Minutes of the 14th Meeting of the Advisory Group on Community Action – The National Rural Health Mission
Voluntary Health Association of India, June 19, 2009
Advisory Group Members present
  • Prof Ranjit Roy Chaudhury – Chair
  • Dr Abhay Shukla
  • Shri Alok Mukopadhyay
  • Dr Dilip Mavalankar
  • Sh. Gopi Gopalakrishnan
  • Dr H Sudarshan
  • Dr Narendra Gupta
  • Dr Saraswati Swain
  • Dr Shanti Ghosh
  • Dr Sharad Iyengar
  • Shri A R Nanda
Representative from GOI
  • Dr Tarun Seem, Dir NRHM
Other invitees
  • Ms Sudipta Mukhopadhyay, CEDPA
  • Ms Pallavi Patel, CHETNA
  • Ms Sunita Singh, CHSJ
  • Mr S Ramaseshan
  • Ms Sona Sharma
  • Dr Almas Ali
AGCA Members who could not attend the meeting and given leave of absence
  • Dr Abhijit Das
  • Sh. Harsh Mander
  • Ms Indu Capoor
  • Ms Mirai Chatterjee                                       
  • Dr R S Arole                                                                            
  • Dr Thelma Narayan                                                      
  • Dr Vijay Aruldas
  • Dr M Prakasamma

Mr. Alok Mukhopadhyay welcomed the members to the meeting. He shared with the members that with the new Health Minister in place and chances of the social sector having more resources in the new budget, one needs to assess how to get better participation of NGOs at the state level. He emphasized that this was an important meeting as a lot of energetic effort had gone into community monitoring with positive results and its continuity needed to be ensured.

Prof Ranjit Roy Chaudhury chaired the meeting. Welcoming the participants, he emphasized that the meeting was important as future initiatives for AGCA were to be discussed and several ideas thrown up in earlier meetings were to be prioritized and taken forward.

Prof Chaudhury reiterated the fact that the TOR for AGCA was specifically to advise on and suggest ways of developing community partnership and ownership for the Mission and stressed that AGCA should particularly avoid getting into implementation directly as that was not part of the mandate for the Group.

Mr A R Nanda, Executive Director, PFI welcomed the participants and special invitees to the meeting. He conveyed that out of 19 members, 7 had requested for leave of absence.   As Dr Thelma Narayanan was absent, Mr. Nanda conveyed her suggestion that a small committee could be formed to take the nutrition agenda forward.

Agenda Item No. 1: Confirmation and Action Taken on the minutes of the 13 AGCA Meeting held on January 23, 2009

The minutes of the 13th AGCA meeting were confirmed.

Ms. Sona Sharma highlighted the actionable points from the 13th meeting of AGCA. Members had no suggestions/comments and the minutes were finalized. Dr. Sudarshan felt that the revised monitoring tool must be shared amongst the members. Mr. Nanda explained that the entire tool has not been revised and as of now, the revisions suggested by the state nodal agencies and TAG members have been included as a matrix in the manual printed.

Agenda Item No. 2: Formal Closure of the Community Monitoring project
  • Status of community monitoring at the state level : The members shared the following information:
    • In Karnataka, the project had gone ahead with planning and monitoring rather than just monitoring. Village health plans had been prepared by the VHSCs over a three day exercise and they had completed two rounds of monitoring in the project area. The community planning and monitoring has now been included in the state PIP and funds are being utilized from NRHM as well as a World Bank project for scaling up the intervention to the whole state.
    • In Rajasthan a similar initiative has been taken up in 180 villages, where the community monitoring programme is going on. Health needs assessment was done by the village health committee members, facilitated by the nodal organization. The assessment identified the areas/gaps and reasons for difficulty in accessing health care and reasons for the ill health situation in the villages and those areas have been taken up for action. The processes required to achieve 100% immunization, 100% ante-natal care and 100% institutional delivery at the village level were also documented and brought out in a printed format.  Training of other government officials was also done and the Government of Rajasthan is taking the initiative forward in the entire state. Manuals for training of VHSCs are also being developed.
    • Community Monitoring is not being taken forward in Madhya Pradesh and has not been included in the State PIP. At the state level culmination workshop, the issue of taking it forward was raised repeatedly, without any satisfactory response. It was suggested that a Mission from the AGCA comprising Mr. Narendra, Dr. Swain and Dr. Thelma could go and meet the Secretary Health, Government of Madhya Pradesh to discuss the issue.
    • Swain informed that the entire NRHM implementation including the community monitoring has slowed down in Orissa state, which could be due to the political situation. Members were urged for support to ensure that it picks up pace once again.
  • Formal acceptance of the Review Report by AGCA: Recommendations from the review were discussed and Members endorsed the recommendation that planning and monitoring must be linked. Discussions on formal acceptance of the review and its recommendations ensued as follows:
    • Reservations were expressed on the state reports of Rajasthan and Maharashtra. It was felt that these reports had near identical conclusions and recommendations and did not capture many of the state specific positive processes and innovations.

