COMMUNITY ACTION FOR HEALTH

Item

Title
COMMUNITY ACTION FOR HEALTH
extracted text
RF_COM_H_101_SUDHA

<SO AA H - ' 01

COMMUNITIZATION PROCESS
1.

What is CAH?

CAH stands for 'Community Action for Health'. This is a project that continuation of a pilot process
known as Community Based Monitoring and Planning (CMP). The CMP pilot process was implemented
as part of the communitization aspects of the National Rural Health Mission(NRHM). The process was
initiated by the Advisory Group on Community Action (AGCA) under NRHM. The AGCA proposed a pilot
process in 9 states to actualize the concept of Community Based Monitoring and Planning that was
conceptualized by the NRHM in its Framework of Implementation. It was decided to request a number
of civil society organizations to lead the process in the different states in partnership with the state
governments. The pilot phase was funded by the central government. It was expected that after the
pilot phase the state governments would take over the ownership, running and funding of the process.
In Tamilnadu, it was decided to change the name from Community Monitoring and Planning
to Community Action for Health after the Pilot phase.
it is important to note that the name of the process was changed from Community Monitoring and
Planning to Community Action for Health to emphasis that without 'action' the process is incomplete
and that the whole process is driven by a 'joint learning approach' with openness and spaces for
reflection.

2.

What is the aim of the CAH process?

As mentioned earlier the idea of the CAH process is to actualize the concept of communitization that is
introduced in the Framework of Implementation of the NRHM. The concept of communitization involves
increasing the ownership of the community for the health system. This increased ownership is seen to
increase both utilization as well as accountability of the system to the people. This combination of
increased ownership, utilization and accountability will contribute to health system strengthening and
the achievement of the goals of the NRHM. This overarching framework also provides space and
opportunity to take forward the community health approach predicated on inclusive community
involvement. Visit this link Vision and Mission of this CAH process.
3.

What are the steps of the CAH process?

The following are the basic steps of the CAH process:
• Village Health Water Sanitation and Nutrition Committee (VHWSNC) expansion to include wider
representation for all community groups and geographical areas of the panchayat. This expansion was
done by holding meetings in all the hamlets of the project area and explaining the NRHM mission and its
goal, the CAH process to the people and getting volunteers and suggestions from the community for
VHWSNC members. The team is finally rapporticed in the first committee meeting with explanation of
roles and responsibilities of the member.
• Orientation and training of the VHWSC committee members is the next major step. The whole
committee is oriented to the process. Subsequently 2 to 4 per committee is intensively trained on the
health, health care, health rights and CAH process.
• The next step is the monitoring process where a set of tool developed by the state nodal NGO in
consultation with the other process partners SHS, DPH and partner NGOs, the people is used to collect
the perspectives / assessments of the services available at the village and PHC by the committee

1

member/people. The scoring will be marked in colours as red, Yellow and green representing the status
of the particular service asseeking attention, moderate, good
• After this the information collected is collated into the Panchayat Health Status Report Card (HSRC).
Thus one Report card is evolved for each Panchayat.
• In the next step of the process is the Panchayat Health Planning Day (PHP). In the Health Planning day
the VHWSNC members present the Panchayat Health Status Report Card to a group consisting of the
representatives of the Public Health department including the Village Health Nurse(ANM/VHN) and the
Medical Officer (MO), the Panchayat President (PRl), the Aanganwadi workers (AWW) and members of
the community. During this meeting the various questions / sections receiving a 'red' color are discussed
in detail with an aim of converting this 'red' score to'green' in six months or with in the next cycle of
monitoring. Thus a Panchayat Health Action Plan is evolved.
» Subsequently this is shared with officials at the PHC, Block and District level.
• Every month the VHWS committee meet and discuss the issues arising out of the Panchayat Health
Plan and its follow up.
• The whole monitoring and planning cycle is repeated every six months.

4.

Have the VHWSNC members been able to the use the tools easily?

The tools were built after many rounds of discussions and pilot testing. In fact there have been minor
and a few major changes with each round of monitoring based on feed back received. Based on an
external evaluation and the feedback of the the people and the government officials the tool used in the
pilot phase was extensively modified to bring it to its present generic shape.
The major challenge we faced was teaching the members the logic behind the various health
entitlements so that the monitoring could be linked to action. Apart from this one area of difficulty was
the names of the equipment, however this was overcome by inserting pictures of the relevant
instrument / infrastructure.

Given its piloting and iterative feedback the tool is quite understandable and usable.
One of the interesting finding is that tool not only helps capture people's perceptions on health, but in
addition by probing a number of dimensions also spread a lot of awareness and initiated interesting and
in-depth discussions on health.
5.

How much time does it take to fill the tool and complete one cycle of monitoring and
planning?

