Population Foundation of India, April 08, 2013
Advisory Group Members present
- Dr Abhay Shukla
- Dr Abhijit Das
- Mr A R Nanda
- Dr H Sudarshan
- Dr Narendra Gupta
- Prof Ranjit Roy Chaudhury
- Dr Thelma Narayan
- Dr Vijay Arul Das
- Ms Poonam Muttreja
Representative from GOI
- Ms Limatula Yaden, Director-NRHM, MoHFW
- Dr Rajani Ved, Advisor, Community Processes, NHSRC
- Dr Renu Khanna, SAHAJ
- Mr Alok Vajpeyi
- Ms Sona Sharma
- Mr Bijit Roy
AGCA Members who could not attend the meeting and were given leave of absence
- Dr Alok Mukhopadhyay
- Dr Dileep Mavalankar
- Mr Gopi Gopalakrishnan
- Ms Indu Capoor
- Ms Mirai Chatterjee
- Dr M Prakasamma
- Dr Sharad Iyengar
- Dr Shanti Ghosh
- Dr Saraswati Swain
Ms Poonam Muttreja welcomed all the participants to the twenty fifth meeting of the AGCA. She requested Prof Ranjit Roy Chaudhury to chair the meeting. Prof Chaudhury mentioned that the national drug regulatory policy is being revamped. Scientific rationale will form the basis of all future decisions. The draft policy has been uploaded on the website for comments and inputs. He requested AGCA to send their inputs on the draft policy and mentioned that a separate meeting could be organized to discuss this further.
Ms Muttreja shared that Mr Manoj Jhalani (Joint Secretary -Policy, MoHFW) had conveyed his inability to participate in the AGCA meeting due to the National Program Coordination Committee (NPCC) meeting. Ms Limatula Yaden (Director- NRHM, MoHFW) will represent the Ministry, in the post lunch session.
Ms Muttreja provided an update on the AGCA proposal on ‘Strengthening Community Action under NRHM’ submitted to the MoHFW. Mr PK Pradhan (Secretary, Health and Family Welfare, MoHFW) and Ms Anuradha Gupta (Additional Secretary and Mission Director- NRHM, MoHFW) had been requested to expedite the process, after which inputs on the proposal were sought from the National Health Systems Resource Centre (NHSRC). Subsequently the Secretariat had received feedback from the Ministry and a response to the same has already been sent in March, 2013.
In addition, Ms Muttreja mentioned that Ms Gupta has offered to follow up with State NRHM Mission Director’s, who had not included Community Based Monitoring and Planning (CBMP) in their State Programme Implementation Plans (PIP). Ms Gupta has also suggested organizing the next AGCA meeting at the Ministry.
Confirmation and Action Taken on the Minutes of the 24th AGCA (May, 2012) and AGCA Planning Meeting (August, 2013)
The members confirmed the minutes of 24th AGCA Meeting held on May 28, 2012 and the AGCA Planning Meeting held on August 1-2, 2012.
Action Taken -24th AGCA Meeting (May 28, 2012) and AGCA Planning Meeting (August 1-2, 2012)
|Sl. No.||Actionable Points||Action Taken|
|1.||Develop a terms of reference and seek approval from the Ministry to utilize the unspent balance from the pilot phase, for start-up activities.||Proposal and budget on ‘Strengthening Community Action under NRHM’ developed and submitted to the Ministry for approval in November, 2012. Feedback received from the Ministry in February, 2013 and revised proposal submitted in March, 2013|
|2.||Facilitate a meeting of State Government NRHM officials to build their perspectives on operationalizing community action||Presentation on ‘ Community Action’ made by the AGCA, during the meeting of State Health Secretaries and Mission Director’s in September, 2012.|
|3.||Develop a road map to strengthen institutional capacity within the State Governments on community action and assist them in implementation.||The road map has been included in the proposal submitted to the Ministry.
In addition, on request from the Secretariat, the Mission Director-NRHM, has written to the State Health Secretaries/ Mission Directors to include CBMP as an integral component of their State PIP, in the next FY 2013-14 and to seek support from AGCA Members in designing the roll out plans. Based on this, many State Governments requested support from AGCA Members/ Secretariat.
