Population Foundation of India, September 18, 2009
Advisory Group Members present
- Dr Thelma Narayan – Chair
- Dr Abhijit Das
- Dr H Sudarshan
- Dr Narendra Gupta
- Shri Alok Mukopadhyay
- Dr Shanti Ghosh
- Ms Indu Capoor
- Dr Vijay Aruldas
- Shri A R Nanda
Representative from GOI
- Dr Tarun Seem, Director, NRHM
- Ms Sunita Singh, CHSJ
- Mr S Ramaseshan, PFI
- Ms Sona Sharma, PFI
AGCA Members who could not attend the meeting and were given leave of absence
- Dr Abhay Shukla
- Sh. Gopi Gopalakrishnan
- Dr Dilip Mavalankar
- Sh. Harsh Mander
- Ms Mirai Chatterjee
- Dr R S Arole
- Dr M Prakasamma
- Prof Ranjit Roy Chaudhury
- Dr Saraswati Swain
- Dr Sharad Iyengar
Mr. A R Nanda welcomed the members and special invitees to the meeting. He conveyed that this time out of 19 members, ten had requested leave of absence due to their prior commitments. He requested Dr Thelma Narayan to Chair the meeting.
Welcoming the participants, Dr Thelma Narayan summarized the agenda for the meeting. The agenda included an update on the community monitoring, formation of Regional Resource Centre and a national dissemination for community monitoring, followed by future initiatives for Community Action.
Agenda Item No. 1: Confirmation and Action Taken on the minutes of the 14th AGCA Meeting held on June 19, 2009
The minutes of the 14th AGCA meeting were confirmed.
Action Points from the 14th AGCA Meeting
- A Mission from AGCA to Meet Secretary ( Health), MP
It was decided in the 14th meeting that a three member mission from the AGCA comprising Dr. Narendra, Dr. Swain and Dr. Thelma could go and meet the Secretary Health, Government of Madhya Pradesh to discuss the issue of community monitoring and inclusion of the same in the State PIP. The team was yet to plan the visit, however three members (Dr. Abhijit Das, Dr. Ahbay Shukla and Dr. Narendra Gupta) had attended the national workshop organized by the Government of India in Orissa, where a discussion was held with Joint Secretary, MP for inclusion of CM programme in their state PIP. They were informed that the main issue faced was the approach of the state facilitating organization. It was decided that before visiting the state of MP, some more groundwork is required to be prepared with responses to these issues.
It was also suggested that apart from MP, the members should also look at the other states where the CBM is not being taken forward and decide whether the AGCA should play a role. This is critical since wherever there is a time gap, there would be a loss of learning and the entire history of what was done, will be lost.
- A Note on State Reservations for inclusion in the State Review Reports of Maharashtra and Rajasthan
Dr Narendra and Dr Shukla have sent their comments regarding the state reservations on the review reports. It was felt that the AGCA can’t bind the evaluator down except when there are factual errors, which need to be pointed out.
It was decided that the comments sent in by Dr. Narendra and Dr. Shukla, annexed with these minutes, can be appended as observations/clarifications by the Rajasthan and Maharashtra Nodal Agencies along with the respective state reports. However, the national report would remain unchanged.
- Closure of Project Accounts with states and submitting final UC to GoI
Mr Ramaseshan shared the status of receipt of audited UCs from the states. Audited UCs had not been received from the states of MP, Maharashtra and Chhattisgarh. Updation of state information on the NRHM website is due from Maharashtra, Madhya Pradesh, Tamil Nadu, Karnataka, Chhattisgarh, Assam and Jharkhand. The state reports are yet to be received from Madhya Pradesh, Tamil Nadu, Chhattisgarh, Assam and Jharkhand.
During the Joint Review Meeting in Assam, the MoHFW team met VHA Assam team who shared that they were facing some problems with the state government and district implementing agencies. Dr Alok Mukhopadhyay was requested to intervene for getting the required documents and UC from VHA Assam.
Further Action: One person from CHSJ and a senior person (from accounts) from PFI should visit the states to sort out problems if any and get the final UCs and other documents.
- Data collection on deaths and births
A meeting was to be fixed with the Registrar General of India on the concerns related to data collection and the need to identify the causes of death, as there were a lot of complications on causes of death statistics especially in rural areas. This needs to be followed up with Dr Mavalankar.
