Health: Community Based Monitoring in Velhe, Pune

Volunteers visit every project that AID supports to observe the work first-hand and get familiar with some of the people and their perspectives. Sonali Rahagude, a computer engineer and volunteer from Seattle visited Velhe, near Pune, where AID partner SATHI empowering local communities to make public health services function responsibly.

In September 2016, I travelled to Velhe Taluka, Pune, Maharashtra where an organization called Support for Advocacy, Training and Health Initiatives (SATHI) along with a local group called Rachana have implemented Community Based Monitoring.

I visited the following places:

A gram panchayat, where I talked to the sarpanch and some Auxiliary Nurse-Midwives (ANM) and Accredited Social Health Activists (ASHA).
A Primary Health Unit (PHU) where I talked with a veteran Community Based Monitoring (CBM) advocate.
A rural hospital, where I met with a newly appointed Technical Health officer.

What is Community Based Monitoring?

The record of the health system in India in providing adequate health services has on the whole been poor. From the village level, where Anganwadis are poorly maintained/staffed to systemic levels, there are a variety of problems with the health system. Though the Ministry of Health and Family Welfare’s National Rural Health Mission (NRHM) has laid out a number of provisions for rural healthcare, ensuring that these facilities actually reach the masses is an altogether different task.

Community Based Monitoring (CBM) is an accountability framework under the National Rural Health Mission (NRHM). Its key components include community awareness about health rights, data collection on people’s experiences of health services, preparing and publicly displaying pictorial “report cards” with people’s critical ratings, meetings of multi-stakeholder committees to resolve the issues identified, periodic “jan samvad” (public dialogue) amongst many other activities.

The non-governmental organization (NGO) SATHI has been facilitating CBM activities in the state of Maharashtra for 8 years now. SATHI is a team of health professionals and social workers which has been working for nearly 2 decades with an aim to make the health system accountable to people, to establish health rights and change the nature of health services in a way these services become responsive to people.

In Velhe taluka near Pune, Maharashtra, SATHI has partnered with local civil society organization (CSO) Rachana to implement CBM. Rachana undertakes various programs in the field of Rural Community development, covering vital aspects of Education, Health; focusing on Women and Children empowerment. It reaches over 150 villages and hamlets in various tehsils of Pune spread over a large hilly area.

Visit to Gram Panchayat office at Osade village

The Velhe block is situated 60 km from Pune city. It is a semi-tribal area located amidst hills and forests with poor communication and transportation facilities.

I visited the Gram panchayat office at Osade village and talked to the Sarpanch and the Auxiliary Nurse Midwives and ASHA workers.

L to R: SATHI staff Shakuntala Savita, Bhaurao Aher and local community workers

ANMs and CBM community workers discussing health facilities in the village.

The Gram Panchayat office at Osade village (Taluka: Velhe)

Improvements in local health since CBM implementation

The ANMs told me how through CBM, the local villagers have become more aware of their rights and have also improved local sanitation and public health. Before CBM and Rachana intervention, mothers used to drop their kids to Anganwadi and leave. Now, they try to assess the quality of food and verify its nutritional goodness at least twice a week.

The sarpanch has now engaged with a local poultry company and convinced them to donate 100 eggs per day which are being used in Anganwadis. They are also trying to use part of the NRHM fund into buying nutritional food for malnourished kids. Due to all these efforts, the number of malnourished kids in the village has gone down.

Visit to Primary Healthcare unit

I then visited a Primary Health Unit (PHU) which has been revived and made functional through CBM action as well as through efforts of the current MO – Dr. Deokar.

PHU (also called floating clinic) at Panshet

List of PHC monitoring committee members

Bapu Shirke (local CBM activist), R. Dr. Deokar (PHC Medical Officer)

I had a discussion with Dr. Deokar and Bapu Shirke. Bapu Shirke has been a local CBM activist for more than 20 years now. He talked about the state of this clinic before Dr. Deokar (the current Medical Officer) was appointed. The doctors would give preferential treatment to people with better status in the surrounding villages. They would apathetic to the patients who would wait for hours before they were attended. At times when the doctors saw no patients had showed up, they would leave early, way before their work shift ended. This had lead

Improvements in PHU since CBM implementation

After Dr. Deokar got involved in CBM, the people’s trust in the PHU has been restored. The clinic maintains a clean in patient department, clean toilets, drinking water for people who travel from far to come to this PHU. It has led to an increase in the OPD attendance.

