• Dr Abhay Shukla
• Dr Abhijit Das
• Mr Alok Mukhopadhyay
• Mr A R Nanda
• Mr Gopi Gopalakrishnan
• Dr H Sudarshan
• Ms Indu Capoor
• Ms Mirai Chatterjee
• Dr Thelma Narayan
• Dr Vijay Aruldas
• Dr M Prakasamma
• Ms Poonam Muttreja

Representative from the Ministry of Health and Family Welfare (MoHFW)

• Ms Limatula Yaden, Director, National Health Misson, MoHFW

Permanent Invitee

• Dr Rajani Ved, Adviser – Community Processes, National Health Systems Resource Centre (NHSRC)

Representatives from the AGCA Secretariat

• Dr Sanjay Pandey
• Mr Alok Vajpeyi
• Dr Sainath Banerjee
• Mr Gautam Chakraborty
• Ms Francesca Barolo Shergill
• Mr Bijit Roy
• Mr Ajay Misra
• Mr Daman Ahuja
• Ms Tripti Chandra
• Ms Seema Upadhyay
• Ms Jolly Jose

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

• Dr Dileep Mavalankar
• Mr Harsh Mander
• Dr Sharad Iyengar
• Prof Ranjit Roy Chaudhury
• Dr Saraswati Swain
• Dr Narendra Gupta

Ms Poonam Muttreja welcomed the participants  and shared that the objectives of the meeting were to:

• Discuss and finalise AGCAs inputs on the community action component of the draft National Health Policy (NHP)
• Share progress update on ‘Strengthening Community Action for Health under the NHM Programme’ in the last quarter (October – December 2014) and plans for the current quarter (January – March 2015)
• Discuss priority areas for the AGCA proposal for  the financial year 2015-16.

• It would be helpful to organise a meeting with the Family Planning division to discuss steps to operationalise the recommendations of the fact-finding report.
• The MoHFW should consider discontinuing the Expected Level of Achievement (ELA) for family planning.

• Members congratulated the MoHFW for taking the initiative to revise the National Health Policy and emphasising  on comprehensive primary health care.
• The document should urge State Governments to align their existing state health policies as per the revised NHM.
• There is a need to include details on expected outcomes on key health goals along with a set of realistic timelines/ benchmarks for achieving them.
• The MoHFW could consider including a section, which reflects on the key gaps in the implementation of the National Health Policy (2002), especially ‘what has not worked’ and mention ‘how the current policy addresses the gaps’.
• There is no emphasis on addressing issues around gender, social stratification and strategies to reach the most vulnerable.
• Addressing social determinants of health such as nutrition, water and sanitation requires a common framework and a plan to facilitate inter-sectoral/ department convergence. This area needs to be detailed out in the policy document.
• The role of Non-Government Organisations (NGOs) finds little mention in the policy document. The MoHFW could consider including a specific chapter- detailing out the role and engagement with NGOs in supporting the implementation of the NHM.
• Rehabilitative care is an essential component of comprehensive primary health care. Therefore, shifting the entire responsibility of managing the rehabilitative care component to the Ministry of Women and Child Development (MoW&CD) may not work.
• In the finance section, the MoHFW could consider including details on the annual financial projections for the implementation of the health policy.
• The policy needs to share a vision for involving youth and increasing their participation as key stakeholders in achieving the goals of the NHM. Also, emphasis is required on creating greater awareness on the ill effects of tobacco and alcohol consumption.
• Environment and climate change aspects and their impact on health, need to be mentioned in the policy.
• The draft policy mentions the provision of universal primary health care. The principle of universality should however be extended to all levels of health care.
• While mental health finds a mention in the document, there is a need to elaborate on the priority areas and their operationalisation.

• The MoHFW could consider including a section on ‘Right to Health’ in the implementation plan. A phased approach to operationalise the aspect could be deliberated through a consultative process.

• The document needs to include details on (a) continuum of care between the public and private sector and (b) networking between primary and tertiary levels for referral care.

