Minutes of the 20th Meeting of the Advisory Group on Community Action – The National Rural Health Mission
India Habitat Centre, December 24, 2010
Advisory Group Members present
  • Dr Abhay Shukla
  • Dr Abhijit Das
  • Dr H Sudarshan
  • Ms Mirai Chatterjee
  • Dr Narendra Gupta
  • Dr Sharad Iyengar
  • Dr Shanti Ghosh
  • Ms Poonam Muttreja                                                             
Representatives from GOI
  • Mr Amit Mohan Prasad, Joint Secretary, MoHFW
  • Mr Sajjan Kumar Yadav, Director, NRHM, MoHFW
  • Ms P Padmavathy, Deputy Director, NRHM, MoHFW
PFI Representatives
  • Ms Sona Sharma
  • Mr Matish Kumar
AGCA Members who could not attend the meeting and were given leave of absence
  • Mr A R Nanda
  • Dr Alok Mukhopadhyay
  • Dr Dilip Mavalankar
  • Mr Harsh Mander
  • Ms Indu Capoor
  • Dr M Prakasamma
  • Dr R S Arole
  • Prof Ranjit Roy Chaudhury
  • Dr Saraswati Swain
  • Dr Thelma Narayan
  • Dr Vijay Aruldas
  • Sh. Gopi Gopalakrishnan

Ms Poonam Muttreja welcomed the members to the 20th AGCA meeting.  She suggested that the second agenda point: Discussion on Meeting with Planning Commission could be discussed first. This could be followed by the confirmation of the minutes of the last meeting held on September 17, 2010 and other discussion points mentioned in the agenda.

Ms. Muttreja also recommended that an NHSRC representative could be invited to the AGCA meetings as NHRSC is involved in training and strengthening ASHAs at the community level. The group endorsed the idea and it was decided that NHSRC would be invited to the meetings in the future.

Discussion on Meeting with the Planning Commission on Community Monitoring: Suggestions for Next Steps

A meeting to discuss the efforts on community monitoring under the aegis of the AGCA and the way forward, was held at the Planning Commission in the forenoon on December 24, 2010. The meeting was Chaired by Ms. Sudha Pillai, Member Secretary, Planning Commission. Dr. Syeda Hameed, Member, Planning Commission and Dr. N K Sethi, Senior Advisor, Planning Commission, convened the meeting where-in Members of the AGCA and officials from the Planning Commission and the Ministry of Health and Family Welfare participated.

The agenda for the meeting included an overview of the AGCA and the first phase of community monitoring was presented by Ms. Poonam Muttreja. This was followed by state specific experience sharing by the AGCA members and a discussion on the way forward. There was a clear consensus on the need to scale up the community based planning and monitoring component as well as extend it to other sectors.  The deliberations brought out two major action points for follow up:

  • Setting up of a National Resource Centre for Community Action
  • Developing a pilot on convergent community monitoring for services related to ICDS, Water, Sanitation and Health

The two action points were discussed in the AGCA meeting.

  • National Resource Centre
  • Members articulated the need to set in motion the community based monitoring (CBM) component under NRHM. It was felt that inclusion in the PIP is not enough as most states had not initiated implementation of the CBM component. A facilitative process at the national/state level is crucial.
  • The members requested Mr. Prasad, Joint Secretary, MOHFW, to support the process of setting up a National Resource Centre in a time bound manner.
  • The resource centre could initially be at the national level, which could support resources at the state level. The processes would be worked out at the centre where as the technical group would include resources drawn from the state.
  • The secretariat/resource centre would need dedicated staff, with substantial experience in community based processes.

Mr Amit Mohan Prasad made the following points in response to the above:

  • The Planning Commission would like the process of community monitoring or communitization to take place and get embedded in the eight EAG states and Assam on a priority basis.
  • The Planning Commission is also keen on convergent community action as many other programs, which are associated with health, are also rolling out in these nine states. One such program is the Sabla/nutrition program in 200 districts by the Ministry of Women and Child Development (WCD).
  • Annual Health Survey has been instituted through the Registrar General of India (RGI), which is to be carried out in these nine states. 284 districts in these states have been covered. There is thus an opportunity to show the outcomes.
  • In order to make a resource cell sustainable, long term and measurable, it is essential that the cell is located within the states rather than at the national level. The AGCA was requested to locate two-three potential resources/institutions within the nine states and build their capacities to take forward the community monitoring. The Ministry would organize a 2-3 day national workshop for the orientation.

It was decided to revise the concept/proposal around developing the communitization skills of identified institutions/organizations within the high focus states. The proposal would include a lean structure at the national level to support the effort.

Convergent Community Monitoring

In the meeting at the Planning Commission, the AGCA was requested to share a note/proposal for a pilot on multi-sectoral community monitoring for services related to ICDS, Water and Sanitation and Health. Key discussion points by the AGCA members on the topic were:

