• Mr A R Nanda
• Dr Abhay Shukla
• Mr Alok Mukhopadhyay
• Dr H Sudarshan
• Ms Indu Capoor
• Ms Mirai Chatterjee
• Dr M Prakasamma
• Dr Narendra Gupta
• Ms Poonam Muttreja
• Prof Ranjit Roy Chaudhury
• Dr Sharad Iyengar
• Dr Vijay Aruldas

MoHFW officials present

• Mr C.K. Mishra, Additional Secretary and Mission Director, National Health Mission (NHM)
• Mr Manoj Jhalani, Joint Secretary-Policy
• Dr Arpana Kullu, Consultant, NHM
• Ms Neha Aggarwal, Consultant, NHM

NHSRC officials present

• Dr Satish Kumar, Advisor – Public Health Planning, National Health Systems Resource Centre (NHSRC)
• Dr Padam Khanna, Senior Consultant – Public Health Planning, NHSRC

Special Invitees

• Dr Aparajita Gogoi, Centre for Catalyzing Change
• Ms Madhuparna Joshi, Centre for Catalyzing Change
• Mr Rohit Singh, Gram Vaani

AGCA Secretariat staff

• Dr Sanjay Pandey
• Ms Sona Sharma
• Mr Alok Vajpeyi
• Mr Bijit Roy
• Mr Daman Ahuja
• Dr Ajay Mishra
• Ms Seema Upadhyay
• Ms Tripti Chandra
• Mr Saurabh Raj
• Ms Jolly Jose

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

• Dr Saraswati Swain
• Dr Thelma Narayan
• Dr Abhijit Das
• Mr Gopi Gopalakrishnan

Permanent invitees who could not attend the meeting and were given leave of absence

• Dr Sanjiv Kumar, Executive Director, NHSRC
• Dr Rajani Ved, Advisor, Community Processes, NHSRC

Ms Poonam Muttreja welcomed the participants and thanked Mr C.K. Mishra, (Additional Secretary and Mission Director, NHM, MoHFW), Mr Manoj Jhalani (Joint Secretary-Policy, MoHFW) for their guidance and continued support for strengthening community action for health. Mr C.K. Mishra and Mr Manoj Jhalani requested for an update on the AGCA activities.

Update on the progress of AGCA activities

Bijit Roy on behalf of the AGCA Secretariat presented an Update on the ‘Strengthening Community Action for Health under the National Health Mission (NHM) Programme’ for the period June – September 2015. The presentation included activities undertaken at the national and state levels, challenges and support required from the MoHFW. He also shared the plans for the next quarter (October-December, 2015).

The following points were made by the AGCA members:

• In Maharashtra, funds for community action have been approved under the Record of Proceeding (ROP) in August 2015. However, the Memorandum of Understanding (MoU) and transfer of funds to SATHI-CEHAT (State Nodal NGO) has yet to be done. The State Mission Director has sought guidance from the MoHFW on whether it should continue with the existing State Nodal NGO or opt for a fresh selection process.
• In Rajasthan, 300 PHCs are being outsourced under Public Private Partnership (PPP). Most of these PHCs are located in peri-urban areas. This initiative would have implications on referrals of patients to private hospitals, charging of costs for additional services, and especially linking these PHCs with sub-health centres, Accredited Social Health Activists (ASHA) and Village Health Sanitation and Nutrition Committees (VHSNC).
• In Gujarat, a unit cost of Rs 110 has been approved for training the members of each VHSNC. The approved amount is insufficient for training and adequate resources need to be allocated for training as well as long term mentoring of VHSNCs.
• With increased focus on the ASHAs, the ANMs are slowing drifting away from the community. There is also lack of motivation among ANMs. Therefore, there is a need to redefine the role of ANMs. It is also essential that the ANM, ASHA and Anganwadi Worker (AWW) work as a team.
• Changes in the State NHM Mission Directors has affected/delayed the pace of programme implementation, especially in Bihar, Tamil Nadu, Karnataka, Gujarat.
• Each state needs to develop a long term perspective plan for community action.
• Appropriate level of primary level care needs to be provided at PHCs, prior to referral of patients. It has been observed that there is over use of referral emergency transportation for transfer of patients to the higher level health facilities. There is a need to undertake a review/ audit of the referral outcomes.
• Institutional structures need to be developed at the state level for selection and oversight of NGO activities. There is also a need for an institution like NHSRC, which could review and mentor NGOs on financial management.

Feedback from the MoHFW

Mr Mishra and Mr Jhalani shared the following points:

