social audit of maternal health services in uttaranchal an effective mechanism for monitoring health...
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SOCIAL AUDITof Maternal Health Services in
Uttaranchal
AN EFFECTIVE MECHANISM FOR MONITORING HEALTH
SERVICE PROVISION
Background to the Social AuditOur experiences and studies show- There is high maternal mortality in the
area; existing health services are of poor quality and poorly accessible for women
There is no community monitoring or state accountability: low information about what Government health programmes are meant to provide
Panchayats have low interest in women’s health issues (never on the meeting agenda)
Objectives of Social Audit
To carry out a community based audit of the state maternal health services in Uttaranchal towards…
Social Audit towards …
Creating a demand for maternal health services from the community
Increasing responsiveness to community needs in health providers and managers
Principles of Social Audit To take permission from the state health
department To maintain confidentiality of all sources of
information To cross-check and verify all information To ensure informed consent to any
information that is made public To ensure that no punitive action is taken as
a result of the audit To ask all actors for their suggestions to solve
the problems
Scope of Social AuditArea – 2 blocks in two districts of
Uttaranchal state
Within each block, - 10 villages - 2 Sub-Centres - 1 PHC
TEAM: Included Panchayat members, women’s group leaders and NGO staff
Steps of the Social Audit – Preparations (July 04)
We obtained accurate information about available maternal health services and facilities from the government
Capacity building of team through training programme, field visit and PHC visit
Developing Social Audit tools, field testing Taking permission from district CMO Taking permission of village Panchayats
Steps of the Social Audit – Information gathering by team
Conducting interviews and observations in 2 PHCs
Conducting interviews and observations in 4 ANM Sub-centres
Conducting group discussions in 20 villages Documenting 17 case studies of maternal
deaths and experiences of family planning services in RCH camps
Steps of the Social Audit - Sharing Collated findings and shared with
audit team for internal checking Shared with community in 20
villages for consent Shared separately with CMOs,
MOICs and ANMs for consent Printed the Audit Report in Hindi
Sharing of Audit findings
Shared with the community, media and Panchayat leaders in a Public Gathering (March 2005)
Outcomes of the Social Audit – Gaps Emerging No one document defining what
services women are entitled to Lack of material or staff for health
education and public awareness Information given only regarding female
sterilization No involvement of Panchayats in
maternal health activities
Gaps contd. Lack of women doctors in PHCs/CHCs
– poor system of referral in emergencies
Very limited range of services despite ‘RCH camps’
Lack of essential equipment in Sub centres for ante-natal check-ups, delivery and post-partum care; gaps in supply and maintenance/ repair
Outcomes of the Social Audit – Success with service providers
Health department supported entire audit process – for the first time ‘reminded of their responsibility by the community’
The PHC has 3 doctors including a woman doctor who goes to the villages; deliveries are conducted and there are curtains – referral is through a written slip
Success with service providers …
ANM’s community level work has improved, gives more information about health programmes
She comes when called home for deliveries and does not charge money for home deliveries, also stopped giving the injections to speed up labour
ANM has better relations with women’s group, keeps up contact, attends meetings
The ANMs are staying in the SCs with community support, women help her during immunization camps
ANMs provide improved ANC and cover remote villages now
Outcomes of the Social Audit – Success with community Panchayats at village and block level are
actively involved in the issue of maternal health services
Women have created a pressure so that Panchayats are now taking up health issues as an agenda in meetings
Women are now clear about their entitlements when they seek health services
Women’s groups monitor the quality of care in RCH camps
Future Community Action
Formation of a group with Panchayat representatives, women leaders, government health managers to take the audit process forward
Some challenges It is not easy for an NGO to facilitate an
audit process while maintaining a relationship with the government
It is not easy to create a relationship with the Panchayat leaders on a ‘women’s issue’
The informants were hesitant to provide accurate information about the actual state of maternal health services
More challenges … Making the audit report was difficult – to
maintain accuracy while not alienating the health providers - to ensure that the audit report was accepted by all stakeholders
The public sharing of the audit report had to be only fact-based, not fault-finding or accusation
ConclusionThe experience shows it is possible to ~ Impartially audit quality of maternal health
services with the cooperation of the health department and the community
Make Panchayats actively involved in maternal health and make them a ‘voice’ that demands accountability from the health system
Change the client-provider relationship to empower even non-literate rural dalit women users to exercise their rights in health services
Recommendation for 11th Five Year Plan
The effective implementation of NRHM in rural areas depends on –
The monitoring of services by community user groups at the point of service delivery
Shared quality parameters for both users and providers
The informed demand created among users: empowerment of users to negotiate for quality services
Institutionalizing Social Audit in 11th Five Year Plan
Both public and private service provider institutions must go through regular social audit
The Social Audit must be carried out with full participation of community /users, Panchayats, the service providers and administrative officials
The Audit has to be facilitated by an NGO which has a good rapport with the community and the Panchayats
Costs of Social Audit
For the NGO to facilitate the Social Audit in 2 districts in 2 blocks (1 PHC, 2 Sub-Centres and 10 villages) cost was Rs 2 lakhs.
This includes preparation, training, audit activities, sharings and publication of audit report
This does not cover the NGO’s costs of building rapport with the Panchayats and community women for the previous three years
Acknowledgements
Community members of Nainital and Udham Singh Nagar districts
Government of Uttaranchal Health Department
Audit team members, other NGOs who helped with the process
SAHAYOG and MacArthur Foundation for resources
~ Thank You
Sunita Shahi,
PRAYAS
Nainital
Uttaranchal
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