Population Foundation of India, March 14, 2008
Advisory Group Members Present
- Dr Shanti Ghosh
- Prof Ranjit Roy Chaudhury
- Dr Abhay Shukla
- Dr Narendra Gupta
- Dr Abhijit Das
- Dr Thelma Narayan
- Dr H Sudarshan
- Dr Sharad Iyengar
- Ms Indu Capoor
- Dr M Prakasamma
- Dr Saraswati Swain
- Dr Alok Mukhopadhyay
Ministry of Health and Family Welfare
- Mr G C Chaturvedi, Mission Director, NRHM, MoHFW
- Dr Tarun Seem, Director, NRHM, MoHFW
- Dr Hamid Khan, Consultant, NRHM, MoHFW
Others in Attendance (invited)
- Mr S Ramaseshan, PFI
- Dr Almas Ali
- Ms Sudipta Mukhopadhyay, PFI
- Dr Ruth Vivek
- Ms Sunita Singh
AGCA Members who could not attend the meeting and given leave of absence:
- Dr Vijay Aruldas
- Dr R S Arole
- Dr Rani Bang
- Ms Mirai Chatterjee
- Dr Dilip Mavlankar
- Mr Harsh Mander
- Mr A R Nanda
Prof Ranjit Roy Chaudhury welcomed all participants including the new AGCA members. The two of the new members, Mr Gopi Gopalakrishnan and Dr Prakasamma introduced themselves. The chair also welcomed Dr Hamid Khan, Consultant, NRHM, MoHFW.
Agenda 1: Action Taken and Confirmation on the minutes of the 9th meeting
Following are the action taken from the last meeting:
- PFI had submitted the expense statement to MoHFW in January 2008
- Ms Mirai Chatterjee had circulated a concept note on Inclusion of Dais (TBAs) in NRHM to AGCA members
- Renamed the current activity as ‘Community action and monitoring for NRHM’ and TAG on Community Monitoring as ‘TAG on Community Action’
- CD containing the IEC material was sent to the Ministry for uploading in the NRHM website
- Request has been sent to the states for regional language IEC materials for uploading in the website.
All members confirmed the last minutes.
Agenda 2: Activities Relating to First Phase of Community Monitoring
Dr Ruth Vivek and Ms Sunita Singh made a presentation giving the overall state-wise updates of the community monitoring programme and the status report of the National Secretariat, which is attached as ‘Annexure A’.
Responding to the release of the balance installment from the Ministry, Dr Tarun Seem mentioned that the Ministry was in the process of approving the budget of then entire programme and release of the next installment of 3.15 crores at the earliest.
The AGCA members mentioned that only 15% of total allocations for NGOs under NRHM have been released. They recommended that the Ministry should increase the resources to NGOs.
State-wise sharing of Innovations:
Dr Abhay Shukla presented that the community monitoring programme is being implemented in a mission mode with active involvement of people’s organizations in the state. It is not only based on formal tools but documenting of adverse results, misutilization of untied funds. A collective dialogue was organized in Nandurbar district by the block nodal NGO on the issue of an extraordinarily high quotation being approved for civil work in a PHC, following which approval for the quotation was scrapped. In Pune district, the organisation involved in monitoring at block level raised the issue of the purchase of dubious homeopathic medicine to reduce malnutrition, which was being paid out of VHC untied funds in several villages. This was communicated by the block and state nodal NGO to various officials including the Mission Director, following which such purchase has been stopped. A public report card in the form of a poster, which would be marked and publicly displayed in the village has been developed and is being printed for use by the Village Health Committees. A state convention on community monitoring was organised by the State Health Mission in Mumbai on 12th March 2008, which was attended by the Secretary, Family Welfare, State Mission Director, state, district, taluka and PHC health officials along with NGO / CBO representatives from the five first phase districts. The objective of this convention has been to promote positive interaction between government and civil society, to send a strong positive message to undertake monitoring at all levels and to jointly plan the next phase of community monitoring activities. Particularly monitoring and dialogue should become a regular feature at the village level.
