• Prof Ranjit Roy Chaudhury
• Mr A R Nanda
• Dr Saraswati Swain
• Dr Abhay Shukla
• Dr Alok Mukhopadhyay
• Ms Indu Capoor
• Dr Abhijit Das
• Dr Narendra Gupta
• Dr Shanti Ghosh
• Dr H Sudarshan
• Dr Thelma Narayan
• Ms Poonam Muttreja

Representatives from GOI

• Mr Amit Mohan Prasad, Joint Secretary, MoHFW
• Mr Ajit Kumar, Deputy Director-NRHM, MoHFW

PFI Representatives

• Mr Krishan Dhawan
• Mr Bijit Roy

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

• Dr Sharad Iyengar
• Ms Mirai Chatterjee
• Dr Dilip Mavalankar
• Mr Harsh Mander
• Mr R S Arole
• Mr Gopi Gopalakrishnan
• Dr Vijay Aruldas
• Dr M Prakasamma

Ms Poonam Muttreja welcomed all the participants to the twenty- third meeting of the AGCA. She requested Prof Ranjit Roy Chaudhury to chair the meeting. The following points were discussed prior to the deliberations on the agenda items:

• As the current phase of the NRHM will be completed in April 2012, it was suggested that a small group from the AGCA should seek an appointment with the new Union Health Secretary to discuss issues on community action, which need to be incorporated in the next phase of the NRHM. Ms Poonam Muttreja requested members to share the specific issues on community action which to need to be discussed with the Union Health Secretary. Thereafter, a letter seeking an appointment for the meeting will be sent by the Secretariat.
• Prof Ranjit Roy Chaudhury shared that the NRHM Media Center/ NHSRC has brought out some good reports, particularly on ASHAs, JSY and HMIS. These could be reviewed and used as a reference in the AGCA meetings.

• Targets on family planning are being strongly imposed by some of the State Governments, including Madhya Pradesh. She mentioned that in Madhya Pradesh, strong actions were being taken against ANMs and CMOs for not meeting their family planning targets, including suspensions.
• The existing practice of setting targets for family planning based on calculations at the state/district levels, termed as the Expected Level of Achievement (ELA), should be discontinued. Family planning requirements should be based on the community needs assessment of each locality (village/ ward). The village/ ward plan should feed into the development of block, district and state level plans.
• In states like Andhra Pradesh and Madhya Pradesh the entire focus of the Health Department is being shifted from delivery of maternal and child health services towards achieving family planning targets. The ANMs and gynecologists are mostly busy in managing family planning camps.
• There is need for greater attention on increasing contraceptive choices and promoting quality family planning services as an entitlement, to enable people to demand for family planning / sterilizations services.
• Issues of sex selection and improving the quality of care within existing family planning programs also need to be addressed.

In response to the points above, Mr Amit Mohan Prasad shared the following:

• The ELA approach puts a pressure on service providers to reduce the high unmet need for contraception. The government has to provide some targets/ estimations to the states to measure efforts being made.
• Ideally, the Community Needs Assessment (CNA) should be adopted for developing the family planning requirements. However, aggregation of village health plans to develop the block, district and state plan is a lengthy and difficult process to adopt.
• Family planning should be repositioned within the framework of maternal and child health. Equal emphasis should be put on promoting limiting methods as well as spacing methods. To increase the adoption of family planning services at the community level, condoms and OCPs are being planned to be distributed through the ASHAs.
• There is a need to push for more human resources (especially obstetricians and gynecologists) in the NRHM to ensure adequate attention to both, maternal and child health and family planning programmes.

• The Health Department’s efforts were entirely focused on the sterilization programme. There were 18 Obstetricians, 8 Anesthetists in the district, but very few institutional deliveries were being conducted.
• Most of the 24 X 7 PHCs visited were found to be non functional.  There were shortages of essential drugs, IFA and, RCH Kits – A and B in most health facilities.  These shortages are primarily because of a failure to adopt an appropriate procurement and supply chain management system.
• The laboratory services were non-existent as the facilities did not have the budgets to procure reagents for conducting the tests. Urine and hemoglobin tests were not being conducted as a part of the regular ANC by ANMs.
• There are long delays in disbursement of JSY benefits to women and ASHAs.
• A high proportion of beneficiaries were accessing services from private nursing homes due to poor quality of services in the public health facilities. This is resulting in high out of pocket expenditure for beneficiaries, like Rs 1000/- for an ANC to Rs 10000/- for a C –Section.
• There has been an increase in NSV acceptors. However, the demand and use of temporary methods of contraception are still very low.

