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Community of Practitioners on Accountability and Social Action in Health

COPASAH Communique

Issue 2, March 2013

Inside this issue:

Mobilising Roma Communities for Community Monitoring of Health Services : Experiences and Insights of Center Amalipe, Bulgaria	2
Scientists, Researchers, and Policy-makers call for improving the quality of Maternal Health Care	6
Social Accountability in Health – the role for Independent Review and Advocacy	11
Community Monitoring in Nepal	14
Localising Development: Does Participation Work?	16
In Conversation with Pradip Prabhu	19
Strengthening Community Capacities, Evidence and Voice in Promoting Accountability and Social Justice in Health in Zimbabwe	21
Monitoring and Accountability Work to enhance the Immunisation Coverage and Preventive Health Care Services for Roma Ethnic Minority in Macedonia	23
Expanding Accountability Work to the Provincial and National Level in Guatemala	32
South Asian Practitioners Workshop in India on Community Monitoring for Accountability in Health	33
Are 24 x 7 PHCs in Maharashtra really Providing Services Round the Clock?	35
Community Action for Health in Tamil Nadu	38

To Begin With…..

With its second issue, our newsletter has got named “Copasah Communique”. Unlike communiqués issued by governments and those in power, we expect our communiqué to be a platform for interaction and dialogue. With this issue, we welcome experiences from a new region- Eastern Europe.
Community monitoring, we know depends upon the political context of a country and the spaces and opportunities that exist for the citizen initiated dialogues on accountability issues. It also depends upon ‘voice’ or the mobilised articulation of the citizen’s opinions and demands. The various experiences from Bulgaria and Macedonia show how the extremely marginalised Roma communities are now successfully able to carve out spaces for dialogue in these new democracies.
The need for the communities to be represented on policy platforms came out very strongly at one of the plenary sessions at the Global Maternal Health Conference organised in Arusha (Tanzania) between the 15th and 17th of January 2013. The plenary which was aimed at building a ‘movement’ around maternal health had researchers, policy makers and representatives from technical organisations on the panel but did not have any one representing the woman’s or community perspective. The one health care issue which was radically affected influenced by a ‘movement’ is HIV-AIDS. The community of People Living With HIV-AIDS were able to create such a strong ‘voice’ that they continue to be very important people at all platforms of negotiation. Unfortunately, the same cannot be said in the case of other health issues.
COPASAH has begun as a small effort of practitioners to build and strengthen a larger community of practitioners, who are working directly with communities building ‘voice’, finding opportunity and spaces to influence policy and programme implementation in the interest of those who get left out. Healthcare is increasingly becoming more technocentric and expensive. Unless we are able to build stronger citizens’ voices for better and more effective health services which are funded and managed by public resources, access to healthcare may end up becoming a defining factor of a world divided into the haves and have-nots. In the interests of effective, equitable and accountable health care system, we need more efforts and we hope COPASAH Communiqué can become a platform for sharing and learning about these.

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COPASAH Communique

Mobilising Roma Communities for Community Monitoring of Health Services : Experiences and Insights of Center Amalipe, Bulgaria

“Wherever Roma live, they are objects of exclusion and discrimination. Even in the most developed EU member-states, the living conditions of Roma are similar to the ones of marginalised populations from the developing countries.”

Background
Roma are the biggest European minority who came from India 15 centuries ago and live in all European countries as well as in certain parts of America. In general, wherever Roma live, they are objects of exclusion and discrimination. The educational, social, economic and health status of Roma is far behind that of the majority population. Even in the most developed EU member-states, the living conditions of Roma are similar to the ones of marginalised populations from the developing countries.
According to the last census there are 326,000 Roma in Bulgaria but expert estimations of the Council of Europe put this as much higher at 700000–800000 persons, i.e. roughly 10 to 12% of the population of the country. This makes Roma the biggest ethnic minority in the Bulgaria.
Problem Being Addressed
The health status of Roma community in Bulgaria is significantly lower than that of majority Bulgarians. For example, the life expectancy of Roma is 10 years less than that of ethnic Bulgarians. Roma child mortality is 24/1000 compared to 9.9/1000 for ethnic Bulgarians. Several surveys carried out by OSI – Sofia, World Health Organisation, World Bank, Amalipe and others, reveal serious problems that adversely affect the health status of Roma.
One area of concern is the provision of health care services in Roma communities, both in the rural areas (where about two thirds of Roma live), as well as in the biggest Roma city neighborhoods (ghettos). General Practitioners (GPs) are the backbone of the Bulgarian health care system. All insured individuals are expected to be registered with a GP. However, the insufficient number of GP practices in Roma populated areas limits the chances of Roma to receive permanent health care close to their residence: for example in some villages populated mainly by Roma, the GP visits only two days a week. Discrimination against Roma often exists among medical staff. In addition, since many Roma do not have health insurance, they cannot use health care services except in emergency cases.
Bulgaria has a relatively strong policy framework for addressing Roma health, including the Health Strategy for Integration of Disadvantaged Persons belonging to Vulnerable Ethnic Minorities, the Health chapter in the National Roma Integration Strategy and the Action Plan for the Decade of Roma Inclusion. However, the implementation of these is extremely poor: there is a lack of proper financial and administrative back up as well as lack of mechanisms for participation of Roma community and civil society in implementing the documents for Roma integration. As a result, the activities directed at improving the health status of Roma are either implemented notionally or not implemented at all.
One of the main reasons for this is the lack of appropriate monitoring and evaluation (M&E) mechanisms. Currently the “official” M&E of all Roma integration policy (including the one in health field) is carried out within the frames of the so-called “administrative monitoring.” That means it is done by the same institutions that should implement the activities. Roma community is in no way engaged in this process.

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There is a clear need to introduce a different approach that allows the Roma community to play an active part in the process.
Finally, Roma people’s awareness about health at present is low, especially at grass-root level. A majority of Roma lack knowledge about their rights, entitlements and obligations in health field. The experience from a project implemented in 2011 showed that even middle-class Roma lack such a knowledge. As a result, Roma are not aware what kind of health services they should receive and of what quality. They are also not aware about many aspects of desirable health-seeking behavior eg. vaccination related, communicable disease related, child nutrition related, identification and care-seeking for health related problems and so on. This limits the opportunities for community led advocacy for improving the quality of health care provisions.
Approach
Center Amalipe, based in Veliko Turnovo, is the biggest Roma organisation in Bulgaria. It promotes dialogue and understanding across ethnic groups as an important mechanism for increasing understanding about the status of Roma and for initiating efforts for improving it. In 2011, Center Amalipe started its project “Community Monitoring for Health Care Services in Roma Community: Strengthening Community Mobilisation and Advocacy” with financial support from Open Society Institute – New York. The overall purpose of the initiative was to introduce community monitoring of the health care services among Roma and other vulnerable ethnic groups in Bulgaria in order to strengthen bottom up advocacy. This would enable local communities to engage in policy and governance processes at the local level, thereby improving health service delivery and improve health outcomes in the long run.
The Centre Amalipe team received support from Dr. Abhijit Das from the Centre for Health and Social Justice in India, in developing its methodology. The key component of community based monitoring was the process of “community inquiry”. Our team applied the method respecting the specifics of the work in Roma community in Bulgaria and combining community inquiry with two other elements: community mobilisation at grass-root level and follow up advocacy. These three elements formed a comprehensive approach for empowering the local Roma communities and improving the health care service delivery at grass-root level.
A very important part of the process was to strengthen community mobilisation and self-organisation at the grassroots level for carrying out the community based monitoring. This part was as important as the inquiry itself since community monitoring could not be reduced to a sociological or demographic survey but a mechanism through which the community takes ownership of the process. That is why, within the project we established two-level structures for supporting the community monitoring implementation:
In every pilot community a Local Club for community development was formed: this was a volunteers club that brought together young people, women, informal leaders, to discuss certain community issues and together with the community moderator, to implement volunteer activities of community interest;
Community Development Centers were formed at municipal level: municipal coordinators worked in these centres to coordinate and support the activities of the Local Clubs for community development, to moderate the processes within the community and to facilitate the contacts with health care and other institutions.
These structures proved to be an efficient framework for fostering community mobilisation, implementing the community inquiry and the follow up advocacy for improving the

“Our team applied the method respecting the specifics of the work in Roma community in Bulgaria and combining community monitoring with two other elements: community mobilisation at grass-root level and follow up advocacy.”

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COPASAH Communique

“The first task of these community structures was to support small initiatives of local importance, leading to the mobilisation of the community and to make people believe in their own powers and abilities. These were various sports and cultural activities at the local level. Later, they started to organise community discussions and other events. All these initiatives raised the activeness of the local people and their self-organisation.”

health care services delivery at grass-root level.
The process
We started by applying the model in two municipalities situated in Central Bulgaria: Veliko Turnovo and Pavlikeni. The first activities were directed at activating the local Roma communities. Our team looked for pro-active people, with potential, who would be willing to work for their community and who believe that things can change through their personal participation and civic engagement. We traveled to many places, talked to people in local communities, met with local leaders and representatives of local authorities. Now in the third year of our work, we have been able to identify such people in the Roma neighborhood of Kaltinets (Gorna Oryahovitsa), the villages of Vodoley and Ledenik (Veliko Tarnovo District) and the villages of Batak, Varbovka, Stambolovo and Byala Cherkva (municipality of Pavlikeni). In all these places Local Community Development Clubs with tens of volunteers have been formed. In addition, Community Development Centers have also been established at municipal level in Veliko Turnovo and Pavlikeni.
The first task of these community structures was to support small initiatives of local importance, leading to the mobilisation of the community and to make people believe in their own powers and abilities. These were various sports and cultural activities at the local level. Later, they started to organise community discussions and other events. All these initiatives raised the activeness of the local people and their self-organisation.
Since the beginning of the programme in 2011, four surveys have been conducted using the "community inquiry" method. They were conducted by volunteers from the local clubs, organised by the Community Centers and supported methodologically by the team of Amalipe. This survey includes both quantitative and qualitative stages. For the purposes of quantitative research at the first stage of the inquiry, the team collected and processed standardised questionnaires interviewing people literally from door to door in order to assess access to health care and the quality of services that people receive. Some of the questions related to insurance status, maternal and children's health care, access to primary, emergency and hospital care. For the purpose of qualitative research, focus groups and community discussions were organised in order to further understand the reasons behind the main findings from the quantitative research.
Thereafter, based on the conclusions from the research, the local communities / activists from the local groups, supported by the Community Centers and our team initiated advocacy activities: before the Regional Health care Inspectorate, the municipal authorities and the service providers.
What Were the Outcomes of Our Approach
Between the first two rounds of the community inquiry, respondents who could identify their local primary care physician increased from 83% to 94% and those not receiving an annual health check decreased from 72% to 60%. In addition, the respondents able to access medical examinations free of charge increased from 46% to 58%. However, both inquiries reflected significant problems in access to health care, for example, over 50% of women over 18 years did not have health insurance and payments for services that are supposed to be free remain prevalent.
One of the strongest achievements of the project has been the mobilisation of Roma communities around health, which has resulted in increased demand for annual health exams and government guaranteed free

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services. We have also seen positive changes in the health system, including more rapid and adequate response times by emergency services to Roma communities. As a result of the advocacy with the Regional Health Inspectorate, they have recognised the problem of the absence of primary care doctors in Roma communities, an issue identified by community concern and validated through monitoring. The Inspectorate is now exerting greater oversight over contracted doctors to ensure they are present in Roma communities on their assigned days and hours. Through monitoring, problems were also uncovered that cannot be resolved at the local or regional levels, such as lack of access to health insurance for marginalised groups. To address these larger issues, Amalipe plans to advocate with the national Ministry of Health and the centralised Health Insurance Fund for a minimum package of health services for disadvantaged persons. Finally, community monitoring has helped Amalipe connect our advocacy at the national and European Union levels with the direct experiences of Roma communities.
Problems Experienced and Things Amalipe Would Do Differently
The strength of the type of community monitoring undertaken by Amalipe is its ability to transform the relationship between communities, service providers and decision-makers at the local level. It focuses on community experience as the central indicator for assessing both access to and quality of services. Strengthening community mobilisation as well as establishing sustainable community structures (such as Local Community Development Groups, Community Development Centers)appears as an essential element of the model.
Amalipe is now leveraging their monitoring efforts to promote the validity of community experiences to inform policy and practice and secure additional space for civil society and community participation. For example, in early 2012, the Bulgarian national Roma strategy and action plan was approved by the Parliament, but it did not contain provisions for the inclusion of civil society participation and/or community perspectives in monitoring or specify ways to strengthen government’s own monitoring mechanisms. In June 2012, Amalipe organised an European Commission Hearing on the monitoring components of the national Roma strategies and action plans. By influencing the monitoring aspect of the national strategies and action plans, we hope to complement our community monitoring work and create additional space for advocacy based on community experiences.
In the future, Amalipe proposes to expand the community monitoring work throughout Bulgaria using a network of community and health-social centers we have established with EU funds. We hope that this strategy will help ensure that the results of multiple monitoring efforts are relevant for national advocacy.

