managers’ manual · phc primary health centre ppmc phc planning and monitoring committee rks rogi...

(2005-2012)

Community Monitoring of Health Services Under NRHM

MANAGERS’ MANUAL

Managers’ Manual onCommunity based Monitoring

of Health services under National Rural Health Mission

Drawing from NRHM Framework of Implementation

Prepared byTask force on Community Monitoring

Of Advisory Group on Community Action

Based on the Proposal sanctioned by Mission Directorate of NRHM, MoHFW, Government of India

ii

Contents Abhijit Das, Sunita Singh & Ruth Vivek with support from

Technical Advisory Group (TAG) & Advisory Group on

Community Action (AGCA)

Editing Elisa Parija

Layout & Design Runu Saxena, Rahul Sharma

Production Coordinator Moumita Ghosh

Published December, 2008

Printed at Design Solutions

iii

The National Rural Health Mission (NRHM) was launched on the 12 April 2005, with the goalof improving the availability of and access to quality health care by people, especially for thoseresiding in rural areas, the poor, women and children. To ensure that the services reach thosefor whom they are meant, the NRHM proposes an intensive accountability framework thatincludes community-based monitoring as one of its key strategies.

The NRHM Framework for Implementation outlines the composition and broad roles ofmonitoring and planning committees at various levels. These outlines were to be subsequentlyelaborated for developing the process of community monitoring. The Advisory Group forCommunity Action (AGCA) is a standing committee within the NRHM, constituted to supportand advise the MoHFW in implementation and review of the NRHM across the country. TheAGCA took a lead in initiating discussions with the MoHFW to develop a detailed proposal onhow “Community Monitoring” could be rolled out in a phased manner across the country.Through a process of discussions and deliberations, the AGCA developed a comprehensiveproposal for decentralised ‘Community Monitoring” with the active partnership of theDepartment and civil society institutions. The proposal was then forwarded Union Ministry ofHealth and Family Welfare (MoHFW) for implementation on a national scale. The MoHFW hasapproved this first phase of the “Community Monitoring” proposal and has suggested theAGCA for a special Task Group for overseeing the implementation.

The AGCA has established a Task Group for technical support and oversight in implementingthe project and it is being chaired by Mr. A R Nanda of PFI, the convenor of AGCA. ASecretariat has also been established jointly by Population Foundation of India (PFI) andCentre for Health and Social Justice at New Delhi (CHSJ).

This Manual is based on project proposal that has been approved for different stakeholders inthe community.

Preface

iv

Ms S Jalaja, Ex-Mission Director, NRHM, MoHFW, Government of India.Mr G C Chaturvedi, Mission Director NRHM, MoHFW, Government of India.Mr Amarjeet Sinha, Joint Secretary, MoHFW, Government of India.Dr Tarun Seem, Director, NRHM, MoHFW, Government of India.Mr Ganga Kumar, Deputy Director, NRHM, MoHFW, Government of India.

Mission Directors of Nine States;Mr S. K. Lohani, Mission Director, NRHM, Government of Odisha.Mr Madhukar Chwodhari, Mission Director, NRHM, Government of Maharashtra.Ms Darshaniya Ahluwalia Mission Director, NRHM, Government of Chhattisgarh.Dr J B Ekka, Mission Director, NRHM, Government of Assam.Dr Manohar Agnani, Mission Director, NRHM, Government of Madhya Pradesh.Ms Girija Vaidyanathan Mission Director, NRHM, Government of TamilNadu.Mr V. Srinivas Mission Director, NRHM, Government of Rajesthan.Dr Pradeep Kumar Singh Mission Director, NRHM, Government of Jharkhand.Mr Nilay Mitash Mission Director, NRHM, Government of Karnataka.

All members of the Advisory Group on Community Action.All members of the Technical Advisory Group of AGCA.All members of State Mentoring Committee of concerned states.All State Nodal Organisations.All District and Block level NGOs.All Health Providers and Managers at District, Block, PHC and community level who wereassociated with the process.Members of the different Panchayati Raj Insititutions in the nine states.Members of the different level of Monitoring and Planning Committees in the nine states. Members of the Village Health and Sanitation Committees.

AndCitizens of India who were engaged in this process across the nine states.

