officer (SIO) to address the grievances reported to the helpline. Because of his working knowledge of the health department,
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the officer has been able to negotiate with health authorities to provide real time grievance redressal.
For example, if a call is received about a doctor or para-medical staff being unavailable in a health facility, the SIO calls up
the immediate officer in the hierarchy through a closed user group (CUG) phone that has been provided to all officers in
the health department. Through discussions and explorations of alternative options to address the gap in service, the SIO
facilitates an immediate systemic response to the grievance, for example by re-allocating a doctor or staff from another
facility close by.
The health authorities in Tamil Nadu appreciate the importance of such real time grievance redressal even if they
opposed to the earlier model where grievances were brought to a forum like that of the District Collector for redress. They
feel this model of real time grievance redressal ensures that services reach the citizen when he or she actually needs them
without waiting for an administrative process to be completed before redress can happen, sometimes too late to save the
life of the concerned person.
The above stories signify certain critical features of GR mechanisms in the health sector that are essential for providing an immediate
response.
1. GR mechanisms for health must be functional 24X7 in order to be able to provide immediate response to a complainant.
2. They must be linked with a facilitator who can liaise with the health system to provide such an immediate response. This facilitator
may be an administrator who knows the working and personnel of the health hierarchy, a civil society or elected representative
who is able to immediately contact a health care provider and has the power to negotiate a response, or a health care provider
himself/herself.
3. The health system to which the GR mechanism is linked must be reasonably functional, in order to be able to respond immediately
and with reasonable effectiveness to the grievance of a complainant. There are examples from field visits to states where such
functioning health systems are lacking.
Redressal
Along with an immediate response, a grievance redressal mechanism should be able to provide redress to the complainant. This may
be in the form of –
l Ensuring he/she gets the service that was the cause of the complaint, or
l In the failure of being able to provide such a service, he/she gets compensated, either in the form of an apology, a financial
compensation, or through other means.
To give substance to a grievance redress protocol, the following conditions must be satisfied:
a. Designation of a dedicated Grievance Redress Officer who is responsible for accepting grievances and issuing dated
acknowledgements.
b. Time bound redress of grievances and completion of enquiry.
c. The obligation of the Department to provide a written response to the complainant on the status of redress within a defined time
period.
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d. Presence of an independent appellate structure for escalation of complaints.
e. Provisions for enforcing the penalty on erring officials and awarding compensation to aggrieved complainants.
For the sake of impartiality in addressing this step, it is essential that the redress process is handled by an independent body.
For example, in Maharashtra, the GR committee consists of persons from outside the health system, including PRI members and civil
society institutions, thus providing some amount of independence to the committee. Similarly, the public hearing process in Andhra
Pradesh has representation from multiple stakeholders.
On the other hand, the redress process within the helplines in Madhya Pradesh and Tamil Nadu are vested within the administrative
system. This takes away to some extent from the impartiality of the system. This also has implications for the effectiveness and credibility
of the redress.
Some of the case studies that are given below, illustrate how this step of redressal works in different initiatives.
Ensuring entitlements in Madhya Pradesh
The Chief Minister helpline in Madhya Pradesh has ensured that citizens can call up the helpline, understand their entitlements
under various schemes and also register their grievances if they feel their entitlements have not been met.
Mr Manoj Balwanshi of Chhindwara district complained to the CM helpline as his wife had not received the benefits under the
Indira Gandhi Matrutva Sahayata Yojana. Within a week of complaining to the helpline, the amount was received in his wife’s
account. Mr Balwanshi feels that the helpline is very useful as the government staff does not usually respond to citizens belonging
to the lower or middle class when they request for their entitlements.
Similarly, the list provided by the health department, Government of Madhya Pradesh shows that several women have received
their entitlements under the Janani Suraksha Yojana after complaining about the delay in disbursements to the CM helpline.
Addressing corruption through social audits in Andhra Pradesh
The social audit process of the Society for Social Audit, Accountability and Transparency (SSAAT) in Andhra Pradesh and
Telangana has helped unearth several instances of corruption in the implementation of NREGA. One such instance is from
Ramachandrapuram Gram Panchayat in Kanagal mandal of Nalgonda district.
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In this Gram Panchayat, the land was cleared for cultivating juliflora under the NREGA. It was recorded that 20 acres had
been cleared. When the social audit was done that year, it came to light that in reality only three acres had been cleared.
Further, scrutiny of records and interviews with the farmers revealed that they had been paid for work on three acres. The
commensurate amount for 17 acres had been divided between the Sarpanch, the field assistant (FA) and the technical
assistant (TA).
These details were read out publicly in the Gram Sabha. Faced with the indisputable evidence, the concerned persons
accepted that they had indeed engaged in the corruption. The findings of the social audit were subsequently presented at the
public hearing; the action was initiated against the concerned persons including suspension of the FA and TA, recovery of the
amount from them into the NREGA account, and revoking of the cheque signatory powers of the Sarpanch.
This incident has also led to systemic changes – the NREGA funds are now directly transferred from the mandal office to the
beneficiary’s account, rather than go through the Sarpanch and FA.
These different models reveal some critical features necessary for effective and timely redress.
l The grievance redress mechanism must be accessible and able to register the grievance.
l While functionaries within the health system will necessarily be involved in the steps of immediate response and
systemic feedback, it is essential that an independent facilitator is also involved in redressal process and this is
seen to be impartial and credible.
Feedback to the health system
However, a good grievance redress mechanism would not stop with this. In order to learn truly from the grievance redress
mechanism, it is necessary that a systemic feedback to be put in place in the health system that would alert authorities to
what kinds of grievances arise and what would do to prevent such grievances in future. In Tamil Nadu, for example, such a
systemic feedback is in place as described in the case study. In the absence of such a system, grievance redressal remains
limited to individual cases, and does not become a tool for systemic improvement.
Most grievance redress mechanisms have a system whereby information is collated over a period of time and analysed. Such
information is also usually fed back to the system and has the potential to be used for making systemic change.
Systemic learning from the grievance redress mechanism
– Anti Rabies vaccination in Tamil Nadu
The 104 helpline in Tamil Nadu has developed a system whereby daily feedback is provided to the different directorates of
the health department based on the type of grievances received. A nodal officer has been appointed in each directorate to
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study this feedback and to take an appropriate action. This has resulted in a system being responsive and instituting systemic
changes based on the learnings from the grievances received.
One such instance is that of the use of anti-rabies vaccine at government health facilities. Earlier the practice was to wait for
five patients who needed the anti-rabies vaccine, to open a vial of ARV in order to ensure that the vaccine did not go waste.
However, this resulted in significant waiting time for patients. This was recorded by the 104 helpline as a frequent recurring
grievance. The Directorate of Public Health, on receiving this feedback, has now passed an order that it is not necessary to
wait for five patients to open a vial.
The following critical factors are essential for a systemic response to be mounted:
l The GR mechanism is linked to a health system that is functional and responsive.
l The complaints made to the GR mechanism are constantly monitored, the results are to be collated and analysed and
emerging patterns need to be studied.
l It is necessary that a senior authority with the power to make systemic change within the health system, to be responsible
for such monitoring and to analyse and act on recurrent patterns of grievances.
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CHAPTER 3
STRUCTURE OF
GRIEVANCE REDRESSAL
MECHANISMS
For GR mechanisms to be in place and function effectively, institutionalised spaces for redressal are necessary. While it is possible to
register a grievance through the existing administrative hierarchy, there are currently no specific mechanisms that focus on redressal
of such grievances, and even when present, assessments of these show them to be largely non functional (Indian Institute of Public
Administration).
This chapter will focus on the grievance redress mechanism structures that have been tried out in some models, which fulfill various
steps in the process of redressal. The following topics will be focussed on:
1. Types of spaces for grievance redressal
2. The administration and facilitation of grievance redress mechanism
3. Interface with the health system
4. Interface within the line departments
Types of spaces for grievance redressal
The different models studied as part of this review, have put in different structures to facilitate grievance redressal. As the existing
systems for grievance redressal through the administrative hierarchy are largely non-functional, some new spaces exclusively for
registering and redress of grievances have been created. Many of these spaces are a combination of administrative and political
mechanisms. These include:
• The use of helplines like in Madhya Pradesh or Tamil Nadu – both of these, while nesting within the administrative
hierarchy, is backed by political sanction. These can be approached at specific times of the day throughout the year.
• Spaces like community based GR committees, like those in Maharashtra, specifically constituted for the purpose of
redressing grievances. These committees have a wide range of stakeholders including administrators and elected
representatives. The meetings of the committees are held periodically.
• The social audit cell of Andhra Pradesh, has used public hearings for grievance redressal. The hearings involve multiple
stakeholders too. Again, these are organised at periodic intervals.
Who participates in these spaces varies according to the nature of the space. While experience with community accountability
mechanisms has resulted in significant learnings on ensuring participation and inclusion of the component as a key principle for
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community accountability spaces, there are not many such experiences with GR mechanisms. This is probably the GR mechanism
is nested within the administrative structure and responding to a demand for better services from the community. However, different
experiences do highlight different ways of involving multiple actors in the grievance redressal process.