Community Action for Health

• The component on community action for health is weak and finds scattered mention in various sections of the document. The MoHFW should consider including a specific chapter on the overall approach and focus areas on community action for health. The MoHFW could refer to the note submitted by the AGCA in January 2015 in this regard. A copy of the AGCA’s note on community action for health is enclosed for reference as Annexure 2.
• Essential components of community action for health should include:
  • Increasing community awareness on health entitlements
  • Generation of community based evidence on people’s experiences of accessing health services

• Community monitoring through feedback in multi-stakeholder forums and public accountability events like Jan Samvads (Public dialogues)
  • Participatory health planning at community and health facility levels and through inputs in development of block and district health plans.
  • Grievance redressal mechanisms to facilitate timely resolution of issues.
  • Adequate financial resources (at least 2% of the total allocation of the NHM budget) must be earmarked to support community action and accountability mechanisms.
• Capacity building, strengthening community awareness and facilitation of participatory processes may be ensured through suitable civil society organisations.

• The policy should emphasise on strengthening bottom up planning processes, wherein issues/ gaps identified in village health action plans are reflected and feed into the block, district and state NHM Programme Implementation Plans (PIPs)
• The Health Management Information System (HMIS) data collected by service providers is used as a key parameter to measure progress and guide decision making. While this is necessary, it is also important to seek community perception/ feedback on health services. In addition, processes need to be developed to facilitate triangulation of the HMIS and community monitoring data. This aspect needs a mention in the policy document.
• The policy needs to detail operational mechanisms to ensure timely and effective grievance redressal.
• The stress on greater decentralisation is encouraging. However, there is little detail on the role of various tiers of Panchayati Raj Institutions and Urban Local Bodies and the nature of their engagement with the health systems to support implementation of health programmes.

Population stabilisation and family planning

• The approach on population stabilisation should be guided and take into account the reproductive rights framework, with India being a signatory to International Conference   on Population and Development.
• Details on inter-linkages between population and development, equity, gender, sexual and reproductive health are missing in the document. These aspects should be    included and detailed out in the implementation plan.
• There is little emphasis on reproductive health and family planning. The MoHFW could refer to the note submitted by PFI in January 2015 in this regard. A copy of the PFI’s       note on family planning is enclosed for reference as Annexure 3.

Human Resources

• The policy is silent regarding the non availability of doctors in rural areas and how this would be addressed. This needs to be detailed out. Members suggested considering reinitiating the three-year certificate course/diploma course for doctors to address the critical gap.
• Emphasis is required to develop soft skills of health workers on social aspects of health along with the ongoing efforts on technical skill building.
• The policy should clearly give details of how the human resources would be deployed and their duties.   This should be especially detailed for community based frontline workers (ASHAs, ANM and Nurses) at the primary level.
• Many states have discontinued/ sized down the Male Health Workers (MHWs) cadre in the recent past. Continuation and strengthening of this cadre is important to facilitate male involvement, disease surveillance and planning on health determinants.

Regulatory mechanisms — the public and private sectors

• The quality of medical education in the private sector is an area of concern. Higher investments are required to strengthen public institutions, along with a framework to   regulate and monitor the quality of education in private medical institutions.
• Both the private and the public sectors should be made accountable for the services they provide. This would include (a) operationalising an effective regulatory mechanism            to ensure adherence to Standard Treatment Protocols under a comprehensive      legislation/ Clinical Establishment Act (b) protocols on patients’ rights (c) display of           service guarantees and (d) regulation of care through multi-stakeholder bodies.
• Accreditation of services to the private facilities should take into account both price and
  • Under Corporate Social Responsibility, MoHFW and State Governments should seek support from the private sector for managerial and technical innovations, along with leveraging additional financial resources.

AYUSH and local health traditions

• The policy needs to acknowledge the practice and contribution of traditional forms of medicines, especially in remote tribal areas.
• The implementation plan should detail the operational aspects on how AYUSH and local traditions would integrate and complement each other.
• Mention of yoga in the policy is encouraging. However, the section requires further detailing on how it would be integrated and operationalised within the public health system.

Groups with special health needs

• The MoHFW should collaborate with the Ministry of Labour and Employment (MoLE) to work out mechanisms to include occupational health and safety in primary health care.
• Mental health should also be integrated within primary health care, especially for early detection and screening. In addition, health functionaries should be oriented and trained on addressing issues of mental health at the primary health care level.

