• Dr H Sudarshan
• Prof Ranjit Roy Chaudhury – Chair
• Dr M Prakasamma
• Dr Abhay Shukla
• Dr Abhijit Das
• Dr Narendra Gupta
• Dr Shanti Ghosh
• Ms Indu Capoor
• Dr Sharad Iyengar
• Dr Alok Mukopadhyay
• Dr Vijay Aruldas
• Mr A R Nanda

Representatives from GOI

• Mr Amarjit Sinha, Joint Secretary, MoHFW
• Dr Tarun Seem, Dir NRHM, MoHFW
• Dr Hamid Khan, Consultant, NRHM, MoHFW

Other invitees

• Ms Seema Gupta
• Dr Ajay Khare
• Dr D N Sharma
• Dr Sudarsan Das
• Mr Kaushik Saikia
• Ms Sunita Singh
• Dr Ruth Vivek
• Dr Kumudha Aruldas
• Mr S Ramaseshan
• Dr Almas Ali
• Ms Sona Sharma
• Ms Sudipta Mukhopadhyay

AGCA Members who could not attend the meeting and given leave of absence

• Dr Dilip Mavalankar
• Sh. Gopi Gopalakrishnan
• Sh. Harsh Mander
• Ms Mirai Chatterjee
• Dr R S Arole
• Dr Thelma Narayan
• Dr Saraswati Swain

• The government values the partnership with NGOs over and above its regular channels.
• The government recognized that the process of community monitoring would require intensive handholding, which was therefore kick started through the current project funding mode through NGOs.
• The AGCA was one among many other fora within the government to advise on key aspects of NRHM. The reason why the meetings of the AGCA and the ASHA Mentoring Group were kept separate was to ensure that each played an important but independent and focused role within the overall plurality and diversity of NRHM. The government is keen to learn from the experience of the first phase of the community monitoring programme and is open to suggestions and comments from the public. That is why all materials are made available on the NRHM website.
• On the question of what happens to states which are not included in the current phase, Mr Sinha mentioned that Dr Seem recently shared the information of the first phase programme with all state mission directors. However realising that a mere discussion was not enough, GoI has asked state to set up grant in aid committees to take the process forward with facilitation by NGOs. For example the government was considering civil society involvement in rolling out the 5^th ASHA training module which is a self actualization, empowerment module that does not lend itself to the standard cascade approach of training. Mr Sinha requested all AGCA members to take up the 5^th ASHA module training in their states.
• Realising the role of NGOs the government was committed to greater NGO support. In this regard the government was in the process of revising the MNGO programme to facilitate greater involvement of NGOs in areas where they have expertise. GoI expects state governments to actively partner with NGOs in future.
• The concurrent evaluation of NRHM will be finalized for one third of all the districts in the country. The report will be available by September 2008. Also the DLHS – 3 report will be available by September 2008.

• VHSC formation & Orientation
  • Completed in 5 states
  • AWWs & ASHAs are acti
  • vely involved
  • VHSCs have gone into planning also but need hand-holding
  • Space for direct interaction between villagers and service providers and between health care providers and unions (e.g. TN)
  • Opportunity for involvement of dalit women, adolescent girls
  • Self-help groups are very helpful
  • Need to build in health workers perspective

• Role of PRI
  • At the village level the involvement is promising but at the higher level it is not good.
  • Recognition and involvement of PRI is important for effectiveness & sustainability of committees

• Relationship with Government
  • It has been proactive with participation in the workshops & trainings
  • Participation in mentoring group meetings is low
  • District governments apprehension in interference from block and district PRI members
• Innovations
  • Role play, PRA techniques, Pictorial tools & score card used in trainings
  • Training of VHSC members is being conducted in phases
  • Village health day used as a public platform to share results of survey
  • Media
  • States in the process of actively engaging with media & to identify Media fellows
  • State Media plan in the pipeline

• Recommendations for future TOR for AGCA
• Role of AGCA-TAG beyond CM program
• Discussion over Innovations & documentation
• Setting up resource centre for CM
• Review & finalisation of Manuals, Posters & brochures
• TOR for External Review of CM program
• Website & Database discussed

• Since the VHSCs have already developed the village profile, a plan should be developed for VHSCs to move towards community based planning.
• There was positive media engagement in the state especially the local press. Therefore a media toolkit may be developed.
• The fund utilisation was also good.

Rajasthan: Presentation made by Dr Narendra Gupta, representative Prayas, state nodal NGO of Rajasthan.

