12th meeting minutes – September 2008 – Community Action for Health

Minutes of the 12th Meeting of the Advisory Group on Community Action – The National Rural Health Mission
Population Foundation of India, September 18-19, 2008

AGCA members present:

Mr A R Nanda (chair)
Dr Abhay Shukla
Dr Abhijit Das
Dr Alok Mukhopadhyay
Ms Indu Capoor
Ms Mirai Chatterjee
Dr Narendra Gupta
Dr Shanti Ghosh
Dr Thelma Narayan

Ministry of Health and Family Welfare, GoI

Mr S K Das, Additional DG (Stats), MoHFW
Dr Tarun Seem, Director, NRHM
Mr Praveen Srivastava, Director (Statistics), MoHFW
Dr Hamid Khan, Consultant, NRHM

Members who are absent:

Prof Ranjit Roy Chaudhury
Dr Vijay Aruldas
Dr H Sudarshan
Harsh Mander
Dr M Prakasamma
Dr R S Arole
Dr Sharad Iyengar
Dr Dilip Mavalankar
Dr Saraswati Swain
Gopi Gopalakrishnan

Special Invitees/Co-opted Members

GTZ Office India
Dr D N Sharma
Dr Suranjeen Prasad
Dr Sudarsan Das
Mr Ameer Khan
Dr Ruchira Neog
Dr Ajay Khare
Dr Sylvia Selvaraj
Dr Dhananjay Kakade
Dr Renu Khanna
Dr S Ramanathan
Dr Ashok Dyalchand
Dr Kumudha Aruldas
Mr S Ramaseshan
Ms Sudipta Mukhopadhyay
Dr Almas Ali
Dr Ruth Vivek
Ms Sunita Singh

Introduction

Mr Nanda welcomed all those present particularly the representatives from MOHFW, GTZ, the representatives from the state nodal NGOs and the three consultants who have expressed an interest to undertake the review of the community monitoring programme. He hoped that GTZ would benefit from the presentation and also share its interest in the community based monitoring and planning effort in the future. Mr Nanda congratulated Dr Narendra Gupta for taking over as managing trustee of Health Watch. Health Watch played a key role in rights based advocacy in the design of RCH-2 and NHRM.

Agenda Item 1: Confirmation of minutes of the 11^th AGCA meeting.

It was mentioned that Dr Tarun Seems suggestions on the minutes were due incorporated. Members confirmed the minutes. The actionable points from the last meeting were all related to the progress of the community monitoring programme and would be covered in the presentation on the progress of the programme.

Agenda Item 2: Progress of Phase – I Programme on Community Monitoring

Dr Abhijit Das presented the progress of the above mentioned programme. The presentation included the following:

State wise progress. A copy of the presentation is attached.
Review

The state wise progress reflected that significant progress has been made in every state since the last quarter. Al preparatory activities have been completed including preparation of tools and trainings. 80% of report cards are ready. In many states like Maharashtra and Chhattisgarh community action efforts have also been initiated as an outcome of the monitoring process. The presentation also highlighted the various innovations adopted across states. Based on the progress following are the recommendations. All states involved including the TAG members recommended that the entire process require continues support beyond 30 September 2008.

Following the presentation AGCA members and state nodal NGO representatives discussed the programme. Following are the highlights of the discussion.

The programme was a good beginning. It has helped check the robustness of the approach. The processes in the programme use a health entitlement approach. In this case the process and involvement has been empowering. It has shown that such data is required at the village level, which is useful to the community and provides people’s perception of services. The tool and the processes will be useful for policy planning, academics and for community action.

However in order to take the programme to scale the various advantages and disadvantages of detailed centralized information as outlined in the programme should be reviewed. Lessons may be drawn from similar problems faced by NREGA, RCH-2 that includes community based processes such as social audits and Community Needs Assessment (CAN) respectively.

There was need to integrate the NRHM data information as overall social development indicators at the village level. Convergence is a critical aspect. Positive facilitation by voluntary organisations can help allay fears and improve convergence between community and government.

The entire effort is still viewed largely as an NGO initiative. There is need for greater involvement of Panchayats and health acre providers in the process.

Recommendations

Based on the status of progress of the programme following are the recommendations made.

Recommendation 1: The current Phase I community monitoring programme must be extended to 31 December 2008.

This will allow all state processes to be completed.
The review process to be completed.
The budgeting norms should be revised to allow for human resources associated with coordination of activities to be included within the activity costs.

Recommendation 2:

The activities must continue in the area in which it has been introduced for at least two more rounds for grounding the process.

VHSCs require further hand holding to own and manage the process
Providers need to part of the process for some more time for them to appreciate the process
The benefits of this process will not show unless repeat rounds of CM are conducted and two more rounds require facilitation

Recommendation 3: Most state have not included CM in their current state PIPs so GoI must facilitate the continuation of the process

GoI could consider providing minimal support for the next six months for ensuring two more rounds. Results will become clearer and next PIP will also be due
GoI is requested to write to states to add CM to current PIP on priority basis
GoI is requested write to states to provide support to CM through the District Planning budget already available in PIP

Recommendation 4:

Extension and up scaling of the process will require continued engagement of the voluntary sector

National level and state level technical/ resource support groups with voluntary sector lead/participation
The plan and budget required should be included within the state and district budgets
Community level facilitation of the process to continue through block and district VOs

Responding to the recommendation, Dr Tarun Seem highlighted that community based monitoring is implementation of the NHRM framework. It is institutionalized in the NRHM framework. Protocols for sustainability (funding) needs to be worked out with state governments after 30 September through supplementary PIP. He mentioned that government of Karnataka has already agreed to support the process in four districts in the state.