AGCA has provided technical support to the following states in developing the CBMP component in the state PIPs: Jammu & Kashmir, Gujarat, Uttar Pradesh, Assam, Rajasthan, Madhya Pradesh, along with existing states like Maharashtra, Tamil Nadu and Bihar (nine states).
|4.||Development of training curricula, operational guidelines, modules and materials for VHSC and RKS
|The national VHSNC guidelines are being developed by NHSRC. The Secretariat, along with Dr Rakhal Gaitonde (SOCHARA), Ms Pallavi Patel (CHETNA), participated in the initial meeting to develop VHSNC guidelines in January 2013.
In addition, the AGCA has shared a note with the Ministry on ‘Strengthening VHSNC through active engagement with Panchayati Raj Institutions (PRI) ‘ in April, 2013
|5.||Capacity building of professional managers and providers on accountability and transparency, quality, equity, integrity at the block, district and state level.
|The Ministry invited the Secretariat to orient MoHFW Nodal Officers/ Consultants (facilitating development of State NRHM Project Implementation Plans -PIP), on the CBMP process, in November, 2012. A work plan and budget template was also shared to guide development of the CBMP component.
In addition, the Secretariat facilitated a workshop on CBMP in Uttarakhand in March, 2012. The workshop was organized by Voluntary Health Association of India (VHAI)
|6.||Support the development of an effective complaints/ grievance collection and redressal mechanism which enables active community engagement.||Action points 6 to 8 have been included in the AGCA proposal submitted to the Ministry|
|7.||Identify potential institutions/ organizations at the state level, including Regional Resource Centers (RRC) and build their capacities to take forward community action.|
|8.||Support the development of an Advisory Group on Community Action at the State level|
The following points were shared by the AGCA members:
- Support was also provided to the State Government in Sikkim in developing the CBMP component of their State PIP, in addition to the nine states mentioned above.
- In the 12th Five Year Plan period, AGCA as a group, needs to widen their scope and concentrate more on community action for health, not just limiting itself to community monitoring.
- Participatory training methodologies and processes on Community Action in Health (CAH) needs to be developed, especially for training of VHSNC members, health provider and managers.
- AGCA needs to capture both the positive aspects as well as the systemic constraints emerging from the implementation of CBMP. A set of action points should be periodically shared with Ministry as recommendations from the AGCA. In addition, issues of administrative and financial constraints in the implementation of community action (including CBMP) should be taken up with Ministry on a priority basis.
- The Secretariat could request selected state representatives to present experiences, challenges and lessons learnt in implementation of community monitoring at the AGCA meetings.
- The AGCA should consider leveraging outside funding for supporting the Secretariat from national donor agencies.
- CBMP has been included as a conditionality in the PIP guidelines for 2013-14, as a result, many states are including the component in their state PIPs. AGCA members should visit selected states to provide the necessary handholding and support to state governments in rolling out CBMP.
- The next AGCA meeting could be organized at the Ministry, preferably on a Saturday. This would enable greater representation/ participation of senior officials from the Ministry.
Discussion on increasing of Community Participation and Accountability in the next phase of NRHM
- Update on inclusion of Community Based Monitoring and Planning (CBMP) in the State Programme Implementation Plan (PIP) for FY 2013-14
Mr Bijit Roy presented an update on the inclusion of CBMP component in the State PIPs for FY 2013-14. A document compiled by the Secretariat with inputs from AGCA members, State Nodal Agencies and State NRHM Officials was shared with the group. The details are enclosed in Annexure- A. A snapshot of the status is as follows;
- Five states (Bihar, Maharashtra, Karnataka, Jharkhand and Odisha) have continued CBMP implementation
- In three states (Rajasthan, Madhya Pradesh and Assam) CBMP has been re-initiated post the pilot phase of implementation in 2007-09 .
- Three new states (Jammu & Kashmir, Gujarat and Uttar Pradesh) have included CBMP in the PIP 2013-14 – the Secretariat along with AGCA members, have supported the State Governments in developing the CBMP component for their PIPs
- Updates from other states are not available as state PIPs are still being finalized and they are yet to be uploaded in the NRHM website.
The group discussed the following points:
- There have been drastic cuts in the MoHFW’s proposed budget for the next FY 2013-14. It is expected that there will be minimal increase in the overall outlay over the last year’s budget, which would barely cover the inflation. As a result, continuity and expansion of innovations, including CBMP is likely to get adversely affected in most states.
- The AGCA should emphasize to the Ministry that a certain proportion of NRHM budget should be earmarked to support community action and accountability processes at various levels through NGOs. This could be a part of the 5% allocation for NGO grants.