• The main issue in Rajasthan is that there is no village level health and sanitation committees are formed. As per the present decision of the state government, only Panchayat level health and sanitation committees are being  This would require a discussion with all state NGO partners and the government. A meeting with the government is scheduled for June. Mr. Amarjeet Sinha said that the GOI has sent full amount of Rs. 10,000/- per revenue village for forming VHSC and village health plans to Rajasthan and we are hoping that these will be formed.
• Dr Gupta also shared the newspaper reports related to the programme, a copy of which is attached in Annexure 2.
• The RKS will become the PHC level planning and monitoring committee.
• Four PHC level  Jan Samvads were already held in Chittor district.
• Letter head for VHSCs have been developed.
• A fixed day meeting date was being decided for meeting of VHSCs.
• Dr Sharad Iyengar added that the state had new Mission Director. The VHSC meetings were also not being held regularly. There was also a problem of capacity of the committees to undertake monitoring and planning. The committees were not ready. The issue of corruption in JSY is coming up in VHSCs.

Dr Hamid based on his field visit congratulated the NGOs doing good work under the programem in Rajasthan. He mentioned that both men and women were participating in VHSC meetings as was evident in Jodhpur. He suggested the IEC materials in Marwari or any other local dialect could be developed for greater familiarity and use among villagers.

Maharashtra: Dr Abhay Shukla mentioned the following:

• People’s organisation have played an important role in the programme in the state and
• Their involvement has been an innovative approach to implementing the programme and adding value beyond the regular framework (note on Thane process attached in Annexure 3).
• The state level convention held earlier by the Mission Director was innovative in ensuring and building ownership of the state and district government and developing district level plans.
• Innovative pictorial tools were also developed like the village health calendar and the report card.
• There was good media coverage in the state (copy attached in Annexure 2).
• Community monitoring has been included in the state PIP although the budget is yet to be allocated.
• The main challenge is delay in issue of GR for formation of PHC and CHC level committee formation. A letter from GoI in this regard will be useful.

Maharashtra will share the case study protocol with other states.

Madhya Pradesh: Dr Abhay Shukla and Dr Ajay Khare presented the highlights of the programme.

• Note on process of involvement of community in Bardwani district was circulated where community is already monitoring the PHC and CHC in Pati block of Bardwani district. This has led to non literate adivasis going to the CHC and PHC for health services.
• Private doctors are also monitored in the process.
• All VHSCs have been formed.
• In 14 villages data gathering has started.
• There was over reporting of institutional delivery in JSY whereas facility survey reveals under utilized facilities.
• Man power shortage acute in MP. Most PHC’s do not have doctors.
• I-cards will be issued to VHSC members.
• Script writing workshop was held as part of media involvement.
• There is lack of response from the state government in including community monitoring in state PIP. GoI facilitation required for interaction with state government and including community monitoring in the state PIP.

Dr Sharad Iyengar, Dr Shanti Ghosh and Dr Prakasamma reflected that there was need for further probing into reuse of syringes, doctor client confidentiality issues and privacy although experience from Andhra Pradesh reflects that women prefer someone to accompany them during delivery.

Dr Tarun Seem mentioned the following:

• There was lot of innovation in the state.
• Committees are yet to be oriented after GR is issued.
• The pictorial report card was good and should be shared with the state government.
• All pictorial tools of the state should be translated into English and shared with other states.
• GoI has been regularly requesting the states to facilitate the community monitoring activities in phase 1 states. The need for proactive participation by the State Mission shall be reiterated.

Chhattisgarh: Dr D N Sharma representative of state nodal NGO in the state presented the progress.

• A workshop for District Managers was organized on January 20-21, 2008. A total of 32 participants including civil society members of State CBM mentoring group participated.
• District level orientation workshop was organized in the following districts:
  • Kawardha (Kabeerdham) on January 27, 2008
  • Koriya (Vaikunthpur) on March 12, 2008
  • Bastar (Jagdalpur) on March 17, 2008
• Government of Chhattisgarh, Department of Health and Family Welfare has proposed three districts (in addition to pilot districts) in its Project Implementation Plan (PIP) for the year 2008-09.
• Published a set each of guidelines (2), folders (3) and posters (2).
• District-wise activity plan for the period from May 2008 to August 2008 has been prepared.
• Till June 15, 2008, 135 VHSCs and 27 PHC Monitoring Committee and six out of nine block monitoring committees have been formed.
• First meeting was conducted with the following till June 15, 2008 –
  • VHSCs (135/102)
  • PHC Monitoring Committee (27/11)
  • Block monitoring committees (09/2)
  • ToT (03/0)

