• Dr Abhay Shukla
• Dr Narendra Gupta
• Dr Sharad Iyengar
• Mr A R Nanda
• Ms Mirai Chatterjee
• Dr Saraswati Swain
• Ms Indu Capoor
• Dr H Sudarshan
• Dr Abhijit Das
• Dr Alok Mukhopadhyay
• Ms Poonam Muttreja

Representatives from MoHFW

• Mr Manoj Jhalani, Joint Secretary -Policy, MoHFW
• Ms Limatula Yaden, Director- NRHM, MoHFW

Special Invitee

• Dr T Sundararaman, Director- National Health Systems Resource Centre (NHSRC)

Representatives from AGCA Secretariat

• Dr Sanjay Pandey
• Ms Sona Sharma
• Mr Alok Vajpeyi
• Mr Bijit Roy
• Mr Saurabh Raj
• Ms Jolly Jose

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

• Ranjit Roy Chaudhury
• Dr Thelma Narayan
• Dr Dileep Mavalankar
• Mr Gopi Gopalakrishnan
• Dr M Prakasamma
• Dr Shanti Ghosh
• Mr Harsh Mander
• Dr Vijay Aruldas

• The Union Cabinet has recently approved the National Urban Health Mission (NUHM) as a sub-mission of the National Health Mission (NHM). The NUHM aims to provide equitable health services in urban areas with 50,000+ population size, focusing on urban poor and marginalised section.
• Under the NHM, there are four types of flexi pools (i) NRHM-RCH Flexi pool which includes, RCH and Health Systems Strengthening components (ii) NUHM; (iii) Communicable Disease Control Programmes; and (iv) Non-Communicable Disease Programmes.
• Incentive fund has been introduced to encourage health sector reforms. This includes support for initiatives such as (a) mandatory disclosure and social audit; (b) creating a public health cadre, rational deployment of human resources; and (c) free medicine scheme etc. Within the overall state resource envelope, 90% is generally earmarked for normative allocations and around 10% for performance based funding.
• All Non Communicable Diseases Control Programmes of the 11^th Plan have been segregated into two parts (a) interventions upto the district hospital level including prevention and promotional aspects to be covered under the NHM component, and (b) schemes for tertiary level care to be taken up under Health Sector component.
• The RMNCH+A strategy intends to improve the delivery of continuum of care. A 5/5 matrix has been developed and shared with states to focus on the critical five key interventions, within each aspect.
• More than 15,000 ambulances and over 3,000 other vehicles have been put in place for patient transport. Call-centre based systems like 108 and 102 have also been introduced for easy transportation. The goal is to ensure that all patients reach a PHC within half an hour and to the FRUs within one and half hours time. In addition, social audit for services being provided through mobile medical unit and ambulances have been initiated in many states, since last year. States have been asked to mandatorily place the details of service utilisation in the public domain.
• Allocation of part of the resources to health facilities is to be based on the patient load such as load of In-Patient (IPD), Out- Patient (OPD) and institutional deliveries etc.
• Processes for moving to the free medicine scheme have been initiated and are in different stages of implementation, across 28 States/ Union Territories. Currently, States are spending Rupees 3,500 crore on drugs, while about Rupees 2,000 crore is being provided by the Ministry under various schemes of the NHM. Drugs and supplies in kind under RNTCP, HIV/AIDS, NVBDCP etc are also being provided. However, a lot of back end work, including appropriate supply chain and other support systems are required to effectively implement the scheme.
• Rashtriya Bal Swasthya Karyakram (RBSK) is a new initiative aimed to screen over 27 crore children from the age group of 0 to 18 years for 4 Ds – Defects at birth, Diseases, Defi­ciencies and Development Delays including Disabilities. Children diagnosed with illnesses shall receive follow up treatment, including surgeries at tertiary level, free of cost under NHM. Screening of the new-born, both at the public health facilities and community level, is an important component of the programme. Regular health screening of pre-school children upto 6 years of age using Anganwadi as a platform is an essential component of the scheme. Children from 6 to 18 years of age studying in Government and Government aided schools would also receive regular health check-ups. Children who are being diagnosed for any of the 30 identified illnesses would receive follow-up referral support and treatment, including surgical interventions at tertiary level, free of cost under this scheme. District Early Intervention Centre (DEIC), based at the district hospital would provide curative services under the RBSK, through a dedicated team of 14 health personnel.