- Proposal on Resource Cell at PFI
A proposal for setting up of the Resource Cell at PFI was circulated. Major points of discussion were as follows:
- The proposal for setting up of Resource Cell will be submitted to GoI only after the closure of the pilot phase project accounts with states and submission of final audited UC to MoHFW.
- Dr. Tarun Seem informed that the concept of a resource cell had been mooted and once approved, PFI will be asked to submit a proposal for the same. The budget included in the proposal needs to be broad and open so as to have flexibility in terms of quantum of work to be taken up.
- PFI/CHSJ collaboration in the Resource Cell needs to be defined. However, the modalities could be worked out later between PFI and CHSJ.
- A majority of the members felt that the Resource Cell needs to include action (in a lab mode as in community monitoring) as a mechanism to push things.
- The Resource Cell could develop prototypes of promotional material which could then be adapted by the states after pre-test. Core content for the material could be developed centrally.
- The Resource Cell is meant to strengthen the AGCA secretariat to make the AGCA more effective for providing assistance to NRHM. The AGCA meets every quarter, however there is immense scope for work in between – the states need guidance on PIP preparation, follow up of specific recommendations of the CRM, media handling, etc. Regional secretariats can also be set up based on the high focus and non high focus states.
- NRHM could take an initiative by involving 2-3 AGCA members in the preparation of PIP as well as CRM. For the forthcoming CRM during 3rd to 13th November, 2009, GoI will send letters to the AGCA members requesting participation in the CRM.
- There are two ways of participating CRM/JRM: (a) AGCA can help in setting up the agenda and (b) can participate as a member of the team.
- Dr. Alok Mukhopadhyay informed the group of a mid term review of the 11th Plan for all social sector programs carried out in all states from the beneficiaries’ perspective. It was found that in some places people did not even know 10% of the government schemes. Dr. Mukhopadhyay offered to facilitate a meeting with members of the Planning Commission to give them feedback from the community monitoring experience. This could be organized before December, 2009.
Agenda Item No. 2: Updates on Community Monitoring
Update from Dr. Tarun Seem : A press conference was organized by MoHFW on NRHM as a flagship programme where two aspects were highlighted by GoI (a) progress over the first 100 days of present government under the flagship programme, NRHM and (b) a web based HMIS is in operation – every state is now sending facility level patient records into the computer system, which gets collated at various levels and a health MIS is created. The whole paradigm is now on the HMIS web page. Part of it has started part is in the preparatory phase but from district to state and state to Government of India, dataflow has reasonably stabilized. This has been brought out as a publication – HMIS : preliminary observations and data issues, based on data fed into the web based HMIS. Copies of the said documents were distributed at the meeting. A newsletter with RCH poster pull outs has been brought out by MoHFW which will be sent to PFI.
When the state PIPs are sent to the GoI, they are appraised by a National Programme Coordination Committee (NPCC), headed by Mission Director, comprising all Programme Divisions i.e. RCH, NRHM, IEC, training, Disease control etc and the draft PIPs circulate among the various divisions of the Ministry for the comments. The comments are sent to the states; the states revise the PIPs and send it back for a second round of discussions. After this, a product called the ‘Record of Proceedings’ comes out from the NPCC, which is uploaded on the web-site. This is the document which the state health societies’ refer to while seeking release of money. NPCC proceedings have taken place on four occasions in the past (2005 – 2009). Four sets of record of proceedings are available on the website.
A mapping exercise of these records of proceedings over the years has also been completed, which is being put up on the web site. The analysis throws up interesting facts regarding the plans and could be used to identify gaps in planning. For instance, capacity building of VHSCs has not been funded in most states. The mapping of PIPs would be sent to the states before the CRM scheduled to be held on 3rd to 13th of November, 2009. A soft copy of the mapping has been sent to PFI, which could be shared with the members.
