Exposure visit to Pune district from 4th March to 6th March 2013

Visiting team members: Ms. Sunanda Ganju, Mr. Dilip and Ms. Mahima Taparia(SAHAJ) Ms. Rita and Ms. Urmila (ANANDI) and Ms. Neha (TF)

Background

For the past one year, SAHAJ has been collaborating with ANANDI ( working inDahod and Panchmahals districts) and Tribhuvandas Foundation (Anand district)for the project on ‘Enabling Community Action to Promote Accountability forMaternal health’ in Gujarat .As community monitoring is an integral part of theproject, SAHAJ decided to learn about experiences in Maharashtra (where CBMhas already completed 5 years) by visiting two NGOs in Pune district namelyMASUM in Purandhar taluka and RACHNA in Velha taluka and the State NodalAgency SATHI with the following objectives:-

To know about the process of community based monitoring and planning.

To know achievements, challenges and learning from experiences ofdifferent NGOs related to CBM

To know experiences of the community members regarding CBM.

To know the development process of report card, Jan Sunwai and its use atcommunity, block, district and the state level.

Under the NRHM , Community based monitoring of health services was started in2007 in Maharashtra as well as certain other states in India.CBM in Maharashtrahas completed 5 years in five pilot districts (Amravati, Nadurbar,Osmanabad,Pune and Thane) covering 15 blocks and 225 villages. In Maharashtra SATHI, astate nodal agency coordinates with district and block nodal NGOs and worksclosely with the State Health department.CBM processes related to NRHM areorganized at the village, PHC, block , district and state levels. A monitoringcommittee at each level collates the findings from the level below related tohealth system and passes it to the next level once or twice year. Some of the keyprocesses in Community based monitoring are:

1. Filling health report cards

2. Public hearings

3. Networking of civil society organization at multiple levels

4. Periodic state level dialogues

5. Media coverage

For SAHAJ, ANANDI and TF, this was a new experience as CBM is yet to beinitiated in Gujarat as a Government program under the NRHM. SAHAJ has beeninvolved in community monitoring in urban slums of Vadodara for demandinghealth entitlements, ration cards, monitoring PDS outlets, housing and Anganwadicentres. Similarly ANANDI has also been working on rights of tribal women inDAHOD and Panchmahals through sangathans but to witness how CBM workswith patronage from the government was something worth learning about.

Day 1

MASUM (Mahila Sarvangeen Utkarsh Mandal)

Date: 4th March 2013

Time: 11.30am to 6.00 pm

Field Visited: Saswad village in Purandar Taluka

1.0 Background

MASUM has been working since the past fifteen years in Purandar (Pune District)and Parner (Ahmednagar District) Blocks of Maharashtra with the oppressed,marginalised and minority groups with an emphasis on their participation in allactivities and programmes. It aims at creating awareness about various forms ofexploitation and abuse faced by the underprivileged and the minority groups inthe community and helps them organize themselves to deal with such violations.MASUM is a development group with a feminist perspective and a democraticapproach. MASUM works mainly on the issues of Health, Domestic Violence,Women's Resource Development and Self-Employment, and Capacity buildingwith rights approach.

We met five PHC committee members, one Zilla panchayat board member andMASUM’s three team members were present namely Ms. Hemlata, Mr.Ravi andMr. Mangal.

Meeting with MASUM -4.3.13

2.0 The CBM Process

The Community based monitoring process has a monitoring committee at PHC,block and district level. There is one rural hospital per block which is 36 beddedand one PHC is supposed to have 6 beds. We observed that one woman was amember of Zilla committee .According to Ravi, there are 2 such women in thecommittee and they are very powerful. At each level, members from the healthsystem like MO, BHO, ANM/LHW, PRI members and NGOs represent themonitoring committee.

2.1 Training VHSNC committees

In 2007, when the CBM process started, MASUM covered 5 villages in onePHC. At that time, people did not use PHC and Rural Hospitals were almostdefunct. One of the core functions of community monitoring is to activatethe VHSC (Village Health and Sanitation and Nutrition Committee).

