36th meeting minutes – Jane 15, 2017

• Mr A R Nanda
• Dr Abhay Shukla
• Dr Abhijit Das
• Dr Thelma Narayan
• Dr Narendra Gupta
• Dr Sharad Iyengar
• Ms Indu Capoor

Officials of Ministry of Health and Family Welfare (MoHFW) present

• Ms Limatula Yaden, Director, NHM
• Ms Amita Chauhan, Consultant, NHM

Officials of National Health Systems Resource Centre (NHSRC) present

• Dr Satish Kumar, Senior Advisor, Public Health Planning
• Dr Manoj Kumar Singh, Consultant, Public Health Planning

AGCA Secretariat Staff

• Mr Alok Vajpeyi, Director – Programmes (Acting), PFI
• Mr Bijit Roy
• Mr Daman Ahuja
• Mr Smarajit Chakraborty
• Ms Seema Upadhyay
• Mr Saurabh Raj
• Ms Jolly Jose

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

• Dr Vijay Aruldas
• Dr M Prakasamma
• Dr Saraswati Swain
• Mr Gopi Gopalakrishnan
• Dr H Sudarshan
• Ms Mirai Chatterjee
• Mr Alok Mukhopadhyay
• Ms Poonam Muttreja

Permanent invitees who could not attend the meeting and were given leave of absence

• Dr Rajani Ved, Executive Director (Officiating), NHSRC

• Share updates on the ‘Strengthening Community Action for Health (CAH) under the National Health Mission’ programme for the period December 2016 to June 2017.
• Discussions on:
  1. National Health Policy: Deliberations on the community action aspects.
  2. Commemorating 10 years of CAH under the NHM.
  3. Selection and continuation of State Nodal Organisations for managing implementation of CAH.
  4. Priorities and operationalising the AGCA proposal for the FY 2017-18.

AGCA members confirmed the minutes of the 35th AGCA meeting on December 16, 2016.

Compliance on Action Points from the 35th AGCA meeting

Bijit Roy shared an update on the Action Taken on the 35th AGCA meeting.

• There is a need to have a state level institution which can provide support and facilitate implementation of CAH processes. Options such as either having a team within the State Health Resource Centre (SHRC) or establishing an autonomous facilitation cell like Society for Social Audit, Accountability and Transparency (SSAAT) in Andhra Pradesh and Telangana under the Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS) can be explored. A certain percentage of NHM funds could be earmarked to support the state facilitation structures.
• The AGCA Secretariat is working closely with the Regional Resource Centre-North East (RRC-NE) to strengthen implementation of CAH. In a similar manner, the AGCA Secretariat should work close with the NHSRC and SHRCs to take forward the agenda of CAH.
• The Secretariat should undertake periodic reviews of CAH implementation in the states. Implementation issues and gaps should be presented at the AGCA meetings and shared with the MoHFW for support.
• The MoHFW is laying emphasis on institutionalising grievance redressal mechanisms. The Confidential Report (CR) of the District Chief Medical Officer and the Hospital In-Charges will now include a section on patient satisfaction and redressal of grievances. This provides a window of opportunity to link and address community level issues and gaps which are emerging through the CAH process.
• The scope of grievances should also encompass protection of rights and safety of frontline workers and service providers, as violence against them is becoming an emerging issue.
• Platforms for regular dialogues and interactions between service providers of the hospital, frontline workers like ANM and ASHAs and the community should be developed for sharing feedback as well as understanding limitations of the health system in providing services. This will help mitigate grievances and develop mutual trust among the community and health officials.
• Skills of service providers (especially of doctors and nurses) should be developed to address community grievances and adverse situations.
• As part of the Decentralised Participatory Health Planning (DPHP) process, efforts should be made to seek inputs on community needs and aspirations and develop specific proposals for inclusion in the District and State Programme Implementation Plans (PIPs).
• The DPHP tools developed by the AGCA and the NHSRC can be pre-tested in Maharashtra and other states. The documents subsequently need to be shared with the MoHFW for inputs and dissemination with State Governments.

