• Dr Shanti Ghosh
• Dr Saraswati Swain
• Dr Abhay Shukla
• Dr Narendra Gupta
• Dr Abhijit Das
• Dr Alok Mukhopadhyay
• Ms Indu Capoor

• Dr Ajay K Khare
• Mr Tej Ram Jat
• Dr Rakhal Gaitonde
• Dr Dhananjay Kakde

• Dr Sylvia Selvaraj
• Ms Sunita Singh
  

• Dr Tarun Seem
• Dr Dinesh Baswal

• Mr S Ramaseshan, PFI
• Dr Almas Ali, PFI
• Ms Sona Sharma, PFI
• Ms Sudipta Mukhopadhyay, PFI
• Dr Sanjit Nayak, PFI

• Dr K Pappu
• Prof Ranjit Roy Chaudhury
• Dr Thelma Narayan
• Dr Shyam Ashtekar
• Dr Rama Baru
• Ms Mirai Chatterjee
• Dr Jaiprakash Narayan
• Dr Vijay Aruldas
• Mr A R Nanda
• Dr R S Arole
• Dr Sharad Iyengar
• Dr H Sudarshan

• Request for approval for one additional district of Maharashtra and Karnataka state sent to MoHFW by Secretariat. Approval due.
• The task group meeting on the first phase programme on community monitoring of services under NRHM was held on 13 September 2007 to finalise the tools.
• Revised budget was prepared by the Secretariat and discussed at the discussed at the budget committee meeting at MoHFW on 29 August 2007. The minutes of the budget committee meeting have been circulated. Revised budget to be submitted by the AGCA today.
• Four documents mentioned in the minutes were to be made available to the AGCA. The Secretariat is yet to receive these documents.

• The approval letter for Maharashtra and Karnataka has been issued.
• The immunization report is available on the website. He will also make available the working papers on maternal health.

• The communitisation process is lacking in NRHM. Need to understand how the community perceives ASHA.
• Those who are implementing the programme at the state and district level have not imbibed ideas, values and concepts of NRHM.
• There is need to reflect and ensure that those who are the implementers understand the value of NRHM, the role of PRIs and the follow-up of AHSA.
• Tremendous enthusiasm has been generated with the selection and training of ASHAs. But tragically follow-up is extremely poor. The training is not enough to empower AHSA to be able to conduct all the activities envisaged. There is need for handholding, strengthening her as part of a collective of new community based health worker.
• District officers are of the opinion that ASHA has been thrust upon them. There is disconnect between ASHA and district authorities. This needs to be changed and ASHA should be integrated into the system.
• The system of release of resources under NRHM stills follows the old pattern. As seen from grassroot implementation efforts in Arunachal Pradesh by VHAI and Karuna Trust the process of release of resources and funds is lengthy and the amount does not reach on time. Administrative processes continue to pose a hurdle. There is need to fast track the administrative processes. Mechanisms of administrative processes need to be looked into at the state level.
• NGO involvement in the entire program has been low. Integration of smaller NGOs remains elusive. There is need to build greater ownership among NGOs.
• There is no understanding at the Panchayat level of NRHM. There is no creativity in utilizing untied funds.
• There should be greater focus on states where the implementation of the programme has been difficult.
• Need to address the issue of corruption and political appointments.

1: Materials/posters/CDs:

• Six posters designed
• Four Posters designed in Maharashtra by SATHI- CEHAT
• Briefing kit on community entitlements, roles of providers and frameworks of accountability – English and Hindi – distributed to all states
• Community Monitoring Brochure – English and Hindi distributed
• Four pamphlets for community – designed in Hindi
• CD being prepared with soft copies of all materials

2) Model Curriculum for Trainings and Workshops: 

• Manual draft designed and circulated
• Draft Workshop and Training Curricula designed and circulated
• Model presentations prepared and circulated
• TAG finalizing

3) Tools Development

• Draft Community Mobilization protocols being finalized by TAG
• Draft Community Monitoring protocols being finalized by TAG