Where GR mechanisms have been implemented through the formation of community based committees, multiple actors need to be
included in the committees. For example, in Maharashtra, the GR committees include health care providers at different levels, elected
representatives of the Panchayati Raj Institutions and civil society members. The constitution of these committees would have the same
principles like any other committees constituted for community participation and met the similar challenges such as intensive processes
for selection of its members; ensuring inclusion of representatives from different marginalized social groups and exclusion of elite
classes in the committee.
Similarly, public hearings can also be spaces where multiple stakeholders come together to discuss and solve grievances, and where
people with the power can redress grievances or refer it to appropriate authorities for redress. Many projects/initiatives of community
participation have used such public hearings for grievance redressals which often bring together health care providers, health authorities,
elected representatives and civil society members along with citizens. In public hearings, discussions and redressals are often mediated
by a third party facilitator – this could be a senior level administrator, an elected representative, or a member of the judiciary. Experiences
from community action programmes in Maharashtra and Bihar have used in such public hearings extensively and showed how issues
like drug availability, absenteeism by the doctor, illegal charging, etc. at facilities have been solved through discussions in these public
hearings.
Auditing Standards of Social Audit under the MGNREGA have attempted to lay down the minimum conditions that need to be met for
processes like public hearings to be objective and evidence-led. These include parameters such as ensuring independence and fairness
in the proceedings of the hearings, minimum quorum, ensuring participation of the most disadvantaged and marginalized, manner of
presenting information, recording of proceedings, handling of conflicting testimonies, amongst other things.
On the other hand, structures like helplines are spaces set up by the administration where the administrative system can be reached by
citizens. Helplines are in place in Tamil Nadu and Madhya Pradesh where these have been outsourced to a private provider, who runs a
centralised call centre that houses the helpline and receives the calls from citizens. The operators who receive the calls are trained to
respond to grievances and direct them towards an appropriate administrative authority for resolution. They may also be supported by
the paramedical staff or retired administrative staff. This model may not necessarily involve participation by community members except
for registering their grievances. These mechanisms thus, view the citizen as a consumer seeking services rather than as a participant
in the process.
Thus, while a GR mechanism could be either community based or completely vested within the administration, this has implications for
its ownership and credibility. If a GR mechanism is completely vested within the administrative system, specific efforts need to be made
to provide some transparency and independence through the appointment of an independent ombudsperson to redress grievances.
Legitimacy of the space
Whatever the type of space, it needs to have legitimacy in both the eyes of the system and the user. This is what the system gives one
of its core attributes listed earlier – credibility. Such legitimacy can be gained in many ways. This could be through administrative
sanction for the space like in Maharashtra or Tamil Nadu, where the health department or the political authority provides legitimacy
to the space. The administrative institutionalisation of the space like the social audit cell of Andhra Pradesh can be an important way
of providing legitimacy. The social audit cell is a recognised distinct department with committed funding (1% of total state MGNREGA
budget) from the state, and its findings are used by the state for its own monitoring. The inclusion of the social audit findings into those
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of an independent public body like the Comptroller and Auditor General (CAG) adds further legitimacy to the space.
In some other states, the grievance redress structures have been given legitimacy through the use of legislation. For example, Public
Service Acts have been passed in states like Madhya Pradesh and Bihar that provide a legal framework for the provision of public
services. These Acts lay the modalities and timelines for the provision of various public services and also provide ways to address
grievances, including punitive financial sanctions on government staff when such timelines are not met. Such legislative action protects
the grievance redress mechanism from ad hoc changes.
Thus, legislation to provide a legal framework for grievance redress mechanisms can be seen as a best practice that lends
its sustainability and credibility in the eyes of the citizens. This also makes it justifiable, thus increasing chances of citizens being able
to use it as a right.
Madhya Pradesh Public Services Guarantee Act
“The Madhya Pradesh Public Services Guarantee Act 2010 guarantees the delivery of basic public services to citizens within
a stipulated time frame and sets in place accountability mechanisms for failure to do so. Under the Act, 52 key public services
like issuing caste, birth, marriage and domicile certificates, drinking water connections, ration cards, copies of land records
have been notified. A time period has been fixed for the delivery of each service. If officials fail to perform their duties and do
not provide these services on time, they have to pay a fine starting from Rs 250 per day to a maximum of Rs 5,000. The Act
provides for a two stage appeal process. In the event that a citizen does not receive notified services in time, he can appeal
to the first appellate authority. If the first appellate authority is negligent or if a citizen is dissatisfied with the decision, he can
file an appeal with the second appellate authority. The second appellate authority has the power to impose fines and order
disciplinary action against officials. Where fine is imposed on the delinquent officer, the applicants are paid compensation for
the inconvenience caused to them.” (http://www.mp.gov.in/en/web/guest/impschemes).
The MP government has also put in administrative mechanisms to implement the Public Service Guarantee Act. A State
Agency for Public Services has been set up as a registered autonomous body for the effective implementation of the Act.
The agency has a mandate to provide policy guidance for delivery of public services and also to perform the third party
assessments of service delivery.
In addition, Lok Seva managers have been appointed at every district level to coordinate the implementation of the Act and
services under it.
Administration and facilitation of grievance redress mechanism
Different models also differ in terms of who administers the grievance redress space and who facilitates such redress.
Administration of the space involves ensuring that meetings of the committees or hearings take place at regular intervals,
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helplines function in a time-bound manner, and reports are collated and submitted to the appropriate authority at specified intervals.
In the case of GR committees or public hearings, the space is usually administered by a civil society organisation or an institution
involved in it. For example, the civil society organisations that facilitate the community action for health process also facilitate the GR
mechanism in Maharashtra. In Andhra Pradesh, the Society for Social Audit, Accountability and Transparency has been set up under the
Department of Rural Development and is in-charge of conducting social audits, identifying grievances and conducting public hearings.
In the case of state initiated helplines like in Tamil Nadu or Madhya Pradesh, the administration of the space has been handed over to
a private company under a public private partnership model. The private company takes responsibility for ensuring that the space
runs smoothly, collates reports periodically and submits to the state.
Figure 4: Structure of the 104 helpline, Tamil Nadu
Tamil Nadu Health
PPP
Systems project
GVK-EMRI
Block Medical Officer
for Trauma Support
104 Helpline
Call centre
Citizen with
Denial of Services
Directorate of Public
Health
Directorate of Medical
Services
Directorate of Medical
Education
Consumer
feedback
System feedback
Service Improvement
Officer
Feedback
Concerned
health provider/health authority
Immediate Response
Redress
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Figure 5: Structure of the Grievance Redress Committee, Maharashtra
District Planning and Monitoring
Committee
Block Planning and
Monitoring Committee
Information from
Community Monitoring
Block Grievance Committee
- Elected Representatives
- Health Care Providers
- NGO Representatives
Village Health and
Sanitation Committee
Citizen with
Grievance
Health Care
Provider with
Grievance
Different models have implications on the amount of ownership - there is of the mechanism among the concerned community. There
may be higher ownership in case of mechanisms that involve community members and elected representatives; in structures, the
ownership may be limited where the role of the citizen is limited to registering a complaint. This also has implications for the credibility
of the mechanism.
Whatever the facilitation model, ensuring transparency, for example, making information on every step of the grievance redress
available in the public domain would help in increasing credibility of the model.
These different models also differ in who facilitates the actual grievance redress – this is described in more detail in the chapter on
processes.
Interface with the health system
While these are structures that are in place to register grievances, there also has to be an institutionalised way whereby the grievance
is fed in to the health system for further action and redress.
Some mechanisms have used the presence of health care providers or health authorities in GR spaces as a means of interfacing with
the health system. For example, the presence of health care providers in grievance redress committees in Maharashtra and the presence
of authorities like the Project Director of MGNREGA in public hearings in Andhra Pradesh, ensure that the grievance is heard by them
and action is initiated. However, these mechanisms are restricted to the actions of these individual providers/ health authorities and do
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not seem to have institutionalised structures where the grievance can be taken up by higher level authorities, for example, at the state
level, if necessary.
Where the GR mechanisms are administered by the government machinery, some have used the service of facilitators who play a
specific role of interfacing with the health system. For example, in the Tamil Nadu helpline, the Service Improvement Officer plays the
role of interfacing with the health system. He is a retired administrative officer from the public health system employed by the private
company to which the helpline has been outsourced. He contacts the appropriate authority with his ability to redress the grievance and
also provides regular collation and feedback to the different health authorities.
The Madhya Pradesh helpline has a more structured and institutionalised method for interfacing with the health system. All public
service officials have been mapped across all districts and categorised into four different tiers. The helpline staff forwards the grievance
to the appropriate authority in the concerned department who is listed as the first tier officer setting in process the motion of grievance
redressal.
These models underscore the importance of having a structured and institutionalised method for the GR mechanism to interface with
different levels of the health system.
