Minutes of the 18th Meeting of the Advisory Group on Community Action – The National Rural Health Mission
Population Foundation of India, June 17, 2010
Advisory Group Members present
  • Dr Thelma Narayan
  • Dr M Prakasamma
  • Dr Abhijit Das
  • Dr Narendra Gupta
  • Shri Alok Mukopadhyay
  • Dr Shanti Ghosh
  • Ms Indu Capoor
  • Dr Abhay Shukla
  • Dr Saraswati Swain
  • Shri A R Nanda               
Representative from GOI
  • Mr Puneet Kansal, Director, NRHM
Special invitees
  • Dr Tarun Seem, PHFI
  • Ms Sudipta Mukhopadhyay, CEDPA
  • Ms Sona Sharma, PFI
AGCA Members who could not attend the meeting and were given leave of absence
  • Ms Mirai Chatterjee
  • Dr H Sudarshan
  • Dr Dilip Mavalankar
  • Sh. Harsh Mander
  • Dr Vijay Aruldas
  • Dr R S Arole
  • Dr Sharad Iyengar
  • Prof Ranjit Roy Chaudhury
  • Mr Gopi Gopalakrishnan

Mr. A R Nanda welcomed the members and the special invitees to the 18th AGCA meeting. He shared the agenda of the meeting and conveyed that this time ten members were attending the meeting and nine members had requested leave of absence due to their prior commitments and from the GOI, Mr Puneet Kansal, Director, NRHM would be attending the meeting.

Mr Nanda mentioned that Dr Arole so far had attended only one meeting. However, Mr Harsh Mander has never attended any meeting. Dr Narendra Gupta was requested to speak to Mr. Harsh Mander to request him to participate in the AGCA meetings.  Mr Nanda asked the members to join him in congratulating Ms Mirai Chatterjee and Dr Harsh Mander for being selected as members in the National Advisory Council, (NAC). He further added that there were two special invitees in the meeting: Dr Tarun Seem, who left the Ministry after 5 years of his service as Director NRHM, currently with PHFI and Ms Sudipta Mukhopadhyay, who was associated with NRHM when she was in PFI and is currently with CEDPA India.

Mr Nanda said that the outcomes of the National Dissemination Meeting on community monitoring held on 16th June, would be shared followed by a discussion on the steps for future action. The dissemination meeting, he informed, drew the participation of government representatives from various states, other stakeholders including VHSC members, PRI members, field level staff and the media etc.

Mr Nanda introduced the new Director, NRHM Mr Puneet Kansal, who was earlier in Finance and Infrastructure division of the Ministry.

Agenda Item No. 1: Confirmation and Action Taken on the minutes of the 17th AGCA Meeting held on March 15, 2010

The minutes of the 17th AGCA meeting were confirmed.

Ms Sona Sharma, PFI briefed about the following seven actionable points emerging from the 17th AGCA meeting and its action taken.

Sl. No. Actionable Points Action to be taken
1. It was decided to form a sub-group for Community action for family planning/contraceptive programme under NRHM, with Dr Abhijit Das, as convener, Dr. Thelma Narayan, Dr. Mirai Chatterjee, Dr. H Sudarshan, Dr Saraswati Swain and secretarial support would be provided by PFI (Dr. Almas Ali and Ms. Sona Sharma), The sub-group would collate evidence and prepare a white paper to be taken forward. It was also decided that every meeting of AGCA would have this as an agenda item. Background material was forwarded by Dr. Abhijit Das to the group. Further action is to be taken.
2. A letter should be written by the group to the Ministry to invite AGCA members for all civil society consultations. To be done
3. There must be a clear cut communication from the Centre to the states regarding the involvement of AGCA members/Nodal NGOs in PIP monitoring, with specific names mentioned as was done for the pilot on community monitoring. Done
4. Dr Narendra Gupta should write a note on the issue of money for free treatment as most of the state governments are not in a position to put extra money for the same and it would be taken up as an agenda in the AGCA meeting Note was circulated at the meeting for further discussion.
5. Some of the names such as Dr Sunil Kaul (The ANT, Assam), Dr Mohammed Shakeel (CHARM, Bihar), Dr Ajay Khare (MP Gyan Vigyan Samiti, MP) were suggested for inclusion in the AGCA, However, it was decided that those being recommended would first be asked to agree, especially since it involved dedicating their time to the Group. Members to respond on whether the proposed members have been contacted.
6. Proposed to hold the National Dissemination on Community Monitoring on June 16, 2010 Held on June 16, 2010 at India International Centre.
7. The Ministry also needed to be asked for response to the resource centre proposal. Included as an agenda item for the meeting today

In response to the above, it was suggested that the action at point one has to be expedited (white paper to be developed by the sub-group on community action for family planning) and shared at the next AGCA meeting in September 2010.

