TRAINING ON COMMUNITY ASSESSMENT OF HEALTH EXPENDITURE · 2019-03-17 · TRAINING ON COMMUNITY ASSESSMENT OF HEALTH EXPENDITURE (3rd to 7th March 2010) A REPORT Conducted by: Centre

TRAINING

ON

COMMUNITY ASSESSMENT OF HEALTH EXPENDITURE (3rd to 7th March 2010)

A REPORT

Conducted by: Centre for Health and Social Justice

Flat No 3-C First Floor H Block, Saket, New Delhi 110017

at

The Action Northeast Trust (The Ant)

Udangshree Dera, Vill Rowmari, PO Khagrabari (via Bongaigaon) District Chirang (BTAD), Assam 783380, INDIA

TRAINING ON COMMUNITY ASSESSMENT OF HEALTH EXPENDITURE

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CONTENTS Glossary…………………………………………………………………………………………2 Background of the project……………………………………………………………………...3 Objectives of the Training……………………………………………………………………...3 Training Methods Applied……………………………………………………………………..3 Day one: Session I: Registration and Context Setting…………………………………………………4 Session II: Introduction of the participants…………………………………………………..4 Session III: Expectation Setting………………………………………………………………5 Session IV: Introduction to the project……………………………………………………….5 Session V: Understanding Health Service System……………………………………………7 Session VI: Introduction to the concept of Health and……………………………………….7

financial entitlements under NRHM

Day two: Session VII: Review of Day one………………………………………………………………9 Session VIII: Health Expenditure and Service Utilization……………………………………....9 Session IX: Preparing for Community Assessment of health expenditures………………..…13 Day Three and four Session X: Field Visits……………………………………………………………………...17 Session XI: Presenting the findings………………………………………………………….17 Day Five Session XII: Sharing of field experience, observations…………………………………….…18 Session XIII: Planning for a community awareness Campaign

around financial entitlements related to health - Orissa ……………………………………………………………………...23 - Assam……………………………………………………………………...25

ANNEXURES I: Training Agenda……………………………………………………………………….26 II: List of Participants……………………………………………………………………..27 III: Presentation…………….……………………………………………………………...28 IV: Findings of Field Visit on March 04-05, 2010……………………………………….….30


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GLOSSARY AMG Annual Maintenance Grant

ANM Auxiliary Nurse Midwife

APL Above Poverty Line/Level

ASHA Accredited Social Health Activist

AWW Aanganwadi Woman Worker

BPL Below Poverty Line/Level

CHC Community Health Centre

CHSJ Centre for Health and Social Justice

CMP Common Minimum Programme

DAP District Action Plan

DPM District Programme Manager

GDP Gross Domestic Product

IBP International Budget Partnership

IPHS Indian Public Health Standards

JSY Janani Suraksha Yojana

MO Medical Officer

NGO Non Governmental Organisation

NMBS National Maternity Benefit Scheme

NRHM National Rural Health Mission

PHC Primary Health Centre

PIP Programme Implementation Plan

PRIs Panchayati Raj Institutions

RKS Rogi Kalyan Samiti

RTI Right to Information

SHC Sub Health Centre

UPA United Progressive Alliance

VHSC Village Health and Sanitation Committee

VIPP Visualisation In Participatory Programmes


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Background of the Project On 12th April, 2005, the Government of India announced the NRHM, a new vehicle for providing public health services for the rural poor. The NRHM not only proposed to strengthen service delivery but also promised a substantial increase in the health outlay from the national government (from less than 1% to around 2 – 3%). Since then it has introduced a flexible financing mechanism comprising of Annual Maintenance Grants and Untied Funds at various levels starting from the community up to the district hospitals. NRHM has laid down norms for flexible financing at the community and facility levels for locally initiated planning. These include:

Untied grants at the VHSC – 10,000/year Untied and AMG for SHC – 10,000/year under each head AMG and Grant for Local Health Action for PHC– 50,000/ year and 25,000/year AMG and Grant for Local Health Action for CHC – Rs 1 lakh/year and 50,000/year Corpus grant for RKS.

The total budget available for financial support under Flexipool is roughly equal to 25% of the entire NRHM budget at the national level. In addition to this flexible mechanism, it has also introduced a mechanism of decentralized planning which is already underway through the development of district and state level PIPs. This autonomy to local bodies to plan and implement provides an exciting possibility for decentralized governance and improving transparency and accountability. Another financial component of NRHM includes what is described as “Conditional Cash Transfer” and is best seen in the JSY ( Safe Motherhood Scheme) where a financial incentive is provided to poor women to deliver babies in health institutions. This system had an outlay of over 10 billion rupees in 2008 –09 and is reported to be a major source of corruption at the community level. Objectives of the Training: After the training the participants will be able to:

1. Gain better understanding of NRHM financial entitlements and mechanisms for community participation.

2. Develop understanding about the project. 3. Develop skills in community assessment of health expenditure using participatory

methodology. 4. Prepare an action plan for implementing the project in respective districts.

Training Methods Applied: The following training methods were adopted to ensure effective and quality learning.

1. Lecture 2. Group Activity 3. Field Work 4. Presentation

Training Brief Type: Residential Venue: The Ant, Assam Timing: 10am to 4pm Trainer: Abhijit Das Attending Participants: 11


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Day One: March 03, 2010

Session I: Welcome and Context setting 10 AM - 10:30 AM Facilitator: Sunita Singh There was a brief mention of the background of how the project was conceived in lieu of CHSJ’s three year stint in NRHM and especially the Community Monitoring Process within it. Abhijit Das, the director of CHSJ, met IBP, its health and budget project partner and funder to discuss CHSJ’s interests in furthering the agenda of health budget monitoring within NRHM followed which, Ravi Duggal visited CHSJ to have a better clarity of the organization’s objectives for undertaking health related expenditure tracking and monitoring under NRHM. The understanding was that CHSJ was not aiming to get into any hard core budget tracking but was interested to work in communitizing health expenditure by increasing community interest in health cost and at the same time capacitating them to monitor health related expenditures. Finally, after a year-long process, the project materialized where implementation was initially proposed keeping three states in mind that later shrunk to two states and one district in each state considering the various limitations of a pilot project. Within this time period, CHSJ team had two rounds of capacity building interactions with IBP, first a 10-day long training programme in Kerala to understand the nitty gritties of budget tracking in health, and a second rigorous 5-day long exercise in Mumbai to share methodologies, partner selection criteria, advocacy agenda, technical inputs required etc. After this there was an elaborate partner selection process which culminated into CHSJ selecting two partners, The Humanity, Orissa and The Ant, Assam. With this, the context of the training was set and a formal introduction round followed. Session II: Introduction of the Participants 10:30 AM - 11:00 AM Facilitator: Moumita Ghosh The participants introduced themselves and their organizations, the work that they are currently involved in and about their association with CHSJ. Since some of the participants were meeting each other for the first time, it was felt that there should be more informal interaction amongst themselves that would not only help to break the ice, but the participants would also get to know each other better. This would ensure better participation in group activities throughout the workshop. The participants were asked to choose a partner whom s/he is meeting for the first time, interact for 15 minutes after which each pair can publicly share details about their partners.

