Minutes of the 19th Meeting of the Advisory Group on Community Action – The National Rural Health Mission
Population Foundation of India, September 17, 2010
Advisory Group Members present
  • Prof Ranjit Roy Chaudhury
  • Dr Abhijit Das
  • Shri Alok Mukopadhyay
  • Dr Shanti Ghosh                                                                                              
  • Dr Abhay Shukla
  • Shri A R Nanda
  • Dr Sharad D Iyengar
  • Ms Poonam Muttreja
Representative from GOI
  • Mr Puneet Kansal, Director, NRHM
Special invitees
  • Dr Tarun Seem, PHFI
  • Ms Kavita Narayan, PHFI
  • Dr Almas Ali, PFI
  • 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
  • Mr Gopi Gopalakrishnan
  • Dr Saraswati Swain
  • Dr Prakasamma
  • Dr Narendra Gupta
  • Dr Thelma Narayan
  • Ms Indu Capoor

Prof Ranjit Roy Chaudhury chaired the meeting and welcomed the Members and special invitees to the 19th AGCA meeting.  He wished Mr A R Nanda for his retired life and expressed the hope that his association with the AGCA continues in an individual capacity. Welcoming Ms Poonam Muttreja, the new Executive Director, PFI, Prof Roy Chaudhury said that the Members look forward to her leadership not only in this committee but in the Foundation as well.

Mr. Nanda thanked Prof Ranjit Roy Chaudhury for taking the responsibility of chairing the meeting and giving his wise counsel and advice. Mr Nanda mentioned that Ms Poonam Muttreja should be an integral member of this group not just in her capacity now as ED, PFI but also since she has been a civil society activist on health/social issues for a long time.

Prof Roy Chaudhury shared two important points, which were discussed at the meeting of the Central Council of Health and Family Welfare, held in September 2010, where-in the Union and State Ministers of Health and Family Welfare participated:

  • NRHM was highly praised by the state Ministers. It was suggested that as the ASHA is doing good work, she should be involved in more activities. However, they were not satisfied with the AYUSH component. This aspect could be noted for the monitoring by AGCA members as well. Alternate strategies to mainstream AYUSH were sought including better utilization of the 4 lakh Gram Vaidyas in the country.
  • A proposal on a three and a half year bachelors’ course on rural health, followed by a six months internship, was circulated among the Ministers present. Except for three or four states, where similar programs exist, the other states have been given the option of introducing the course.

Prof. Roy Chaudhary informed the group that the Medical Council of India is being reorganized. Many new medical colleges are being started and the number of seats are being increased.  The retirement age for teachers will be increased to 70 years. As part of the PPP initiative, many new colleges will be opened with railways, ESI medical college with the army etc. There will be a change in the entire health system: with an increase in the number of doctors and more rural health batches.

Agenda Item No. 1: Confirmation and Action Taken on the minutes of the 18th AGCA Meeting held on June 17, 2010

The minutes of the 18th AGCA meeting were confirmed.

PFI briefed about the following actionable points from the 18th AGCA meeting and the action taken.

Sl. No. Action Points Action Taken
1. Sub-group on Community Action for Family Planning/Contraceptive Programme under NRHM should expedite development of the white paper and present it in the next AGCA meeting in September, 2010. This was to be discussed in the meeting
2. A review of the status of community monitoring in the states from the first phase, especially in states like Karnataka(where the effort is being expanded to the entire state) and Orissa(where a new model for community monitoring is planned), could be proposed to the Ministry. Balance funds from the project could be proposed to be used for this review. To be done
3. The printed report of the first phase disseminated in the meeting on June 16, 2010, is to be re-printed after correcting typographical errors and further disseminated. The report has been reprinted by CHSJ and circulated.
4. Sharing of the experiences of the first phase of community monitoring should not end with the dissemination meeting. The next opportunity for a sharing is the upcoming quarterly meeting of Mission Directors in Bhopal on July 2-4, 2010. Some AGCA members could attend the meeting, put up a poster exhibition, distribute the report and also share the experiences during informal interactions with the Mission Directors. Some of the AGCA members:  Dr Narendra Gupta and Dr Abhijit Das and Mr. Dhananjay from SAATHI-CEHAT attended the meeting of Mission Directors in Bhopal on July 2-4, 2010. Members would be briefed in the meeting.
5. The grievance redressal mechanism proposed in Maharashtra is to be shared with the AGCA members (by Dr. Abhay Shukla). AGCA to recommend a grievance redressal mechanism to GOI after a review in the next AGCA meeting. A note prepared by Dr. Abhay Shukla on the Grievance Redressal has been circulated, which is to be discussed in the meeting
6. 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 The following AGCA members visited the states of –
Dr Saraswati Swain – Orissa
Dr Narendra Gupta  – Himachal  Pradesh
Dr Abhijit Das – Bihar
Dr Abhay Shukla – MaharashtraThe reports of the above state visits will be discussed in the meeting.
7. Mr. Puneet Kansal had agreed to follow up and inform the group on the status of the proposal for a resource centre for AGCA. Mr Kansal would inform the group in the meeting
8. It was felt that the AGCA needs to undertake intensive advocacy on the issue of free treatment and reducing out of pocket expenses on health for the masses. To be discussed in the next AGCA meeting