4) National Workshop and Stakeholder Consultation 

• Three day workshop was conducted between 19 and 21st July. Attended by over 50 participants (Resource Persons) for the 9 states. Programme details and State reports were shared, and discussion on protocols for community mobilization and monitoring took place.
• National Stakeholders Consultation on NRHM organised in collaboration with Centre for Health and Social Justice (August 8th 2007). Over 100 people participated (Attended by Mission director and other officials, officials from planning commission, AGCA members, international organizations, civil society organizations and experts)

Challenge(s): following are the challenges:

• The process of mutual communication is not yet been set-up
• Documentation part is not yet been regularized
• Technical support from TAG hasn’t been properly institutionalized or regularized
• Functioning feedback mechanism has not been established with the state
• Difficulty to keep timeline in absence of timely financial disbursement

An update on State Level Processes of the Community Monitoring

• Assam :

• AGCA member – Dr Narendra Gupta, State NGO representative Dr Sunil Kaul and National Secretariat PO met with Mission Director, Dr. J.B. Ekka.
• Muhammed Zaheer Abbas Majumder, State NGO Coordinator was appointed as the nodal officer.
• The state mentoring group has been constituted by the Mission Director on 20^th August 2007.
• The pilot districts have been discussed, finalized and notified by the NRHM directorate are – Chirang, Dhemaji and Kamrup rural
• It was decided that the two-day state level workshop would be organized either in first or second week of July 2007 – but had to be postponed
• GO has been issued stating Voluntary Health Association of Assam (VHAA) as the state nodal organization. The MoU is being processed by PFI.

Chhattisgarh

• Early June National Secretariat PO met Health Secretary.
• On 6th July 2007, preparatory meeting was organized with civil society organization in the presence of a government observant.
• The mentoring team was formed in the meeting.
• Three districts were selected for community monitoring with the consultation of Secretary health. They are Baster, Kawardha, Koriya.
• A consortium has been formed to take forward the CM process (PFI, CGVHA and Sandhan). Sandhan is the lead NGO.
• The first mentoring group meeting took place on 25th July 2007
• The state level workshop took place on August 17th and 18th, attended by government officials, mentoring group members and NGOs
• Blocks were selected and a detailed plan of action was prepared
• Second mentoring group meeting took place on August 18th 2007
• Block level NGOs name has been recommended by district offcial Health Secretary along with mentoring team will finalized the name
• Village and Sub-centers have been selected

Maharashtra

• State workshop level workshop was organized on 7-8th June 2007 in Pune. First state mentoring committee meeting held on 7^th June 2007.
• Five districts selected for CM are; Nandurbar, Amravati, Osmanabad, Pune and Thane
• Nodal NGOs agreed upon and accepted by State health department
• Block nodal NGOs identified in all blocks
• TOT was organized August 7-11 2007 in Pune
• Second State mentoring committee meeting took place on 8th August
• First circular on community monitoring issued by State Health Ministry in August 2007.

Madhya Pradesh

• State level workshop was organized on 29th – 30th May 2007. The workshop was attended by Director, Health & Family Welfare, Commissioner, Panchayat & Rural Development, Govt. of M.P, CMO, Chairpersons Health Sub Committee, Zilla Panchayat, NGOs, AGCA members, State Mentoring team members & resource persons
• Blocks, PHC and villages finalized
• Coordination between PRI and Panchayat at district level worked out
• Letter for formation of Village health and Sanitation committee from Panchayat issued and committees are under formation.
• Five day State TOT held at Bhopal on 16th to 20th August 2007.

Orissa

• Four districts for community monitoring in first phase were selected representing 4 geographical zones of the state; Nawarangpur, Jharsuguda, Mayurbhanj, Kendrapada
• The process of selection of one NGO per block is over
• State level workshop on community monitoring was organized on July 24th
• The TOT will take place on 18th Sept
• The AGCM has decided not to choose any district level organization, as the coordination in the district and CM process is the responsibility of mentoring group members.

