The project as a pilot has been introduced in 9 states of the country including Rajasthan where Prayas has been selected as the nodal agency for the implementation of the program. Currently, the pilot project in the state covers 180 villages from the four districts, namely, Alwar, Chittorgarh, Jodhpur and Udaipur (45 villages per district). Three blocks from each district have been identified and from each block three PHCs have been selected. From each PHC 5 villages have been identified, making it 15 villages per block.

There are 5 Levels of monitoring committees:

Village health and sanitation committee

PHC Health monitoring and planning committee

Block Health monitoring and planning committee

District Health monitoring and planning committee

State Health monitoring and planning committee

The Composition of monitoring committees is as follows:

One-third PRI representatives, One-third health officials, One-third CBO / NGO representatives including non-official delegates from lower committees , Chairperson – from Panchayat Executive chairperson – Health official Convener – from CBO / NGO

The main objective of the program is to develop synergy and partnership between the public health service providers and community for regular communication and coordination between them to enable better delivery and utilization of health services. The role of PRAYAS was to mobilize the communities and prepare them to come together, take responsibility and influence decisions. State Nodal Agency assists in implementing the decisions taken at the Community Monitoring Mentoring Team. Arrange for technical and resource support to district/block level NGOs. Support the process of adaptation, translation and publication state level materials/manuals. Supervise community level documentation processes, Maintain documentation of state level processes. Provide progress, process and financial reports and documents to the National Secretariat on a regular basis. Financial support and disbursement to district level and block level processes. Maintain state level accounts. Supervise progress and support processes/activities at the district, block and community levels. The role was challenging because of various reasons. Firstly it involved a decisive change in the balance of power, likely to be resisted at various levels of the public health system. Secondly, health officials had to be an active participant in the process but may not be assumed to be its sole and prime mover. Thirdly, it was important that genuine voices from the community get represented in the process. Fourthly, panchayats are major stakeholders but at the same time they often represent the elites of the village. To bring voices of the disadvantaged and marginalized in the forefront was a challenge. Fifthly, community may be disinterested in the beginning due to continuing disappointments from the status quo.

The implementation was carried out in various phases:

Preparatory phase : Distributing pamphlets to literate people Putting up poster in the common meeting place (e.g. near temples, wells, market place, etc.) , Informal meeting with key people (leaders of CBOs, women leaders, Pradhan, in the village) to get an idea about General layout of the village Different social groups in the village and where they stay, key health problems of the community , key service providers of the area, expense related to health problems, Communities opinion of the existing services and use of government health facilities and service providers. Village meeting to share findings, share NRHM information and facilitate information of VHSC. Sharing the Village health services profile in the village and informing community of NRHM and community monitoring in NRHM Pamphlets and posters and leaving multiple sets behind in the community. Elicit interest from members of the community about formation of village health and sanitation committee.

formation and strengthening of Village Health and Sanitation Committees (VHSCs), primary health centers (PHCs), and district and block committees;

community level investigation and monitoring involving village health report cards and facility score cards; and

Sharing of reports (through public hearings) and planning at the PHC, village, and block levels.

The very act of including a local NGO explains the importance of familiarity and identification for community action. The civil society organizations and NGO’s for participation in various committees were selected by examining them on their response to a questionnaire which assessed their experience of monitoring public services, organizing public dialogues or public hearings. The selection could also be facilitated by the mentoring team of the respective level, with guidance from the mentoring team of the higher level. The volunteers working with the NGO are usually locals. They know the people, their aspirations and needs. Villagers identify with them and trust the information they give. To bring people together there should be some incentive. Also, there should be both short term and long term benefits to keep the action alive. In this case the short term benefit was the improvement in infrastructure as the government was pouring in money and the long term benefits were many. Improved health of the people, increase in power to influence government policies, platform for discussing other developmental issues and so on. They approached it by making it a non zero sum game wherein there is ample for everyone and one person will benefit from the involvement of other. Also everyone was affected by the concerned issue in one way or the other. May be poorest of poor, women and children were affected more due to vulnerability and discrimination but lack of ample heath services creates disadvantage for everyone. For example, snake bites are quite common in villages and non- availability of the required medicine in the nearest PHC may prove fatal. In this case risk is same for everyone. So, it was tried to communicate the need for community monitoring rapidly through meetings, posters and workshops. PRAYAS attempted to spread awareness in a village by flooding their minds with the goodness of the new program. It was a strategy to keep the time period for mobilization just 3 days to avoid slackness in the process. This was done to produce a contagion effect, so that people develop an urge to move out of the current situation and take charge. People were given assurances that their participation will be sought in planning of health services, they should help in solving problems faced by health machinery but, at the same time, the villagers would point out any negligence or mistake made by health employees while providing health service, Villagers should also be given information about what action has been taken to avert mistakes pointed out by the villagers to Medical Officer. Since the monitoring will not be efficient without perspective of women and coming into picture, it has been ensured that two out of four members of Block Community Monitoring Facilitation Team will be women. Women are the ones who are most seriously affected by quality of health care due to their reproductive capacity.

