• Dr Abhay Shukla
• Dr Narendra Gupta
• Dr Thelma Narayan
• Dr Sharad Iyengar
• Ranjit Roy Chaudhury
• Ms Indu Capoor
• Dr Vijay Aruldas
• Dr Abhijit Das
• Mr Alok Mukhopadhyay
• Ms Poonam Muttreja

Representatives from GOI

• Mr Keshav Desiraju, Secretary, Health and Family Welfare, MoHFW
• Ms Anuradha Gupta, Additional Secretary and Mission Director-NRHM, MoHFW
• Mr C K Mishra, Additional Secretary, MoHFW
• Mr Manoj Jhalani, Joint Secretary (Policy), MoHFW
• Mr Nikunja B. Dhal, Joint Secretary (Urban Health), MoHFW
• Ms Limatula Yaden, Director NRHM, MoHFW
• Ms Arpana Kullu, Consultant, MoHFW

Special Invitee

• Dr Rajani Ved, Advisor, Community Processes, National Health Systems Resource Center(NHSRC)

PFI Representatives

• Dr Sanjay Pandey
• Ms Sona Sharma
• Mr Bijit Roy
• Ms Jolly Jose

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

• Dr Dileep Mavalankar
• Mr Gopi Gopalakrishnan
• Ms Mirai Chatterjee
• Dr M Prakasamma
• Dr Shanti Ghosh
• Dr Saraswati Swain
• Mr A R Nanda
• Dr H Sudarshan
• Mr Harsh Mander

• Efforts should be made to and work closely with Panchayati Raj Institutions (PRI) and strengthen their capacities on community action such as organizing Village Health Sanitation and Nutrition Day (VHSND).
• Experiences from the recent Mid Day Meal (MDM) incident in Bihar have revealed that there was virtually no involvement of the community in the management of the program. The incident could have been averted through active engagement of the community in monitoring the delivery of MDM services at the village level.
• Community monitoring (CM) process should aim to cover key programmes such as NRHM, ICDS and MDM. The community groups, especially PRI members should be sensitized on their entitlements. They should also be given due recognition and their concerns need to be heard.
• Issues and learning’s emerging from the CM process should be appropriately reflected into Programme Implementation Plan (PIP) at the block, district and state level.
• Norms and guidelines need to be developed for reimbursing costs to community members for their oversight role.
• ASHA programme has been working well on the ground. This makes a strong case for higher investments in ASHA education. ASHA should also be given specific responsibilities in promoting community action.
• The CM process should be expanded to include more than Reproductive and Child Health (RCH) interventions such as non communicable diseases, access to regular treatment for long term illnesses etc.
• The National Urban Health Mission (NUHM) being rolled out in states will require a component of CM and oversight. There is need to deliberate on the modifications, which would be required in implementing the component in the urban context.

Ms Anuradha Gupta, Additional Secretary and Mission Director shared the following points:

• There is strong articulation of CM in the NRHM Implementation Framework. However, the scale-up of the program has been very limited.
• Structures like VHSNC, RKS (Rogi Kalyan Samities) and PRIs are important for facilitating community engagement. However, members of these committees are mostly unaware of their roles and responsibilities. The AGCA should support states in developing a comprehensive strategy for their capacity building and mentoring.
• In some states, there are issues of trust deficit wherein the relationship among Civil Society Organizations (CSO) and the state have become acrimonious. The health system feels that CM is a fault finding exercise. There is need to strengthen collaboration and ensure that there is a shared vision of CM at the state level. In addition, there should be a code of conduct for CSOs and Government for taking forward the collaboration.
• CSO facilitating the implementation of CM also need to develop a withdrawal plan, allowing the community to take over and sustain the program.

Dr Rajani Ved, Advisor, Community Processes, NHSRC, shared the following points:

• In Chhattisgarh, strengthening of VHSNC is being done through the Mitanin programme structure The state has appointed a VHSNC Coordinator at the block level, to support and guide VHSNCs in monitoring the delivery of services on health and other social determinants. This model could be adopted by other states. In addition, NGOs should be actively involved in facilitating the training of VHNSC members.
• During the State Nodal Officers Meeting in July, 2013, some officers mentioned that there is no long term follow up by the AGCA. There is need to develop a mechanism to hand hold and support states in implementing the CM component.
• In the Guidelines for Community Processes, the section on Public Services Monitoring Tool includes a set of indictors. States should be encouraged to use the tool for monitoring the delivery of services.
• NHSRC is also developing a training module for VHSNC. This would be finalized and circulated soon.

