Minutes of the 16th Meeting of the Advisory Group on Community Action – The National Rural Health Mission
Population Foundation of India, December 15, 2009
Advisory Group Members present
  • Dr H Sudarshan –  Chair
  • Dr Thelma Narayan                           
  • Dr Abhijit Das
  • Dr Narendra Gupta
  • Shri Alok Mukopadhyay
  • Dr Shanti Ghosh                                                                                              
  • Ms Indu Capoor
  • Dr Vijay Aruldas
  • Dr Abhay Shukla
  • Shri Gopi Gopalakrishnan
  • Dr Sharad Iyengar
  • Shri A R Nanda
Representative from GOI
  • Dr Tarun Seem, Director, NRHM
Other invitees
  • Dr Almas Ali, PFI
  • Mr S Ramaseshan, PFI
  • Ms Sona Sharma, PFI
  • Ms Jolly Jose
AGCA Members who could not attend the meeting and were given leave of absence
  • Dr Dilip Mavalankar
  • Sh. Harsh Mander
  • Ms Mirai Chatterjee                                       
  • Dr R S Arole                                                                            
  • Dr M Prakasamma
  • Prof Ranjit Roy Chaudhury
  • Dr Saraswati Swain

Mr. A R Nanda welcomed the members and other invitees to the 16th AGCA meeting. He shared that this is an important meeting as the AGCA has been asked to develop a framework for increasing involvement of Civil Society Organizations in NRHM. He conveyed that this time four members had requested leave of absence due to their prior commitments and some of the members would be joining in the meeting for some time. He requested Dr H Sudarshan to Chair the meeting. 

Agenda Item No. 1: Confirmation and Action Taken on the minutes of the 15th AGCA Meeting held on September 18, 2009

The minutes of the 15th AGCA meeting were confirmed.

Action Points from the 15th AGCA Meeting

Ms Sona Sharma, Joint Director (A&C), PFI briefed the following actionable points and its action taken from the 15th AGCA meeting:

  Actionable Points Action Taken
1. One person from CHSJ and a senior person (from accounts) from PFI should visit the states to sort out problems if any and get the final UCs and other documents. Mr CSN Murthy, Finance Officer had visited Chhattisgarh on December 7-8, 2009 and M P on December 9-10, 2009 to sort out the problems in connection with final UCs and other documents. Ms Sunita Singh, CHSJ also visited Chhattisgarh.
2. The AGCA recommendations on Community Monitoring would be edited by Dr Abhijit Das and circulated among members for their concurrence. A note was circulated to the members by email and the copy of the same is enclosed for discussion at the 16th AGCA meeting.
3. A letter to be sent by Mr A R Nanda to the AGCA members who have not attended the last three meetings. It was found that Dr R S Arole once chaired the meeting and Mr Harsh Mander attended none of the meetings – action to be taken.
4. The issue of maternal health can be taken up in the 16th AGCA meeting for further discussion. Since other issues have to be taken up in this meeting, it has been postponed to the next meeting.
5. Dr Vijay Aruldas requested time in the next AGCA meeting to present experiences from the four-state project on NRHM strengthening. Dr Vijay Aruldas’ presentation has been included in the agenda

Status on Community Monitoring (First Phase)

Mr S Ramaseshan, S&T, PFI shared that as per the decisions of the 15th AGCA meeting held on September 18, 2009, Mr CSN Murthy, Finance Officer, PFI had visited Chhattisgarh and Madhya Pradesh and sorted out the problems in connection with the submission of  audited Utilization Certificate.  He said that since then audited Utilization Certificate has been received from Chhattisgarh and as far as MPVS is concerned, as the auditors were out of town when Mr. Murthy visited, the audited UC from MPVS is yet to be received. He said that the audited UC from Maharashtra has also been received for a part portion and the balance is expected to be received from them shortly. The tables showing the status of NRHM as on 14.12.2009 (finance and others) are attached as Annexure I.