Feedback on National Dissemination Workshop at Bhubaneswar, Orissa
A three member team (Dr. Abhijit Das, Dr. Abhay Shukla and Dr. Narendra Gupta) from AGCA was invited to make a presentation along with Dr Tarun Seem on the community monitoring process to a large meeting of state health functionaries, including Secretaries and Mission Directors. It was a joint presentation wherein the rationale and concept of the CM programme was presented by Dr Tarun Seem and experiences and results from implementation of the programme were presented by the AGCA members. Dr Seem summarized the presentation in terms of how it can be taken forward in state PIPs. An exhibition of the publications developed for community monitoring including manuals, leaflets, posters and film on CM was set up at the meeting venue. As it was a large meeting, one to one interaction opportunities with the participants were fewer.
After the National Dissemination Workshop at Bhubaneswar, officials from J&K approached Dr Narendra Gupta for technical assistance. PFI has also been receiving requests from states like Bihar, UP and Punjab for technical assistance in setting up CM programme under NRHM. Bihar has made some progress while in UP only preliminary discussions were held. It was suggested that before the PIP is ready by next year, the AGCA should give them appropriate advice and organize a workshop if required. PFI should continue coordinating with the states and involve AGCA members in supporting the states.
Agenda No. 3: Discussion on National Dissemination Workshop
The following suggestions were made by the members:
- CRM is a very good forum and in the CRM National Dissemination Workshop, a half hour slot can be included for conveying findings from community monitoring.
- Dissemination is to be deliberate. We have already done one round of dissemination to the topmost persons of the states. However, there are other stakeholders in this process and we need to be deliberate in terms of looking at the states where this has not moved or states where it has not been considered as priority. In any one state there may be an NGO which may be very strong or a DP who can take the lead. It should be a learning workshop – ½ day for methodology and another ½ day for applying it.
- Regional workshops will be much better rather than organizing a one big workshop. If the programme is to be included in the state PIP, then the tool kit has to be localized. The purpose of the national dissemination workshop needs to be clear.
- One national workshop (may be 2-3 hours disseminating to bilateral and multilateral agencies) with simple pamphlets, needs to be organized in Delhi. For empowering states, regional/state level workshops could be organized.
- The dissemination should be part of the total exercise for PIP development. It would be an energetic effort at the state level and could start working with enthusiasts and leave out the cynics. Should identify states accordingly.
- Audience for the regional workshops should be those who were involved in the implementation at the state level such as ASHA coordinator, VHSC coordinator, State Programme Managers etc. as these people are not oriented on community monitoring under NRHM.
- Today there is no need to organize national or state dissemination workshops. The need of the hour is to lobby with states for inclusion of CM in PIP by whatever means possible – either by drum beating with the press, national TV and with Plan Commission people as right now is the time for planning. There will be no money for community monitoring next year unless it is included in the PIPs.
- The word monitoring should be deleted and replaced with community based empowerment and action/community based planning as the word monitoring is what puts off most people.
- Briefing the Parliamentarians on community action would be useful. A policy brief on what works and how it works could be developed.
The discussion concluded with an agreement that right now it was more important to lobby strongly with the state governments to include community based planning/empowerment and action in the state PIPs.
Agenda Item No. 4: Future Initiatives on Community Action under NRHM
The members discussed in detail about strategies to initiate community action around nutrition. Important points discussed were:
- A concept paper on nutrition had been circulated by Dr. Thelma Narayan in the previous meeting. The next step would be to move to a position paper with action points.
- Issues to be promoted under nutrition are: to encourage mothers’ to breastfeed till first six months; after that home made soft foods can be given to the child in adequate quantities 4-5 times a day. Unless we do this, distribution of food will not work. The emphasis of the Aanganwadi Centre should be changed to focus on younger children (under 2) and pregnant women.
- The remuneration package for ASHA should include nutrition aspects. ASHA should make sure that pregnant women have IFA, take care of the delivery aspects, breastfeeding, immunization and complimentary feeding.
- As far as nutrition for families is concerned, monitoring is very important – what is done and who gets it? 6-7 Ministries are involved in the nutrition process. Communities need to be involved in the feeding as tribal women are not in a position to feed 4-5 times a day due to their busy schedule with livelihood. In 4 blocks of Gujarat, the Government has mandated ‘Matru Mandals’, which work under DWCD. These Matru Mandals have been quite effective in coordinating and monitoring all the nutrition aspects.
- Governments are now coming with fortification solution which is also not effective. Studies have shown that with fortified flour, the Hb level of men has risen but not women. So, it is a complicated issue.