The following points were shared by the AGCA Members:

• The members suggested that Community Based Monitoring and Planning (CBMP) should be renamed as Community Action for Health (CAH). This will widen the scope of community engagement not just limiting it to community monitoring. The suggestion was endorsed by the Ministry.
• The AGCA members could be invited to participate in the NGO selection processes at the state level.
• AGCA could regular reports to the Ministry highlighting issues, which require attention/ support at the field level. The AGCA Secretariat could take the responsibility of compiling reports from the states and sharing it with the Ministry.
• In last seven years of NRHM, a lot has been achieved, especially with the ASHAs and VHSNCs on the ground. Looking forward, more attention is required to ensure rights of grass root workers, rest rooms in health facility for Accredited Social Health Activist (ASHA) and other workers, addressing issues around their safety etc. In addition, there is need to include a cross- cutting gender theme as a part of the National Health Mission (including both NRHM and NUHM).
• CM of nutrition services under the ICDS and MDM schemes have been initiated in selected blocks in Maharashtra. Issues emerging from the process requires action from three line Ministries- Health and Family Welfare, Women and Child Development and Education (Sarva Shiksha Abhiyaan). Therefore, there is need to develop a mechanism for inter-ministerial/departmental dialogue.
• In Maharashtra, inputs have been provided to incorporate community priorities and innovations in of the Block PIPs, across 6 blocks in FY 2013-14. However, most of these elements were dropped at the PIP finalization stage at the district and state level. There has to be a mechanism to ensure that  community priorities and innovations are retained as the processes are being finalized at the district level.
• In Maharashtra, RKS is emerging as a potential space for promoting community engagement. Joint meeting of the VHSNC and RKS are being organized to discuss on how resources available with the RKS be optimally allocated to address the patents priorities. A recent evaluation shows, 30-60% of the RKS funds are now being utilized on the basis of the patient priority.
• Ms Muttreja mentioned that the AGCA Secretariat and AGCA members have been volunteering their time to provide technical assistance to various state governments on CM. As of now there is no formal mechanism to ensure long term follow up by AGCA members. It is to ensure long term support to states, that the AGCA has submitted a proposal on ‘Strengthening Community Action under NRHM’ to the Ministry.

• CM is a complex and relatively new process, which requires intensive facilitation at the state and district level. Most of expertise on the process lies at the state level. Therefore, while the overall process should be coordinated by the Secretariat, the support structure will need to be decentralized. Provision should be made for a Program Manager to be attached to the AGCA members actively engaged in running the CAH program. The Program Manager, alongwith the AGCA member would provide support to a cluster of states in rolling out CM.
• There is need for greater synergy between AGCA, NHSRC and National Institute of Health and Family Welfare (NIHFW). To begin with, sessions on CM should be included in the training curricula of District and Block Medical Officers and District Program Managers (DPM), being organized at NIHFW. On this suggestion it was clarified that AGCA and NHSRC work in close collaboration.
• Operational Sub-Committee (OSC) will have to be constituted on specific theme areas. The OSC would provide overall guidance in rolling out processes for technical support. The OSC would comprise of AGCA members, experts and consultants. The OSC should also include a thematic group on process evaluation and documentation to ensure research rigour. The proposal could also include specific roles for research institutions.
• The AGCA should review and provide feedback on the criteria for selection of NGO (as outlined in the National NGO Guidelines). For implementation of CM, preference should be given organizations, which have prior experience of working on rights based / accountability issues.
• Evidence based outcomes need to be included in the proposal. To this, Ms Muttreja responded that as this was a proposal for technical support and actual implementation would happen through the state governments, it is not possible to include outcome indicators. However, specific deliverables such as number of states provided assistance for developing CM component for state PIPs, development of manuals and guidelines for VHSNC and RKS, processes for selection of NGOs developed and capacities of a cadre of master trainers developed, have been included in the proposal.
• Mental health should be included as a component of the CM process.