Particulars Facilitated by - Registration and Context Setting Sunita Singh, Moumita Ghosh - Introduction of the participants - Expectation Setting Time : 10 a.m. to 4 p.m. - Introduction to the project - Understanding Health Service System Language: Hindi & English - Introduction to the concept of Health and

financial entitlements under NRHM


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Session III: Expectation Setting of Participants 11:00 AM - 12:00 Noon Moderator: Sunita Singh At the beginning of the training, participants were given VIPP cards and were asked to write their expectations which were:

1. Know more about NRHM budget and the strategies to track the budget at every level which should be participatory.

2. Have more understanding of Financial Entitlements under NRHM. 3. Methodology of community assessment of health expenditure and also the way it is

implemented. 4. To know more about NRHM expenditure and how to track it identifying the gaps and

strengths of the process of healthcare under NRHM. 5. Preparing for community assessment of health expenditure. 6. Improve functioning of health facilities and functionaries, encourage and guide community to

participate in monitoring of financial entitlements. 7. How to simplify “budgets” for community understanding. 8. Able to do health budget analysis and tracking. 9. Understand how community can track health expenditure.

It was clarified that health budget analysis and tracking (8) is a vast area that requires expertise and time to arrive to some understanding and currently this is outside the scope of the project. CHSJ and its state partners will in the due course of the project focus on the Flexible grants and financial transactions under JSY that are flowing into the facilities and supervised by committees at various levels. Session IV: Introduction of the Project 12:00 PM - 12:30 PM Facilitator: Sunita Singh A brief presentation (refer Annexure III) was made about the project, its objectives, strategies and outcomes. Discussions emerged on the following and participants also shared individual experiences. Flexible Financing and Decentralized Planning While introducing the project, there was a discussion on flexible financing and decentralized planning as significant strategies under NRHM. Participants were actively engaged in discussing that flexible financing mainly relates to the mechanism of providing grants to institutions to be used as per their requirements and planned at their own level. These grants are untied and not bounded by any pre-decided activities and can be expended according to immediate local health needs. The local committees responsible for supervision of these funds will have absolute discretionary powers of planning and spending this money. Regarding decentralized planning, participants felt that there is a paradigm shift from planning happening in Delhi, and being implemented in states to planning happening at the local level i.e. village, block, district and then state. Thus through decentralization under NRHM, planning and allocation is based on local realities and hence needs. This, the participants agreed would eventually lead to effective implementation of NRHM through better service delivery, improved quality of care and increased utilization of services. One of the participants from Orissa shared his experience of being involved in preparing the block level PIP. As a first step, village level planning was done; some VHSCs also got involved in this


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process. There was a more formal meeting this time between the ANM, ASHA, AWW, NGO members, PRI representatives where a plan/proposal was prepared taking into consideration local health needs. This was taken up for discussion and prioritization at the block level. Looking at the priority areas, allocations were made according to the PIP framework available at the block level. This also evoked the question of whether baseline surveys were essential for conducting enquiries about genuine health needs so as to arrive at a more specific and focused plan for the village or else immediate needs may go unnoticed. But in this case ( Orissa ), the ANMs and ASHAs already maintained registers of health profile, disease prevalence, which were considered to be sufficient evidence and hence baseline surveys were not carried out. But it was agreed upon that baseline surveys are crucial to arrive at an understanding of the health situation of the area. At one point, the facilitator cited examples of DPMs complaining that the maternal health funds are all being siphoned under JSY, a centrally sponsored scheme. The participants too agreed that even the Community Monitoring process under NRHM has revealed various instances of misappropriation of this fund. Despite lack of preparedness of health facilities, institutional deliveries under JSY have drastically increased over the years. One of the objectives of this project would also be to track this. Government Spending vs. High out of Pocket Expenditure and Low Community Participation While elaborating on the objectives of the project, the facilitator mentioned about the ratio of government spending to utilization of health services which shows that despite high expenditure ( related to flexi funds), utilization of services is low; out of pocket expenditure is high. Communities are availing more and more of private facilities. The direct and indirect costs (bribe paid to providers, wage loss, attendance etc.) incurred are beyond their capacities. This usually pushes the community into the vicious circle of indebtedness and hence poverty or death as the last resort. Besides this, communities take little or no interest in understanding health related expenditure which also leads to lack of participation in planning and hence monitoring. So at this point of time what can be the various provisions for tracking the flexi funds and JSY money at the village, block and district level. In reality, spending is not in accordance to community needs i.e. community cannot directly benefit from this spending. They are more comfortable as end-users or beneficiaries of government welfare programmes and hence take little or no initiative in participating in planning for their own benefit. This compounded with lack of awareness and attitude of service providers further impedes their involvement in planning. Direct and Indirect Costs It was essential to mention the various types of costs incurred while availing health care services in order to assess expenditure on health care. These costs were listed and the participants were asked to sort them into the direct and indirect cost categories and what emerged was this which showed that the participants had a fair understanding of the above. Direct Costs- Registration Fee, doctor’s fee, medicines, Travel cost, diet(ideally nutritious/special diet is recommended during illness) etc. Indirect Costs-Bribes paid at the health facility, wage loss due to absence from work, attendance cost for escorting etc. Quality and Range of Services A small discussion also followed on this where the participants were able to differentiate between the two. What emerged was that range of services refers to the types/areas of health care services a facility can provide whereas quality is judged against certain set standards (IPHS) laid down within the public health system. Hence, mere presence of amenities/provisions is not enough; they should be


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functioning as per the set standards. Basically both range of services and quality complement each other. Session V: Understanding the Health Service System: Time: 12:30 PM - 1:30 PM Facilitator: Sunita Singh and Moumita Ghosh This session happened in the form of group activity. Participants were asked to form groups of 3 and each group had to act as a facility for eg. Group 1- SHC, Group 2-PHC and Group 3-CHC. Each group was given a set of VIPP cards with health services and health personnel written on them. The groups had to sort these cards according to the services provided and personnel present at their facilities. Also, they were required to fix the remaining unmatched cards in other facilities. After the groups had finished putting up the cards on their respective charts, they had to take a closer look at all of the charts in order to find out errors if any and reshuffle them. The groups were actively engaged in discussing and completing this process. From this activity, it emerged that the participants had good knowledge and understanding of the Health Service System. The community monitoring film prepared by CHSJ was shown to the participants in order to make them understand what community participation means, till what extent community is able to raise their voices against violation of their health rights, negotiate with the providers, and are able to realize their right to health. Session VI: Introducing the concept of Health and financial entitlements under NRHM Time: 2:30 PM - 4:30 PM Facilitator: Sunita Singh and Moumita Ghosh Participants were asked to return to their groups and were given the draft entitlement kit prepared by CHSJ. They had to read the document carefully and thoroughly to identify the gaps in the information, whether there is a need to add/remove any information, what is the current status of their state in relation to health and financial entitlements. Following this, they were required to make a presentation on VHSC, SC; PHC,CHC; RKS, JSY. The groups presented their findings and some interesting state specific instances were cited. These include:

• In Orissa, the VHSC account is operated by AWWs and PRI member instead of ASHAs. • The document does not mention about health camp and emergency health needs as some of the

activities that can be pursued from the untied funds under VHSC. • There can be overlapping of activities under Untied and AMGs at various levels. • In Orissa, the Mission Director has brought out a fixed guideline for spending untied funds.

This is to be circulated at every level. The concern here is how untied are these funds then? • There is no planning. Most of the funds are spent on infrastructure; sometimes even for

personal use because ultimately they are untied and have to be spent. Till what extent these funds should be untied is also a question.