Information of basic services and facilities included questions on healthfacilities, Mamta diwas, immunization, blood test, Anganwadi services, andquality of care at the PHCs and so on.

Thereafter, MASUM gave trainings to the VHSC members and built theircapacity and created awareness through group discussions, print medialike photographs, news paper articles and local TV news channels. Theyalso gave them RTI training. While selecting committee members, theyfocused on committed people so they could work effectively. Thus,trainings at village level, State level and district level were conducted.

As a rule, PHC and RH committee meet 3 times in a year and discuss theproblems, plan their action plan and start implementing it. During JanSunwai, Arogya sabha (VHSN) committee members fill up the report cardand display it in a prominent place in the village. MASUM also arrangesvehicles during Jan Sunwai so that everybody including health systemofficials can attend the meeting on time.

Apart from training VHSNC members, MASUM has set up a separateAarogya Mandal for the marginalized women and men so that Sarpanchdoes not use it for political gains.

3.0 Jan Sunwai

According to the staff, most of the officials at lower level like MO and BHOresent the community monitoring mechanism because they are exposed infront of their seniors during Jan Sunwai. Citing one situation, the staff saidthat during one Jan Sunwai, one woman complained to the CDHO that theparticular BHO present in the meeting had asked her for money. When theCDHO enquired whether it was true, the BHO had to accept the allegation.

Committee members of the PHC and Zilla Parishad informed us that afterCBM, many changes have been observed like a sonography machine hasbeen installed in the PHC and driver is on duty, medical store andpostpartum room facility has also been instituted in the PHC.

4.0 Impact of CBM

The team said that because of Jan Sunwai, corruption has lessened andhealth services have improved. In one instance, the MPW (Multi PurposeWorker) was not visiting his village but after villagers complained during Jan

Sunwai, he started coming regularly. Ms Hemlata further added that JanSunwai is a very powerful medium to mobilize action and create awareness.

Earlier OPD in Rural hospitals were 30-40 per day, now it is 300-400 perday.

PHC and Zilla level members said that earlier all problems were beingpresented to the health authorities through the organization but nowpeople go to the authorities unaided by MASUM staff and ask for theirproblems to get resolved.

When we asked what difficulties they had to face, one volunteer said thatdue to political pressures there are lots of problem and many times mediaused MASUM’s name to elicit some information which created questionsabout the organization’s credibility and reputation.

5.0 Problems and Challenges

However, all this was not achieved without difficulties and challenges. In theinitial years, when they called 100 people for trainings and meetings, only 2 to 10people attended the meeting. Feeling depressed, they decided to start trainingsin small groups in the village. When the first report card was filled up and sharedwith the community in front of the health officials during Jan Sunwai, volunteersbecame motivated and people started participating in this process. As MASUMbuilt capacities and guided the VHSNCs, the committee’s members graduallystarted taking up the issues and questioning the medical officers and othergovernment authorities regarding their entitlements.

6.0 Lessons to be learnt (MASUMs perspective)

It is very important to select interested and motivated volunteers from thecommunity.

Unity of VHSNC committee is a big strength.

Involvement of youth in taking up responsibilities can take this workforward.

Creating awareness at all levels is important so that the general villagersdon’t depend only on committee to give them information about theirrights and entitlements. The organization shares the GR to the people sothat people know government plans for the year and the activities planned.

They found that in the last 5 years only 5 motivated members wereworking who could sustain the CBM work in the selected area.

MASUM team said that if one works with most marginalized and poor,results are visible in a short period of time as it motivates them toparticipate in this process and the future leadership also emerges from thisgroup.

Using different training mediums is very important to make trainingseffective.

When we asked about sustainability of the groups, Ravi, one of the teammembers said that the community would need support for another 15years because they needed to spread awareness about entitlements to allvillages.

Using media is a good strategy for increasing awareness of the communityand advocacy.

One should try to build capacities of the community so that they learn topresent their problems to the authorities. NGO should be only for guidance

One volunteer commented that many people in the VHSNC are involved inthe program because of their political interests. At present travel expensesare given to the volunteers and they also expect that the members mayreduce after the project finishes but the guidance and technical supportthat the NGO offers will be very beneficial for CBM.

