GHV's Blog

Accountability for RMNCAH in India: The Critical Role of Civil Society

June 22, 2016 09:00


Learning from Community Action for Health

Poonam Muttreja, Executive Director, Population Foundation of India
Nejla Liias, President and Founder, Global Health Visions


With the 2015 launch of the Sustainable Development Goals (SDGs), the Global Strategy for Women’s, Children’s, and Adolescents’ Health, and the Global Financing Facility (GFF), the world is poised to improve the survival, health, and wellbeing of women, children, and adolescents. In particular, making progress in India is crucial because it bears so much of the world’s burden of mortality and morbidity. In 2015, India accounted for an estimated 15% (45,000) of all maternal deaths (303,000) worldwide [1]. Indeed, India’s own reproductive, maternal, newborn, child, and adolescent health (RMNCH+A) strategic approach, launched in 2013, directs states to address the major causes of mortality and issues of access to care across the full continuum of care, with a special focus on reaching the most vulnerable [2].


Global and national goals, plans, and strategies are just the first step, however. The accountability mechanisms put in place to ensure that budgets, programs, and policies are implemented effectively and benefit the target communities are equally important. India can learn valuable lessons from examples of accountability mechanisms led by or involving civil society, several of which were outlined in the recently released report Engendering Accountability: Upholding Commitments to Maternal and Newborn Health.


Community Action for Health (CAH),for example, is one program with social accountability practices that could be applied to the Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCAH) field. It is a key strategy of the National Health Mission (NHM), a flagship program of the Government of India, which places people at the center of the process of ensuring that the health needs and rights of the community are being fulfilled. It allows them to actively and regularly monitor the progress of the NHM interventions in their areas. It also results in communities participating and contributing to strengthening health services.


CAH processes are organized at primary and community health centers, and at the village, block, district, and state levels. In most states, a state-level civil society organization (CSO) manages community-based monitoring and planning processes with district and block level CSOs and the state health department. Now operating in 205 districts across 19 states, CAH has the potential to make a huge impact.


The process involves the following steps:

  1. Create community awareness on health entitlements, and the roles and responsibilities of service providers.
  2. Train and mentor Village Health, Nutrition and Sanitation, and Patient Welfare Committees (Rogi Kalyan Samitis) to undertake community monitoring of health services.
  3. Form and train planning and monitoring committees at the state, district, and block levels to discuss and take action on issues and gaps that emerge from the community monitoring process.
  4. Collect data using tools such as report cards and expenditure reviews.
  5. Compile and analyze data using a scoring system categorized into good, average, and poor services.
  6. Share results of the community monitoring process with stakeholders at the facility, block, and district levels.
  7. Develop solutions to problems that incorporate local input and planning.
  8. Organize public dialogues to provide a forum for engagement of the community with health providers to share key findings and discuss proposed solutions.
  9. Take corrective action by engaging with officials on plans to address key issues and concerns.
  10. Use media as an ally to enhance pressure on stakeholders and keep them accountable.

Four key lessons in accountability that the RMNCAH community can take from the CAH model include:

  1. When civil society and government work together, health service delivery improves. CAH is a unique government-led mechanism that seeks to improve service delivery by engaging with civil society and community structures created under the NHM. The process is guided by the Advisory Group on Community Action (AGCA) Committee constituted by the Ministry of Health and Family Welfare, and for which the Population Foundation of India hosts the secretariat. Partnership between government and civil society allows for dialogue and understanding between citizens, health care providers, and government officials.
  2. CAH brings the “public” into the public health system. CAH engages citizens and civil society to improve health care delivery and connects community voices and data to action. The AGCA also regularly participates in the Common Review Mission, which provides critical inputs and suggestions on the effectiveness of the NHM implementation at the grassroots level.
  3. Accountability works. An external evaluation of the CAH pilot phase that was undertaken across 36 districts and 9 states between 2007 and 2009 observed that the process: (a) empowered the community (especially marginalized groups) to engage with the health department; (b) strengthened service delivery and facilitated communities in availing health entitlements with improved range, access, and quality of services during health outreach sessions and in the  public health facilities; (c) enabled local-level planning and corrective action; and (d) enhanced accountability among the service providers, seen in the increased availability of staff in health facilities, timely and adequate distribution of drugs, and a decrease in demands for informal payments. Since then, the CAH processes have been simplified and adapted to the state and local contexts to enable easier adoption and scale up.
  4. There is still work to be done. Political will and the capacity to implement accountability mechanisms among both civil society and government vary tremendously throughout the country. Thus, more resources and support are needed to continue strengthening skills and commitment. This is a common challenge across many accountability efforts in India. The NHM is now developing an institutionalized mechanism for grievance redressal, as a weak or absent mechanism for timely and effective redressal has a negative effect on trust and participation of communities in the processes. Additionally, limited engagement with elected representatives to advocate for corrective action and planning on issues and gaps emerging from the CAH – especially at the state and national level – poses a challenge to scale up.

Efforts like CAH can provide a unique value-add to the RMNCAH accountability landscape. It is not the only high-impact accountability initiative in India involving or led by civil society (see the Engendering Accountability India Case Study for others), but it is an exemplary one. And at this critical juncture – as India and the world embark on a new era of focus on women, children, and adolescents under the SDGs, Global Strategy, and the Global Financing Facility – we strongly encourage those involved to keep the critical role that civil society plays in accountability top-of-mind and to draw on lessons learned from successful approaches like CAH. Applying accountability strategies ensures that resources are spent wisely and impact the lives of those they aim to benefit.