It has been found that a full set of tools covering all the dimensions of health services will take 5 days of
time. In addition the PHC and HSC facility survey and exit polling take 1 day. Thus in all the committee
members have to spend 6 days every six months on monitoring activities. Individual interviews (for the
immunization and ANCI Delivery / PNC) take about 40 minutes to 1 hour per interview. Group
discussions (for school health / adolescent health / village services) take about 30 to 40 minutes.

In terms of planning about 3 days of preparations are required for every day of Panchayat Level
planning.
Every month there is a VHWSNC meeting to follow up the various action plans.

2

6.

What is the human resource pattern of the CAH project?

The project is implemented through the state nodal organisation (SNO) at the state level, district nodal
organisation (DNO) at the district level and cluster/block nodal organisation (CNO) at the cluster/block
level.

At the state level there is a state resource/training team consists of 6 individuals from NGO and 2 more
from department.
At the district level the project has district resource/training team consists of 2 individuals from NGO
and 1 more from department.

At the cluster/block level there is the cluster/block resource/training team consists 2 individuals from
NGO and 1 more from department.
At the panchayat level there is one coordinator for every 10-15 panchayats (in all there are 150)

What is the governance structure of the project?

7.

There is a project governing body consisting of eminent academics and civil society representatives who
governs the entire process.
The primary group that advises the State Nodal Organisation is the State Implementers Group consisting
of the Implementing NGOs, representatives of the civil society, representatives of the SHS and the DPH.
At the district level there is the district mentoring committee which mentors the process at the district
level in which DDHS, implementing NGOs, representatives of the civil society were members.
SOCHARA has a special sub-committee to provide internal mentorship and over-sight to the
implementing team.

8.

What is the role of the Civil society groups in the process?

The role of the civil society groups in the project are as follows:

• Capacity building of the VHWSC committees. This is done in collaboration with the local health staff
including the VHNs and the Health inspectors.
• Facilitating of the work of the VHWSC. This is done through the interaction with PRI officials and the
Public health sector workers and facilitating their cooperation with the process.
• Sensitization of all involved about the potential impact of the process.
• Developing systems of sustainability of the process.
9.

How does the project propose to strengthen the public health system?

As mentioned in the Framework of implementation of the NRHM the one of the 5 pillars of the NRHM is
Communitization. By increasing ownership of the public health system by the community the process
not only hopes to increase demand and utilization of the public health services but also in parallel
increase the accountability of the system to the people.

Apart from this the data generated at each level is unique and these dimensions are not collected by the
3

routine HMIS. Thus the process provides valuable information to the health system at different levels.
This information will go a long way in identifying gaps in the system and enabling the system to fill
these. This is through not only the Panchayat Health Plan but also through the block, district and state
level consolidation and analysis of the data.

Moreover as this designed to initiate community action for health following the Panchayat Health Plans,
it hopes to further strengthen the system by the process where people get a deeper understanding of
their entitlements as well as the constraints within which the system works. The process also allows the
system a chance to understand the people's perceptions of the services and thus enable the system to
see the perspective of the people. This two way enhancement of understanding will contribute to
system strengthening.
Systematically / programmatically this approach has led to a deeper understanding for the need of the
perspectives of the health providers to find greater space within the initiative (and indeed overall
governance of the health system). Community Support mechanisms for the PHC and the HSC can be
evolved. Also critically workers' rights components and occupational health dimensions of public sector
workers needs greater attention.

10. What are the innovations by the CAH project in Tamilnadu?
Some of the key innovations by the project are as follows:
• The development of a simple visually rich tool that not only collects information but also provides
awareness of the various entitlements.
• The capturing of caste disaggregated data.
• The use of SMS for the efficient transmission of data.
• The evolution of a worksheet for the evolution of a Panchayat Health Action Plan.
What are the key learning from the implementation of the Community Action for Health
Project in Tamil Nadu?
We present the learning from the implementation of the CAH project under the following heads:

11.

Learning about the health services at the Village and PHC level gathered during community monitoring
and planning sessions.
• While the availability of services is very good in rural Tamil Nadu, the quality of these services and
especially the educational component of the services are poor. Thus in the study of immunization
services while the proportion of 'green' answers for the question on availability overall is 87%, the
proportion of greens to the question on quality falls to 77%, and further to 48.5% with regards to the
educational / awareness components. Similarly while 93% reported having at least 5 AN check up of
them only 59% were informed / counseled about the changes that would occur during pregnancy and’
informed about the danger signs to look out for.
• The system is hugely skewed to the Maternal and Child health services while the other services seem
to be neglected. Thus for example as reported earlier roughly 87% report having at least 5 AN check ups
while only 28.2% of adolescent girls contacted reported the presence of an adolescent group in the
village, and only 56% of the people met reported availability / accessing treatment of minor illnesses at
the village or sub-center.
• Further even within the MCH services while immunization and ANC and promotion of institutional
deliveries is focused on, post natal care is very poor. Thus while 87.4% reported receiving all
4

