Health Equity and Governance
Our Work From the Beginning.
Health Equity and Governance – CHSJ began its operations soon after the National Rural Health Mission (subsequently the National Health Mission) was launched with the promise of better health for the rural poor. Health equity was at the core of NRHM. Health equity is concerned about differences in health outcomes and access to health services between different groups of people and is aimed at bringing about a level playing field. It interrogates whether these are fair or just and avoidable and whether they deprive people of opportunities. It also suggests ways of overcoming these circumstances through systematic efforts. Governance relates to ways in which public systems are designed and delivered. CHSJ has been particularly involved in finding ways to ensure that marginalised communities are empowered and enabled to be represented in the governance process to achieve health equity.
1st Phase (2005 – 2010) – The National Rural Health Mission introduced the important concepts of community participation and accountability into public health planning for the first time in India. CHSJ undertook several initiatives to strengthen these components.
2nd Phase (2010 – 2015)- During these years CHSJ’s focus shifted to strengthening the health equity and governance related practices at the community level. CHSJ initiated one pilot projects to understand how men could be engaged in a gendered practice of accountability in Madhya Pradesh, and in another pilot understood how communities could get engaged in health budgeting and expenditure tracking at the local level. On the other hand, CHSJ started facilitating process of learning and exchange to strengthen the field of citizen led accountability practice in the field of health. Some of the projects implemented by CHSJ during these years were as follows.
- Rapid Assessment of NRHM implementation (Ph 2)
- Supporting Community Participation in State NRHM Implementation
- Community-based Health Expenditure monitoring
- Swadhikar – Securing of Health rights by marginalised Communities
- Capacity Building on Health Governance and Social Exclusion
- Strengthening Learning Communities on Social Accountability in Health
3rd Phase (2015 – 2020) – The emphasis of CHSJ’s work in Health Equity and Governance shifted to building capacity among community-based organisations and to fostering learning collectives. CHSJ also started working more closely with organisations of marginalised communities like trade-unions and with community groups like bidi workers and manual scavengers. CHSJ continued to foster a global community of practitioners on Social Accountability in Health as it hosted the Global Secretariat of COPASAH drawing attention to the need for incorporating it into public policy and highlighting key practices.
Health Equity and Governance – Projecy Details
Strengthening Community Participation and Accountability in the NRHM ( 2006 – 08) – The National Rural Health Mission (NRHM) was launched April 2005 to develop a new architecture of the health system to enable it to provide access to quality health care services to the rural poor. Community participation was a key element of NRHM and CHSJ was engaged in several initiatives to promote Community Participation with a focus on Accountability within NRHM. CHSJ was among the first organisations in the country to draw attention to the need for Accountability in health policy and programming.
- Annual Consultations on NRHM – NRHM was developed in close collaboration with civil society experts. Many of CHSJ’s Advisors and the then Director were involved in this process. Community engagement was a key element of NRHM during its inception. CHSJ convened an annual Civil Society Review of NRHM implementation in NRHM high focus states for three years.
- Leadership Training of District Programme Managers – NRHM included a process of decentralised planning and monitoring. A new cadre of District Programme Managers (DPM) were introduced as the fulcrum of this decentralised implementation process. CHSJ conceived a Leadership Training Programme for DPMs in partnership with the University of Washington. Two rounds of this training programme were held, first in collaboration with National Institute of Health and Family Welfare in New Delhi in 2009 and then again in 2010 for all the DPMs of Assam in collaboration with the State NRHM, Assam.
- Decentralised Planning in NRHM – CHSJ contributed to developing the NRHM Decentralised planning framework. It implemented a pilot project for decentralisation planning in Rajasthan supported by UNICEF and SC Mathur SPRI, Jaipur. The results of this pilot were shared with the MoHFW.
Community Monitoring of NRHM (2007 – 09) – CHSJ was the Technical Secretariat for the Advisory Group on Community Action (AGCA) and in partnership with Population Foundation of India implemented the pilot project on Community Monitoring on NRHM (2007 – 09) in 36 districts of 9 states across the country. The pilot project was meant to introduce accountability of the health system to communities and was supported by the Ministry of Health and Family Welfare Government of India, and the process of Community Monitoring was subsequently included within the regular planning process of the state government NRHM. This pilot project covered 1620 villages across the country and CHSJ conceptualised and coordinated the overall process with the support of AGCA members and state Nodal Agencies. This methodology has subsequently been expanded into Community Action in Health and continues to be implemented in a majority of states in the country.
Rapid Assessment of NRHM (2009 – 2010) – NRHM promised to bring quality and affordable services to the rural poor in India. It included an accountability framework and CHSJ facilitated a number small-scale studies which were conducted as a dip-stick evaluation to understand NRHM implementation. These studies were shared with the MoHFW and Planning Commission of India and these were acknowledged as important sources of independent feedback by the government
- Rapid Assessment of Health Programmes (RAHP) – RAHP was a year-long capacity building programme for training researchers in the non-government sector to conduct small scale studies using robust methodology. Twelve NGOs from different states were trained through the first round of RAHP and the reports were shared with policy makers. The training implemented in partnership with the School of Public Health University of Washington USA
- Small Scale Studies – Several small-scale studies were also conducted independently to look at various dimensions of health care service delivery in specific areas and among specific population groups.