Feedback from AGCA Members:

• It was recommended that the Ministry should request AGCA members to participate in the state level CRM briefing meetings and also share findings from the community monitoring processes with the CRM members.
• The Ministry should regularly review the action taken by various State Governments on the gap areas/ recommendations of the CRM visits.
• There is a need for an in-depth review on the management and administrative issues like private practice by government doctors, procurement and availability of drugs and initiating reward systems for health functionaries who are performing their job well.
• Participatory process evaluation methods like appreciative enquiries, outcome mapping etc. could be used in the CRM. These participatory methods will help in analyzing factors like the implementer’s perspectives and challenges.

Dr Thelma Narayan was requested to send a note on the inclusion of participatory methodology in the CRM. This would be discussed in the next AGCA meeting and later submitted to the Ministry.

Feedback from the Ministry:

Mr Amit Mohan Prasad shared the following points on the CRM:

• The CRM team visited fifteen states (ten high focus and five non-high focus states) during November 8 to 15, 2011. A detailed TOR, including a 16 points chart and handbook containing the major findings of the previous CRMs were provided to each team.  The teams were requested to review progress on the current Annual Programme Implementation Plan (PIP) as well as action taken on the previous CRM recommendations.  A national meeting was organized by the Ministry in which all the CRM team members and the different divisions of the Ministry were present.
• A national CRM report (including state chapters) is being developed. The dissemination meeting is proposed to be organized in January, 2012. The Ministry will invite state government representatives, CRM team members, AGCA members and donor agencies to participate in the meeting.
• Some of the key recommendations, which emerged from the CRM review, include; (i) strengthening procurement and supply of RCH drugs (ii) review of policy regarding private practice by government doctors, (iii) review of data on maternal mortality rate (RGI and SRS).
• The Ministry has constituted an integrated field monitoring team in the 264 high focused districts across 21 states for ongoing review of the NRHM.

• The members emphasized the need to institutionalize a grievance redressal mechanism, particularly at the district level by constituting a District Vigilance Committee. The committee could be chaired by the Member of Parliament/Member of Legislative Assembly (as in the NREGA) and include the District Collector and Chief Medical Officer as members in the committee.
• The process of grievance redressal needs to be participatory, with active involvement of civil society groups. Joint reviews need to be conducted for cases of maternal / infant deaths. This process will enable a dialogue between the complainant and concerned officials/ health functionaries. It will also help in identifying the systemic barriers/ failures and negligence/errors of health functionaries.
• The National Campaign for People’s Right to Information (NCPRI) has prepared a draft on the Right to Service Delivery and Grievance Redressal Bill, 2011. It was suggested that the AGCA could review the NCPRI draft and provide inputs on health related aspects.

• Community action needs to focus on determinants of health like nutrition, access to safe water and sanitation, which are an integral part of NRHM. There is need to develop a clear strategy on integrating community action on health determinants.
• There is a need to assess the burden of work which ASHAs have and recommend to the government to consider an appropriate honorarium. The delays in payment of performance based incentives also need to be addressed. The need for a mentoring/supervision for the ASHA’s was brought up.
• The implementation of the VHSC component under the NRHM has been very weak. There is a need to strengthen these committees through systematic trainings and ongoing mentoring plan, as in the ASHA program.
• There is need for better convergence between the Health and Women and Children Departments to improve the delivery of service at the grassroots level.
• Enhancing counseling and communication skills of frontline functionaries is very much needed to facilitate behavior change at the community level.

• A strong resource centre, with dedicated human resources and funding is required take issues on community action forward and provide necessary inputs to the Ministry and State Governments.
• The role of the National Secretariat needs to be enhanced with more concrete roles like undertaking action research, supporting and monitoring community action issues at the state level.
• The AGCA should take stock of the implementation of the community action component under the NRHM by the various state governments. The review will broadly include (a) the current scale of implementation, funding support (b) identify instances of effective implementation (c) identify challenges in implementation (d) generate recommendations for future action. This review could be funded from the unspent balances from the pilot phase. A proposal from the AGCA could be submitted to the Ministry for approval.
• The scope of community monitoring should be expanded to integrate nutrition, water and sanitation components. There should be a single committee at the village level, which provides oversight on the nutrition, water, sanitation and health services like the Village Health, Sanitation and Nutrition Committee (VHSNC) in Maharashtra.

Mr Amit Mohan Prasad made the following suggestions:

• Under the RCH programme, there are Regional Resource Centres (RRC) at the state level.  Their mandate could be expanded to include the component of community action. The AGCA / State Nodal NGOs could develop capacities of the RRC to facilitate the process of community action.
• In the NRHM Annual PIP Guidelines, it has been mentioned that community monitoring would be funded by the state government. Therefore, the Ministry cannot directly allocated funds to the AGCA.
• The State Governments should consider making the VHSNC, a sub-committee of the Gram Panchayat.  Under the 12^th Five Year Plan, ANM, Anganwadi Workers and ASHA should also be brought under the oversight of the VHSNC of the Gram Panchayat.