vaccinations (for children) on time and ANC is reported as 87%, not more than 25% of mothers who
delivered in the last six months reported receiving any Post natal care at the village level.
• One of the interesting findings that have emerged is that there seems to be a clustering of indicators
at the block level - thus some blocks are good performers in all services and some are consistently poor.
This probably underscores the importance of the health team in the provision of good quality health
services.
• Even 6 years after the launch of the NRHM a number of indicators of transparency and accountability
of the health system are very poor. Thus not more than 26.3% of groups of people we met reported the
presence of a citizen's charter in the PHC, only 9.2% knew about the Patient Welfare society and about
31.7% knew about the VHWS committee.
• The people continue to feel that staff in PHC treat them rudely - the overall proportion of negative
replies is 27% (range 51% to 8%). Similarly people report a high level of corruption with only 66.4%
(range 80% to 2%) saying they did not give any money to the staff during delivery, and only 57.8% (range
83% to 4%) reported not giving any money to the VHN for availing of the maternity benefit.
Learning relevant to the long term sustainability of the process

People
• The people are greatly enthusiastic about the process and the project has been able to identify at least
4-5 individuals at each panchayat level who have received training and seem capable about taking this
process forward.
• The people continue (even in a state like Tamil Nadu) to consider government services as those of first
choice and especially so if some of the problems of the system like the attitude of the staff and
corruption are taken care of.
• People recognize the systemic constraints under which the peripheral health workers work and are
very forgiving in their attitude towards them, especially when they see attempts by the health worker to
provide services to them under difficult circumstances. Thus despite the fact that Post Natal care was
supposed to be home based care, a number of women answered 'green' to the question though they
were asked to come to the PHC for this service - justifying this by saying that the VHN was doing a lot of
work, told her come to the PHC and looked after her very well there.
• We need to appreciate the fact that while in the present project mode people are willing to come and
take part in the VHWSC meetings voluntarily and with a lot of enthusiasm, there are a huge number of
systemic constraints (alluded to in later sections) that need to be recognized. Most importantly the
indirect costs borne by these individuals also need to be recognized. Thus the system needs to be seen
as more responsive to the people if this process is to be sustained.
Panchayat Raj Institution
• The newly elected panchayat presidents seem very enthusiastic to do something for the community
that elected them (elections were held in September 2011). This gives us a unique window of
opportunity to strengthen the panchayat ownership of this process and getting them to take a more
proactive and leadership role.
• The panchayat representatives including the presidents did not have any awareness about the role of
the VHWSC and about their role vis-a-vis the health system. This was true not only for those elected for
the first time, but even for those who have been reelected and who have had a number of stints in
positions of power.
• There seems to be very little constructive and supportive interaction between the health system and
the panchayat representatives. Thus while the panchayat is supposed to be the third rung of

5

government etc. there is very little interaction. This impacts greatly on the long term sustainability of
the process as it is embedded in the panchayat system.
• Interaction with panchayat presidents also reveal a number of evidences of a fractured community on
the basis of caste, political party and gender. Thus panchayat presidents are known to discriminate
against people of other castes, of a different political party etc. during these processes. While this is a
reflection of the larger reality of society, such issues have a major impact on the long term sustainability
of the process.
Health System
• One of the major findings of the project has been that the health staff themselves have very little
awareness about the NRHM its scope and activities. Thus our staff were some of the first to bring about
awareness about the term and what it means to many of the staff at village and even block level.
• There seems to be no orientation of staff at all levels about the process and its importance.
• The system itself is extremely hierarchical and thus staff at each level are very hesitant to respond to
the people's demands. This constrains system responsiveness to a great extent.
• The system continues to see people as ignorant and sees / treats people very patronizingly.
• The peripheral workers are working under huge systemic constraints. Thus for example in one meeting
at the PHC level the people were
requesting the VHNs to share their monthly tour program with the VHWSC so that they could mobilize
people to make full use of the VHNs visits. However the VHNs refused and explained how the PHC had
all the posts vacant a number of years, so it was the VHNs who were deputed to the duties of the
various staff including the pharmacist etc. under these circumstances though she had a monthly tour
program, she knew very well she was not going to be able to follow it!

What were the key constraints for the implementation of the Community Action for Health
Project in Tamil Nadu.
Constraints for the implementation of the Community Action for Health project in Tamil Nadu can be
discussed under-social context, health system related and larger political context.

12.

