Significant improvements presented, major unresolved health system issues raised.
by Abhay Shukla
Community based monitoring of health services, a process for health system accountability being implemented with support from National Rural Health Mission, completed five years in June 2012. As part of this process in Maharashtra, a State Level Culmination and Review programme in the nature of a ‘State level Jan Sunwai’ was organized on 3rd July 2012 at Arogya Bhavan, Mumbai. During this workshop over 160 participants including elected Panchayat representatives, Public Health officials from State, District and block levels and Public health functionaries, Public health experts belonging to the State mentoring committee and representatives of facilitating NGOs and CBOs contributed. The focus was on discussing and resolving health services related issues in CBM pilot districts Amaravati, Nandurbar, Osmanabad, Pune and Thane, from where most of the participants had come. During the programme, the wide range of improvements in frontline health services induced by the community monitoring process were shared, along with the range of key unresolved health issues. These were shared by PRI members from village, Panchayat samiti and Zilla parishad levels from various districts, whose active participation was notable. During the programme members of the newly formed State monitoring and planning committee, MLAs Dr. Anil Bonde and Dr. Namdev Usendi shared their suggestions and inputs.
Speaking during the programme Dr. Bonde (Independent MLA and medical doctor from Amaravati) said “Medical officers and health staff should understand that the community monitoring process is not to oppose them but rather, to improve services. Hence we should cooperate with and support this process.”
On this occasion a booklet with compilation of 35 stories of positive change due to community based monitoring titled “Footsteps paving the path of change” was released. Several Zilla Parishad and Panchayat Samiti members from various districts and across the political spectrum recounted how the community monitoring process has helped to improve health services in their area. This included reporting of significant increase in deliveries taking place in public health facilities; most patients in community monitoring areas no longer being asked to buy medicines from outside the facility, greater popular involvement in planning for use of untied funds, and definite improvement in behavior of health staff towards patients. In this context, eighteen health officials and public health employees who have actively participated in the community monitoring process, and have ensured significant improvements in health services in their areas across five districts were felicitated.
From each district, civil society activists and PRI members presented key issues which have remained unresolved despite being raised through the CBM process, and District officials (District Health Officer and Civil Surgeon) were asked to respond. Lack of specialist services in CHCs of Amaravati, illegal charging of patients for abortions and cesarean operations in Pune, centralised and problematic expenditure of RKS funds for facilities across the district in Nandurbar, ANMs not staying in their sub-centre villages in Osmanabad and poor quality of construction of health facilities in Thane were among the many issues presented. The problematic decision by NRHM to deny village untied funds (Rs. 10,000 per village) to 73 forest villages in Nandurbar on technical grounds was unanimously and strongly critiqued. To resolve many of these issues, decisions were taken or suggestions were given, which will need to be followed up further within districts. Further common and cross cutting major issues such as shortages of medicine supply, vacant posts of medical officers and staff, poor quality of construction of health facilities in several places, and need for reallocation of villages vis-à-vis public health facilities were also strongly raised. It was emphasized that these issues will need to be dealt with at policy level by the State health department.
Taking into account the discussion, Director of Health Services Dr. Archana Patil said “Community monitoring and the Health department have the same objectives of improving public health services. We are committed to addressing the issues being pointed out during this process”. It was decided that a state level meeting with participation of civil society organizations, for further detailed discussion on the key systemic issues emerging in the CBM process would be organized in the last week of July, and necessary decisions to address issues would be taken.
The civil society organizations participating in the programme have decided to follow up key decisions taken during the State workshop, and to continue to pursue action on unresolved issues in their respective districts. This would require strategies that draw upon the evidence and community mobilization generated in Community based monitoring, but would need to be broader than this process, moving in the direction of socio-political campaigns. Yet with the broad based participation including active contribution by large numbers of political representatives in the 3rd July programme, an important further step has been taken towards bringing unresolved health system issues onto the socio-political agenda.