Social Audit of Health Services

Improving Family Planning Services in UP, India

2001 - 2005

Abhijit DasCentre for Health and Social Justice,

India

Introduction to Presentation

1. What is Social Audit

2. Applying Social Audit to Health related public programming

3. Example of applying social audit to a health issue in India

4. Challenges

1. What is social audit

Variety of Audits-

• Internal Audit – Efficiency, Financial

• Statutory Audit - Financial

• Performance Audit, Compliance Audit

• Environmental Audit

• Social Audit – multiple definitions

Social Audit- Evolving definitions

•  A process of measuring and reporting an organisations social and ethical performance. (Caledonia Centre for Social Development) ‘mid 1990’s’

• A ‘social hearing’ ‘gaze’( Dr Wan Ying Hill –Glasgow Caledonian University)

• A means of collectively probing and understanding information by citizens ( Amitabh Mukherjee)

• A community assessment of public records to evaluate how well public resources are used and how to improve performance (OSI-PHW)

• The audit of a Programme / Scheme by the community with active involvement of the primary stake holders and in collaboration with the Government (MKSS) ‘mid 2000s)

Social Audit : Key Elements

Linked to • Accountability• Review of Performance of a Public Programme• ‘People’s interest’ or ‘Social’ is Central to the

review process• Review of public documentation of ‘performance’

and ‘expenditure’ • Public ‘data’ and ‘records’ are reviewed by

stakeholders/ non traditional auditors

A Working Definition

• It is the systematic gathering of information about the social impact of government/public programmes/ service delivery.

• The information is collected by the users or from the perspective of the user of services/ affected community.

• The information could relate to the population level situation, to the level of the delivery of services and to the experience of the intended beneficiary/user in receiving or not receiving the services

• The results are shared publicly to reinforce the rights/ entitlements of the users and the responsibilities and accountability of the providers

• Allows for the empowerment of users and the improvement in service delivery

Social Audit and Rights Based Approaches

Identifying Gaps

Identifying Stakeholders

2. Social Audit in Health

Conditions which facilitate• Guidelines for the provision of services• Documentation related to the provision of

services • People’s own experience indicates there is a

problem in service delivery and they are willing to provide testimonies during public sharing

• An audit team• An arbitration / hearing mechanism

Steps

• Identification of the problem in the public programme

• Gathering public documentation• Reviewing records for fulfillment of

obligations, transparency, accountability..• Correlating documented evidence with

people’s experience • Public sharing• Follow up advocacy

Documentation related to Health services

• Documents relating to services, standard operating procedures and quality protocols

• Documents relating to performance – HMIS/ service statistics, Outcome records, Health survey findings,

• Documents relating to treatment or provision of service / medical records – Out patient record, Prescriptions, In patient records, Bed-head tickets, Laboratory/ Investigation records, Informed Consent forms, Surgical notes, Discharge records. ( Caution : Ethical issues relating to use of medical records )

• Fact-finding in case of reported human rights violations

Verification of records

• Sample surveys to verify the accuracy of population based health statistics and HMIS/ service statistics

• Observation and review of records for compliance of quality standards

• Individual testimonies for verification of quality compliance (ethical issues)

• Fact finding documentation with back up medical records

Arbitration/ Hearing Team

• Public Health Experts

• Legal Experts

• Eminent citizens

• Government Functionaries

3. Social Auditing to Improve Family Planning Services

in Uttar Pradesh, India

A Case Study

Uttar Pradesh - An Introduction

Strong bastion of caste based politics

Most populous statein the country – 190 mil

Gangetic plain Rich agricultural land Politically

important but poor governance

State with poor socio-

demographic indicators

Feudal hangov

er

The Problem in Public Programming : Coercive Population Control Program

with Poor Quality of Care• Long history of coercive population control

programme in India• India adopts a Target Free Approach based on

Voluntary and Informed choice through in National Population Policy

• UP passes a population policy which includes Targets for different methods

• News papers report that a 13 year old girl has been forcibly ‘sterilised’ and reported as a 27 year old mother of three children in health facility records

Our Background

• Network Heathwatch Forum UP (HWFUP) comprising of public health experts, health activists, women’s rights activists

• HWFUP had earlier history of working on issues related to reproductive health and rights – engaged in post ICPD processes in India

• HWFUP was committed to securing reproductive rights for women

Role of Social Auditing in our

Advocacy Campaign

Building stakeholdership

Joint Policy Analysis and Opinion Poll .

