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BRIEF RESEARCH ARTICLE
Year : 2014  |  Volume : 58  |  Issue : 1  |  Page : 65-68  

Community based monitoring under national rural health mission in Maharashtra: Status at primary health centers


1 Professor, Community Medicine, MGM Medical College, Kamothe, Navi Mumbai, Maharashtra, India
2 Pro-Vice Chancellor, Maharashtra University of Health Sciences, Nashik, Maharashtra, India
3 Epidemiologist, Community Medicine Department, Punjabrao Deshmukh Memorial Medical College, Amravati, Maharashtra, India
4 Professor and Head, Preventive and Social Medicine Department, Govt. Medical College, Dhule, Maharashtra, India
5 Professor and Head, Preventive and Social Medicine Department, Seth G S Medical College, Mumbai, Maharashtra, India
6 Professor and Head, Preventive and Social Medicine Department, IGMC, Nagpur, Maharashtra, India

Date of Web Publication5-Mar-2014

Correspondence Address:
Prakash Prabhakarrao Doke
Professor, Department of Community Medicine, MGM Medical College, Kamothe, Navi Mumbai - 410 209, Maharashtra
India
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Source of Support: Shri Vikas Kharage, Mission Director NRHM Maharashtra for providing us the opportunity and fi nancial support to conduct the study and Joint Director Dr. Satish Pawar for supporting it., Conflict of Interest: None


DOI: 10.4103/0019-557X.128173

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   Abstract 

This study compares the implementation of community-based monitoring (CBM) in 45 primary health centers (PHCs) in the pilot phase in Maharashtra with the equal number of randomly selected PHCs not implementing CBM (non-CBM) from the same districts. Information was collected by teams from Community Medicine Departments by visiting selected PHCs. Establishment of monitoring committees and training of medical officers (MOs) had been completed as required but only 36.36% MOs were trained. Only 43.18% MOs received the facility report card. Most of the MOs (90.90%) attended Jansunwai and opined that it had increased community awareness and the barriers between the people and PHC staff were broken. There was no difference in fund utilization and meetings of Rugna Kalyan Samittees. Percentage of Institutional deliveries and women receiving Janani Suraksha Yojana benefits among home deliveries was more in the non-CBM group of PHCs.

Keywords: Community based monitoring, National Rural Health Mission, Primary health centers


How to cite this article:
Doke PP, Kulkarni AP, Lokare PO, Tambe M, Shinde RR, Khamgaonkar MB. Community based monitoring under national rural health mission in Maharashtra: Status at primary health centers. Indian J Public Health 2014;58:65-8

How to cite this URL:
Doke PP, Kulkarni AP, Lokare PO, Tambe M, Shinde RR, Khamgaonkar MB. Community based monitoring under national rural health mission in Maharashtra: Status at primary health centers. Indian J Public Health [serial online] 2014 [cited 2019 Nov 21];58:65-8. Available from: http://www.ijph.in/text.asp?2014/58/1/65/128173

Community-based monitoring (CBM) is an important component of National Rural Health Mission (NRHM) in India and was initiated as a pilot project in the year 2007. The pilot project itself was very large covering nine states (Assam, Chhattisgarh, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Orissa, Rajasthan and Tamil Nadu). In each of these states, three to five districts were selected as per criteria laid down. [1] First-phase CBM was started in 1620 villages from 324 primary health centers (PHCs) situated in 108 blocks of 36 districts. The project is implemented through non-governmental organizations (NGO). CBM in Maharashtra was started in 45 PHCs, from five districts namely Pune, Amravati, Nandurbar, Thane and Osmanabad. Almost all the selected PHCs excluding from Osmanabad were tribal PHCs. Government of Maharashtra desired to undertake an evaluation of the first phase before up-scaling the project. This article pertains to the evaluation of CBM at PHC level with the following objectives; to study the implementation process of CBM in CBM-PHCs in accordance with guidelines of Government of India and to assess the effect of CBM process by comparing selected indicators of CBM-PHCs and randomly selected non-CBM PHCs from the same districts.

In Thane district, the CBM process could not be implemented in one PHC because it was shifted from tribal to the non-tribal area. This was revealed only after the visit of the team. This PHC was included in non-CBM PHC group. For comparison, 45 PHCs were selected by multistage simple random sampling. In the first stage of sampling, three blocks were selected from each district from an alphabetical list of all non-CBM blocks and by generating three random numbers with computer. In the second stage, three PHCs were selected from each of the selected blocks from the alphabetical list of all PHCs in the block and by generating three random numbers with computer. Thus, non-CBM group comprised 46 PHCs including the PHC in Thane district mentioned above. The number of CBM-PHCs is 44 due to this reason.

