Exploring perceptions and functioning of Rogi Kalyan Samiti in selected districts of West Bengal: Emphasizing on Maternal and Child health services-Nupur Basu

1. 1
Exploring Perceptions and
Functioning of RKS in West Bengal
Emphasis on Maternal & Child Health
A Formative Research Study Initiative
Conducted by
CINI Regional Resource Center
Supported by
Ministry of Health and Family
Welfare, Government of India

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About CINI RRC
Child In Need Institute (CINI), a NGO with national level recognition
Prominent works in the domains of health, nutrition, education and
protection for more than three decades now
Guided by its mission – Sustainable development in health, nutrition,
education and protection of child, adolescent and woman in need
In 2002 CINI recognized as Regional Resource Center for West Bengal,
Jharkhand and A&N island by Ministry of Health and Family Welfare,
Government of India under the RCH-II project of NRHM
Key responsibilities : Capacity building and nurturing of MNGOs through
trainings, documentation and dissemination of best practices, networking
and advocacy – Overall, Strengthening RCH programme implementation
and promoting GO-NGO partnership
CINI RRC

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Background (1)
Health intricately linked with development
Developing countries still struggling with poor indicators,
particularly with respect to MCH & Nutrition
MCH - area of concern in India since independence
Need for improved health service delivery, community
ownership and decentralized processes of planning and action

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National Rural Health Mission (2005-2012) aims at addressing
these concerns so as to accelerate achievement of MCH targets

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Background (2)
Rogi Kalyan Samiti, a key initiative of NRHM in strengthening
health delivery systems
Originated as a committee of people’s representatives at a
hospital in Indore, Madhya Pradesh. Later incorporated in NRHM
RKS committed for the optimal utilization of services, rendering
transparency and accountability of the health service providers
to community
Rogi Kalyan Samiti in West Bengal constituted at PHCs (from mid
2006), BPHCs, sub divisional hospitals, and district hospitals. Also
in state medical colleges and state general hospitals
CINI RRC

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Background ( 3 )
Members drawn from health, administration, PRI, NGO and
IMA. Leading PRI representative as chairman and health
representative as convener and secretary
Funding source –
Annual Maintenance Grant
Untied fund
Proportion of user charges at specific levels (Not applicable at
BPHC & PHC level)
Self generated fund

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Need for the study
Certain facts emerged from the field visits, common opinion and
available reports
Extent of the association of the RKS Members (particularly from
non-health field) with the structure varies
Common apathy of community members towards utilizing public
health facility services
 Low awareness in community regarding the existence of RKS in
the facility service centers
Very few studies on RKS available
Need emerged to understand and explore possibilities in
popularizing MCH issues through RKS by collating first hand field
experiences

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Significance of the present study
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 The study is nearly an unprecedented attempt in the region to
instigate political will to act upon “less focused” component of
NRHM
Brings rural experiences for discussion
Can lend strong voice to urge for improvement of health
services and commensurate with the overwhelming endeavor of
bringing community closer to the institutional services
Substantiate evidences for making health system responsive to
community demands
Can enhance GO-NGO collaboration in health service delivery

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Study Objectives
4.Understand perceptions of constituent members about RKS
6.Analyse functioning of RKS with reference to maternal and
child health activities
8.Collate perceptions of users and local community members
about institutional health service
Community opinions collected to understand health seeking
practices, particularly MCH from facility centers
4. Identify the limiting factors in RKS
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Study Methodology (1)– area selection
•Cross-sectional explorative study done in three districts of the
state. Major focus on qualitative investigation
•District selection on the basis of Institutional delivery as it has some
linkage with the institutional set up where women and other users
go for services linked to MCH.
•Inst. Delivery in West Bengal 49.2 % (DLHS-III, 2007-08). This was the
cut-off point
•Districts divided into three groups as ‘better performing’, ‘average
performing’ and ‘under-performing’ in respect to its institutional
delivery. One district from each of the 3 categories were randomly
chosen.
•While Birbhum(52.8%) was chosen from the category of average
performing districts, Nadia(76%) and U.Dinajpur(39%) were chosen
from categories of ‘better performing’ and ‘under performing’
category respectively.
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Study Methodology (2)
3 blocks per district chosen through simple random method.
CMOHs helped in block identification
1 PHC under each selected BPHCs were selected. Transportation
feasibility was considered during PHC selection