For more details on CAH, please visit www.nrhmcommunityaction.org. And see the documentary film about the work of CAH at https://www.youtube.com/watch?v=GFmzyaHkT50&feature=youtu.be


[1]Trends in Maternal Mortality: 1990 to 2015 (estimates by WHO, UNICEF, UNFPA, World Bank group and the United Nations Population Division

[2] The acronym RMNCH+A was specifically developed by the Government of India as part of its 2013 strategy, and is thus referred to as such here. However, throughout the remainder of this post, the more ubiquitous RMNCAH acronym will be utilized.

Accountability in Global Health: What works, what doesn’t, and what we need to do about it

September 25, 2015 09:00


A side-event at the UN General Assembly, and two new reports, shine the light on accountability processes at the global, regional, national, and sub-national levels. Spoiler alert: civil society engagement in countries is critical.

Christine Sow, President and Executive Director, Global Health Council
Lola Dare, President and Chief Executive, CHESTRAD
Nejla Liias, Founder and President, Global Health Visions


During this week of the UN General Assembly, New York’s streets are buzzing with global health and development leaders moving from one event or meeting to the next, discussing a host of important issues, and fighting for the chance that “their issue” might break through the noise. But, as we embark upon a new set of global Sustainable Development Goals (SDGs) to improve the lives of people and our planet, there is one theme that is relevant across all of the issue areas, and critically important to the achievement of the SDGs: accountability. Without accountability for goals and commitments, there is little point in making them.


As global health advocates, we share a passion for accountability because it means that decision makers will follow through on their promises to improve the health and well-being of all people, especially the most vulnerable. And, beyond that, we share an even greater passion for ensuring that advocates, government representatives, parliamentarians, health professionals, and other stakeholders understand how to put accountability into practice, calling for action to reward, mitigate unintended negative effects, or implement sanctions as each matter might require: What’s working? Who’s making it work? What’s not working?  


We are not alone in this quest: partners at all levels are more interested than ever in getting the accountability piece right. While we all bask in the excitement of the UN’s adoption of the post-2015 development agenda, as advocates we ultimately have one thought on our minds: what are the means of effective implementation and accountability? 


Specifically, how are we going to hold duty-bearers accountable? How will we hold governments – and yes, we’ll say it  development partners, to their commitments to improve the health of women, children, and communities? How can we translate press releases into policies, policies into practice, and practice into healthy lives?


Yesterday’s event on accountability at the Rockefeller Foundation, organized by Global Health Council, together with CHESTRAD International, Global Health Visions, Action for Global Health, and International AIDS Alliance, revolved around precisely these questions. Global Health Visions shared the results of a provocative new report Engendering Accountability: Upholding Commitments to Maternal and Newborn Health, which profiles accountability processes at the regional, national, and sub-national levels, outlining what’s working, what’s not, and what changes we need to make to help country accountability efforts flourish. It contains in-depth landscape analyses of India, Nigeria, and Uganda, as well as detailed findings and recommendations that apply to accountability efforts across the board.


Additionally, CHESTRAD’s new report Amplifying Whispers and Enabling Action: Global Accountability in the Sustainable Development Goals, released in collaboration with Global Health Council, is a critical contribution to the field of accountability, examining lessons learned from the MDGs on accountability, improving the technical and supply sides including goals, indicators, measurement, data availability, and quality. The report explores the role of stakeholders (including civil society) and calls for increased investment in demand-side functions on accountability to reduce fragmentation and promote alignment. It identifies an urgent need to incentivize political will for behavior change among development partners, technical agencies, and global programs. It further calls for greater motivation to enable the watchdog role of civil society at the country level, to hold to account within the multi-layered, multi-sector accountability framework for global health in the Sustainable Development Goals.  


With so many key players in accountability in one place, Thursday’s event served as an important touch point for the week, and the years ahead, to remind stakeholders that accountability must be a critical part of the conversation, to discuss how to make accountability work effectively, and to ensure that civil society plays a central role. As we move towards key milestones in accountability – including immediate ones like the PMNCH “Accountability Breakfast” and the launch of the new Global Strategy for Women’s, Children’s and Adolescents’ Health, and longer term ones, such the High Level Political Forum’s 4-yearly Summits to review progress on the SDGs – we want to take this opportunity to raise our voices in support of accountability practices that make targets, indicators and partner behaviors matter.


The takeaways from yesterday’s event are clear:

  • We need to empower civil society to do this important work – they must be at the center of local, national, regional, and global accountability efforts, within an inclusive, supportive accountability framework. But they can’t do it alone. Many need resources, support and technical assistance, and capacity building. And first things first – let’s do a better job making sure they have a meaningful seat at the table.
  • Top-down approaches need to go the way of the dinosaur – start local. We need to shift our strategic focus towards national and sub-national partners. The disconnect between commitments at the global level and awareness of commitments among stakeholders at the country level is holding us back.
  • To that end, we need to monitor fragmentation and improve partner behavior.  Alignment and coordination at the country level matter more than ever before to achieve the 17 goals and 169 targets of the Sustainable Development Goals.  Political will for improved processes and behavior change are critical, shifting incentive systems from attribution to contribution and through meaningful, resourced and enabled civil society engagement in accountability frameworks across programs and at all operational levels.
  • We all know data is important - but it is just not enough. There are many efforts focused on the collection and perfection of data. We need to work to connect data to action to achieve the change we want. Even “imperfect” data can be a part of the solution, especially when it is local, user-centric, and accessible in real time. At the same time, scaled investments in measurement, performance, data quality and dialogue are required to balance demand and incentivize political will for behavior change and action.
  • Collaboration is key. There are successful accountability efforts out there, and what they tend to share is robust cooperation between stakeholders—government, civil society, lawmakers, health workers. Let’s start to share these successes and work to scale them up.

When it comes to creating rich, constructive accountability mechanisms that give voice to the most vulnerable and ensure that people everywhere can live healthy lives, we have our work cut out for us. The good news is that today we have a lot more evidence and information on which to base our path forward.