The group suggested that services being provided under new schemes like RBSK could be included in the ambit of community monitoring.

• AGCA members mentioned that in Rajasthan, International NGOs who bring their own funding have huge clout with the State Government and influence key policy decisions. UN Agencies directly coordinate with the Government and use local NGOs to implement as per their programme mandate. As a result, many local NGOs have been relegated to being the local sub-contractors.

• Programme Officers attached to individual AGCA members have not been approved. Staff based at AGCA Secretariat would work under the guidance of the AGCA members and provide required technical support to the States to effectively roll out the CAH component.
• Review of grievance redressal models/mechanisms could be undertaken alongwith field visits planned to the state.
• Rogi Kalyan Samiti guidelines and training materials should be developed in collaboration with NHSRC.
• Priority should be given on strengthening the existing structures such as VHSNCs, RKS, Gram Sabhas to facilitate the community action processes under the NHM. Especially, capacities of the PRIs need to be developed to create ownership to take the programme forward.
• The AGCA should undertake an initial review/ baseline to assess the realities at the state level such as (a) progress in implementation on CAH in the states till date (b) review lessons learnt from the pilot phase and subsequent period of implementation and (c) subsequently support States in developing plans for systematically initiating/scaling up CAH, with defined outcomes and timelines.

• The Members suggested that roll out of CAH could focus on three broad areas (i) strengthening of processes– community mobilization, activation of VHSNC RKS and Gram Sabhas, community level enquiry, accountability forums such as Jan Samwaad and promotion of community based planning;  (ii) strengthening/ expansion structures such as State AGCA, District Planning and Monitoring Committees (DPMC) and Block Planning and Monitoring Committees; and (iii) adaptation/simplification of materials and methods- including tools, manuals, training and IEC materials.
• Indicators on nutrition, non-communicable diseases and mental health need to included while the CAH manuals and tools are being revised.
• In Odisha, the State AGCA is chaired by the Health Minister and includes officials from Health, Women and Child Development, Rural Development, alongwith civil society representatives. This model could be replicated in other states to facilitate inter-sectoral convergence and coordination. Mr Manoj Jhalani mentioned that the Ministry would send a letter to the States requesting them to adopt the Odisha model. The AGCA Secretariat will share the terms of reference and members in the Odisha State AGCA with the Ministry.
• The AGCA could support the Ministry in developing an activity template for the CAH component, which could be included in the overall State PIP guidelines, being shared by the Ministry. This would assist States in developing a systematic plan for the CAH component. In the absence of the uniform guidelines, the process of PIP development and implementation of the CAH is most likely to get diluted, as has been the case in Madhya Pradesh.
• NGOs play an important and critical role in the implementation of the CAH programme. The nature of engagement of NGOs would change from direct implementation support to facilitation/ mentoring. Factors such as duration of programme interventions and capacities of communities to manage the processes on their own would guide the role transition of NGOs. This may also require focusing on issues more at the district and state levels.
• VHSNCs and RKS are potential spaces to promote community action. However, these committees require intensive capacity building, supportive supervision and mentoring to fulfil their expected roles. In addition, opportunities should be explored for engagement with village/ community groups such as self help groups, youth groups and other community level networks.
• AGCA could support in piloting CAH in selected cities under the NUHM. A specific working group could be constituted to detail out the processes. The first meeting of the working group would be finalized in consultation with Mr. Harsh Mander (who is chairing the Community Processes Working Group on NUHM) and NHSRC.

