• 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

Special Invitees

• Dr Rajani Ved, Advisor, Community Processes, NHSRC
• Dr Renu Khanna, SAHAJ

PFI Representatives

• 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

• 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 12^th 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.

• 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.

• 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 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.

• 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.

• 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.

• 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.

• 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.