Acknowledgements

v

Preface iii

Acknowledgements iv

Glossary vi

Section I Introduction to NRHM 3

Section II Community Monitoring in NRHM 7

Introduction to Community Monitoring 7

Objectives of Community Monitoring 7

Process of Community Monitoring 8

Section III First Phase of Community Monitoring 11

Scale of Implementation of the First Phase 12

Need for involving Civil Society Organisations/ NGOs in the First Phase 12

Role of Civil Society Organisations in the First Phase 14

Section IV Implementing the first phase of Community Monitoring 17

Preparatory Phase 17

District Level Implementation Phase 18

Section V Organisational responsibilities 25

National Level 25

State Level 26

District Level 28

Block Level & Below 28

Tables and Figures

Table 1 Ambit & Scope of Community Monitoring at Different Levels 9

Table 2 Activities in the Preparatory Phase 18

Table 3 State Level Activities in the Preparatory Phase 18

Table 4 Criteria for NGO selection 22

Table 5 Format for NGO Selection 23

Table 6 Organisational Responsibilities at Different Levels 25

Figure 1 Geographical Spread 13

Figure 2 Organogram of Monitoring & Planning Committees 19

Figure 3 Process of Monitoring 21

Figure 4 Organogram 27

Annexures

Annexure 1 NRHM Strategies 31

Annexure 2 Monitoring and Evaluation 32

Annexure 3 Community Monitoring Framework 33

Annexure 4 Composition, Roles and Responsibilities of Monitoring 35

Committees

Annexure 5 Concrete Service Guarantees 42

Enclosed in CD-ROM - Managers' Manual, Training Manual, Monitoring Manual, format

of Process Documentation and other related materials.

Contents

GlossaryAGCA Advisory Group for

Community ActionAYUSH Ayurveda Unani Siddha

HomeopathyASHA Accredited Social Health

ActivistANM Auxiliary Nurse MidwifeAWW Anganwadi WorkerAIDS Acquired Inmmuno

Deficiency SyndromeAPL Above Poverty Line

BPMC Block Planning andMonitoring Committee

CHSJ Centre for Health and Social Justice

CHC Community Health Centers CBOs Community Based

OrganisationsCSO Civil Society OrganisationsCM Community Monitoring CMO Chief Medical OfficerCMHO Chief Medical Health Officer

DOTS Directly ObservedTreatment, Short CourseChemotherapy

DHO District Health OfficerDH District HospitalDPMC District Planning and

Monitoring Committee

FGD Focus Group Discussion

GoI Government of IndiaGDP Gross Domestic Product

HIV Human Immuno-deficiency Virus

HO Health Officer

IPHS Indian Public HealthStandards

IMR Infant Mortality Rate

MoHFW Ministry of Health and Family Welfare

MDGs Millennium DevelopmentGoals

MTA Mother Teacher AssociationMPW Multi-Purpose WorkerMMR Maternal Mortality RateMO Medical Officer

MLA Minister of LegislativeAssembly

MLC Minister of LegislativeCouncil

NRHM National Rural HealthMission

NHP National Health ProgrammesNHRC National Human Rights

Commission

PFI Population Foundation ofIndia

PRIs Panchayati Raj Institutions PTA Parent Teacher AssociationPHC Primary Health CentrePPMC PHC Planning and

Monitoring Committee

RKS Rogi Kalyan SamitiRTI Reproductive Tract Infection

SHG Self Help GroupSHC Sub- Health CentreSC Scheduled CasteST Scheduled TribeSTI Sexually Transmitted

Infections

TOT Training of TrainersTAG Technical Advisory Group

VHSC Village Health and SanitationCommittee

VHC Village Health Committee

3

There is an increasing recognitionthat despite significantimprovements in health parameters

like life expectancy at birth of and thereduction of infant mortality, there arelarge parts of the country where peoplecontinue to have very poor access tohealth care services and their health statuscontinues to be abysmal. A highproportion of the population continues tosuffer from and die of preventableconditions like maternal deaths, malariaand tuberculosis. Persistent malnutritionand high levels of anaemia amongstchildren and women is widespread. Due tothe poor status of public health systemspeople are also facing poverty andindebtedness from the costs incurred inseeking health care. Public spending onhealth in India, especially on preventiveand promotive health is also very low inIndia. On the other hand, private and outof pocket, expenditure on health is veryhigh, about three times higher than thepublic expenditure. Thus, there is anurgency to deal with multiple healthrelated crisis that the rural poor in the

country are faced with. There is also theneed to transform the health system intoan efficient, transparent and accountablesystem delivering affordable and qualityservices.