Interface within the line departments
Health is much more than health care alone and is determined by several determinants, all of which may not be under the purview of
the health department directly. The issues such as denial of services/ grievances related to water and sanitation, public distribution
system, or the Integrated Child Development Services (ICDS) for example, may adversely affect a person’s health. There is thus, a need
for grievance redress mechanisms in the health sector to be able to interface with other allied departments.
In the case where the GR mechanism encompasses several or all departments of the government, the inter-sectoral action becomes
easier there. For example, in Madhya Pradesh, the CM helpline covers all departments of the government and thus, has the potential
to build in such interdepartmental action for grievance redressal. In practice, though this does not seem to be happening currently, the
private provider managing the call centre of the helpline merely forwards the complaints to the appropriate person in the designated
department. If a senior level administrator can take charge of such intersectoral/ interdepartmental action, the helpline structure offers
scope for wider alliances within the departments for redressals.
On the other hand, where the GR mechanism is run solely by the health department or given legitimacy by the department alone,
such inter-sectoral action becomes difficult like in Tamil Nadu. However, as described in the case study that follows, the committed
involvement of the senior facilitator ensures some level of action even when the grievance is to be addressed by other departments.
But this needs to be institutionalised. In such cases, separate grievance redress mechanisms run by different departments could be
interlinked so as to be able to promote intersectoral action – for example, setting up automatic connections/forwarding mechanisms
between helplines of different departments.
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Inter-sectoral action – challenges in Tamil Nadu
The 104 helpline in Tamil Nadu is under the purview of the health department and covers only the services provided by the
department directly. This provides challenges for resolution of grievances that are related to health, but fall outside of the
purview of the health department.
On the day we visited the helpline, there were several calls related to pig menace from a particular town in the state. This was
because there had been press coverage of the same issue in the town on that day. This fell under the purview of the municipal
administration and not the health department. Thus, the health helpline could not directly resolve this issue.
However, the Service Improvement Officer was resourceful enough to provide the number of the concerned person to be
contacted in the municipal administration to each of the callers, thus not turning them away completely.
This shows that the integration of allied sectors to health under one helpline may be useful in achieving inter sectoral
coordination in redressing grievances.
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Grievance Redressal Mechanisms for the health sector in India
CHAPTER 4
THE
CONTEXT
The context in which grievance redress mechanisms operate influences the way they function. This section will look at how context
influences the grievance redress mechanism under the following three heads:
1. Context of the health system
2. Socio-cultural context
3. Political context
Context of the health system
For a grievance redress mechanism to be effective, and to provide the first step of immediate response, the GR mechanism needs to
be situated within a health system that is in a position to respond adequately to the grievance. This would be possible only when the
health system is functional.
For the system to provide an immediate response, the health system needs to be not just functional, but also in a position to mount
procedures within a short notice that would remedy the situation. The helplines in Madhya Pradesh and Tamil Nadu provide a contrasting
study of how a well functioning health system would be able to provide an immediate response. While both helplines are able to provide
redress, Tamil Nadu fares better in mounting an immediate response than Madhya Pradesh. Similarly, a reasonably well functioning
health system in Maharashtra again seems to be able to provide an immediate response through involving actors outside of the health
system as shown in the case study in the previous chapter.
Similarly, for the grievance redress mechanism to be able to lead to systemic change, it needs to work within a system that is
responsive. Systems need to be put in place to facilitate learning and course correction based on it, and the health system needs to be
mature enough to accept that it has gaps and act on it. The case study of how Anti Retro Viral injections were provisioned for patients in
Tamil Nadu shows how a responsive system can learn and institute changes based on a grievance redress mechanism. As mentioned in
the previous chapter, a senior level health functionary needs to play the role of a champion for leading such systemic change.
What would be an effective GR mechanism on account of weak health systems? Though there are no experiences on this that the review
could refer to, a few suggestions can be made. It may be the best to start with things that are doable first and then moving on to other
things. An escalating step wise assurance of different service entitlements/health guarantee can be listed for different states
with specific time-frames that each state can commit to.
In addition to the functionality of the health system, one other key feature that determines the robustness of a GR mechanism is the
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attitude of staff within the health administration to redressing grievances. It was seen during the field visits that the health
administrators consider grievances as nuisance value, and therefore, the objective of redress was to reach a formal “closure” of the
grievance. It was not necessarily the same as actual response or redress of the grievance. Unless senior administrators vested with the
responsibility of response or redress and see GR mechanisms as the right of citizens and are sensitised to citizen-centric governance,
such mechanisms will not be truly functional with the original spirit of GR mechanisms. Therefore, sensitisation exercises with health
staff and administrators need to be held to foster an understanding of rights and community/citizen centeredness.
Socio-cultural context
The socio-cultural context of the area where the grievance redress mechanism works, has a role in its effectiveness. Education levels
and access to resources obviously have a role to play generating awareness on citizen’s right and entitlements, and framing an issue
as a grievance. In Maharashtra, the GR mechanism is an outcome of the community action process for health. How does this affect
the types of grievances and the ownership of both the community and the health system in addressing those grievances? How does an
overall environment of seeing the state as a provider of all social sector services like Tamil Nadu affect the access and performance of
the GR system?
It also seems obvious from the data available that persons marginalised in different ways- the ones who may need to access the GR
system the most or who may not have such access. What should a health system do to improve this access? How do social movements
that play a role in addressing caste and gender issues contribute to such increased access? Since GR mechanisms are still in their
nascent stages in most models, many of these questions would need further research and based on the answers to them the GR systems
need to be designed in order to be more inclusive and equitable.
Political context
Given that GR mechanisms are the tools for good governance. However, in the political context in which they are implemented, it plays
a great role in their functions. The level of ownership of the GR mechanism in the health system is also influenced by political will. For
example, the GR mechanisms in both MP and TN are seen to have political backing of the government at the highest level. This
leads to a situation where the mechanism is given high priority. In MP, the GR mechanism is further institutionalised through law,
thus giving it even more legitimacy. In the absence of such a law, the Tamil Nadu mechanism, while institutionalised administratively,
runs the risk of being dismantled when the political commitment wanes.
The social audit cell of Andhra Pradesh is a striking example of how political commitment can strengthen a process over a long term.
Such political commitment from successive governments, mediated through committed bureaucrats and politicians, has resulted in the
process being institutionalised to the extent of being a separate department of the government and receiving committed and continued
funding. The results of the social audit now feed into established processes like the CAG report, which also strengthen the process.
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Grievance Redressal Mechanisms for the health sector in India
CHAPTER 5
LEARNINGS,
CHALLENGES AND
WAY FORWARD
The earlier chapters have looked at grievance redress mechanisms as a measure of enabling good governance and ensuring
accountability. They have also described the various models of grievance redress studied in this review and analysed them from a
framework that looks at how effective, efficient and credible they are in providing the different steps of grievance redressal, and from
the point of view of access to the most marginalised.
When looking at the GR mechanisms in the context of public health or administrative systems in which they are vested – the lack of
devolution of power, their hierarchical nature, very weak public systems in many states, and also the hierarchical nature of society in
which the systems function – needs to be kept in mind. Without the commitment to addressing these challenges through multi-pronged
approaches, any grievance redressal mechanism will be a mere routine process with no real contribution to systemic change. Specific
efforts need to be made to make GR mechanisms rights based, and to address inherent power hierarchies present in the systems
and put in specific measures to overcome them. Also, financial and systemic readiness of public systems to actually address
grievances that are registered through such mechanisms need to be ensured.
Thus, a grievance redress mechanism cannot be a stand-alone solution to systemic weakness – it has to be a complementary
strategy to an overall political and administrative commitment to democratising and making public systems more accountable and
community centred.
This chapter lists the learnings on grievance redress mechanisms from the perspective of policy makers and programme managers who
would want to set up such GR systems. Also, since this monograph focuses on the health sector, these recommendations are specific
to the health sector in India, though some of them may be generic and can be extrapolated to other sectors and contexts. While given
the different contexts in different states of the country, one prescriptive model of GR mechanism is not feasible. The chapter ends with
a framework that highlights the key components that any GR mechanism in the health sector must include.
1. GR mechanisms are essential to establish accountability and responsiveness of the health system. However, they are distinct from
accountability mechanisms. Investment needs to be made in both accountability and GR mechanisms distinctly and separately to
promote good governance.
The public health system needs to be accountable and responsive to the needs of the community it serves. By enabling the community
to reach the health system and receive redress for any gaps in services, GR mechanisms are a way of establishing such accountability.
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Seen from a rights perspective, GR mechanisms are essential for the health system to be effective, responsive and accountable.
However, they are distinct from community accountability mechanisms and need to be invested indistinctly and separately.
2. A GR mechanism must be effective, efficient and credible.
An effective GR mechanism must be –
• Effective, i.e. capable of providing appropriate and adequate redress
• Efficient, i.e. able to provide redress in a timely and cost effective manner
• Credible, i.e. trustworthy in the eyes of the citizens it is supposed to serve.