• In Assam, JSY money is disbursed through A/C payee cheques to beneficiaries opting for institutional deliveries. No incentive is given for home delivery. Instead all women are provided Rs. 1000 under National Maternity Benefit Scheme (NMBS).

• The problems of providers should not go unnoticed because it affects the quality of services • In Orissa, village PIP(for Rs.10,000 untied fund) is already in its way.


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• Auditing of untied funds is taking place. NRHM has its own panel of auditors who takes care of auditing at all levels. Registers are prepared and sent to the supervisory committees in a particular format to be filled up. The auditors do not physically visit the facilities but the registers are sent to them.


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Day Two: March 04, 2010

Session VII: Review of Day One Time: 10:00 AM - 11:00 AM Moderators: Sunita Singh, Moumita Ghosh The day started early with two participants presenting a review of the earlier day. In addition, participants also put up their significant learnings and confusions continued from earlier day.

Learnings Confusions • Structure and scope of the project • Variations and innovations in other states • Understanding of health facility and

flexible financing • Management of funds / untied grants • Gaps and differences in budget,

allocation, release, utilization and reporting mechanism

• Orienting community about NRHM issues

• Monitoring of health system • Health and financial entitlements • Information about VHSC, SC, PHC,

CHC (personnel, services, funds, accountability)

• Structure and procedure of programme implementation under NRHM in other states

• Understanding health service system

• How to see the VHSC/RKS accounts without using RTI

• How can the AMG that comes in the Gram Panchayat be used in Health.

• What is the current expenditure and trends of planning? What is the source of information for this and how to collect?

• Can the administrative system be simpler? • Difference between PHC, PHC(New),

Additional PHC and upgraded PHC. • Influencing DAP.

Session VIII: Health Expenditure and Service Utilization Time: 11:00 AM - 1:00 PM Facilitator: Abhijit Das In order to understand how this project evolved, it is essential to have some understanding of the history of NRHM and public health expenditure in India. NRHM was conceived during UPA-I (first

Particulars Facilitated by - Review of Day one Abhijit Das - Health Expenditure and Service Utilization - Preparing for Community Assessment of Time : 9 a.m. to 4 p.m

health expenditures Language: Hindi & English


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phase of the UPA government) governance. UPA-I being a coalition of different political parties with different political motives agreed upon a common election manifesto, i.e. the CMP. The agenda under CMP was to increase health spending from less than 1% to 2-3%. This becomes significant because NRHM (also launched during this period) to some extent has been started to fulfil this agenda. Also, it is important to mention that since year 2000 onwards, studies supported by World Bank were conducted on health expenditures across different countries and the findings showed that the patterns of spending on health care in India was different from that of others. In India, people end up spending most while utilising/availing health care services while in other countries, it is simply the opposite; here people pay less while utilising health services, i.e. visiting a health facility, buying medicines, consulting doctor etc. The services are either free from the government (eg. Europe, England etc.), or are paid through insurance (i.e. the payment is made beforehand without considering how much money one has during treatment which also means that the quality of treatment is not dependent on the person’s ability to pay). But in India, neither the public health system is prepared to provide free health services nor is there any provision of health insurance. Hence people usually incur high expenditure while accessing health care services. Also the type of treatment is not decided by need but by people’s ability to pay. So the quality of health services will depend on the strength of people’s pockets. This is one of the greatest limitations of the public health system in India. In lieu of this, it has to be understood that since health expenditures cannot be anticipated, savings pattern does not fit or cannot be planned to meet such unanticipated expenses. This often leads to depleting people’s economic base, thus pushing them to indebtedness. In reality 25% of population visiting facilities to access health care services fall out from APL to BPL category leading to a very high level of impoverishment. So, in India if the expenditure on health per family is Rs. 5, the government will provide services for Rs. 1 and rest Rs. 4 has to be incurred by the family from its pocket which is among the highest in the world. The Indian government spends only 1% of GDP on health whereas the expenditure is 6% of GDP which means that the rest 4-5% has to be expended from people’s pockets. This is the historical context of health spending in India in the backdrop of which NRHM has been formulated. The primary objectives of NRHM has been to

1. Increase public health expenditure to 2-3% of GDP( which is presently around 1.1%) 2. Reduce out of pocket expenditures incurred on health at the personal/family level that is

leading to poverty. In order to meet these objectives, NRHM has introduced local financing mechanism that has already been discussed; also it talks about District Planning for the first time i.e. planning should initiate at the village level, block level and then district level. This is the first year where all the 602 districts across the country have prepared their plans that have formed the basis of the state PIPs. Hence, our efforts during this two year period (i.e. the project tenure) would be to

• change the existing pattern of receiving health care- i.e. from one’s ability to pay to health care needs

• reduce out of pocket expenditure on health needs at the individual/family level • facilitate this process through community involvement and participation

This is the broad objective of the project. The understanding is that

• there will be effective use of the decentralized planning and financial allocation process. • NRHM service delivery system will take care of one’s health needs rather than one spending

from her/his pocket.


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• NRHM services are strengthened, facilities are improved according to needs, utilisation of services will increase and cost of care will be reduced.

Currently community monitoring under NRHM lacks the financial component. It is only about monitoring of health service delivery. So, if we are able to gather some ground level evidence after this project may be after 2-3 years (since this is an experiment) then we may look forward to having this additional criterion in the community monitoring process. Opinions of participants, especially that of the state partners were sought on whether there is a possibility of carrying this forward in sync with the community monitoring process. Participants shared their experiences of the community monitoring process. It emerged that this process had generated a lot of fear and a feeling of encroachment among the providers. Orissa partner shared one of their study findings. This was a comparative study on antenatal and postnatal care conducted in VHSC and non-VHSC villages. The study showed that in non-VHSC villages, the service delivery was poor, women have not availed complete antenatal care and postnatal services were almost zero whereas in VHSC villages 75% women have availed complete antenatal and postnatal care services. In case of unavailability women not only demanded these services but also questioned the system. These women were already aware of their entitlements and knew what to ask for. The learning is that if there is awareness and demand at the grassroots level and it is within the capacity of the local health system to deliver, then it is possible to deliver the set range and quality of services. Similarly for this project if it is possible to strengthen the local health system with these funds (flexible), the range and quality of services will improve. But certain services are community monitoring resistant like transfers and postings. At this point of time if there is an effort to affect district planning then it is expected that system will improve, utilisation will increase. This will be reinforced. The objective should be to try to build the concern rather than fear. Without trust building, there will be little space for negotiation. It is essential that there are more friends than foes. How to take this forward? The money factor should be discussed while talking about health. It is essential for people to understand that health is money. Generally the attitude regarding health is that it is not a layman’s job, it requires expertise to understand its technicalities. These misconceptions about the financial aspect of health often leads to lack of interest and hence awareness. Here the immediate step should be to help people associate health with money or monetise health and thus add this financial dimension to health entitlement, services and community monitoring. So the process or experiment (since this is an exploratory process) is likely to have the following steps:

1. Health Expenditure Assessment – to be conducted by community itself and not by organization

2. NRHM Entitlement Awareness – This can happen before or simultaneously with the first step. Somewhere, this process may have already happened.