The National Rural Health Mission hasbeen conceptualised and is beingimplemented to bring about thesefundamental changes in the way health

SECTION-I

Introduction to NRHM

Reduction in Infant Mortality Rate (IMR) andMaternal Mortality Ratio (MMR).

Universal access to public health servicessuch as Women's health, child health, water,sanitation & hygiene, immunization, andNutrition.

Prevention and control of communicable andnon-communicable diseases, includinglocally endemic diseases.

Access to integrated comprehensive primaryhealthcare.

Population stabilization, gender anddemographic balance.

Revitalize local health traditions andmainstream AYUSH.

Promotion of healthy life styles.

MANAGERS’ MANUALCOMMUNITY MONITORING

GOALS

care services are being delivered to therural poor. The goal of the Mission is toimprove the availability of and access toquality health care by people, especiallyfor those residing in rural areas, the poor,women and children.

The Mission seeks to provide universalaccess to equitable, affordable and qualityhealth care which is accountable, at thesame time responsive to the needs of thepeople, reduction of child and maternaldeaths as well as population stabilisation,gender and demographic balance. In thisprocess, the Mission would help achievegoals set under the National Health Policyand the Millennium Development Goals(MDGs).

In order to achieve its goals andobjectives the Mission seeks to forgeeffective partnerships between theCentral, state and local governments.There are flexible mechanisms built intothe Mission so that local needs andpriorities can be identified and addressedand local initiatives promoted.Intersectoral convergence is also seen as akey strategy of the Mission for improvinginterventions in preventive and promotivehealth. The Panchayati Raj Institutions(PRIs) and the community have beengiven key roles in the management ofprimary health care programmes as well asinfrastructure.

Some of the key areas that have been

identified for concerted action within theNRHM framework of action are as follows:

Well functioning health facilities Quality and accountability in thedelivery of health services. Taking care of the needs of the poor andvulnerable sections of the society andtheir empowerment.Prepare for health transition withappropriate health financing.Pro-people public private partnership.Convergence for effectiveness andefficiency.Responsive health system meetingpeople’s health needs.

The expected outcomes from theMission are:

Reduction of Infant Morality rate to30/1000 live births by 2012. Reduction of Maternal Mortality to100/100,000 live births by 2012. Reduction of Total Fertility Rate to 2.1by 2012. Reduction of Malaria Mortality Rate by50% up to 2010 and an additional 10%by 2012. Reduction of Kala Azar Mortality Rateby 100% by 2010 and sustainingelimination until 2012. Reduction of Filaria/Microfilaria Rate by70% by 2010 by 80% by 2012 andelimination by 2015.

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To provide effective healthcare to rural population throughout the country with special focus on 18states, which have weak public health indicators and/or weak infrastructure.

18 special focus states are Arunachal Pradesh, Assam, Bihar, Chattisgarh, Himachal Pradesh,Jharkhand, Jammu and Kashmir, Manipur , Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh.

To raise public spending on health from 0.9% GDP to 2-3% of GDP, with improved arrangement forcommunity financing and risk pooling.

To undertake architectural correction of the health system to enable it to effectively handle increasedallocations and promote policies that strengthen public health management and service delivery inthe country.

To revitalize local health traditions and mainstream AYUSH into the public health system.

Effective integration of health concerns through decentralized management at district, withdeterminants of health like sanitation and hygiene, nutrition, safe drinking water, gender and socialconcerns.

Address inter State and inter district disparities.

Time bound goals and report publicly on progress.

To improve access to rural people, especially poor women and children to equitable, affordable,accountable and effective primary health care.