To achieve this end, there is a need for a minimum uniform grievance redress framework for the health sector that consists of the
following:
• Recognition of the fact that any violation of norms, guidelines and entitlements as mandated by schemes implemented under
the NHM constitutes as a grievance
• Dated acknowledgement for grievances submitted by complainants
• Dedicated “Grievance Redress Officers” who should be tasked with the responsibility of receiving grievances in all physical
points of service
• Time bound procedures for redressing grievances and completing enquiries, if any
• Giving the reward to aggrieved complainants and penalties to officials/functionaries who found to be the cause of the
grievance.
3. A GR mechanism must have a three-tier response. Immediate real time response is crucial, and this needs to be a 24X7 system.
Since the health sector often provides services that could mean life or death, any GR mechanism in the health sector must have
three tiers of response: an immediate response system, a system to provide redress and measures to establish systemic feedback
and learning. The component of immediate real time response is unique to the health sector and is crucial to the success of any GR
mechanism.
An immediate response mechanism needs to be a 24X7 system. Different modalities have been tried in different models. These include
a helpline and designating a person as a point of contact. These immediate response mechanisms could be designed to function either
through a centralised system at the state level or could be established at the district level.
4. GR mechanisms must be designed to promote access for the most marginalised
In order to promote equity, GR mechanisms must ensure that they can be reached by even the most marginalised. Systems like helplines
and one-stop centres can help in promoting such access but have to be complemented with active processes on spreading awareness
on rights and entitlements. Without this, the added advantage of easy access through a telephone, the effort will not translate into the
benefit.
5. Systematic pro-active disclosure of information on financial and physical parameters at all stages of implementation of health sector
schemes is a necessary supplement to efforts towards improved accountability structures. Transparency and access to information
are required by citizens to hold implementing structures accountable to their mandate. Towards this end, it is recommended that NHM
develops real time, transaction based and open information system (online and offline) that suo-moto discloses information regarding
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Grievance Redressal Mechanisms for the health sector in India
expenditure and performance of the schemes on a regular basis.
6. There must be a designated person/centre which would facilitate an immediate 24X7 response
In order to facilitate an immediate real time response, GR mechanisms in the health sector must be staffed with a facilitator who would
be able to mount such a response. Such facilitators could be at the state level, for example, the Service Improvement Officer of the
Tamil Nadu model, or at the district level or the local help desk of Melghat region of Amravati district in Maharashtra. In all matters
concerning efforts to strengthen accountability, there is an inherent need for independent and accessible mechanisms for facilitating
citizens (particularly the most marginalized i.e. elderly, women, children, disabled, Dalits, etc.) to hold the administration accountable.
7. A functional, responsive health system is essential to respond in an immediate fashion
In order to provide an immediate real time response, a health system has to be functional at different levels. In the absence of such a
functional system or at least efforts to make the system functional, the GR mechanism will be limited to provide only limited redress.
8. The redress component of any GR mechanism must be implemented through an independent body outside of the system.
For the sake of credibility, the GR mechanism needs to be seen as impartial. Thus, the redress component of the GR should be
implemented through an independent body constituted outside of the public health system. This could be in the nature of a district or
state level committee or an independent ombudsperson. Adequate human resources and funds need to be allocated to assist the support
structures.
9. System loops need to be built in within the GR mechanism for systemic change
In order to make the GR mechanisms relevant for systemic improvement, they must be treated as learning systems. Thus, systemic
feedback loops need to be built in to enable health systems to learn from GR mechanisms and put in systemic level changes to ensure
grievances do not recur.
10. People’s role in the planning of policies related to health care must be institutionalized through transparent and participatory
pre-legislative processes. There must be systematic platforms for citizens and affected communities to participate in the process by
which policies and schemes are designed in the health sector. Similarly, there must be mandated mechanisms by which people can
monitor and evaluate the performance of schemes rolled out in their names through institutionalized social audits of health programmes
facilitated by an independent social audit unit in every state.
11. GR mechanisms can be made effective through political and administrative will with legitimacy and commitment towards systemic
strengthening
GR mechanisms need political will for them to be effective. Such political will can provide them with legitimacy, through a comprehensive
legal framework like a Grievance Redress Law applicable to all public spending. Moreover, Government must dedicate at least 1% of the
budget of NHM towards rolling out practical interventions for greater transparency and accountability in its implementation. By securing
1% of programmatic funds towards this end, the administration can be assured of a better utilization of the 99% of the remaining funds.
In short, a grievance redressal mechanism is not a modular component that can be added on independently to a public system. While it
needs independent structures as discussed above, it needs to be clearly linked and embedded in the public system and be accompanied
by both political and administrative commitment to democratisation and accountability. Anything less than this will reduce grievance
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redress mechanisms into routine processes with little potential for improved governance.
The figure below follows a generic framework for a GR mechanism in the health sector with different components highlighted. This needs
to be adapted according to local context and needs.
Figure 6: A generic framework for a Grievance Redress mechanism in the health sector
Inter-sectoral Mechanisms
Face to face interaction
with higher authorities
Transparency &
Accountability
Confidentiality &
Protection
Registration
services
Service provider
Public
Grievances
Awareness
Programmes
Recognise & handle
as grievance
Registration of
grievances
Access
- Resources
- Geographical
- Communication
Infrastructure
Administrative and
Political commitment
Legal framework
Immediate response
Redressal
Systemic response
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Grievance Redressal Mechanisms for the health sector in India
CASE STUDIES OF MODELS
ON GRIEVANCE REDRESSAL
THE 104
HEALTH HELPLINE IN
TAMIL NADU
Introduction
The Government of Tamil Nadu has been running the health helpline which serves as a model for both information provision and for
receiving complaints and grievance redressals.
The Tamil Nadu government launched the health helpline in December 2013. According to senior health managers in the state, the need
for the helpline was felt as there were no avenues for real time grievance redressal for the public when accessing health care services in
the public sector. An online helpline that providing integrated health information while simultaneously facilitating resolution of grievances
was seen as a possible option. This was then modelled based on experiences with 104 helpline from Andhra Pradesh and Assam and
tailored to the needs of the state.
This helpline was launched to offer the following services:
1. Health advice: Free advice regarding ailments and first aid support. This is based on the algorithmic model for which
modules have been specially developed.
2. Health information: On various government facilities and specialities
3. Counselling: On health issues, including mental health
4. Serve as a grievance cell: Facilitate resolution of delays and deficiencies in service.
Structure
The operation of this helpline has been outsourced under a public private partnership mode to GVK EMRI. The Tamil Nadu Health Systems
Project offers technical support to operate the helpline.
The helpline is presently run as a 20-seat centre, 24X7 in three shifts. Different levels of service providers answer the calls as detailed
below.
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• Registration Officers: They are the first level contacts who receive the calls. They collect basic information regarding the
caller and identify his/her needs. They have a minimum qualification of 12th standard pass or graduate and are fluent in the
local language (Tamil). Each shift has six Registration officers.
• Health Advice Officers: They are qualified paramedics to whom the call gets forwarded if the caller seeks health advice
or information. In order to maintain uniformity and standards, they have been provided with standard algorithms that assist
them in the provision of information and advice. Each shift has six Health Advice officers.
• Medical Officer: There is one medical officer on duty on every shift to answer calls that the health advice officers are
unable to handle satisfactorily or need further support with.
• Counsellor: There are three counsellors on shift duty from 7 AM till 10 PM who answer calls on mental, adolescent and
sexual health. They are qualified psychologists.
• Service Improvement Officer: A service improvement officer functions from 8.30 AM till 3 PM to receive grievances and
facilitate their resolutions. He/She is an administrative officer retired from the government service in the health department
and with experience in the structure and functioning of the public health system.
In addition, a medical officer of the level of Block Medical Officer under the Directorate of Public Health has been deputed to the 104
call centre to oversee and provide technical support.
From the government’s side, a project officer under the Tamil Nadu Health Systems Project (TNHSP) and its Project Director oversee
the helpline and provide technical support.
Figure 7: The Flow of Information on 104 Health Helpline, Tamil Nadu
24X7 Functioning of 104 Health Helpline
Caller
104 Call Centre
Registration Officer
Health Advice
Officer
Counsellor
Service
Improvement Officer
Medical Officer
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Grievance Redressal Mechanisms for the health sector in India
Grievance redressal process
One of the core functions of the 104 helpline is to function as an online grievance redressal and resolution help centre. The primary
person in the team is the Service Improvement Officer (SIO).
• When a call is received regarding complaints on service delivery, it is forwarded to the SIO who speaks directly to the caller
and gets the details of the grievance.
• Based on the nature of the grievance, she/he then contacts the concerned authority with power to resolve the issue real
time. For example, if the issue is regarding services in a PHC, he calls the concerned Block Medical Officer, if the issue is
concerned with a taluk hospital, he calls the concerned Registered Medical Officer. To facilitate this, the government has
recently provided over 2,500 Closed User Group (CUG) mobile lines. (Reliance is the service provider).
• Depending on the feedback received from the concerned officials, she/he then contacts the caller again if necessary, to
provide feedback and also understand if the grievance has been resolved. The time frame for this varies and depends on the
nature of the issue and the time expected to resolve it.