Through their efforts, this clinic has been sanctioned by government to become a Primary Healthcare Center (PHC) back in 2013. But they need a new building and more facilities for it, and no help from the govt. has been received in that regard yet. The neighboring land belongs to the irrigation department, so it is not easy to procure land; this has been the stance of the health officials.

Visit to Velhe Rural Hospital (RH)

The rural hospital at Velhe is a small dilapidated one storied building. Just to give you an idea of the remoteness of this place, it took us 1 hour to travel from Osade village to this hospital by car.

Velhe Rural Hospital

Improvements in Rural Hospital since CBM implementation

Mr. Konde (Rachana) gave me an overview of the changes brought to the hospital’s conditions through CBM. Planning of utilization of patients welfare funds has improved due to involvement of people’s representatives in its monitoring.

The Rural Hospital initially did not have a sustained water supply. In summer, gastro-epidemics are high in this area. Patients have to use toilet water again and again. Many patients would complain about lack of water. In the Rogi Kalyan Samiti (RKS) or Patient Welfare Committee meeting, an idea of joining the Hospital water tank with that of a nearby village was presented. This lead to installation of network of pipelines and now the Rural Hospital has 24 hour supply of water.

Two water filters were requested by civil society representatives in the RKS body, for drinking water for patients. This issue was not addressed for 2 years. When it was brought up again in RKS meetings and CMBP workshops, expenditure for it was finally sanctioned.

Instructions about biomedical waste management in the lab

Feeding room

Apart from effective funds utilization, many other improvements were brought about through CBM action,

Glass panes of windows were repaired and the windows were fitted with mosquito nets.
The lab in the hospital was nonfunctional, it was cleaned up and is being used now.
The board displaying the stock of essential medicines would never be updated, this is being done now.
The record keeping for medicines has improved, as such, the RKS has a better idea of the amounts needed every year.
There was seating arrangement for relatives visiting admitted patients. These were installed after the issue was brought up in the RKS meeting.

Stools put in the waiting area of the hospital through CBM action

List of essential medicines with their disbursed and balance amount in the hospital lab

Dialog with Public Health Officials

At the Rural Hospital, we met Dr. Tidke, the Technical Heath Official (THO) for Velhe (and Purandar, staff shortage in a known issue with public health institutions). I was fortunate enough to witness an interaction between him, other health officials and the CBM committee members. It was interesting to see a difference in attitudes towards public health of both parties.

Health officials discussing with Mr. Konde(R) from local CSO

CBM committee members raising issues with Health officers

In the discussion, the CBM committee members raised various issues with the health officials.

A particular Primary Healthcare Center (PHC) in the area did not have a CBM committee board for patients’ reference.
Health officials holding staff meeting at another PHC do not involve CBM committee members.
There is no complaint box for patients to use.
An incident where health officials hurriedly created a soak pit outside the PHC only because district officials were about to visit.
A health worker sent a patient’s husband to the city to get a syringe worth Rs. 2 when it was apparently already available at the facility. The person ended up spending Rs. 50 for the travel and the treatment was delayed for no reason.
Staff not being regularly available at the PHC.

Witnessing this discussion made me realize the complexity of carrying out CBM in action on ground. The officials wanted to paint an “all is well” picture. Getting them in the same state of mind and eliciting cooperation from them must be a herculean task often times. And one has to be careful not to offend them in anyway; everyone in the discussion was talking in a very pacifying manner.

The public health system in India is riddled with complex interconnected problems at various levels. Apathy and superiority complex in many public health workers, distrust of people in the rural health services and lack of general health rights awareness are just some of them.

Because of the effective implementation of the CBM process by SATHI in Velhe, people got more aware of health and health rights, they have started getting treatments at PHCs, asking money for the health services has stopped, availability of medicines has substantially improved. In addition to this, there has been a wave of local activists who have taken up CBM and have been doing the job with utmost commitment.

My biggest realization out of this site visit was the effectiveness of CBM at various levels — village, PHC and Rural hospital (RH). Given the dire state that our public health institutions are usually in, where patients are ill-treated, RHs don’t even have benches for relatives to sit outside or a clean lab for performing tests, an efficient CBM ecosystem is the most effective and the only tool that empowers people to bring about changes in the public health institutions and provisions, with a reasonable turn around time. In my opinion, I can describe CBM as a way of democratizing the public health system for the benefit of the masses.