Social Context
• One of the major constraints that the project has faced has been the 'indirect' costs faced by the
community members who are expected to voluntarily take part in the various activities of the VHWSC.
These include the following:
• Most of the marginalized communities and especially the women usually attend the MNREGA work
and depend on these for wages. Thus when meetings and work are expected and it means give these up
obviously it reduces the chances that people living in such in secure conditions will be able to
participate. However these are the very people who we aim the process at.
• Given the above 'competition' with MNREGA and coupled with the number of NGOs that give people
sitting fees for all trainings and meetings there is a general tendency to expect money for this type of
work.
• Communities are riddled by caste and gender differences, this obviously affects the full
implementation of the process. Thus in villages people of different castes refuse to sit together and it is
very difficult to build up community wide ownership of the process.
• Alcoholism has been reported from a number of districts as problematic. A number of meetings are
disrupted by people who are drunk. Similarly project staff (especially women) and VHWSC members
who are women are especially insecure.
• The lack of transport is another constraint for the mobility of the members both between villages in a
panchayat and between their village and the PHC and HSC.
6

• In one of the districts the presence of a large number of industries and even a proposed SEZ in the
area has led to a fracturing of the community and an inability of implementing such programs smoothly.

Health System related
• It has been found on a number of occasions that people are not very motivated to hold the
government system accountable. This is for the following reasons:
• Most people are unable to access government schemes due to middlemen or corruption, thus they are
not very interested in spending more energy on these schemes.
• The more educated and wealthy even among the marginalized communities corner most benefits thus
leaving the most marginalized more frustrated.
• In general the more wealthy and influential capture the benefits.
• In addition the above the government is seen as poor in many situations and due to rudeness most
people prefer going to the private sector. Thus not wanting to spend too much energy holding the public
sector accountable.
• Frequent transfers of the doctors and officers means that those in decision making posts even at the
local level need to repeatedly be oriented to the process thus leading to a lack of continuity.
• The health department views the community either as ignorant or as not interested in their own
health little appreciating the structural factors leading to this (some as described above). This attitude of
superiority and patronage is not conducive for processes to develop transparency accountability.
• The peripheral workers are working under severe systemic constraints and in a very hierarchical
system. Unless this is sorted out these workers will only get more and more frustrated and will be
unable to engage with such processes.
Larger political context
• Regime change leads to a the introduction of a whole new set of schemes and the consequent ignoring
or sidelining of older schemes. This leads to a lot of uncertainty and lack of continuity in schemes like
this requiring longer term support.
• Political parties have their presence even at the village level, this has led to problems in getting people
of different political parties together for health issues.
• Local influential people have a tendency to hold the key to participation from the community, lot of
care needs to be given to developing a rapport with these people, else there is a danger of their making
the situation very difficult for the implementation of the project.

13.

Have there been any studies that have evaluated the process externally?

Yes, a number of studies have been done on the project as well as specific components of it. These are
listed below:

• Ramanathan S, External Evaluation of the Community Monitoring and Planning Pilot Phase - 2009.
Submitted to the AGCA. Government of India.
• Garn, Kristine. "If men were angles... Dynamics of Accountability in the Community Based Monitoring
of Health services program, Tamilnadu, India. 2010. Thesis M Sc Public Health. University of
Copenhagen.
• APAC- VHS. Gender Audit of the Tamilnadu Government Health services - 2011. Submitted to
Government of Tamilnadu.
• Santosh S. Qualitative study on awareness and attitude of community towards the CAH process in
Pulicat area, Minjur Block. 2011. Study as partial fulfillment of Community Health Learning Program.
Society for Community Health Awareness Research and Action (SOCHARA).

7

• Tajne, Satish and Sharma, Shweta. Critical Evaluation of the Community Monitoring Project as an
Innovative Intervention Directed at Health Improvement Focusing on the Role and Involvement of PRI
Representatives in the Process. 2011. Project Report of Internship period with TNVHA. Tata Institute of
Social Sciences, Mumbai.
• Tajne, Satish and Sharma, Shweta. Costing Study On Expansion And Training Of VHWSC 2011. Project
Report of Internship period with TNVHA. Tata Institute of Social Sciences, Mumbai.
• Apart from this a documentary film of the whole process is being developed.

14.

What are the key steps to be taken by the government that will help support the
implementation of the process in the future?

• Formation of a multi-stakeholder group at the state and district level to mentor this process as well as
learn from it. This is similar to the AGCA at the Central level.
• Urgent and proactive steps by the government to orient staff to the philosophy and advantages of this
process at the earliest.
• Steps to conduct regular inter-sectoral meetings to ensure action / responsiveness to the peoples
demands by all departments concerned.
• Institutionalization of feedback from the community and grievance redressal in the health system.
• Introducing elements of this process into routine HMIS system to motivate health staff to take this
seriously.
• Commitment to expansion of this process not only to other levels of the health system like secondary
and tertiary levels, but also including private sector and also other departments. Only when this
becomes a universal phenomenon will it be really sustainable.
• Further expansion of the project to other parts of the state - which will include active learning from
this effort as well as a multi-stakeholder consultative process and the inclusion and involvement of
academic institutions.
• Structural reform within the system to enable all workers to respond at their level to the community.
For more details, please visit http://cahtn.in/faq.php#l. What is CAH

8

(Co KB" i 0 I

COMMUNITIZATION PROCESS
1.