• In case the grievance is still not resolved, the SIO escalates the call along with a pre-determined hierarchy based on the
nature of the complaint and the specific directorate it concerns. This system is still under development. A software that will
aid in this escalation in a time bound manner, has been developed and was being tested when the field visit was made.
• The SIO also forwards the reports of grievances received each day to the concerned Directors with a copy to TNHSP for
further action wherever necessary. Senior health managers in the state informed that they had attended to grievances
received through the 104 helpline to put in systemic changes.
According to the data available with 104 helpline, a total of 2,866 calls on grievances were received till December 2015. Of these, 80-
90% calls were resolved within 24 hours according to the 104 helpline officers.
The calls received range over a variety of issues including delays in service provision at particular health facilities, unavailability of staff
including doctors, rude behaviour of health care staff to patients, perceived poor quality of care and delay in receiving benefits under
the government schemes like the Maternity Benefit Scheme. Some calls were on the issues that are allied to health but are beyond the
purview of the health department like mosquito control and pig menace.
The health helpline does not entertain grievances on services in the private sector as this is seen as beyond their purview.
Learnings and challenges
1. The Tamil Nadu model is an important example of how a functional health system can be effective in providing immediate
response and also in learning from grievances and instituting systemic correction.
2. The helpline also highlights the need for allied sectors to be involved or interconnected with the GR mechanism so as to
provide redress to broader issues related to health.
3. The model receives legitimacy for administrative sanction even though some states opposed to sanction legislative legitimacy.
This could prove a barrier to the sustainability of the GR mechanism if political commitment wanes.
4. One of the operational challenges has been the high rate of attrition of call centre employees and therefore, the need for
repeated trainings/orientations.
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GRIEVANCE REDRESSAL
COMMITTEES IN
AMRAVATI DISRICT,
MAHARASHTRA
Introduction
The Community Based Monitoring and Planning (CBMP) programme is being implemented in Maharashtra since 2007. One of the
outcomes of this process has been the realisation that with increased awareness of rights, there is a need for a grievance redress
mechanism to address issues and grievances arising both from citizens and the monitoring process. It has been understood that while
social and community accountability mechanisms are important to bring in systemic change and ensure accountability, they need to be
complemented by a robust grievance redressal mechanism that will respond to and redress individuals’ experiences of gaps in service.
Thus, block and district level grievance redress committees were piloted in selected districts.
The community based monitoring and planning programme in Maharashtra has been facilitated at the state, district and block levels
by civil society organisations led by Support for Advocacy and Training to Health Initiatives (SATHI). These civil society groups have also
facilitated the formation of grievance redressal committees with the aim of taking forward the processes under this programme and
institutionalising community participation within the health sector. The GR mechanism, while distinct from the community accountability
mechanism under the NHM, acts complementary to it. One such example of a GR mechanism is in Dharani block in Melghat region of
Amravati district, which was studied as part of this monograph. The Dharani block is having more than 75% of the tribal population and
historically it lags behind with poor socio-economic health indicators. Many villages in the block are far flung with poor road connectivity
and are inaccessible during the rainy season. Communication facilities are poor. Earlier, Melghat had been in focus for its high infant
and child mortality.
Structure
The block level Takrar Nivaran Samiti (Grievance Redress Committee) in Dharani block, Amravati district, was formed in 2015 as part
of efforts to institutionalise support structures for the community action programme and makes it sustainable. The membership of
the committee consists of multiple stakeholders - the Taluk Health Officer, the Medical Superintendent of the Sub-district Hospital, a
representative from the ICDS programme, the Sabhapati of the Panchayat Samiti, and representatives from both civil society and the
media.
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Grievance Redressal Mechanisms for the health sector in India
Its formation and facilitation has been done by different civil society organisations involved in the community action programme at the
state, district and block levels.
In addition, in order to address inter-sectoral issues related to health, a Mahasangh has been set up in the block, consisting of various
civil society organisations working on health and allied issues including Public Distribution System (PDS), education and MGNREGA.
While this is an independent effort by the local civil society organisation outside the purview of the NHM, it is an effort to make inter-
sectoral action possible.
Process
The Takrar Nivaran Samiti meets once every three to four months to discuss and address grievances. It receives grievances from both
the community and health care providers while also taking cognizance of issues arising out of the community monitoring process. Thus,
the registering of a grievance in this model is much more informal when compared to helplines run in other states and can be done
through social networks of citizens, elected representatives and civil society. However, the support and facilitation provided by local civil
society organisations that are rights based, and the long history of engagement with community action processes has ensured that rights
awareness has been imbibed by the citizens and fostered by the CSO, making possible the framing of a gap as a grievance.
Once a grievance is received, it is discussed by the committee at its regular meeting. The presence of different stakeholders in the
committee helps resolution of issues during discussions. The committee also takes up issues that need immediate response by involving
different members of the committee depending on the nature of the issue.
Health care providers also often reach out to the committee for help with issues that involve promoting community awareness to seek
health care. The committee members provide support to the providers. Examples of these have been discussed in previous chapters.
However, since there is no grievance redressal committee presently at the district or state level, issues that need resolution at these
higher levels, for example, staff recruitment or postings, cannot be resolved by this grievance redress committee. Also, apart from the
Mahasangh which is a civil society space, there is no linkage formally with other sectors, leading to gaps in intersectoral response.
Learnings and challenges
1. The Maharashtra GR committee highlights the potential role a multi stakeholder committee can play in providing redress.
The presence of health care providers in the committee ensures immediate engagement of the health care system, while
civil society members and elected representatives on the committee help to provide support and oversight.
2. At present, as the GR committee is only at the block level, its function is limited to block level issues, and it is unable to
address issues that need state level resolutions.
3. The presence of independent persons from outside of the health system in the committee provides it with a potential to be
a third party resolution mechanism for the stage of redress.
4. The concept of an inter-sectoral GR space like the Mahasangh has the potential to address broader issues related to health,
which needs to be explored further.
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THE CHIEF MINISTER
HELPLINE IN
MADHYA PRADESH
Introduction
The Madhya Pradesh state government has put in several innovations in e-governance in the last few years. Of these, the CM helpline
is meant to be a grievance redressal mechanism for the entire state.
The CM helpline was launched in July 2014. It is designed as a one-stop helpline where a citizen can lodge a complaint related to any
of the government departments.
The helpline offers the following functions:
1. Provides information on over 400 government schemes across 56 departments
2. Registers complaints
3. Provides a platform for citizens’ suggestions
Structure
The operation of this helpline has been outsourced under a public private partnership mode to Surevin, a Business Process Outsourcing
(BPO) company selected through a tendering process. An officer of the grade of Under Secretary has been appointed as the Director of
the helpline.
The helpline is run through a call centre that has been provided a toll free number, 181, and is functional every day from 7 AM to 11 PM.
The BPO has appointed call centre operators who are conversant in the local language and its different dialects. They have also received
training on the different schemes covered by the helpline and the functions of the different state government departments. One of the
key features of the system is that it is completely paperless.
For launching the helpline, a mapping of officers in each department was done. The officers have been graded as belonging to different
levels to facilitate addressing grievances in a hierarchical fashion. In addition, nodal officers have been appointed in each department to
monitor the redress of grievances concerned with that department.
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Grievance Redressal Mechanisms for the health sector in India
Figure 8 : Structures of the Chief Minister Helpline, Madhya Pradesh
Process Re-engineering
Level 1
(Block Level Officers)
Level 2
(District Level Officers)
Level 3
(Division Level Officers)
Level 4
(State Level Officers)
The grievance redress process has been brought under the ambit of the Public Service Guarantee Act, 2010 that provides a legislative
framework for the process.
Process
The grievance redress process of the helpline is through the following steps:
1. First, the call is received from the aggrieved citizen at the call centre by the operator. It is then registered under predefined
categories, classified as pertaining to a particular department and a specified geographic area and forwarded to the
concerned Level 1 officer as already mapped under the system.
2. The Level 1 officer is expected to take action to resolve the grievance within seven days. He/she can then log on to the
system either through the website or through a mobile phone to register the action taken to resolve the grievance.
3. Once this is received from the officer concerned, the call centre calls up the concerned citizen, explains the action taken
and enquires if the citizen is satisfied. If the citizen affirms that he/she is indeed satisfied, then the complaint is treated as
marked and closed.
4. Under the following two circumstances, the complaint automatically escalates up to the next level officer, and cyclically all
the way up to Level 4.
i. If the lower level officer does not resolve the complaint within seven days, or
ii. If the complainant expresses dissatisfaction with the resolution offered.
5. There is a provision for special closure of a complaint even if the complainant is not satisfied by a level 3 or 4 officers, or if
the complaint is deemed to be frivolous or invalid.
The helpline is monitored at the ministerial level. The government’s commitment to the programme at the highest level is marked by
the Chief Minister who himself randomly calls any 5 complainants every day and checks their satisfaction with the resolution offered.
The BPO managing the helpline also prepares a block/ district/ department wise analysis of the numbers and types of complaints
received and presents this analysis at the departmental meetings periodically. This helps data analysis at different levels and has the
potential to feed into programme planning.