Currently there is a delay in government order for formation of PHC, block and district level committees.
Another important progress has been a draft concept note on community monitoring submitted by SATHI CEHAT for the state PIP. A proposal is to generalize the programme in 12 districts of Maharashtra.
The members appreciated the efforts in the state and mentioned that the many of the key highlights could be models for other states to follow. Dr Tarun Seem pointed out that the state nodal NGO should handhold the process of creation of the community monitoring committees which should undertake the social audit dialogues. The process of setting up the committees at various levels may need to be accelerated.
Mr Sudarsan Das mentioned that the programme has already generated discussion on community action. Overall, there has been excellent support from the state government. However, there still exists administrative bottleneck such as mandatory registration of all VHSCs, which is delaying the process at the grassroots level. He also shared that all 180 VHSCs have been formed in the state and are currently undergoing the process of registration. The transparent and well documented process of block level NGO selection adopted by KCSD has been accepted by the government. It is hoped that the block and PHC level planning and monitoring committees will be formed by April 2008.
Dr Tarun Seem impressed upon the group that the current quarter should focus on the process of initiating the formation of the various structures for monitoring and planning at the state, district, block and PHC levels. It was mentioned by Dr Tarun Seem that GoI has already clarified that VHSC are not expected to be registered societies as per the guidelines.
Dr Abhay Shukla presenting on behalf of the state nodal NGO, MPVS shared that in Madhya Pradesh the training of block facilitators has been completed. The VHSC formation has also been completed in the state. Currently the process of orientation of VHSC members has begun. An important highlight is that in many places ASHAs are actively involved, including as block facilitators, for community monitoring. A Jan Sunwai was also organized on a voluntary basis by a people’s organisation involved in monitoring in Khetia PHC in Badwani district, where the issue of illegal charging for basic health services was raised. Ms Indu Capoor mentioned that the state also has media sharing and public involvement in the process. She suggested that such type of news could be put on the website of NRHM.
Dr Abhijit Das said that state nodal agencies should keep update National Secretariat about the activities that they are carrying out; use AGCA group to rotate the information.
The members suggested that the voluntary processes such as Jan Sunwais undertaking independently by the state nodal NGO should not be mixed with that proposed under the programme. Emphasis should be provided for formation of the various structures and the role that the committees can play in the various processes on monitoring including Jan Sunwais.
Dr Thelma Narayan mentioned that all the preparatory activities have been completed at district level. The state nodal NGO initiated dialogue and discussion at various levels to create a space to build bridges between community and the government through this programmme. This is because the TN government often doesn’t allow the participation of civil society in the process. The formation of the VHSCs and the various committees is due in the state.
Dr Thelma also mentioned that the community monitoring programme in Tamil Nadu should also undertake advocacy of various state level policy decisions such as replacing of Vans with Gems, monitoring of state level policy on human resources for health etc. Various block level meetings with Pries are being organized to build awareness on NRHM and hold Pries accountable. She said that there have been meetings with PRI, the meetings highlighted the lack of awareness among PRI members on NRHM field level health functions. She said that there is lack of budget to train PRI members thus she urged that the GOI should take note of this issue and discuss it at the centre.
Dr Narendra Gupta mentioned that all VHSCs have been formed in the state. Number of issues have emerged during the course of formation of VHSCs. Govt. of Rajasthan is required to be requested that VHSCs are formed at village levels because one of the main task of the VHSC is to develop health plans. Secondly, the issue of recognition and their linking up with gram/ward sabhas is equally important. Dr Narendra Gupta shared about the demand of DA by the medical officers and other providers while attending the PHC level committee members training. The dilemma was that if service providers are paid DA then what happens to representatives of community? He sought opinion and experience of other implementing organizations. Members suggested that the budget provision for orientation of PHC committee should be referred for this.
