Population Foundation of India, July 29, 2011
Advisory Group Members present
- Dr Abhay Shukla
- Mr A R Nanda
- Dr H Sudarshan
- Dr Narendra Gupta
- Dr Sharad Iyengar
- Dr Shanti Ghosh
- Dr Alok Mukhopadhyay
- Ms Indu Capoor
- Dr Saraswati Swain
- Ms Mirai Chatterjee
- Dr Thelma Narayan
- Ms Poonam Muttreja
Representatives from GOI
- Mr Amit Mohan Prasad, Joint Secretary, MoHFW
- Dr Sajjan Singh Yadav, Director-NRHM, MoHFW
- Dr. T Sundararaman, NHSRC
- Dr. Rajani Ved, NHSRC
- Dr Arundhati Mishra
- Dr Rashmi Pachauri
- Ms Sona Sharma
- Mr Bijit Roy
- Ms Kavita Puri Arora
- Ms Sindhu Nambiath
- Ms Parul Sharma
Mr Jagannath Kompella
- Mr Krishan Dhawan
AGCA Members who could not attend the meeting and were given leave of absence
- Dr Abhijit Das
- Dr Dileep Mavalankar
- Mr Harsh Mander
- Dr M Prakasamma
- Dr R S Arole
- Prof Ranjit Roy Chaudhury
- Mr. Gopi Gopalakrishnan
- Dr Vijay Aruldas
Ms. Poonam Muttreja chaired the meeting at the request of the members present. She welcomed all the participants to the twenty-second meeting of the AGCA. She introduced Mr Bijit Roy, who has taken charge as the Programme Officer, Community Action and will be coordinating the AGCA work at the National Secretariat. She also introduced Mr Krishan Dhawan, Management and Planning Expert, who is supporting PFI in its organizational planning and development.
The members confirmed the minutes of the previous meeting held on April 5, 2011.
Key deliberations and decisions taken at the meeting are as follows:
Follow up on the AGCA team’s Barwani visit
Dr H. Sudarshan briefed the members on the status based on the visit by the AGCA team to Bhopal and updates from Barwani. Ms Mirai Chatterjee shared with the group the issues related to maternal deaths in Barwani and Jodhpur, which were discussed at the National Advisory Council (NAC) meeting. NAC had sent in a letter to the Secretary Health, seeking information on action taken. The government response to their letter only mentioned the series of meetings held with various officials and constitution of field monitoring teams in the 264 high focus districts. There was however, no mention of any concrete action being taken.
The members made the following suggestions on further action that could be taken up by the AGCA:
- AGCA should focus its recommendations on community interface and the communitization aspects, such as institutionalizing help desks, organizing regular review meetings, conceptualizing district specific models for community based monitoring (CBM) and institutionalizing redressal mechanism. The scope of these recommendations can be broadened to other districts in Madhya Pradesh as well as in the other states.
- There is an increase in service uptake due to the Janani Suraksha Yojana (JSY), resulting in high case load for deliveries in district hospitals. It was suggested that doctors are not required to conduct normal deliveries, especially given the shortage of doctors in the district hospitals and CHCs. Normal deliveries could be handled by trained nurse midwives and only cases requiring emergency obstetric care need the attention of doctors. The midwifery approach should be adopted with appropriate training and supervision of nurse midwives as a part of the solution in dealing with the case load when there is a shortage of doctors.
- The role of medical colleges in setting standards of care and providing guidance to district level health personnel and facilities is critical. Accountability mechanisms need to be established within these facilities, which would include maternal and perinatal death reviews and audits. In the next phase of NRHM, government plans to provide large scale funding to medical colleges to strengthen their role in mentoring and supervision. AGCA should recommend that such funding be linked to adherence of best practices and review of outcomes including caesarean, maternal and perinatal deaths
- The Madhya Pradesh State Government continues to focus on population control with incentives and targets for sterilization. This is being termed as Expected Level of Achievement (ELA). The AGCA should send in a resolution to the State Government, which emphasizes that family planning programmes should be implemented with a focus on better health for women. This should include contraceptive choices through a rights based approach as mentioned in the National Population Policy 2000. AGCA should recommend removal of targets and incentives in family planning programmes. In addition, Quality of Care (QoC) indicators for family planning also need to be monitored.
