Population Foundation of India, January 16, 2015
Advisory Group on Community Action Members present
- Dr Abhay Shukla
- Dr Abhijit Das
- Mr Alok Mukhopadhyay
- Mr A R Nanda
- Mr Gopi Gopalakrishnan
- Dr H Sudarshan
- Ms Indu Capoor
- Ms Mirai Chatterjee
- Dr Thelma Narayan
- Dr Vijay Aruldas
- Dr M Prakasamma
- Ms Poonam Muttreja
Representative from the Ministry of Health and Family Welfare (MoHFW)
- Ms Limatula Yaden, Director, National Health Misson, MoHFW
- Dr Rajani Ved, Adviser – Community Processes, National Health Systems Resource Centre (NHSRC)
Representatives from the AGCA Secretariat
- Dr Sanjay Pandey
- Mr Alok Vajpeyi
- Dr Sainath Banerjee
- Mr Gautam Chakraborty
- Ms Francesca Barolo Shergill
- Mr Bijit Roy
- Mr Ajay Misra
- Mr Daman Ahuja
- Ms Tripti Chandra
- Ms Seema Upadhyay
- Ms Jolly Jose
AGCA members who could not attend the meeting and were given leave of absence
- Dr Dileep Mavalankar
- Mr Harsh Mander
- Dr Sharad Iyengar
- Prof Ranjit Roy Chaudhury
- Dr Saraswati Swain
- Dr Narendra Gupta
Ms Poonam Muttreja welcomed the participants and shared that the objectives of the meeting were to:
- Discuss and finalise AGCAs inputs on the community action component of the draft National Health Policy (NHP)
- Share progress update on ‘Strengthening Community Action for Health under the NHM Programme’ in the last quarter (October – December 2014) and plans for the current quarter (January – March 2015)
- Discuss priority areas for the AGCA proposal for the financial year 2015-16.
Confirmation and Action Taken on the Minutes of the 29th AGCA meeting held on September 11, 2014
The members confirmed the minutes of the 29th AGCA meeting held on September 11, 2014.
Dr Sanjay Pandey, Director Programmes, PFI shared an update on the Action Taken on the 29th meeting.
Compliance on action points of the 29th AGCA Meeting
|Sl. No.||Action Points||Responsibility||Action Taken|
|1.||Revise agenda of the National Consultation on Community Action for Health as per suggestions of the MoHFW and AGCA members||AGCA Secretariat||The National Consultation on Community Action for Health was organised on October 28-29, 2014 with support from the MoHFW and the AGCA.|
|2.||Share the list of invitees along with an invitation letter with the MoHFW for sending out invites for the National Consultation on Community Action for Health||AGCA Secretariat|
|3.||Constitute a sub- committee comprising representatives from the NHSRC and the AGCA to suggest steps which allow aggregation and incorporation of village level plans into the District and State Programme Implementation Plans (PIP)||NHSRC and AGCA Secretariat||The first meeting of the sub-committee was held on November 28, 2014 and its minutes shared with AGCA members and NHSRC on December 23, 2014.
Update on deliverables
a) Inputs on State PIP Guidelines shared with AGCA members on January 13, 2015
b) Documentation of community based planning model – in progress.
c) Review of training modules-to be done with NHSRC.
|4.||Rework the Community Action for Health tools and User’s Manual as per the MoHFW comments||AGCA Secretariat||Guidelines for Programme Managers and the User Manual on Community Action for Health were revised as per inputs from the MoHFW and released at the National Consultation in October 2014.|
|5.||Request MoHFW to organise a joint meeting of the AGCA Secretariat with the Ministry of Women and Child Development (W&CD) to explore opportunities to initiate monitoring of nutrition services under the Integrated Child Development Services (ICDS) programme.||AGCA Secretariat||Both the AGCA Secretariat and the WCD teams have shared the materials on Community Action for Health. The meeting with the W&CD team was planned in the first week of January 2015. However, due to the Nutrition Committee meeting in Bhopal on January 8-9, 2015, the planned meeting was postponed to the last week of January 2015.