Article by: Deyan Kolev, Momchil Baev
Deyan Kolev is Roma activist from Bulgaria, Chairman of AMALIPE Center for Interethnic Dialogue and Tolerance. He has MA in Philosophy and MA in History. Deyan has authored of 7 books on Roma history and culture, 5 textbooks on Roma culture and 6 reports about the Roma integration policy in Bulgaria. Member of the Monitoring Committee of Human Resources Development Operational Program and of European Roma Platform.
To know more about the work done by AMALIPE, please CLICK HERE

“As a result of the advocacy with the Regional Health Inspectorate, they have recognised the problem of the absence of primary care doctors in Roma communities, an issue identified by community concern and validated through monitoring. Community monitoring has helped Amalipe connect our advocacy at the national and European Union levels with the direct experiences of Roma communities.”

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COPASAH Communique

Scientists, Researchers, and Policy-makers call for improving the quality of Maternal Health Care

“The concept of continuum as a constellation of services and interventions for mothers and children from pre-pregnancy/adolescence, through pregnancy, childbirth and the postpartum period, until children reach the age of five years. Such an understanding of continuum includes sexuality education, family planning, antenatal care, delivery care, postpartum care, and the prevention and management of newborn and childhood illnesses.”

The past 25 years of the safe motherhood movement has seen extraordinary successes - notably a 33% reduction in maternal mortality from 409,053 in 1990 to 273,465 in 2011; however as 2015 draws closer, it is clear that many countries will be unable to achieve the Millennium Development Goals. The question that is being raised is how will the gains of the past be protected and how can unfinished business be addressed. As a contribution to the process of redefining human development for women after 2015, the Maternal Health Task Force held a conference in Arusha on improving the quality of maternal health care. Co-organised by Management and Development for Health, and sponsored by the Bill and Melinda Gates Foundation, the MacArthur Foundation, UNICEF and UNFPA the Global Maternal Health Conference brought together over 800 experts in maternal health in Arusha, Tanzania. The three day conference (15-17th January 2013) was marked with rich discussions and a sharing of the latest evidence on improving the quality of care for women during pregnancy and childbirth.
Sessions/presentations:
The context of the workshop was set with the session on ‘MNCH Continuum of Care: Has it helped or hurt? Planned as a debate among the presenters, the session sought to analyse if the efforts to define and advance the continuum of care (COC) framework contributed to progress in improving maternal health and if it did, then how much did it contribute, as well as if it did not then what could be done about it. Panelists included Wendy Graham (Professor of Obstetric Epidemiology at the University of Aberdeen), Marleen Temmerman (HOD of Reproductive Health and Research, WHO) Friday Okonofua (Professor of Obstetrics and Gynaecology at the University of Benin, Nigeria) and Richard Horton (Editor in Chief of The Lancet).
Moderating the discussion, Marge Koblinsky (USAID), began by defining the concept of continuum as a constellation of services and interventions for mothers and children from pre-pregnancy/adolescence, through pregnancy, childbirth and the postpartum period, until children reach the age of five years. This continuum she held, promotes the integration of services across two dimensions: across the lifespan, and across levels of the health system, from households to health facilities Such an understanding of continuum includes sexuality education, family planning, antenatal care, delivery care, postpartum care, and the prevention and management of newborn and childhood illnesses.
Panelists agreed that the adoption of the COC framework has helped the cause by bridging the gap between different constituencies related to women’s and children’s health. They also agreed that presenting women’s and children’s health as linked and as an integrated whole appealed to policy makers and governments. However, panelists also listed some of the problems with the COC concept, one of which was that the continuum tended to view women and adolescents primarily as mothers or future mothers resulting in the neglect of crucial cultural, social and economic determinants of health and survival, including female education and empowerment, gender based violence, abortion and family planning services for adolescents. These crucial areas were often not woven into policies and programmes and no or very limited resources were allocated for them. It also led to the compartmentalisation of women resulting in, for instance, the ANC period being given more importance than the PNC period. Further, the COC approach did not give importance to the quality of care issues.

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However despite these shortcomings both the panelists and the audience felt that the COC approach was a valuable one and it should be revised to add some of the missing elements, namely:
Recognition of the importance of quality of care
Responsiveness to the needs of girls and women throughout the life cycle, not just in relation to pregnancy and childbirth
Links to the cultural, social and economic determinants of women’s and children’s health
I however felt that although issues of quality of care and impact of social inequalities were discussed there was silence around the issue of home births.
The session entitled ‘Incorporating women’s voices in healthcare quality assurance programmes’ was based on a research study conducted by PHFI in collaboration with the London School of Hygiene and Tropical Medicine (LSHTM) and University of Aberdeen, UK. Entitled ‘Women’s perception of quality and satisfaction with maternal health services’, the research sought to explore what women really valued when seeking delivery related care, and what was their current status of satisfaction in the context of the Janani SurakshaYojana (JSY – a conditional cash transfer scheme to promote institutional delivery) in the state of Jharkhand, India. The study tried to identify the aspects of care and the factors that influenced a woman’s decisions of where to deliver. The study stressed that to improve the quality of health services, it was critical to understand the expectations and satisfaction level of women. The researchers felt that the creation of a scale which would systematically assess women’s satisfaction with health services would be a step forward for safe motherhood in India.
The survey was conducted in Jharkhand among 500 women, 95% of who belonged to marginalised groups (Scheduled Castes, Scheduled Tribes and Other Backward Classes). Eighty five percent of the respondents had a family income of less that Rs. 5000 and 53% of the women were illiterate. The study findings showed that more than a third of women delivered at home because they could not reach the facility on time, 40% of women spent more than the Rs.1,400 incentive given to them for delivery under the JSY, one out of seven women preferred home delivery for fear of abuse at the health facility and nearly two-fifths of women said that they preferred home delivery due to better comfort and privacy. Despite this, the study found that a large number of women interviewed reported satisfaction with the services. Instead of concluding that the scale could not be used to accurately capture ‘satisfaction’, the researchers shared that they were in the process of advocating with the state government to use the scale as a tool to assess quality of care provided by public health facilities.
The session on ‘Rights-based approaches to improve maternal health’ included presentations on using human rights based approaches and the law to reduce preventable maternal mortality and morbidity. Alicia Yamin (Harvard School of Public Health) presented the Technical Guidance note on human rights based approaches drafted by the UN Human Rights Council which stresses on the empowerment of women and girls and the participation of affected populations, including marginalised groups towards reducing maternal mortality. The note provides guidance on budgeting and planning, adopting a national health plan as a core obligation of the right to health, and underlines implementation in practice and stresses the importance of accountability and monitoring. Kerry McBroom’s (Human Rights Law Network) presentation shared the successful use of law as a tool to hold government accountable for preventable maternal deaths.

“The study stressed that to improve the quality of health services, it was critical to understand the expectations and satisfaction level of women. The researchers felt that the creation of a scale which would systematically assess women’s satisfaction with health services would be a step forward for safe motherhood in India.”

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“The findings showed that despite services that lacked quality, women reported being satisfied with the public health system. These findings clearly bring out the fact that the most marginalised populations tend to accept discriminatory treatment rather than question it.”

Kerry shared the case of Shanti Devi and Laxmi Mandal and more recently the Barwani cases which were used to move the court to deliver landmark judgments recognising maternal mortality as a violation of women’s fundamental right to life.
The presentation by Matthias Sachse Aguilera (Oaxaca State Safe Motherhood Committee) on the quality of care during pregnancy in Mexico, shared the findings from a research by the Mexico Safe Motherhood Committee. The Safe Motherhood Committee (composed of government and civil society agencies) supports the development and implementation of reproductive and maternal health policies and programmes, with an emphasis on southern states in Mexico with large indigenous populations where access to quality maternal health services is limited. The findings showed (much like the research findings from India) that despite services that lacked quality, women reported being satisfied with the public health system. He added that these findings clearly bring out the fact that the most marginalised populations tend to accept discriminatory treatment rather than question it.
‘Making women-centered care a reality’ had Pamela Putney (PATH) sharing how putting women at the center of care helped to bring about dramatic changes in two hospitals in the Dominican Republic. She held that throughout the world, women are humiliated and abused in subtle and overt ways during childbirth, which is a time of intense vulnerability. Although a substantial amount of attention is focused on maternal mortality reduction, very little attention has been paid to documenting and tackling the significant barriers posed by disrespect and abuse of women in facilities. Pamela shared that the TRAction implementation research had shown that putting women at the centre of care and providing hospital staff with support and understanding had helped to improve the quality of care provided, resulting in a reduction of maternal deaths.
Jashodhara Dasgupta’s (SAHAYOG) presentation ‘Participation of informed users in monitoring quality of care’ provided a picture of the changes that had been brought about by the Mahila Swasthya Adhikar Manch, a grassroot women’s organisation in the state of Uttar Pradesh, India. Through her presentation, Jashodhara showed how an informed user community could negotiate unequal power equations and claim their rights and entitlements. The active participation of users, she claimed, has promoted a culture of answerability among providers and district health managers towards improved quality of care. Stephanie Kujawski (Columbia University Mailman School of Public Health) in her presentation ‘The association between disrespectful and abusive treatment during childbirth and health care satisfaction and future facility utilisation in the Tanga Region of Tanzania’ stated that respectful care can be framed as several issues including human rights, quality of care, equity and public health. She argued that it was necessary to focus on changing systems rather than people to combat disrespect and abuse during child birth.
The session on ‘Maternal health policy and advocacy’ brought out the importance of the issues of accountability and social justice. Marta Schaaf’s (AMDD, University of Columbia) presentation highlighted that accountability could be thought of as a condition in which individuals who exercise power are constrained by external means and by internal norms. Explaining further she added that accountability could transform the workings of power in the health system to ensure that it functions as a core social institution; a place where inequalities are redressed, rather than confirmed or even exacerbated, a just workplace where health care workers at all levels feel supported and are motivated by professionalism.

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Tabina Sarosh’s (Shirkat Gah) presentation ‘Women’s health, a social justice issue: Monitoring MDG5 a and b services in Pakistan’ highlighter the findings of Shirkat Gah's in-depth research on the progress achieved so far under MDG 5. The research findings delineated the barriers faced by women in accessing information and services related to sexual and reproductive health and the gaps in implementation found in the Punjab region of Pakistan. Sarosh highlighted the issues of women’s access to family planning and reproductive health services, the link between unsafe abortion and maternal health, reproductive health needs of adolescent girls, impact of secondary education in improving reproductive health options, and government initiatives pertaining to MDG 5. Ngemeera Mwemezi (Care International, Tanzania) described their development of an accountability tracking tool that helps national bodies measure and evaluate their accountabilities to international commitments on MNCH by examining their own policies and strategies.
The last session that I attended was on “Maternal death surveillance and response for better quality of maternal health care”. The session began with Maurice Bucagu’s (WHO) presentation on the global situation of implementing maternal death reviews. Explaining the background to this he described the framework developed by the Commission on Information and Accountability (COIA) to ensure that the resources committed for women and children’s health were honored. This accountability framework identifies a set of indicators for results and resources, proposes an action plan to improve health information systems, and explores opportunities to improve access to information through the use of information technology. The first step is for countries to conduct an analysis of the strengths, weaknesses and gaps related to the seven key components of the Country Accountability Framework (CAF) which include civil registration and vital statistics, monitoring of results, maternal death surveillance and response, innovation through use of information and communications technology (ICT), resource tracking, review processes, and advocacy/action by a multi-stakeholder national team. The findings of the accountability assessment form the basis for the development of a roadmap of priority actions for strengthening national accountability. Maurice then presented the assessments made by countries for the maternal death surveillance.
Florina Serbanescu (Centers for Disease Control and Prevention) in her presentation described maternal mortality as one of the worst tragedies in health care. Measuring maternal mortality, she felt, was important as it was a sensitive indicator of inequity being intimately linked with the status of women and their access to health care. She also held that it indicated the disadvantage within and between developing and developed countries. She added that there was an increasing demand for estimates of maternal mortality both in terms of the level where it occurred and causes of maternal death. However measuring maternal mortality was fraught with challenges because it required information on various components such as pregnancy status at/near the time of death and the cause of death which were often unknown or misclassified. Further there was the problem of underreporting of deaths in poor, remote rural areas and a tendency to omit deaths occurring in homes or in transit. The system of vital statistics registration was incomplete in many countries with the death certificate not reflecting the relationship between pregnancy and death. Another major constraint was the monetary implications of establishing a sentinel surveillance system to track maternal deaths, which was compounded by the lack of political will among governments.

“Maternal mortality is one of the worst tragedies in health care. Measuring maternal mortality, she felt, was important as it was a sensitive indicator of inequity being intimately linked with the status of women and their access to health care. She also held that it indicated the disadvantage within and between developing and developed countries.”