We sought co-ordination from Community Medicine Department from medical college close to implementing the district to conduct the study. The evaluation of CBM in Pune district was carried out by State Health System Resource Centre (SHSRC), Pune. The study design and the questionnaire were finalized after pretesting in one PHC not included in the study and after discussion with the participating colleges. For each district, excluding Pune, one team consisting of postgraduate student and one faculty from the department was constituted. Public health specialists from SHSRC visited the PHCs in Pune district. The study teams visited PHCs, carried out inspection and interviewed medical officers (MOs). The teams visited the PHCs at least twice.

For each PHC, the sources of information were a specially prepared and pretested questionnaire for PHC MO in charge, records of PHC (this included information about utilization of annual maintenance grants, un-tied fund [UTF], meetings of the Rugna Kalyan Samittees [RKS] etc.) and on the spot observations made by the teams on selected activities, including availability of selected drugs.

Report published by SATHI, [2] the state coordinating agency for Maharashtra was also resorted. This study was carried out in 2010-2011 with financial assistance from NRHM.

We observed that monitoring committees at PHC level were established as per the guidelines. The training at PHC level was not supported by block/district level faculty. Only 16 (36.36%) MOs were trained. Duration of training varied from 1 to 3 days. The three priority areas identified by MOs for additional training were community participation, parameters of grading the PHC in "Green," "Yellow" and "Red," in facility report cards, conduction of "Jansunwai."

Only 19 MOs admitted receipt of facility report card of their PHC during 2009-2010 and showed it to the investigators. Forty MOs from CBM PHCs stated that they had attended Jansunwai of their PHC. The top three points, as per MOs, in order of frequency that were discussed in Jansunwai were non-availability of medicines, non-availability of referral services and absence and behavior of staff.

Changes perceived by MOs as a result of CBM in general and Jansunwai in particular were Increase in awareness about health rights, increase in awareness about benefits such as Janani Suraksha Yojana (JSY) and lessening of barriers between people and PHC staff.

Numbers of PHCs from the two groups, displaying important information/services are shown in [Table 1]. The details of frequency of meetings of the executive body and governing body of RKS held in the PHCs in 3 years are given in [Table 2]. The CBM/non-CBM groups of PHCs received a total of Rs. 21,752,778 and Rs. 23,538,415 respectively during this period. The percentage of utilization of grants was 81.4% and 84.5% respectively. The purpose of utilization of UTF was also studied wherever separate accounting was available. Utilization of UTF for providing financial assistance for referral of needy patients was rare, both for CBM as well as non-CBM PHCs.
Table 1: PHCs displaying important information/availability services

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Table 2: RKS Committee Meetings in 2007-2008 to 2009-10

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Information about the place of delivery and benefit given under JSY was not available from two PHCs each in both groups. The total number of deliveries in CBM/non-CBM PHCs during the study period was 21,327 and 23,117 respectively. The institutional deliveries were 15,013 (70.4%) and 19,116 (82.7%) respectively. Among those who delivered in the hospital, 6821 (45.4%) women from CBM-PHCs and 8722 (45.6%) women from non-CBM-PHCs were paid a benefit under JSY. The number of women delivered at home and were paid JSY benefit under these two categories were 2874 (45.5%) and 2045 (51.1%) respectively.

The non-availability of selected 10 drugs on the day of a visit was almost similar in both groups. About 10 to 15 PHCs did not have syrup trimethoprim + sulfa methaxozole and syrup paracetamol in both groups.