THE VISION OF THE MISSION

there is anurgency to deal

with multiplehealth relatedcrisis that the

rural poor in thecountry arefaced with

5

MANAGERS’ MANUAL

Reduction of Dengue Mortality Rate by50% by 2010 and sustaining at thatlevel until 2012. Increasing Cataract operations to 46lakh until 2012. Reducing Leprosy Prevalence Rate from1.8 per 10,000 in 2005 to less that 1 per10,000.Maintain 85% cure rate in theTuberculosis DOTS series through theentire Mission Period and also sustainplanned case detection rate. Upgrading all Community HealthCenters (CHC) to Indian Public HealthStandards (IPHS). Increase utilisation of First ReferralUnits through increased bed occupancyby referred cases from less than 20% toover 75%. Engaging 4,00,000 female AccreditedSocial Health Activists (ASHA).

At the community level it is expected that:

There will be increased awareness aboutpreventive health including nutrition.There will be a trained worker availableat the community level with a drug kitfor common ailments.A monthly Health Day will be organisedwhere services related to maternal and

child health, for ex. immunisation,ante-natal check-ups and nutritionalservices will be available.Generic drugs for common ailmentswill be available at the sub centre andgood hospital care will be assuredthrough availability of doctors, drugsand quality services at PHC/CHC level. There will be improved facilitiesavailable for institutional deliveries andthe Janani Suraksha Yojna will alsoprovide opportunities for subsidisedhospital care for those below thepoverty line.Mobile medical units will ensureavailability of services to remoteunderserved areas.There will be provision of safe drinkingwater and household toilets.

To ensure that these outcomes areachieved, and quality and accountablehealth services which are responsive andtake care of the needs of the poor andvulnerable sections of the society areattained — community ownership andparticipation in management is seen asan important pre-requisite withinNRHM. Thus, community monitoring isan important component for achievingthese results.

COMMUNITY MONITORING

Through household and health facility survey that involve Village Health Teams and discuss findingslocally.

Through Health Camps that bring a range of health services to the community and makes them awareof their entitlements.

Through "Public Hearings" or Jan Sunawai oganized periodically where people share their experienceof seeking health care. Such Jan Sunwais may be organized twice a year, or at least once a year atPHC, block and district levels.

Through training and orientation of village Health Teams for community action.

By building team of Community Workers like Aangan Wadi Sevika , ASHA, School Teacher, MahilaSamakhya worker, PTA/MTA' members, etc.

By involving group like SHGs, Community based organizations, MTAs, PTAs, literacy volunteers,Containing Education Centre volunteers, etc. who have motivation for Community action.

By making local level health functionaries visit households frequently.

By making Block and District level Health Mission teams, including NGOs, organize a series ofactivities like health camps, public hearings, etc.

HOW TO TRIGGER COMMUNITY ACTION?

community ownership andparticipation inmanagement isseen as animportant pre-requisitewithin NRHM

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CommunityMonitoring in NRHMIntroduction to CommunityMonitoring The accountability framework proposed inthe NRHM is a three-pronged process thatincludes internal monitoring, periodicsurveys and studies and community basedmonitoring. Community monitoring isalso seen as an important aspect ofpromoting community led action in thefield of health. The provision forMonitoring and Planning Committees hasbeen made at PHC, block, district and statelevels. The adoption of a comprehensiveframework for community-basedmonitoring and planning at various levelsunder NRHM, places people at the centreof the process of regularly assessingwhether the health needs and rights of thecommunity are being fulfilled.

The community monitoring processinvolves a three way partnership betweenhealth care providers and managers

(health system); the community,community based organisations andNGOs and the Panchayati Raj Institutions.The success of the community monitoringprocess will depend upon the ownershipof the process by all three parties and adevelopmental spirit of ‘fact-finding’ and‘learning lessons for improvement’ ratherthan ‘fault finding’.

The objectives of community basedmonitoring are as follows:

It will provide regular and systematicinformation about community needs,which will be used to guide theplanning process appropriately.It will provide feedback according to thelocally developed yardsticks, as well ason some key indicators. It will provide feedback on the status offulfilment of entitlements, functioningof various levels of the public health

SECTION-II

system and service providers,identifying gaps, deficiencies in servicesand levels of community satisfaction,which can facilitate corrective action ina framework of accountability. It will enable the community andcommunity-based organisations tobecome equal partners in the planningprocess. It would increase thecommunity sense of involvement andparticipation to improve responsivefunctioning of the public health system.The community should emerge as activesubjects rather than passive objects inthe context of the public health system. It can also be used for validating thedata collected by the ANM, Anganwadiworker and other functionaries of thepublic health system.