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“CSOs in India were complimenting the government’s efforts by incorporating additional perspectives to MDRs related to social determinants of health, non-obstetric causes of death, entitlements, continuum of care, discrimination/denial. The analysis by CSOs differed from that done by the government, in that it is done within a framework of rights and accountability rather than a technical and largely bio-medical investigation.”

implications of establishing a sentinel surveillance system to track maternal deaths, which was compounded by the lack of political will among governments.
This session also had country presentations on maternal death notification and review system in China and the 4 African countries presented by Song Li (Ministry of China) and Triphonie Nkurunziza (WHO) respectively. Another presentation was on the role of civil society organisations in maternal death reviews in South Asia presented by Jashodhara Dasgupta (SAHAYOG). Jashodhara mentioned that civil society organisations (CSO) in India were complimenting the government’s efforts by incorporating additional perspectives to maternal death reviews (MDRs) related to social determinants of health, non-obstetric causes of death, entitlements, continuum of care, discrimination/denial. The analysis by CSOs differed from that done by the government, in that it is done within a framework of rights and accountability rather than a technical and largely bio-medical investigation. She also mentioned that CSOs have the advantage of being able to obtain information from community members in a more non-threatening manner than a government representative. Further in the context of South Asian countries where maternal mortality was high, especially among most vulnerable socio-economic groups, a few crucial questions pertained to who conducts the MDR (government representative/CSO), why it is undertaken (fault finding/fact finding), what is investigated (only bio-medical causes of death versus health system lapses and socio economic factors), who gives data (providers/women’s family), how is the data processed (all deaths reviewed/sample of deaths in selected sites aimed at promoting learning) and how is the analysis used (is it made public and as a feed back for system improvement and promoting accountability). Jashodhara mentioned that in India, CSOs were in dialogue with the Ministry of Health and Family Welfare to ensure their representation on state committees. CSOs were also pushing for accountability by addressing parliamentarians and National Human Rights Commission on this.

Article by: Y.K. Sandhya
Ms. Y.K. Sandhya is the Programme Manager for the women’s health and rights team, SAHAYOG, India. She oversees and assists the team as well as is engaged in research. She is also coordinates a national network called the National Alliance for Maternal Health and Human Rights that advocates for improved quality of maternal rights for the marginalized women in India. She was the recipient of the Indian Council of Social Science Research Doctoral Fellowship from 2000 and the UGC – DSA scholarship awarded from 1994 - 1996.
To know more about the work done by NAMHHR, please CLICK HERE
To know more about the work done by SAHAYOG, please CLICK HERE

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Social Accountability in Health – the role for Independent Review and Advocacy

There is an increasing recognition that advocacy is an important tool to persuade government agencies to adopt evidence based policy solutions; this presupposes that advocacy needs to be based on evidence and facts to bring a meaningful policy change. While the role of research, meta-analysis, review of evidence and evidence based advocacy is essential for promoting good public policy, it is also important to continue following up the policy implementation process through independent reviews. Two international alliances who have been successful in such actions in the context of maternal health are Partnership for Maternal, Newborn and Child Health (PMNCH) and Women Deliver.
Bringing a change in public policy is challenging; systems also do not change immediately after the policy decision or even when additional resources start flowing. In fact, the additional resources can have a distorting effect at the operational level. Any system has inertia i.e., it resists change, and public systems also have this characteristic. Operational changes are only possible when there is adequate support for the essential human, material and financial resources necessary for the change.
Agencies which are interested in changes in the public system are justifiably pleased when there is any interest shown in policy changes, and in many cases go the extra mile to provide the necessary resources to support and facilitate the change that is desired. From this point onwards there is a commonality of interest between the public institution which has agreed to change and the supporting agency in finding evidence which justifies the change. In India an example to reflect this policy shift is the Janani Surakshya Yojana (JSY) to promote institutional delivery. There was an International policy interest in India’s high levels of maternal mortality from the time the 5th MDG was set up in 2000. The PMNCH was established in Delhi in April 2005, and soon Government of India became interested in the issue. The JSY budgets have since then increased substantially. Since then the rates of institutional deliveries are being tracked assiduously and there has been a congratulatory air as these rates have rocketed.
Once an agreement for policy change is endorsed and the change processes is rolled out, all agencies – UN agencies, Donors, International NGOs and the national government and its implementation mechanisms, all have the same interest – to show that this policy change was necessary and is giving results. As a result, the time for critical questioning is suspended as all the supporters join in wishing the programme success. Unfortunately, this suspension of critical questioning while probably important for policy change to take root, may lead to tremendous costs for those who are least able to pay it. For example, in the case of India’s maternal health programme no one asked as JSY was being rolled out and institutional delivery rates were counted – whether the measures for emergency obstetric care, postnatal care, infection prevention practices in the delivery site have improved. It is not possible to improve maternal health without these improvements, and even today after five years of the programme implementation, we don’t have clear affirmative answers to these questions.
The question that may well be posed is “What is the harm if these questions are not asked?”

“Once an agreement for policy change is endorsed and the change processes is rolled out, all agencies – UN agencies, Donors, International NGOs and the national government and its implementation mechanisms, all have the same interest – to show that this policy change was necessary and is giving results. As a result, the time for critical questioning is suspended as all the supporters join in wishing the programme success.”

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“While women are continuing to suffer, the overall commonality of interest and the anxiety to see the changed policy succeed has made most parties who would otherwise be interested, silent. In such a situation it is necessary to find ways of supporting both the process of evidence gathering and a ‘party’ who will ‘stick their necks out’ to present the unpopular data which shows the gaps and challenges the establishment anxiety to succeed.”

The harm, if one can call it that, is that now many more women are coming into ‘institutions’ to deliver, but one doesn’t know the exact consequences. If one visits the maternity wards of a public hospital in rural UP or Bihar, the overcrowding and lack of hygiene will take ones breath away. If one enquires at a PHC how they have been managing their emergency obstetric care, chances are there will be no records. If one enquires whether women who deliver, stay for the mandatory 48 hours there will be an uncomfortable silence. If this is the situation on the ground, then the possibilities are that women continue to face some maternal morbidities or deaths despite JSY. Some of this news is coming out as the Barwani deaths, the Jodhpur deaths, the Godda deaths and so on. While women are continuing to suffer, the overall commonality of interest and the anxiety to see the changed policy succeed has made most parties who would otherwise be interested, silent.
Change is necessary. Many players are necessary to support and facilitate change. For the change process to move forward it is necessary for a critical engagement through evidence and argument. Till a government agrees on a policy change, International Organisations and Donors and other advocacy players bring evidence and arguments to the policy table to influence this change. Once the argument is won and the need for policy change accepted and change process underway, the critical engagement changes into a collaborative engagement. This collaboration is necessary, but the need for critical engagement should not stop.
If all the necessary policy players are engaged in the collaboration – some providing technical support; others provide financial assistance, still others assisting in joint operational projects, who remains to provide the necessary critical evidence and arguments? In some cases those who disagree to this larger process of collaborative engagement are straight away dismissed.
It is necessary to call attention to both contextual operational realities for fine-tuning the process of change, and to understand whether the initial assumptions about change were true. There are limits to how effective internal data systems will be for this purpose. My own experience of seeing internal data being interpreted in many health related policy change efforts shows that the supporters (donors, technical experts) become equally anxious to show results and so ignore and even hide contrary evidence. I have also known people to ask the results to be presented in a way that they appear to show results rather than identify the gaps.
In such a situation it is necessary to find ways of supporting both the process of evidence gathering and a ‘party’ who will ‘stick their necks out’ to present the unpopular data which shows the gaps and challenges the establishment anxiety to succeed. The data needs to be robust and stand examination for validity and authenticity and the party who presents the data needs to do so in a manner which is both respectful and critical.
Citizens groups are increasingly being seen as an important component of social accountability mechanisms. The challenge in the health sector is to provide citizen’s groups with the capacity and resources to generate robust data about citizen’s experience of service delivery at the lowest levels. Unfortunately, this work does not receive technical or financial support, even though it is crucially important to the overall success of the programme. In some cases small grants for accountability are being built into the overall project budget– as in the case of community monitoring within the state PIPs in NRHM. However, the main implementation challenge in this case will be anxiety of the programme manager who manages the fund disbursement.

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It requires clarity of purpose for a programme manager to continue to fund a process which will generate evidence about gaps in a project s/he actually wants to show case as a success. There is clearly a conflict of interest as it is contrarian and therefore often ignored.
There is thus a need to find an alternative funding pathway to support strengthening of citizen’s groups as well as the process of independent evidence generation which will highlight the process of policy change as it unveils itself on the ground. There is also perhaps a need to support different ways in which evidence is presented so that it can influence the policy process. Academic papers and discussions in policy platforms and consultations may need to be supplemented with Public hearing, People’s Tribunals and if necessary legal petitions. This is necessary for the development of robust policy solutions to address the needs of poorest of the poor in different parts of the country.
The Centre for Health and Social Justice (CHSJ) has been involved in the process of generating evidence on the rollout of different components of NRHM through Rapid Assessment Studies and Citizen’s Reports. It has developed a training programme for conducting such studies in collaboration with the Global Health Leadership Programme of University of Washington and has trained over 25 NGOs across India. These reports are acknowledged as sources of independent feedback both by the Planning Commission and the Ministry of Health and Family Welfare. CHSJ has also supported activists, organisations and networks to organise Public Dialogues and Consultations and also helped the individuals who have faced human rights violations and activists to prepare robust briefs which have helped them file cases in High Courts and the Supreme Court of India. We believe in strengthening the alternate process of evidence generation and presentation of data. We also believe that the strength of any policy is finally not only in the way it is perceived by the weak and the most marginalised but also in its converting their experience into robust evidence and strengthening the accountability chain.

“There is thus a need to find an alternative funding pathway to support strengthening of citizen’s groups as well as the process of independent evidence generation which will highlight the process of policy change as it unveils itself on the ground. There is also perhaps a need to support different ways in which evidence is presented so that it can influence the policy process.”

Article by: Dr. Abhijit Das
Dr. Abhijit Das is a Steering Committee member of COPASAH and also, Director of Centre for Health and Social Justice (CHSJ) a policy research and advocacy institution around health and human rights and men and gender equality in India. His areas of interest include maternal health rights, equity, human rights, accountability and governance in health programming, quality of care of health care service delivery and health and population policy.
To know more about the work done by CHSJ, please CLICK HERE

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Community Monitoring in Nepal

“The Surveillance groups have been trained to undertake facility survey of primary health care centres and also audit maternal deaths that take place in the village. Selected surveillance groups have also been trained to monitor the available comprehensive abortion care facilities.”

Community monitoring in Nepal, until now has only been a part of community forestry and has focused on building the capacity of forest user groups and networks to play a proactive role in not only protecting forests but also on what produces can be used and monitoring to ensure that the most marginalised have easy access to minor forest produces. However, health has not been prioritised and community monitoring has not been a part of the health system in Nepal.
Beyond Beijing Committee (BBC) has been working since 2003 and since the past one and half years has been trying to integrate community monitoring to ensure that the marginalised women’s sexual and reproductive health rights are protected. BBC has been working in the three districts of Morang (Terai region), Lalitpur (hilly region) and Makawanpur (between hilly and Terai)1 BBC has mobilised women and youth in all these three districts; and built their capacity to take the community monitoring process forward.
The groups that have been formed are known as surveillance groups and comprise of 9-11 members, representing each ward. These surveillance groups have been trained to undertake facility survey of primary health care centres and also audit maternal deaths that take place in the village. Selected surveillance groups have also been trained to monitor the available comprehensive abortion care facilities.
The surveillance groups are trained to assess services based on standard protocols developed by government of Nepal. The focus is on whether the poorest of the poor avail incentives provided by the government such as transportation incentives on institutional delivery, incentives after 4 ANC checkups, etc. Once this information is collected, the CBO partners of BBC in each of the three districts analyse the data, and these are disseminated locally through biannual grassroots meeting with the local stakeholders of Village Development Committee, and at district level, the findings are disseminated in the district advocacy dialogue and similarly, at the national level through national policy dialogue.
Some of the key challenges to community monitoring process in Nepal are:
Political instability in the country is a major challenge. Elections are yet to be held to form the committees in the village level as well as to form parliament at the national level. This is a major road block to bureaucratic accountability and the decision making process.
Recruitment of health professionals at the local level have been delayed, this has resulted in dependence of the community members on private providers who probably are not qualified to provide health services.
Though interacting with the district and local administration is easy and there is a space to share the issues or concerns,

1 Each district has small administrative divisions called as Village Development Committees (VDCs). BBC has been working in 16 VDCs of Morang and Lalitpur and all 43 VDCs of Makawanpur district. Each VDC is further divided into 9 wards.

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However, the space is only for discussing problems and issues, no concrete positive change has ever taken place. The commitments that are made are verbal, which are often forgotten, and officials also do not have the authority to take decisions due to the fluid political situation. Officials are also frequently transferred making it difficult to have a dialogue to bring about changes.
Community people are less motivated to work voluntarily in the community. So it is a challenge to build the capacity of the community volunteers who eventually drop out.
It has also been a challenge to deal with expectations as government officials as well as representatives from the media expect incentives to participate in programmes implemented by NGOs.
To ensure that the most vulnerable and under privileged groups access and avail quality health care it is important and imperative that community is provided a space to speak out, and sadly enough, community monitoring has not been a priority in Nepal. However Beyond Beijing Committee (BBC) has been striving to create a platform to integrate community monitoring in order to ensure that the marginalised voice at the local as well as at national and international level is heard and quality of service is improved.