3. Financial Plan and Expenditure Monitoring – Monitoring of financial planning and implementation(expenditure) at the local level

4. Health Service Utilisation – Monitoring – This is already part of the first phase of community monitoring.

5. Decrease in Health Expenditure and Increase in Public Service Utilisation – an evaluation of the process

The current assumption is that cost of care is high and public service utilisation is low. NRHM seeks to increase this utilisation. So the theory of change would be that once people are aware of their


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health entitlements as well as the high cost of health care borne out of pocket, they would be interested to know more about the financial allocations and services under NRHM, strive to improve service delivery, increase utilisation and reduce their health related expenditures. This would also improve their health status. This process will currently happen at the lower level but there are long term possibilities to work at the district and state level. Communities would not be able to impact at these levels. CHSJ has plans to understand the budget process at the national and state level and once that is done, there will be another round of interaction with the partner organizations to demystify the financial process at the state and district level. Participants were sceptical as to how to influence policy on the basis of such small scale assessment. The suggestion was that in an exploratory initiative it is difficult to handle large scale assessments since the number of factors that can be controlled reduces. At this point of time it is important to extract the learnings that emerge which would help to upscale in future. This project is being initiated only in those states where community monitoring has taken place through which service delivery and utilisation has been observed and hopefully financial dimension will be another feather in the same cap. Further, after two years, the partners can think of expansion. In order to conduct assessment of health expenditure and that too with communities, the information required will be as follows: Burden of disease • How much illness

• Type/kind of illness Patterns of service delivery • Type of service ( Public / Private) and

the associated costs of care. • Cost of Care / Ability to pay (

Formal/Informal) Socio-economic status • Economic status

• Social Position • Knowledge / Education

Demographic Characteristics • Population/number of people /Family Size/ Age Distribution

• Physical / Geographic Location If the above information is obtained from a village, then the expenditure on health can be estimated. What is the procedure of acquiring information in a village setting? In this context it is important to understand and differentiate the various ways in which information may be gathered. Like in literary terms getting information is a one-way process where the interviewer questions and the respondent answers. This is the most prevalent method of collecting information where once the information is collected, the researcher or surveyor analyses it at her/his own level and develops more understanding about the information. The information givers are excluded from this process of demystifying the information. But here in this project, the information will be collected, shared and understood together with the community. This will be a two way process where the information seeker and giver both are simultaneously informed, i.e. the information stimulates the thinking process and understanding of the giver also. The latter gets a chance to analyse this information at her/his level, becomes aware; hence the process of monetising health begins here.


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Following are some of the methods of collecting information:

• Survey • Focus Group Discussion • Key Informer • In-depth Interviews

One should be careful in using these methods and should be aware as to where and when these methods are needed or are to be used. The following are the steps followed in analysing any information and are part of all qualitative or quantitative research processes: Jumbled unclassified, unsorted information >> break information into bits, sort and classify on the basis of particular themes >> look for new relationships >> new information / story Session IX: Group exercise: Free listing of unorganized information A small exercise followed where participants imagined themselves as residents of the village Udangshri Dera and accordingly created their family structure, along with their socio-economic position. Here, the trainer played the role of the village organiser who is organising a meeting with the villagers in order to understand the current health position and disease prevalence in the village. He wants the villagers too to be part of this process and together understand their health problems. Each family was asked to share the health status of their family members. The specific questions asked were

• What are the diseases prevailing in the village now? • What were the diseases that were prevalent since last year? • What are the diseases that have affected people in the neighbouring areas?

The health problems that emerged from this were enlisted by one of the most literate (imagined to have completed high school education and can write english) members and was called free listing. Sorting and classification Once the diseases were listed, the villagers were asked to refer to the list and answer some specific questions related to the kind of treatment.

• What are the diseases that have been treated at home? • Which ones required specialised treatment i.e. consulted doctors, had to take medicines,

required hospitalisation etc.? The responses were classified into three categories:

1. Diseases that were treated at home. 2. Diseases that required medicines, hospitalisation etc. 3. Diseases where people had no idea regarding the treatment, or were not treated due to lack of

money or any other economic resource, or they resorted to superstitious practices.

The question should be around how and where the money was spent. The most prevalent/frequently occurring diseases where villagers had incurred recurrent expenses were filtered from the above. Next, the villagers were asked regarding the place of treatment/what facility they have availed for their treatment.


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Matrix ranking of facilities The most prevalent diseases (on VIPP cards) were arranged in a column and the facilities were placed in a row. The arrangement of the VIPP cards was like this. Next, the villagers had to identify the place which they would prefer to visit first for treatment of a particular disease and subsequently the next place if not treated in the first place. They were given multi-coloured paper strips (or symbols can be used for various diseases) for ranking the facilities in order of preference/prioritisation. → Points to be noted

• Create a subgroup of hospitals/facilities and find out in detail about the expenditure incurred. • Find out how much each family spends per year and what are the possibilities of spending. • Make some deliberate choices from the list of diseases as per the magnitude of the problem;

for example if more numbers of people suffer from a particular health problem, the same needs investigation. Avoid having information for all health problems.

• Start mapping with free listing followed by matrix ranking. • Categorise health problems into common and rare. Among the common diseases remove

those that could be treated at home. Keep those that need special care – further investigation • There may be a number of problems that are rare in the village.

In-depth interview on expenses After ranking is done, an in-depth interview (with the villagers) on the above diseases followed in order to get an idea about the differential costs borne by the villagers when they visit various facilities. Out come of the exercise: By the end of this exercise the community is expected to become aware of the different types of health problems and the costs incurred at different facilities (what costs at what facilities?)

Disease Facility

1 2 3


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→Points to be noted

With this exercise the unit cost can be obtained which can further be converted to cost for the population. It is to be kept in mind that the community at this point should be aware of the entitlements under NRHM and also how NRHM is strengthening facilities at the lower level. Hence mobilisation/awareness towards maximum utilisation of NRHM facilities and services should ideally happen along with the expenditure assessment. One should remember that this is not simply a research process but mainly an awareness generation process. There is a need to identify leadership to mobilize the community.

• The free listing and ranking should be done with a group of 20-25 people. • The community people must write their problems on the cards instead of us writing for them. • The community should lead the process followed by a group discussion. • The steps of the ranking should be as follows: Ranking of providers vs. illnesses >>Cost of

that particular problem >>Cost incurred in that particular facility. • The population dynamics could be understood by health mapping after following the steps of

ranking. • Community may be unable to recall health related expenses thus the illness of last one year

should be investigated only. • For specifics and detailed information in-depth interviews need to be carried out. • The results of the findings need to shared with the community and this could be the beginning

of our NRHM entitlement campaign. • Frequent visits to the community are essential to understand how things are taking shape. • After the health mapping exercise is over, the place should be cleared and things put back in

their original places before leaving the premises.

NRHM Entitlements Health Cost of Care- illness; provider/facility

Status of services / Financial Plan / Expenditure

Population Based cost of care (family/community)

Change in financial plan and expenditure pattern

Increase service delivery/ utilisation

Reduce Cost of Care

Reduction in poverty


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Participants had to return to their original groups and were asked to put down some mechanisms for investigating at the VHSC-SHC, RKS-PHC, RKS-CHC, levels as well as work on JSY allocation. The investigation was around the following:

• What information is required? • Where will they get the information? • How will the information be collected?

