community action for health in universal health care

8/13/2019 Community Action for Health in Universal Health Care

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Community Participation andUHC

Reflections from implementing the CommunityAction for Health process in Tamilnadu

Rakhal GaitondeSociety for Community Health Awareness Research and Action

(SOCHARA)


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Plan of Presentation

Key recommendations of the HLEG report.

Key messages.

The context of the presentation - The CAHprocess.

Questions emerging from practice.

Reality check.


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KEY RECOMMENDATIONS OFTHE HLEG REGARDING

COMMUNITY PARTICIPATION Strengthening institutional mechanisms for

community participation in health governanceand oversight at multiple levels (rural and

urban). Transformation of existing Health Committees

into health councils.

Organizing periodic health assemblies. Participatory governance, review and

oversight will be supported by legal, adequatefinances and capacity building.


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KEY RECOMMENDATIONS contd.

Increasing the number of community healthworkers to two workers per village andequivalent urban administrative unit.

Enhancing role of PRI and electedrepresentatives in health governance andcommunity oversight.

Enhancing the role of CSOs in deliveringinformation, enabling participation,community mobilization, capacity building


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KEY RECOMMENDATIONS contd.

Instituting a formal grievance redressalmechanism.


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The life of the concept

Alma AtaComprehensive Primary HealthCare - an approach not just a set of services

Health and Human RightsSpecialRapporteur's delineation of participation aspart of the Right to Health.

Democracymoving from representative to

deliberative democracy. Warmi, Manandhar, EKJUT, IMAGE, CLICS.

Elinor Ostrompolycentric governance


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Competing meanings...

Different groups of people interpret / givedifferent meanings to the concept.

Giving rise to differing motivations.

Leading to implementation diversity.

This can lead to dif ferences in evaluat ing

effect iveness and impact.....


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CAH as it is

NGO / Civil Society Perspectiv

Rights / accountability

Health System / higher levels

Control over lover level staff

Communities

GrievanceRedressal

Access toresources

Health System

Lower levelStaff

Reaching targets

Ensuring peopleAccessGovernmentservices

Multiple perspectives...


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The CAH process


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Community based monitoring and planninganemerging approach for accountability

Community members and localactivistsidentify gaps, issues, prioritiesfor change

Perspective of peoples

health rightsand accountability ofpublic servicesis at the core

Challenging the hierarchy of power andmoving towards certain kind of

equalization of power


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Structure at the state

level

V

PHC PHC PHC PHC

Taluka Taluka Taluka

DIST DIST

STATE Integrate

Integrate

Integrate

Integrate

VV VVVV V V V V V

VillageHealth &

Sanitation

Committees

TalukaPlanning andmonitoringCommittees

DistrictPlanning and

monitoringCommittees

State Planningand

monitoringCommittees

PHC Planning and

monitoring

Committees

KEYINSTITUTIONS

STATE MENTORING GROUP

Planning and

monitoringreports

Committee formation and information


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Committee formation and information

flowpilot processState Planning

& MonitoringCommittee

District Planning &Monitoring

Committee

Block Planning &

Monitoring

Committee

PHC Planning &

Monitoring

Committee

Village Health and

SanitationCommittee

AppropriateAc

tion

&I

nterventio

n

Feedback

& Reports


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The Tool


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Change after six months of monitoring invillages of Velhe block, Pune

October 2008 April 2009


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Sample Village Health Report Card


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Case studies of CAH

Ownership of government services increased.

Also a functionality of increase investment ininfrastructure during the NRHM period.

Kanniyakumarishift to Governement PHC,Thiruvallurshift away from Satyavedu,

Invitations for meetings from Panchayat notNGO any more.


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Case Studies of CAH

Discussion on route of the Mobile MedicalUnit, where it stops in a given village etc.Information regarding its regular program.

Involvement of a number of people fromoutside the Health departmentBDOs, MLAs,Panchayat district chairpersons, Collectors


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Good ratings for village level Health services across220 villages in Maharashtra over 3 phases

48%

61%

66%

30

35

40

45

50

55

60

65

70

Phase 1 Phase 2 Phase 3

1050


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Higher increase inpeoples OPDutilisationin PHCs covered byCBM

600

650

700

750

800

850

900

950

1000

1050

Thane district

OPD per PHC

per month

741 679 869

Thane CBM

OPD per PHC

er month

767 722 1028

07-08 08-09 09-10

17%

34%

0

5

10

15

20

25

30

35

Increase in Thane

district PHCs OPD

Increase in Thane CBM

PHCs OPD


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CAH ...challenges wrt action forhealth

Changes still is a topdown processmorebased on higher officials diktat - the differencebetween people's democracy andadministrative democracyCollector.

What type of changes are happeninganextra ambulance being posted is easier thangetting the timings of the PHC, ICDS on a

board. Very little freedom to respond at lower levels.

Untied funds were still not brought under thecontrol of the committees.


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Wh th l i th


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Who are the people in thecommittee?

Ultimately the onus for change andleadership fall on the most marginalized andusually those that can least afford such

indirect costs to demanding their rights. How do we facilitate capacity building and

enabling them to talk to powerin a systemthat systematically dis-empowers them?


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Who are they holding accountable?

What ever the systemic issueswhat isvisible and measurable by the community aregaps in the performance of the lowest / most

peripheral staffwho usually also bear thebrunt of being at the lowest level of a stiflinglyhierarchical system.

Unrealistic and competing demands from thesystem and from such processes like CAH.

Doctor and data.

VHN posting and ATP.

H d th t th


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How does the system see thepeople?

The socialization of the systemhow dothey see people?

Ignorant

Irrational

What will it take for them to see people asequal partners?


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ROLE OF CIVIL SOCIETY

NGOs / People's movementsschools ofcitizenships, creating spaces, enabling theoccupation of spaces.

Academics and intellectualsresearch anddocumentation of topics critical in advancingthe people's agenda.

How much do you critique? Towards furtherweakening, further strengthening, Movingbeyond confrontation to co-production.


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Borrowing from Thailand...


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Brazil - Health councils

A landmark of the Brazilian UHC is communityparticipation, guaranteed by a network of over 5,000Municipal Health Councils, 27 State Health Councils,and the National Health Council, involving some

100,000 individuals in this voluntary work.Most of the decisions on healthcare such as budget,construction of health facilities, implementation of healthprograms, etc., must be approved by health councils


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Brazil - Health councils

All social sectors are represented inthese councils:

clientele or communityrepresentatives (50%)

health providers plus healthmanagers / officials (25%)

healthcare workers (25%)

Community Participation the way


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Community Participation, the wayforward

Community Participation is a fundamental right. There is enough evidence that participation leads to

tangible changes.

There is enough evidence that participation leads to

system strengthening.

There is are a number of international examples tolearn from.

We have a home grown experience of communitymonitoring and planning / Community Action forhealth, over the last 4 years that needs to be

studied and discussed.


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Thank You!

community action for health in universal health care

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