 Primary data gathered through:
–Semi-structured interview with RKS members, as many as possible but
emphasis on key members
–FGD with community members
–Checklist for facility survey enquiring about IPD,OPD, Kitchen, toilets,
medical equipments/medicines and general logistics
–Analysis of the minutes of the RKS meetings and the financial
statement within a reference period of 6 months.
Field work conducted from March-early June 2008

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Study Points
Sample
Emphasis on
BPHC and
PHC levels.
Information
from District
hospitals was
collected for
cross
checking
DistrictBlock Primary
Health Centre
(1 lac approx.)
Primary
Health
Centre
(30000-25000
popl.)
Uttar
Dinajpur
Hemtabad Baharail
Goalpokher Goagaon
Islampur Sujali
Birbhum Muraroi 1 Chatra
Md Bazar Rampur
Nanoor Kirnahar
Nadia Krishnanagar 2 Nowapara
Tehatta Chotonolda
Nakashipara Dharamada
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Limitations

Availability of RKS members (various factors: PRI
elections, busy schedule, not available during study
period, outbreak of bird flu etc.)
Sample too small to represent the district situation–
this is more exploratory than a methodic investigation
Unavailability of documents at some places
Very short study period and remotely located study
point

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Obj 1: To understand awareness of RKS among its
members
Perception of Members
According to majority of the respondents importance of RKS are:
“platform for public-private partnership”
“leading to greater transparency in financial dealings”
“promoting convergence between health and PRI”, opportunity for
monitoring services “
Perceptions are large and distant without emphasizing RKS’ immediate role in
improving service delivery component
Only district level health personnels could refer explicitly to guidelines.
Many members not sure about their roles and responsibilities.
Comparatively, health personnel (MO,BMOH) and signatories (health and
PRI representative) have a idea on their role as signatory. BAM has better
idea of financial transactions
Overall, different representatives from the non-health sectors exhibited a
wide range of understanding and involvement with RKS
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Obj. 1: Contd..
Some members (IMA and NGO) feel they can’t
contribute as discussion are mostly on financial
matters

Members like Nurse and Laboratory technicians
highlighted constraints of health services, like
unavailability of medicines, equipments, staff
residential insecurity which could have been resolved
through the RKS
At the BPHC and PHC level none could assertively draw
linkage between RKS and improvement in maternal &
child health services
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Obj 2: Analysis of functioning of RKS with reference to
MCH activities
Functioning (Regularity of monthly meetings)
Regular meeting and more participation are important
It ensures frequent interaction of members as stage setting for joint
action
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DistrictLevel of
instn.
No. of
meetings
held
Comments
Uttar
Dinajpur
BPHC 9/12 Elected representatives remain
absent
BMOH engagements on emergency
duty
MO occupied with too many admin.
responsibilities
Panchayat Election
Outbreak of Bird flu
Meeting get merged with block
health samity meeting
Arrange meeting only when fund is
received
PHC 7/12
BirbhumBPHC 9/12
PHC 8/12
Nadia BPHC 10/12
PHC 13/12
Nadia exhibits
more number
of meetings
despite same
hardships
across the
state

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Functioning (Member Representation in meetings)
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5/103/97/9MLA
7/106/9-Swasthya Karma
dhakshya
6/107/96/9Sabhapati
6/108/99/9BDO/Jt. BDOAdministration
5/106/96/92
nd
MO
Dept. Representative
member
U DinajpurBirbhumNadia
Health BMOH 9/9 9/9 10/10
MO-PHC 7/7 8/8 13/13
ZP member repr.6/7 8/8 13/13
Pradhan 6/7 6/8 13/13
Civil SocietyIMA represen-
tative
- 0/9 1/10
NGO 11/16 3/17 14/23
• Attendance of BMOH
as convener at all levels
•Less participation of
members from non-
health sectors due to
their loose association
with health domain
•Representation of PRI
members more at PHC
than BPHC
•Very low participation of
civil society
representatives at all
levels