Day: 2

SATHI (Support for Advocacy and Training to Health Initiatives) Date: 5th March 2013

Time: 10.30am to 5.00 pm

1.0 Background

'SATHI is the action Centre of Anusandhan Trust evolved from CEHAT. The SATHIteam originated in 1998 as part of CEHAT Pune and after working for more than 7years as an action team in CEHAT, from 1st April 2005 has developed into full-fledged action centre of Anusandhan Trust with Headquarters in Pune. SATHIenvisages a society, which has realized its right to health and health care:

A society which has eliminated health inequities, by removing the structuralbarriers which today prevent the majority from accessing healthy livingconditions and quality health care;

A society which instead of the current pathological model of development,has adopted a developmental path which fosters health of both the peopleand their environment;

A society where people, are not appendages of the health care system; areits prime movers and have universal access to appropriate health care as ahuman right.

To realize this long term goal, SATHI's strategy is to contribute as a team of pro-people health professionals, to the movement and initiatives towards such asociety, by focusing on the aim of realization of health and health care asfundamental human rights. More recently, SATHI has initiated collaborativehealth initiatives with four people's organizations in Maharashtra and MadhyaPradesh for advocacy at broader level for Primary Health Care and Health Rights;training on Health Rights and in Community Health Initiatives and action-researchrelated to Health Advocacy.

In 2007, SATHI was chosen as a State Nodal agency under NRHM for impartingtraining on Community based monitoring and planning to 30 NGOs. In 2007, CBMwas implemented in five pilot districts (Amravati, Nadurbar, Osmanabad, Puneand Thane) initially covering 15 blocks and 225 villages. In 2009, the state NRHMextended the process to eight additional districts expanding the total coverage to13 districts and 800 villages. It also compiles the data of all the 30 NGOs located in13 districts .We met with the following:-

1. CBM –Project Coordinator – Shri Bhausaheb

2. ICDS- Project Coordinator – Dr Arun Gadre

3. MP – CBM Coordinator – Rakesh

4. Research team – Lead by Deepali

5. Advocacy and Planning team

After the first round of introductions, we requested Bhausaheb to tell us aboutthe CBM process and the development of the Report card.

Meeting with SATHI – 5.3.13

2.0 Report card

We met the research and advocacy team who told us about the varioususes of data. They suggested that if we wished to advocate for some issue,we should present the data through small pamphlets to the healthauthorities.

SATHI research team shared the process of developing a report card with usin which 50 % achievement indicated a bad situation, 50–75 % for asatisfactory situation and >= 75 % for a good situation. This was furthertranslated into a color code like red (50%), yellow (50-75%) and green(>=75%).

3.0 New projects

Dr Arun Gadre , has been using community based monitoring forsupplementary nutrition given in the anganwadi centers by using variousmethods like household surveys, Focus Group discussions and individualinterviews.

Mr.Bhausaheb also said that earlier they used CBM work on the websitebut health officials opposed and made it difficult for us to work with them.So they decided to make another website under NRHM where they put alltheir tools like report card , facilities that improved due to CBM and relatedachievements.

He also talked about the project on using Central SMS to check theprocurement and availability of medicines in the health centers.

He also showed a film on CBM named ‘How Government hospitals becameours after CBM’ and discussed the process of community monitoring.

4.0 Impact of CBM

Information on the impact of this program in all 13 districts ofMaharashtra can be accessed through their website and their reports.

Utilization of grants for sub centers/PHCs is also being monitored. Citingone example, Bhausaheb said that it was revealed that grants for oneparticular sub centre and PHC had been utilized for repair work but thehealth department did not have any bill/voucher to prove that it hadindeed been spent on that.

Mr. Rakesh (SATHI, M.P) who works in Barwani district, Madhya Pradeshtalked about the Jagrut Adivasi Dalit Sangathan which has been workingon livelihood and rights of adivasis since many years. Through CBM, nowwomen are getting their entitlements in the district hospital where, twoyears back highest maternal deaths were recorded. However, hereported that nobody takes responsibility for women who get referredor die on the way before reaching another hospital.

