Demanding Accountability of Health Services: Lessons learned from local level monitoring and advocac

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Demanding Accountability of Health Services
Lessons learned from local level monitoring and
advocacy

• NARIPOKKHO
• APCRSH
• 29 October 2007
• Hyderabad, India

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About Naripokkho

• A membership-based womens activist
  organisation.
• Working for the advancement of womens rights
  and entitlements and building resistance against
  violence, discrimination and injustice.
• One of the thematic areas of Naripokkhos
  work is womens health and reproductive rights.

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Concerns

• High Maternal Mortality 3.8 per thousand live
  birth
• High Maternal Morbidity
• High Infant Mortality-54 per thousand live birth
• Poor governance and implementation failures

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Problem

• Implementation and delivery failures in the
  health sector due to lack of Accountability,
  Transparency, Monitoring and Supervision
• Leading to undesirable outcomes
• Womens access to health services low
• Widespread corruption in the health sector
• Quality of service lacking and not ensured

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Naripokkhos Intervention

• Accountability project -Ensuring accountability
  of local health authority and service providers
  to people specially to women
• Action research project supported by Royal
  Tropical Institute (KIT) Netherlands
• September 2001 March 2003
• Working area Pathorghata, Borguna
• WHRAP project-Women Health and Rights Advocacy
  Partnership
• A South Asian Partnership project coordinated by
  ARROW supported by DFPA
• Advocacy project, from April 2003
• Working area- Greater Barisal division in four
  districts.
• 12 Upazila Health Complexes, 4 District
  Hospitals, 3 MCWC a Medical College Hospital is
  being monitored
• 28 CBOs are working in partnership

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Average number of both male and female patients
per month in Pathorghata UHC (Indoor Outdoor)
Showing gradual rise of patients in the facility
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Average number of female patients per month in
Pathorghata UHC (IndoorOutdoor)
Steady rise of women patients in the facility
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Accountability Project Implementation Framework
MOHFW
National
Member of Parliament Pourashava
Local Health Authority
International
/
Fora
Union
Parishad
Local Journalists Teachers
UHAC
Media
UHC
NARIPOKKHO
Sankalpa
Trust
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WHRAP Project Implementation Framework
MOHFW
National International Fora
Pourashava/ Union Parishad
Local Health Authority
Local Journalists
Women Leader
UHAC
Media
Village Doctor, Dai
UHC
NARIPOKKHO
Sankalpa Trust
CBO
CBO
CBO
CBO
CBO
CBO
WG WG WG WG WG WG
WG WG WG WG WG WG
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Implementation Strategy

• Replication of the accountability model
• Capacity building of partner organisations (CBOs)
• Regular monitoring of local level government
  facilities by local CBOs
• Collection, compilation and analysis of facility
  based information
• Need assessment of facilities especially on EmOC
• Engaging different stakeholders, in and outside
  the government
• Campaign, Lobbying and Advocacy

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EmOC Policy

• First Aid EmOC to be available in every Union
  Family Welfare Centre
• Basic EmOC to be available in every Upazila
  Health Complex
• Comprehensive EmOC to be available in some
  Upazila Health Complexes, all Maternal and Child
  Welfare Centres, District Hospitals and Medical
  College Hospitals

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The Situation in Pathorghata

• Out of 7 Union FWCs in Pathorghata Upazila, none
  are providing delivery services or first aid
  emergency obstetric care though each facility has
  1 to 2 trained FWVs and FWA. In each union 25-40
  deliveries take place every month. Yet, the
  service could be easily made available by the
  FWVs with the help of the 2-3 trained TBAs
  available in every union if the co-operation is
  established.

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Findings

• Pathorghata Health Complex has comprehensive
  EmOC center but for the last four years no
  caesarian section or blood transfusion has taken
  place. So the number of referred cases is very
  high.
• In rural Bangladesh women prefer not to travel to
  facilities for delivery except in emergency. So
  they manage to come to the facilities at the
  eleventh hour. At that time if they are referred
  to another facility far away it invariably
  results in death or disability.

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Findings on Pathorghata CEmOC
Age Category of Women who attended UHC (n 284)
Majority are young woman
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Education Status of Women (n 284)
Most of them have some education
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Distribution of the respondents by source of
treatment received before coming to health
complex (n262)
Treatment received Frequency
Percent Village doctor
43 15.1
Dai
81 28.5
Kabiraz/ Baidyo/ Ojha/ Panipora 24
8.5 Nurse/ HW/ FWV
8 2.8
Pharmacy
12 4.2 NS
4
.4 Total
262
100.0
Primary providers are Dais and village doctors.
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31 different types of emergency obstetric
patients were received in Pathorghata EmOC
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Distribution of the respondents by general
condition at departure
General condition at departure
Frequency Percent Fully recovered
216 69.7 Not much improved
14 12.0 Referred 48
16.9 Dead
4 1.4 NS
21 5.1 Total
284 100.0
A large number of patients were referred due to
unavailability of comprehensive EmOC services
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Distribution of the respondents by receiving EOC
services by distance of UHC/EOC at Pathorghata
(n 284)
Most of the respondents were from the adjacent
area.
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Lessons learned

• Decentralization of power and authority can
  improve local service delivery especially the
  doctors recruitment, the provision of medical
  supplies and logistics are decentralized.
• CBOs can play an important role in monitoring
  health services
• Media and local government can contribute to
  improve services through regular observation ad
  reporting

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Lessons ..

• Participation in the process of demanding
  accountability can empower local communities
  especially women
• In the absence of a specific monitoring body,
  other local bodies can play a critical role for
  ensuring accountability and solving problems
  locally,

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Lessons.

• Few anesthetists in the country and the
  uncoordinated posting of obstetricians and
  anesthetists renders EmOC facilities useless and
  so this problem should be addressed.
• Comprehensive primary health care should be
  prioritised over vertical programs. Thats why
  unification of department of health and
  department of family planning is a must.

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Thanks