The Members also needed to get in touch with the new members proposed for AGCA (point 5 above), once it is formally found out if they are interested, then the AGCA Secretariat can send their names to the Ministry.

Discussion on Future Action: Sub-group for Community Action for Family Planning/Contraceptive Programme

The discussions included the following:

  • It was enquired whether there was any national review done of family planning during the last 10 years and if not, should the AGCA recommend an extensive review?
  • One needs to be aware and wary of the growing international pressure around population stabilization where-in the attempt is to link population stabilization to food security and climate change, which is also influencing the Indian policy process.
  • The Family Planning Division of the Ministry is now in much better position to negotiate with states on Family Planning.  Around five years back, the scene was different and the repositioning of family planning is indeed well warranted. Now more trained people are identified for counseling at the field level and more laparoscopes are available.
  •  The sub-group may consider engaging with both JSK and FP Division. The FP Division could be invited to a meeting and the agenda for further action presented to them.
  • In the workshop on Repositioning Family Planning, organized by the MOHFW, the first session was a Political session, which was worrisome.  Everybody is not thinking in a similar manner. The Minister went into clear Malthusian thinking. The last session included state secretaries’ presentations in which some of the changing population dimensions such as age at marriage, spacing etc were missing from the action agenda of the states.   The JSK presentation also started with Population Explosion on its headline.  This is problematic.  It is absolutely essential to engage with these two efforts because from collective experience and academic wisdom is very clear that these kind of terms tend to create fear, which is not in the right direction.
  • It was suggested that the two distinguished colleagues, Dr Harsh Mander and Ms Mirai Chatterjee, who were also members of the NAC should take the issue up at that level. In order to facilitate the same, it was essential to write the white paper quickly.
  • It was suggested that both the Jansakhya Sthirta Kosh (JSK) and the Ministry should be invited to make presentations of their versions of repositioning of family planning along with necessary evidence, data and information, and the AGCA members can present theirs. This would help initiate a dialogue that could bring all key stakeholders on the same page. This could be in the form of a consultation at the national level followed by state level consultations to ensure a synergy in the perspectives.
  • It is essential to identify the stakeholders with a fundamentalist and Malthusian way of thinking and work towards changing their perspective.
  • Some studies have also been done on JSY.  JSY has come only in 2008.  Therefore, it is too early to properly judge the impact. Some infrastructure also started improving because of NRHM. Incentive is also a factor. The RGI figure of maternal mortality is done in a very indirect method. The real picture will only emerge in 2012-13, because we don’t have the registration of complete births and deaths. The RGI is not even compiling the data of institutional delivery and the available current data is meaningless. The Ministry even doesn’t invite anyone from the RGI for attending any of the meetings.
  • The word ‘population’ has a past baggage and past history such as UNFPA, Population Foundation, World Population Day etc. so, it was suggested that the word used should change.  Even the Hopkins University has now abolished the word ‘population.’
  • In order to influence a change in perspective, we should approach institutes such as the Lal Bhadur Shastri Institute, Mussoorie to influence the bureaucrats before they become Collectors.
  • Some of the organizations: PHFI/IIM could initiate some courses on Population, Health and Development and support the Government.
  • Conditional cash transfers are becoming a popular way of delivering services and its better utilization. We should see how they are influencing social sector delivery programmes and should build a perspective on this.
  • Another opinion voiced was that conditional cash transfers need to be conceptualized within the system change. If we take it out of the systemic change, that is happening and start watching it, it will make no sense because the white cell doesn’t have a life/legitimacy of its own. The system in which we learn to find out from where people come, what they need and what new inputs are needed, whether they need to put a cooler/air conditioner/centre cooling facility, more IV plants, eating place, disable friendly van etc, will come as a part of the system. The CCTs must not be pulled out of the system.  They have logic within the system. That is how the system uses it.
  • A series of monitoring indicators need to be worked out to assist the government, which need to be added in the HMIS.
  • Financial aspects such as non utilization of funds allocated in the PIPs also need careful review and action.