Karnataka

• On 25th July 2007, a civil society meeting was held at the Community Health Cell (CHC).
• In the meeting it was decided that the project in Karnataka will be called Community Planning and Monitoring of Health Services (CPMHS).
• The state mentoring group has been formed by the civil society side but the health department has yet to approve it.
• Karuna Trust has been selected as state nodal NGO
• The three pilot districts Chamarajnagar- Yelandur, Kollegal and blocks have been finalized

Tamil Nadu

• Two days state level meeting was done in Chennai on 30th and 31st May. The civil society organisations from various backgrounds were participated.
• The state level nodal NGO has been identified. I.e. Tamilnadu Science forum (TNSF).
• State level Mentoring committee members were identified. In the mentoring committee representatives from academic, resource and human rights groups also included.
• The districts were finalized with their suggestion. Kanniyakumari, Perambalur, Dharmapuri, Vellore and Thiruvallur are the five districts choosen to carryout community monitoring project activities.
• Districts were identified along with the district nodal organisation. The districts were chosen on the basis of civil society organisation’s strength in the particular district. Since this is pilot project the criteria was justified by the participant organisations

Rajasthan

• M.L. Jain, Director AIDS/Hospital Administration Rajasthan has been appointed as nodal officer.
• The three member committee consisting of Dr. M. L. Jain, Dr. Shiv Chandra Mathur, Director SIHFW and Dr. Narendra Gupta chose four pilot districts Chittorgarh, Udaipur, Jodhpur and Alwar.
• State Mentoring Group has been constituted.
• The state level workshop was held on the 27 and 28th of July 2007. The district level health department health officials and the CSO’s had participated.

 Jharkhand

• The Mission Director got who had been briefed about community monitoring has been transferred.
• The state health secretary, Mr. Siyaram Prasad Sinha, has made a query on the community monitoring plan so a decision is still pending on the file.
• GO has not been issued as yet.
• Suranjeen Prasad, Mr. Kaushik Saikia and Dr. Anant are keeping a track of the developments at the state level

Challenge(s)

• In few states processes at the state level have been slower than anticipated
• Frequent transfers of officials
• Health department politics
• Political and bureaucratic dynamics
• Government is still seeking clarification about the process of CM
• Delay in getting GO
• Due to late release in fund have delayed CM process in states

• Meeting held with Mr R.K. Meena (Principal Health Secretary) on 2^nd April 2007 in Jaipur
• State nodal officer appointed. Dr. M.L Jain is the state nodal officer.
• Organised state level meeting on 8^th May in Jaipur
• State level mentoring group has been formed.
• All the blocks in each of the 4 pilot districts have been finalised.
• Government order for state nodal NGO has been issued.

• Five day State TOT held at Bhopal on 16^th to 20^th August 2007.
• Preparations underway for organising district level workshops.
• District level coordinators have been selected.
• Block level coordinators have been selected.

• Regarding development of website for the programme, he suggested that a consultant be appointed for developing the website instead of an agency. The site can be hosted by NIC.
• The progress of the programme should be mentioned in the MoHFW website. The status of selection of state nodal NGOs with the names and details should be mentioned in the website.
• Dr Seem requested that his email id be included in the e-group on community monitoring.
• Members of the National ASHA mentoring team have been given responsibility for supporting the ASHA programme in specific states. They should link up with AGCA members related to the state and community monitoring mentoring teams at the state level to help the formation of State ASHA mentoring teams. GoI will provide government order mentioning the same.
• The ToR for the budget committee meeting also includes preparation for the sustainability of the project. PFI to create audit trail of learning and preparations for the second phase proposal to be undertaken at the earliest.
• All materials/tools to be shared with NHSRC, NIHFW, SIHFW in the pilot states and SHRC Raipur.

• The process of mutual communication is not yet been set-up
• Documentation part is weak
• Technical support from TAG hasn’t been properly institutionalized of regularized
• Functioning feedback mechanism has not been established with the state
• Difficulty to keep timeline in absence of timely financial disbursement

• AGCA member – Dr Narendra Gupta, State NGO representative Dr Sunil Kaul and National Secretariat PO met with Mission Director, Dr. J.B. Ekka.
• Muhammed Zaheer Abbas Majumder, State NGO Coordinator was appointed as the nodal officer.
• The mentoring group members have been
• The pilot districts have been discussed and finalized – Chirang, Dhemaji and Kamrup rural
• It was decided that the two-day state level workshop would be organized either in first or second week of July 2007 – but had to be postponed
• GO has been issued stating Voluntary Health Association of Assam (VHAA) as the state nodal organization. The MoU is being processed by PFI.