Feedback from the Ministry

• Revised proposal has been submitted to the Ministry on August 13, 2013. The Ministry is yet to review the revised proposal.
• AGCA members should focus on building state level capacities to implement CM. One of the strategies would be to develop a State level AGCA, in each state. There could also be one structure for Community Processes as a whole, combining the ASHA and the VHSNC groups. This is working quite well in states such as Madhya Pradesh and Odisha. Guidelines for formation of this group, inclusion of CSOs and outlining the role of AGCA within this group need to be detailed out.
• In each state, a roadmap should be developed to cover all districts and blocks, within the next 4-5 years. The implementation of CM should initially focus on the 184 high priority districts, with the weakest health indictors. These districts are now receiving 30% higher financial allocations and technical support from development partners is also being harmonized. The CM process should also review progress based on the district score cards and dashboard indicators, on a quarterly basis.
• If the decision on selection of NGOs is entirely left to the states, they might select NGOs who will not be able to do anything. Therefore, AGCA members should be involved in processes for selection of NGOs at the state level.
• The CM tools should developed keeping in mind the program priorities such as (a) Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) -new interventions such as Janani Shishu Swathya Karyakram-JSSK and Home Based New Born Care-HBNC, Rashtriya Bal Suraksha Karyakram-RBSK; (b) Communicable Diseases; (c) Non Communicable Diseases and (d) Health System Functioning
• The Secretariat should submit a Quarterly Progress Report to the Ministry The report would include details on progress in the roll out of the CBMP program and also highlight the issues which require support, in each state. In addition, the AGCA should develop a quarterly newsletter. It was suggested that the website may serve that purpose.
• A separate guideline for selection of NGOs to implement the CM component would be difficult. Efforts should focus on selecting the right NGOs and building their capacities.
• AGCA should revise the proposal based on the discussion in the meeting and submit it to the Ministry at the earliest. The Ministry would take fifteen days to review and approve the proposal.

• The website should be called Community Action for Health
• Details on state level activities and resource allocations for CM should be included in the website.
• Sub-committee of the AGCA should be formed to vet the content which goes into website.
• A section on progress reports and newsletters on CM to be included.
• Efforts could be made to gather experiences and case studies on CM processes, beyond the AGCA members work.
• Website should have a Hindi interface.

• Secretariat oriented the State Nodal Officers (managing Community Processes portfolio) on CM in July, 2013
• AGCA members have a facilitated visioning and planning meeting in Madhya Pradesh in July, 2013. The next meeting for developing the CM tools is planned on August 23-24, 2013.
• Secretariat has assisted in re-working the CM proposal and budget for Uttar Pradesh. The state would include the component in their Supplementary PIP request.
• Secretariat is reworking Jammu and Kashmir CM proposal and budget. This would submitted in their Supplementary State PIP request .

• Request for a date to organize a visioning and planning meeting has been sent to the Gujarat Government. A confirmation on the date is awaited.

iii) Orientation Workshop for State Nodal Officers and NGOs on CM

• The workshop will be organized on September 16-17, 2013 in New Delhi by the AGCA Secretariat under the guidance of Mr. Manoj Jhalani and Ms Limatula Yaden.
• Agenda for the workshop has been shared with the Ministry and AGCA members for their inputs
• Invitations for the workshop have been sent out by the Ministry to the State NRHM Mission Directors.

• The Ministry has approved the CM proposals for 15 states in the current FY 2013-14. These states include Himachal Pradesh, Karnataka, Maharashtra, Gujarat, Madhya Pradesh, Bihar, Jharkhand, Chhattisgarh, Rajasthan, Odisha, Mizoram, Sikkim, Tripura, Manipur and Meghalaya.
• An amount of approximately Rupees Eighteen Crores have been allocated to these states. The Ministry will send out letters regarding the involvement of AGCA members in rolling out the program in these states.
• The Ministry has informed the other states to include the CM component in their Supplementary PIP request. The Ministry would allocate adequate resources to states, based on  their Supplementary PIP request.