After sharing, the participants started preparing for the next days’ field visits. The groups were assigned the following tasks: Group 1- Interview ANM about VHSC funds and JSY money Group 2- Interview MO/Staff about RKS and Untied Fund Group 3- Had to go into the village, organise meeting and work on disease burden and cost of care The participants should have the following in hand before starting for the field:

• Introduction – greet and introduce each team member followed by the purpose of this exercise.

• Questions – what should be asked, list it down. • Role division and responsibilities of the team members • Documentation – appoint a person in-charge of documenting the process


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Day Three & Day Four: March 05-6, 2010

Session X : Field Visits The first day of the field visit was in Nandurbari village. The village was about an hour and a half’s drive from the training centre. The team started at around 11 a.m. On the way, the cars had to cross two river tributaries (Aai and Makra) over kutchha bridges. It turned out to be an exciting trip and participants were in high spirits. One of the cars carrying Goup 3 drove towards the village and the other carrying Groups 1 & 2 stopped at the Subhaijhar State Dispensary (PHC grade). Here group 1 went on to interview the ANM whereas the other group started interacting with the doctors( 1-Ayush, 1- MBBS and 1- Rural Health Practitioner). In between, the ASHA and the village health organiser had already organised a meeting with the villagers and as soon as the group 3 reached, the exercise on health expenditure assessment was initiated. The next two groups also joined after some time to watch and understand the process. The field work was over by 2:30p.m. and the groups reached the training centre at around 3:30 p.m. for presenting their findings. After this, there was a small exercise on village mapping based on which health mapping would be done in the village the next day. The next day’s visit was to Amlaiguri village. Few members also visited the Amteka SHC and mini PHC (run by a NGO), spoke to the ANM and the doctors regarding SHC untied funds and RKS funds. At Amlaiguri village, participants engaged the villagers (mostly women and some men) in mapping their village. Once households were identified and located in the map, the exercise on disease burden was initiated. Following this, the participants divided themselves into groups and conducted in-depth interviews with those women who had the maximum disease burden. Focus Group Discussions were also part of this process to understand more about JSY entitlements. Session XI: Presentation of the findings The findings are attached as Annexure IV

Particulars Facilitated by: - Field Visit Abhijit Das - Presenting the findings Field Support: Sunita Singh, Moumita Ghosh


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Day Five: March 07, 2010

Session XII: Sharing Observations Time: 9:00 AM to 12:00 Noon Facilitator: Abhijit Das Participants shared their experience of health mapping at Amlaiguri village. Participants had the following observations based on the field visits :

• Lack of prior preparations leading to over consumption of time during mapping exercise. • Language was a barrier because translation was time consuming causing restlessness among

community members. • Neither primary data was available beforehand, nor was any verification procedure carried out

before proceeding for interaction with the community. This created confusion while identifying houses during health mapping.

• Women were not aware about the households. • Villagers were not briefed about the objectives of the process thus it created confusion and

took time. • There is a need to have a map in hand to find exact locations of houses. • Villagers had expectations from the team. • There was too much involvement of the team members and too little of the villagers while

creating the map. The latter should have been allowed to participate fully during this map making exercise with some support from the team.

• ASHA and few elderly community representatives tried to overpower community members. In lieu of the above observations, it is important to keep in mind the following while creating a village map:

• Prior preparation is required • Rapport building with the community is important which would inevitably make the situation

more conducive for any kind of interaction/exercise with the community. • Mapping is one activity that requires two, three facilitators. • Two, three people should not ask questions at the same time. There should be a lead person

who will have the questions ready beforehand. The supporting person in turn may talk to the lead to give a clue as to whether things are progressing fine or not. This person can also offer help by identifying things/questions that may have been left out.

Particulars Facilitated by - Sharing of field experience, observations Abhijit Das, - Review of the exercises carried out Support

in the last two days Sunita, Moumita - Planning for a community awareness

Campaign around financial entitlements related to health


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• Role clarity is important or else, there will be anxiety among the team members. • In order to do mapping, it is necessary to have an idea of the village and its landmarks in order

that correct symbols are used to depict them. This would be helpful to avoid any confusion. • Space management is essential while creating a map. Facilitators should not enter inside the

map. This would make it more inclusive. • Community should be given sole responsibility of making their own map. • The first 10-15 minutes would be required to understand the directions and the details

required in a map. • Listing households becomes easier if houses are numbered with the name of the head of the

household in a map. • The information that has been provided by villagers should be crossed checked and verified

by other older people or the onlookers. • The team should take a back seat and give charge to the community. This will establish

community ownership of the process. • By dealing with senior people and other influential people of the village the team should be

careful as they can sabotage or can overpower the process. • Any point of disturbance/ unnecessary intervention (senior village folks, powerful community

representatives) should be neutralised because this exercise does not require experts. • Once the map is made, rechecking it for completeness. Here, some background information

i.e. demographic information (population, number of households etc) will help avoid under/over counting. The count of birth rate need to be followed in the map and the information can be obtained from the ASHA and ANM.

• The community should be seated or present in such a way so as to have a complete view of the map.

• After the map is done on the ground, it is important for the team members to draw it on the chart paper. Women’s/villages signature could be taken on the back of the chart paper; it will help them to remember. A copy of the map should be handed over to the community for purpose of reference and also because it is an important visual representation of their village.

• While arranging households in a map it is important to keep a tag on those households that are remotely placed as these might be instances of marginalisation.

• The health mapping exercise will be sequential i.e. Create Map >> Free listing of diseases >> go back to map Map gives distribution of disease by population and their prevalence can follow after this. • The map can also form a basis for understanding the socio-economic position of the

households and hence can be stratified as APL / BPL households. • After having done with the map, investigation around disease burden should be carried out.

The easiest way is to start investigation around delivery.

→Points to be noted • Co-facilitation is very important in mapping exercise; we should have more people for this

purpose. • In the team one person should take lead, one person should ask the question and other person

should support the exercise (support staff). • The lead person in the team has prime responsibility of connecting with the community and


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the support staff should only communicate with the lead person instead of the community. • Material management is very essential and it should be available before hand. • The physical representation of the map should be as per the geographical context thus it is

important to stroll around before the exercise begins. • As lack of clarity leads to over anxiety thus it is important to have clear cut role and

responsibilities division among the team members. • In order to break the ice, the team has to take little more lead in the beginning until the

community gets fully involved and be there to just facilitate the process. • The size of the map should be manageable. Enough space should be left outside the map for

people to stand and watch, thus space management is important. • People should be allowed to take their time initially for the first 15 to 20 minutes and there is

no need to rush. • Each household needs to numbered and named as per the head of the family, this will help

the people to locate houses by the name of the head of the household. Challenges faced

1. Accuracy of information became a question as ASHA tried to take a lead and was overpowering. Others got very little scope to talk.

2. Health Problems for the entire village were not reflected. 3. Questions for the interview were not prepared before hand. 4. Information related to a particular side of the village was missing which lead to the question of

marginalisation and need to be further explored. Mapping and free listing These are two different methods and should be chosen as per our requirement and sequence of activities. Map provides us information on the distribution of diseases across the population where as free-listing provides information around prevalence of different kinds of diseases, degree of their prevalence. Map could be used as a reference document and we can have multiple analyses based on the information obtained from a map.