Process of Community Monitoring The exercise of community monitoringinvolves drawing in, activating, motivating,and capacity building and allowing thecommunity and its representatives e.g.Community Based Organisations (CBOs),people’s movements, voluntaryorganisations and Panchayatrepresentatives, to directly give feedbackabout the functioning of public healthservices, including giving inputs forimproved planning of the same. Thecommunity and community-basedorganisations will monitor demand/need,coverage, access, quality, effectiveness,behaviour and presence of health carepersonnel at service points, possible denialof care and negligence. The monitoringprocess will include outreach services,public health facilities and the referralsystem.

The key Institutions for CommunityMonitoring as laid out in theFramework of Implementation are:

Village Health and SanitationCommittee (VHSC).The PHC Planning and MonitoringCommittee.The Block Planning and MonitoringCommittee.The District Planning and MonitoringCommittee.

The State Planning and MonitoringCommittee.Guidelines regarding the composition,

roles and powers of these committees havebeen laid out in detail in the Framework ofImplementation and are reproduced inAnnexure 4.

The monitoring process will beginwith a village report card being preparedby the Village Health and SanitationCommittee after consulting villagerecords (ex. ASHA records or ANMrecords or the Village Health Register)and also by conducting interviews andmeetings with potential beneficiaries(like women who are pregnant or haveundergone childbirth in the recent past,or those with small children) tounderstand the community members’experiences and problems faced, as wellas assess the extent to which key servicesare being delivered effectively. TheMonitoring Committee at eachsubsequent level would review andcollate the reports coming from thecommittees dealing with unitsimmediately below it. For example, BlockCommittee will receive and review theVHSC reports while the DistrictCommittee would receive and review thereports from all Block Committees.However, the monitoring committeeswould not only rely on reports, butwould also make their own independentobservations on selected key parameters.Each committee would appoint a smallteam drawn from among its civil societyand PRI representatives who would visiton a quarterly/six-monthly basis, a smallsample of units (say one facility or twovillages) under their purview and directlyreview the conditions.

This will enable the committee to notjust rely on reports but to also have afirst-hand assessment of conditions intheir area. For example, the PHCcommittee representatives would visittwo villages and conduct groupdiscussions in each trimester selectingdifferent villages by rotation. Similarly,the Block Committee representativeswould visit one PHC by rotation in eachtrimester. The monitoring committees at

8

the provision for Monitoring

and PlanningCommittees has

been made at PHC, block,

district and statelevels

9


PHC/Block/District levels will beresponsible for making an assessment ofthe functioning of the major health carefacility at their respective level(PHC/CHC/District Hospital).

Sharing of the findings of monitoringcommittees will not only take placethrough the periodic report submitted tothe next level of monitoring committee,but also through periodic public sharing.Monitoring committees at PHC, Blockand District level will be involved in six-monthly or annual Jan Samvads orpublic hearings at their respective levels,where committee members would sharethe results of their findings and also getdirect feedback of the situation,

including possible presentation of casesof denial of health care. Similarly, theState Planning and MonitoringCommittee will conduct an annualpublic meeting open to all civil societyrepresentatives where the State Missionreport and independent reports will bepresented and various aspects of designand implementation of NRHM in thestate, including state specific healthschemes, would be reviewed anddiscussed enabling corrective action to betaken.

A broad outline of the ambit and scopeof community monitoring at differentlevels is given in the Table below

Table-1 Ambit & Scope of Community Monitoring at Different Level

Community MonitoringCommittee

Periodicity of Monitoring Activities to be undertaken

Village Health and SanitationCommittee

Quarterly a. Reviews Village Health register, Village health calendar.

b. Reviews performance of ANM, MPW, ASHA.c. Reviews communities own experiences as

beneficiaries of services.d. Sends brief three monthly report to PHC committee.

PHC Monitoring and PlanningCommittee

Quarterly a. Reviews and collates reports from all VHSCs. b. An NGO / PRI sub team conducts FGDs in three sample.

villages under PHC.c. Visit PHC, review records, discuss with RKS members.d. Send brief three monthly report to Block committee.