De-briefing on Meeting of Mission Directors in Bhopal on July 2-4, 2010

Mr Puneet Kansal briefed that the structure of the workshop was modified as the Secretary, GoI wanted a detailed field review. Therefore, only one day was left for the discussions on the topics planned. The AGCA members did not get a presentation slot but they had informal interactions where experiences were shared with the officials present.

Prof Ranjit Roy Chaudhury suggested that the AGCA should have a meeting with the Minister for Health and Family Welfare and brief him about the work being undertaken by the group.

Dr Abhijit Das recommended that AGCA should be informed and invited whenever there is a consultation/meeting on NRHM/NRHM components. AGCA should be a permanent invitee to all the NRHM meetings of GOI.

State Visits by the AGCA members: Report from Maharashtra

Mr Abhay Shukla and Dr Dileep Malavankar had a discussion with the Mission Director Maharashtra on 26th August at Pune. A list of issues that needed to be discussed had been sent to the MD in advance. The report circulated to the AGCA members details out all the issues discussed. Some points highlighted in the meeting were:

  • Community Based Monitoring (CBM): The state had included eight new districts this year for the CBM programme. Nodal NGOs have been identified for the districts after a thorough selection process following all the government norms.  However, the final approval for selection of NGOs has been withheld, till date for unknown reasons.  The issue was raised with the Mission Director who ensured some action. However, no action had been taken so far.  Shukla expressed concern over this and requested a discussion on the possible corrective action in such a situation.
  • Displaying lists of guaranteed health services in the PHCs and rural hospitals. Lists have been developed based on the NRHM document but they have not yet been put up. The matter was brought to the notice of the MD and it was suggested that where all services are not available, the list could still be put up with a note at the bottom on the services not currently available. Now it is hoped that the list of guaranteed health services for PHCs/rural hospitals will be put up in the next one month.
  • Village Untied Funds: There is no record of how these funds are being used. As part of the community monitoring process, the local activists analyzed the records for 3 districts of Maharashtra: Pune, Nandurbagh and Amaravati districts. In Pune district in 45 villages, 90% was spent for Aanganwadi Centres (AWC) and not a single paisa spent on referral services. In most cases the VHSC was not even consulted and is being completely bypassed. It was suggested that there must be an explicit instruction that no funds should be spent without the VHSCs involvement. The Aanganwadi worker doesn’t come under the health department, hence coordination is a problem. There is no analysis of the utilization of untied funds. PHCs only report the total amounts spent. The MD said that they are planning to change the signatory from AWW to ANM, which may not really solve the problem because the real problem lies in the process of decision making for the utilization of funds.
  • Civil Society Participation in Rogi Kalyani Samiti: There is a letter from the Mission Director informing that the all CBM districts/blocks/ the CBM related nodal NGOs should be represented in the Rogi Kalyan Samiti as observer, which is not currently happening in all districts.
  • Reorganization of Villages under PHCs: An exercise done under the community monitoring process revealed that many villages were around 70 km away from the PHCs. There were PHC’s closer to the village, but were not their official PHC’s. To expect a woman to travel 70 km to collect the JSY money or expect the ANM to collect vaccines and visit villages that far should not have to take place. A list of such villages has been drawn up and shared with the health department. The issue was raised with the Mission Director who said that this is a political decision to be made by the Zila Parishad. Nevertheless, it was felt that the Health department should suggest that a reorganization that is more rational will lead to better service provision.
  • Feedback from ASHA: There were a whole range of issues which emerged. An ASHA mela had been organized in Maharashtra by SAATHI-CEHAT where nearly 100 ASHAs from various tribal districts shared their experiences and reports.  Non- availability of medicines was one of the key issues raised and 70% of the ASHAs reported that the compensation is not being given on time. Another issue raised was that the ASHA undertakes many activities like health education, awareness generation activities, treatment of minor illness etc. for which no compensation is provided to them even though in Maharashtra, a lot of funds have been allocated for drug kits (Rs.2000/-). It has been suggested that the VHSC untied funds be allowed to compensate the ASHA within certain limits; such as Rs 2/- per patient that the ASHA treats for minor ailments or a lump sum amount could be provided for such services.
  • Some funds proposed in the NRHM PIP are to be earmarked for innovations. Now that the decentralized planning is being initiated and people are coming with new ideas and proposals, can this be included as part of the innovations? A group of villages can come together and develop proposals for innovative activities.