The Secretariat proposes to invite W&CD officials at the next AGCA Meeting.
|6.||Share a draft Memorandum of Understanding (MoU) with the MoHFW to finalise modalities of collaboration with the NHSRC||AGCA Secretariat||Draft tripartite MoU was shared with the MoHFW on November 21, 2014. Regular follow up has been done by the Secretariat for early release of funds.|
|7.||Share a draft MoU for partnership between State Governments and NGOs for CAH implementation||AGCA Secretariat||Shared MoU with AGCA members on January 14, 2015.|
|8.||Share three chapters of the Training Manual for Rogi Kalyan Samiti (RKS) with AGCA members||AGCA Secretariat||Chapters were shared with the AGCA members on September 29, 2014.|
|9.||Provide inputs on the draft National Health Policy||AGCA Members and Secretariat||1) Note on Community Action for Health for the National Health Policy shared with the MoHFW on December 16, 2014.
2) The Draft Health Policy was reviewed by the AGCA Secretariat and shared with AGCA members for inputs and suggestions on January 2, 2015.
|10||Request the MoHFW to share the letters issued to the State Governments regarding:
i. Continuation of planned activities as per FY 2013-14 approvals
ii. Integration of community process structures and components
iii. Request the Tamil Nadu Government to reinitiate implementation of the CAH programme
|AGCA Secretariat||Letters (i) and (ii) shared with AGCA members on January 13, 2015. Will follow up with MoHFW on (iii) letter.|
|11.||Send a letter to the MoHFW and the NHSRC to link the Community Action for Health website with their websites||AGCA Secretariat||Request to the MoHFW to facilitate linking of the AGCA website with the NHM and NHSRC websites sent on December 9, 2014|
|12.||Send updated attendance list to the AGCA members, along with a specific email to members who have not been attending meetings regularly, to inform the group regarding their availability and willingness to participate in the AGCA meetings||AGCA Secretariat||E-mail sent to the AGCA members in January 2015.|
Prior to the discussion on the agenda items, Ms Muttreja shared an update on the follow up on the sterilisation deaths in Bilaspur district, Chhattisgarh. She mentioned that PFI had met the Secretary, Health and Family Welfare, MoHFW, to brief him on the findings and recommendations of the fact finding report.
The AGCA members suggested the following:
- It would be helpful to organise a meeting with the Family Planning division to discuss steps to operationalise the recommendations of the fact-finding report.
- The MoHFW should consider discontinuing the Expected Level of Achievement (ELA) for family planning.
Overview of the draft National Health Policy
Dr Sanjay Pandey made a brief presentation on the draft National Health Policy (NHP). The presentation focussed on the goal, key principles, objectives, policy directions on adequate investment, preventive and promotive health, health care services, key policy shifts and suggestive areas for discussion. Dr Pandey requested the AGCA members for their inputs on the draft policy document. A copy of the presentation is enclosed for reference as Annexure 1.
The inputs provided by the AGCA members were:
Content and focus areas
- Members congratulated the MoHFW for taking the initiative to revise the National Health Policy and emphasising on comprehensive primary health care.
- The document should urge State Governments to align their existing state health policies as per the revised NHM.
- There is a need to include details on expected outcomes on key health goals along with a set of realistic timelines/ benchmarks for achieving them.
- The MoHFW could consider including a section, which reflects on the key gaps in the implementation of the National Health Policy (2002), especially ‘what has not worked’ and mention ‘how the current policy addresses the gaps’.
- There is no emphasis on addressing issues around gender, social stratification and strategies to reach the most vulnerable.
- Addressing social determinants of health such as nutrition, water and sanitation requires a common framework and a plan to facilitate inter-sectoral/ department convergence. This area needs to be detailed out in the policy document.
- The role of Non-Government Organisations (NGOs) finds little mention in the policy document. The MoHFW could consider including a specific chapter- detailing out the role and engagement with NGOs in supporting the implementation of the NHM.