Action Points

  • After discussions on the above, it was decided that the reservations on the report would be sent to the author/reviewer and his response sought on the same. Both these (the reservations expressed and the response) would be added on to the report which could then be formally accepted by AGCA.
  • It was also recommended that the AGCA could, on the basis of the review report, frame a set of recommendations and forward the same to the MOHFW. It was decided that a small sub-group comprising Dr. Abhay Shukla, Dr. Sudarshan and Dr. Narendra Gupta would frame these recommendations.
  • Review of the film on the project: The film CDs were distributed to the members for review later owing to time constraint. Members agreed to review the same on their own and to share the feedback.
  • Dissemination plan for the resource manuals and cd : MOHFW requested for 150 sets of the manual and cds and it was suggested that 50 copies each could be sent to the 9 pilot states, the rest could be distributed during the dissemination meeting for the project.
  • National Dissemination Meeting for the project: The need for a dissemination meeting was agreed upon and the following was discussed:
  • Dr Tarun Seem informed the group that the Ministry organized a national workshop with the Mission Directors and Health Secretaries of all states every 3-4 months and each workshop had a specific theme as a focus. The next such workshop was to be held in the second week of August wherein the theme was community processes and action. The AGCA Members would be invited to share the community monitoring experiences during this workshop.
  • Members also agreed that there should be dissemination to a larger audience in addition to the workshop. This dissemination meeting could be held in the last week of August or the first week of September, 2009.

Action Points

  • A steering group for working out the detailed plan for this meeting was formed, comprising Dr. Abhay Shukla, Dr. Sudarshan and Mr. Alok Mukhopadhyay.
  • A crisp document detailing the processes and activities under the project should be printed for sharing at the dissemination meeting.
  • Tarun Seem mentioned that Rs 2000 crores (it is likely that more funds would be allocated for NRHM in the forthcoming budget) has been promised for NRHM and possibly there would be more allocations in the coming budget. He agreed that the planning and monitoring should be linked right from the village level – however, one needs to take into account the current capacities at the village level. Every state prepares the PIP and more than 500 Integrated District Health Action Plans have already been made.
  • A web based MIS which gives utilization and services data in the health facilities is ready for launch. Once launched, the web-based MIS would enable identifying local needs upto the village level and village level planning would then be possible.
  • All the states have been asked to include Community Monitoring in the State PIP and in the NRHM implementation. In Madhya Pradesh some issues do exist and they need to be addressed bilaterally.