All the stages described for implementing CBM [1],[2],[3] were undertaken by the nodal NGO agency in Maharashtra. The training of MOs was not satisfactory on two grounds. There was less coverage (only about one-third) and lack of uniformity in duration. Almost all trained MOs opined that the training was moderately to extremely important. Even in the 3 rd year of implementation only 43.2% MOs were aware of receiving facility report cards. The findings of this study indicate that MOs are not averse toward the idea of public hearing as more than 90% attended Jansunwai. MOs acknowledged positive changes in awareness brought by Jansunwai. Their suggestions for improvements are also valuable. The driving forces behind CBM are concept of right to health and right to information. The right to information is fulfilled through the displaying of status of functioning of the institution and such displaying is expected to reduce the lacunae. CBM implementation has not resulted appreciable change. In an evaluation of CBM in Uganda, there was 32% increase in suggestion box availability. [4] Convening of meetings was far less than an expected total of 18-36 meetings of Executive committee and 12 meetings of Governing body during the 3-year period. There was no significant difference in the average number of meetings in the two groups (P > 0.05). It was informed by almost all MOs that the meetings of the executive body and governing body are convened on the same day. Although, the minutes of these meetings were available with these PHCs, none of them could show evidence of its communication to the block level committee. There was no appreciable difference in utilization of funds also. The efforts at raising money for RKS funds locally were seen in very few blocks. The Comptroller and Auditor General of India has also criticized functioning of RKS. [5] The long-term objective of transfer of ownership of the institutions to the local community may be jeopardized. The important indicator of availing facilities of institutional deliveries was higher in non-CBM group. As well the proportion women delivering in the house and receiving JSY benefits was higher in non-CBM group of PHCs. Both these findings may be the outcome of better conveyance facilities in non-CBM group of PHCs. Similar project in one district of Maharashtra observed improved health care behavior. [6] In another study in Uganda, significant reduction in under-five mortality was observed. [7] The state nodal agency in its report selected 10 essential drugs and checked "satisfactory availability." [2] We checked availability of almost same drugs in a different manner. The list of important identified 10 drugs in our study included anti-rabies vaccine and excluded tablets fluconazole. Ideally, these drugs should not be out of stock, at any given point of time. The pattern of availability of the drugs was similar in the both groups. Although CBM is a novel idea; its continuation and up-gradation must be justified. Change in functioning is a slow process but even after 3 years of implementation there was not difference between CBM and non-CBM group of PHCs in the functioning with respect to the system or institutions created under NRHM. We recommend that, training duration should be uniform and suggestions of MOs should be considered while designing training. Clear instructions about maintenance of records of different funds, recording of minutes of the meetings and greater emphasis on the importance of mandatory display items need inclusion.


   Acknowledgments Top


We sincerely thank Shri Vikas Kharage, Mission Director NRHM Maharashtra for providing us the opportunity and financial support to conduct the study and Joint Director Dr. Satish Pawar for supporting it. We deeply acknowledge the coordination extended by the Community Medicine Departments from participating Medical Colleges. We also thank all the MOs of the PHCs who communicated the information very positively.

 
   References Top

1.National Rural Health Mission: Managers′ Manual on Community Based Monitoring of Health Services Under National Rural Health Mission: Mission Director. New Delhi: National Rural Health Mission, Department of Health and Family Welfare, Govt. of India; 2008.  Back to cited text no. 1
    
2.Compiled Report of Community Based Monitoring of Health Services Under NRHM in Maharashtra (2007-2010). Pune, Maharashtra, India: SATHI; 2010.  Back to cited text no. 2
    
3.Garg S, Laskar AR. Community-based monitoring: Key to success of national health programs. Indian J Community Med 2010;35:214-6.  Back to cited text no. 3
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4.Nyqvist MB, Svensson J. Community based monitoring of primary health care providers in Uganda. Evaluation; J Pal Evaluation Summary. Available from: http://www.povertyactionlab.org/evaluation/community-based-monitoring-primary-healthcare-providers-Uganda. [Last accessed on 2012 Jun 15].  Back to cited text no. 4
    
5.Report of the Comptroller and Auditor General of India, for the year ended 31 March 2009 (civil), Government of Maharashtra. Ch. II. Performance reviews. Available from: http://www.pibmumbai.gov.in/English/PDF/E2010_RP4.PDF. [Last accessed on 2012 Jun 15].  Back to cited text no. 5
    
6.Dongre AR, Deshmukh PR, Garg BS. A community based approach to improve health care seeking for newborn danger signs in rural Wardha, India. Indian J Pediatr 2009;76:45-50.  Back to cited text no. 6
    
7.Bjorkman M, Svensson J. Power to the people: Evidence from a randomized field experiment of a community-based monitoring project in Uganda, June 2007. Available from: http://www.cid.harvard.edu/neudc07/docs/neudc07_s2_p11_bjorkman.pdf. [Last accessed on 2012 Jun 15].  Back to cited text no. 7
    



 
 
    Tables

  [Table 1], [Table 2]


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