- Rehabilitative care is an essential component of comprehensive primary health care. Therefore, shifting the entire responsibility of managing the rehabilitative care component to the Ministry of Women and Child Development (MoW&CD) may not work.
- In the finance section, the MoHFW could consider including details on the annual financial projections for the implementation of the health policy.
- The policy needs to share a vision for involving youth and increasing their participation as key stakeholders in achieving the goals of the NHM. Also, emphasis is required on creating greater awareness on the ill effects of tobacco and alcohol consumption.
- Environment and climate change aspects and their impact on health, need to be mentioned in the policy.
- The draft policy mentions the provision of universal primary health care. The principle of universality should however be extended to all levels of health care.
- While mental health finds a mention in the document, there is a need to elaborate on the priority areas and their operationalisation.
- The MoHFW could consider including a section on ‘Right to Health’ in the implementation plan. A phased approach to operationalise the aspect could be deliberated through a consultative process.
- The document needs to include details on (a) continuum of care between the public and private sector and (b) networking between primary and tertiary levels for referral care.
Community Action for Health
- The component on community action for health is weak and finds scattered mention in various sections of the document. The MoHFW should consider including a specific chapter on the overall approach and focus areas on community action for health. The MoHFW could refer to the note submitted by the AGCA in January 2015 in this regard. A copy of the AGCA’s note on community action for health is enclosed for reference as Annexure 2.
- Essential components of community action for health should include:
- Increasing community awareness on health entitlements
- Generation of community based evidence on people’s experiences of accessing health services
- Community monitoring through feedback in multi-stakeholder forums and public accountability events like Jan Samvads (Public dialogues)
- Participatory health planning at community and health facility levels and through inputs in development of block and district health plans.
- Grievance redressal mechanisms to facilitate timely resolution of issues.
- Adequate financial resources (at least 2% of the total allocation of the NHM budget) must be earmarked to support community action and accountability mechanisms.
- Capacity building, strengthening community awareness and facilitation of participatory processes may be ensured through suitable civil society organisations.
- The policy should emphasise on strengthening bottom up planning processes, wherein issues/ gaps identified in village health action plans are reflected and feed into the block, district and state NHM Programme Implementation Plans (PIPs)
- The Health Management Information System (HMIS) data collected by service providers is used as a key parameter to measure progress and guide decision making. While this is necessary, it is also important to seek community perception/ feedback on health services. In addition, processes need to be developed to facilitate triangulation of the HMIS and community monitoring data. This aspect needs a mention in the policy document.
- The policy needs to detail operational mechanisms to ensure timely and effective grievance redressal.
- The stress on greater decentralisation is encouraging. However, there is little detail on the role of various tiers of Panchayati Raj Institutions and Urban Local Bodies and the nature of their engagement with the health systems to support implementation of health programmes.
Population stabilisation and family planning
- The approach on population stabilisation should be guided and take into account the reproductive rights framework, with India being a signatory to International Conference on Population and Development.
- Details on inter-linkages between population and development, equity, gender, sexual and reproductive health are missing in the document. These aspects should be included and detailed out in the implementation plan.
- There is little emphasis on reproductive health and family planning. The MoHFW could refer to the note submitted by PFI in January 2015 in this regard. A copy of the PFI’s note on family planning is enclosed for reference as Annexure 3.
- The policy is silent regarding the non availability of doctors in rural areas and how this would be addressed. This needs to be detailed out. Members suggested considering reinitiating the three-year certificate course/diploma course for doctors to address the critical gap.
- Emphasis is required to develop soft skills of health workers on social aspects of health along with the ongoing efforts on technical skill building.
- The policy should clearly give details of how the human resources would be deployed and their duties. This should be especially detailed for community based frontline workers (ASHAs, ANM and Nurses) at the primary level.
- Many states have discontinued/ sized down the Male Health Workers (MHWs) cadre in the recent past. Continuation and strengthening of this cadre is important to facilitate male involvement, disease surveillance and planning on health determinants.