- The State Government in Punjab is initiating CBMP in FY 2013-14. The component is planned to be implemented by the State Institute of Rural Development (SIRD) in partnership with local NGOs. The AGCA could consider providing need based support in rolling out the process, especially sharing guidelines for selection of NGOs.
- In Madhya Pradesh, the state had initially planned to scale up CBMP in around ten-twelve However, only five districts were included in the final draft of the PIP.
Feedback from the Ministry
- Many states have included CBMP in their State PIPs. However, State NRHM officials may not be aware of the implementation aspects of the component. The AGCA needs to strengthen capacities at the state level, including creating awareness on what processes and activities should be budgeted in their PIPs. Members suggested that the Ministry should allow the AGCA to utilize the unspent funds from the pilot phase to support these activities.
- The Ministry has already sent out letters to the State NRHM Mission Directors informing them to seek advice/guidelines from the AGCA members in rolling out CBMP in their respective states. It was suggested that copies of the letters should be sent to the AGCA for necessary follow-up.
- In Madhya Pradesh, the State Government has merged community processes (ASHA) and community action components. The state has constituted Mentoring Group on Community Action (MGCA) at the state, district and block to guide the implementation process. This may be a model that other states could adopt.
- The States have been given the flexibility to prioritize their activities and earmark resources for each activity, within their overall state resource envelope. The Ministry will accordingly sanction their plans and budget.
Based on the above feedback, five states- Uttar Pradesh, Gujarat, Jammu & Kashmir, Andhra Pradesh and Madhya Pradesh were identified wherein the AGCA members could provide support to the State Government in planning and rolling the CBMP component in a systematic manner. In addition, the AGCA members could facilitate an Orientation Workshop of State Nodal Officers on CBMP at the national level. The AGCA would send a budget seeking approval from the Ministry to support a set of interim activities at the national and state level.
Although Mr. Alok Mukhopadhyay could not participate in the meeting, he has mentioned that Voluntary Health Association of India (VHAI) has a strong presence in the states of Uttar Pradesh, Jammu & Kashmir, Madhya Pradesh and Andhra Pradesh. He suggested that the AGCA members travelling to these states could coordinate with the VHAI State Chapters for support and to ensure continuity.
- Discussion on NGO Guidelines and Strengthening of VHSNC
The Ministry had requested the AGCA to suggest steps for Strengthening of VHSNC in the next phase of NRHM. The note prepared by the Secretariat, was circulated to the AGCA members and feedback received from them has been incorporated.
In addition, the following points were shared by the AGCA members:
- The Secretariat should share the AGCA note on ‘Strengthening of VHSNC in the next phase of NRHM’ with NHSRC.
- The VHSNC should finally be made accountable to the Gram Sabha. They should share their plans and brief the community on the progress health issues at the Gram Sabha meeting, at least twice a year. In addition, VHSNC should regularly report to the Gram Panchayat.
- The ‘planning’ component has not been explicitly mentioned in the note. This needs to be appropriately included in the document.
- VHSNC should to be mandated to monitor nutrition services. A National Nutrition Security Coalition has been set up under the chairmanship of Prof M S Swaminathan. The AGCA should get details of the coalition’s efforts from Save the Children (National Secretariat) and World Vision. Dr Thelma Narayan and Dr Abhay Shukla volunteered to develop a note on inclusion of nutrition component in community monitoring.
- The national VHSNC guidelines are being developed by NHSRC. The guidelines will include a section on CBMP. A working group had been constituted to design the content. The group had met in January, 2013. The first draft of the guideline has been circulated to the working group members for inputs. The guidelines will be shared with the AGCA for inputs and suggestions. The AGCA members suggested the following points in the VHSNC guidelines a) inclusion of monitoring of nutrition services under the Integrated Child Development Scheme-ICDS by the VHSNC b) outlining the process of village health planning and role of the VHSNC members c) the guidelines should include a separate note on the role of VHSNC in CBMP. A smaller AGCA group could develop the note.
- Discussions and inputs on the note on ‘Management Development Index (MDI) for implementation of NRHM through PRIs
The Ministry had shared a note on ‘Introducing a Management Devolution Index (MDI) for Implementation of NRHM through Panchayati Raj Institutions (PRIs’) for inputs from the AGCA. The MDI is a tool to measure the extent to which implementation of NRHM is being devolved to PRIs. The note includes a suggestive list of indicators that could be used to develop a composite index to measure the progress made by the states in devolving implementation of NRHM through PRIs.
The comments received from the AGCA members, have been compiled by the Secretariat for discussion at the meeting and will be sent to the Ministry on behalf of AGCA.