Other suggestions:

• Care for the elderly– Operational details on care for the elderly are missing. While developing  the implementation plan, a consultative process may be adopted to develop a list of services for the elderly, especially at the primary level.
• Funding for All India Institute of Medical Sciences (AIIMS):  The policy mentions plans to set up 15 new AIIMS. However, considering the cuts in the health sector funding, the financial resources required to support the initiative need to be given.
• Generic and rational drug use: Prescribing generics and the rational use of drug should be an integral part of medical education.
• Use of Information Communication Technology:  Increased coverage and reach of mobile services provide a huge opportunity to design and implement cost effective strategies for providing messages on health services and entitlements, especially for unreached areas/groups. This needs to be included in the policy document.

Feedback from the MoHFW

Ms Limatula Yaden, Director- NHM, shared the following update regarding the draft NHM policy:

• The development of the draft NHM policy was undertaken through a very consultative process. This includes (a) meetings with State Health Secretaries and Mission Directors to seek inputs on priority areas; (b) visits by the MoHFW teams to states to understand the their perspectives and implementation issues; and (c) formation of thematic/ technical  groups to seek inputs on specific areas.
• The process at the MoHFW is being handled by Mr Arun Panda (Additional Secretary) with support from the Joint Secretaries.
• The AGCA could consider seeking an appointment with Mr Panda to share suggestions on the draft policy.
• In addition, detailed inputs/ suggestions could also be provided on the policy, which has been uploaded on the  MoHFW website.

• The states should find value in initiating and expanding the implementation of community action for health. The AGCA needs to develop a group of advocates, who could dispel the distrust and create ownership for the process in the states.
• In the PIPs, many states are only including plans to organise visioning meetings at the state, district and block levels. The AGCA Secretariat needs to work closely with the State NHM teams to support and guide in the development of a comprehensive strategy and action plan to implement the component.
• It may be difficult to allocate additional human resources to manage the Community For Health portfolio at the state level. Efforts should be made to work with the existing community process structures.
• There has been delays in transfer of funds through the treasury route.

Feedback from the AGCA members

• The Secretariat should actively engage with the AGCA members to strategize processes at the state level.
• Efforts should be made to support and strengthen processes in a few states, which have shown interest, rather than investing energies across all states.
• In states, where there is potential, the emphasis should now be on (a) strengthening the State AGCAs to provide guidance to the implementation processes (b) mapping of potential civil society organisations which could support and implement the component, and (c) documenting and sharing innovations with states on various approaches on community action.
• The Secretariat should coordinate and finalise a meeting with the Ministry of Women and Child Development to discuss the next steps for collaboration on community monitoring of the Integrated Child Development Services (ICDS).
• As there is very little experiences on community based planning, it would be good to support a pilot in  two or three states (one district each) over the next two years. The experiences from the pilot could then be documented and shared with the MoHFW for adoption in other states and districts. The next meeting of the AGCA sub-group on community based planning should be organised in February 2015 to further deliberate on this issue. Dr H Sudarshan, Ms Mirai Chatterjee, Ms Indu Capoor and Dr Abhay Shukla volunteered to guide the process.

• A differential approach should be adopted in providing technical assistance to states in the next phase. Members suggested guide implementation and   demonstrate the effectiveness of community action in a few selected states, where maximum energies should be concentrated,  while generalised support could be provided to other states for orienting nodal officers, development of PIPs etc.
• There varied understanding among states on essential/non-negotiable components of community action. Efforts should be made to insist states to retain this emphasis as processes are being implemented.
• Community Action for Health should be linked with the Swachh Bharat Abhiyan of Government of India for greater visibility.
• The AGCA should support/ guide implementation of pilots in selected areas such as community based planning, grievance redressal, use of information technology, community action in urban areas etc. Experiences and lessons from the pilots should be documented and shared with states for adoption.
• The AGCA could explore opportunities for additional funding to support its work on community action.
• The Secretariat should develop and share the proposal note with members for inputs and suggestions by the first week of February 2015.