In response to the points above, Mr Amit Mohan Prasad, Joint Secretary, MoHFW shared the following:
- MoHFW promotes spacing and limiting methods equally. Efforts for repositioning family planning in the context of maternal and child health have also been initiated.
- The unmet need for family planning is a result of a supply side deficit rather than a lack of demand. The ELA approach puts pressure on service providers to reduce the unmet need. Providers are being sensitized to address the needs of the community and promote a basket of family planning choices.
Government’s engagement with NGOs under NRHM
Mr Amit Mohan Prasad had requested AGCA members for their suggestions on the role of NGOs, which could feed into the NRHM Working Group discussions for the 12th Five Year Plan.
The key suggestions from the group on this were:
- There are already successful joint ventures of NGOs and Government for managing Primary Health Centers (PHC). However, current the financial arrangements include a contribution from NGOs, which is not sustainable. This needs to be modified in the 12thFive Year Plan.
- Existing partnerships between NGOs and the Government, such as the Public Private Partnerships (PPP) models, ASHA mentoring, strengthening of First Referral Units (FRU) etc. provide ample scope for engagement and co-operation.
- An NGO cell led by the AGCA or the National Health Systems Resource Centre (NHSRC) could be created, with around 5-6% of the NRHM budget being earmarked as well as disbursed to NGOs in the 12th
- The Department of Science and Technology (DoST) has an effective framework for collaboration with NGOs. This framework could be reviewed as a model for NGO-MoHFW collaboration. Dr. Sajjan Yadav was requested to coordinate with the DoST to access the framework and circulate it among AGCA members.
- The State Government should develop an operational mechanism for assessment and accreditation of NGOs at the state and district level. Further, there is also a need to establish mechanisms for capacity building and supportive supervision for NGOs.
- Regional Resource Centers (RRC) under the MNGO scheme are good structures to support the capacity building of NGOs. Adequate resources need to be allocated for the same.
- ASHAs need substantial handholding particularly in the unreached areas. The role of NGOs is to strengthen the ASHA and create forums for interface with the health department for redressal of their grievances.
- There is need to sensitize the State Governments that the role of NGOs at times could be adversarial. However, both NGOs and the Government need to move forward and work together with a level of mutual trust and understanding.
- NGOs could provide support in capacity building and strengthening of community led processes: ASHA, VHSC including community monitoring, management of Rogi Kalyan Samiti and district planning.
- The NGOs could provide technical support to the government on:
- Health impact assessments
- PCPNDT Act and its enforcement
- Monitoring rational use of drugs
- Monitoring the private health sector on issues around commissions for diagnostics, quality of care, grievance redressal, etc
- Monitoring referrals to private hospitals
- Insurance gate keeping for Rashtriya Swasthya Bima Yojna(RSBY)
- Monitoring private practice by government doctors
- Strengthening processes for reinforcing patient’s rights in the Maternal and Child Health (MCH) guidelines: right to information, access to records and investigation reports, right to seek a second opinion etc
While responding to the above points, Mr Amit Mohan Prasad made the following suggestions:
The government would like NGOs to engage with NRHM at a larger scale. The NGOs can help in bridging the gaps in service delivery, community empowerment, demand generation etc. He mentioned that the MoHFW was looking forward to concrete suggestions on formulating guidelines for engagement with NGOs.
It was decided that the above recommendations would be circulated among the AGCA members for further inputs and later sent to the MoHFW.
Role of NGOs in Community Monitoring
Based on the discussions during the last AGCA meeting, a note (prepared by Dr Abhay Shukla) on role of NGOs in Community Action under the NRHM was circulated. NGOs have been involved in training, advocacy, networking and building an implementation framework for the CBPM process in the pilot states. In some states, the role of NGOs has been reduced/diluted, which is a matter of concern. In Maharashtra, the government has suggested that there should be an exit policy for NGOs. It was felt that there needs to be a phased transition plan for NGOs, which needs to include a maintenance phase.
The suggestions regarding the role of NGOs in CBPM process could be sent by the MoHFW to the pilot states, which would include: (a) process of selection of rights based NGO (b) how the role of NGOs could be modified over different phases of program implementation, including a mentoring support in the maintenance phase.