The system also offers transparency in the process of complaint resolution. The status of any complaint is available in the public domain
and can be traced out on the helpline’s website through a unique ID provided to each complainant.
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Figure 9: The Processes in the Chief Minister Helpline, Madhya Pradesh
Operator asks for caller’s
basic details and registers his
complaint/provides information
Call Centre
Operator
Call centre Operator
notifies the Level 1 Officer
about the complaint
through a call and a SMS
Citizen dials 181
and tells about his
problem/seeks
information
If the caller is
satisfied then the
case is closed
Operator calls the citizen
and tells him about the ac-
tions taken by the officer
Level 1 Officer
There are two ways of
disposing a case
Level 1 Officer may
dispose a case through
CM helpline Portal
In this case complaint
is partially closed
Level 1 Officer may either
call 18002330183
Call Centre Operator
notifies the Level 1 Officer
about the complaint
through a call and an SMS
alert
Level 1 Officer
has 7 days time
to dispose a
case 1
In case of any
of the given 2
conditions
Case is escalated
to Level 2 Officer
2 Level 2 officer has 7 days
time to dispose a case
There are three cases
in which a complaint moves to the
next level officer.
1. If the officer doesn’t dispose a
case within 7 days
2. If the citizen is not satisfied by
the actions taken/reply given by
the officer
3
In case if any of these
three conditions
reoccur
Case is escalated to
Level 3 Officer
Level 4 Officer has 7 4
days time to dispose
a case
In case of reoccurrence of any
of these two conditions, case is
escalated to Level 4 Officer
Level 3 Officer has 7
days time to dispose
a case
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Key features of the CM helpline
1. Simple one call for Grievance Redressal – paperless system
2. Responsibility assigned as per the hierarchy for an accurate closure of grievances
3. Accurate analysis possible based on demographic issues and complaint data, and it’s actionable
4. Potential of the data to be used for programme planning
5. Timely resolution of complaint due to the automatic escalation system
6. Assessment of good governance based on citizen satisfaction
Learnings and challenges
1. It covers all departments, thus has potential for facilitating inter-sectoral action.
2. Enacting of legislation to provide public services with legitimacy. This results in institutionalisation of the grievance redress
mechanism making it more sustainable.
3. One of the key challenges of the health system is that it is nested within a system that is not well functional. Though, it is
good at resolving issues like that of procedural lapses, it does not seem capable of real time redress in its
present status.
4. The lack of a well functioning health system also results in no systemic improvement.
5. Geographic synchronization among all departments is a challenge.
6. Internet penetration in tribal districts is low.
7. Quantum training of officers within a short span of period affects quality.
8. Department wise officers mapping and updation is a tedious process.
9. Department wise uniform complaints bifurcation and their movement seem to be difficult.
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GRIEVANCE REDRESSAL
THROUGH SOCIAL
AUDIT OF THE MGNREGA
IN ANDHRA PRADESH AND
TELANGANA
Introduction
The erstwhile Andhra Pradesh (now Andhra Pradesh and Telangana) government had institutionalised a process of social audit of the
MGNREGA over the past several years. This has served as a model for up-scaling of community monitoring in the development sector.
Though it is not related to the health sector, it was decided to study this model as well and learn from it on how grievance redressal can
happen within social sector programmes.
The Andhra Pradesh government set up the Society for Social Audit, Accountability and Transparency (SSAAT) as an independent
society under the Department of Rural Development to conduct social audits of the Mahatma Gandhi National Rural Employment
Guarantee Scheme (MGNREGS) in 2009. More recently, SSAAT has also been conducting social audits of welfare schemes of other
departments within the Government of Andhra Pradesh and Telangana including the Social Security Pension (SSP), Integrated Watershed
Management Programme (IWMP) and the Aam Admi Bima Yojana (AABY). Currently, the eighth round of social audit of the MGNREGS
has been completed.
Structure
SSAAT has a unique structure of being a public sector society but being headed and staffed by persons belonging to civil society. For
example, the present Director of SSAAT has a history of long association with various people’s movements. The Deputy Director of SSAAT
is a government administrative service officer.
SSAAT has also kept its overheads low by having one centralised office in Hyderabad and no district offices. The organogram of SSAAT
is given below:
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Figure 10: The Society for Social Audit, Accountability and Transparency Organogram, Andhra Pradesh
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In addition to the staff at the central office, there are staff who conduct the actual social audits. They include State Team Monitors (STMs),
State Resource Persons (SRPs), District Resource Persons (DRPs) and Village Social Auditors (VSAs). Of these, the Village Social Auditors
work for honorarium while the rest are salaried employees of SSAAT.
SSAAT also has assured funding from the government – 1% of the MGNREGA budget is earmarked for SSAAT.
Process
The social audit of MGNREGA conducted by SSAAT, has multiple well defined step-wise processes:
Preparatory processes
1. Social audits are conducted in various blocks and districts of the state based on a pre- determined schedule. Intimation
letters are sent out to each of these blocks regarding the dates of the social audit.
2. On the dates of the social audit, the social audit team consisting of SRPs and DRPs, reaches the mandal (block) and meets
with various officials and PRIs like the Sarpanch to familiarise them with the process of the social audit. They also ask the
officials to get together all the relevant records for verification.
3. In the field, volunteers from the same mandal are identified to play the role of VSAs. The criteria for selection of VSAs
include: must be class 8 pass, and not belong to the family of the sarpanch, ASHA etc. The VSAs as a norm, hail from the
first generation of landless and marginal farmers. They undergo a two-day training facilitated by the DRPs at the mandal
level.
4. Following this, a couple of days are spent at the mandal office to verify the available records. A minimum of 75% of the
records need to be provided to the social audit teams for the audit process to start. If this is not provided, the concerned
officer can be penalised.
5. A coordination and review meeting is held on the fifth day following which the teams move to each of their allotted Gram
Panchayats. VSAs who are from the same mandal are part of the team that verifies records in a village that is not their own.
Social audit processes
6. At the Gram Panchayat, the teams do a house-to-house verification in each hamlet and village of MGNREGA records and
tally the entries on job cards with those of attendance, payment, work completed etc. Worksite verification is also done to
ensure that the said work has actually been completed. This whole process takes four to five days.
7. The teams have very strict rules of conduct to be followed during their stay in the village. They have to stay in a
government building and not in any individual’s house, they have food from the house of a person belonging to a
marginalised group and should pay for it, no alcohol is allowed etc.
8. On the fifth day, a Gram Sabha is held where a report on the audit is presented. This report is based on a pre-defined
format that lists out general information, non financial information, grievances, procedural lapses and
financial deviations.
9. The Gram Sabha meeting is minuted by the Village Secretary. Government officials are deputed to attend these Gram
Sabhas as independent observers. The Field Assistant (FA) of the MGNREGA is expected to respond any queries at the
Gram Sabha. Some issues get clarified at this stage itself which are recorded in the minutes.
10. Subsequently, at the mandal level, a public hearing is held. At this, a Decision Taken Format (DTF) is presented Gram
Panchayat wise and is also given to the Project Director (PD) of MGNREGA who chairs the public hearing. It is also
attended by the Assistant Project Director, District Vigilance Officer (DVO), Mandal Parishad Development Officer, Sub
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Divisional Magistrate, FAs, Sarpanch and Village Secretaries.
11. As the DTF is presented, the PD takes spot decisions on most issues and fills them on the DTF. These decisions are
forwarded to the DVO who then acts on them in a time bound manner.
12. Issues that cannot be resolved at this level are submitted to the Commissioner of Rural development by SSAAT.
13. At the public hearing, the DVO also presents a report of the previous public hearing and an update on actions taken.
In addition to the regular auditing as above of MGNREGA, SSAAT also conducts periodic special audits of other programmes based
on requests from the state government.
Learnings and challenges
1. The Andhra Pradesh programme is an important example of institutionalisation of a right based monitoring and redressal
mechanism within a large government programme. The mainstreaming of the programme and the political and bureaucratic
will that have made it possible, are key learnings.
2. The programme also exemplifies how community participation and ownership of the whole process make it rights based
and community centred.
3. It also showcases how transparency can be integrated into every aspect of a programme and can act as a means to ensure
good governance.
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GRIEVANCE REDRESSAL
MECHANISM FOR ASHA
IN ODISHA
Introduction
The National Rural Health Mission envisioned universal access to health, with a strong focus on community involvement. This was to
enhance the people’s participation in health and enable action on its various social determinants. ASHA and Village Health Sanitation
and Nutrition Committees have been the key instruments for achieving this goal. The ASHA programme has evolved and made progress
in significant ways since its inception.
ASHAs are undertaking a wide range of activities which include counselling on improved health practices, motivating married couples
to ensure birth spacing, prevention of illness and complications and appropriate curative care or referrals for pregnant women,
newborn, young children as also for malaria, tuberculosis and other conditions1. After Chhattisgarh, Odisha is the only state that
has a robust ASHA support structure in place. The state has been able to demonstrate that continuous handholding and mentoring
to the service providers and strong political will to strengthen the system, leads to a responsive and pro-people programme delivery.