• The AGCA should suggest sustainable models for community action, which can be integrated within the existing health system. Efforts should be made to strengthen the existing structures for ASHAs, VHSNCs, Rogi Kalyan Samitis (RKS) and Panchayats.
• Community level planning is not being reflected in the development process of the Programme Implementation Plan (PIP). The element of community participation is weak. The AGCA and the NHSRC should suggest strategies to institutionalise the process of community based planning.
• Funds are always available with the states to continue implementation of approved schemes. There is a need to convince and mobilise the states to continue work on community action for health.
• The AGCA should work closely with the NHSRC in developing strategies, modules and guidelines on community action. Support should be provided to states to a) develop an integrated approach for strengthening the VHSNCs, RKS and community monitoring components, b) roll out VHSNCs and RKS training, and c) community based planning and monitoring.
• The National Health Policy (NHP) 2015 is being finalised. There is expected to be a change in the funding and cost share proportions between the Centre and the state.   With the 14th Finance Commission recommendations, states will have to increase their cost share. Discussions are underway with states to decide on the cost sharing proportions.
• Components such as free drugs and diagnostics are already being implemented in the states under the NHM, which were a part of the proposed National Health Assurance Mission (NHAM).
• Facilitation of community action processes requires specific skills and perspective. It is therefore, a challenge to identify capable NGOs through an open bidding process.  Efforts should be made to develop a mechanism for empanelment of NGOs, which specialise in the area of community monitoring in a rights based approach. The states could then select NGOs from this list. The AGCA can suggest the mechanism in this regard to the MoHFW.
• Regarding the issue on Maharashtra, it is the state's discretion to decide on the selection and continuation of NGOs. The MoHFW will share its response to the letter from the State Mission Director.
• The MoHFW has shared its feedback with the Government of Rajasthan regarding the plans to contract 300 Primary Health Centres (PHC) under PPP. It has been mentioned that the option of contracting out of health facilities should only be explored for inaccessible and hard to reach areas, which should comply with the guidelines and standards. However, health being a state subject, the final decision rests with the state.

Discussion on strategies for sustainability of community action for health

The following points were suggested by the AGCA members:

• The Panchayati Raj Institutions, health functionaries and the community have to be brought together on a common platform for effective community action. The AGCA should engage with the Ministry of Rural Development and Panchayati Raj and the State Institutes of Rural Development (SIRD) to increase focus on health issues in the Gram Panchayat and Gram Sabhas.
• The State Health Resource Centre (SHRC) could be given the responsibility of providing support for facilitation role for the community action component, where the SHRCs are strong. A sub-unit or a consortium of organisations can be created within SHRC, to facilitate implementation support. An option could also be to adopt a model similar to the Society for Social Audit Accountability and Transparency (SSAT) in Telangana and Andhra Pradesh, wherein an independent society has been set up by the Department of Rural Department to conduct social audits of the Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS).
• The VHSNC and RKS provide spaces for community representation. However, community engagement in these forums is low. There is a need to develop a perspective plan for strengthening the capacities of the VHSNC and the RKS. This will require long term resource commitments.
• Efforts should be made to sensitise and involve elected representatives – Members of Parliament, Members of Legislative Assembly and Zila Panchayat members.

Discussions on decentralised health planning

Bijit Roy shared an update on the discussions in the sub-committee on decentralised health planning organised on September 30, 2015, which was chaired by Ms Mirai Chatterjee.

The following points were discussed: 

• A systematic approach should be adopted for piloting the process of decentralised health planning. The sub-committee should a) review the status of decentralised planning in the states, b) document the models/experiences and c) review existing guidelines and tools for PIP development. These learnings should be collated and form the basis of the pilot.
• The component of decentralised health planning should be included in the terms of reference of the 9th Common Review Mission (CRM).
• The MoHFW has urged the states to submit the district health plans for all high priority districts, alongwith their state PIP.
• Resources for the development of the District Health Action Plan (DHAP) are specifically budgeted in most state PIPs. In addition, 10 per cent of funds are earmarked for ‘innovation’. These funds should be leveraged to pilot the process of decentralised health planning.

• Interventions with EWRs will need to ensure that new members are oriented on the process after each panchayat election.
• In Maharashtra, an SMS-based survey has been undertaken to collect data on specific issues such as the presence of doctors in 24/7 PHCs and availability of essential medicines.
• The IVRS helps in easier collection and compilation of data and should be shared with organisations implementing community action.

• The other concern on outsourcing is regarding the provision of guaranteed health services and accountability of the PHCs to the community.
• It would be helpful to understand why the government is outsourcing the PHCs. If the intention is to reduce costs on health care, then it is a concern.

Discussions on other issues

• The role of AGCA members is to provide advice and guidance on community action. Members should move out of implementation roles, as that leads to conflict of interest.
• There is a need to reflect on the AGCA Terms of Reference (ToR) to assess if the committee is working as per its mandate or if there is a need for modification, based on the current and changing scenario.
• The AGCA meeting agenda should focus on strategic issues. This will allow ample time for discussion and consensus.

Discussions on upcoming priorities

Roll out of community action for health in Delhi

Dr Abhay Shukla mentioned that a meeting was organised with Dr N Vasantha Kumar, Additional Secretary to the Chief Minister, Government of Delhi, to share experiences and explore possibilities to initiate community action for health in Delhi.

Subsequently, a meeting with potential organisations was recently convened, without involving the AGCA Secretariat and following the processes.

Bijit Roy shared that Dr Monika Rana, State Programme Officer, District State Health Mission, had requested for a meeting with the AGCA Secretariat to seek inputs on the pilot design, following a meeting with Dr N. Vasantha Kumar. Dr Rana had shared that the community processes institutions – The Mahila Arogya Samiti (MAS), the Jan Swasthya Samiti (JSS) and the District Level RKS are weak. The process for the  formation of the Mahila Arogya Samitis (MAS) is being planned.  The primary and secondary level health infrastructure in the state is also weak and services are mostly being provided by the tertiary care facilities. It is, therefore, premature to initiate community monitoring of health services. Efforts should first focus on preparing the ground for community action, which include (a) building the capacity of state and district community processes teams to manage the process, (b) formation of MAS, (c) training and mentoring of MAS, JSS and District RKS, and (c) institutionalising a set of minimum health guarantees, which could then be monitored periodically.

AGCA members suggested the following:

• Detailed planning for the pilot should be coordinated by the Secretariat with support from the AGCA members.
• A systematic process should be adopted for identification and selection of NGOs.