What is CAH?

CAH stands for 'Community Action for Health'. This is a project that continuation of a pilot process
known as Community Based Monitoring and Planning (CMP). The CMP pilot process was implemented
as part of the communitization aspects of the National Rural Health Mission(NRHM). The process was
initiated by the Advisory Group on Community Action (AGCA) under NRHM. The AGCA proposed a pilot
process in 9 states to actualize the concept of Community Based Monitoring and Planning that was
conceptualized by the NRHM in its Framework of Implementation. It was decided to request a number
of civil society organizations to lead the process in the different states in partnership with the state
governments. The pilot phase was funded by the central government. It was expected that after the
pilot phase the state governments would take over the ownership, running and funding of the process.
In Tamilnadu, it was decided to change the name from Community Monitoring and Planning
to Community Action for Health after the Pilot phase.
It is important to note that the name of the process was changed from Community Monitoring and
Planning to Community Action for Health to emphasis that without 'action' the process is incomplete
and that the whole process is driven by a 'joint learning approach' with openness and spaces for
reflection.

2.

What is the aim of the CAH process?

As mentioned earlier the idea of the CAH process is to actualize the concept of communitization that is
introduced in the Framework of Implementation of the NRHM. The concept of communitization involves
increasing the ownership of the community for the health system. This increased ownership is seen to
increase both utilization as well as accountability of the system to the people. This combination of
increased ownership, utilization and accountability will contribute to health system strengthening and
the achievement of the goals of the NRHM. This overarching framework also provides space and
opportunity to take forward the community health approach predicated on inclusive community
involvement. Visit this link Vision and Mission of this CAH process.
3.

What are the steps of the CAH process?

The following are the basic steps of the CAH process:
• Village Health Water Sanitation and Nutrition Committee (VHWSNC) expansion to include wider
representation for all community groups and geographical areas of the panchayat. This expansion was
done by holding meetings in all the hamlets of the project area and explaining the NRHM mission and its
goal, the CAH process to the people and getting volunteers and suggestions from the community for
VHWSNC members. The team is finally rapporticed in the first committee meeting with explanation of
roles and responsibilities of the member.
• Orientation and training of the VHWSC committee members is the next major step. The whole
committee is oriented to the process. Subsequently 2 to 4 per committee is intensively trained on the
health, health care, health rights and CAH process.
• The next step is the monitoring process where a set of tool developed by the state nodal NGO in
consultation with the other process partners SHS, DPH and partner NGOs, the people is used to collect
the perspectives / assessments of the services available at the village and PHC by the committee

1

member/people. The scoring will be marked in colours as red, Yellow and green representing the status
of the particular service asseeking attention, moderate, good
• After this the information collected is collated into the Panchayat Health Status Report Card (HSRC).
Thus one Report card is evolved for each Panchayat.
• In the next step of the process is the Panchayat Health Planning Day (PHP). In the Health Planning day
the VHWSNC members present the Panchayat Health Status Report Card to a group consisting of the
representatives of the Public Health department including the Village Health Nurse(ANM/VHN) and the
Medical Officer (MO), the Panchayat President (PRl), the Aanganwadi workers (AWW) and members of
the community. During this meeting the various questions/ sections receiving a 'red' color are discussed
in detail with an aim of converting this 'red' score to'green' in six months or with in the next cycle of
monitoring. Thus a Panchayat Health Action Plan is evolved.
• Subsequently this is shared with officials at the PHC, Block and District level.
• Every month the VHWS committee meet and discuss the issues arising out of the Panchayat Health
Plan and its follow up.
• The whole monitoring and planning cycle is repeated every six months.

4.

Have the VHWSNC members been able to the use the tools easily?

The tools were built after many rounds of discussions and pilot testing. In fact there have been minor
and a few major changes with each round of monitoring based on feed back received. Based on an
external evaluation and the feedback of the the people and the government officials the tool used in the
pilot phase was extensively modified to bring it to its present generic shape.

The major challenge we faced was teaching the members the logic behind the various health
entitlements so that the monitoring could be linked to action. Apart from this one area of difficulty was
the names of the equipment, however this was overcome by inserting pictures of the relevant
instrument / infrastructure.
Given its piloting and iterative feedback the tool is quite understandable and usable.

One of the interesting finding is that tool not only helps capture people's perceptions on health, but in
addition by probing a number of dimensions also spread a lot of awareness and initiated interesting and
in-depth discussions on health.

5.

How much time does it take to fill the tool and complete one cycle of monitoring and
planning?