Equity in Access to Healthcare Services
- Access to medicines (2005 -08) – The project Tracing Pharmaceuticals in South Asia (TPSA) was implemented in partnership with SAHAYOG, Lucknow, Martin Chautari, Nepal and University of Edinburgh, UK. The purpose of this project was to understand the distribution and access to medicines related to key health issues. The distribution pattern of three index drugs – Rifampicin, related to the tuberculosis treatment and part of the national TB control programme, Oxytocin – a drug used for controlling post-partum bleeding and for augmenting labour and related to the maternal health programme, and Fluoxetine an antidepressant drug were studied in this project.
- Equity in National Health Programmes ( 2009 – 11) – CHSJ conducted several studies to understand the equity in health service delivery. These included desk reviews based on existing data as well as field investigations. These included
Rapid Assessment of NRHM implementation 2 (2011 – 13) – The Second Round of the RAPH training using the earlier methodology developed with the University of Washington was conducted in collaboration with School of Public Health, SRM University, Chennai. Over forty representatives from eighteen NGOs were trained in two cycles one for institutions based in the Southern India in Chennai and one for institutions in North India in Delhi. The reports were shared as Research Briefs with Policy Makers.
Supporting Community Participation in State NRHM Implementation (2009 – 11) – CHSJ provided support to the State NRHM offices in Bihar and Sikkim to implement community mobilisation and community monitoring once the pilot phase was completed.
Community-based Health Expenditure monitoring (2011 -12) – In partnership with The Ant in Assam and The Humanity in Odisha CHSJ develop and piloted an approach to develop a community monitoring methodology to understand and monitor flexible financing mechanisms that had been introduced through the NRHM at the village and district levels. This pilot project was implemented with support from International Budget Partnership (IBP) in USA.
Swadhikar – Securing of Health rights by marginalised Communities (2012-14) – This project was implemented in partnership with National Coalition of Dalit Human Rights (NCDHR) in the state of Madhya Pradesh. The objective of this project was to work with community-based organisations who were working with marginalised Dalit and Muslim communities and build their capacity to participate effectively in the NRHM community participation processes to improve access to health services. This project was funded through the Poorest Area Civil Society (PACS2) project of DFID.
Strengthening Learning Communities on Social Accountability in Health ( 2012 – 2015) – CHSJ was involved a founding member of the global health accountability collective COPASAH. The main purpose of this collective was to highlight the practices around accountability and citizen participation around health services and enable practitioners to build their skills through mutual learning exchanges. In the process CHSJ was also involved in building skills and competencies in implementing community based social accountability practices in India, and in other South Asian countries as well as regions like Eastern Europe, Africa and Central America.
Capacity Building on Health Governance and Social Exclusion (2013 – 14) – CHSJ provided technical support to the Poorest Area Civil Society (PACS2, supported by DFID) project partners in seven states of UP, Bihar, Jharkhand, Chattisgarh, MP, Odisha and West Bengal. This included building an social exclusion analysis perspective and planning empowerment activities accordingly at the local level.
Access to Health for Women Bidi Workers (2017 – 19) – Beedi or hand rolled mini cigars are very popular tobacco products used by the poor and rural communities in India. Over 5 million workers, mainly women are involved as rollers in this primarily home-based industry. There are many social security and health policies meant for workers of the beedi sector, but these are poorly implemented. CHSJ conducted a participatory study into the implementation of these social security measures in the three states of Tamil Nadu, Madhya Pradesh and West Bengal. The results of the study were shared with the concerned stakeholders, and the relationships with the CBOs continue.
Social Accountability and Marginalised Communities (2015 – 2020) – CHSJ started working on health issues of marginalised communities like Dalit agricultural workers, and manual scavengers with CBOs in South India. In these states health systems and health indicators are considered to be relatively better compared to the north, but there are glaring cases of social inequality. Through support from CHSJ local groups were able to build their capacity in applying social accountability tools to improve their access to better health care services using Human Rights Commissions, women’s rights commissions extensively during this phase. Over 100 petitions to these commissions by local networks. CHSJ facilitated community based participatory processes for strengthening health governance. Building civil society coalitions was an important outcome which facilitated the civil society leadership from diverse fields such as journalists, social activists, researchers, gram panchayat members and lawyers. Maternal Health Rights Campaign emerged as voice of people on health rights matters and a unique experiment on Engendered Accountability incorporating principles of gender equality and male responsibility into accountability for health rights was implemented.
Coordinating COPASAH Secretariat (2015 – 2020) – CHSJ is a founding member of the global network, Community of Practitioners on Accountability and Social Action in Health (COPASAH) since the time it was launched in 2011. COPASAH is a community of practitioners with over 400 members from over 40 countries who learn and share from each other on community led practices around accountability and health governance. CHSJ was earlier coordinating the Asian regional Secretariat and the Communication hub but later assumed the responsibility of the Global Secretariat. As the Global Secretariat CHSJ coordinated knowledge making in social accountability. CHSJ specifically contributed to knowledge processes through unique contributions like the E-learn CBM module and case studies like Manual Scavengers and Dalit Women issue papers on Social Accountability in East-Southern Africa.
Hosting Global Symposium on Citizenship Governance and Accountability in Health (2018 -19) – As the Global Secretariat of COPASAH CHSJ hosted the COPASAH Global Symposium (COPGS) on Citizenship, Governance and Accountability in Health in New Delhi between the 15th and 18th of October 2019. In the last few years the Accountability and Governance is being increasingly seen as essential to the fulfilment of the Universal Health Care and Sustainable Development Goal agenda. Members of COPASAH are among the leading practitioners of social accountability and community action in the field of Health and as a group have contributed significantly to the emerging discussions on community-centred and citizen-led processes in the field of health.
Reports & Resources
NRHM Consultation Reports
Community Monitoring Pilot Project
Rapid Assessment of NRHM
Health Equity Studies
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