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