- Make sure that the girls are well nourished. Age at marriage of girls is also extremely important as most of the girls in our country are getting married before 18 years and start producing children at the age of 15-16. A whole life cycle approach is required.
- Training module on nutrition for ASHAs can be revised. Already some training has been given to ASHAs and the issue can be raised with the ASHA mentoring group.
- In Karnataka, as nutrition is a challenge, tool for community monitoring of nutrition has been evolved. Every Anganwadi Centre has committees called Bal Vikas Samiti in Karnataka which has included nutrition aspects and it is doing tremendous work there, which can be strengthened.
- Some options for future action suggested were:
- a study could be conducted based on the collective experience and the recommendations emerging from the study could to be disseminated at a larger consultative fora including nutrition group, ASHA mentoring group and other groups working on nutrition. This could be followed by lobbying for the inclusion of recommendations at the state level.
- An additional much more focused nutrition module for monitoring and management of malnutrition could be developed for ASHA training.
- A pilot effort to include nutrition in community monitoring could be initiated.
The options are many and the AGCA needs to decide what would be the best way to
- There is a lot happening in states by active civil society groups such as right to food campaign, JSA, Karnataka rally on draft food security bill etc. A sub group of AGCA can be formed comprising members who are willing to lobby on the issue, who can spend time on understanding the issue.
- Evaluation of ASHA programme is going to take place country wide. If nutrition gets flagged in the evaluation, it can show up as a gap. The AGCA can then help to develop a community action strategy to fill the gap.
- The Government can ask some of the states to include community monitoring in their state PIP and to include incentives to ASHA and also AWWs for monitoring nutrition.
The discussions concluded on an agreement that strong community action is needed on a priority basis, which could include
- incentives for ASHA,
- developing a tool on nutrition for inclusion in CM, and
- CHETNA could develop a training module on nutrition.
A TAG/sub-group was formed comprising Dr H Sudarshan, Dr Abhijit Das, Ms Indu Capoor (Convener), Dr Thelma Narayan, Ms Mirai Chatterjee, Dr Dileep Mavalankar and Dr Shanti Ghosh. Operational mechanisms for the sub-group would be worked out by Ms Indu Capoor and shared with the members.
AGCA Recommendations on Community Monitoring
A three member group was to frame a set of recommendations on community monitoring to be sent to the GOI. Dr. Narendra had circulated a draft note on the recommendations.
It was decided that the recommendations would be edited by Dr Abhijit Das and circulated among members for their concurrence. It was felt that there should only be three key recommendations.
Ms Aruna Kashyap’s Note
Ms Kashyap’s note on maternal mortality was discussed at the meeting. The following suggestions/comments were made:
- As maternal death is a critical issue under NRHM, AGCA should partner with all such enterprises to ‘listen and consider’.
- Maternal mortality is a strong community component and it happens within the family.
- A thematic consultation on maternal health with focus on community action can be organized with funding from GoI.
It has been decided unanimously that the issue of maternal health can be taken up in the next AGCA meeting for further discussion.
Interim Actions by AGCA Members
Dr Thelma Narayan concluded the meeting by reiterating interim actions to be taken by the Members as follows:
- Interactions with Planning Commission to be facilitated by Dr. Alok Mukhopadhyay
- National Dissemination Process – to start with active lobbying at the state level for inclusion of community monitoring in state PIPs.
It was suggested that Mr Nanda should write to AGCA members to volunteer to take up the states for lobbying with state governments for inclusion of CM programme in their state PIP and to help the state implementing agencies to settle the first phase of project accounts with PFI. Dr Narendra Gupta agreed to visit the states of Assam and MP as he is familiar with those states. Dr H Sudarshan will visit J&K. As lobbying with states should end by 1st week of December 2009, the AGCA members should make their visits before that. Support for travel expenses of the members would be sought from the GOI. The feedback/reports from the state visits can be discussed at the next AGCA meeting.
- Nutrition Planning – the TAG/sub-group to take the agenda forward
Dr Vijay Aruldas requested time in the next AGCA meeting to present experiences from the four-state project on NRHM strengthening.
It was recommended that a letter to be sent by Mr A R Nanda to the AGCA members who have not attended the last three meetings.
The date for the next meeting was fixed for Tuesday the 15th December, 2009 at PFI.