Considering the above, the state was chosen to study the ASHA grievance redressal system, which is yet to mature in other states.
ASHAs are contributing significantly to improve the public health scenario, acting as an interface between the community and the
public health care system. A well functioning ASHA thereby contributes to better health outcomes. However, they also face many
issues and difficulties in delivering their services. In view of this, the Grievance Redressal Mechanism was set up initially in each
district to identify and resolve the issues and difficulties of ASHAs. Often it was not possible for an ASHA to tender her grievance
to the district committee. A grievance redressal mechanism for ASHAs at various levels was therefore, required and established.
Objective
The objective of the grievance redressal procedure is to provide an easily accessible system to ASHAs for settlement
of their grievances. And also, to adopt measures in the health system and at the community level leading to their
increased job satisfaction resulting in improved productivity and efficiency of the ASHAs and of the health system.
1 http://www.mohfw.nic.in/WriteReadData/l892s/Chapter1015.pdf
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Figure 11: Structure of the Grievance Redress Mechanism for ASHAs in Odisha
Community Processes Resource Centre
District level ASHA
Grievance Redressal Committee
Block level ASHA
Grievance Redressal Committee
Sector Meeting
ASHA Facilitator
ASHAs
Process
The procedures followed for addressing grievances of ASHAs start with the ASHA facilitator.
The ASHA facilitator: The ASHA facilitator is the first person in direct contact with the ASHAs. She is placed from among the ASHAs in
the structure as a mentor to support them in their day-to-day work. The ASHA facilitator mentors around 20 -30 ASHAs in her area. The
ASHAs approach her to seek support in weak areas, as well as for advice and redressal of any grievance they may face. The issues that
are beyond the scope of the ASHA facilitator, or are common to many ASHAs in the region, are raised at the sector-level meeting. These
issues generally relate to incentives or supply of ASHA kits, drugs etc.
Sector Meeting
l The designated nodal person known as Sector-in-Charge conducts the monthly sector meeting for ASHAs.
l The meeting is a forum for addressing grievances of ASHAs as a group at the sector level.
l A structured format is used for noting the grievances and subsequently submitted to the block health administration on a
monthly basis. Copies of the same are kept with the sector-in-change for reference and follow up.
l The grievances which are beyond the capacity of the block health administration are either submitted to the District Planning
and Monitoring Unit (DPMU) or the sector-in-charge.
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l A register is maintained at every level which has details of the grievance, date of submission or reporting, date of the
meeting of the grievance redressal committee and resolution of the grievance.
l Most of the grievances especially related to supplies like the home based newborn care kit, drugs, and uniforms, are noted
at the sector level and shared with higher level, which is the block, by the sector-in-charge.
ASHA Grievance Redressal Committee at the block level
The Block ASHA Grievance Redressal Committee is constituted with the following members:
l Block Medical Officer – Chairperson
l Block Programme Manager – Convenor
l Block Data/CP Manager – Facilitator
l One government representative from the non-health sector i.e. Women and Child Development/ICDS/
Rural Development/PRI/Education
l One representative from non-governmental agencies
l One invitee sector-in-charge of the block on a rotation basis
l One invitee ASHA SATHI of the block on a rotation basis
At least two of the five members would be women in leadership position.
Role of the Committee
l The Block Programme Management Unit (BPMU) acts as the block-level ASHA Grievance Redressal Committee.
l It has a landline phone number and PO Box number, both of which are publicised and displayed at the Sub Centre, Sector,
PHC and CHC levels.
l The jurisdiction of the committee is limited to the respective block and its working hours are concomitant with that of the
office hours of the BPMU.
l The Committee maintains a register of grievances which includes the name of the ASHA, date of receipt of the grievance,
details of grievance and redressal.
l As per the guidelines, the complaint that is registered telephonically needs to be submitted in writing with relevant
documents attached for the committee to act on it. A signed receipt of the complaint should be provided to the complainant.
l The committee meets on a monthly basis to discuss on the grievances redressed by the ASHA SATHI & Sector-in-charge and
discusses the cases which are still unresolved.
l The chairperson of the committee assigns the task of an officer who takes action on the grievance and also maintains an
action taken report.
l A grievance is forwarded to the District ASHA Grievance Redressal Committee, if it is beyond the Block administration to
resolve it. Further, if the ASHA is not satisfied with the decision taken by the block level committee on her grievance, she may
appeal to the chairperson of the District ASHA Grievance Redressal Committee or the Zilla Swasthya Samiti or Collector’s
Grievance Committee.
l A monthly report with details of grievances addressed by the Block ASHA Grievance Redressal Committee is communicated
to the District ASHA Grievance Redressal Committee by the concerned BPMU.
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ASHA Grievance Redressal Committee at the district level
The District ASHA Grievance Redressal Committee is constituted with the following members:
l District Collector / Chief District Medical Officer (CDMO)-cum-District Mission Director is the Chairperson
l One nominee of the CDMO is designated as Secretary of the Committee.
l District Programme Manager (DPM) acts as the Convenor and the Assistant Manager ASHA of the district is the facilitator of
the committee.
l Two representatives are from the non-health government sector (WCD, ICDS, Education, RD & PRI)
l Two representatives are from non-governmental agencies, of which one is from an academic institution.
l One invitee (Block Medical Officer) on a rotation basis.
At least three out of five selected members would be women in leadership positions or from within academic institutions.
Role of the Committee
l The District Programme Management Unit acts as the District ASHA Grievance Redressal Committee with a functioning
landline phone number and P.O Box number both of which are widely publicised and displayed at the Sub Centre, Sector,
Primary Health Centre, Community Health Centre & District Hospital.
l The committee meets once a month to discuss the grievances addressed by the ASHA SATHI, communicated by the BPMU
or directly through ASHA.
l If the committee feels that the grievance is beyond its control, it may be forwarded to the Mission Directorate, NHM or the
State Health Society. Further, if the ASHA is not satisfied with the decision taken by the district committee on her grievance,
she can appeal to the Collector’s Grievance or Mission Directorate, NHM or State Health Society.
l The Secretary writes to the concerned officer who is required to take action on the grievance. A reply has to be sent within
21 days to the complainant. A written documentation of the action taken report is also to be maintained and certified by the
members of the committee. If the officer denies the substance of the complaint, which is also to be recorded.
l It is the duty of Assistant Manager ASHA to give a report on the details of grievances redressed by the District ASHA
Grievance Redressal Committee to the Mission Directorate, NHM Odisha on a monthly basis.
With the strong system in place and continuous supportive supervision from the state, the grievances are resolved on a monthly
basis. The issues that require intervention at higher levels are also followed up and the entire process well documented at each level
of intervention. The grievances submitted in writing relate to supplies or incentives. There are no documented grievances related to
personal issues. The grievances that are common to a large number of ASHAs are raised through the ASHA Association formed in the
state.
Learnings and challenges
l Continuous supportive supervision greatly helps in strengthening the system and bringing accountability and ownership of
the service providers as well as the community.
l The system needs to build mechanisms to ensure confidentiality and safeguard the complainant with regard to personal
grievances.
l The ambit can be increased to seek inputs/feedback from the community regarding the functioning of health facilities and
outreach services.
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JAWAABDEHI YATRA
IN RAJASTHAN
Introduction
Beginning on December 1, 2015, a 100-day long “Jawaabdehi Yatra” travelled to each one of the 33 districts in the State of Rajasthan.
The Yatra was undertaken by approximately 80 people in a large bus, accompanied by a van called the ‘RTI on Wheels’. The Yatra was
organised by the Soochna Evam Rozgaar Abhiyaan (SR Abhiyaan) consisting of volunteers from around 150 organisations.
Objective
The Yatra was conducted with the objective of informing citizens of their rights and entitlements and facilitating them in registering
grievances being faced by them in accessing basic services and tracking the progress of the same.
Structure and process
The Yatra spent an average of three days in each district with nukkad sabhas, block level meetings, seminars and workshops, RTI and
accountability clinics, street theatre, songs, distribution of pamphlets, grievance redress camps and melas, followed by discussions and
meetings with the administration in every district.
While travelling through the districts, the Yatra identified accountability related issues, particularly in areas of education, health, NREGA,
ration, pensions, human rights, mining, silicosis, environment, Dalit, minority, gender, issues of artisans and nomadic communities, tribal
communities, The Forest Rights Act, PESA, and provided a platform for people to articulate suggested measures that can be taken up
in these sectors for enhancing accountability.
During the course of the Yatra, a total of 9,297 grievances were lodged by people facing difficulties in accessing their entitlements/
basic services. The largest number of grievances registered was with the Food and Civil Supply Department- a total of 2,911 grievances
(almost 30% of the total number of complaints). The second one was with the Social Justice and Empowerment – 1,626 complaints.
