Minutes of the 3rd Meeting of the Advisory Group on Community Action – The National Rural Health Mission
Population Foundation of India, June 27, 2006
Members Present:
  • Dr Shanti Ghosh – in Chair
  • Dr Thelma Narayan
  • Ms Indu Capoor
  • Dr Abhay Shukla
  • Dr Saraswati Swain
  • Dr H Sudershan
  • Mr A R Nanda
Representatives of Mission Director, NRHM, Ministry of Health ad Family Welfare: 
  • Dr Tarun Seem
  • Mr Ganga Kumar
Others in Attendance (invited):
  • Dr Abhijit Das, Centre for Health and Social Justice, New Delhi
  • Dr Narendra Gupta, PRAYAS, Rajasthan
  • Ms Sapna Desai (deputed by Member Ms Mirai Chatterjee)
  • Dr P C Bhatnagar (deputed by Member Mr Alok Mukhopadhyay)
  • Dr Almas Ali, Senior Advisor, PFI
  • Ms Sudipta Mukhopadhyay, PFI
  • Ms Shrabanti Sen, PFI
Members who could not attend the meeting:
  • Prof. Ranjit Roy Choudhary
  • Dr N H Antia
  • Mr Shyam Ashtekar
  • Dr Sharad Iyengar
  • Dr K Pappu
  • Dr Rama Baru
  • Dr R S Arole
  • Dr Rani Bang
  • Dr Jaiprakash Narayan
  • Dr Vijay Aruldas

The third meeting of the Advisory Committee on Community Action was organized with the main agenda of deliberating on strategic frameworks for facilitating community monitoring in NRHM and reviewing the proposal submitted to MoHFW by Prayas, Rajasthan. Mr A R Nanda welcomed the participants and requested Dr Shanti Ghosh to Chair the meeting.

Agenda No 1: NRHM Update – presentation by NRHM representative

Dr Tarun Seem presented an update on NRHM. The presentation highlighted the following areas:

  • Institutional framework of the Mission
  • ASHA
  • Infrastructure
  • Manpower Development
  • State Initiatives
  • Reducing Maternal and Child Mortality
  • Reducing Disease Burden
  • Decentralisation
  • Financial Achievements
  • Timeline
  • Progress Till Date
  • Outcome Budget
Some of the highlights of the presentation were
  • -State Health Societies constituted in 28 states
  • -State and district level societies merged in 28 states
  • -30 states have signed MoUs with GoI
  • -68,086 ASHAs trained in addition to 55,000 Mitanins
  • -Untied funds of Rs 10,000 released to sub centers (total of Rs 206 cr)
  • -2346 24×7 PHCs operational
  • -Task forces on Medical Education and integration of RMPs constituted. This task force
  • would be in addition to the regular Medical Education.
  • -Under decentralization 122 District Health Action Plans have been prepared.

Dr Seem mentioned that the update is available on the NRHM website.

The members appreciated the comprehensive update on NRHM.

During the discussion members raised the concern over indiscriminate processes in selection of ASHA in some cases and the lack of clarity at the state, district and block level on the guidelines for selection of ASHA. It was also stated that for districts with low female literacy it was difficult to select suitable candidates as per the ASHA selection guidelines. The members suggested that formal government order could be issued by Union Health Ministry allowing selection of less educated women (including NGO trained health workers) as ASHAs for districts with low female literacy.  Dr Seem emphasized that selection of ASHA should be undertaken through a decentralized process at the community level for those women who are reasonably enabled, articulate and interested. The advisory Group on Community Action suggested that the above recommendations and suggestions be shared with the ASHA mentoring group.

Members stated that there was lack of clarity and confusion regarding the amount of untied funds available for the states towards expenses on each item under NRHM. Members suggested that the NRHM should inform the states and civil society organisations on the amount of untied funds available.

It was suggested that certification under Medical Education for contracted doctors should be provided after completion of compulsory two years rural posting. Dr Seem requested the group to advise on aspects of Medical Education and issues related to recruitment and posting of contracted doctors.

Under Janani Suraksha Yojana the members suggested that all deliveries should be the responsibility of the public health system. Funds under the scheme should be provided to pregnant women 15-20 days before the delivery date or in installments as per the ANC dates. Treatment of anemia should include proactive coverage of all anaemic women instead of the limited approach of treating only pregnant women for anemia. Similarly tetanus toxoid should be freely available to persons with injuries requiring such immunization. The group has recommended the need for Dai training and continuing education to be taken up, along with supply of Disposable Delivery Kits (DDK) for home deliveries.  Also, the group has suggested the urgent need to improve the quality of antenatal and postnatal care and the importance of treating and preventing anemia during childhood, adolescence and during pregnancy.

There was a strong suggestion by many members that future updates should include achievements and gaps. Reporting on NRHM should include reporting on all determinants of health, including access to safe water, sanitation and nutrition at village level (if not household) is necessary instead of limiting to RCH. Social determinants of health, such as gender, caste, exclusion etc, should also be specifically addressed. The Mission should also provide regular press statements on the change of norms related to various provisions under NRHM. The Mission should provide regular communication to the states including printing and disseminating large number of relevant Mission documents in vernacular languages. Members also suggested that the Mission should be proactive towards developing concrete strategies towards integrating RCH-II into NRHM both at the national and at the state level. Programme specific integration also relates to integrating immunization with polio under NRHM. The members recommended that a bottom up approach should be adopted towards developing District Action Plans, which should include issues related to district health management.