Dr. Shukla informed that a second visit is planned in November, 2010 where various stakeholders will be called and all aspects will be reviewed. He concluded with the observation that if a major activity defined in the PIP has not taken place for a significant period of time, some action should be taken, else, at the end it will be realized that half of the activities never happened.  He recommended that this is the right time for corrective action.

Deliberations by the Members

  • Mr Puneet Kansal informed the group that the GoI is in the process of sending guidelines to the state governments for the preparation of the next PIPs. AGCA was invited for giving state specific suggestions/recommendations (short) on community monitoring aspects which would be conveyed to the states.
  • It was suggested that the document compiled last year and submitted to the Ministry is as relevant for the next PIP and should be circulated.
  • Two issues were flagged for utilization of the untied funds for VHSCs: one is that the AWW is spending funds mostly for the Anganwadi centre and the other is the process of planning and decision making where, the decision is being taken by one or two persons as against the mandate of the VHSC for decisions as a group. In Rajasthan, the PHC gave instructions to an ANM for buying a table, BP instrument etc. The ANM informs the Sarpanch. As a result, the VHSC is being bypassed and the health department is taking decisions. It was suggested that a formal advisory should be sent to the Secretary Health to request the states to look into this issue.
  • Dr Abhay Shukla was requested to circulate the checklist used in Maharashtra for community monitoring as a model for other states.
  • It was decided that before the next AGCA meeting, the group will do detailed reviews in at least four states and the report will be submitted to the Ministry. The report should be well structured and should include: what has happened, what was allocated in the PIP, what was observed during the visit and suggestions/modifications. The positive aspects also need to be included to give a balanced picture.

Report from Assam, Uttar Pradesh and Jammu & Kashmir

Mr Alok Mukhopadhyay shared that VHAI had taken up three states: Assam, Uttar Pradesh and Jammu & Kashmir.  In J&K, given the situation, nothing much can be done and in the other two states, the state VHAs  have been asked to look at some specific districts to understand what is happening in community monitoring.  After the process is complete, the issues and recommendations will be taken up at the state level.

Report from Bihar

Dr Abhijit Das informed that very little has happened in Bihar under the communitization process. There was, however, adequate space for communitization in the state PIP.  The Government of Bihar was extremely cooperative and there was a nodal person deputed during the visit. The following aspects were shared:

  • In Bihar, the VHSCs were being formed at the panchayat level with provisions for setting up Nigrani Samiti’s at the revenue village level. Till date 92% formation of the 8500 VHSCs has taken place. The first tranche of untied funds have been released to these VHSCs even though they have not been trained or provided guidelines on how to spend these untied funds.
  • The state has introduced two new posts – District Community Mobiliser (DCM) and the Block Community Mobiliser (BCM) to facilitate the ASHA in the implementation process. It was suggested to them that these functionaries could support the entire communitization process and not just the ASHAs. The idea was accepted and it was decided that each district and block would have an NGO mentor. There is a need to train these mentors through the AGCA Secretariat.
  • RKS in Bihar have existed since the time of the formation of the State Health Societies. A visit to a PHC revealed that the list of telephone numbers of all members of the RKS was prominently displayed at the PHC. From the records it was clear that RKS meetings are organized every month. They have been doing limited problem solving at the local level. However, important problems like the running of the OPD, had not been addressed. These were shortage of examination tables, stethoscopes and space, especially for women clients.
  • One panchayat, which had a VHSC in place, was also visited. While the AWW knew there was a VHSC, the members of the VHSC did not even know they were members.  There was a huge deficit in training of VHSCs.  Village Health Nutrition Days have not been initiated in Bihar. They have currently planned to start VHNDs on a pilot basis in two blocks of one district, Khagaria and will then upscale.
  • The PHC staff shared some of their concerns and limitations: they have six beds in the PHC while 8-10 deliveries are taking place per day. The staff strength at the PHC is very small. It was suggested that the State Health Society should organize a state level consultation on inclusion of informal providers. National level experts could be invited to the meeting. The limits and potential for involvement of informal providers along with a role for TBAs could be discussed in the meeting.
  • The AGCA at state level is being formed and a forward looking plan has been made.