In-depth interview and costing As cost is a very sensitive issue, we should make sure that people who have got direct benefit (cash/kind) from the community are not around as their presence may severely impact data reliability and validity. Also we have to keep in mind that people/community will not be able to relate the types of formal/informal expenditure incurred and would need our help to understand and recall. The facilitators must prepare a list of cost/table which will ease this task Recap of the exercises carried out during field visits SL. What exercises Why 1 Mapping of village Socio-Economic details

Details of Providers Distribution of diseases across population

2 Free listing of diseases Different kind of illness – Range and Variety3 Sorting Commonness, Treatment, Expenses -

provider 4 Matrix Ranking Provider-wise preferences


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Diseases x Providers Cost Cost of access to illness severity

5 In-depth interview with one person at a time (Cost of Care for particular disease)

Detailed expenditure Direct / Indirect Costs

6 In-depth Interviews – ANM, ASHA, MO Financial entitlement mechanism and its implementation status

7 Focus Group Discussion Cost of Care, Ability to Pay Summary Report Should consist of the following information:

• Common illnesses / Commonly used services • Cost of care of different illnesses focusing on high expenditure illnesses • Expenditure for delivery – normal and complicated cases • Cost of care according to provider – focus government facility • Estimated health expenditure of village • Consequences of health expenditure • Entitlement implementation status

- Financial entitlement - Implementation ( planning & expenditure) status

In addition to the above, cost of health care of 5 sample households can be tracked periodically (every 3 months). The health expenditure may be worked out in the following format.

Health Expenditure Health Condition Cost

(1) No. of person x episode

(2) Total (1 x 2)

Institutional Delivery (normal) 3750 3 11250 Home delivery 1000 2 2000 Malaria ( medicines from pharmacy) 3000 10 30000 Malaria ( hospitalisation) 24000 1 24000 Diabetes 12000 1 12000 Surgery (Gall bladder stone) 14000 1 14000 Total 93250 During interaction with the community, it is essential to know/understand people’s reactions (bitterness, whether they are provoked, sad etc.) while they recall their health expenditures, along with their knowledge about public services and their expectations from the public health system. Question of entitlement awareness is raised here. Entitlement awareness is the key component for mobilisation. This has to happen once with the communities and another with VHSC/RKS committee members. There is also a need to reconsider village level planning, proper and justified utilisation of RKS money, systematic functioning of VHSC and RKS. VHSC and RKS are those democratic spaces which can be strengthened to use these flexi finances reasonably. If the expenditure is reduced once these committees become active and funds utilised as per local needs and simultaneously if these changes are periodically documented and shared, efficiency changes are bound to happen. The expected outcome will be regular VHSC and RKS meetings. The purpose here is to find out - How health expenditure can be reduced? - How NRHM entitlements can be made more effective?


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It should be kept in mind that NRHM looks for two types of inputs: - System Strengthening - Community Strengthening Moving Forward Next Steps Smaller Steps

1. HEALTH ASSESSMENT - Inform DPM/Mission Director - Identify villages - Orientation meeting with community

leaders - Training of VHSC (Assam) /Gaon Kalyan

Samiti (Orissa) Leaders - Secondary information about villages/area - Community Health Assessment - Sharing – Plan (entitlement awareness)

2. ENTITLEMENT AWARENESS 3. RKS CAPCITY BUILDING

- Booklet - Leaflet - Women’s Group / common meeting - Wall writing / permanent hoarding - Door to door information - Song/play

ASHA, RKS /MO Expectations from NRHM and what they will contribute

What the community will do and how?

How this will be done? What will be the role of NGOs


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Session XIII: Planning for Community Awareness Campaign around Financial Entitlements related to Health for Orissa State Facilitator: Sunita Singh

ORISSA

District - BOLANGIR

Block - PATNAGAR

PHC 2BAHNISHA

SHC 1 SUHAMUDI

SHC 2 BAHNISHA

PHC 1 SOLBANDH

Village 2 JAMBAHAL

Village 3 BABEJORI

SHC 2 JOGIMUNDA

Village 4KHALIA

PHC 3TAMIA

Village 1TENTELKHUNTI

Village 2NOKTASOR

Village 3RENGSIL

Village 4To be selected

SHC 1 BARPADAR

Village 1RALCHIUDAR

Village 2KUNDABAHLI

Village 3KHUTUNAPANI

Village 4 To be selected

SHC 3 BALIPOTA

SHC 2 BONIMUNDHA

Village 1 THAKPARA

SHC 1 PANDOMUNDA


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Activity Timeline: Orissa State

Sl. Activities Timeline Remarks 1 Inform DPM/Mission Director March 15, 2010 2 Training of VHSC, Staff of

Organisation, Volunteers March 26-28, 2010

3 Orientation Meeting with community leaders / hospital staff (RKS members)

April, 2010 full month

4 Secondary Information Entire April, 2010 for 12 villages

5 Community Health Assessment July, August, September, 2010

6 Sharing Plan July, August, September, 2010

CHSJ will give entitlement kit to partner by April 1st week

7 Entitlement Awareness Booklet in Oriya May, 2010 Leaflet in Oriya May, 2010 CHSJ has to give leaflet in

English by April end-May 1st week

Women’s/common group meeting

June, July, August, 2010

Wall writing June, 2010 Door to Door information July, August, 2010 - CHSJ will decide how may

households will be taken for correct representation of data. This will depend on the number of villages.

- CHSJ will complete

guidelines/questionnaire for collecting door to door information. This will be completed by May 15, 2010 and circulated to partners for their inputs.

Song/Play etc. June 8 Process Documentation Regular according to

progress Format will be provided by CHSJ by May 15th, 2010

9 Partner Meeting in Orissa Expected that the first round of investigation will have been completed by this time

October 20th , 2010 Within this time period, CHSJ needs to look and analyse district budgets.

10 Capacity building of RKS and VHSC

October, 2010


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Session XIII Contd… Planning for a community awareness Campaign around financial entitlements related to health for Assam State The state partner will provide details on the following by March 31, 2010

- Geographic Scope - Timeline of activities - Details of Team Members

It has been suggested that the state will take a big and a small village (considering that there are hamlets within every VHSC village) under every sub centre in order that the population is representative enough for the assessment and also avoid exclusion of certain categories of population.


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ANNEXURE I : TRAINING AGENDA

Five days Training on

Community Assessment of Health Expenditure at

The Action Northeast Trust (The Ant) Udangshree Dera

Vill Rowmari, PO Khagrabari (via Bongaigaon) District Chirang (BTAD)

Assam 783380 INDIA Objective(s) of the Training:

1) To increase knowledge about NRHM financial entitlements and mechanisms for community participation

2) To develop understanding about the project 3) To develop skills in community assessment of health expenditure using participatory

methodology 4) To prepare an action plan for implementing the project in respective districts

S/N Particular Time 1 Day One Registration and Context setting 10:00 AM to 10:30 AM Introduction of the participants 10:30 AM to 11:00 AM Expectation Setting Introduction to the project 11:00 AM to 12:00 Noon Understanding Health Service System 12:00 to 1:00 PM Lunch 1:00 PM to 2:00 PM Introduction to the concept of Health and financial entitlements under

NRHM 2:00 PM to 4:00 PM

2 Day Two Review of Day one Introduction to NRHM and its entitlements – service related and financial Lunch 1:00 PM to 2:00 PM Preparing for Community Assessment of health expenditures 3 Day Three and four Conducting investigation into current health related expenditures –

identifying the gaps – in Entitlement Awareness; in Utilisation of Public services and the reasons for these gaps. ( Participatory exercises)

