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Community Monitoring of National Rural Health Mission in India

Bridging ‘demand’ and ‘supply of accountability: Roundtable The Hague, April 19, 2013. Community Monitoring of National Rural Health Mission in India. Divergent Experiences and Challenges. Abhijit Das CHSJ and COPASAH. Introduction to CBM in NRHM.

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Community Monitoring of National Rural Health Mission in India

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  1. Bridging ‘demand’ and ‘supply of accountability: Roundtable The Hague, April 19, 2013 Community Monitoring of National Rural Health Mission in India Divergent Experiences and Challenges Abhijit Das CHSJ and COPASAH

  2. Introduction to CBM in NRHM • A new coalition Government comes to power in 2004. Coalition has Left parties support in Parliament and civil society participation in social sector policy think-tank NAC (National Advisory Council) • National Rural Health Mission introduced by Govt of India as a new delivery mechanism for health services for the poor in 2005 with strong civil society participation • Community based monitoring introduced both as a component of ‘communitisation’ and accountability • Government of India entrusts piloting of CBM to civil society groups through an advisory committee AGCA. • CBM piloted across nine states between 2007 -09. 35 districts – 1620 villages covered through GoI support. Pilot evaluated. GoI says states must include in their own state plans and budgets

  3. Community monitoring after 2009 Limited non-Government endorsed processes are there in some states After repeated letters/ requests/ instructions from Government of India Continues in the same trend as the pilot in a couple of states Has still not started in many states Continues in a somewhat modified manner in a couple of states Has been started in couple of states Has stopped after the pilot

  4. Two Divergent Experiences Maharashtra • Not a High Focus State but continues CBM from pilot phase • Strong Civil Society stewardship of CBM ; led and implemented by civil society organisations • State supports and expands CBM but continually asks for phase out plan • Improvement of health services clearly documented • Has also started generating political support at the local level • Many operational challenges including reduced and delayed funding • Uttar Pradesh • A High Focus state in NRHM but excluded from CBM because of poor performance benchmarks • Civil society led accountability efforts give way to a strong community led accountability process • Women’s health rights forum (MSAM) of 12,000 women from 200 villages in 10 districts • Empowerment - Strong local leadership – engagement with public health system – many small gains • Women leaders enter electoral politics at the local level

  5. Community level challenges • Community • Apathy/ fatalism • Lack of faith in public services – health world view and past experiences • Services • Huge gaps and deficiencies • High levels of privatisation • Community – authority relationship • Reluctance for ‘complaint’ may need the same providers service later • Kinship relationships -

  6. Challenges Maharashtra • Rhetoric vs Intent • Limited to local problems and local solutions. ‘CBM resistant’ problem • Seen by managers as a support to administrative oversight of frontline functionaries and better planning • No redressal mechanism established even after 5 years Uttar Pradesh • Politically important state – ‘unaccountable’ political leadership; • Historical donor/external aid management skills • Deeply entrenched corruption • NGO – State relationship : NGO beholden-ness • Overall low political mobilisation of communities – caste politics

  7. An interesting Conundrum • Enabling conditions met – provision in policy guidelines, official endorsements, standards/procedures/tools, citizen opportunities, facilitating organisations, funds BUT • Inadequate roll-out after enthusiastic start up • Operational resistances of different nature • Losing interest/energy among communities without appropriate changes in services

  8. Some thoughts…. • Framing of the issue and focus- • Economic / efficiency - ‘ demand – supply’ (Outcome) or Active Citizenship/Deepening Democracy - ‘rights- obligation- entitlement’ (Process) • Intent vs Rhetoric – ‘fashion’ vs political intent. • Different aspirations - Shorthand solutions for fundamental state failures vs Improved/targetted planning and service delivery vs Accountable public services (Populist/Bureaucratic/Political) • Governmentality – bureaucratic subversions • Dynamic/changing nature of the actors and their interests –political compulsion , bureaucratic interests, citizen-leader transitions

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