Grievances were collected through grievance camps that were organised on the last day of the time spent in any district. Grievances
were registered on the “Sampark Portal”, which is the Rajasthan State Government’s mechanism for grievance redressal. It is a single
window online portal where a person can register his or her grievance. Each complaint gets a receipt number that can be used online
to track the progress on action taken on the complaint. The Jawaabdehi Yatra decided to utilize this available platform, and requested a
separate account whereby it could register a large number of complaints with the Sampark Portal and track them together. The Digital
Empowerment Foundation (DEF) is continuously tracking the grievances. By April 11, 2016, out of the 9,267 grievances registered with
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the Yatra, 5,939 had been uploaded on the portal, and 2,925 were disposed off by the Government.
An Accountability Mela was organised in each district headquarters where the pending issues and grievances of the people were
brought to the attention of the administration. Subsequent to the ‘Accountability Mela’, a delegation from the Yatra met with a team
of district level officers, including the District Collector to highlight grievances being faced by the people of the district. These include
the following:
a. Rations: Names being left off the National Food Security Act (NFSA) list, failure to deliver rations through the Point of Sale (POS)
machines causing exclusion and allowing for new modes of corruption, lack of transparency regarding those eligible for rations under
the NFSA. Based on the learnings that emanated from the Yatra, the delegation suggested that the appeal process be made simpler for
those left off the NFSA list; and those who satisfy the criteria of automatic inclusion be immediately added to the list; take feedback by
the Administration from the people on the working of (POS) machines; list of beneficiary names under the NFSA be printed and put up
in the ration shops.
b. Pensions: People were unaware that an account has been opened in his/her name beacuse of corruption and inefficiency of the
Business Correspondents (BC) system. Based on the learnings that emanated from the Yatra, the delegation suggested that the banks
create an MIS system so that people aware of when money comes in, and when money is taken out; that a day be fixed for pension
payments by BC so that the elderly do not have to travel multiple times, and if paid, be paid in a group, it would hence, be difficult for
the B.C to take advantage.
c. Education: It was observed in the school that there were vacant positions for subject teachers, lack of playgrounds, non-functional
toilets due to lack of regular water supply, and poorly maintained records. The Yatra requested figures on each of these issues from the
Education Department of all the districts.
A survey of different state institutions i.e. Community Health Centres (CHCs), Primary Health Centres (PHCs), Schools, Anganwadis, Atal
Seva Kendras (ASKs), Public Distribution System and Fair Price Shops was conducted with a view to understand the effectiveness of the
service delivery system. The main findings that emanated were:
a. Health: The survey team visited 20 CHCs and 14 PHCs in selected districts. It was found that each centre fell short of basic health
services that they are supposed to provide, and lack of experience in the provision of diagnostic and curative services. There were
shortage of staff, infrastructural gaps, non functional operating theatres, pathology labs, labour wards and ambulances.
b. Education: The survey team visited 44 schools in 12 districts. More than 70% of senior secondary schools surveyed which lacked
subject teachers. Toilets have been built in most schools, but are not functional because of a lack of constant water supply, and many
schools were found to lack of a playground.
c. Fair Price Shops: Since the passing of the Food Security Act, 2013, a large number of people who were beneficiaries before, have
been dropped from the list for no explicable reasons. The survey team found that no shops had a list of eligible recipients on display.
d. Anganwadi Centers: The survey team visited 23 Anganwadi Centres, most of which lacked basic facilities like drinking water
and toilets. It was found that the AWCs do not open regularly, or on time. The Anganwadi workers were largely ignorant of women’s
group responsible for the preparation of supplementary nutrition, take home rations (THR). Few children were seen at the AWCs during
working hours.
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Learnings and way forward
The Yatra presented the draft Accountability Bill for discussions, considerations, and advocacy to people and the administration, as a
means of building a comprehensive legal framework of accountability of public officials and government to the people of the state. The
Bill advocates for institutionalizing citizens’ charters for every public department, job chart for public officials, time bound grievance
redress norms, an independent appellate process for grievance redress, right of citizens to be heard in public collective platforms,
transparency and participation in the pre-legislative process and social audits for monitoring public spending. Access to information like
the RTI, this bill aims to turn the accountability of public officials from their seniors towards the people. The SR Abhiyan is advocating for
the passage of the Draft Accountability Bill in Rajasthan. In addition, the campaign continues to present the issues of accountability in
the implementation of public programmes. It also directs its efforts towards strengthening local decentralized mechanisms to promote
better transparency and accountability.
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ANNEXURE 1
Department of Administrative Reforms and Public Grievances
Guidelines for Public Grievance Redress
The Department of Administrative Reforms and Public Grievances (DARPG) is the nodal agency for policy making on public grievances.
The Department has issued the following important guidelines to all Ministries/ Departments of the Central Government for handling
grievance redress and to strengthen the grievance redress machinery to make the administration more responsive to the needs of the
people. In order to achieve this, all Ministries and Departments are required to:
l Designate a senior officer as Director of Public Grievances/Grievance officer in every office including all organizations under them.
l Observe every Wednesday as a meeting-less day in the Central Secretariat offices when Director of Public Grievances should be
available at their desks from 1000 hrs to 1300 hrs to receive and hear public grievances. Field level officers having contact with the
public, have also to declare one day in the week as a meeting-less day.
l Deal with every grievance in a fair, objective and righteous manner.
l Analyse public grievances received to help identification of the grievance prone areas in which modification of policies and procedures
could be undertaken with a view to making the delivery of services easier and more expeditious.
l Issue booklets/pamphlets on the schemes/services available to the public indicating the procedure and manner in which these can
be availed and the right authority to be contacted for services.
l Pick up grievances appearing in newspaper columns which relate to them and take remedial action on them in a time bound manner.
l Strengthen the machinery for Redress of Public Grievances through strictly observing meeting-less day on every Wednesday displaying
name, designation, room number, telephone number etc. of Director of Grievances at the reception and other convenient places, placing
a locked complaint box at reception, and giving more publicity about the grievance redress machinery.
l Set up Staff Grievance Redress Machinery and designate a Staff Grievance Redress Officer.
l Include the Public Grievances work and receipt/disposal statistics relating to redress of public grievances in the Annual Action Plan
and Annual Administrative Report of ministries.
l Fix time limits for disposal of work relating to public grievances and staff grievances and strictly adhere time limits.
l Inform complainants the name, designation and office telephone number of the official who is processing the case. The time frame
in which a final reply will be sent should also be indicated.
l Constitute Lok Adalats/Staff Adalats, if not already constituted, and hold them every quarter for quicker disposal of public as well as
staff grievances and pensioners’ grievances.
l Constitute a Social Audit Panel or such other machinery, if not already constituted, for examining areas of public interface with a view
to recommending essential changes in procedure in order to make the organization more people-friendly.
l Establish a single window system at points of public contact, wherever possible, to facilitate disposal of applications.
l Notify MTNL separately about directory entries pertaining to Public Grievance Redress Officers.
l Issue a reasoned and a speaking reply for every grievance rejected.
l Quarterly progress reports regarding the receipt and disposal of grievances in the Ministry/ Department and organizations under it
which should be monitored by the Joint Secretary/Director (Public Grievances) every month.
l Each Ministry/Department should prepare a consolidated directory of officers holding public/ staff grievances responsibility.
l Should give wide publicity of Director (PG) through Citizens’ Charters, broadcast of audio-visual capsules, sports and websites.
l Focus attention on analysis of public grievances to identify the grievance-prone areas and implement systemic changes to reduce
grievances.
l Brochures/Pamphlets prepared by various Ministries/Departments and their subordinate/ autonomous agencies may be kept at
accessible contact points including railway stations and bus stands.
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l Citizens’ level of satisfaction should be measured on a regular basis.
l In order to make the grievance redress mechanism more effective, the following steps need to be taken:
i. Careful analysis of grievances.
ii. Decision on grievances to be taken at a fairly senior level.
iii. Forwarding the grievances to the departments concerned for prompt redress.
iv. Reply to complainant informing details of authorities setting grievances.
v. Obtaining reply/report from the departments concerned.
vi. A reasoned reply to the complainant, if a grievance cannot be settled.
l Place Citizen’s Charters of Ministry/Department and organisations under them on the website.
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National Rural Health Mission-Meeting people’s health needs in rural areas. Framework for Implementation 2005-2012.
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Potts H. Accountability and the right to the highest attainable standard of health. Human Rights Centre, university of Essex,
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Murthy RK, Klugman B. Service accountability and community participation in the context of health sector reforms in Asia:
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George A. using Accountability to Improve Reproductive Health Care. Reproductive Health Matters. 2003;11(21):161–70.
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Ministry of Health and Family Welfare, Government of India. 6th Common review mission report 2012. New Delhi.
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Ministry of Health and Family Welfare, Government of India. 8th Common review mission report 2014. New Delhi.
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High Level Expert Group Report on universal Health Coverage for India. Planning Commission of India, 2011, New Delhi.
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Robinson, Nick, Closing the Implementation Gap: Grievance Redress and India’s Social Welfare Programs (August 19,
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Huss, R., Green, A., Sudarshan, H., Karpagam, S. S., Ramani, K. V., Tomson, G., Gerein, N. (2010). Good governance and
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