Preparation, Field work and presentations

4 Day five Sharing the community assessment results with the community Lunch Planning for a community awareness campaign around financial

entitlements related to health


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ANNEXURE II – LIST OF PARTICIPANTS Sl.No. Name Organisation Mobile /

office phone E-mail

1 Dr. Saim Mohammed Khan

SAHAYOG, New Delhi

9891178909 [email protected]

2 Ekta SAHAYOG, New Delhi


3 Ruhul Amin CHSJ, New Delhi 09953125218 [email protected]

4 Sadananda THE HUMANITY, Bolangir, Orissa


5 Jiban Behra SODA, Mayurbhanj, Orissa


6 Gouranga Mohapatra

THE HUMANITY, Bolangir, Orissa


7 Bibhuti Bhushan Nayak

THE ANT, Rowmari, Assam


8 Sunil Kaul THE ANT, Rowmari, Assam

9435122042 03664293802

[email protected]

9 Gajen Brahma THE ANT, Rowmari, Assam


10 Jaya Rajbongshi THE ANT, Rowmari, Assam


11 Moumita Ghosh CHSJ, New Delhi 9810663406 [email protected]

12 Sunita Singh CHSJ, New Delhi 9873482235 [email protected]


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ANNEXURE III - PROJECT PRESENTATION

Monitoring of Health Expenditure Budget – In two

states of India

Centre for Health and Social Justice

BackgroundNRHM has laid down norms for flexible financing at thecommunity and facility levels for locally initiated planning. • Untied grants at the VHSC – Rs 10,000 per year• Annual Maintenance Grant (AMG) for SC – Rs 10,000

per year• AMG and Untied Grant for Local Health Action for PHC–

Rs 50,000 and Rs 25,000 per year• AMG and Untied Grant for Local Health Action for

Community Health Centre – Rs 1 lakh and Rs 50,000 per year

• Corpus grant for Rogi Kalyan Samiti.

• The total budget available for financial supporunder Flexipool is roughly equal to 25 per centhe entire NRHM budget at the national level.

• In addition to this NRHM had also introduced decartelized planning at the state level (PIP) athe district level (district action plan)

• NRHM also talks about “Conditional Cash Transfer” and is best seen in the Janani SurakYojna ( Safe Motherhood Scheme)

• The JSY money has total expenditure of over billion rupees in 2008 –09 and it is reported tomajor source of corruption at the community le

Problem statement

• High out of pocket expenditure on health• Low public expenditure on Health • No mechanism of monitoring of health

expenditure • Lack of people’s participation in

monitoring

Objective The general objective of the project is; to facilitate

community to do budget related monitoring and expenditure tracking in two states of India.

Specific objectives: • To increase communities’ involvement and

interest in budget and expenditure tracking.• Train and facilitate community to do monitoring

of health expenditure at the village level.• To increase transparency and accountability

among health providers and government health department regarding health expenditure.

Expected out come(s)

• Improve range and quality of services available at public health facility

• Utilization of publicly finance health care system will increased

• Cost of health care (out of pocket expenditure) at the family level will be reduced

• Influence District Action Plan (DAP)


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Methodology The project will use the social audit and health services

related monitoring methodology. There are two layers of investigation;1) At the community level:The project will be implemented over 20 villages, 6 healthfacilities and 2 districts in 2 states. Only those states,districts, blocks and villages are selected where alreadycommunity monitoring of NRHM has been carried out. Atthe village level VHSCs will be responsible to carried outthe monitoring process. The Village health expenditureprofile will be filled by PRA method and shared with thecommunity subsequently.

2) Desk Review: Desk search and review of literature will be done,

like state level PIP and district action plan, union and state budgets, state annual plans, NRHM data sheets, eleventh five year plan and sanction and released letters of grants-in-aid to state health societies.


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ANNEXURE IV – FINDINGS OF FIELD VISIT ON MARCH 04-05, 2010

Group- 1 : Interview with ANM to understand JSY, Untied Fund/AMG and ASHA to understand VHSC and untied fund

Process stated with the self introduction and purpose of visit. We went to the Dispensary of on 5th March 2010 with the group 1 members. We have discussed with

1. Rasmi, ANM in the dispensary in contractual and taking care of 9 villages

2. Thagimala, ANM in contractual taking care of 7 villages

3. Endi, ASHA

4. Sineliu, ASHA

5. Ralati, ASHA

Finding of the discussion with ANM:-

All the three ASHSs have come to the dispensary to know why the NMBS fund has not delivered. All the ASHA spoke the NMBS fund has not got by the beneficiary last three month. This fund has given to the beneficiary after 3 month and after 3 Antenatal checks up. All the pregnant women get this fund through the Assam Govt. It was previously Rs. 500/- and from March 2009 it has increased to Rs. 1000/-.

All the women are getting Rs. 1400/- under JSY in case of institute delivery. All the payments are in A/C pay check. Previously the JSY fund was delayed from one month to one year but now it has streamline and beneficiary gate the fund immediate after delivery in the dispensary depend upon the check availability otherwise it takes maximum 3 week. To get the JSY fund beneficiary has to produce JSY Card and registration slip of the institute where the delivery happened. ANM are come to know about JSY in the monthly meeting presented by the DPM but they have not get any written guideline. We also came to know that in case of seasering the women have to get Rs. 1500/-, but it has not work in that PHC. All the beneficiary get Rs. 500/- as transportation cost at the time of delivery in case of fund availability but the ANM told the DPM has verbal instated transportation cast will Rs. 300/- but they are given Rs. 500/- to all. No one get any fund incase of home delivery. It has instructed to the Bank that the beneficiary account has open in “0” balance.

ANM were told that in that dispensary no staff nurse and clerical staff has appointed and they are doing the nurse work and paper work so they are unable to attend the home visit in the village, even they fix the village visit on Mon day and Thurs day. JSY fund has maintained by the dispensary doctor. All the medicines are supply through that dispensary to the beneficiary but in case of unavailability beneficiary purchase from own pocket. ANM are member in the VHSC committee but they neither attended the meeting nor know about the VHSC. As these ANM are attached to the PHC they have not detail idea about the untied fund but they spoke that two type of fund has come to the sub center. After the delivery women are return to house after 3 to 4 hours in case of normal delivery but in case of complication women are refer to CHC. Per month 17 to 20 deliveries happened in that PHC and in last month 6 have happened.


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Discussion with ASHA

• All the three ASHA know about VHSC

• DPM told to form VHSC in all the village and informed how to form and who will be the member of the committee but they have not get any written document or instruction about formation of VHSC

• All the three ASHA are the secretary of the VHSC in their village and VCDC chairmen are the chairmen of the committee and other members are AWW, Teacher, Pradhan etc.