Discussion – Key Points

  • It was emphasized that the planning has to be done from below and pointed out that the state plans are taking into account the district plans not the village level plans and at best take only an impressionistic account. This is the history since 1997. The need to get serious about a concrete strategy to build up the capacity of the Village Health and Sanitation Committees to draft village level plans was highlighted.
  • One suggestion was to link planning and monitoring together for GP level plans on pilot basis in 9 states.
  • A second suggestion was that some of the village plans should be prepared , which can be considered as the basis for block, district and state plans.
  • It was pointed out that there are NRHM plans and state/district health plans included in the state/district budget of the state government and the two do not get linked. Secondly  the monitoring aspects – very basic requirement of public health i.e. registration of births and deaths are not being followed and even the causes of death are not identified. The state should find out the causes of death and publicize the same and should take some actions. Since there is no demographer at the district level, the plans are passed on to the state. Building the capacity at the district level for an accurate data collection is thus missing.
  • Nanda informed the members that PFI is yet to receive the state reports from Assam, Madhya Pradesh and Tamil Nadu. To close the first phase of the Community monitoring project, the reports like process documentation and state dissemination workshop report are yet to be received from all the states except Orissa and Karnataka. The Utilization Certificate is also awaited from the states of Tamil Nadu, Madhya Pradesh, Maharashtra and Chhattisgarh.
  • Mr Nanda emphasized the need for early completion of all the pending works related to the project and also urged for the early settlement of advances and early closure accounts of the project.
  • There should be efforts to get the report published in some international publication and some of its findings must be shared in the Parliament. There is a Parliamentary Forum on Population Health with Mr. Tarlochan Singh as the Chairperson. AGCA members could have a meeting with the Parliamentary Forum once it is reconstituted.

Action Points:

  • Taking into cognizance the various suggestions/comments, Dr. Tarun Seem suggested that the AGCA could draft a resolution/recommendation in this regard and forward to the Ministry.
  • As suggested by Dr Tarun Seem, the AGCA unanimously decided to keep 31st July, 2009 as the last date for submission of state specific reports, audited Utilization Certificate and Receipts and Payments account and also agreed that all the state specific informations should be uploaded by the concerned state in the NRHM website. Balance grant remaining with the state/district/block level NGOs should be refunded forthwith to PFI. This will enable PFI to close the project accounts and render final Utilization Certificate to GoI and settle the grant dues if any with GoI.
  • The Chair agreed to Dr. Tarun’s suggestion and stated that the AGCA will draft a resolution/recommendation based on the discussion.
  • It was suggested that a meeting should be fixed with the Registrar General of India on the concern of data collection to identify the causes of death, as there were a lot of complications on causes of death statistics especially in rural areas. However, some of the states have been progressive in collecting the data on deaths and births. Much money has been spent by UNICEF on disease surveillance. Dr. Mavalankar was requested to prepare a two pager on this and share with RGI and can take it up in the next AGCA meeting.
  • Roy Chaudhury concluded the discussion with an agreement that there would be efforts towards sharing the Report findings with a larger audience.
Agenda Item No. 1: Future Initiatives on Community Action under NRHM


The following suggestions on Nutrition emerging from the 13th AGCA meeting were reviewed :

  • Undertake studies on impact of action on nutrition and other social determinants.
  • Engage Ministry of Health and Family Welfare to provide inputs and action on nutrition through a national stakeholders workshop.
  • Nutrition should be located within NHRM and not limited to RCH
  • Need for separate bodies to oversee various ministries since nutrition as an issue is located within various ministries.
  • Need for strategic input by AGCA in nutrition e.g. alliance on nutrition for dialogue with multiple actors and ministries. Also link up with ASHA mentoring group.
  • Equity issues within NRHM as one step getting involved in nutrition.
  • Develop fact sheet on nutrition.
  • Add nutrition and equity agency in the 9 pilot states and link with community monitoring implementation groups.

Members endorsed the suggestions of the Discussion Paper and stressed on the need to proactively follow the issues.

  • There is need to train the VHWs, ANMs and the ASHAs on nutrition related issues and they can in turn talk to the family members about the causes of malnutrition, infection and its prevention.
  • As surveillance for children on nutrition based facts could not be done for all. VHSC could pilot this in some states and ASHAs could be perhaps made responsible for this.
  • Village Health Committees could be converted into Village Health, Sanitation and Nutrition Committees. Through IPK in Andhra, actual feeding programme  has  shown tremendous  achievements for mother and child, which can be replicated as a model under NRHM. As 70% of the children below the age 3 are anaemic, pediatric iron should be made available.
  • In Maharashtra while focusing on community monitoring, there was an effort to cover some other issues like nutrition, irrigation, water supply etc. VHSCs under NRHM can be given the mandate to monitor the AWC and the extreme cases can be identified and given more attention.
  • Tarun Seem responded that NRHM has guidelines covering nutrition component for the infant and young child. There is a provision of post natal visit. The ASHA training programme could perhaps include incentives for undertaking nutrition related work.He suggested that three steps can be taken under NRHM: (a) discharge card could have an IEC material on nutrition, (b) post natal visit of the ANM could have counseling on breastfeeding included as a protocol, and (c) ASHA training on nutrition and inclusion of incentives to track malnutrition.
  • Chaudhury summed up the issue stating that Dr. Thelma’s proposal on nutrition has been accepted in principal.