• Processes at the state level have been slower than anticipated

Jharkhand-

• The Mission director got who had been briefed about community monitoring has been transferred.
• The state health secretary, Mr. Siyaram Prasad Sinha, has made a query on the community monitoring plan so a decision is still pending on the file.
• GO has not been issued as yet.
• Suranjeen Prasad, Mr. Kaushik Saikia and Dr. Anant are keeping a track of the developments at the state level.

• Frequent transfers of officials
• Health department politics

• The three member committee consisting of Dr. M. L. Jain, Dr. Shiv Chandra Mathur and Dr. Narendra Gupta chose four pilot districts Chittor, Udaipur, Jodhpur and Alwar
• The state level workshop was held on the 27 and 28^th of July 2007. The district level health department health officials and the CSO’s had participated.

• Political and bureaucratic dynamics

• Initial discussion happened with the state health secretary and Director of Public health services.
• Draft GO has been sent from Health Secretary to the mission director

• Two days state level meeting was done in Chennai on 30^th and 31^st May. The civil society organisations from various backgrounds were participated.
• The state level nodal NGO has been identified. I.e. Tamilnadu Science forum (TNSF).
• State level Mentoring committee members were identified. In the mentoring committee representatives from academic, resource and human rights groups also included.
• The districts were finalized with their suggestion. Kanniyakumari, Perambalur, Dharmapuri, Vellore and Thiruvallur are the five districts choosen to carryout community monitoring project activities.
• Districts were identified along with the district nodal organisation. The districts were chosen on the basis of civil society organisation’s strength in the particular district. Since this is pilot project the criteria was justified by the participant oranisations

• Government is still seeking clarification about the process of CM
• Delay in getting GO

• On 25^th July 2007, a civil society meeting was held at the Community Health Cell (CHC).
• In the meeting it was decided that the project in Karnataka will be called Community Planning and Monitoring of Health Services (CPMHS).
• The state mentoring group has been formed by the civil society side but the health department has yet to approve it.
• Karuna Trust has been selected as state nodal NGO
• The three pilot districts Chamarajnagar- Yelandur, Kollegal and blocks have been finalized.

• Karnataka project funding yet to be sanctioned at the national level

• 16^th April 2007 in Bhopal state preparatory meeting was organized
• One state level resource group was formed comprising civil society and government officials for time to time technical support
• Five districts were chosen for the CM looking at the geographical diversity; Guna, Sidhi, Bhind, Badwani and Chindwada
• State level workshop was organized on 29^th – 30^th May 2007. The workshop was attended by Director, Health & Family Welfare, Commissioner, Panchayat & Rural Development, Govt. of M.P, CMO, Chairpersons Health Sub Committee, Zilla Panchayat, NGOs, AGCA members, State Mentoring team members & resource persons
• Blocks, PHC and villages finalized
• Coordination between PRI and Panchayat at district level worked out
• Letter for formation of Village health and Sanitation committee from Panchayat issued and committees are under formation.
• Five day State TOT held at Bhopal on 16^th to 20^th August 2007.

• Delay in getting GO

• State Mission Director and Director of Health services attended State Health Assembly organised by JSA – 22-23 Feb., preliminary discussion on CM pilot.
• State workshop level workshop was organized 7-8^th June 2007 in Pune
• Five districts selected for CM are; Nandurbar, Amravati, Osmanabad, Pune and Thane
• Nodal NGOs agreed upon and accepted by State health department
• Block nodal NGOs identified in all blocks
• TOT was organized August 7-11 2007 in Pune
• Second State mentoring committee meeting took place on 8th August

• Government is still seeking clarification about the process of CM
• Involvement of Panchayats yet to get organised in significant manner, likely to develop with field level activities