Fact- finding /Documenting Case-studies

Secondary Data Analysis

Public Hearing

Study of 10 camps

Filing a case in Supreme Court

Sharing results with media

Centrality of EvidenceReview of Evidence

• Total no. of live birth -5million/yr• Target for sterilisation 600,000/yr and increasing

annually• Achievement – 3 -400,000/yr• Failed sterilisation/reconception – 5% or 12,000 -

15000/yr• Complication – upto 50% • Death from sterilisation – not counted but reported in

papers• Over-reporting on other methods – upto 20times ( CuT)• No of maternal deaths – 40,000 (approx)• Unsafe delivery 3- 4 million.

Sources of Information

• National Family Health Survey

• State Family Planning Service Statistics (HMIS)

• Studies conducted by state research organisations

• Hospital/ Sterilisation Camp records

• Verification – Fact finding Cases and Camps

Verifying Users Experiences : Documenting Case- Studies

Over 100 case-studies collected• Women who had died in childbirth after the

child was conceived after sterilisation• Women who had died during sterilisation

and the team had left the woman unattended and disappeared

• Women who had infections/complications which was not treated in the public sector and ended costing large sums of money

Verifying Compliance of Quality Standards

Ten Sterilisation Camps were studied using government mandated quality benchmarks

• Doctors were often not informed about quality parameters

• Doctors not following infection prevention procedures

• Doctors not following recommended surgical procedures

• Women not treated with dignity• Women not provided options for informed choice

Publicly Sharing the results

• Public hearing / Jan Sunwai – face to face sharing of affected people (testimonies) with a set of subject matter and human rights experts, media persons and government functionaries

• Sharing results with bureaucrats and programme managers

• Sharing results over the media – in our case we had a Parliamentary enquiry over poor quality of services

Conducting Social Audit

Preparations• Knowledge of

government policy/programme provisions

• Ability to conduct documentation / studies

• Strong alliance with Affected groups/Community

Helpful conditions• Need for service/ change

explicitly acknowledged• Availability of some

Standard operating procedures and quality parameters concerned with the service at hand

• Some relationship with provider which will enable them to participate in sharing processes

Primarily Conducted by facilitating organisation/s which possess skills documentation and advocacy

Results of our Campaign

• Supreme Court orders relating to compliance of quality standards and compensations applicable to the entire country

• Introduction of Family Planning Insurance Scheme for paying compensation to all cases of failure/re-conception, complications and deaths

• Setting up Quality Assurance committees at all districts in the country which now cover all aspects of health service delivery (NRHM)

• The benefits of these two mechanisms apply to over 5 million women undergoing sterilisation every year

4. Lessons and Challenges

• Our initial arguments on coercion using the ICPD PoA and the National Population Policy as benchmark was not successful in getting a response from the state family planning programme. However advocacy based on this benchmark was successful in stopping a proposed legislation “UP Population Control Act/Bill”

• There was lack of political will at the state level so most of our achievements were at the central level

• We had to sustain our advocacy beyond social audit and move to litigation

Challenges (contd.)

• When we found that coercion was not a very sustainable framework for argument we added the dimension of quality. We had ‘discovered’ quality parameters during our review of documentation.

• We face criticism from some quarters that the Supreme Court guidelines have reduced access to sterilisation services in places

• Population Control mindset continues be widespread with the Supreme Court upholding another population control law relating to 2 child norm in 2002. Among bureaucracy there is concern about inadequate practice of family planning and a temptation to re-introduce family planning targets.

Thank you

Acknowledgements : All members of Healthwatch Forum, Uttar Pradesh and members of SAHAYOG and CHSJ