In addition, members shared the following points:
- The Prime Minister has constituted an Expert Committee, under Mr Mani Shankar Aiyar’s Chairmanship to examine how the Panchayati Raj Institution might be leveraged for effective delivery of public goods and services, including health. The committee had invited PFI to make a presentation on Family Planning and Community Monitoring. Subsequently, PFI has shared a note to the committee for including the ‘community monitoring and family planning’ component in their report.
- Mr Jairam Ramesh, Minister for Rural Development and Minister for Drinking Water and Sanitation (Additional Charge), has shared that the centre would only release funds to states after they finalize their MDI, under the National Rural Drinking Water programme. If a similar condition is enforced for the NRHM funding, it could lead to a very complicated situation, as many states are yet to put in place the process of decentralization and may not have the capacity to take forward the process devolution.
Sharing of Evaluation Findings of CBMP in Maharshtra : Dr Renu Khanna
Dr Renu Khanna presented the evaluation of the CBMP programme in Maharashtra (Annexure B).
The presentation detailed the objectives, methodology, case stories of changes and challenges. The key recommendations made by the evaluation team were:
- The role of civil society organizations (CSOs) is critical: sufficient and timely resources need to be made available for CSOs to continue building capacities of the disadvantaged communities
- Alternative institutional arrangements need to be explored to ensure regular and timely disbursement of funds to CSOs
- Regular dialogues need to be held between CSOs and health officers to clarify expectations and create a common understanding
- The state government should organize a meeting to discuss issues emerging from this evaluation and prepare a plan for follow up action.
Dr Renu Khanna recommended that the AGCA could consider conducting regular reviews of the CBMP programmes as guidelines and structures require revisions based on the implementation experience in diverse contexts.
The group discussed the following:
- While CBMP does lead to increased utilization of services, there have been limitations in the study. Service utilization data collected from three districts had inherent problems and could not be analysed. This will require a broader study and cross verification of data to corroborate the outcomes of the CBMP process.
- Experience from Maharashtra has shown that while the CBMP process has be able to largely address problems at the local level, systemic issues are not being resolved. These problems cannot be solved through Jan Sunwais alone and need concerted intervention by the government, especially at the state level.
- Experience from Tamil Nadu has shown that rather than adopting a confrontation approach at Jan Sunwais, an orientation and involvement of the District Collector and District Health Officials in the CBMP process increases the chances of joint problem solving.
Dissemination of the evaluation findings will be organized in the state with support from the Government of Maharashtra. The group was requested to go through the report and send their feedback to Dr Khanna.
Discussion on Adherence of Quality Parameters in Family Planning Camps
Dr Abhijit Das shared information about the family planning camp organized in Malda district of West Bengal where 106 women were sterilized and left in the open without any follow up services. Such reports are being regularly covered through the mainstream media.
The following points were discussed:
- Members agreed that providing feedback from the field on quality of care in the provision of family planning and maternal health services are a part of the AGCA’s mandate and must be taken up.
- The AGCA should look into various dimensions of family planning services, and not only restrict itself to issues around sterilization.
- Simple tools/ checklists could be developed that enable the community to monitor quality of care in family planning camps. Some tools have been developed by Centre of Health and Social Justice (CHSJ), which could be further adapted. In addition, the AGCA could also refer a) tools developed for assessing quality of maternal health services in twenty districts of Madhya Pradesh b) other guidelines developed by the Jan Swasthya Abhiyaan and MoHFW guidelines on Quality of Care.
- The root cause of the problem is the reiteration of family targets through the mechanism of Expected Level of Achievement (ELA). There is push especially to the Chief Medical Officers (CMO) and Block Medical Officers (BMO) for achieving targets, which is most often at the cost of quality.
Update on Community of Practitioners for Accountability and Social Action in Health (COPASAH)
Dr Abhijit Das introduced the COPASAH as a community of practitioners, who share their interest and passion in the field of community monitoring for accountability in health and engage in exchanging experiences and lessons; sharing resources, capacities and methods; and in networking and capacity building among member organizations. Its mission is to nurture, strengthen and promote collective knowledge, skills and capacities of community oriented organizations and health activists primarily from Africa, Asia and Latin America. Two AGCA members – Dr Abhijit Das and Dr Abhay Shukla are the members of this society. COPASAH had organized a three-day experience sharing meeting for academic/community practitioners in Mumbai on February 20-22, 2013. Dr Das suggested that the AGCA could explore synergies with COPASAH in taking forward the agenda of community monitoring.