• Ms Mirai Chatterjee Gujarat, Bihar, Madhya Pradesh
• Dr H Sudarshan Karnataka, Arunachal Pradesh and Meghalaya
• Regarding the technical support to states, the AGCA members agreed to facilitate processes in the following states:
  • Dr Narendra Gupta, Rajasthan and Sikkim
  • Ms Indu Capoor, Gujarat and Rajasthan
  • Dr Abhay Shukla, Maharashtra and Madhya Pradesh
• A landscape study should be undertaken to map the promising CAH models and potential organizations, which could anchor the roll out of processes, especially at the state level.
• The initial state visits being undertaken by the AGCA Members need to focus on constitution/ re-vitalization of the State AGCA.
  • Dr Sharad Iyengar, Rajasthan and Himachal Pradesh
  • Dr Vijay Aruldas, Mizoram
• Dr Abhijit Das Maharashtra, Orissa and Jharkhand
  • Dr Alok Mukhopadhyay, Jammu and Kashmir, Odisha  and North East States(excluding Mizoram and Nagaland)
  • Dr Thelma Narayan, Tamil Nadu, Madhya Pradesh (in a supporting role)
  • Secretariat Bihar, Jammu and Kashmir, Jharkhand and Uttar Pradesh

• Technical support over the next five months i.e. November, 2013-March, 2014 would focus in 10 states – Gujarat, Mizoram, Madhya Pradesh, Karnataka, Maharashtra, Tamil Nadu, Odisha, Bihar, Rajasthan and Jharkhand.
• There is need to undertake a detailed review of potential challenges in states such as Madhya Pradesh, Rajasthan, Odisha wherein the implementation were stalled since the completion of pilot phase. As the processes are being re-initiated in these states, considerable challenges still remain. The review would help in a deeper analysis of the issues and challenges, and provide guidance on taking more informed decisions, as the process is now being scaled up.
• Dr Abhay Shukla, Dr Narendra Gupta and Ms Poonam Muttreja volunteered to visit Madhya Pradesh to resolve the implementation challenges.
• The AGCA Secretariat will ensure timely sharing of updates/correspondences from the states with Members.

• National Orientation of State Nodal Officers on CAH

A two-day orientation of the state nodal officers on Community Action for Health was organized by the AGCA with support from the MoHFW on September 16-17, 2013, in New Delhi.   The objectives of the workshop were to a) increase understanding on CAH for enhancing accountability of health services; b) share experiences of various CAH models/interventions; and c) develop skills in planning, implementation and scaling-up of CAH.

40 State Nodal Officers/ State level NGOs from 22 States/ Union Territories[1] participated in  the workshop. Representatives from MoHFW, Mr. Manoj Jhalani (Joint Secretary-Policy), Ms Limatula Yaden (Director- NRHM) and Ms Preeti Pant (Director- Urban Health) chaired/ facilitated various sessions during the workshop.

The workshop was facilitated by Dr Abhay Shukla, Dr Narendra Gupta, Dr Vijay Aruldas  and Ms Poonam Muttreja- Member AGCA. In addition, specific sessions were facilitated by Dr Rakhal Gaitonde (SOCHARA), Dr Nitin Jadhav ( SATHI- CEHAT), Mr. Ritesh Laddha and Ms Sona Sharma and Mr. Bijit Roy (AGCA Secretariat).

• Technical support to states to initiate/scale-up CAH

The Secretariat, alongwith the AGCA members provided the following support: (i) Facilitated planning and tool development meeting in  Madhya Pradesh, (ii) Supported NRHM team in Uttar Pradesh to develop their State PIP for the CAH component, this is included in Supplementary State PIP request, pending approval from Ministry (iii) Supported  NRHM team in Jammu and Kashmir, in re-working State PIP, this is included in Supplementary State PIP request, pending approval from Ministry;  and (iv) Facilitated state-level CAH planning in Gujarat.

