Social Audit of Health Services

1. Social Audit of Health Services Improving Family Planning Services in UP, India 2001 - 2005 Abhijit Das Centre for Health and Social Justice, India

2. Introduction to Presentation • What is Social Audit • Applying Social Audit to Health related public programming • Example of applying social audit to a health issue in India • Challenges

3. 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

4. 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)

5. 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

6. 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

7. Social Audit and Rights Based Approaches Identifying Stakeholders Identifying Gaps

8. 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

9. 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

10. 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

11. 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

12. Arbitration/ Hearing Team • Public Health Experts • Legal Experts • Eminent citizens • Government Functionaries

13. 3. Social Auditing to Improve Family Planning Services in Uttar Pradesh, India A Case Study

14. Uttar Pradesh - An Introduction Strong bastion of caste based politics Most populous state in the country – 190 mil Gangetic plain Rich agricultural land Politically important but poor governance State with poor socio- demographic indicators Feudal hangover

15. 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

16. 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

17. Filing a case in Supreme Court Role of Social Auditing in our Advocacy Campaign Sharing results with media Study of 10 camps Public Hearing Fact- finding /Documenting Case-studies Secondary Data Analysis Joint Policy Analysis and Opinion Poll . Building stakeholdership

18. Centrality of Evidence Review 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.

19. 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

20. 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

21. 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

22. 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

23. 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 Conducting Social Audit Primarily Conducted by facilitating organisation/s which possess skills documentation and advocacy

24. 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

25. 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

26. 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.

27. Thank you Acknowledgements : All members of Healthwatch Forum, Uttar Pradesh and members of SAHAYOG and CHSJ