“To ensure that the most vulnerable and under privileged groups access and avail quality health care it is important and imperative that community is provided a space to speak out”

Article by: Ms. Rakshya Paudyal
Ms. Rakshya Paudyal has been working as Program Officer, Women’s Health and Rights Advocacy Partnership (WHRAP) project, in Beyond Beijing Committee (BBC) since 2011. WHRAP is a project rooted on evidence-based advocacy for enhancing access of the marginalised women and young people to information and services on sexual and reproductive health rights (SRHR), especially in the areas of safe motherhood, safe abortion, uterine prolapse and nutrition/anemia since 2003. Rakshya and her team from BBC have successfully mobilised mother’s group, female community health volunteers (FCHVs), youth groups and established surveillance groups to undertake community monitoring in the three districts of Morang, Lalitpur and Makawanpur.
To know more about the work of Beyond Beijing Committee, please CLICK HERE

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Localising Development: Does Participation Work? By Ghazala Mansuri and Vijayendra Rao (2013)
A Book Review

“Though there is unanimity on local participation as a preferred method among policy makers, development specialists, activists, there has been a persistent doubt whether such insistence on community participation has actually worked effectively. Is there solid evidence supporting the view that going through communities works better than the central state?”

This research report revives the debate on participatory development and addresses the complexities and controversies very candidly surrounding the leitmotif of participatory development approach in the development projects sponsored by the World Bank, International donors and governments. Some of the key questions that this report tries to make an attempt to answer are:
Has participatory development benefited the poor and marginalised?
Has it given them a voice to exercise their choice over development planning and process involving them?
Over the last two decades participatory development has emerged as an essential principle in development projects sponsored by the World Bank, other international donors, governments; local participation promises multiple benefits for people from reduction of poverty, to expanding livelihood opportunities to strengthening good governance. Though there is unanimity on local participation as a preferred method among policy makers, development specialists and activists, there has been a persistent doubt whether such insistence on community participation has actually worked effectively. Is there solid evidence supporting the view that going through communities works better than the central state? What has been its real impact on local people for whom the project is financed, designed and implemented?
The question of efficacy of participatory development, which has since been an inbuilt norm in local development projects, and World Bank has allocated $85 billion for this, its results are a matter of great concerns. The policy research report “World Bank Policy Research Project – Localizing Development: Does participation work?” is a critical study about its implementation and impact. Such a study was long due for all concerned in development of the poor-- donors, policy makers, researchers, activists and even those project managers who are sincerely pursuing monitoring and evaluation of such projects. This study reviews more than 500 empirical studies of participatory development and provides a comprehensive and coherent perspective on the complex and controversial issues involved in such development projects.
In this study, Mansuri and Rao examine the successes and failures of participatory approaches, and the conditions under which such a process is likely to yield results or failures. This challenge has brought out many uncomfortable and controversial questions to the forefront, which may not paint an optimistic picture of the community projects; it nonetheless suggests many mechanisms to make it work despite constraints posed by inequality in local social and power structure, geography, vested interests, institutional support both at national, state and local levels. Such variables sometimes make it impossible and hopeless for carrying on with such projects, but through counterfactual methods, they raise concerns yet see hope in such approaches and suggest several mechanisms rather than withdrawing such approaches.
World Bank and other international donors along with governments have sponsored many development projects in the field of poverty

To access the book online, please visit the following:
http://siteresources.worldbank.org/INTRES/Resources/469232-1321568702932/8273725-1352313091329/PRR_Localizing_Development_full.pdf

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reduction, livelihood options, health, nutrition and education, women’s empowerment, etc., across developing countries having different types of government structures, social, political and economic structures and inequality, degree of political stability, and level of democratisation. What is revealing and remarkable is that success of such projects across countries and local areas has wide ranging variations. The community driven projects emphasise community engagement in service delivery and in design and implementation of the project intended for them.
The authors talk about two types of participation: organic participation and induced participation. While organic participation is the desired goal, it is not naturally available in most communities as civic participation is not encouraged, and wherever they get involved in community projects, it is the voice of the local elite that prevails because of unequal social structures. Therefore, there is a need of intervention through such development projects to induce local participation cutting across the existing structures where the poor and marginalised can also voice their concerns. But is it to much to expect?
On the basis of their comparative study of trajectories of several development projects, the authors conclude that the local context is a crucial factor in determining the success and effectiveness of the project. Donor-driven participatory projects often ignore the fact that effective civic engagement does not develop along a predictable trajectory. Moreover “Civic society failure” is as common as market and government failures. Civic groups (village communities, urban neighbourhoods, school councils, water user groups) do not always cooperate and work for common interest, their response could be limited by problems of coordination, inequality, asymmetric information, collective action, etc.
Corruption is a major issue, and evidence suggests much of social funds get misappropriated by local officials and politicians and very little reach the poor and marginalised even in a democratic set up. Participants in community organisations tend to be disproportionately from wealthier, more educated and more politically connected households. Participation by poor, low caste residents are lower in more unequal communities. Donors cannot be substitutes for non functional central government, effective local oversight requires well functioning institutions at the centre and reforms that enhance judicial oversight, allow for independent audit agencies, and protect and promote the right to information and the media.
It is clear from the study that there is no alternative to participatory development. The authors are convinced that this is the only sensible way to push development. As a remedy, they recommend a robust monitoring and evaluation (M & E) system. Most World Bank-funded participatory projects have not made an effort to build effective monitoring and evaluation systems that take into account qualitative analysis of the local structures, culture and politics and needs of the poor and marginalised. To be effective, participatory development projects require constant adjustment, learning in the field, and experimentation.
The study has several limitations. The decentralisation evidence focuses on the demand side.

“Civic society failure” is as common as market and government failures. Civic groups (village communities, urban neighbourhoods, school councils, water user groups) do not always cooperate and work for common interest, their response could be limited by problems of coordination, inequality, asymmetric information, collective action, etc.”

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“The authors suggest making contextually sensitive and long term and constantly innovative strategies in response to local realities to turn such projects into a large scale, state driven, bureaucratically led enterprise. However it seems to be a herculean challenge for the donors to engage communities and the state machinery and institutions. “

Though the authors recognize the value of decentralisation of resources and authority as a necessary condition for project’s success and long term benefits, it is not clear what difference does a development project make in the absence of supportive state, good institutions, governance, and local cooperation? To what extent induced participation can harness organic participation and also how participatory approaches deepen democracy and empower people to press for policy reforms and open up for community to debate and shape up their priorities and needs.
The authors suggest making contextually sensitive, long term and constantly innovative strategies in response to local realities to turn such projects into a large scale, state driven, bureaucratically led enterprise. However, it seems to be a herculean challenge for the donors to engage communities and the state machinery and institutions. The study has increased the understanding as to how the development projects are limited, but falls short of making exhaustive guidelines and requirements for the donors to effectively design their project at their level and work out a dynamic monitoring and evaluation system. More case studies needed to be included to show both successes and failures so lessons can be incorporated by donors and practitioners.

Review by: Ms. Sarita Barpanda
Sarita Barpanda is working as Programme Director in Centre for Health and Social Justice and coordinating all work relating to governance and accountability related to the health sector at CHSJ. She has been working in the development sector for last twenty years, and has wide ranging experience in the field of sexual reproductive health and rights, HIV/AIDS, public health population development, gender justice, human rights at state, national and international level.
To know more about the work of CHSJ, please CLICK HERE

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In Conversation with Pradip Prabhu

Pradip Prabhu of Kashtkari Sangathana, Maharashtra, is a leading social activist with over four decades of experience of working with tribals, advocating for their rights and dignity. Pradip holds a Masters Degree from Tata Institute of Social Science, and has been closely associated in the campaign for Right to Information and was the State Convener of Soshit Jan Andolan in Maharashtra.
Pradip Prabhu has been a facilitator on governance reform and he has been closely associated with a number of civil society platforms. Viz.:
National Convener (Campaign for Survival with Dignity) working on Forest Rights Law-2002
Member of National Committee, People’s Campaign for the Right to Information
National Convener (National Front for Tribal Self Rule) working on Panchayats (Extension to the Scheduled Areas) Act 1996- 1993
General Secretary, Kamgar Va Majur Sangh, Trade Union of Migrant Labourers-1996
Leadership and Cadre Building for Peoples Organisations in MP, Odisha, Jharkhand, Chhattisgarh -1990
Mr. Prabhu shared his perspective on deepening democracy in India during the Mumbai, South Asian Regional Workshop during 20-22nd February 2013. Following are excerpts of his discussion with Dr. Abhijit Das, Director, CHSJ
AD: Seven years of National Rural Health Mission (NRHM) has in many ways revitalised health in India. NRHM has expanded funds, created a vision, provided a space to state and the district to undertake local planning, they have pushed for decrease in maternal deaths and infant mortality. Why do you think the benefits of NRHM have not been felt universally and why is it so low?
Pradip Prabhu: There is a need to see it through a different dimension. I will cite three examples The first example is related to community monitoring. Now there is a practice of the ANM announcing her monthly programme to the community members. In one of the meetings that I attended the ANM became nervous and started to cry, she cried because she suddenly realised that the people knew what her work was and what she was supposed to do. So in this case her trauma was because she was accountable for the work that she was supposed to do. The second example is from the district of Sundargarh in Orissa where the Block Supervisors were asked to do one activity and one effort on their own time. One Block Supervisor ‘Chabi Mohanty’ within six months brought down the IMR (which was high in the area) to zero. Chabi Mohanty did this by building a network of service providers at the community level and asked each of the service provider to take responsibility of following up in one village and ensure that each woman was provided with institutional delivery services. When the Chief Secretary of the state asked her why she did it, Chabi responded and shared that for the first time she felt that she was a citizen. In the third incident, evaluators who visited a PHC asked the Medical Officer present there as to where the Lady Medical Officer of the PHC was. The Medical Officer responded and said that he had asked her to go home and he could take care of the evaluation.
These three incidents reflect the true essence of how democracy is working in India. Schemes and programmes are being rolled out, but nothing has been done to change the mind set or bring attitudinal changes. We have not done any work to deepen democracy.

“These incidents reflect the true essence of how democracy is working in India. Schemes and programmes are being rolled out, but nothing has been done to change the mind set or bring attitudinal changes. We have not done any work to deepen democracy.”

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“The data that is provided depends on what is asked for, not necessarily the data that has been collected or collated. The whole problem (here) is how ‘rights’ have been constructed. Rights in India have been constructed in the property context, it is as if I enjoy rights against the whole world. The rights holder and the duty bearers in health look at each other as adversaries. So there is a need to address the fundamental concept of rights.”

Mahatma Gandhi promoted gram sabha or village self rule, while Nehru promoted bourgeoisie parliamentary democracy. Eventually Gandhiji lost and in the process we have created inefficiency an instrumentality that does not allow a discourse of citizens.
AD: Accredited Social Health Activists (ASHAs – village level health volunteers) and Village Health Sanitation Committees (VHSC) have been established in every village to support in strengthening and making health services more accountable. Are they dealing with their responsibility and deepening democracy by creating accountability and transparency?
Pradip Prabhu: I will cite another example here. Tamil Nadu is considered to be one of the progressive states. One of the District Welfare Officers (of Tamil Nadu) shared that when data is requested by the head office at the state level, the data that is provided depends on what is asked for, and not necessarily the data that has been collected or collated. The whole problem (here) is how ‘rights’ have been constructed. Rights in India have been constructed in the property context, it is as if I enjoy rights against the whole world. The rights holder and the duty bearers in health look at each other as adversaries. So there is a need to address the fundamental (concept of) rights. The mistake is of combining ASHAs who are duty bearers and VHSCs who are the rights holders, the ASHAs will align herself with the system and this will result in them looking at VHSCs as adversaries rather than allies. Rights can never be implemented, rights are always enforced, and so where health is concerned, rights will be enforced against the state. Majority of the ASHAs come from affluence and she represents the elite. Rights holder is constantly fighting against duty bearers. ASHAs are a theoretical mistake as she is a duty bearer. In theory it is difficult for ASHAs and VHSCs to work together. Community monitoring is a good attempt to bring the marginalised into mainstream.
In Nagaland, the Chief Secretary strongly felt that communitisation was the answer after the peace accord was signed and he promoted it. This has resulted in drastic improvement in service delivery. The salary of service providers at the community level goes through the Village Health and Sanitation Committee. It is not only health but also education which has been handed over to the village committees. Two things happened with community involvement- one government run schools became popular and second private schools slowly closed down. So the answer to bad government is not ‘no government’ but ‘more people and community involvement’.
AD: Today in India can we ask questions on performance, has a space been created to ask questions?
Pradip Prabhu: In the mind of the bureaucrat, accountability and transparency are disempowering. They do not see accountability and transparency as a process to stimulate community participation. Let me give you an example. In a remote PHC in Sundargarh, water was a problem and the Medical Officer did not have funds so he placed this issue in the Gram Sabha. The Gram Sabha took a decision and helped the PHC in accessing water by placing a 2kilometre pipe from the water source to the PHC. Here, the sharing of a problem with the community also generated a community solution.
For the maturing of a democratic process we need to create situations and places where questions can be raised continuously. Democracy allows people to participate in the discourse of power. This is possible only if people are given a voice. The Jan Sunwai (public hearing) is a platform which provides people this space.