• Up-gradation of the CAH website

Content editing and updation on the national processes of the website is nearly complete.  Work on the section on ‘State Processes’ is currently underway. The demo URL of the website is  http://html.catpl.co.in/community_action/index.html

Mr Roy shared that during the pilot phase of Community Monitoring, the website content and vendor contract was managed by Center for Health and Social Justice (CHSJ) through an agency- Guwahati Dotocom Services. Post the pilot phase, the website was handed over to the MoHFW. The Secretariat continued to pay for domain renewal and server space charges to the vendor, since 2010. Upon receiving the approval from MoHFW, the vendor was requested to share website contents. However, the vendor sent a bill for Rs 60,000 (@Rs 15,000/ annum as maintenance charges-without prior contractual agreements). Subsequently, website was taken off and vendor did not respond to emails/ phone from Secretariat. The  Secretariat contacted Dr Abhijit Das, Member AGCA and Director CHSJ to request for access to the data.  However, even after continuous efforts Dr Das was unable to facilitate access to the data from the vendor. After a point, Secretariat took a decision not to further negotiate with the vendor. Most contents from the old site have been retrieved after a lot of effort by the Secretariat, except community enquiry data.

AGCA Members mentioned that efforts should continue to retrieve the community enquiry data, from the earlier vendor. The Secretariat has requested Dr Das to facilitate access to the data from Guwahati Dotcom Services.

• Organizing AGCA meetings

Two AGCA meetings were organized between April – September, 2013. The 25^th  AGCA meeting was organized on April 8, 2013, followed by the 26th AGCA meeting on August 21, 2013 (organized in Nirman Bhawan, MoHFW).  The minutes of the two AGCA Meetings have been finalized and circulated in consultation with the Ministry.  

A copy of the presentation, along with a brief on interim activities is enclosed for reference in Annexure ‘B.’

Financial and Administrative Guidelines

Members shared that in most states there are substantial delays in receipt of funds to NGOs to implement the CAH programme. This has resulted in disruption/ discontinuity in implementation of the programme activities at the field level.  The Members requested that the Ministry should direct States to develop appropriate financial and administrative guidelines to ensure disbursement of adequate and timely allocation of financial resources. In addition, the Ministry could explore the option of earmarking specific resources for supporting accountability functions under NHM, in line with the Andhra Pradesh Social Audit Cell (under the Mahatma Gandhi National Rural Employment Guarantee Act)

Dr. T Sundararaman suggested the State should encourage NGOs to submit three year program plan and budget, which is in line with the current NHM PIP Guidelines. The disbursement of funds could however, be done on an annual basis.  The States should also make necessary provisions for ensuring programme continuity for intervening gap- between the close of the fiscal year (March end) and period of approval of the State PIPs (usually upto June-July).

Sharing of Experiences from the 7^th Common Review Mission (CRM) Visits

Mr Alok Vajpeyi, Head,  Core Grants and Knowledge Management, PFI  made a presentation on the CRM findings from Vaishali district in Bihar. Mr Vajpeyi’s presentation was divided into two sections (i) general observations/experiences on infrastructure, quality of care and RCH; and (b) community processes.  A copy of the presentation is enclosed for reference in  Annexure ‘C.’

Key observations on implementation of Community Processes are as follows:

• PRI members are not actively involved in the functioning of the VHSNC, RKS and District Health Society.
• RKS meetings are mostly organized on a need-basis. The minutes of RKS minutes are not being appropriately documented.
• Village Health Sanitation and Nutrition Days (VHSNDs) are being organized on Wednesdays and Fridays and sometimes even on Monday, on rotation. During VHSND, only services such as immunization and ante-natal care are being provided, followed by discussion on health issues.
• Two rounds of trainings for ASHA on module 5, 6,& 7 have been organized till date. ASHAs involvement in tracking pregnant women, review and reporting of infant and maternal deaths is weak.
• No drug kits have been provided to ASHAs since 2009.

• It would be considered a conflict of interest if the state AGCA has a decision-making role in selecting the implementing organization.
• However, if AGCA plays only an advisory and mentoring role, then there is no conflict of interest and it would be essential for the implementing organization to be involved.