Deliberations by the Members

  • It is evident that Bihar requires continuous support, which could be provided by the AGCA resource centre once approved by the Ministry.
  • The most significant aspect emerging from the report is the need for a secretariat at the block and district levels for communitization. The district level support for communitization (DCM) exists in many states like Rajasthan, who restrict themselves to supporting ASHAs. Their capacities could be built to look at other aspects of communitization also. It could be a policy decision from GOI that these functionaries at the block and district be linked with the communitization process.
  • Mr Puneet Kansal requested the Members for suggestions for strengthening the RKS and VHSCs. It was suggested that for communitization activities such as VHSC training etc., there was a need for NGO mentors at the state and district levels to guide the states on a long term basis.
  • Dr Sharad Iyengar, Dr. Abhijit Das and Dr Abhay Shukla were requested to develop a paper on Mentoring NGOs in the context of community action under NRHM : including the role of AGCA in helping the NGOs  link up to the Government.

Prof Roy Chaudhury commended the Members for doing a great job during the monitoring visits and recommended that a report be shared with the highest authorities.

Plan for State Visits by Other Members and CRM Participation

Mr Nanda mentioned that the objective of the state visits by AGCA members was to give inputs for the forthcoming Common Review Mission (CRM), which is likely to be held in November.  The following points were discussed:

  • It will be useful to get detailed reports from the AGCA members for and prior to the CRM. The AGCA members who have undertaken state visits could be a part of the CRM.
  • The AGCA as a group, should send in the names of Members willing and available to participate in the CRM. The AGCA Secretariat would coordinate the same and convey to the Ministry.
  • The Members requested that the Ministry should consider including AGCA recommended non-members (with expertise in the sector) in the review teams, as many AGCA members may not be available on the scheduled dates.
  • A total of 17 states, nine high focus states and 8 non high focus states have to be covered in the CRM. The GoI will share the list of states.

 National Resource Centre Proposal

Mr Puneet Kansal informed the meeting that there was not much progress in taking forward the proposal and that he would be able to give more information in the next meeting.

It was suggested that some Members should meet with the Secretary and stress on the need for a resource centre.  

Issues related to travel by AIR India

The Members conveyed the problems related to travelling only by AIR India for the AGCA meetings. These included primarily the fact that the IA flights timings were not convenient for a day trip and would mean spending almost three days for a one-day meeting. The group made the following recommendation:

  • As PFI is given a grant for organizing the meetings, the Ministry should consider including the travel costs of the AGCA members in the grant and give PFI the responsibility of reimbursement to the Members. The GOI travel rules would not be applicable if this change is done.

It was decided that PFI should send a letter conveying the above suggestion to the Ministry for approval.

Sub-group on Family Planning/Contraceptive Programme

The following was discussed:

  • Dr Abhijit Das stated that he had circulated a lot of materials to the group but had not received any response. He suggested that a Drafting Committee be set up as sub-committees over e-mails don’t work.
  • A group including the ED, PFI and members of sub-group should have a discussion with the Family Planning Unit of the Ministry. Mr Amit Mohan Prasad, Joint Secretary, MOHFW could be requested to Chair the meeting. Dr. Kiran Ambwani and other members from the Family Planning unit and the Adolescent Health unit would also be invited. During the meeting, concerns/strategies related to repositioning of family planning be discussed very carefully in order to achieve better results based on a community perspective.
  • Mr Puneet Kansal requested Dr. Abhijit Das for a concept note to be sent to him and he would then take it forward with the Joint Secretary.
  • The group requested for the GOI’s instructions to the states on Family Planning. AGCA would like to review the instructions from the point of view of avoiding any possible misconceptions.
  • It was suggested that the group should request Dr. Kiran Ambwani for the guidelines, which could be reviewed by the sub-group. Based on the review, a set of recommendations would be submitted in the meeting with JS. The Sub-group could meet prior to the meeting with JS for preparing the recommendations.

