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 . 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 .
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:
- Create community awareness on health entitlements, and the roles and responsibilities of service providers.
- Train and mentor Village Health, Nutrition and Sanitation, and Patient Welfare Committees (Rogi Kalyan Samitis) to undertake community monitoring of health services.
- 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.
- Collect data using tools such as report cards and expenditure reviews.
- Compile and analyze data using a scoring system categorized into good, average, and poor services.
- Share results of the community monitoring process with stakeholders at the facility, block, and district levels.
- Develop solutions to problems that incorporate local input and planning.
- Organize public dialogues to provide a forum for engagement of the community with health providers to share key findings and discuss proposed solutions.
- Take corrective action by engaging with officials on plans to address key issues and concerns.
- 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:
- 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.
- 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.
- 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.
- 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
Trends in Maternal Mortality: 1990 to 2015 (estimates by WHO, UNICEF, UNFPA, World Bank group and the United Nations Population Division
 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.