Dr H Sudarshan mentioned that the government order for the programme has been issued by the state NRHM directorate. Four districts have been selected in the state. However, there was need for clarity on the issue of ASHA selecting VHSCs. He shared that the Health department had agreed to budget for capacity building of VHSCs in the state PIP. The VHSCs in Karnataka is part of the PRI Act (as statutory bodies). He mentioned that instead of creating parallel group at the PHC level, it is the RKS which will undertake monitoring activity. He said that every village that falls under each PHC would be covered and formation of VHSC would be done. First two to three days capacity building of the VHSC members would be done.
Dr Alok Mukhopadhyay shared the report of the Independent Commission. The report mentions the following:
- Lack of community ownership
- Fatigue of too many committees
- Lack of clarity on Panchayat participation
- Emergence of new forms of corruption
- Non-utilization of funds
He highlighted the need for a meeting/separate forum to discuss convergence of various sectors, role of civil society in strengthening the public health system especially in the poor performing districts. Dr Sudarshan responded that the discussion on convergence should be held at the level of the NRHM mission steering committee. He mentioned that the TOR for the AGCA should be revisited and revised. Dr Prakasamma supported this idea.
Agenda Item: Community Action
Dr Abhijit Das identified four areas for community action. (i) oversight at the state and national level (ii) interactions with the state mission director, (iii) strengthening of panchayats, and (iv) district level capacity building. Dr Das mentioned that this could be done with suggestions from NHSRC and also creating independent resource centre on community action. The members recommended the review of all reports of NRHM at the national level by the AGCA.
Dr Tarun Seem suggested the following:
- Nodal person for interface between MOHFW and national Secretariat – it was decided that Ms Sudipta will be the interface.
- PFI to conduct an in-house financial audit of the prorgamme.
- The national secretariat to facilitate greater discussion on the progress of the programme in the EAG states. The secretariat should also provide greater facilitation and support for the programme in the EAG states.
- National convention to be held for sharing the experience of the programme with state Mission directors and civil society representatives from the 9 states. It was discussed that this should be organized at the earliest to facilitate further state level processes. MoHFW to propose the dates for the meeting.
- Set of IEC materials may be displayed in PFI
- All IEC materials to be sent to AGCA members. A print-ready copy of all IEC materials to be sent to the IEC division. MoHFW.
Dr Seem also mentioned that the community monitoring in the first phase is to implement the process and not only demonstrate. This phase should provide guidelines for issuing of GOs, process of identification of stakeholders, development of report cards, development of tools and standards.
The members also discussed the other items in the agenda which were raised such as (i) plan for IEC/BCC dissemination, (ii) community radios for health, (iii) CSO based health test to assess in referral by PHC to tertiary hospitals, (iv) platform for involvement of un/semi qualified practitioners in health care delivery, and (v) integration with CSOs working on education, gender, water and other issues. It was agreed that in order to provide inputs in a range of issues there needs to be a role clarification for the AGCA. It was decided that a two day meeting of the TAG will be held to (a) planning for community action (b) review the role/ToR of AGCA. National secretariat to circulate the date of TAG meeting. The proposed venue is either Mumbai or Pune. Dr Sudarshan suggested that a separate meeting to discuss budget and what could be done beyond community action could be called.
Post Lunch Session
Dr H Sudarshan chaired the post lunch session. Dr Saraswati Swain mentioned that the revised name of the programme should be circulated to all the states.
Ms Indu Capoor shared the note on the dai training. She mentioned that the workshop is to be held don 8-9 April 2008. There was a request for the AGCA to co-host the meeting as part of the organizing committee. She emphasized that the dai was an important link between the community and institutional delivery. After discussion the members differed on the role of the AGCA in co-hosting such activities. Some shared that co-hosting does not mean endorsing the issue but examining the issue. The recommendation from this meeting should be tabled at the AGCA for endorsement. Dr sharad iyengar and Dr Prakasamma disagreed and mentioned that such co-hosting is not part of the role of AGCA. Others agreed that the AGCA could co-host the meeting and joint invitation could be sent out.