5.0 Problems and Challenges

Delay in disbursal of funds for CBM work- Mr. Bhausaheb said that thegrant for the current year was yet to be released and greatly influencedthe quality and speed of the work carried out by NGOs. Those NGOswho were funded by non government funds could manage their workbut those who were totally dependent on government grants found itvery difficult to deliver.

6.0 Lessons to be learnt (SATHI’s perspective)

Dr. Arun also suggested that NGOs should play the role of a guide butactual implementation should be done by the community itself.Whenever meetings or Jan sunwai’s are held, the BHO and MO shouldbe informed well in advance otherwise the health officials find someexcuse to remain absent if the meetings are planned at a short notice.

When we asked which type of NGOs were able to produce betteroutcomes , Mr. Bhausaheb said that those NGOs who had a history ofRights based work found that CBM fitted into their work perfectly andneeded very little support to carry out this work. However, those NGOswho did not have this approach were slower and faced many difficulties.He also mentioned that in Maharashtra, many NGOs were influenced bynaxal movement so CBM further strengthened their ideology.

Day: 3

RACHANA (Society for Social reconstruction)

Date: 6th March 2013

Time: 11.00am to 1.30 pm

Field visited: Vela Taluka’s Ruley village

1.0 Background

RACHNA has been involved in rights based work since its inception and workswith national networks like Ration kruti samiti, Anaa Sureksha Abhiyan, JanSwastya Abhiyan and on local level with Mahila Bal haak Andolan on issues likequality education, qualitative changes in health facilities, food security, child

rights etc. Rachana also worked as regional convener at western Maharashtralevel and Swati Chavan (founder) was active as Maharashtra state convener ofBAL haak abhiyan which addresses child rights issues like education, health etc.Rachana was involved in addressing health and education related issues inSolapur , Kolhapur, Satara, Sangli and Pune districts of western Maharashtra from2003 to 2010.

Mr.Kondhebhau, the main representative of the organization told us that doingCommunity Based Monitoring for health facilities was easier for them comparedto other organizations because RACHNA had already been involved in rights basedwork from the beginning. We visited Ruley village and had a meeting in a templewith 11 members who included members of RACHNA and Kajal Jain (MASUM),Bachat mandal members, Anganwadi members, VHSC committee members andvillage women.

Mr. Kondhebhau said that they had a history of demanding rights for issuesrelated to water, health, education and other development related issues. In2003, people decided to demand for a sub centre in Ruley as there were no healthfacilities in the village. When one political party visited the village during anelection campaign, children of 9th and 10 standard put forth their demand for asub centre. Soon after the election, land for a sub centre was earmarked in thevillage. However, when the construction work did not start, villagers again putforth their demand for construction of the centre. An amount of Rs.15 lakhs wasspent on the building but the opening was further delayed because the healthauthorities could not get some political person to inaugurate it. So, people putforth this issue during Jan Sunwai and the sub centre was finally inauguratedwithin a week after the meeting. In one meeting, school going studentscomplained to the government officers that they wanted a school up to 10 th

standard and also demanded that the board exam centre should be set up in thevillage itself. Further, they also complained about unavailability of toilets in theirschool. As a result, now in Ruley, children need not travel miles to study up to10th standard and moreover board exam center is right in their village!

Meeting with RACHNA team – Ruley, Velha taluka 6.3.13

Meeting at Ruley village with Aanganwadi workers, VHSNC members and RACHNA team-6.3.13

2.0 Impact of CBM

Due to CBM, two anganwadis have opened in the village.

One of the highlights of this village is the proactive VHSNC committeewhose members plan and monitor the utilization of untied funds. Earlier,the decision about utilization was taken by ICDS officials who werespending this grant on unnecessary expenditures which were not directlyrelated to health. Through CBM, VHSCN members became aware that thisgrant can be solely used for health and told the ICDS department that thecommittee would use the grants as per their health needs and would notlike any interference on that account. This year, the committee decided tospend the grant on increasing awareness about anemia through IECmaterial and brought iron kadais and distributed it in the community. Theyalso bought additional calcium tablets as the number supplied by the Govt.

was insufficient. Due to these activities, the village ASHA worker has beengiven an award for ‘best ASHA worker’ in Pune district.