It has been found that a full set of tools covering all the dimensions of health services will take 5 days of
time. In addition the PHC and HSC facility survey and exit polling take 1 day. Thus in all the committee
members have to spend 6 days every six months on monitoring activities. Individual interviews (for the
immunization and ANC / Delivery / PNC) take about 40 minutes to 1 hour per interview. Group
discussions (for school health / adolescent health / village services) take about 30 to 40 minutes.
In terms of planning about 3 days of preparations are required for every day of Panchayat Level
planning.

Every month there is a VHWSNC meeting to follow up the various action plans.

2

6.

What Is the human resource pattern of the CAH project?

The project is implemented thrqugh the state nodal organisation (SNO) at the state level, district nodal
organisation (DNO) at the district level and cluster/block nodal organisation (CNO) at the cluster/block
level.

At the state level there is a state resource/training team consists of 6 individuals from NGO and 2 more
from department.

At the district level the project has district resource/training team consists of 2 individuals from NGO
and 1 more from department.
At the cluster/block level there is the cluster/block resource/training team consists 2 individuals from
NGO and 1 more from department.
At the panchayat level there is one coordinator for every 10-15 panchayats (in all there are 150)

What is the governance structure of the project?

7.

There is a project governing body consisting of eminent academics and civil society representatives who
governs the entire process.
The primary group that advises the State Nodal Organisation is the State Implementers Group consisting
of the Implementing NGOs, representatives of the civil society, representatives of the SHS and the DPH.
At the district level there is the district mentoring committee which mentors the process at the district
level in which DDHS, implementing NGOs, representatives of the civil society were members.
SOCHARA has a special sub-committee to provide internal mentorship and over-sight to the
implementing team.
8.

What is the role of the Civil society groups in the process?

The role of the civil society groups in the project are as follows:

• Capacity building of the VHWSC committees. This is done in collaboration with the local health staff
including the VHNs and the Health inspectors.
• Facilitating of the work of the VHWSC. This is done through the interaction with PRI officials and the
Public health sector workers and facilitating their cooperation with the process.
• Sensitization of all involved about the potential impact of the process.
• Developing systems of sustainability of the process.

9.

How does the project propose to strengthen the public health system?

As mentioned in the Framework of implementation of the NRHM the one of the 5 pillars of the NRHM is
Communitization. By increasing ownership of the public health system by the community the process
not only hopes to increase demand and utilization of the public health services but also in parallel
increase the accountability of the system to the people.
Apart from this the data generated at each level is unique and these dimensions are not collected by the

3

routine HMIS. Thus the process provides valuable information to the health system at different levels.

This information will go a long way in identifying gaps in the system and enabling the system to fill
these. This is through not only the Panchayat Health Plan but also through the block, district and state

level consolidation and analysis of the data.

Moreover as this designed to initiate community action for health following the Panchayat Health Plans,
it hopes to further strengthen the system by the process where people get a deeper understanding of
their entitlements as well as the constraints within which the system works. The process also allows the
system a chance to understand the people’s perceptions of the services and thus enable the system to
see the perspective of the people. This two way enhancement of understanding will contribute to
system strengthening.
Systematically / programmatically this approach has led to a deeper understanding for the need of the
perspectives of the health providers to find greater space within the initiative (and indeed overall
governance of the health system). Community Support mechanisms for the PHC and the HSC can be
evolved. Also critically workers' rights components and occupational health dimensions of public sector
workers needs greater attention.

10. What are the innovations by the CAH project in Tamilnadu?
Some of the key innovations by the project are as follows:
• The development of a simple visually rich tool that not only collects information but also provides
awareness of the various entitlements.
• The capturing of caste disaggregated data.
• The use of SMS for the efficient transmission of data.
• The evolution of a worksheet for the evolution of a Panchayat Health Action Plan.

What are the key learning from the implementation of the Community Action for Health
Project in Tamil Nadu?
We present the learning from the implementation of the CAH project under the following heads:

11.

Learning about the health services at the Village and PHC level gathered during community monitoring
and planning sessions.

• While the availability of services is very good in rural Tamil Nadu, the quality of these services and
especially the educational component of the services are poor. Thus in the study of immunization
services while the proportion of ’green’ answers for the question on availability overall is 87%, the
proportion of greens to the question on quality falls to 77%, and further to 48.5% with regards to the
educational / awareness components. Similarly while 93% reported having at least 5 AN check up of
them only 59% were informed / counseled about the changes that would occur during pregnancy and
informed about the danger signs to look out for.
• The system is hugely skewed to the Maternal and Child health services while the other services seem
to be neglected. Thus for example as reported earlier roughly 87% report having at least 5 AN check ups
while only 28.2% of adolescent girls contacted reported the presence of an adolescent group in the
village, and only 56% of the people met reported availability / accessing treatment of minor illnesses at
the village or sub-center.
• Further even within the MCH services while immunization and ANC and promotion of institutional
deliveries is focused on, post natal care is very poor. Thus while 87.4% reported receiving all
4