Then the issue regarding uploading of the state specific information in the Community Monitoring website was discussed.  Mr Seshan mentioned that at the meeting held at the office of Dr Tarun Seem it was decided that –

  • The contract for maintenance of the website was extended for some more time so that rest of the information can be uploaded in the website using the services of CHSJ.
  • Ms Sunita Singh was deputed to Assam and Chhattisgarh to assist the states in uploading the data in the website.
  • To reimburse the travel expenses in connection with the state visits and the expenses related to the maintenance of the website from out of the project funds.
  • Since there is a compatibility problem with regard to the transfer of the website to the NRHM website, the same will remain in the website maintained by CHSJ/PFI and a link will be provided at NRHM website for all future references.

PFI and CHSJ had agreed to render their honorary services for some more time in completing the above tasks and submit the final audited UC to GoI.

Further, Mr Seshan informed that the Comptroller and Auditor General of India (CAG) audit was conducted during November 17-30, 2009 in PFI and it was the first time that a CAG audit was carried out at PFI.  He also informed that there were no major adverse observations received from the audit and it was successfully completed.

Agenda Item No. 2:  De-briefing on meeting with Mr P K Pradhan, Mission Director (NRHM) on November 3, 2009 at Nirman Bhawan, New Delhi

A small group of AGCA members including Dr Narendra Gupta, Ms Indu Capoor, Dr Thelma Narayan, Dr Saraswati Swain and Dr Abhay Shukla met with Mr. P K Pradhan to brief him on the first phase of community monitoring implemented in nine states. The group strongly recommended that the community monitoring and action needs to be included in the State PIPs in order to take the process forward.  The Mission Director suggested that AGCA could assist in (i) scrutinizing specifically whether the aspect of community monitoring and action is included or not in the state PIPs, and (ii) propose a specific road map for community action, including provisions to be made in the state PIPs.

Dr Abhijit Das mentioned that a note on ‘Strengthening Community Action in NRHM: Recommendations for Action within State PIP’ was circulated by email on November 30, 2009 and feedback on the same was awaited.

Mr Nanda mentioned that all the states have to complete their PIP (2010-11) preparation and submit to GoI by the end of December 2009 and the discussion will start by 2nd part of January or early February 2010. Some states the civil society groups have taken an initiative to get involved in the PIP development. For example in UP, the development partners formed small groups to work out recommendations on different issues based on experiences in the field. As a secretariat, PFI is also trying to include CM activities in the Bihar state PIP.

Feedback on Community Action from the states/CRM by AGCA Members

  • In Chhattisgarh, the efforts were made to take the CM programme forward and even in the inclusion of state PIP. However, the NGO response is very poor there.
  • Dr Narendra Gupta shared that in Rajasthan there was no problem: it has been included in the PIP, the funds are available for the process and received ‘go ahead’ sign from the Ministry. It was decided to upscale the CM activities in the existing districts with the involvement of more PHCs, more villages and more CHCs.
  • Ms Indu Capoor mentioned that when we think of pure form of CM and how it was done, it is very difficult to replicate within the government system. Gujarat VHSC module was developed and CHETNA has done the ToT for all the districts.
  • In Tamil Nadu, a series of meetings was held on CM at the state level and found that there is a resistance to using the word ‘community monitoring’, so it should be community empowerment, planning and monitoring. The state has planned to intensify the efforts in the same districts by including more villages.
  • In Karnataka, the programme is going ahead. World Bank has accepted the proposal and called for expression of interest in selecting the nodal agencies for technical assistance to scale up the programme to the entire state.
  • In Maharashtra, the state selected 8 district level NGOs in 8 new districts through an elaborate systematic process. A newspaper advertisement with clear criteria and experience was given in all the eight districts for inviting expression of interest. 200 applications were received from 8 districts and 5-6 NGOs were shortlisted in each district based on the criteria. A Joint Appraisal Team was appointed and they visited each district and interviewed each shortlisted NGO.  As ASHA is completely cut off from the CM programme, the attempt this year would be to link with ASHA and VHSC in the scaling up programme. In the existing five districts in Maharashtra, the programme has been intensified.  There are three models. Some NGOs have taken new blocks, some have taken new PHCs within the existing blocks and some have taken new villages within the existing PHCs and thus, covering the entire PHCs.  It was suggested that a note on the process adopted in Maharashtra could be circulated as a model to others.
  • Dr Alok Mukhopadhyay briefed about the Mid Term Appraisal of the 11th five year Plan by the Planning Commission. The process is completed now. From every state of India, the beneficiaries (NRHM, minorities, women and child health programme) were called for the meeting.  Rs 1200 crores have been earmarked for the minorities and there are 130 programmes. The Mid Term Appraisal showed that most people know only four programmes. It was suggested that as community monitoring is inevitable in all social sector programmes, the mechanisms adopted in community monitoring and other related programmes like ICDS should come into the knowledge of the people at the grass roots.
  • Dr Sudarshan reiterated the need for ‘triangulation’ stating that it is only with triangulation that the community monitoring data gets authenticity and gets incorporated in the District level Planning.