Regulatory mechanisms — the public and private sectors
- The quality of medical education in the private sector is an area of concern. Higher investments are required to strengthen public institutions, along with a framework to regulate and monitor the quality of education in private medical institutions.
- Both the private and the public sectors should be made accountable for the services they provide. This would include (a) operationalising an effective regulatory mechanism to ensure adherence to Standard Treatment Protocols under a comprehensive legislation/ Clinical Establishment Act (b) protocols on patients’ rights (c) display of service guarantees and (d) regulation of care through multi-stakeholder bodies.
- Accreditation of services to the private facilities should take into account both price and
- Under Corporate Social Responsibility, MoHFW and State Governments should seek support from the private sector for managerial and technical innovations, along with leveraging additional financial resources.
AYUSH and local health traditions
- The policy needs to acknowledge the practice and contribution of traditional forms of medicines, especially in remote tribal areas.
- The implementation plan should detail the operational aspects on how AYUSH and local traditions would integrate and complement each other.
- Mention of yoga in the policy is encouraging. However, the section requires further detailing on how it would be integrated and operationalised within the public health system.
Groups with special health needs
- The MoHFW should collaborate with the Ministry of Labour and Employment (MoLE) to work out mechanisms to include occupational health and safety in primary health care.
- Mental health should also be integrated within primary health care, especially for early detection and screening. In addition, health functionaries should be oriented and trained on addressing issues of mental health at the primary health care level.
- Care for the elderly– Operational details on care for the elderly are missing. While developing the implementation plan, a consultative process may be adopted to develop a list of services for the elderly, especially at the primary level.
- Funding for All India Institute of Medical Sciences (AIIMS): The policy mentions plans to set up 15 new AIIMS. However, considering the cuts in the health sector funding, the financial resources required to support the initiative need to be given.
- Generic and rational drug use: Prescribing generics and the rational use of drug should be an integral part of medical education.
- Use of Information Communication Technology: Increased coverage and reach of mobile services provide a huge opportunity to design and implement cost effective strategies for providing messages on health services and entitlements, especially for unreached areas/groups. This needs to be included in the policy document.
Feedback from the MoHFW
Ms Limatula Yaden, Director- NHM, shared the following update regarding the draft NHM policy:
- The development of the draft NHM policy was undertaken through a very consultative process. This includes (a) meetings with State Health Secretaries and Mission Directors to seek inputs on priority areas; (b) visits by the MoHFW teams to states to understand the their perspectives and implementation issues; and (c) formation of thematic/ technical groups to seek inputs on specific areas.
- The process at the MoHFW is being handled by Mr Arun Panda (Additional Secretary) with support from the Joint Secretaries.
- The AGCA could consider seeking an appointment with Mr Panda to share suggestions on the draft policy.
- In addition, detailed inputs/ suggestions could also be provided on the policy, which has been uploaded on the MoHFW website.
Briefing meeting with the MoHFW
After the meeting, a sub-group consisting of AGCA members – Ms Mirai Chatterjee, Ms Indu Capoor, Dr M Prakasamma and Dr Sanjay Pandey (Director Programmes, PFI) met Ms Arun Panda (Additional Secretary, MoHFW) and Ms Sheela Prasad (Economic Advisor, MoHFW) and shared the AGCAs feedback/ inputs on the draft policy. Mr Panda requested the team to provide detailed inputs on the policy document, which the MoHFW would consider while finalising the document.
Update on the progress of AGCA activities
Dr Ajay Misra, Programme Manager – AGCA Secretariat made a presentation on the progress of the AGCA activities during September – December, 2014. The presentation focused on an update on the progress on programme deliverables at the national and state levels, challenges, support required from the MoHFW, and plan of action till March 2015. A copy of the presentation is enclosed as Annexure 4.
Feedback from the MoHFW
- The states should find value in initiating and expanding the implementation of community action for health. The AGCA needs to develop a group of advocates, who could dispel the distrust and create ownership for the process in the states.