• The State Advisory Group on Community Monitoring formed
• State secretariat for AGCM is in place
• Four districts for community monitoring in first phase were selected representing 4 geographical zones of the state; Nawarangpur, Jharsuguda, Mayurbhanj, Kendrapada
• The district officials were briefed about the community monitoring by AGCM members in two subcommittees.
• Blocks for community monitoring were selected as per the suggestion of the officials and other community leaders in the concerned districts.
• The process of selection of one NGO per block is already over.
• The letters about provisional selection of NGOs were also issued by the state secretariat.
• The one day orientation to selected NGOs on community monitoring is completed
• The consultation meeting on 11th April 07 built up a consensus among participant NGOs on having Kalinga Centre for Social Development KCSD as the State Nodal NGO for Community Monitoring.
• The proposal of selection of Nodal NGO finally approved by the Mission Director, NRHM, Orissa vide his letter no. OSH&FWS/4603(4)/101/07 dated 22nd May 2007.
• The formation of community monitoring group is formally approved by the Mission Director, NRHM vide his letter no. OSH&FWS/4645/101/07 dated 24th May 2007.
• A broad criteria was fixed by the AGCM
  • Presence of individual NGOs/CBOs in the area.
  • Geographical accessibility of the blocks.
  • Need of the community (served and underserved area)
• Two sub committees were formed
• The members of Sub committee visited two districts each
• State level workshop on community monitoring was organized on July 24^th
• The TOT will take place on 18^th Sept
• The AGCM has decided not to choose any district level organization, the coordination and CM process is the responsibility of mentoring group members.

• Due to timely release in fund is have delayed CM process in the state

• Early June an AGCA representative met Health Secretary
• On 6 July 2007, preparatory meeting was organized with civil society organization in the presence of government observant
• The mentoring team was formed in the meeting
• Three districts selected for community monitoring are Baster, Kawardha, Koriya
• A consortium has been formed to take forward the CM process (PFI, CGVHA and Sandhan)
• The first mentoring group meeting took place on 25th July 2007
• The state level workshop took place on August 17^th and 18^th, attended by government officials, mentoring group members and NGOs
• Blocks were selected and a detailed plan of action was prepared
• Second mentoring group meeting took place on August 18^th 2007
• Block level NGO selection is in process two districts (Baster and Koriya) have done the selection.

• District administration is still seeking clarification about the process of CM

• Selection, Training and Functioning of ASHAs
• Implementation of RCH 2 in NRHM
• Integration of components ( different National Health Programmes)  and health determinants ( nutrition, sanitation, water etc.) in NRHM
• Strengthening Services
• Decentralisation and Community Ownership

• Services must be based on the principle of continuum of care. The health centres must be easily accessible and equipped sufficiently to meet the local health requirements, more importantly with a well-established referral system and emergency transport facilities.
• Doctors and other health providers should not only be knowledgeable about their subject, but should also be culturally competent and must have skills to deal with poor rural women and communities. Doctors should be trained for community-health orientation, empathy and gender sensitivity.
• Many CHCs, PHCs and sub center still need structural and functional up-gradation. Lists of such upgraded PHCs and CHCs must be widely available, with the details of services available being displayed outside the centers.
• The prescribed levels of health care must be provided at all centers and this must be regularly monitored through a system of accreditation.
• Essential drug lists must be available in all the health facilities and accordingly the medicines must be made available. Medicine procurement and distribution mechanisms must be strengthened and free medicines must be ensured to the poor. Medicine kit must also be available with the ASHAs, which must also be refilled timely.
• Special focus must be given to developing systems and guidelines to provide special health care of the vulnerable and marginalised groups including dalits, tribals and other forest dwellers, people affected with HIV, migrant groups and so on – based on their cultural practices and socio-economic situations they live in.
• Similarly special and immediate attention is required to develop systems for ensuring effective health care services during natural disasters, like droughts and floods.
• The roles and functioning of AYUSH department within NRHM must be properly defined. Functions of Ayush doctors, in relation to allopathic practitioners (which include the nursing staff) at the health centres must be clarified immediately.
• Much resource goes into the pulse polio programme and it continues to affect regular service delivery at the periphery, still, polio has not yet been eliminated. The pulse polio programme thus needs a serious and careful revision.
• Vacancies, especially that of service providers must be filled up on a priority basis. In some places it may even be necessary to revise the staffing pattern according to the levels of services that must be provided at various health facilities; accordingly posts must be quickly sanctioned or training provided to the existing staff. Fresh appointments have to be made and contractual appointments must not be treated as a permanent staffing mechanism.
• A transfer policy must be formulated to prevent frequent and irregular transfers of providers and other key functionaries.
• Complete information about various NRHM programmes and schemes (eg RKS, IPHS) should be available with all the Medical Officers and ANMs.
• To ensure a regular presence of health staff in peripheral /remote areas special steps need to be taken. To provide an enabling environment for them following methods can thus be suggested here – providing incentives for serving in rural / difficult areas, develop a good system of referral and backup support (technical and functional) from higher institutions, continuing training module for ANM, revamping the cadre of male health worker.
• Urban Health section must be dealt in more detail in the PIP. Urban health system is dominated by corporate players, and has been completely dissociated from the general healthcare system of the country. Integration between rural and urban health is important.
• Partnership with the private sector must be a thoughtful process, with considerations made to differentiate between engagement with for- profit and non-profit sector. Contractual appointments do not assure long-term quality performance and system stability.
• Costs in private sector are high but there are no regulatory mechanisms for quality assurance. Regulation and standard setting for the private sector needs to be done on a priority basis.