Community Action for Safer Motherhood: UNICEF

The following were the recommendations/discussions by the members on the concept note circulated:

  • As of now, there has been a greater concentration on processes and inputs and in order to be more focused on key outcomes like deaths, it would be a good idea to take in death enquiry methodology within community monitoring. This could be done on a pilot basis in some states through building capacities of NGOs working on community monitoring, assessing impact on community and then scaling up. The focus could be on the flagship program of JSY.
  • While UNICEF had concentrated on maternal deaths so far, the pilots could also include peri-natal death enquiry.
  • Sudipta would circulate the report on the MAPEDI project in Orissa to the Members.
  • Web-based MIS could reflect the maternal deaths. AGCA can facilitate/recommend an analysis of the web-based MIS at the state level, once it is launched.
  • There was a general agreement by the Members on the need to do a pilot in some states.


Mr. Mukhopadhyay shared with the members that a meeting was called by the PMO to discuss the idea of ‘Mainstreaming AYUSH.’ In the current state of affairs AYUSH is having sufficient resources. There is a need to create a Centre of Excellence for Ayush and a dialogue between ayush and allopathy. As a pilot project the Tamil Nadu co-location experience must be further upscaled.

Public Private Partnership

  • Dr Abhay Shukla stated that since there are no national guidelines on PPP the states implement as per their own understanding. If AGCA approves a Resource Centre, which can undertake studies on impact of PPPs on health rights violation.
  • Sudarshan mentioned that a framework on PPP is being developed and must be made available on internet and felt that PPP needs to be decentralized.
  • Members felt that PPP should be part of a larger discussion and needs more time however two resolutions were recommended: 1) Overall the power to negotiate a pro-poor PPP arrangement should lie with the states and 2) All PPP agreements should be made public in order to check corruption.
  • The AGCA Resource centre could undertake studies on impact of PPPs on health rights violation.

Resource Centre
Mr. Nanda mentioned that the need for establishing a national observatory was discussed in the last AGCA meeting. CHSJ had circulated a note on the proposed resource centre, which included a budget.

Key discussion points were:

  • As the expected outcomes of a resource centre would include functions of an implementing agency and outsourcing activities to produce reports, the resource centre could be added on to the AGCA Secretariat.
  • Most Members felt that as there is already an AGCA Secretariat, the same could be made a resource centre with a budget for specific activities and additional human resource, without making it a very elaborate structure.
  • Once the AGCA/TAG decides on an agenda, the resource centre could recruit appropriate agencies to implement the activities with dedicated support through Secretariat.
  • Dr. Tarun Seem shared a paper on ‘Road Ahead for Community Empowerment under NRHM.’ where in it was proposed that a special cell be set up in the Ministry to specifically act as a resource centre for community action under NRHM and which would also follow up on the community monitoring. However, the Members felt that the resource centre should not be an additional responsibility for the Government and should rest with the civil society.

Action Point:

  • The AGCA unanimously suggested that PFI  – the National Secretariat for AGCA to function as ‘Resource Centre’ to provide necessary input to the AGCA and also to have constant touch with the Central Government and various state governments for research, review and advocacy on ‘Community Action and Community Monitoring under NRHM.’  It was also suggested that all expenses relating to the above incurred by PFI shall have to be met by GoI under NRHM.  Further, it was suggested that to start with PFI may have 2-5 persons and field/area level experts may be hired as and when required for research, review and advocacy. A formal proposal in this regard is to be submitted by PFI to GoI for consideration and approval.

Prof. Roy Chaudhury concluded the discussions with the recommendation that PFI should look at the possibility of strengthening the Secretariat as a resource centre and submit a proposal to GoI.

The next AGCA meeting is proposed to be held on 18 September 2009 (10.30 A.M.) at PFI.