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Maternal Health Study

– Prarthana Rao, Programme Officer

In 2000, Public Affairs Centre (PAC) conducted a Citizen Report Card (CRC) study of maternal health services offered by Maternity Homes (MH) and found that the quality of service delivery was far from satisfactory. Together with other NGOs in the city, certain reform measures were recommended. A decade later, a repeat CRC exercise in these MHs in the city was carried out to understand if there were any changes in service delivery. The quality of service still remained poor. Corruption was still rampant and entitlements like Madilu Kits were not reaching the beneficiaries. There were lots of hurdles in availing the benefits of the maternal health schemes like Janani Suraksha Yojane. Basic facilities like drinking water, clean toilets, and ambulance facilities were missing in many of these Maternity Homes.

Table : Details of Expenses by patients at the maternity homes

N

% of Users who Paid for service

Stipulated User Fee(Rs.)

Paid stipulated amount (%)

Received receipt %)  (for stipulated amount)

Paid more than stipulated amount (%)

Received receipt % (for more than  stipulated amount)***

1

2

3

4

5

6

7

8

Registration

117

70

5

33

69

67

44

Iron and folic acid tab

95

2

0

NA

NA

0

Scanning

17

77

100

92

25

8

0

Blood test*

105

64

70

83

46

17

60

HIV Test

94

21

0

NA

NA

21

55

Urine Test

107

45

0

NA

NA

45

44

TT Injection

114

27

0

NA

NA

27

7

Syringe

114

29

0

NA

NA

29

6

Bed Charges

66

33

0

NA

NA

33

50

Delivery(N/C)**

66

67

300/350/500

55

48

45

37

For Baby seeing

65

26

0

NA

NA

26

0

Immunization

118

36

0

NA

NA

36

9

Family planning

76

12

0

NA

NA

12

11

 

* Blood test amount includes HB, cholesterol, Sugar and VDRL charges **N- Normal, C – Ceasarian; NA – Not Applicable *** what Users reported as receipts were not from the regular receipt book, instead it was mostly on blank white chits mostly used for prescriptions.

With financial and technical support from IBP, partnership with grassroots organisations and a tactical nod from the Health Department of the BBMP, PAC sought to implement a model called the Maternity Home Monitoring Committee (MHMC) that would help users to voice their demands and play a role in service delivery as well.

Figure : Complete Satisfaction with services of BBMP Maternity Homes

 

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During informal interactions with the users it came out very clearly that often lack of resources was cited as reason for lack of service delivery. For example madilu kits were not given because there was no supply, milk was not given in stipulated quantities because additional quantity of milk could not be purchased if the patient load was more. Hence PAC decided to do a root cause analysis and find out if lack of funds was responsible for poor quality of services and took up detailed budget analysis of BBMP maternal health budgets. Some initial efforts on tracking some of the funds like User Fee, free food for inpatients were also made in selected MHs to understand the issues further. These exercises revealed that there were some gaps in supply of medicines, issue of receipt for User fee collected, procurement of sufficient quantities of milk for in-patients etc.

Community Score Card

Looking at the issues, it was felt that there was a need to bring the users and the service providers to a platform for a face-to-face discussion that could help resolve most of the issues. Community Score Card (CSC) approach was chosen where a set of indicators pertaining to the issues that came out of CRC and budget analysis were developed. User groups were asked to rank these indicators based on their recent experiences with reasons for scores. The same was done with the hospital staff in exclusive meetings. Both the set of scores were displayed along with reasons cited in a forum by bringing the staff and the users together. A well moderated discussion helped resolve many of these issues during the meeting. A joint action plan was also drafted for further follow-up with clear indication of responsibilities of users and service providers. During the interaction, it was realised that there is a potential for users and service providers to work together to improve the quality of service delivery, hence a users’ committee called the Maternity Home Monitoring Committee (MHMC) was set up.

User- Provider interface

MHMC consist of 8-10 members who are selected from the catchment areas of these maternity homes who have availed services from the maternity home in the past and are availing services currently as well. They visit the MH on a regular basis (once in fifteen days) and monitor the progress as per checklists provided to them. They share their observations on the implementation of the agreed action plan and also other changes related to quality of services taking place in the MH, on a fortnightly basis with the officials of the health department of BBMP. They also build awareness among users in the community on maternal health and entitlements from the MH, through smaller informal meetings between MHMC members and users in their own respective localities, mobilizing community members to participate and take advantage of the various awareness camps, health camps etc. organized by BBMP in these areas.

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Key achievements

a. Users of health facilities monitoring the availability and quality of services at these facilities.

b. Creation of a space for regular interaction between service users and health providers

c. Increase in accountability of front line service providers to the community.

d. Capacity building of MHMC members to understand and engage with broader health system issues.

Key challenges and learnings

a. Since it is process intensive, upscaling of such an initiative is a challenge. Making this a systemic initiative with external facilitation by civil society could be a way forward.

b. While this project has shown that communities can monitor services upto the referral level, taking this to tertiary facilities, given the amount of technicalities involved in medical care at this level, is a challenge.

c. User- Provider interface platforms such as MHMC require external facilitation and support to function constructively.

Figure : MHMC members’ sharing information about maternal health entitlements with urban poor women

members.jpg

Figure : MHMC members sharing observations with MH staff in regular follow-up meetings

 

members1.jpg

 

“Citizen Committees serve as messengers within the user community and also help in building a good relationship between the users and the staff. These committees have to be set up in all the maternity homes in the city”- Medical Officer from a BBMP Maternity Home.

“PAC’s efforts of putting in place citizen monitoring committees have been very useful. We would pay huge amounts of money earlier to avail services from maternity homes but now, we pay only the stipulated user fee and also get official receipts for the amount we pay”- Users of BBMP Maternity Homes in Bangalore.

 

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