Under this project, work has been done by the Dharohar organization in the Nainital district. This work was done by the organization in two sub-centres in each block in the Nainital district.
Community Monitoring in NRHM
Introduction to Community Monitoring: The accountability framework proposed in the NRHM is a three-pronged process that includes internal monitoring, periodic surveys and studies and community-based monitoring. Community monitoring is also seen as an important aspect of promoting community-led action in the field of health. The provision for Monitoring and Planning Committees has been made at PHC, block, district and state levels. The adoption of a comprehensive framework for community-based monitoring and planning at various levels under NRHM places people at the centre of the process of regularly assessing whether the health needs and rights of the community are being fulfilled. The community monitoring process involves a three-way partnership between health care providers and managers (health system); the community, community-based organisations and NGOs and the Panchayati Raj Institutions. The success of the community monitoring process will depend upon the ownership of the process by all three parties and a developmental spirit of ‘fact-finding’ and ‘learning lessons for improvement’ rather than ‘fault finding’.
The objectives of community-based monitoring are as follows.
It will provide regular and systematic information about community needs, which will be used to guide the planning process appropriately. It will provide feedback according to the locally developed yardsticks, as well as on some key indicators. It will provide feedback on the status of the fulfilment of entitlements, functioning of various levels of the public health system and service providers, identifying gaps, deficiencies in services and levels of community satisfaction, which can facilitate corrective action in a framework of accountability. It will enable the community and community-based organisations to become equal partners in the planning process. It would increase the community's sense of involvement and participation to improve the responsive functioning of the public health system. The community should emerge as active subjects rather than passive objects in the context of the public health system. It can also be used for validating the data collected by the ANM, Anganwadi worker and other functionaries of the public health system.
Process of Community Monitoring
The exercise of community monitoring involves drawing in, activating, motivating, and capacity building and allowing the community and its representatives e.g. Community Based Organisations (CBOs), people’s movements, voluntary organisations and Panchayat representatives, to directly give feedback about the functioning of public health services, including giving inputs for improved planning of the same. The community and community-based organisations will monitor demand/need, coverage, access, quality, effectiveness, behaviour and presence of health care personnel at service points, possible denial of care and negligence. The monitoring process will include outreach services, public health facilities and the referral system.
The key Institutions for Community Monitoring as laid out in the Framework of Implementation are.
Village Health and Sanitation Committee (VHSC).
The PHC Planning and Monitoring Committee.
The Block Planning and Monitoring Committee.
The District Planning and Monitoring Committee.
The State Planning and Monitoring Committee.
The monitoring process will begin with a village report card being prepared by the Village Health and Sanitation Committee after consulting village records (ex. ASHA records or ANM records or the Village Health Register) and also by conducting interviews and meetings with potential beneficiaries (like women who are pregnant or have undergone childbirth in the recent past, or those with small children) to understand the community members’ experiences and problems faced, as well as assess the extent to which key services are being delivered effectively. The Monitoring Committee at each subsequent level would review and collate the reports coming from the committees dealing with units immediately below it. For example, Block Committee will receive and review the VHSC reports while the District Committee would receive and review the reports from all Block Committees. However, the monitoring committees would not only rely on reports but would also make their own independent observations on selected key parameters. Each committee would appoint a small team drawn from among its civil society and PRI representatives who would visit on a quarterly/six-monthly basis, a small sample of units (say one facility or two villages) under their purview and directly review the conditions. This will enable the committee to not just rely on reports but also have a first-hand assessment of conditions in their area. For example, the PHC committee representatives would visit two villages and conduct group discussions in each trimester selecting different villages by rotation. Similarly, the Block Committee representatives would visit one PHC by rotation in each trimester. The monitoring committees at PHC/Block/District levels will be responsible for making an assessment of the functioning of the major health care facility at their respective level (PHC/CHC/District Hospital). Sharing of the findings of monitoring committees will not only take place through the periodic report submitted to the next level of the monitoring committee but also through periodic public sharing. Monitoring committees at PHC, Block and District level will be involved in six-monthly or annual Jan Samvads or public hearings at their respective levels, where committee members would share the results of their findings and also get direct feedback of the situation, including possible presentation of cases of denial of health care. Similarly, the State Planning and Monitoring Committee will conduct an annual public meeting open to all civil society representatives where the State Mission report and independent reports will be presented and various aspects of design and implementation of NRHM in the state, including state-specific health schemes, would be reviewed and discussed enabling corrective action to be taken. A broad outline of the ambit and scope of community monitoring at different levels is given in the table below.