Details about the South Asian Regional Workshop on 20-23 February 2013, can be found on the COPASAH website. For reports, photographs and session details, please CLICK HERE

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Strengthening Community Capacities, Evidence and Voice in Promoting Accountability and Social Justice in Health in Zimbabwe
Training and Research Support Centre (TARSC)

What motivates us?
TARSC’s objective is to provide training, research and support services to communities, community based groups and non-governmental organisations to develop capacities, networking and action and to interact with the state and private sector on areas of social policy and social development. We work with membership based civil society and public sector institutions to use a spectrum of tools for building knowledge linked to voice and experience of affected communities and actors, including participatory action research and community based research and monitoring. This is based on our understanding that knowledge and evidence of conditions at community level is essential to advancing socio-economic wellbeing and that the systematic processes that produce marginalisation and inequality also need to be challenged.
Different approaches but one goal
We recognise that knowledge and action is built from a range of approaches that are determined by context.
Community Monitoring: We use a sentinel site surveillance approach to gather evidence on key areas of social and economic rights such as health, education, income, employment, production, gender and food security. These issues are defined by civil society as priorities for state policy and practice and for watching private sector activities. Community monitors living in sentinel sites are drawn from membership based civil society.
Community Based Research: We have deeper rounds of community research on specific focused issues, such as waste management, primary health care, or social security. These issues reflect the concern of civil society or their members or were raised during the monitoring process. The research explores what should or could be done on the specific issue to feed into discussions and negotiations on actions or policies that could be taken as a result of the findings. The people gathering the evidence are more directly involved in the dialogue around the evidence and the actions that follow it.
Participatory Reflection and Action: We do work that gathers and uses evidence through participatory action research (PAR) in which community members affected by problems actively participate in

“This is based on our understanding that knowledge and evidence of conditions at community level is essential to advancing socio-economic wellbeing and that the systematic processes that produce marginalisation and inequality also need to be challenged.”

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“The pivotal factors which turn these potentially disabling factors into facilitators depends on the communities and their civil society organisations, specifically their leadership and levels of democracy, their capacity to support social dialogue and action, their consciousness and perspective, and their ability to forge trust and a sense of solidarity.”

gathering and reflecting on their own experience and evidence to identify actions, particularly the actions people can take themselves to produce change. For instance, in youth reproductive health issues (Auntie Stella) and through the Health Literacy Programme where we are raising direct action such as how communities and health workers can work more effectively together in responding to community health needs.
Community Photography: We have used community photography within the PAR work as another form of bringing community level evidence to the levels where it can influence local, national or regional policy dialogue, eg., through the Eye on Equity Work within EQUINET.
Lessons Learnt
The conditions that demand various forms of community monitoring relate to contexts of economic disparities, poor control over productive capacities and resources, dwindling state services and political uncertainty. Yet, these are also the contexts and conditions that disable this work! The pivotal factors which turn these potentially disabling factors into facilitators depends on the communities and their civil society organisations, specifically their leadership and levels of democracy, their capacity to support social dialogue and action, their consciousness and perspective, and their ability to forge trust and a sense of solidarity.
As a result of these processes, communities and civil society have managed to
raise specific problems, eg., unfair distribution of maize grain;
raise the profile or prioritization of issues in national policy documents and through policy debates, eg., on primary health care in the National Health Strategy;
raise information and perspective on specific issues, eg., responsibilities for tackling solid waste in local areas; and
raise direct action, such as how communities and health workers plan for work in the catchment areas of health centres.
These actions have had a positive impact on government responsiveness to specific issues, improvements in public services especially at community level, and increased empowerment of citizens in engaging with state actors. These approaches have the potential to bridge local issues into national policy dialogue.
At the same time, TARSC recognises that local level engagement and actions may not address structural determinants, building power around less fundamental determinants that are more accessible to local action while leaving key areas of state and private sector performance unchanged.

Article by: Barbara Kaim
Barbara Kaim is a Steering Committee member of COPASAH and also, Programme Manager at Training and Research Support Centre, Zimbabwe
To know more about the work done by TARSC, please CLICK HERE or mail at admin@tarsc.org

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Monitoring and Accountability Work to Enhance the Immunisation Coverage and Preventive Health Care Services for Roma Ethnic Minority in Macedonia

Summary
The process for improved immunization coverage of Roma children started since 2009. Thus in the period 2009 – 2010, a group of civil society organisations led by Association for Emancipation, Solidarity and Equality of women in Macedonia – ESE, conducted a situation analysis and advocacy strategy based on it, using the approach of applied budget work. The advocacy process resulted in adopting specific measures for increased immunisation coverage of Roma children in the Programme for active health care of mothers and children for 2011, which is a preventive health programme adopted by the Government and implemented by the Ministry of Health. The specific measures consisted of the following: additional visits by the outreach (community) nurse service in Roma communities aimed for identification of non-immunized Roma children, educational workshops on the topic of immunisation and child health aimed for Roma parents and conducted by the primary health care centers and printing of educational materials for immunisation on Romani language and their distribution in Roma communities.
After the adoption of the measures, there was a need for continuous monitoring in order to hold the Government accountable for the implementation of the provided measures for increased immunisation coverage of Roma children from the programme for active health care of mothers and children. The previous work of ESE regarding the applied budget work showed that the main obstacle in the accountability work is the lack of transparency of the Governmental institutions in the health care, which hinders the effort of the organisations to fully monitor the implementation of the different measures from the Programme. Thus, there was a need for introducing an additional monitoring mechanism, which will complement with the budget monitoring work. Because of that, since 2011, the community monitoring work was introduced in order to monitor the implementation of the activities aimed specifically for Roma minority within the Programme for active health care of mothers and children. For this purpose, four Roma CSOs have started the process of capacity building and implementing the community monitoring work, these are the following: Center for democratic development and initiatives – CDRIM; LIL - Association of educationists and for protection of the rights of women and children; Roma SOS – Roma association for multicultural affirmation; and CSO KHAM.
In the period 2011 – 2012 the Roma organisations conducted the community monitoring process in the Roma communities, while ESE continued with the budget monitoring process on national and local level. Findings from both monitoring processes showed that there is a lack of implementation of the adopted measures in the Roma communities, including the budget cuts and non proper budget execution.

“There was a need for continuous monitoring in order to hold the Government accountable for the implementation of the provided measures for increased immunisation coverage of Roma children from the Programme for active health care of mothers and children.”

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“Lack of education and poverty greatly hinders the access of Roma people to proper quality health care services, often facing hidden discrimination and violation of patients’ rights. These circumstances are leading to major health disparities among Roma people in regards to the majority of population, including higher prevalence of chronic diseases and shorter life expectancy in regards to the rest of the population”

Merging the findings from both monitoring processes showed how the budget cuts and the lack of commitment for implementation of the measures on national level reflects on local level and the negative impact that it has on Roma communities, regarding the lack of coverage with preventive health care services and insufficient immunisation coverage of Roma children, finally resulting in continuation of health disparities among Roma in regards to other ethnic groups in Macedonia.
Introduction
Roma minority1 represents marginalized group of population in Macedonia, from many different aspects, including socio-economic situation, education, employment, housing, social protection, health status and access to health care services. Lack of education and poverty greatly hinders the access of Roma people to proper quality health care services, often facing hidden discrimination and violation of patients’ rights. These circumstances are leading to major health disparities among Roma people in regards to the majority of population, including higher prevalence of chronic diseases and shorter life expectancy in regards to the rest of the population in Macedonia.
The health care system in Macedonia provides immunisation services and other preventive health care services (including outreach nurse visits and educational workshops) through the network of the primary health care centers, which are part of the primary health care level. The immunisation process, and the above mentioned preventive services, in Macedonia are guaranteed for every child that is living on the territory of the country and it is free of charge. Immunisation coverage rate of children in Macedonia on national level is above 95%, yet the research conducted by CSOs in 2010 showed that the immunisation coverage rate among children from the Roma ethnic minority is far lower and it varies from 35% to 85% for different vaccines. This situation resulted in several outbreaks of vaccine preventable diseases in the Roma communities throughout Macedonia in the period 2010 - 2011. This situation indicates that the general policies regarding the immunisation process are not sufficient to reach the children from the Roma ethnic minority, thus, justifying the need for adoption and implementation of specific activities aimed for Roma people, which will lead towards improved immunisation coverage of Roma people.
In the same period, Association ESE conducted a process of national monitoring of the implementation of the activities and budget execution of the Programme for active health care of mothers and children for 2011.
Community monitoring process
The community monitoring process in Macedonia is supported by Open Society Foundations – Accountability and Monitoring in Health Initiative (OSF – AMHI), and the consultant providing technical assistance in community monitoring approaches for the entire process was Dr. Abhijit Das from CHSJ, India. The entire process of community monitoring is coordinated by Association ESE, which also provides technical assistance to the other four organisations.
The Roma CSOs have started conducting the community monitoring process in eight municipalities in Macedonia, which are the municipalities where these organisations are based and have previous working experience. The municipalities are the following: CDRIM working in the municipality Shuto Orizari;

1 According to the last census (2002) total of 53.789 Roma people live in Macedonia, which represents 2,66% of the total population, yet other relevant studies show that the actual number of Roma people is much higher, and it varies between 80.000 to 135.000 people. This fact is mainly due to the fact that many Roma groups report themselves as members of other ethnic communities in front of the officials. Also Roma people represent the only minority where significant number of people are not officially registered in the state, although they live in Macedonia for generations.

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LIL working in the municipalities Gjorce Petrov, Saraj and Karposh; Roma SOS working in the municipality Prilep; and KHAM working in the municipalities Delcevo, Pehcevo and Vinica. Regarding the municipalities where the monitoring is conducted, the municipality of Shuto Orizari is the largest Roma municipality with majority of inhabitants belonging to Roma ethnic group, and is part of the city of Skopje, the capital of Macedonia. The municipalities of Gjorce Petrov, Saraj and Karposh are also part of the city of Skopje, municipalities of Delcevo, Pehcevo and Vinica are in the eastern part of the country and municipality of Prilep is in the central – west part of the country. Roma people in the last seven municipalities represent minority of the population and mostly living in separate communities from the majority of the population.
The community monitoring process started with capacity building process of the staff from the partner organisations, including ESE, KHAM, CDRIM, Roma SOS and LIL. The capacity building process started with two workshops on which the staff from the organisations were able to obtain knowledge regarding the basics of community monitoring and the various methods and tools used in the community monitoring process.
After the initial capacity building process the Roma organisations started with the implementation of the community monitoring process, which was delivered through the following steps: community mobilization, community inquiry and advocacy, including national and local level advocacy.
Community mobilisation
Despite the level of the marginalisation of the Roma people in Macedonia, there was a lack of social mobilisation and self-organisation among the Roma people. Numerous Roma based CSOs are working in the Roma communities and these CSOs are offering direct services for Roma, are representing the community and advocating on the behalf of the community. Thus, the process for mobilisation of the community in order for them to proactively seek their rights to health was firstly introduced with this concept.
In the initial phase of the community mobilisation each of the organisations identified individuals from the communities where they work, these individuals were either recognised as informal leaders, or they have a potential to have further influence the community. This process initiated with the exercise of “mapping the village”, which helped the organisations to identify the different settlements within the Roma communities, and to identify key persons from each settlement. For this purpose KHAM created three coordinative (informal) bodies in each community where they work, LIL created informal body from young volunteers and informal body from Roma mothers of minor children, Roma SOS created forum of parents in which Roma parents of minor children were included and forum of young people in which young Roma leaders were included, CDRIM also created group of volunteers and Roma mothers of minor children.
At the beginning, these groups from the communities were trained on the following issues: the rights for preventive health care services related to immunisation, specific measures aimed for Roma people from the Program for active health care of mothers and children and for all the aspects related to the process of immunisation. After this process, the informal bodies from the community helped

“Despite the level of the marginalization of the Roma people in Macedonia, there was a lack of social mobilization and self-organisation among the Roma people. Thus the process for mobilization of the community in order for them to proactively seek their rights to health was firstly introduced with this concept”

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“In the process of capacity building, the organisations working on community monitoring learned that it is essential to strengthen the community and to mobilise them in order for the community to be empowered to seek their rights for the health care services. This is important because only an aware and mobilised community can successfully advocate for their own rights”

the CSOs to prepare and implement the process of strengthening of the knowledge of the entire community regarding the above mentioned issue. Thus, in the communities where the four Roma CSOs work, large proportion of the Roma parents of minor children got familiar with their rights related to immunisation and other preventive health care services for their children. On the workshops and public discussions in the communities in several occasions, health staff from the primary health care centers were invited, which helped to start the discussion between the Roma community and health professionals regarding the rights and process of immunisation.
In the process of capacity building, the organisations working on community monitoring learned that it is essential to strengthen the community and to mobilise them in order for the community to be empowered to seek their rights for the health care services. This is important because only an aware and mobilised community can successfully advocate for their own rights.
Community inquiry
After the initial activities for community mobilisation and strengthening of the community, the four Roma CSOs in process coordinated and led by Association ESE started to prepare the methodology and tools for the community inquiry.
The main objectives of the community inquiry were the following: to assess the level of coverage of Roma people with the preventive health care services including immunisation coverage, visits by community (outreach) nurse, educational workshops for children’s health and immunisation, distribution of health promotional materials regarding immunisation and child’s health; to assess the satisfaction of Roma people with the previously mentioned services; to assess the main barriers that Roma people face when approaching immunisation services and other preventive health care services; and to assess the possible obstacles that prevent primary health care centers from fulfilling their duties regarding the preventive health care services.
For the purpose of conducting of the community inquiry, the following tools were prepared: questionnaire for interview with Roma parents, questionnaire for focus group discussions with Roma parents, questionnaire for exit interviews with Roma parents and questionnaires for interviews with health care workers from the primary health care centers, including immunisation department, outreach nurse unit and management. The prepared tools were first pilot tested in the Municipality of Delcevo. The experience from the pilot survey helped to further refine the tools, thus, after the testing the final versions of the tools were prepared.
In the meantime the four organisations in a process coordinated and assisted by Association ESE prepared the methodology for implementation of the inquiry on the field. For this purpose, each Municipality where the CSOs work was, was divided in several settlements for which the Community score cards were prepared. Thus, in total it was agreed that the inquiry will be conducted in 16 settlements and for each settlement a community score card will be prepared. Additionally health care workers from the primary health care centers in the same municipalities will be included in the inquiry.