CM Progress and Planning in other States by Dr Tarun Seem

The following points were discussed:

  • The PIP process is on not over. Maharasthra is getting 2.5 crore in the current year. Some states have not included CM in the PIP.
  • Somebody from the group needs to take ownership of the states as the process is little more professional. The PIPs are being prepared using the district plans and the district plans are prepared in a decentralized manner. A small group consisting people from NHSRC, NIHFW are guiding the plan process. AGCA though not currently involved could be included in the planning process in the next year. The Secretary, Ms Sujatha Rao has very comprehensive views on NGO engagement in NRHM, which need to be discussed.
  • NGO involvement for the next phase in the state PIP, after the community monitoring phase I over, the Government of India is going to support only for 6 states in the country, as it is a very complex, and the people in the state are not there to handhold. The amount of work done in the states of Assam, Jharkhand, MP, Orissa and Maharashtra, is commendable. There are states, which have not included community monitoring at all such as Uttarakhand, Punjab and Gujarat whereas UP has committed an amount of Rs 20 lakhs. Gujarat has not committed a lot of money but, it seems to have lot of activities there.
  • All the documentation related to the PIP preparation is on the website of the Ministry. It is in public domain. The reports such as DLHS, CRM, JRM, Community Monitoring and Planning Commission evaluation report are used for the process.
  • A central support to the community monitoring initiative is not going to work in Phase II because the first has not given a comfortable completion as far as the audit is concerned and the money was a complex issue. The state will directly put into the state PIP and the money will be issued by the government to the state government/SHRCs directly, except some small amount of money such as travel etc to PFI as the AGCA Secretariat. Some illuminations will be done even in those lines.
  • Triangulation is very important, it is there in JRM and RCH commitment and possible to do it in some of the states as model.
  • In most of the states plans are maturing. More and more funds are going to be untied funds such as RKS. More money is going for travel and capacity building. Therefore, CM or CA should be keeping an eye on that.
  • The Secretary, Ms Sujatha Rao desires that the issue on NGO involvement in CM programme should be broadened. All types of participation – RKS, mentoring group, CRM, TB, Malaria, Leprosy etc. needs to be there.  Everybody is engaging NGOs in a fragmented manner.  Therefore, there is a need for a comprehensive policy for a meaningful engagement with the civil society.
  • GIA committee needs to be constituted at the central and state levels whereas the AGCA may need to contest for a space there, may be voting rights will be there. Otherwise every state will design their own model and some of the progressive states like Gujarat and Maharashtra will score up and Chhattisgarh and Jharkhand will fail again in the process. Otherwise, again the work will be concentrated on the BIMARU states and other high focused states will get all the attention.
  • CRM results will be shared with the rest of the country and the reviewers. Based on the reports, 1/3 of the districts are doing miserably like other social sector programmes. There is a scope to activate the community monitoring programme through a selected group not only at the state level but at the central level also, those districts where nothing happening. Funding issue – crores of money has been funding to NGOs through agencies but, in some states nothing has happened.  There is a possibility of synergy. One link worker can also do community monitoring role, if they are being paid.
Agenda Item No. 3: Discussion on Overaching Framework for NGO Engagement under NRHM

Based on the email received by Dr Tarun Seem regarding NGO engagement under NRHM, an AGCA sub- group consisting Dr Abhijit Das, Dr Thelma Narayan, Dr Abhay Shukla, Dr Almas Ali and Ms Sona Sharma, prepared a draft power-point presentation on ‘Framework for Involvement of Civil Society Organizations in NRHM’ on the previous day of the AGCA meeting i.e. on December 14, 2009 and circulated to the members for their feedback.