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Functioning (MCH as priority issue)
By and large, MCH issues and activities get less priority in meetings
and action (e.g fund expenditure)
Overall, MCH issues discussed ( in order of
frequency):
- JSY availability status
- Resolutions for Purchase of equipment and supplies
- Updating cases of Referral transport
- Sterilisation camps/services
- Repairing labour room and making renovations
Decision to spend funds on infrastructure expansion
& up gradation, making arrangements for electricity
and water, change of signatories and convey major
decisions etc. are gross agendas in meeting
Quality of services and care for the users are least
prioritised/highlighted in discussions.
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Most of the BPHC study points are equipped with General instruments like,
B.P machine, Weight machine, thermometer, stethoscope, autoclave etc.
Few points have child specific instruments like, Baby resuscitation kit, sucker
machine
However,
Though X-Ray and Ultra Sonography are present at BPHCs but rarely used
due to non-positioning of operators
Even in Rural Hospitals, beds number far below than sanctioned (30 as
against 50)
Most places solely relies on referral of sick new borns due to non availability
of neonatal health support system in contrast to the heavy demands from
the community
In some points there are sheer evidences of lacunae in logistic
arrangements (Bed sheets and pillows were missing
Absence of basic health facilities is a serious issue across the PHC
study points
In many places basic facilities like, electricity hampering cold chain and beds
were missing or unclean
Basic equipments like thermometer and first-aid is dysfunctional for long
Security of staff and the equipments were basic problems
Staff vacancy is a major issue like pharmacist
Rarely OPDs open on time and usually close early
Functioning of RKS in monitoring & responding to MCH
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RKS members can assume greater responsibility in monitoring,
identifying service gaps, reporting and taking action for
sustaining health service development
Quality of care and services is also needed
Some common issues at both levels where serious attention is
required:
Cleanliness, a serious gaps
No mechanism to get User Feedback
Subsequently, grievance redressal systems not functional fully
Poor Female privacy during checkup and treatments
Poor Bed facility, thereby seriously affecting post partum care
In most places even minor repair of essential equipments take long
time for decisions to come from higher authority
A regularized monitoring of health services by RKS is rarely practiced
Facility staff seldom takes initiative to report paucity of any
services/facilities
Functioning (RKS in monitoring and responding to MCH services

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Functioning (Financial management)
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 During the study period (2007-08) all the study points received
fund
 Nadia has evidences of generating fund through utilization of
institution’s resources
Also only study points in Nadia has evidences where PRI members
channelised their fund into health institution development at both
BPHC & PHCs.
 Aggregately study points utilized fund in MCH services, like
•One time purchasing and repairing of labour room and related materials
•Purchasing equipment (e.g, nebuliser, mucus suckers, baby resuscitation kit
and medicines etc.)
•Organising sterilisation camps
•Referral cases.
•Developing IECs for MCH
The expenditure amount however varied in a wide range

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Functioning (Financial Management)
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 More expense for construction, expansion and upgradation of
infrastructure
 In contrast low on quality of services like appointing a sweeper, waste
disposal, cleaning undergrowths, repairing ambulance shed, water purifier,
urinals, window panes of maternity wards etc.
Unspent amount a major area of concern
Financial guidelines not percolated beyond the district in many places
Most head of expenditure were non-recurring (like, renovations,
construction etc.)
Low practice of regularly stock checking the existing equipments. So
recurring costs are not frequently reflected
Absence of signatories, particularly PRI representative
Late arrival of fund
Planning for fund expenditure done after fund arrival and not beforehand
Importantly places where basic ammenities were absent like electricity and
security
Maintaining documents for Financial transactions need serious attention
 Financial dealings for many PHCs are done at the Block level, thereby
dampening the spirit of decentralisation
Overall, funds spent scantily benefit mothers and newborns