In response to the above, Mr. Puneet Kansal, Director, NRHM, GOI shared the following:

  • This year the PIP approval was delayed by around a month. However, the states are well aware about the activities included in the state PIPs and they were given an indication of the activities which would be approved, at the time of sub-group and NPCC meetings.
  • The Family Planning Division of the Ministry is undertaking lot of activities under maternal and child health. It would be good to be in touch with the FP Division for updates of the programme.
  • The focus under JSY is currently on two aspects: quality of health care and reducing leakage in the payments.  27 monitorable indicators have been included in the PIP for every state. These have been mentioned in the NRHM website.  Progress of the states will be monitored on the basis of these indicators.
  • Every quarter we get a financial report (FMR) from the states. These are analyzed and DO letters are sent to all the states on the basis of analysis of expenditure.  The states provide feedback with reasons for the lapses and at the end of every financial year, they consolidate the Financial Monitoring Report.

Mr A R Nanda requested the government to share a brief summary on what has happened in the states on financial and other aspects under NRHM, as it is very useful to understand the ground realities of the states. FMR can be asked for by the NGOs at the state level too.

National Dissemination Briefing and Discussion on Next Steps

The National Dissemination Meeting on Community Monitoring of the pilot states was held on 16th June, 2010.  The purpose of the meeting was to introduce CM and its outcomes to other states. While the participation from other states was limited, a variety of experiences from the nine states were shared in the meeting. These included presentations by the Mission Director, NRHM, Maharashtra, Director RCH, Karnataka, PRI members, media, Government representatives  from J&K, Gujarat and UP and NGO participation from Bihar, UP, J&K and Punjab.  The following comments were made by Members:

  • It was felt that the dissemination meeting was overall a successful effort and was recommended that up-scaling of the programme should not be straight jacketed and should have some level of flexibility in community level actions.
  • While the diversity and flexibility is desirable, it was strongly recommended that some core non-negotiables in community based monitoring should not be compromised.  For instance, the civil society plays a very significant role, which needs to be carried forward in a particular way. If that gets marginalized, as it appears it is being done in some states such as Orissa, it is problematic.
  • Some discussions were required for a strategy or broad plan for states like MP, which is not going ahead with community monitoring beyond the pilot phase.

Discussion on Future Action:

  • In consideration of the fact that Karnataka was the only state which has scaled up the CBPM process in the entire state and Orissa was taking it forward in a different manner, a review was recommended in these two states to understand what is happening in both the states and how to take the programme forward. It was suggested that the balance funds from the first phase of community monitoring could be utilized for this purpose.
  • The group suggested to reprint the National Report as it contains many editorial errors.
  • Mr Puneet Kansal shared that the Ministry has planned a three day meeting of NRHM Mission Directors of all the states at Bhopal in the first week of July, 2010.  The theme of the meeting will be ‘Reaching the Unreached’. It was suggested that a few AGCA members could be invited to the meeting and further dissemination of the CBPM process could be done through a poster exhibition, informal interactions with the state officials etc. to take the process forward.
  • Concerns were expressed regarding the fact that we have regulatory authorities for everything, but for health, which is potentially life threatening intervention we still don’t have any kind of regulatory body which has teeth. It was broadly agreed that a Grievance Redressal Mechanism for health is highly desirable especially in cases where the community is not getting any services.
  • Dr Abhay Shukla shared that a redressal mechanism is to be introduced in the Maharashtra PIP this year.  This has been suggested in the five districts where the CBM is underway.  At the district level, there would be a functional group including a three member team: an ombudsperson (retired senior journalist), a representative of state nodal NGO involved in the CBM programme, and a representative from the health department.   He further suggested that AGCA can develop guidelines for setting up a redressal mechanism.
  • Mr Puneet informed that the Ministry was taking the help of Quality Council of India in evaluating the facilities.  This action will be in three round of inspections. The first two rounds will be for improvements and mutual discussions for improvement of small aspects like running water, electric connection, cleanliness etc.  The third round will be to decide whether to award a family friendly hospital certification to the facility.
  • Mr. Nanda concluded the discussion with the suggestion that the grievance redressal mechanism proposed in Maharashtra is to be shared with the AGCA members (by Dr. Abhay Shukla). AGCA may recommend a grievance redressal mechanism to GOI after a review in the next AGCA meeting.