• All the VHSC formed in this area from the year 2007 but they get fund only two time, in January 2009 and January 2010

• They have get total Rs. 20,000/- till date

• ASHA has gave Rs. 1000/- to open the account initially and return back after getting the fund

• Account are in the joint account of ASHA and VCDC chairmen

• There has no specific guide line for VHSC to the ASHA

• Funds are utilized on purchase of stationary, snacks in the meeting, sanitation and transportation cost to poor women in the time of delivery, but they have not return the fund

• They have prepared the action plane of the VHSC fund following the guide line but some time it has change

• Monthly VHSC meeting are conducted in the villages and ASHA has call the meeting

• All the record and Accounts of VHSC are maintained by the ASHA

• VCDC chairmen check the record and accounts regularly

• All the record are opened for the community

• They have not given any account report to any body

• VCDC chairmen are cooperating but some area VCDC chairmen are demand money for signature in the check

• ASHA are unaware about the village health plane and neither they have made any health survey nor prepare any health plane

• They have never ask any body about why they have not get every year the VHSC fund

• They expressed that this fund is not sufficient for the vest village and it should be increase

Report of FGD with the women with one year child

• Most of the delivery happened in the Subajhar PHC, which is one and half kilometer from the village

• In case of savior the patents refer to Vetagan CHC, which is 12 kilometer from the village

• Previously Gynecologist was in the Ventagan CHC but now no Gynecologist

• For normal delivery women have to stay maximum 2 days and in case of CS they have to stay 3 to 4 days in the hospital


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• Most of the medicine are purchase by the patent, very normal medicines are supply rarely in the hospital

• To meat the health expenses most of the time they depend on lone with the interest of 5% to 10% per month for a specific time period, if the time period excide the interest increased

• Some time they sell their land and animal to meat the expenses with distrace sell

• For normal delivery the direct expenses are Rs. 3000/- to Rs. 4000/-

• The are satisfy with this expenses because the private clinic expenses are more then Rs. 10,000/-

Expenditure of normal delivery at Vetagan CHC

• Vehicle cost to CHC 400/-

• Food for 5 person including ASHA 500/-

• Medicine 1000/-

• Travel cost of the attendants 500/-

• Return vehicle cost 400/-

• Doctor fees 400/-

• Blood test 50/-

• Nurse (3) 300/-

• Sweeper 50/-

• ASHA 100/-

• Registration 5/-

• Mandays loss of 3 person for 7 days @Rs.100 2100/-

• Interest of lone of Rs.3000/- 2000/-

Total 7805/-


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Group -3 Health Burden

We started with an introduction & there after we made environment through the conversation about their village, occupation & agriculture so that they may be started feeling familiar. When they started feeling familiar we initiated talking about the disease they found in between 8-9 month. Around 10-12 women out of 35 participated in free listing of disease i.e.- malaria, B.P. Gastec, during delivery and so on only in their own language. After free listing some women & men participated in sorting out the disease into two parts, home based remedy & treatment with cost. After that we had a discussion with the community that for cost based treatment where all they go or available, they told us the name of all the institutions govt. & non govt. & we pen it down on the cards. Then we made matrix of disease & asked them where they go for treatment & if it doesn’t cure where they move for. After completing this we asked them about the treatment cost they went for a place to another for treatment. For instance we took malaria and the cost of the treatment the family invested on.

Bongai Gaon

Dis

ease

Ph

arm

acis

t

Dis

pen

sary

(G

ovt.

)

C.H

.C.

Private (St.Augustine, Lower Assam, Agarala etc.)

Govt.

Gu

wah

ati

Cost Services Cost Services 5/-Rs. Registration 500/-Rs. Medicine

10/-Rs Test

1200/-Rs. 13000/-Rs

Travel Food Plus Medicine

500/-Rs Food

200/-Rs. Wage lose*

400/-Rs. Wage lose*

Mal

aria

1215/-Rs

Total 14600 Total

*Daily wage of one person= 100/-Rs. per day For the general health problems local resident of Nagdanbari take medicine from the neighboring medical stores otherwise they prefer to go to the nearest health centre, Nagdanbari Dispensary which is one km. away from their residential place. If they were not treated at health centre, they go to CHC then Private Hospital, Bongai Gaon then Guwahati for proper care of ailments. Observation:

1. It was very difficult to get the information of diseases during the discussion because people were saying that they had not been suffered from any disease for long time approximately seven month.

2. People were informed us that all the deliveries have been taken place in institutions for one year.

3. Physical appearance of the residents was healthy. 4. Those who were sitting in the last rows were not participating actively.


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Group -2 Interview with Providers

On the third and fourth days of the training we conducted field visits and along with other activities a small interview was held with the doctors at the Subaijhar PHC in Bongaigaon district. The interview was designed to train the participants handle such situations and to see the possibilities and challenges that would arise when communities practice the actual work of budget tracking. We prepared lists of information needed, possible sources of this information and the strategy to be adopted to collect the same. The interview was conducted by a team of three trainees under the guidance of the trainers. The one hour long interview helped in collecting and discussing the following facts about the Hospital Management Committee (known as Rogi Kalyan Samiti in some other states) of the PHC. Composition of the HMC- the HMC consists of 7-11 members and it includes some other villagers who remain active in the committee but are not considered as members. The existing committee has 11 members in total. Meetings- the committee sits for planning and review meetings on basis of needs. As the doctors said the meetings of the HMC are generally held once in a month. However, sometimes they don’t conduct any meeting in the whole month while in some other times more than one meetings are held in a month. Sometimes they also sit in case of emergency situations mostly if there is a mishap or conflict involving the villagers and the hospital staffs. Services- -OPD- -Emergency services for accidents -services for normal delivery -referrals Expenditure pattern (total fund received in the last year was Rs. 125,000. they don’t know what was the distribution, that is, how much of it was untied/annual maintenance grant or corpus fund) -Most of the funds (around 70%) are utilized for repairing/maintaining infrastructure -rest of the amount is used in buying some equipment, a few medicines, kerosene for generator, ASHA’s rewards, payments for ambulance driver, sweeper etc. and other necessary items for emergencies. Some amount of money is kept for meeting emergency needs. Last year they have bought one generator worth Rs. 46,000. Approval/ sanction A proposal is placed before the Committee in the committee meeting and then the resolutions are passed. There is no process of emergency approval or release of emergency funds. Records Records are maintained and furnished in the form of cash book, vouchers and registers. Limitations/challenges -extreme scarcity of equipments -no electricity and high price of kerosene -funds are released very late. The last fund was released in the month of January 2010 which is to be spent by March 2010.


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-for meeting the multiple needs, it is needed to make adjustments in the expenditure which often goes outside the guidelines (for spending a particular type of fund for particular services etc). This is questioned by the auditor which creates a lot of trouble. Health Mapping On the second day of field visit, we conducted a health mapping in the village. First, the villagers were facilitated to draw a map of the village. The map was prepared on the courtyard of a house using paper pieces, pictures, colours etc. It depicted roads, houses, paddy fields, hospitals, ring wells, ASHA houses and other land marks that are shown in a location map. Apart from this the map showed the following health information about the village. This information refers to the experiences of the respondents in the last one year: -households/families which have experienced child birth in their family in the last one year -households/families with normal child birth -households/families with cesarean child birth -families having institutional delivery -families having delivery at home -families where there was occurrence of malaria -families that have experienced serious illness leading to institutionalisation of the patient -families with chronic illness After marking the mentioned households in the map, individuals from some of these households were interviewed for understanding the costing of availing a particular health service. Different direct and indirect expenses (e.g., wage loss) were estimated to come up with the total expenditure incurred by the family in getting treatment for a particular health issue. These mapping and costing were to some extent guided by information collected earlier about various diseases occurring in the village and the services taken for the same.

TRAINING ON COMMUNITY ASSESSMENT OF HEALTH EXPENDITURE · 2019-03-17 · TRAINING ON COMMUNITY ASSESSMENT OF HEALTH EXPENDITURE (3rd to 7th March 2010) A REPORT Conducted by: Centre

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