Expansion of programme on community action into other states
The discussion focused on the following:
- Role of state mentoring group – members differed in their views on the role stating that the group could become part of the state planning and monitoring committee, or the existing State mentoring committee could continue as a separate body.
- Role of state nodal NGO – would become a technical support agency providing inputs to the state mission.
- Need for mapping of capacity of NGOs in the nine states and other proposed states.
- Involvement of MNGOs in the process.
AGCA members recommended that letters should be sent to the states regarding expansion of the programme statewide.
Role of AGCA in ASHA mentoring group
The suggestion that AGCA members should give inputs to the State ASHA mentoring committees in various states was reiterated. It was suggested that based on existing responsibility of individual AGCA members for community monitoring in specific states, these members could also be involved in the ASHA mentoring committees in the same states. A list with names of AGCA members to be involved in respective states may be sent by the AGCA national secretariat to MoHFW, following which the Ministry could circulate a letter to State Health departments / Health Missions recommending inclusion of AGCA members in their respective ASHA mentoring committees.
AGCA authorized Dr Abhijit Das to make presentation for the EPC meeting
Interaction with Mission Director
Dr Abhijit Das made a presentation on the overall structure, process and implementation process of the programme on Community Monitoring of Health Services under NRHM. He also highlighted the positive processes as reported from the various state reports including inclusion of the process of community monitoring as part of state PIPs. The Mission Director mentioned that the Mission is in full swing and currently in the middle phase of implementation. He raised the concern for the need for machinery to get physical, financial progress on time and develop audit mechanisms. He shared that community monitoring is being branded as a unique feature of NRHM. He appreciated the exhaustive processes being adopted in the first phase of the programme, but expressed the need to focus on empowering people rather than emphasizing on reporting. He hoped that the process would initiate enquiry and sensitize the community to ask questions and how to demand within limited resources, introduce quality checks for each state and institutionalize the proposed structures of community monitoring and planning.
Mr Ramaseshan, Secretary and Treasurer, PFI chaired the session on interactions.
Members responded by sharing that the state nodal NGOs were trying to implement the programme in a campaign mode in the villages. They suggested that there is need to undertake the following:
- The mass media should carry media spots advertising that basic / guaranteed health services were free.
- User fees continue to form a barrier in accessing health services for the poor who do not have BPL cards, hence user fees should be largely eliminated or made nominal
- Provide clarity on the notion that NRHM is promoting privatization in an already highly privatized system
- Identify processes to address non-health sector determinants, corruption
- Emphasizing post natal care
The Mission Director mentioned that the government wants to encourage private sector participation but ensuring that the poor does not pay. The urban health mission will focus on private sector pilots such as in managing health centres. The decision on user fee varies from state to state and as an issue where the centre cannot be prescript. He agreed that the human resource shortage is critical particularly in the high focused states. Therefore, emphasis is being given on locating specialists at PHCs and CHCs.
The meeting concluded with a vote of thanks by Mr Ramaseshan.
11th AGCA Meeting on June 13, 2008
- The current quarter should focus on the process of initiating the formation of the various structures for monitoring and planning at the state, district, block and PHC levels.
- PFI to conduct an in-house financial audit of the community monitoring programme.
- The state nodal NGO at Orissa may discuss the matter of registration of VHSCs with the Mission Director as the GoI has already clarified that registration is not necessary.
- The role of the AGCA should be discussed and TOR for the AGCA should be revisited.
- Review of all reports of NRHM at the national level by the AGCA.
- MoHFW to propose the dates for the national convention (comprising of Phase 1 states, Mission Directors and NGOs).
- National secretariat to circulate the date for meeting of TAG on community action
- The revised name of the programme should be circulated to all the states.