AGCA could support in developing the operational mechanisms for engagement of NGOs at the state level. It was felt that the MoHFW needs to play a key role in reinforcing and legitimizing the role of NGOs with the state governments, as well as recognizing their contribution in the CBPM process.
Proposal on Integrated Action Plan (IAP)/Left Wing Extremist (LWE) districts
A draft proposal developed by the sub-group was circulated amongst the members. On behalf of the team, Mr Bijit Roy made a presentation on the draft proposal.
Mr Amit Mohan Prasad shared that NRHM is a decentralized model and that the MoHFW cannot give funds directly to the AGCA to implement community monitoring in the IAP/ LWE districts, as in the pilot phase. He stressed on the need to engage with the state and district administration to leverage resources and increase state ownership.
The AGCA members made the following suggestions:
- As it is a very challenging situation, the AGCA members recommended that the program should be implemented only with an assured financial support from the MoHFW. Leveraging financial support for program implementation from each state would be a difficult proposition and would result in disbursement and implementation delays.
- National and Regional Resource Centers are very essential for providing technical support to the various state governments on the implementation of CBPM and adequate resources need to be allocated for the same.
- The AGCA should only have an advisory role in the implementation of the program in the IAP/ LWE districts. PFI could lead the implementation of the program as the nodal agency.
- MoHFW could send a circular regarding the involvement of AGCA in CBPM in the IAP /LWE districts and suggest inclusion of the component in the next financial year (2012-13) Project Implementation Plan (PIP).
- The IAP/ LWE districts have poor health determinants, for which NRHM is accountable. In order to bring about improvements in the health indicators, these districts require long term resource commitments and a structured plan, including building synergistic partnerships with NGOs.
- A detailed district and block wise situation assessment needs to be undertaken prior to deciding the program scale and implementation timelines.
- There are many NGOs, who have been working in the IAP / LWE districts for the last 15-20 years without problems. These NGOs could play an important role in program implementation in the selected districts.
Role of ASHAs in the NRHM
Ms Mirai Chatterjee shared that the Universal Health Coverage (UHC) report would be submitted to the Planning Commission on August 1, 2011 and subsequently it will be made available in the public domain. The UHC report includes the following recommendations for ASHAs:
- There should be two ASHAs per village with role specifications. One ASHA would be responsible for health education and promotion and the second for service delivery.
- ASHA should receive a fixed amount of Rs 2,000 per month, for upto 6 hours of work plus incentive based remuneration as under the national programmes.
Dr Rajani Ved shared the following discussions from the ASHA Mentoring Group meeting;
- There should be clarity n the roles and responsibilities of ASHAs (both preventive and promotive) in correlation with the other service providers like ANM, MPW and AWW and their role in the VHSC.
- It was recommended that the ASHAs should be accredited and provided career opportunities within the health system.
- Community Process Facilitation Centers to support ASHA training and mentoring should be established
- The over burdening of ASHAs, poor payment mechanism and support structures and need for intensive capacity building and mentoring were discussed
- The key recommendations by the AGCA team on ASHAs’ were;
- The government should consider an honorarium for ASHAs in addition to their performance based incentives
- They should be recognized as full time workers
- Skill upgradation and career development plan for ASHAs needs to be instituted
- An additional incentive could be given to ASHAs for making home visits to vulnerable families and in inaccessible hamlets.
Community Monitoring in Bihar
Ms Poonam Muttreja shared that PFI has been appointed by the State Health Society as the State Nodal cum Technical Agency for implementing CBPM in Bihar. The program will be implemented in 5 districts, covering 300 villages in 10 blocks in the first year (May 2011- April 2012). A brief presentation on the program roll out plan was made by Mr Bijit Roy. He requested AGCA members to provide their technical support to strengthen the roll out of the program in Bihar.
Community Action Experience Sharing Meeting
Dr Abhay Shukla suggested that the AGCA could organize a national workshop with field practitioners on Community Action to share their experiences and lessons learnt. The meeting could also include sharing of CBPM implementation in the states, along with innovations and challenges. It was also suggested that funding sources for organizing the meeting would need to be identified.
PFI felt that the work plans need to be looked into prior to taking this forward.