• Mr Desiraju mentioned that a letter signed by Secretary, Women and Child Development (W&CD) and Secretary, Health and Family Welfare could be sent to the states to initiate joint monitoring of services. Subsequently, a joint meeting with the W&CD could also be organized.
• Monitoring of ICDS services could be included as a part of the CM process, especially in states where CM is being implemented for some time.
• Scope of CM could be also expanded to monitor nutrition services being provided under the Mid Day Meal scheme.
• Frontline health workers (ANM) should be oriented to monitor the quality of supplementary nutrition being served in the Anganwadi Centres.

• Service delivery in slums needs to be improved rather than focusing on health seeking behaviour of the slum dwellers.
• Women in slum areas are very busy with their daily chores. Therefore, there is need to ensure that health services reaches their doorstep.
• Issues of behaviour of service providers and demands for informal payments (both the private and public sector) require special attention.
• Reaching the unreached should be a priority area under the NUHM. Specific strategies need to be designed to reach out to the most marginalized groups such as pavement dwellers.
• Health services in urban areas are primarily provided by the private sector. There is need to introduce stringent regulation and monitoring of services being provided by them.
• Mapping exercises should be undertaken to identify potential CSOs in urban areas, who could be involved in the implementation of the NUHM. NGOs working with marginalized groups should be involved in the situational analysis exercises.
• Due to migration, different languages are spoken within a cluster of slums. This aspect needs to be considered in the process of selection and orientation of community health workers.
• AGCA could support in developing the guidelines for MAS and RKS. In addition, it could also support in piloting CM models in selected cities.
• MAS by its definition is not inclusive. The committee should also have the flexibility of including men, especially single male migrants.
• There should be a mechanism to monitor and ensure that free beds are being provided to Economically Weaker Sections (EWS) in the large trust hospitals.
• The AGCA members requested Mr Dhal to share the NUHM Implementation Framework along with budget.

• Theme based OSC need to be constituted to advise the Secretariat in operationalizing the program at various states. External experts could be invited to provide inputs in the OSC.
• A Training of Trainers (ToT) needs to be organized for staff who would facilitate process at the national and state level.
• Each AGCA member could provide support to a maximum of three states (2 being optimal). Provision would be made in the budget for a full time support person to assist the AGCA member in rolling out the CM processes at the state level.
• Technical support to states could be divided into three sections on basis of the progress made in the implementation of CM- (i) new states (ii) states where processes have to be re-activated, (iii) mature states- requiring scale up planning. This will be helpful in developing a detailed workplan for support to states.

The AGCA members agreed to visit the following states:

• Dr Thelma Narayan                         –              Meghalaya
• Dr Sharad Iyengar                            –              Himachal Pradesh
• Dr Vijay Aruldas                                                –              Mizoram
• Dr Abhijit Das                                     –              Sikkim, Bihar, Orissa
• Dr Narendra Gupta                         –              Manipur
• Ms Indu Capoor                                                –              Gujarat and Rajasthan
• Dr Abhay Shukla                               –              Madhya Pradesh