Role of AGCA in monitoring PIP implementation

  • It was suggested that the GoI should write a letter to the state Governments informing them of the AGCA members who will be involved in the monitoring component of the state PIPs.
  • AGCA members offered to take on the responsibility of monitoring the PIP implementation (of the community monitoring component to begin with), with each member taking on the responsibility for one or more states as follows:

Dr Thelma Narayan           :           Madhya Pradesh

Dr Shanti Ghosh                :           Delhi

Dr Saraswati Swain           :           Orissa

Dr Prakasamma                :           Bihar

Dr Narendra Gupta          :           Rajasthan, Punjab, Himachal Pradesj, Haryana

Ms Indu Capoor                :           Gujarat, Rajasthan

Dr Dilip Mavalankar         :           Gujarat, Maharashtra, Madhya Pradesh

Dr Alok Mukhopadhyay   :           Uttar Pradesh, Jammu &Kashmir, Assam

Dr Abhijit Das                    :           Uttarakhand, Jharkhand, Assam

Dr Abhay Shukla               :           Maharashtra, Goa

Dr Sudarshan                    :           Karnataka

Mr Sunil Kaul                     :           Assam

Dr Sharad Iyengar             :           West Bengal, Orissa

Ms Mirai Chatterjee          :           Andhra Pradesh, Tamil Nadu

The above would be shared with the members not present and they would be requested to suggest the states they would like to take up.

  • In order to initiate the involvement of AGCA in monitoring the community action component of the PIP implementation, it was decided that each member would take the responsibility of checking the state PIPs of the respective states for the inclusion of the community monitoring component and providing initial feedback to GOI through AGCA within a week.
  • This would be followed by a proposal to the Ministry regarding monitoring of the PIP implementation by the AGCA members. Travel and other costs for the members should be included in the proposal. The indicators and scope of work for the members also need to be worked out and included in the proposal. Dr. Tarun Seem and Dr. Abhijit Das would draft the proposal. The proposal on National Resource Cell is still pending, which needs to be followed up with the Mission Director.
  • The communitization aspects which the AGCA members would need to monitor include community based monitoring, RKS, ASHA programme and training of VHSCs.

The discussion was followed by two presentations by CHETNA: Ms Pallavi Patel, Deputy Director, CHETNA on the Navsari Project on Reducing Maternal Mortality, Gujarat State and Ms Smita Bajpai, Programme Officer, CHETNA on Community Monitoring through Public Hearing in Rajasthan.

Other Matters Discussed:

  • Dr Narendra Gupta raised the issue of free treatment and free medicines to all, stating that Out of Patient Expense (OPE) in health is not reduced at all. This is the biggest barrier for increasing people’s engagement with the public health system. MMR, IMR, etc. are not likely to decline, if we do not concentrate on this issue. He suggested that AGCA should carry out more intensive advocacy by way of organizing one day consultation, in which state representation is ensured.  He further emphasized that as part of community action, we should write to the Ministry that some more research is required on the per capita drug expenditure in different states.
  • Dr Abhay Shukla agreed that it is a very important issue as even in the CBM process when people were asked why they didn’t go to the PHC, they replied that medicines are not available there. Some effective action in terms of overhauling the systems of procurement and distribution of essential medicines at the PHC along with a time bound increase in budgets is urgently required. The budget is inadequate as per the total population requirement.
  • Mr Puneet informed that the government is aware of the issue and has started taking action. Increase in the state expenditure on medicines is also one of the agendas of NRHM and Rajasthan has one of the lowest state per capita expenditure on purchasing medicines. NPCC had a subgroup meeting during the approval of PIPs and looked into the issue of purchasing of medicines.  Second issue is procurement. The GOI is persuading the states to adopt Tamil Nadu model and more and more states are doing so. Logistics, warehousing and managing inventory are also areas for reform.

It was decided that the next AGCA meeting would be held at PFI on September 17, 2010 at 10.30 A.M.