vaccinations (for children) on time and ANC is reported as 87%, not more than 25% of mothers who
delivered in the last six months reported receiving any Post natal care at the village level.
• One of the interesting findings that have emerged is that there seems to be a clustering of indicators
at the block level - thus some blocks are good performers in all services and some are consistently poor.
This probably underscores the importance of the health team in the provision of good quality health
services.
• Even 6 years after the launch of the NRHM a number of indicators of transparency and accountability
of the health system are very poor. Thus not more than 26.3% of groups of people we met reported the
presence of a citizen's charter in the PHC, only 9.2% knew about the Patient Welfare society and about
31.7% knew about the VHWS committee.
• The people continue to feel that staff in PHC treat them rudely-the overall proportion of negative
replies is 27% (range 51% to 8%). Similarly people report a high level of corruption with only 66.4%
(range 80% to 2%) saying they did not give any money to the staff during delivery, and only 57.8% (range
83% to 4%) reported not giving any money to the VHN for availing of the maternity benefit.
Learning relevant to the long term sustainability of the process

People
• The people are greatly enthusiastic about the process and the project has been able to identify at least
4-5 individuals at each panchayat level who have received training and seem capable about taking this
process forward.
• The people continue (even in a state like Tamil Nadu) to consider government services as those of first
choice and especially so if some of the problems of the system like the attitude of the staff and
corruption are taken care of.
• People recognize the systemic constraints under which the peripheral health workers work and are
very forgiving in their attitude towards them, especially when they see attempts by the health worker to
provide services to them under difficult circumstances. Thus despite the fact that Post Natal care was
supposed to be home based care, a number of women answered 'green' to the question though they
were asked to come to the PHC for this service - justifying this by saying that the VHN was doing a lot of
work, told her come to the PHC and looked after her very well there.
• We need to appreciate the fact that while in the present project mode people are willing to come and
take part in the VHWSC meetings voluntarily and with a lot of enthusiasm, there are a huge number of
systemic constraints (alluded to in later sections) that need to be recognized. Most importantly the
indirect costs borne by these individuals also need to be recognized. Thus the system needs to be seen
as more responsive to the people if this process is to be sustained.

Panchayat Raj Institution
• The newly elected panchayat presidents seem very enthusiastic to do something for the community
that elected them (elections were held in September 2011). This gives us a unique window of
opportunity to strengthen the panchayat ownership of this process and getting them to take a more
proactive and leadership role.
• The panchayat representatives including the presidents did not have any awareness about the role of
the VHWSC and about their role vis-a-vis the health system. This was true not only for those elected for
the first time, but even for those who have been reelected and who have had a number of stints in
positions of power.
• There seems to be very little constructive and supportive interaction between the health system and
the panchayat representatives. Thus while the panchayat is supposed to be the third rung of

5

government etc. there is very little interaction. This impacts greatly on the long term sustainability of

the process as it is embedded in the panchayat system.
• Interaction with panchayat presidents also reveal a number of evidences of a fractured community on
the basis of caste, political party and gender. Thus panchayat presidents are known to discriminate
against people of other castes, of a different political party etc. during these processes. While this is a
reflection of the larger reality of society, such issues have a major impact on the long term sustainability
of the process.

Health System
• One of the major findings of the project has been that the health staff themselves have very little
awareness about the NRHM its scope and activities. Thus our staff were some of the first to bring about
awareness about the term and what it means to many of the staff at village and even block level.
• There seems to be no orientation of staff at all levels about the process and its importance.
• The system itself is extremely hierarchical and thus staff at each level are very hesitant to respond to
the people's demands. This constrains system responsiveness to a great extent.
• The system continues to see people as ignorant and sees / treats people very patronizingly.
• The peripheral workers are working under huge systemic constraints. Thus for example in one meeting
at the PHC level the people were
requesting the VHNs to share their monthly tour program with the VHWSC so that they could mobilize
people to make full use of the VHNs visits. However the VHNs refused and explained how the PHC had
all the posts vacant a number of years, so it was the VHNs who were deputed to the duties of the
various staff including the pharmacist etc. under these circumstances though she had a monthly tour
program, she knew very well she was not going to be able to follow it!
What were the key constraints for the implementation of the Community Action for Health
Project in Tamil Nadu.
Constraints for the implementation of the Community Action for Health project in Tamil Nadu can be
discussed under-social context, health system related and larger political context.

12.