• Not all areas related to RCH services are addressed adequately in the PIPs; some of them that must be dealt in more detail are-
• Adolescent reproductive and sexual health issues are addressed only superficially.
• Gender training for health care providers has to be introduced immediately.
• Equity and access issues for underserved population, including the urban poor has to be defined clearly. The definition of vulnerable population in the PIP is adequate.
• Issues related to maternal health care that need reconsideration include the following
• JSY is being seen as a scheme that covers out of pocket costs for safe delivery. It must be emphasized the JSY support is for nutritional and other support and not for service delivery costs
• Promoting institutional delivery without first addressing or improving the quality of care in these institutions is leading to serious cases of denial of care and the strategy needs to be revisited
• JSY should be seen as a mechanism to strengthen safe delivery should be delinked from institutional delivery.
• Referral systems are very weak almost non-existent and women are ‘ping-ponged’ from one provider to the other.
• Harmful practices like unsupervised use of oxytocin injections before delivery has to be addressed in the programme
• The role of Dais / TBA play a critical role in facilitating access to health services has to be acknowledged and suitable capacity building and empowerment of dais has to be encouraged in remote and underserved areas.

• Expand IEC activities at the village and community levels to provide information about available health services, schemes (including JSY) and other entitlements under NRHM, including the roles of ASHA, for improving community health. There must be wide publicity to the fact that all services mandated through the concrete service guarantees are free.
• ASHA selection and training has not taken place as envisaged in many places.Ensure ASHA training as envisaged and perform regular evaluations of ASHA functioning
• Information about membership, roles and responsibility of Rogi Kalyan Samiti, Village Health and Sanitation Committees etc. must be provided to all stakeholders through a public notice.
• District Action Plan is developed mechanically, without ensuring community participation for addressing the real needs of the community .VHSC has to be activated and village level planning and inter-sectoral coordination must be initiated immediately PRI members must be provided with orientation / training on issues related to community health, village health planning & inter-sectoral coordination

• Information on NRHM functioning has to publicly available at the district and state levels
• Grievance redressal mechanisms and medical and social audits of adverse events and experiences must be instituted and publicized extensively.
• Corruption at all levels is a major problem. It is affecting the functioning of the system and implementation of several programmes. Departmental monitoring, oversight and accountability mechanisms still needs to be developed further and strengthened for meticulous implementation.
• Monitoring should include regulation and performance assessment of NGOs and private providers as well.
• Availability of JSY incentives to women has to be monitored intensively to understand how much money is being received by women and at what time.
• Community monitoring and social audits should be introduced at the soonest for responsible functioning of the public systems.
• The Right to Information must be recognized and used to strengthen governance and reduce corruption
• Roles and potentials of civil society organizations as members of monitoring committees, institutions of capacity building and information gathering must be adequately explored and utilized.