On December 15, 2009, on behalf of the team, Dr Abhijit Das made a presentation on ‘Framework for Involvement of Civil Society Organizations in NRHM’ at the AGCA meeting.  The suggested comments, especially made on the goals, definitions of CSOs, principles and values, role of CSOs, structure etc, with the mutual agreement of the AGCA members were incorporated in the presentation. The revised version is attached as Annexure II.

Dr Tarun Seem mentioned that the NRHM framework envisages Grant in Aid for NGOs (upto 5% of NGO NRHM budget) and the GIA committee is to be set up by the State Health Mission at the state level. The Secretary has very wide view on NGO engagement almost parallel to the health system. As the government is sending so much of money to the state governments which will ensure compliance, the GoI should be able to monitor the outcomes using non-governmental protocols and agencies. That is the level of involvement the Secretary is looking for. Decisions have to be taken by MOHFW regarding the best way for involving the NGOs more effectively in the work of the Ministry.  This is the work of the Ministry: MNGO, AGCA, AMG, RKSs, VHSC, CM, ASHA and other trainings, NDC programmes etc. The Secretary, MoHFW has made the following suggestions for the effective involvement of NGOs in the programme:

  • Acknowledge role of NGOs in monitoring, capacity building, service provisioning
  • Establish SHSRC with assistance of NHSRC, AGCA, States Governments
  • Establish key NGO(s) in each state to work in tandem with SHSRC on various themes
  • Establish GIA committee at the state level with a GoI nominee
  • NGO engagements of all programme constituents of NRHM should be built into the state PIP with the engagement of NHSRC and the contribution of various NGOs
  • States be granted flexibility to continue or modify the MNGO scheme
  • NHSRC to set up a small cell with advisory body like AGCA to mentor NGO engagements under NRHM and corresponding GIA committee at the central govt. level.

Dr Seem said that there are two aspects in the suggestions: (i) to be associated with NHSRC and SHSRC for the activities and (ii) the actual service delivery for funding for GIA as a separate agency.

Discussion by the AGCA members on the above recommendations:

  • Members suggested that the SHSRC concept is an excellent idea, some states are doing well and in some it has not yet been taken up. Wherever the SHSRC has not been established, it needs to be established with the assistance of NHSRC, AGCA and state governments, as it protects the states from corruption and enables the states to ensure proper utilization of NRHM state funds.
  • This is health system oriented. Will it also deal with the health determinants? NHSRC is to set up a small cell with an advisory body like AGCA to mentor NGO engagements under NRHM. Then what is the role of AGCA? Is that a separate body?

Responding to the above, Dr Seem mentioned that SHSRC is outside the health mission group, MSG and other structures. They anyways take care of the determinants. SHSRC by implication will only actualize what the state health mission plans. The existing system continues. NHSRC and AGCA are already there except GIA that has to be established at the central government level.

  • So many committees are already set up like State mentoring Committee (SMC), Asha Mentoring Group in some states, which are functioning well in some of the states.  These should not be dissolved with the advent of SHSRC.
  • An observatory should be set up at every level, so that the processes at the ground level can also be captured.

It was suggested that in the post lunch session the remaining draft documents such as TORs for national AGCA, State AGCA and GIA Committee to be discussed and prepared. The rest of the AGCA agenda was postponed for discussion in the next meeting.

The afternoon session was chaired by Dr Sharad Iyengar . TORs for National and State AGCA and Grant in Aid Committee, the actual relationship between the AGCA and NRHM and the GIA guideline were discussed.

Based on the discussions, the draft TORs for National and state AGCA, SHSRC – Structure and mentoring, and Grant in Aid Committee – Considerations, were prepared, which are attached as Annexure III. It was also suggested that draft guidelines for GIA committee to be edited first by Dr Narendra Gupta and circulated to the sub-group for their feedback. Once these documents are finalized, then a meeting with the Secretary (MoHFW) is to be fixed.

The date for the next meeting was fixed for Monday the 15th March, 2010 at PFI.