• To ensure uninterrupted implementation of activities during ‘interregnum’ period of April to June (period when previous year’s PIP is completed but the new year’s PIP has not yet been sanctioned), routine activities and expenses should be allowable out of the nodal organisations’ own resources and / or previous balance funds. The scope of these routine activities may be defined in context of CBMP to avoid any ambiguity.
• Balance amount available with nodal organisations on 31^st March of any year would be carried forward to the next financial year. Instalment from NRHM in fresh financial year would be made with deduction of such amount.
• State nodal agency should review the financial and activity progress and submit a revised budget keeping in mind the activities planned and funds required for execution of the planned activities, by mid January.
• Second instalment (50% of total approved budget) should be released within 15 days after submission of audited financial report of previous year and unaudited report of first six months (April – Sept.) of current year. Provided that relevant documents are provided, this instalment should be released latest by end October every year.
• Any delays in finalization of the new year’s PIP at national level should not hold up conduction of regular activities by ongoing nodal civil society organisations during the first few months of the financial year (see point f below). Agreement of State NRHM providing Grant in aid by State with the State nodal agency should be signed latest by mid June every year. The first instalment (50% of the total approved budget) should be released within 15 days of signing the agreement with State nodal agency and submission of unaudited report for previous financial year; if these preconditions are ensured by mid June, then funds should be released latest by end June every year.
• Fund transfer / flow guidelines: Many civil society organisations involved in grassroots work may not have abundant reserves, hence sustaining activities in the face of continually delayed or irregular supply of funds by the state becomes extremely difficult. Keeping this in mind, it is essential that fund flow is smooth, timely and regular with minimum hurdles and delays. Following are some broad suggested timelines, based on experience of implementing CBMP activities in Maharashtra over six years (2007-08 to 2012-13). The exact timelines may vary in different states, but the overall objective of time bound and adequate disbursal of funds must be ensured.
• Reporting requirements: Reports would be submitted by nodal civil society organisation to NRHM for both activities conducted and funds utilized. Reports may comprise of following types of documents:
• Activity progress report: This includes statement on progress of activities as per the plan. Any specific support required from the State NRHM for effective execution of the planned activities may be mentioned in the progress reports. Six monthly reporting is desirable, maximum frequency of activity reporting may be three monthly.
• Financial reporting: Financial report should be submitted on the lines of the approved budget. Reasons and justification for any variance in expenditure of more than 10% should be provided. Six monthly reporting is desirable, maximum frequency of financial reporting may be three monthly.
• Revised budget: On basis of progress of activities and the utilization of funds for the first 9 months of the programme, a realistic estimate of both activities and funds should be made to understand the extent to which planned activities and originally approved budget would be accomplished. A revised and reallocated budget could be submitted by mid January in each activity / financial year, indicating the activities set out to be achieved and the funds to be utilized by the end of the year. This would be a revised budget which would guide expenditures during the last quarter of the year.

• External audit of CBMP and other components of NRHM being implemented by NGOs may be conducted by the State NRHM on a yearly basis.
• Auditors appointed by State should visit the State nodal agency and should also visit district wise nodal implementing agencies, while conducting audit of the previous financial year. Details regarding required financial documents and information should be communicated by auditors in advance to nodal NGOs, based on which required information and documents would be provided to the auditors.
• Audit initiated by the State NRHM may be completed and report submitted to the state nodal agency latest by mid-August of the fresh financial year. Compliance report should be submitted by the State nodal agency by end August of the fresh financial year. Any issues related to compliance of the previous financial year should be resolved and closed by end September of the fresh financial year.

• Regarding the proposed CBMP component for next year’s PIP, State NRHM should communicate with the state nodal NGO well in advance (preferably giving at least a month) before the deadline for preparation of annual state PIP. This would allow for state level collective planning by all concerned civil society organisations for next year’s activities, enabling them to prepare and submit proposed CBMP component for the state PIP in the stipulated time.
• At least two meetings need to be organized at state level between nodal civil society organizations and State NRHM officials regarding planning for community action components in the PIP; the first meeting can be conducted during initial stage of PIP preparation, for discussion about key community action processes to be included in next year’s PIP. Following submission of a draft plan and budget by the state nodal organisation, a second meeting can be conducted during finalization of the state PIP, to discuss any modifications being suggested by the state NRHM, related to the plan given by civil society organizations. The State mentoring committee or a sub-group of the same can facilitate these meetings if required. Similar consultative processes may be followed regarding the supplementary PIP.
• There should be timely written communication from state NRHM to nodal organisations about inclusion / exclusion of various heads suggested by civil society organizations in the proposed state PIP, and subsequently regarding approvals or ROPs based on national level discussions (say within one week of the decisions being taken).
• As proportion of the total NRHM budget for each state, some minimum percentage should be earmarked at national level for community accountability and action processes such as CBMP. The percentage should be mentioned in the annual national level guidelines, and corresponding allocation in state PIPs can be reviewed by State mentoring committee at state level and AGCA at national level. AGCA should have a formal mandate to annually review the Community accountability and action components in all State PIPs, before these are finalized at national level.