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Waste disposal point in a RH Wall writing and sound system in a BPHC
Provision for drinking water in a
BPHC
Visitors waiting place in a PHC
Some General Positive Initiatives for Health improvement

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Installation of Referral Map in a R.H
Well maintenance of a public notice
board at a PHC
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Some General Positive Initiatives for Health improvement
Involvement of NGO in premise beautification
of a BPHC
Display of medical services available
through tie-up with a private agency

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Wooden racks made to keep medicines
Privacy for female patients
Glimpses of promising initiatives towards MCH service
improvement
A sick new born care system and a newly renovated labor room

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Obj 3. Collate perceptions of users and others
about institutional health services
–Perception based on personal experiences
“We prefer going to the PHC as it always opens on time”- A common man
“ Medicines for my daughter-in-law were free [at BPHC]” – A mother-in-
law
o“ I do not go to PHC. They have no medicine except for minor ailments”- In
a general FGD
o“They [BPHC/PHCs] only refer us”- A woman
o“Woman do not wish to go to the BPHC if they are once turned out saying
their labor pain is false. It becomes difficult to motivate others- A
Community health worker
o“ Toilets unclean. Dirty stains on bed linens. I did not want to stay there
(BPHC)”- FGD with women
o“ Food is tasteless and insufficient ”- A male acquaintance of an admitted
pregnant woman
o“Saw rodents in my bed. Could have bitten my child in the cot at my
bedside”- An admitted women in the R.H
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Obj 3. (Contd..)
–Opinions formed through anecdotes
“Mothers and children alike die most in hospital due to infection ”-
In a FGD
“Medicines (given) there [PHC] for children are outdated”- FGD with
Mothers
RKS need to take appropriate action for addressing users’
grievance and enhance practice for seeking health care from
facility centers
RKS can assume role of facilitator between community & service
provider to disseminate “correct” information in the community
Has a greater role in creating community awareness and
knowledge
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Obj 4. To identify the limiting factors in RKS
Lack of adequate information about RKS functioning and
members’ roles among all the members
Often guidelines and related orders are not percolated beyond
BPHC
Lack of sufficient capacity to handle financial management and
related aspects by MO-PHC
Delay in fund transfer from higher level
Lack of supportive supervision and monitoring from district levels
Co-ordination issues particularly with NGO representatives and
also PRI & Health
All decisions taken by Block with less empowerment for PHCs
below
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“We are given so many different activities to perform. Representing at RKS
is one of them. If only we had an orientation in it our performance cvould
have been better”- A Panchayat Pradhan in a GP of Birbhum

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Dialogue for development- translating
evidences to policies
A systematic and mandatory orientation of RKS members about their roles
and scope of activity
Continuos capacity building support to health personnels on health
management in realistic term (like basic security to IPD patients, female
privacy)
Simillarly, sensitising PRI representatives on MCH issues in the area
Strengthening fund flows and related systems of monitoring
Reviewing guidelines in light of evolving experiences
Allowing NGOs and ASHAs to actively participate in RKS
Linking RKS meetings at PHC with 4
th
Saturday & other village level
meetings
Putting in place grievance redressal and feedback mechanism - helping
RKS to reach out to users and local communities
Strengthening Monitoring mechanism
Regularised monitoring from dist./Block higher level
Evaluate RKS performance in relation to the village micro plan (DHAP)
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CINI RRC acknowledges the cooperation extended CINI RRC acknowledges the cooperation extended
by the by the Ministry of Health & Family Welfare, Govt. of Ministry of Health & Family Welfare, Govt. of
India &India & Dept. of Health and Family Welfare, Govt. of Dept. of Health and Family Welfare, Govt. of
West BengalWest Bengal, district administration and PRI , district administration and PRI
representatives, all the respondents and various representatives, all the respondents and various
other individuals who made this study possibleother individuals who made this study possible
Thank you!Thank you!
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