- In the PIPs, many states are only including plans to organise visioning meetings at the state, district and block levels. The AGCA Secretariat needs to work closely with the State NHM teams to support and guide in the development of a comprehensive strategy and action plan to implement the component.
- It may be difficult to allocate additional human resources to manage the Community For Health portfolio at the state level. Efforts should be made to work with the existing community process structures.
- There has been delays in transfer of funds through the treasury route.
Feedback from the AGCA members
- The Secretariat should actively engage with the AGCA members to strategize processes at the state level.
- Efforts should be made to support and strengthen processes in a few states, which have shown interest, rather than investing energies across all states.
- In states, where there is potential, the emphasis should now be on (a) strengthening the State AGCAs to provide guidance to the implementation processes (b) mapping of potential civil society organisations which could support and implement the component, and (c) documenting and sharing innovations with states on various approaches on community action.
- The Secretariat should coordinate and finalise a meeting with the Ministry of Women and Child Development to discuss the next steps for collaboration on community monitoring of the Integrated Child Development Services (ICDS).
- As there is very little experiences on community based planning, it would be good to support a pilot in two or three states (one district each) over the next two years. The experiences from the pilot could then be documented and shared with the MoHFW for adoption in other states and districts. The next meeting of the AGCA sub-group on community based planning should be organised in February 2015 to further deliberate on this issue. Dr H Sudarshan, Ms Mirai Chatterjee, Ms Indu Capoor and Dr Abhay Shukla volunteered to guide the process.
Discussions on priority areas for the AGCA proposal
Mr Bijit Roy, Programme Manager, Community Action and Scaling Up shared a brief overview of the AGCA proposal for 2015-18. The presentation focused on an update on the processes supported by the AGCA since April 2013, learning, challenges and priority areas for the next phase. A copy of the presentation is enclosed for reference as Annexure 5.
Feedback from the AGCA members
- A differential approach should be adopted in providing technical assistance to states in the next phase. Members suggested guide implementation and demonstrate the effectiveness of community action in a few selected states, where maximum energies should be concentrated, while generalised support could be provided to other states for orienting nodal officers, development of PIPs etc.
- There varied understanding among states on essential/non-negotiable components of community action. Efforts should be made to insist states to retain this emphasis as processes are being implemented.
- Community Action for Health should be linked with the Swachh Bharat Abhiyan of Government of India for greater visibility.
- The AGCA should support/ guide implementation of pilots in selected areas such as community based planning, grievance redressal, use of information technology, community action in urban areas etc. Experiences and lessons from the pilots should be documented and shared with states for adoption.
- The AGCA could explore opportunities for additional funding to support its work on community action.
- The Secretariat should develop and share the proposal note with members for inputs and suggestions by the first week of February 2015.
Discussions and inputs on State PIP guidelines for the community action for health component
Mr Bijit Roy shared that the MoHFW Guidelines on the State PIPs were reviewed by the Secretariat and shared with the AGCA members for inputs. Members requested the team to share the document with the NHSRC and the MoHFW at the earliest.
The meeting ended with a vote of thanks by Ms Poonam Muttreja.
Action Points from the 30th AGCA Meeting
|Sl. No.||Action Point||Responsibility|
|1.||Organise meeting with the Ministry of Women and Child Development to discuss the next steps for collaboration on community monitoring of the Integrated Child Development Services (ICDS)||AGCA Secretariat|
|2.||Provide inputs on the draft National Health Policy||AGCA Members and Secretariat|
|3.||Develop and submit the AGCA proposal for the next phase||AGCA Secretariat|
|4.||Organise 2nd sub-group meeting on community based planning||AGCA Secretariat|
|5.||Provide regular updates to AGCA members on state processes||AGCA Secretariat|
|6.||Share AGCA’s inputs with the Ministry of Health and Family Welfare on the State PIP template for community action for health component||AGCA Secretariat|