• District nodal agencies were identified in January 2008
• State level workshop was organized in February 2008
• State level training (ToT) was organized in March 2008
• District level workshops and selection of block NGOs were done in May 2008
• Training of block facilitators was organized in June 2008
• The state does not have VHSC. The existing Village Health Committees (VHC) have been formed by the government through NGOs, mobilized through Kalajathas and strengthened by opening bank account and negotiated for Rs 1000 as grant.
• Sub-centre level clusters are formed (5 pilot village per cluster – PHC only at block level)
• Village Health Register prepared and introduced in VHCs
• Government is supportive at all levels
• PRI does not exist in Jharkhand. PRI members in various committees has to be worked out.
• District mentoring groups are playing proactive role beyond community monitoring
• State mentoring group playing important role in JSY implementation
• Time line of activities has been prepared for June to August 2008. District working group meeting, identification of media fellow, formation of sub-centre and block planning and monitoring committee, state media workshop, gram swastha samvad and VHC orientation, block provider orientation will be held in June 2008.

• Dr Tarun Seem responded by stating that the state government needs assistance in implementing this programme. The AGCA and TAG needs to articulate how this technical assistance can be provided.
• Dr Alok Mukhopadhyay mentioned that the state needs technical assistance in macro planning efforts.
• Other members also felt that the state would require more time to implement this programme. A revised workplan needs to be developed in view of district wise and block wise progress.
• Outcome indictor needs to be re-check and revised for the entire programme.

Karnataka: Dr H Sudarshan state nodal NGO representative presented the status of the programme.

• Karnataka would require more time to implement the programme.
• The block and district level NGOs have been selected.
• State level ToT will be held soon.

• Follow-up visits to every state
• Strengthen the documentation systems
• Assist in process documentation in all states
• Facilitate technical support for states where progress is slower
• Evaluate and finalise inputs – manuals, kits, brochures and posters
• Set up the evaluation process

Consolidating in the states where Community Monitoring was initiated this year

• Including in the state PIP is not adequate to nurture and scale up the process
• There must be a recommendation from AGCA for state level continued support for CM process where it has not been explicitly mentioned in PIP
• Some state’s need to develop greater clarity about the purpose and modality of CM
• Introduce community planning and action – to be funded from the centre
• National/State Support Team – to continue to providing support; where financial support has not come from the state PIP the Central government to be requested to provide financial support

Initiating Community Monitoring in new States

• Sharing of the process has to happen with State Mission directors – when the first round of report cards are ready
• State level resource groups with Civil Society participation essential to initiate and nuture the process

• Separate evaluation team for each state – briefed at a common workshop for finalising common methodology
• Participatory – Each state evaluation team to include three people – One member of State CMMGroup, one member from CMMGroup of a second team and an external resource person. One member could also be a AGCA member
• The evaluation should be a learning process and include documentation of innovations as case-studies / lessons
• There should also be standard guidelines for the evaluation process – allowing comparison across states
• We should invite NSHRC/PHFI to be part of the evaluation process so that there is mainstreaming of the learning into other mechanisms set up for strengthening the health systems

Elements for review- operational

• Entitlement Awareness / Empowerment at the community level ( esp. VHSC)
• Involvement of PRIs
• Coordination between : Block providers – Community (VHSC) – NGO/CBO – Health administration ( CMO) and PRI.
• Government Ownership – Influence on the government agenda/policies ; Orientation and involvement of government personnel
• Improvement in services – accountability mechanism – equitable access ( look at issues of gender, caste, ethnicity, religion, migrant/displaced population)
• Skills and Capacity building among facilitating organizations
• Materials and their adaptations – distribution, and community perception

Elements for review – coordination/ administrative support

• Financial mechanisms and reporting and actual fund flows, fund management, expenditure
• Transparency – selection of partners, financial transparency
• Role of Union and State Health Ministry
• Role of the AGCA, TAG, National Secretariat and State Nodal Agencies
• Partnership between GO and Voluntary Sector

Evaluation : Process

• Start the evaluation in a phased manner – five states first – Maharashtra, MP, Rajasthan, Orissa and TN in September
• Identify/form state level evaluation teams from a pool of resource persons
• Prepare – finalise terms of reference
• Evaluation to follow completion of process documentation
• Common methodology finalising workshop to be organised with all the state level teams
• State teams to conduct community level visits to interact with informants on a sample basis and also purposively to assess innovations/good practices