Strategy: People were made partners in managing public health institutions. If certain infrastructure or services were not properly functional, community representatives were involved in finding solutions. Community representatives were significant role in the day-today functioning of the health services at the local level.

People were given clearly defined rights -People should be able to expect and demand basic services in keeping with their needs and expectations. If these rights are not fulfilled, it should be a matter of concern and concerted action for improvement by the public health system and community members.

People were given responsibility to regularize health services provided at the village level. People in the village, were encouraged take up responsibility to support activities for vaccination in the village, etc. Community members were provided training to be able to fulfill their responsibilities and realize their rights.

Ostrom claims that “all efforts to organize collective action, whether by an external ruler, an entrepreneur, or a set of principals who wish to gain collective benefits, must address a common set of problems.” These problems are “coping with free-riding, solving commitment problems, arranging for the supply of new institutions, and monitoring individual compliance with sets of rules.” So, in this case we see government itself wishes to enthuse people to reflect on the quality of health care making government officials, doctors and ASHA workers more committed to their work. Jan Samwad Mobilization & capacity building Encouraged participation of stakeholders to express their experiences and concerns. To sustain a collective action it is important to share the information. This was successfully done under this programme. PHC and block level community monitoring exercises included a public dialogue (‘Jan Samvad’) or public hearing (‘Jan Sunwai’) where individual testimonies and assessments by local CBOs/NGOs were presented. These meetings take place once in six months, here individual cases of denial of services are also addressed. In Jan Samvad Chief Medical Officer of the District or her/his representative , Block Medical Officer Member of District Community Monitoring and Planning Committee Members of PRIs in the block , Members of VHSCs , Member of CBOs in the block are present. The monitoring reports are shared at all levels. Once in every 3 months the village health report card is made in a span of 2 days. One member from the VHSC and one panchayat member is nominated for this purpose.

Leadership: leadership plays a very important role in gearing up any community action. Good leaders can not only increase the probability of success but can also attract people to join the movement. People take up leadership responsibilities in the initial process of community action to reap leadership benefits like social and political recognition and so on. This is because in initial phase input costs are higher and the probability of success is quite low. Keeping this in mind, the arrangement was such that CBOs/NGOs and Panchayat representatives who had shown leading initiative in organizing community monitoring activities at any level were given representation in the next high-level committees. The committees were created from village to higher levels in sequential order. This was an innovative way to go about implementation of a program. Being leader at the village level came as an alluring option to the people.

Capacity building: to ensure effective monitoring it has to be ensured that people are ready for change. For this a lot of measures were taken. Training and enhancing the capacity of Panchayati Raj Institutions (PRIs) to own, control and manage public health services, promoting access to improved healthcare at household level through the female health activist (ASHA), Health Plan for each village through Village Health Committee of the Panchayat, Strengthening existing PHCs and CHCs, and provision of 30-50 bedded CHC per lakh population. Strengthening capacities for data collection, assessment and review for evidence based planning, monitoring and supervision, formulation of transparent policies ,developing capacities for preventive health care at all levels for promoting healthy life styles, reduction in consumption of tobacco and alcohol etc , promoting non-profit sector particularly in under served areas. Another important step was to make people realize that access to good health is their constitutional right and they pay for it. It is the responsibility of the government to give a good life to them.

Through the VHSCs, communities also have become empowered to voice their concerns and take action. Communities have become aware about their rights and entitlements .In a number of cases, local health departments responded to problems raised at public hearings and made appropriate changes in their functioning. There has been a change in the way people perceive health services. Earlier, they saw it as a zero sum game , now they are beginning to see it as a public good. This change will help in reducing disadvantages faced by certain sections of the community , which would eventually result in improvements in health and nutrition outcomes. Previously excluded and marginalized groups have started coming in front. An affirmative approach was used to ensure that Dalits(scheduled castes), scheduled tribes, and women were involved and headed the VHSCs. Community monitoring has built stronger relationships between communities and health service providers, as well. Communities have become more accommodating and have started understanding constraints of health workers. Overall , this program has lead to decentralization of power. Prayas has played a commendable role acting as a liaison between people and government.

Sources:

http://www.prayas.org

http://www.nrhmcommunityaction.org/pages/states/rajasthan.php 

http://www.nagahealth.nic.in