In Ruley village, now home deliveries have decreased.

PHC Panshet, Velha taluka – 6.3.13

Meeting with MO, Sarpanch at Panshet PHC -6.313

Team meeting Distrcit Panchayat member and MO, PHC Panshet – 6.3.13

We visited one PHC at Panshet which is about 5 to 7 kms away from Ruleyvillage and an archetypal success story of community monitoring with acomplete transformation both in structural and managerial aspects. Thiswas reported to be a non functional and a dead PHC. We met the followingat the centre.

1. District Panchayat member

2. MO

3. Hospital Supervisor

4. MHW

5. Deputy Sarpanch (Panshet)

6. Panchayat member – 2

7. Anganwadi worker -2

8. PHC committee member -3

9. RACHNA staff members

10. Kajal Jain (MASUM)

11. Visiting Project team (SAHAJ, ANANDI and TF)

We took a round of the centre where we found that ANC check up ongoingwith the laboratory technician checking blood and urine samples and agynecologist was also present in the room. We also saw the labor room andlot of patients were seen waiting. The health supervisor was very keen toshow us around but Kondhebhau was keen that we meet the MO, DistrictPanchayat member and Sarpanch as they were waiting for us and had toleave immediately. The MO talked about the changes that have occurreddue to CBM. He said that, earlier a small number of patients attended theOPDs but now, 70 to 75 patients are seen every day. Institutional deliveriesare increasing and according to the sarpanch, services of private hospitalsand doctors are not utilized now in the area.

When we asked the MO about the difficulties he had to face when the CBMprocess started, he said, a little hesitatingly that CBM should be there and itencouraged everybody to work. Later, Mr. Kondhebhau informed us thatthe MO was not interested in working in Panshet PHC but due to CBM, hehad no option but to render his services.

According to Mr. Kondhebhau and the Sarpanch, they also raised issuesabout problems faced by doctors during Jan Sunwai like availability ofgood accommodation and other facilities so that they could livecomfortably in the PHC.

The District Panchayat member also said that CBM should have been donelong back. Later, Kondhebhau remarked that political figures like him donot openly oppose the government so it is important to induct him in the

CBM process. He also added that health officials always accept and agreewith the people during Jan Sunwai but try to oppose NGOs.

3.0 Lessons to be learnt (RACHNA’s perspective)

Mr.Kondhebhau emphasized that those individuals who are interested in doingthis work should be chosen and attempt should be made to make the mostmarginalized participate in this CBM process. This is why they keep meetings indifferent clusters of the village and not in the gram sabha so that the marginalizedpopulation is able to participate and raise their voice.

Learning from the three visits (SAHAJ, TF and ANANDI)

Learnt the process of making report card, using website and SMS fortracking and monitoring procurement of medicines in PHCs.

How CBM could be used in Anganwadis for supplementary nutrition andhow it could be used to monitor malnutrition amongst children.

A fully fledged research and documentation centre extends support tothe organization as it is able to produce data that is quickly used foradvocacy. This is a very important learning for us as we are learning toadvocate with the help of data in Gujarat where CBM process is in itsnascent stage. Hence, data complemented by a strategic plan of actionconsidering the political climate of Gujarat ,civil society andcommunities at large will decide the action plan for the next one andhalf year.

Community monitoring work is time consuming and process intensivework.

It is important to work with Government /health officials in a strategicmanner. I also felt that Mr. Kondhebhau from RACHNA very wiselydialogued with the government officials and sought the rightopportunity as they say ‘striking when the iron is hot’ in order to getmaximum mileage for resolving the development issues of the village.For example, he put forth the issues of opening a sub centre or a schooljust before elections so that the political party was forced to deliver.

Awareness and capacity building of community is most important andfor that motivated and committed people from the community arerequired. So identification and selection of such kind of persons shouldbe a priority.

Rachana involved students for demanding school toilets, high school andan exam centre which in itself is a novel strategy.

Jan sunwai is a very powerful platform for advocacy.

Effective use of media and RTI has been done by the NGOs.