Social Context
• One of the major constraints that the project has faced has been the 'indirect' costs faced by the
community members who are expected to voluntarily take part in the various activities of the VHWSC.
These include the following:
• Most of the marginalized communities and especially the women usually attend the MNREGA work
and depend on these for wages. Thus when meetings and work are expected and it means give these up
obviously it reduces the chances that people living in such in secure conditions will be able to
participate. However these are the very people who we aim the process at.
• Given the above 'competition' with MNREGA and coupled with the number of NGOs that give people
sitting fees for all trainings and meetings there is a general tendency to expect money for this type of
work.
• Communities are riddled by caste and gender differences, this obviously affects the full
implementation of the process. Thus in villages people of different castes refuse to sit together and it is
very difficult to build up community wide ownership of the process.
• Alcoholism has been reported from a number of districts as problematic. A number of meetings are
disrupted by people who are drunk. Similarly project staff (especially women) and VHWSC members
who are women are especially insecure.
• The lack of transport is another constraint for the mobility of the members both between villages in a
panchayat and between their village and the PHC and HSC.
6

• In one of the districts the presence of a large number of industries and even a proposed SEZ in the
area has led to a fracturing of the community and an Inability of implementing such programs smoothly.

Health System related

• It has been found on a number of occasions that people are not very motivated to hold the
government system accountable. This is for the following reasons:
• Most people are unable to access government schemes due to middlemen or corruption, thus they are
not very interested in spending more energy on these schemes.
• The more educated and wealthy even among the marginalized communities corner most benefits thus
leaving the most marginalized more frustrated.
• In general the more wealthy and influential capture the benefits.
• In addition the above the government is seen as poor in many situations and due to rudeness most
people prefer going to the private sector. Thus not wanting to spend too much energy holding the public
sector accountable.
• Frequent transfers of the doctors and officers means that those in decision making posts even at the
local level need to repeatedly be oriented to the process thus leading to a lack of continuity.
• The health department views the community either as ignorant or as not interested in their own
health little appreciating the structural factors leading to this (some as described above). This attitude of
superiority and patronage is not conducive for processes to develop transparency accountability.
• The peripheral workers are working under severe systemic constraints and in a very hierarchical
system. Unless this is sorted out these workers will only get more and more frustrated and will be
unable to engage with such processes.
Larger political context
• Regime change leads to a the introduction of a whole new set of schemes and the consequent ignoring
or sidelining of older schemes. This leads to a lot of uncertainty and lack of continuity in schemes like
this requiring longer term support.
• Political parties have their presence even at the village level, this has led to problems in getting people
of different political parties together for health issues.
• Local influential people have a tendency to hold the key to participation from the community, lot of
care needs to be given to developing a rapport with these people, else there is a danger of their making
the situation very difficult for the implementation of the project.

13.

Have there been any studies that have evaluated the process externally?

Yes, a number of studies have been done on the project as well as specific components of it. These are
listed below:
• Ramanathan S, External Evaluation of the Community Monitoring and Planning Pilot Phase - 2009.
Submitted to the AGCA. Government of India.
• Garn, Kristine. "If men were angles... Dynamics of Accountability in the Community Based Monitoring
of Health services program, Tamilnadu, India. 2010. Thesis M Sc Public Health. University of
Copenhagen.
• APAC- VHS. Gender Audit of the Tamilnadu Government Health services - 2011. Submitted to
Government of Tamilnadu.
• Santosh S. Qualitative study on awareness and attitude of community towards the CAH process in
Pulicat area, Minjur Block. 2011. Study as partial fulfillment of Community Health Learning Program.
Society for Community Health Awareness Research and Action (SOCHARA).

7

• Tajne, Satish and Sharma, Shweta. Critical Evaluation of the Community Monitoring Project as an
Innovative Intervention Directed at Health Improvement Focusing on the Role and Involvement of PRI
Representatives in the Process. 2011. Project Report of Internship period with TWHA. Tata Institute of
Social Sciences, Mumbai.
• Tajne, Satish and Sharma, Shweta. Costing Study On Expansion And Training Of VHWSC 2011. Project
Report of Internship period with TNVHA. Tata Institute of Social Sciences, Mumbai.
• Apart from this a documentary film of the whole process is being developed.

14.

What are the key steps to be taken by the government that will help support the
implementation of the process in the future?

• Formation of a multi-stakeholder group at the state and district level to mentor this process as well as
learn from it. This is similar to the AGCA at the Central level.
• Urgent and proactive steps by the government to orient staff to the philosophy and advantages of this
process at the earliest.
• Steps to conduct regular inter-sectoral meetings to ensure action / responsiveness to the peoples
demands by all departments concerned.
• Institutionalization of feedback from the community and grievance redressal in the health system.
• Introducing elements of this process into routine HMIS system to motivate health staff to take this
seriously.
• Commitment to expansion of this process not only to other levels of the health system like secondary
and tertiary levels, but also including private sector and also other departments. Only when this
becomes a universal phenomenon will it be really sustainable.
• Further expansion of the project to other parts of the state - which will include active learning from
this effort as well as a multi-stakeholder consultative process and the inclusion and involvement of
academic institutions.
• Structural reform within the system to enable all workers to respond at their level to the community.
For more details, please visit http://cahtn.in/faq.php#l. What is CAH

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