Grievance Redressal Mechanism

Dr Abhay Shukla shared the Grievance Redressal Mechanism they had proposed in the state of Maharashtra.  The proposal recommended setting up a cell, first in each district and later in each block. The cell would comprise of 3 members– one a retired journalist/professor, who would be the Chairperson and the other two would be the district nodal officer and a nominee of the health department.  The cell would have the mandate to conduct joint enquiries (NGO and Government Officials) or have testimonies presented and recommend remedial action to ensure that the grievance is not repeated.

Subsequently, the State Health Department has set up a State Grievance Cell i.e.– one person situated in Mumbai. This cell has not been publicized at all. The next step is to have regional units which are likely to have mostly officials. The recommendation is that the cell should be moved closer to the people.

Dr. Shukla requested the AGCA to recommend the mechanism proposed earlier, to be piloted, to begin with, in at least some of the CBM states and districts. The second suggestion given is to set up a helpline. This can serve as a first line recourse where people can lodge their complaints. Comments on the above were as follows:

  • We will have to think of a redressal mechanism that gets institutionalized, recorded and implemented. The complaints to the higher authority should not be the first recourse. We could use the RKS, as the first protocol and include grievance redressal in the training being provided. Every RKS meeting should have as its agenda, a review of suggestions and complaint boxes.
  • The experience in Rajasthan in the last two weeks was shared. In Jodhpur some patients and their relatives got very angry with the doctors and beat them up. The doctors, including the private doctors and the chemists, immediately went on strike. The entire health system broke down. Very recently, the Chief Minister inaugurated Swasthya  Chetana Yatra  and said he was pained/shocked with the reaction of the doctors. Such instances could be utilized to suggest that there is a need for a redressal mechanism. We need to position the recommendation for a grievance redressal mechanism in a way that would make the states realize that having one is better than not having any, given that people in power are not likely to want a grievance redressal system.

The discussions concluded with the following recommendation from the AGCA:

The AGCA advises the Government to organize a seminar on development of grievance redressal protocols and offers to be the Secretariat for it. Models from other sectors and countries can be reviewed in the seminar.

Convergent Community Monitoring of Key Social Services

The note shared by Dr. Abhay Shukla was discussed. Dr. Shukla said that in Maharashtra the issues like Anganwadi services, water supply and nutrition etc are so integral to health and continuously come up in CBM Jan Sunwais. These issues could form the base for convergence. Block officials from the other departments should also attend the block level jan sunwais and the issues raised must be addressed by them. At the state level there could be meetings with the ICDS and the Water & Sanitation department, where the issues brought out through the CBM process could be addressed. Separate tools for Anganwadi and water supply have been developed under the CBM in Maharashtra. This has to be matched by some response from above for it to be effective. If NRHM is serious about convergence, this is what could be done to begin with as it does not require any funds at this point in time. All it requires is an administrative will to address health determinants in an integrated manner.

  • It was suggested that AWW supervisors should also be included in the monitoring, as no one talks about their responsibilities and they are not accountable and nor do they support the AWW.
  • The determinants like water supply, sanitation, nutrition etc are part of the TOR in CRM. A similar TOR could be given for the CBM as well.
  • The last meeting for the intersectoral convergence was on 7th September, 2010. Dr Abhay Shukla was requested to circulate the tools developed for AWWs and water supply. Mr Puneet Kansal would include them in the next meeting agenda and get an approval from the WCD to have it included in the community based monitoring of the health department. If the directions go from the WCD, then it would be more effective.
  • It was suggested that the AGCA should get more feedback on convergence issues from different states and methodically list the important responses and submit to the government to reinforce what is happening in the states.
  • It was suggested that AGCA could send a note on Convergent Community Monitoring to the Planning Commission and the Ministry. A sub group: Dr Thelma Narayan, Ms Mirai Chatterjee and Dr Abhay Shukla could compile the preliminary note. Other people, beyond the AGCA could also be invited by the sub-group. In the next intersectoral meeting an AGCA member could be invited to present the note prepared. Mr Kansal was requested to share the minutes of the last intersectoral meeting.

Other Matters Discussed:

Mr Alok Mukhopadhyay had requested the group to allow him to nominate a person in his place as he would be away for eight months. It was decided that as the Members are nominated by name and not by organizations, it would not be possible for Mr Mukhopadhyay to nominate someone in his place.

It was decided that the next AGCA meeting would be held at PFI on December 16, 2010 at 10.30 A.M.