Agenda No 2: Issues of Community Based Monitoring – presentation by Dr Abhay Shukla

Dr Abhay Shukla in his presentation on priorities for NRHM drew the groups attention towards the strategies for community mobilization and action as stated in the NRHM Implementation Framework document ‘National Rural Health Mission: Meeting People’s Needs in Rural Areas’. Dr Shukla emphasized that community monitoring of health should be the core of NRHM. Currently at the national and the state level the government and the larger civil society understand ASHA, institutional delivery and immunization to be the key priorities for NRHM. Dr Shukla mentioned that community monitoring is not an automatic and smooth process. There was an urgent need for this advisory group to undertake proactive facilitation towards informing and involving the civil society on community monitoring which would in turn help deliver the determinants mentioned above. He suggested that the Advisory group might facilitate orientation meetings in various states, involving State health department and NGO representatives, sharing the entire framework and process for Community monitoring. This could help initiate the further process of formation of committees and monitoring at various levels.

Members suggested that NRHM needs to define processes for involvement of NGOs and other civil society agencies at the state and district level. Regular HMIS should be developed. NRHM should invite suggestions and proposals from the civil society organisations on community monitoring. It was mentioned that VHAI was in the process of developing and submitting a proposal to undertake community monitoring at the district level.

Agenda 3: Operationalising Community Monitoring – presentation by Dr Abhijit Das

Dr Abhijit Das presented an initiative of civil society oversight for effective implementation of NRHM. He mentioned the processes undertaken by Centre for Health and Social Justice towards building community action. This involved conducting regional and state level consultations on community monitoring and sharing of information about NRHM and role of civil society in the EAG states. The consultations focused on understanding NRHM processes, sharing information on social audit, community monitoring and other health advocacy initiatives including survey on key NRHM processes at the district level. The consultations highlighted emerging issues such as lack of transparency and sharing of information on NRHM, increased interest among various civil society groups and networks to be part of the NRHM process. Dr Das mentioned that the future steps would include preparing citizens report involving civil society, conducting National Stakeholder Consultation on 26-27 July 2006 in Delhi with the one year report card of NRHM and strengthening district and state level alliances for creative partnership for implementing NRHM.

Dr Das requested the group to provide technical assistance in critical areas towards developing active civil society mechanism for implementation and oversight instead of limiting the response to reviewing project proposals. He urged members to help develop a list of indicators for each stakeholder, to identify appropriate medium to inform the public and to develop mechanism for the civil society to be part of the Joint Review Mission of NRHM. In this context, the ‘People’s Rural Health Watch’ being conducted by Jan Swasthya Abhiyan as an independent watch on NRHM in eight states was also brought to the attention of the group.

Members appreciated the presentation made by Dr Das and reiterated that the group should focus on the priority of advising the government on developing strategies for community action for NRHM. It should not involve itself in action, but provide broad guidelines to NRHM. Suggestions were made that the group should also include presentations from other states on positive approaches towards involving community towards monitoring of NRHM e.g non EAG states. The group recommended that an NGO Forum on NRHM be constituted involving peoples organisations, existing alliances and networks. Members requested representatives of NRHM for official communication and information regarding all documents on NRHM. It was also suggested that an official communication be made by the Union Health Ministry to State governments, indicating that various types of information concerning health services at all levels be made freely available to civil society representatives who approach any Health official or functionary for such information. Members also agreed that they would provide inputs into the process outlined by Dr Das. It was decided that the advisory group would be a partner in the stakeholders’ consultation and have a meeting of the advisory group immediately after the consultation.  The advisory group also requested the Mission representatives that they should also be present during the entire duration of the national consultation to be held on 26-27 July 2006 in Delhi.

Dr Tarun Seem drew group’s attention to the minutes of the first meeting which states the group should draw lessons from various models of community participation and monitoring of health care available in the country for recommendation to the Ministry. Further this group should provide suggestions for the reforms that will be required in medical education so that a cohesive and effective referral chain can be created to support the work of the ASHA. The group would also help the Ministry in identifying credible partners who in turn would implement strategies for community partnership in the mission. Dr Seem emphasized that the group’s mandate is not limited to advise on community action alone but includes advising the government on key components of NRHM.

Members suggested that a small group on community action was necessary to   suggest a systematic process of community monitoring and action at various levels, and develop future steps. It was decided to constitute a Sub Committee on Community Action, which would inform the advisory group to provide suggestions for the government especially to operationalise  the Community monitoring component of the NRHM implementation framework. Dr Abhijit Das, Dr Abhay Shukla, Dr Narendra Gupta and Dr P C Bhatnagar volunteered as members of the sub committee. Dr Abhijit Das would be the point person for the sub committee. Members suggested constituting similar sub committees such as sub committee on HMIS and other relevant issues. Dr Thelma Narayan also agreed to be a member of the sub-committee on community action.

Agenda 4: Review of Prayas Proposal

Dr Narendra Gupta from Prayas Rajasthan presented a brief on the proposal titled “Community Based Planning, Implementation and Concurrent review of Public Health Services”. The group appreciated the presentation and the proposal. Some of the critical responses to the proposal were voices by the group:-

  • The proposal should highlight the objective of building a public health perspective towards developing a replicable model for NRHM.
  • Need for the proposal to be streamlined as per the activities envisaged.
  • It should include documentation component and advocacy component including developing communication tools.
  • The proposal should also build in plan for replicability and sustainability.
  • The budget to be revised as per the activities. It should include the cost of sustainability and also reflect utilization of existing resources and mechanisms.
  • The proposed project should ensure representation from SC/ST communities and women.

The proposal was approved in principle. The proposal, however, needs to be modified according to the suggestions made above and a revised proposal is to be submitted directly to NRHM. Members also agreed that two more projects should be taken up under the implementation framework.

It was decided that the next meeting of the Advisory Group on Community Action would be held on 27th July in 2006 at 2.30 pm at India International Centre, immediately after the National Stakeholders Consultation of 26-27 July there.