Review: Phase I community monitoring programme

Dr Abhijit Das shared the objectives of the review. He mentioned that the review proposed to capture the learning’s from the programme and recommend processes for institutionalization and scaling up. Details of the process is attached. Currently Dr Ashok Dyalchand, Ms Renu Khanna, Dr S Ramanathan and Dr Rajani Ved have expressed interest in undertaking the review. Dr Seem suggested that NHSRC and Planning Commission should also be part of the review.

AGCA members requested letter regarding the review from GoI to all states in the programme seeking appointment of nodal representative from the state government as part of the review. The review document will be presented to the AGCA and shared will all the state governments.

Agenda Item 3: Status of NRHM – Presentation made at MSG meeting.

Dr Tarun Seem presented the status of NRHM. Details of the presentation attached. A copy of the status was also circulated among the members.

Agenda Item 4: Role of AGCA

Dr Mirai Chatterjee as chair of the post lunch session read out the current ToR of the AGCA. These are as follows:

To advise on ways of developing community partnership and ownership for the Mission
To advise on the community monitoring of the various schemes taken up by the Mission
To suggest norms for funding the Schemes and their monitoring
To examine proposals received under NRHM for community/NGO

participation, which are not covered under ongoing Government Schemes

The recommendations of the Advisory Group will be submitted to the Empowered Programme Committee of the National Rural Health Mission
The Population Foundation of India will provide the necessary Secretariat support to the Advisory Group, with suitable assistance from the Ministry of Health and Family Welfare
The meetings of the Advisory Group would be attended by the Mission Director and/or her nominee(s)
The non-official members of the Advisory Group will be entitled to TA/DA with regard to official visits made by them in this connection, as per entitlement.
The Advisory Group may co-opt other experts in the field.

Following is the role of the AGCA as proposed in the 11^th AGCA meeting. Responding to the above following was the suggestion of the AGCA members.

Need for need for convergence within the health sector (with ASHA programme) and convergence with other social sector programmes (NREGA, anti poverty programme) through cross ministry interaction.
There was need to include other topics for discussion at AGCA.
Quarterly AGCA meetings does not fulfill the agenda. Need to develop agenda based position papers, reviews and stronger secretarial support and resource centre mechanism.
Need to focus on determinants of health – action oriented approach e.g. nutrition which brings lot of determinants together.
Community action group should be represented in the MSG, especially proactive members. Members recommended Dr Thelma Narayan as AGCA representative to the MSG.

Responding to the above Dr Tarun Seem mentioned that revisiting the role of AGCA arose from need to find structures and interests of members. Any issues on health can be taken up. The group can propose an institutional mechanism – an observatory, and a sub group of AGCA. GoI may provide funds to PFI as the observatory, which can then conduct studies, co-opt other members, conduct study tours.

Members recommended the above suggestions and mechanism for future institutional support to AGCA. Members also suggested broadening the scope of AGCA to include the following issues along with names of AGCA members as volunteers for preparing background notes for the same through sub groups. All papers will be submitted within one month with focus on community action and sustainable government framework.

Social determinants of health – Ms Mirai Chatterjee (convenor) and Dr Narendra Gupta.
Ayush – Dr Alok Mukhopadhyay
Nutrition – Dr Thelma Narayan (convenor) and Dr Ajay Khare. Focus on pre packaged food and community action on nutrition through a resolution.
Public Private Partnership – Dr Ajay Khare, Dr Abhay Shukla, Dr Dhananjay (convenor).
Concrete service gurantees, decentralized planning, RKS – Dr Abhijit Das (convenor), Dr Abhay Shukla.

Conclusion

Following are the actionable points.

Brief MD, NRHM on progress of Phase I programme, seek support from GoI for activities from 30 September 2008 and notify proposed review process.
Seek direct GoI facilitation in states where there has been no agreement on including community monitoring processes in the supplementary PIP example in Madhya Pradesh.
- Secretariat to sent request to GOI for visit to MP and Orissa.
- GoI to sent letters to all states to include community monitoring toolkit as part of CRM.
Secretariat to send letter to NHSRC seeking participation in programme review.
AGCA to request GoI for providing RCH–2 mid term review report and other evaluations to AGCA.

Minutes of Meeting with Mission Director, NRHM 19 September 2008, Nirman Bhawan

Dr Abhijit Das on behalf of the AGCA members presented the progress of the programme and also highlighted the 4 recommendations of the AGCA and role of AGCA.

The current Phase I community monitoring programme must be extended to 31 December 2008.
The activities must continue in the area in which it has been introduced for at least two more rounds for grounding the process.
Most state have not included CM in their current state PIPs so GoI must facilitate the continuation of the process
Extension and up scaling of the process with continued engagement of the voluntary sector

Responding to the above the Mission Director appreciated the faster pace of progress made under the programme. However he emphasized that the programme was a pilot experiment to develop the tools and institutional process at the state level to undertake communitization under NRHM. He encouraged state nodal NGOs to undertake initiative advocacy at the state level for including it in the PIP the process for which begins from October 2008. Dr Amarjit Sinha and Dr Tarun Seem reiterated that future support for implementing this a programme cannot be provided through the AGCA but through established institutional mechanism through the states with NGO facilitation. GoI would be happy to provide support for facilitating the process as may be required.

Following were the decisions taken:

Secretariat to send request for no cost extension of current programme beyond 30 September 2008.
Secretariat to send request for NHSRC to be part of the review. Based on suggestions by MD, the objective of the review should be to recommend processes for replication and scale-up of the community monitoring programme.
Secretariat to send proposal to GoI for handholding the process of community monitoring for two more rounds which will include national support mechanism.
GoI to send letter to all states requesting for district facilitator to be part of the community based monitoring and planning process.
AGCA to submit concept paper on social determinants on health particularly on nutrition.