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Through the inquiry total of 820 Roma people, parents of children aged 0 – 6 years, were included in the inquiry through the interviews, focus group discussions and exit interviews, as well as 15 health care workers from the primary health care centers.
After the conducted inquiry, organisations started to work on the methodology for preparation of community score cards. For the purpose of assessment in the score cards, the following categories were defined: coverage with health care services related to immunisation; outreach activities (including educational workshops and educational materials); knowledge of Roma people regarding the immunisation, right to immunisation and process of immunisation; access to health care services related to immunisation; delivery of invitations for vaccination; quality of services for immunisation; communication of medical staff with Roma people; activities for identification of non-immunised children; payments; services delivered by the community (outreach) nurses; activities delivered by the Institute for health care of mothers and children; and assessment of the immunisation status of Roma children.
It was agreed that the results in the community score cards will be processed in order to obtain final results in a form of a traffic light. For this purpose, a system of allocating points for all the obtained answers was prepared along with a system for calculating the allocated points into percents, with assigning proper weight of the data collected from the different sources. Thus, percents were calculated for each of the above noted categories, in the meaning that the 100% is the most desirable condition. For the purpose of translating the results into traffic lights, it was agreed that results below 35% (less desirable situation) will be translated into red color, results from 36 – 75% (partially desirable situation) into yellow color and results above 75% (desirable situation) into green color. Three of the organisations decided to merge the findings from the Roma people and health care professionals into the same score card in order for both perspectives to be presented in the card, although appointing smaller weight to the answers received from the health professionals. One organisation decided to prepare separate score card for the results received from the community and separate score card for the results from the health professionals.
After the preparation of the community score cards and the translation of the results into traffic lights, the organisations conducted a process of validation of the results with the community. For the purpose of the validation process, the results were presented in front of a broader group of members of the community. The members of the community agreed with most of the results, but yet in several occasions they have confirmed that some of the results need to be changed. Overall, results in most of the community showed that there is lack of community (outreach) nurse visits in Roma settlements, that there is a lack of educational workshops in Roma communities and that there is a lack of educational materials distributed among Roma people. In most of the communities one of the main problems is that they do not receive at all or not regularly the invitations for immunisation, which are sent through the post service. Also ,the inquiry shoved that the coverage of Roma children with immunisation is far below the national average of immunisation coverage of children. For the purpose of illustration of the final presentation of the result through a score card in this article a score card for three Roma settlements is shown in Table 1.
In the capacity building process, the involved organisations learned the methodology for conducting the community inquiry and the preparation of the results in a form of a community score card.

“After the conducted inquiry organisations started to work on the methodology for preparation of Community score cards. Overall, results in most of the community showed that there is lack of community (outreach) nurse visits in Roma settlements, that there is a lack of educational workshops in Roma communities and that there is a lack of educational materials distributed among Roma people.”

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Local level advocacy goals of the organisations:
CDRIM’s advocacy efforts were aimed towards improved delivery of invitations for vaccination for Roma children, improved hygiene in the Primary health care center and improved relationship between doctors and Roma people;
LIL’s advocacy efforts were aimed towards improved coverage of Roma people with outreach (community) nurse visits and for improved delivery of invitations for vaccination to the Roma children;
KHAM’s advocacy efforts were aimed towards improved coverage of Roma people with outreach (community) nurse visits, towards providing services from pediatrician in one of the municipalities and establishing a health post at the village of Crnik for offering primary and preventive health care services;
Roma SOS’s advocacy efforts were aimed towards improved immunization coverage of Roma children by improved delivery of invitations and raised awareness of Roma people for the process of immunization.

They have all learned that it is essential that the community should be involved in all of the stages of the preparation of the inquiry, conduction of the inquiry and in the preparation of the final results. An important emphasis was given that the final results must be shown in a manner that is easily understandable for the community and through which the community can easily identify problems and monitor the future progress.
Budget monitoring
In the period of 2011 - 2012, parallel with the community monitoring work, Association ESE conducted a national level monitoring of the implementation of the Programme for active health care of mothers and children using the applied budget work approach. In this course, data was collected and analyzed to explore whether the activities aimed for Roma in this Programme were properly implemented on national level and whether the funds allocated for these activities were spent according to their allocation. For the purpose of monitoring, the data was collected through submitting requests to the Ministry of health according to the provisions from the Law for freedom of information. The national level monitoring of the Programme, showed that during the period of 2011, with amendments to the Programme, the activities aimed specifically for Roma people were reduced, in means of scope and budget, and were merged with the activities aimed for other vulnerable groups (rural population and poor people). Despite of the reduced scope and budgets, until the end of 2011, the activities aimed for Roma were not fully implemented and part of the funds aimed for these activities remained unspent. The main challenge during the monitoring of the Program on national level was the delivery of poor quality data, from the Ministry of health, regarding the Programme’s implementation. Often the delivered data was incomplete, confusing or inconsistent.
Advocacy
The partner organisations jointly prepared national level advocacy strategy using the findings from the community monitoring and national level budget monitoring of the Programme for active health care of mothers and children. Based on the findings the following national level advocacy goals were set: adoption and implementation of measures for additional community (outreach) nurse visits in Roma families; adoption and implementation of health education workshops in Roma communities; translation of health educational materials in Romani language and their distribution among Roma communities; proper delivery of invitations for vaccination in Roma communities through employment of couriers for invitation delivery from the members of Roma community; adoption and

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TABLE 1

Category	Roma Settlements
	Settlement Dame Gruev/ / Municipality Gjorce Petrov	Settlement Svinjarnik/ / Municipality Saraj	Settlement Zlokukjani/ / Municipality Karposh
Coverage with health care services related to vaccination	50%	30%	42%
Outreach activities in the Roma communities, implemented by the Primary health care centers (educational workshops and distribution of educational materials)	19.8%	21%	21.8%
Knowledge of Roma people regarding the vaccines and the vaccination as a process	55.66%	41%	49.6%
Access to the health care services for vaccination	70.4%	43%	45.4%
Delivery of invitations for vaccination	9%	2.5%	25.6%
Quality of health care services related to vaccination	83.9%	54.3%	66.5%
Communication of health care staff with the Roma population	79.3%	37.83%	55.3%
Identification of non-immunized Roma children	87.2%	56.66%	94.4%
Payments of the Roma people related to access to immunization services	67%	37.48%	22.5%
Services delivered from the outreach (community) nurse	59.7%	36.16%	51.6%
Level of coordination between the different departments related to immunization process	87.5%	87.5%	87.5%
Implementation of the activities from the Program for active health care of mothers and children and services delivered by the Institute for health care of mothers and children (from the perspective of the Primary health care center)	60%	60%	60%

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“After the conducted national level advocacy the Ministry of health and the Government adopted additional measures aimed for increased coverage with preventive services of Roma people in the Programme for active health care of mothers and children, including the following: additional outreach nurse visits in Roma communities and educational workshops for childrens’ health and immunisation in Roma communities.”

implementation of activities aimed for active screening of the Roma communities in order for identification and immunisation of non-immunised Roma children. At the end of 2012 the national level advocacy process was conducted. For this purpose the organisations have identified the following relevant target stakeholders for the advocacy: member of a Cabinet from the Ministry of health, Member from the Ministry of health responsible for implementation of Roma related health policies within the Ministry, Minister without portfolio – responsible for the implementation of the activities from the Decade for Roma Inclusion in Macedonia. For the purpose of advocacy process a policy brief was prepared, including the findings from the monitoring processes and recommendations for improvement of the situation, and it was submitted to the Ministry of health and to the Government. Also direct meetings were held with the identified relevant stakeholders where the organisations presented the findings from the monitoring and the need for adoption and implementation of specific measures.
Additionally, each of the local organisations started local level advocacy strategy according to the specific problems and needs identified within each of the municipalities. So, the organisations conducted activities for local advocacy in total of eight municipalities. Regarding the local level advocacy process, each of the organisations has chosen to advocate for different issues (shown in the Table 1). For the purpose to illustrate the type of the local level advocacy work that the organisations were conducting, as an example for this article the local advocacy efforts of the CSO KHAM are described, in one of the municipalities where they work.
After the conducted national level advocacy the Ministry of health and the Government adopted additional measures aimed for increased coverage with preventive services of Roma people in the Programme for active health care of mothers and children, including the following: additional outreach nurse visits in Roma communities and educational workshops for childrens’ health and immunisation in Roma communities. Unfortunately the provided measures are not adequately followed with proper budget allocations. In another preventive programme, the Programme for regular medical checkups of school children and students, the Ministry of health and Government adopted measures for field identification of non-immunised school age Roma children that have dropped out of schools, yet again these measures are not followed with proper budget allocation.
Currently, the organisations are working on a process of planning of the advocacy activities on local and national level for 2013.
In order to foster the monitoring and accountability work, the organisations in Macedonia are planning to further build their capacities in the field of social audit. We believe that the implementation of this methodology will greatly contribute to the strives of the Macedonian CSOs to increase the transparency and accountability of the Government and governmental institutions and to improve the service delivery on the field.

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CSO KHAM works in the municipality of Pehcevo, including the village of Crnik, which is one of the rare villages in which majority of population are Roma, since in Macedonia Roma are mostly based in urban communities, living in isolated communities on the outskirts of the cities. During the community monitoring work, the representatives from KHAM found out that the only pediatrician in the Municipality of Pehcevo is retired in 2012 and there is no other Pediatrician in the municipality to replace her. In the same time in the village of Crnik there is no health post, so parents must take their children for immunization in the town of Pehcevo which is located several kilometers from the village. These two problems represent great obstacles for access to immunization services for Roma people, but also for the entire population in this municipality and in the village of Crnik. Thus KHAM decided to address these two problem with the advocacy in Municipality of Pehcevo. For this purpose the local coordinative body consisted from representatives from KHAM and Roma people started a discussion with the Director of the Primary health care center in Pehcevo regarding the issue of lack of pediatrician in Pehcevo. They found support from the Director and reached mutual agreement that the Primary health care center from Pehcevo will send an official request to the Ministry of health in order for the Ministry to approve specialization for pediatrician for Pehcevo. Regarding the issue of lack of primary health care services in village of Crnik, the coordinative body worked together with the Roma community in the village and they have prepared and signed a petition with which the people from Crnik are requesting that a health post should be opened in the village in which doctor and nurse should be working. The health post will provide primary health care services including services for preventive health care and vaccination. The petition was signed by around 300 people and it was submitted to the Primary health care center in Pehcevo and to the Local branch of the Health insurance fund in Pehcevo, in order for these institutions to forward it to the Ministry of health and the National office of the Health insurance fund. The community mobilization and community empowerment process which was conducted by KHAM enabled the Roma community in this village to became aware about their rights and to clearly articulate their problems and to demand the needed change. Thus they have actively participated in all the efforts for ensuring the proper health care services in the village of Crnik.