• The Government of India has limitations in pushing health programmes and priorities to the states, as it is a state subject. It is therefore, not possible for the MoHFW to make legislative provisions for states to adopt an accountability framework on health.
• Inter-ministerial meetings between the Health and Family Welfare and Women and Child Development have been initiated to strengthen convergent action on health.
• Under the third phase of NHM, the MoHFW is focusing on integration of structures and programmes, which include rationalization of Human Resources (HR) who have been deployed under the NHM.
• The MoHFW has taken two initiatives to review and provide feedback to states on implementation progress of the national health programmes: (a) an Independent National Monitoring Scheme is planned to be introduced which would review implementation of various health programmes across the country, especially at the district level and below. Both institutions and individuals can participate in the review process, and b) quarterly video conference with states to assess status of implementation and challenges faced.
• Many states are proposing for additional Human Resources for implementation of CAH as part of their State PIPs, which may not be cost-effective for scaling up. The existing Community Processes structures should be used for CAH implementation.
• Large amounts of funds have been provided to states for training of Village Health Sanitation and Nutrition Committees (VHSNCs), but its efficacy is not known. The MoHFW is planning to undertake an assessment of these trainings.
• The MoHFW has launched the Mera Aspataal (My Hospital) initiative to seek client feedback on services provided in selected public health facilities. This feedback is being analyzed to grade and improve quality of services in health facilities.
• The Common Review Mission (CRM) reports are developed on the basis of a set of checklists, which often do not reflect the realities of the ground and why certain interventions either work or do not work in a particular context. The MoHFW is modifying the Terms of Reference (ToR) of the CRM to include a qualitative section which will capture these details.
• The current phase of the NHM is coming to end on September 30, 2017 and the MoHFW is seeking a cabinet approval for its extension. In line with this, the MoHFW will give an interim approval of the AGCAs proposal for the FY 2017-18 till September 30, 2017. This will be extended on the approval of the next phase of NHM.

National Health Policy: Deliberations on the community action aspects

Mr Nanda requested Dr Satish Kumar, Senior Advisor- Public Health Planning, NHSRC to share an overview of the National Health Policy (NHP) in the context of community action. Dr Kumar shared the following points:

• The National Health Policy has been developed through a consultative process.
• The policy recognises health as a ‘social movement’ towards achieving the goals of the NHP.
• It envisages active engagement of the community in planning and monitoring of health services.
• Panchayati Raj Institutions (PRIs) would be strengthened to play a pivotal role at different levels for health governance, especially addressing the social determinants of health.
• Regional level consultations are planned to be organised to orient the state health officials on the NHP.

• • The Population Commission had identified 12 strategic themes to achieve the goals of the National Population Policy, 2000. Likewise, the National Health Policy should have included a section on strategic themes towards achieving its goals.
  • Population, reproductive rights and fertility regulation have not been appropriately integrated in the policy document.
  • Community Based Monitoring and Planning (CBMP) should be included in the NHP implementation framework, with specifications for allocation of budget.
  • There needs to be a move towards realising right to health care in a phased manner, beginning with comprehensive primary health care especially for maternal and child health, which is now a part of the Janani Sishu Swasthya Karyakram (JSSK).
  • Mechanism for seeking grievance redressal is not detailed in the policy document.
  • Decentralised Health Planning is a mechanism to engage with the community to seek inputs on their health needs and priorities. This also requires allocation of a certain proportion of the health budget to address specific priorities.
  • Members suggested to share the AGCA’s inputs on the NHP implementation framework with the MoHFW and the NHSRC.  The AGCA could also co-opt and seek inputs from external experts on areas such as nutrition, water and sanitation. The following members volunteered to share their inputs.

• A round table can be organised in Delhi to commemorate 10 years of CAH and deliberate on the way forward.
• Officials from the MoHFW, State Governments, public health experts and selected organisations working on community empowerment can be invited to participate.
• Positive outcomes of the CAH process, voices of change from the community, implementation challenges and their possible solutions should be presented at the event.
• The CAH film and spots developed by the Secretariat can be screened at the event.

• Bijit Roy shared that the implementation of CAH processes is being managed by State Nodal Organisations (SNOs) in five states – Assam, Meghalaya, Mizoram, Maharashtra and Punjab. A note on the processes for selection and continuation of SNOs in states is enclosed for reference  as ‘Annexure B.’
• During the pilot phase of CAH, the (SNOs) had played an important role in managing implementation of processes at the state level. To sustain and scale up CAH processes, it is vital to engage with SNOs and sign Memorandum of Understanding (MoU) with them for at least 3-4 years.
• Over the last two years, Maharashtra is following a tendering process to select the SNO. This is leading in prolonged delays in implementation of CAH processes at the district level and below.