Evaluation: Issues for consideration

• Volunteers from AGCA members to participate in the evaluation process
• Volunteers for finalising Evaluation TOR
• Recommending and following up with potential resource persons – external members of the state evaluation teams
• Should we limit evaluation to the 5 states
• Current budget for evaluation – Rs. 60,000/state will be inadequate ( travel costs + resource persons honorarium)

• Instead of an evaluation, a review of the programme should be undertaken which should reflect the government, community, NGO expectation. The review should focus on the good states and positive outcomes for highlighting the learning’s for other states to replicate.
• Next phase should focus on synergy with other efforts under NRHM such as ASHA mentoring and social determinants of health.
• There needs to be good process documentation including measurable indicators and audio visual documentation.
• Ensure dissemination of learning’s and interchange of ideas at different fora.
• Develop framework to suggest institutionalisation of community action.

• Membership is entire civil society
• All members have a base in community based activity
• Rich fund of experience in designing and managing and conducting experiments on community action
• Large number of members have public health expertise

• Provide inputs ( advice, models, feedback) on
• –increased access and utilization of quality health services by all.
• –Involvement of PRI and community in the management of primary health programmes and infrastructure. •
• –Promotion of equity and social justice.
• –promote local initiatives.
• –inter-sectoral convergence for promotive and preventive health care.
• AGCA roles and agenda should evolve with the progress of NRHM – preparatory input, new models, feedback, evaluation
• AGCA should strengthen the culture of evidence based policy making – especially in the context of community level action and experiences
• AGCA should also strengthen inputs on other aspects of community action eg. decentralised planning through the mechanism– concept note – experiment- recommendation
• AGCA should work as a feedback system
• AGCA should be able to commission studies cutting across different states
• There must a system of interface with NHSRC – Seen as a demand side – supply side interface
• The current CM project may require a separate resource centre – delinked from AGCA
• AGCA should continue to have a TAG and resource centre of to support its action

Agenda of AGCA

• Look at convergence issues
• Look at the functioning of the systems
• Look at integration of ‘Determinants of Health’ into NRHM
• Assess functioning Rogi Kalyan Samiti – functioning; links with community etc.
• Status of Concrete Service Guarantees – review progress and status of guarantee and facilities compliance to IPHS etc.
• Review Mid-term indicators – request GoI to revise them if necessary
• Include inputs for setting up new /improving systems – eg. decentralised / community planning

Members to set Agenda

• Members to collectively identify new agenda of concern at next AGCA meeting
• Members should be encouraged to set agenda for discussion – circulate write up on the issue for discussion/consultation
• Advisory agenda should be wide ranging
• Action agenda should be limited

Mechanisms to Support AGCA Functioning

• Continue with TAG – expand in view of other roles
• Expand National Secretariat to Resource Centre
• Regular interface with NSHRC
• Resource Centre should engage in evidence building for the AGCA discussion/consideration
• Resource Centre should conduct experiments and documentation for AGCA discussion/ consideration
• Continue with the autonomous website
• AGCA should be upwardly linked to the Mission Steering Group – common member participation should be specially ensured – coopt other MSG members as special invitees
• Community Monitoring may not excite all members of AGCA. We need to introduce other agenda which will enable other AGCA members to be involved. We should dedicate time in the next AGCA to set out an agenda of issues for engagement – build body of knowledge, enriched discussion.
• To advise on community action we will need to set the agenda – concept note – experiment
• We also need a TAG and Resource Centre to support initiatives in community action- invite for TAG as well

• Interface with RRC.
• Integration in NRHM both at central and state government level.
• AGCA should be independent. TAG should be an expanded group to be part of the resource centre as might be suitable.
• Current AGCA agenda is wide, AGCA should have community based agenda with focus on denials, violations, positive aspects etc.
• Exclusive civil society review of NRHM.
• AGCA agenda should include presentation on overall status of NRHM.
• Retain current AGCA ToR.

• Dai is still undertaking delivery at the institution.
• Dai is the bridge or intermediary between the woman and the service provider and provides valuable psychosocial support..
• If Dai is well trained and supervised she can play a key role. There are many examples and community based evidences where trained Dais’ have helped reduce infant mortality.
• In the consultation there was no dichotomy on home vs institutional delivery. The focus was on her role in taking care of the women’s health as evident from various studies from Nepal, Pakistan and Gujarat.
• Dai can be the birth companion and should be included in JSY.