Article by: Dr. Borjan Pavlovski
Dr. Borjan Pavlovski is a medical doctor and graduated from the Faculty of Medicine of the University “Ss. Cyril and Methodius” in Skopje, Macedonia and is currently pursuing his Masters of Public Health, at the Medical faculty in Skopje. Dr. Pavlovski works in Association for emancipation, solidarity and equality of women in Macedonia – ESE, as Programme coordinator of the programme for public health and women’s health. Dr. Pavlovski’s interest include public health, especially focused on improvement of health status, health rights and access to health care services of marginalised groups of population, including Roma minority, especially women. Dr. Pavlovski also works on the field of improvement of transparency and accountability of the Government, especially in the health care sector.
To know more about the work of ESE, please CLICK HERE

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COPASAH Communique

Expanding Accountability Work to the Provincial and National Level in Guatemala

“Through this work, it has been identified that lack of medicines and availability of emergency transport are among the most pressing issues in all municipalities implementing accountability. Through meetings with local health authorities and municipal government, it became clear that these two problems are systemic and structural.”

For the past 5 years, CEGSS has supported community based organisations from rural indigenous areas, to implement accountability in health work at municipal level (local government). Through this work, it has been identified that lack of medicines and availability of emergency transport are among the most pressing issues in all municipalities implementing accountability. Through meetings with local health authorities and municipal governments, it became clear that these two problems are systemic and structural. For instance, local health facilities depend entirely from provincial and national health authorities for allocation of medicines. The space for action among local authorities to resolve the problem of availability of medicines is therefore very limited. Emergency transport faces a similar situation. Where in some municipalities there may be ambulances, there are no public funding allocated to pay for petrol, hence families requiring emergency transport must bear petrol costs, which can be hefty due to distances from rural areas. Other municipal governments are willing to cover the cost of petrol, however there is no ambulance. Hence, families are required to hire private transport to move relatives to referral hospitals.
Leaders of the 15 citizens’ health councils met early in January to discuss the above situation and decided to expand the accountability in health work to the provincial and national level. An action plan for the year 2013 was agreed that includes:
Meetings with national authorities, members of parliament and the national ombudsman. In these meetings, community leaders will present the systemic and structural problems that affect the delivery of medicines and emergency transport at local level.
Seeking an alliance with social movements working at national level.
Involving non-profit social media with the aim to help the documentation and dissemination of the problems being faced by rural indigenous families while seeking healthcare and requiring emergency transport. Also to document the response of national authorities once these demands are being presented to them.
CEGSS and the community leaders we work with are clear that expanding from local to provincial and national level imposes new challenges and require different skills. For instance, the politics at municipal government are very much different from the politics at national government; community leaders will have to acquire knowledge and understanding of the role of national and provincial government in public policy decision-making and longer and frequent travels from their rural communities to the capital city will now be required.
While we advance in this endeavor, the CEGSS team will document in detail those challenges, our responses (activities, capacity-building, social mobilisation) and the outcomes of our actions. We are expecting that a systematic documentation, will allow us to plan strategic advocacy and at the same time facilitate the learning process out of this new phase of our work.

Article by: Walter Flores
Walter Flores is a Steering Committee member of COPASAH and also, Director of CEGSS, Guatemala.
To know more about the work of CEGSS, please CLICK HERE

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South Asian Practitioners Workshop in India on Community Monitoring for Accountability in Health

Today civil society practitioners, exponents of development and even some of the government functionaries are convinced that community based monitoring (CBM) is one of the real instruments to ensure quality service delivery of the government schemes and programmes for the poor, and deepen democratic process by making the officials accountable; however the main challenge is the lack of acceptance by the government at all levels as well as the involvement of the community in its implementation. In India, the process has begun for quite some time, and has met with some success in different pockets of the country, on the other hand it is yet to take roots and spread all over the communities and villages. We have a long way to go to make it a natural process of functioning democracy.
As a part of the COPASAH initiative a dialogue on community monitoring and accountability in health was organised in Mumbai during February (20-22) 2013. In this workshop, practitioners shared their experiences of community based monitoring both from a health system and community perspectives so as to develop an understanding for enhancing the quality of care within public health programming. The initiative brought out both hopes and challenges faced by the South Asian countries. A total of 30 participants from 9 states in India (Bihar, Chhattisgarh, Jharkhand, Gujarat, Maharashtra, Odisha, Madhya Pradesh, Uttar Pradesh and Tamil Nadu) and two South Asian countries (Bangladesh and Nepal) participated in the three days workshop. The four facilitators who moderated and generated interactive dialogues and debates in each of the session were Dr. Abhay Shukla, SATHI; Dr. Abhijit Das, CHSJ, Renu Khanna, SAHAJ and Jashodhara Dasgupta from SAHAYOG. Presentations by key speakers, panel discussions, talk shows, small group discussions/exercises were undertaken; each of the session was participatory to ensure the voices and experiences of the practitioners were heard. The community shared the real stories and struggles in the workshop and put forth issues faced by the communities, CSOs, and development practioners. Advantages and disadvantages of various methods of Community monitoring—participatory planning, budget accountability, community score card, and social audit -- were discussed and suggestions were offered on how to overcome such obstacles and build understanding and trust between communities and authorities, beneficiaries and service providers. Through examples, various CSOs (for example, ICDDRB’s work in Chakaria, Bangladesh; Beyond Beijing’s work on community monitoring in Nepal; and within India Sochara from Chennai, Masum from Maharashtra; MSAM in UP) discussed their role in community mobilization for their involvement in government planning, implementation and the problems faced by them both from government authorities and communities. Nevertheless, they have helped in activating the process. The case of Nagaland shared by eminent speaker Dr. Pradip Prabhu is a positive example where the Chief Secretary strongly felt that communitisation was the answer to peace accord and he promoted it. This has resulted in drastic improvement in service delivery.
One of the greatest hurdles as Pradip Prabhu highlighted during his plenary session was the fact that the rights

“Presentations by key speakers, panel discussions, talk shows, small group discussions/exercises were undertaken; each of the session was participatory to ensure the voices and experiences of the practitioners were heard. The community shared the real stories and struggles in the workshop and put forth issues faced by the communities, CSOs, and development practioners.”

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“The participants strongly felt that community monitoring processes have met with substantial resistance at all levels, and there is a need to push for stronger mechanisms to not only support in mobilising community and creating awareness about their entitlements but also push for recognised spaces for the community voices to be heard for effective action and guaranteed health services.”

holder and the duty bearers in health look at each other as adversaries. There is also a problem of perception. Sandhya Mishra from MSAM rightly shared, “There is a difference between how community monitoring is perceived at different levels; as practioners, we see it as a way to deepen democracy; however government sees it as feedback (consumer client mode). Government is paternalistic and limits the liberty or autonomy of the community. As a practitioner we talk about accountability and citizen’s voice and with a paternalistic government it becomes very difficult to activate this voice.” The resistance from local officials is a difficult challenge and requires community action.
Community involvement found ways through various forms such as Jan Sunvai (people’s hearing) and Jan Samvads. In Odisha, it was changed from community monitoring to community action for wider acceptance at all levels. In Jharkhand, a block training team was established and traditional folk artists were used for community mobilisation. In Maharashtra, CBMP representatives participated in Rogi Kalyan Samitis (Patient Welfare Committee) meetings to suggest community health priorities.
Community involvement in the state-society dynamic needs to be seen as a cooperative and smoothening process in democracy, and not as adversaries, but such a result seems to be a long struggle. Given the broader context of increasing privatisation of health services, dominance of market forces, corruption at all levels in the service delivery process, lack of response from the government, and cynicism of the community, it becomes all the more difficult to mobilise communities on a sustained basis. Further it is also a difficult task to change the perception of the government officials toward community monitoring as an integral part of development policies and programmes. The participants strongly felt that community monitoring processes have met with substantial resistance at all levels, and there is a need to push for stronger mechanisms to not only support in mobilising community and creating awareness about their entitlements but also push for recognised spaces for the community voices to be heard for effective action and guaranteed health services.
Government’s perception at national, state and local levels needs to be changed through dialogue, discussion, protests, and social mobilisation. The workshop brought out the perception, resistance and progress from both sides through narration and analysis by development practitioners. Knowledge sharing across states and neighbouring countries helped in strengthening solidarity for this common cause and also encouraged in learning about innovative ways to deal with the challenges, as Santosh from Sochara, Tamil Nadu aptly stated, ‘the government will only provide health services but our responsibility is to promote health rights’. This workshop was a small step in this struggle toward achieving this goal.

Article by: Ms. Sarita Barpanda
Sarita Barpanda is working as Programme Director in Centre for Health and Social Justice and coordinating all work relating to governance and accountability related to the health sector at CHSJ.
To know more about the workshop, please CLICK HERE
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Are 24 x 7 PHCs in Maharashtra Really Providing Services Round the Clock?

Background
For people in rural areas, Primary Health Centers (PHCs) represent the first point of contact with a doctor in the public health system. PHCs were established in rural areas for providing the full range of primary health care services to the community. The provision of Maternal and Child Health services including emergency obstetric and neonatal care are an integral part of the services to be provided by the PHC. Keeping this in mind, NRHM has planned to strengthen PHC services by upgrading a significant proportion of PHCs to provide round the clock (24 x 7) services.
At present, in Maharashtra, out of a total of 1809 PHCs, only 397 (about 22% of all PHCs) have been upgraded to 24 x 7 PHCs1. This needs to be viewed in context of the intention expressed in the RCH‐II programme that 50% of PHCs should be made functional 24 x 7 by 2010.2 Services such as 24‐hour delivery services (normal and assisted), essential newborn care and referral for emergencies are critical for labeling any PHC as one that provides round the clock health services.
Process of data collection through SMS
Hence, to assess actual round the clock availability of Medical officer and nurses in 24 x 7 PHCs, a quick survey was conducted by gathering data in CBMP areas from covering 25 PHCs supposed to be providing 24 x 7 services, located across 12 districts of Maharashtra. A community based monitoring and planning (CBMP) block coordinator / facilitator or village health committee member visited each PHC on 23rd January 2013 between 9pm and midnight and enquired about availability of the medical officer and staff nurse / ANM. Information generated was collated by means of SMSs sent from across the state using mobile phones. On 23 January 2013, data was also gathered from 24 PHCs which are ‘non 24 x7’ to assess their status, as a comparison. In addition to this, informal discussions with doctors and nurses working in 24 x 7 PHCs were held to understand aspects related to their availability in PHCs.
Analysis of data
The following criteria were used for the analysis, based on presence / availability of medical officer and staff nurse / ANM at time of visit between 9 pm and midnight on the designated day:
Both doctor and nurse were present, or nurse was present and doctor was available on call in the PHC: classified as Good situation
Neither doctor nor nurse was present but when called, doctor could come to the PHC: classified as Partly satisfactory situation
The doctor was neither present, nor did s/he come to the PHC when called: classified as Unsatisfactory situation.
Key findings regarding availability of doctors and nurses in the studied PHCs are summarized below‐
Out of 25 PHCs designated as having 24 x 7 services, it was observed that in 11 (44%) of the PHCs doctor and nurse were both present, or nurse was present and doctor was available on call in the PHC.
This means that in 44% of the 24 x 7 PHCs, the situation was found to be Good.
In 4 (16%) PHCs, neither doctor or nurse was present but when called, the doctor could become available in the PHC.
This means that in 16% of the studied 24 x 7 PHCs situation was found to be Partly satisfactory.

“Out of a total of 1809 PHCs, only 397 (about 22% of all PHCs) have been upgraded to 24 x 7 PHCs. Services such as 24‐hour delivery services (normal and assisted), essential newborn care and referral for emergencies are critical for labeling any PHC as one that provides round the clock health services.”

1 http://www.mohfw.nic.in/NRHM/Documents/24x7_PHC_Maharashtra.pdf
2 http://mohfw.nic.in/NRHM/Documents/MH/Guidelines_for_operationalising_24_hours_functioning_PHCs.pdf

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COPASAH Communique

“In spite of the availability of all basic infrastructure, sometimes staff refuses to stay in quarters. This is linked to their attitude towards work. It is necessary to change their
negligent attitude and remind them about their responsibility to provide health services.”