  • The VHSC in Maharashtra is already called Village Health Sanitation, Water Supply and Nutrition Committee. So convergence is already present in the mandate, only facilitation and capacity building are required.
  • Many committees exist at the village level: Village Health and Sanitation Committee, Bal Vikas Samiti and Sanitation/Drinking Water Committees – these three committees need to be combined to ensure convergence. A joint circular could be issued to facilitate convergence.
  • To ensure convergence, there are two options. One approach is through directives from the different departments or to facilitate the process through NGOs with the help of a supportive government order, as was done in the pilot phase of community monitoring.
  • It was suggested that the implementation of the community monitoring programme need not be restricted to NGOs, but could involve a range of civil society groups, such as – SHGs, people’s organizations, mahila panchayat members, etc. In order to do so, a mapping of NGOs, CBOs, groups etc is needed.
  • Community monitoring comes under two heads: (i) as part of communitization, and (ii) as part of monitoring. When it stands alone, the probability of systems dissonance is high. However, emphasis should be given on planning together with monitoring. Action plans for village/block/district/state level should be prepared for the next year, which would have legitimacy for the aggregate health action plans.
  • Working with VHSCs is very challenging as there are no clear cut guidelines to identify the representatives/members of the community who are not office bearers. Further, the untied funds are placed with the ANM or Sarpanch at the cluster level. Only in CBM villages, ASHA is a member secretary and a Panchayat Member is the convener/chairperson. Clear guidelines for adequate representation needs to be worked out.
  • Since convergence would also be required at the national level, members enquired whether the Ministry of Health and Family Welfare would take the lead in ensuring action towards convergence.

Responding to the above, Mr. Prasad shared that:

  • All departments are expected to come forward as partners to ensure convergence at the community level and it cannot be anchored by any one department/ministry.
  • Some action has already been initiated. For instance a new Mother and Child Card has been prepared jointly by WCD and MOHFW, facilitated by the Joint Secretaries of the two ministries. This was issued under the joint signatures of Secretary MOHFW & WCD, which has been rolled out to all states with some state level adaptations. This is a good point of convergence and the civil society groups can promote the use of the card.
  • The Block Development Officers have 5-6 officers who report to them: Assistant Development Officer (ADO) statistics, ADO agriculture, Panchayat, Rural Development, etc. These officers report to their departmental officers as well. This is an established model of dual reporting which can be extended to the frontline workers. It has already been suggested that the AWWs should start reporting to both, the CDPO/Mukhya Sevikas as well as the ANMs. The WCD has agreed to this.  If ANMs are able to guide both, the ASHA and AWW, convergence will take place.

Common Review Mission: Feedback on the Community Action by AGCA Members

The AGCA members, who participated in the CRM, were requested to include the status of community action in their reports. The Ministry would share the reports with the states and discuss the status and plan for remedial action in the next review meeting scheduled in January, 2011.

Discussion on SevaUttam Citizen’s Charter and Grievance Redressal Mechanism

  • Five of the AGCA members are in the steering group for SevaUttam Citizen’s Charter and Grievance Redressal Mechanism set up by the Ministry. However, not a single meeting has taken place so far.
  • The Ministry representatives said that two meetings of the working group have taken place and the steering group meeting is likely to take place soon.
  • Proactive disclosure under the Right to Information Act should be included as a part of citizen’s charter. This will make the citizen’s charter more effective.
  • Community Planning, along with Monitoring, has been planned in Karnataka to provide inputs at the district level for grievance redressal. At the district level there is a District Health Society and a Mission. The Mission, a higher level reviewing body than the Society will review the grievances and ask the Society to take corrective action.
  • In Maharashtra this year, a three member committee has been set up at the regional level, which includes a regional director, a civil society representative and a retired judge or senior journalist – who will receive complaints, enquire and make recommendations for corrective action – but the committee hasn’t started functioning so far.
  • A number of structures/missions to address grievances already exist: State Health Mission at the state level, district health mission/Rogi Kalyan Samiti (RKS) at the district/PHC level and VHSC at the village level. These have to be activated and empowered to have the authority and capability to do so.
  • Given that it is difficult for women/community representatives on the committee to pluck the courage to question doctors regarding the use of funds, it will be a big challenge to empower them.

Free Treatment and Reducing of Out of Pocket Expenses on Health for the Masses

Dr Narendra Gupta shared different kinds of models for reducing out of pocket expenses.  A majority of the patients get prescriptions from the doctors and have to buy medicines from the market. 23% of people don’t have access to any medicines because they cannot afford it.  The RKS, VHSC can ensure that unnecessary prescriptions are not given and can monitor the system as they represent the community. The monitoring could start with services related to child birth, wherein it should be ensured that women are not issued prescriptions. This could also be included in the community monitoring programme.

The members suggested that procurement and distribution are very complex issues and not directly related to community action. Therefore, this issue should not be taken up by the AGCA. It was suggested that the issue can be discussed at other forums such as the group working on issues related to universal health coverage.

Update from the MoHFW

Mr Amit Mohan Prasad shared new features, which have been included in the guidelines for the next PIP:

  • The MoHFW has identified around 260 backward districts based on low health and other parameters. For these districts, the GoI will give the resource envelopes to the states for transfering the resources to these districts at the beginning of the planning process.
  • The backward districts will be given a weightage of 1.3 to ensure they get adequate resources to cover the resources/infrastructure gaps prevailing in the districts.
  • States have been asked to allocate unutilized budget lines for research and studies on a mandatory basis. The Ministry has also asked the states to identify 2-3 renowned institutions for impact assessment of the NRHM in their states. The budget for this will also be earmarked.

The government representatives committed to send a letter to all states for the CBM component to be implemented in their states as part of the NRHM framework.

It was suggested that specific suggestions/recommendations on communitization, if any, should be sent to Ms Mirai Chatterjee as she is the member of the National Advisory Council.

Travel by Air India

The members shared the challenges in travel by Air India. Responding to the request from members to resolve the issue, Mr Prasad assured that if details of the travel by private airlines can be sent to the Ministry in advance, the exemption will be facilitated early.

It was decided that the next AGCA (21st) meeting will be held on April 5, 2011 at PFI.