The following were responses from the AGCA members:
- It was observed that ‘research’ has not found mention anywhere in the COPASAH note/document. It was clarified that the main aim of this group is to build knowledge based on field practices. The work done by COPASAH members will be systematically documented and disseminated.
- Members strongly felt that the AGCA and NRHM need to be acknowledged while sharing experiences on community monitoring in India at various forums, including the website of COPASAH. This includes providing appropriate photo credits especially to implementing organizations at the state level. There has been a lack of transparency in sharing the conception and objectives of COPASAH.
Dr Das and Dr Shukla regretted any omissions on their part and reiterated that COPASAH would acknowledge the AGCA/NRHM appropriately in the future. It was decided that AGCA would be unable to endorse or associate itself with COPASAH. However, AGCA members could choose to be associated with the group in their individual capacity.
Discussion on AGCA’s proposal on ‘Strengthening Community Action under NRHM’
The AGCA proposal on Strengthening Community Action under NRHM was discussed. Members mentioned certain typographical errors which needed to be rectified in the proposal. It was also recommended to increase the initial phase of the program from sixteen months to two years.
Feedback from the Ministry
Ms Limatula Yaden shared that the approval has got delayed due to various reasons including transition of concerned officials in the Ministry. The revised proposal submitted by the AGCA in March, 2013 has been reviewed and the process for approval has been initiated. The Ministry will revert to the AGCA regarding the approval of the proposal.
Based on Mr Manoj Jhalani’s suggestion at the last AGCA meeting, Dr Abhay Shukla had prepared and shared the note on ‘financial guidelines for civil society organizations in implementing accountability, community monitoring and planning activities in the context of NRHM.’ (Annexure C) The group discussed the following:
- NGOs working on accountability have a different relationship with the public health system and hence need to retain a certain degree of autonomy, especially on the financial aspects. Currently, the financial control rests with the very agencies that are being held accountable, which is not an ideal situation.
- It was suggested that eventually, the mechanism for conducting CBMP could be merged with the existing societies formed for conducting social audit functions under NREGA. However, as there are organisations currently working on accountability, there is an urgent need for specific guidelines from the Ministry on timely transfer of funds to the implementing organizations.
- It was suggested that Dr Shukla would revise the note to make it more concise and circulate to the AGCA members for their inputs. The Secretariat would compile the feedback from members and share the final note with the Ministry.
- An interim plan of action and budget is to be developed by the Secretariat and submitted to the Ministry for supporting the following activities :
- Organizing a National Visioning and Planning Workshop on CBMP for State Nodal Officers
- Follow up visits by AGCA Members in 5 states (Uttar Pradesh, Jammu & Kashmir, Gujarat, Andhra Pradesh and Madhya Pradesh)
- Up-gradation and maintenance of Community Action webpage
- Quarterly AGCA meetings
- Facilitation cost for AGCA Secretariat (for a period of 6 months i.e. April – September, 2013)
- As TA/DA of the AGCA members has been a long pending issue, AGCA requested the Ministry to grant approval for reimbursement of travel claims of the AGCA members from the unspent balance from the pilot phase lying with the Secretariat.
It was discussed that for the next AGCA meeting, the Secretariat will request the Ministry to hold the meeting in Nirman Bhawan and will finalize the date in consultation with the Ministry.
The meeting ended with a vote of thanks by Prof. Ranjit Roy Chaudhury.
|Sl No||Action Points||Responsibility|
|1.||The AGCA would send a budget seeking approval from the Ministry to support a set of interim activities at the national and state level.||AGCA Secretariat|
|2.||The AGCA note on ‘Strengthening of VHSNC in the next phase of NRHM’ to be shared with NHSRC.||AGCA Secretariat|
|3.||Develop a note on inclusion of nutrition component in community monitoring.||Dr Thelma Narayan and Dr Abhay Shukla|
|4.||Develop a separate note on the role of VHSNC in CBMP to be included in the VHSNC guidelines.||A smaller AGCA group|
|5.||Compile comments on MDI received from the AGCA members and share with the Ministry.||AGCA Secretariat|
|6.||Feedback on the Maharashtra evaluation report to be sent to Dr Khanna.||AGCA Members|
|7.||Revise the note on financial and administrative guidelines to make it more concise and circulate to the AGCA members for their inputs.
Compile the feedback from members and share the final note with the Ministry.
|Dr Abhay Shukla