While in 7 (28%) PHCs doctors were neither present nor did they come to the PHC when called and 3 (12%) PHCs were observed to be closed.
Hence, the situation was Unsatisfactory in 40% (10 PHCs) of the 24 x 7 PHCS.
In case of the non 24 x 7 PHCs studied, the situation was Good in 7 (29%) PHCs, the situation was Unsatisfactory in 7 (29%) PHCs, out of which 4 (16%) PHCs were found to be closed. In 10 (42%) of these PHCs situation was found to be partly satisfactory.
Informal discussions with some doctors and nurses working in the studied PHCs from across 12 districts were held to understand factors related to their availability in PHCs.
Opinions were taken about relevant factors from doctors and nurses who stay in the 24 x 7 PHCs Quarters and PHC that have proper Infrastructural facilities‐ ‘The PHC as well as quarters have basic infrastructural facilities such as water, electricity, lights. So we are able to stay here’.
Attitude of staff‐
‘In spite of the availability of all basic infrastructure, sometimes staff refuses to stay in quarters. This is linked to their attitude towards work. It is necessary to change their
negligent attitude and remind them about their responsibility to provide health services’.
‘Our PHC is located close to the highway. Injured patients may enter any time in the PHC. So I have to stay in the PHC quarter’
‘Staying in PHC quarters is always useful in terms of gaining patients' faith by providing them round the clock services’.
Opinions about relevant factors from doctors and nurses who do not stay in the 24 x 7 PHCs
Shortage of humanpower‐
‘PHCs have been upgraded to 24 x 7 PHC but additional staff is not provided. The ANM alone has to handle OPD, IPD and deliveries. In some places, ANM positions are vacant. Given this situation, the staff tends to lose the spirit of the work. Hence, it is necessary to make provision of additional manpower to provide 24 x 7 services’.
PHC quarters not adequate‐
‘Many PHCs do not have quarter facility and others have few in numbers. Hence only one doctor and one or two other staff members can stay there. If number of quarters is increased then all staff can stay there and provide round the clock service’.
Quarters completely lack basic facilities –
‘The situation of staff quarters is quite poor. The building is very old. Its maintenance is overdue. Who will ensure staff’s safety if they stay here?’
‘When the PHC does not have its own independent building, provision of staff quarter is miles away from the PHC.’
Political interference‐
‘Sometimes certain staff refuse to stay in the quarters, they are able to get away with this due backing received by them from local political representatives.’
The above data show that the overall situation about the availability of doctors and nurses in the 24 x 7 PHCs is not as per expected in over half of these PHCs. Quotes from staff about factors influencing their availability in PHC show that attitude of doctors towards health service, shortage of humanpower, lack of quarters or lack of basic facilities in the quarters, location of PHC being far from the place of

Table ‐1: Availability of doctors and nurses in selected 24 x 7 and non‐ 24 x 7 PHCs
On comparing 24 x 7 PHCs with non 24 x 7 PHCs, data suggest that the situation of availability of skilled staff in 24 x 7 PHCs might actually be worse than non 24 x 7 PHCs in some respects. In non 24 x 7 PHCs the situation was Unsatisfactory in 29% of the PHCs, while in 24 x 7 PHCs the situation was Unsatisfactory in 40% of the PHCs.

	24 x 7 PHCs (sample‐ 25)	Non‐24 x 7 PHCs
Good situation	44%	29%
Partly satisfactory situation	16%	42%
Unsatisfactory situation	40%	29%

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stay provided and political interference are certain attitudinal and systemic reasons behind this.
While upgrading of PHCs to provide 24 x 7 services is definitely a laudable effort, it is clear that mere sanctioning of 24 x 7 PHCs is not enough. Provision of all basic facilities and sufficient human-power in these PHCs is essential to enable them to provide services round the clock. While the health department is promoting institutional deliveries to be conducted in all PHCs to reduce maternal and neonatal mortality, in reality, even half of 24 x 7 PHCs are not able to provide round the clock services.
The following are the recommendations being made to strengthen the services offered by 24 x 7 PHCs‐
Basic infrastructural facilities such as continued supply of water and electricity, telephone, proper building for PHC, staff quarters have to be prioritised. Equipments and medicines required for care during deliveries and emergencies must be available in the PHC. Complaints regarding staff quarters should be addressed as a high priority as it is directly linked with the availability of staff in the PHC.
As mentioned in the guidelines, at least 2 doctors (medical officers) and 3 nurses / ANMs should be placed (preferably recruited on a permanent basis) in these PHCs.
The actual number of deliveries performed during day and night time should be reviewed periodically at the block and district level. The number of deliveries performed during the day (9 am‐5 pm) and night (5 pm‐9 am) should be separately recorded in the MIS. Surprise visits during off duty timing should be made by concerned officials in case of PHCs that are performing lower than expected number of deliveries during night hours.
If villagers or CBMP implementing organisations present complaints regarding inadequate functioning of 24 x 7 PHCs, these should be addressed and resolved in time bound manner by block and district level health officials.
Permanent staff should be recruited and deployed to the maximum extent possible, rather than employing contractual staff.
Overall, this situation raises the question whether 24 x 7 PHCs are really providing round the clock health services. Keeping in mind the above recommendations, immediate steps should be taken at all levels towards strengthening of 24 x 7 PHCs. Only then will all of these 24x7 PHCs be able to live up to their designation.

“Basic infrastructural facilities such as continued supply of water and electricity, telephone, proper building for PHC, staff quarters have to be prioritised. Equipments and medicines required for care during deliveries and emergencies must be available in the PHC. Complaints regarding staff quarters should be addressed as a high priority as it is directly linked with the availability of staff in the PHC.”

Article by: Dr. Abhay Shukla
Dr. Abhay Shukla is Steering Committee member of COPASAH and also, Coordinator, SATHI.
This survey was carried out by district and block nodal organisations implementing community based monitoring and planning in various districts of Maharashtra, supported by NRHM. Coordination of data collection, analysis, report writing and translation has been done by SATHI team members. Technical facilitation of SMS based information management by Nidhi Vij is gratefully acknowledged.
To know more about the work of SATHI, please CLICK HERE

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COPASAH Communique

Community Action for Health in Tamil Nadu

“After the pilot phase, the team including Government of Tamil Nadu decided to change the name from Community Monitoring and Planning to Community Action for Health. It is important to note that the name of the process was changed from CMP to CAH, to emphasize that without action the process is incomplete and that the whole process rests on the tenet of participatory approach with openness and spaces for reflection.”

“Community Action for Health (CAH)”, is a continuation of a pilot process known as Community Monitoring and Planning (CMP) that was implemented as part of the communitisation aspects of National Rural Health Mission in Tamil Nadu. After the pilot phase, the team including Government of Tamil Nadu decided to change the name from Community Monitoring and Planning to Community Action for Health. The process is jointly implemented by the member organisations of “Makkal Nalavalvu Ekkam” (PHM of Tamil Nadu Chapter), Public Health Department of Tamil Nadu and Panchayati Raj Institutions.1
It is important to note that the name of the process was changed from CMP to CAH, to emphasise that without action the process is incomplete and that the whole process rests on the tenet of participatory approach with openness and spaces for reflection.
Currently community monitoring is being implemented in 6 districts, in each district covering 2 to 3 blocks (14 blocks in total). All the villages (3752) under 446 panchayats spread across these 14 blocks are being covered by the project. Hence 54 PHCs, 297 HSCs and 1721 ICDS centers are also covered.
In Tamil Nadu the project is implemented through a state nodal organisation (SOCHARA) along with partnership of district and block nodal NGOs. The state health society (SHS) and the Director of Public Health and preventive medicine (DPH) were joint signatories on the MOU with SOCHARA, and have appointed nodal officers in their respective departments to work with the process. The implementers group, work with the aim to actualise the concept of communitisation that involves increasing the ownership of the community on the health system. The combination of increased ownership, utilisation, sharing of responsibility and accountability will contribute to strengthen the health system and achieve the goals of NRHM.
The key steps followed are:
Identification of volunteers to be members of Village Health Water and Sanitation Committee (VHWSC): VHWSC has been expanded in order to include wider representation of all groups on equity basis and geographical areas of the panchayat. This expansion was done by holding meetings in all hamlets by explaining the process to the people and ensuring

1 The Panchayati Raj Institution is the system of local government in India. The Government of India has decentralised several administrative functions to the local level empowering elected representatives.

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volunteers are involved in the process.
Orientation and training for VHWSC member: Orientation training was provided to all the members of the VHWSC. Monthly meetings to ensure handholding support was provided to the VHWSC members, and this helped in ensuring that from each panchayat 4 to 5 people were intensively trained in community monitoring and accountability process.
Monitoring process: Monitoring was done by the VHWSC committee members; support was provided by the state nodal NGOs and its partners. Tools were developed by the state nodal NGO in consultation with other partner NGOs, health department and community members. The community members actively participated in the process and supported the assessment of the services available at the village and PHC by the people.
Reflection of the monitoring data through health card: The collected information is collated into the panchayat health report card. These report cards are visual and are colour coded. The green signifies good, yellow signifies the need for further improvement.
Panchayat Health Planning Day: The VHWSC members present the panchayat health report card to representatives of the public health department including the village health nurse, PHC medical officer, the panchayat president, the ICDS workers and members of the community. During this meeting, the questions / sections receiving a ‘Red’ color are discussed in detail with an aim to improve service and ensure that the ‘red’ changes to ‘green’ in six months. Thus, a panchayat health plan is developed and is shared with officials at the PHC, block and at district level, and with support from them the plan is rolled out. Every month the VHWSC committee meets to discuss the follow up actions that is required for a particular action processes. The whole monitoring and planning cycle is repeated every six months.

“During this meeting various questions / sections receiving a ‘Red’ color are discussed in detail with an aim to improve service and ensure that the ‘red’ changes to ‘green’ in six months. “

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COPASAH Communique

“Periodically exit poll and opinion polls are conducted at the primary health centers and district hospitals. This supports the community monitoring process and validates the community monitoring process. The process has also given space for village health nurses not only to understand CAH but have also helped them to utilise the VHWSC for awareness building and mobilising communities under various health programmes. Thus it acts as a bridge between the health system and the community.”

Block Federation: Selected VHWSC members represent in the federation that is formed at the block level involving health officials, panchayat chairman (at block level). This helps in cross learning as well as identifying health care services which can be rated as good. This also helps the weaker service delivery point in improving services.
Civil society institutions have played a key role in pushing forward the community monitoring process in Tamil Nadu.
Some of the key activities supported by civil society organisations are:
Building capacity of the VHWSC members (thereby creating human resources to promote health). This is done in collaboration with the local health staffs.
Facilitate and provide handholding support to the VHWSC to roll out the community monitoring activities.
Mass awareness and sensitization about the potential impact of the process.
Supporting VHWSC members to sustain the process.
Support community members to undertake regular dialogue with the decision makers of the health system. This has enabled the VHWSC to strengthen the health service delivery points not only at the community level but also at the block, district and state level.
Periodically exit poll and opinion polls are conducted at the primary health centers and district hospitals. This supports the community monitoring process and validates the community monitoring process. The process has also given space for village health nurses not only to understand CAH but have also helped them to utilise the VHWSC for awareness building and mobilising communities under various health programmes. Thus it acts as a bridge between the health system and the community.
Some of the key constraints or challenges for implementing CAH is as follows:
The VHWSC members mostly being women, attend the MNREGA work and depend on these wages and thus, when meetings and work are expected to be carried out by them it reduces their involvement and participation amidst their insecure economic conditions. In such situations, one of the big challenges is the sustainability of VHWSC without or with only limited handholding by the civil society.

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Communities are riddled by caste and gender differences, this obviously affects the full implementation of the process.
The lack of transport facilities from remote areas is another constraint for the mobility of the members both between villages in the panchayat and between their village and PHC.
Training the project staff in the lights of a community health and movement with the ideologies of democracy and social action is always been difficult and the fact is that the CAH itself is new to them and nurturing them towards movement oriented approach from the project oriented approach is very challenging.
Similarly orienting the health staffs and PRIs and making them involved in the CAH process is a great challenge because of their perceptions and attitudes.
Though in the state of Tamil Nadu, state health administration have focused on expanding community monitoring to cover the entire state; health administration and officials do not have much faith or trust in community monitoring exercises.

Article by: J.S. Santosh, Sochara, Tamil Nadu
Mr. Santosh is currently working as Research and Training Assistant in SOCHARA, Tamil Nadu, India. He has been involved in Community Action for Health in Tamil Nadu for the past year and a half.
To know more about the work of SOCHARA, please CLICK HERE

Growing list of members of COPASAH

Africa
Budget and Expenditure Monitoring Forum
Centre for Economic Governance and AIDS in Africa- CEGAA
Community Working Group on Health- CWGH
DBL- Centre for Health Research and Development
Management Systems and Economic Consultants Ltd
Lusaka District Health Management Team - LDHMT
Training and Research Support Centre- TARSC
The Institute of Social Accountability- TISA
Treatment Action Campaign- TAC
Uganda Debt Network
Uganda National Health Users/ Consumers Organisation
Europe
Immpact, University of Aberdeen
South Asia
Centre for Health and Social Justice
Child in Need Institute- CINI
Society for Community Health Awareness Research and Action- SOCHARA
Deepak Foundation
ICDDR,B
Public Affairs Foundation
SAHAJ- Society for Health Alternatives
SAHAYOG
Sankalp Sanskritik Samiti
SATHI- Support for Training and Advocacy to Health Initiatives
Shikhar Prashikshan Sansthan
Village Health Committee - Sahiyya Resource Centre
Latin America
Centro de Estudios para la Equidad y Gobernanza en los Sistemas de Salud- CEGSS
Foro Salud- Foro de la Sociedad Civil en Salud
Universidade Federal do Rio Grande do Sul
Individual Members
Masuma Mamdani - Ifkara Health Institute, Tanzania
Naresh Kumar - Community Health Cell, Tamil Nadu, India
Neetu Singh - Gramya Sansthan, Madhya Pradesh, India
P. Chandra - D. Arul Selvi Community Based Rehabilitation, Tamil Nadu, India
Shahidul Hoque - ICDDR,B, Bangladesh
Sohail Amir Ali Bawani - Aga Khan University, Pakistan
Sunita Singh, Madhya Pradesh

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