Block Monitoring andPlanning Committee

Quarterly a. Reviews and collates reports from all PHCs.b. NGO / PRI sub team visits at least one PHC of the block,

conduct interviews with MO and make observations. c. Visit CHC and review records, discuss with RKS members.d. Send brief three monthly report to District committee.

District Monitoring andPlanning Committee

Quarterly a. Reviews and collates reports from all Blocks. b. An NGO / PRI sub team visits at least one CHC of the District, conducts

interviews with Incharge, meets Block committee members and RKSmembers, makes observations c. Visits District hospital and reviewsrecords, discuss with RKS members.

c. Send brief three monthly report to State committee.

State Monitoring and PlanningCommittee

Quarterly a. Reviews and collates reports from all Districts.b. An NGO / PRI sub team visits 3 to 5 Districts, conducts interviews with

DHO and District Committee members, makes observations on DH.c. Sends six monthly report to NRHM / Union Health Ministry.

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First Phase ofCommunity Monitoring

The outlines of communitymonitoring process provided withinthe Framework of Implementation

have been developed and elaborated uponby the Advisory Group on CommunityAction (AGCA). The first phase was seen asa learning phase because no similarcommunity monitoring activity, either inthe health sector or in other social sectorshas been implemented on a countrywidescale before. Thus in the first phase theimplementation was supervised at anational level by a specially constitutedNational Secretariat and Task Groupconstituted under the supervision of theAdvisory Group. It was decided that thefirst phase would be of eleven months(March 07-Jan 08), which got extended tillDecember 2008 and covered nine states.

Some reasons because of which it wasdesirable to start with a learning phase, areas follows:

Learning from experiences and mistakes

on a smaller scale, then moving to alarger scale: This is probably the first timein the country that the official healthsystem is institutionalising communitymonitoring of health services on a majorscale. There is scope for many kinds ofexperiences and even deviation fromobjectives, so it is thought to be desirableto try out the process on a smaller scaleand make corrections before moving to astatewide scale.The need to pool expertise and build aninitial critical mass: The number oforganisations with experience in rights-based and accountability-oriented workrelated to the Health sector may not bevery large in many states. Similarly,expertise and commitment related tothis activity within Health departmentsmay also be limited to begin with. Itwould be desirable for facilitatingagencies both within and outside theHealth department to come together,

SECTION-III

share expertise, help launch pilots in afew areas, and analyse experiences,before going to scale at the state level.This would also strengthen ownership ofthe process within the Department.Starting directly with a widelygeneralized model would demand veryextensive involvement of comparativelyfew facilitators from day one; they wouldhave to immediately spread themselvesthin – not allowing much space forinitial development of methodologiesand building a critical mass.The process of developing communitymonitoring is a delicate process thatneeds to be handled carefully.Community mobilisation experiences inthe Health sector show that the initialresponse of community representatives isoften to assertively point out a wholerange of problems, deficiencies, gaps andeven alleged cases of denial of health carewhich may be quite difficult for theHealth officials to digest and take in theright spirit – which could even at times,lead to a virtual breakdown of dialogue.Maintaining the vitality and authenticityof the process, but not allowing completepolarisation, which would disrupt thedialogue and convergence process itselfis a delicate task. Starting by launchingthe community monitoring process allover the state on a large scale mayconceivably lead to potentiallydisruptive situations and evendemotivation of Health functionarieswhich could be avoided by first workingout the process in pilot areas andbuilding appropriate checks and balancesin the methodology before moving togeneralisation.

Scale of Implementation of the First Phase The first phase of the communitymonitoring component of NRHM wasimplemented in 36 selected districts of 9states of the country. These are

Assam ChhattisgarhJharkhand Madhya PradeshMaharashtra OrissaRajasthan Tamil NaduKarnataka

In each of these states a number ofdistricts were selected (between three andfive depending upon the number ofdistricts in the state) on the basis ofregional diversity as well as the presenceof a credible district level NGO/ CivilSociety Organisation, which canfacilitate the implementation. In each ofthese districts three blocks were chosenfor the first phase, and from among thesethree blocks the operational area of threePHCs were selected. Five villages wereselected for initiating communitymonitoring in each of the three PHCareas. The total numbers of districts,blocks, PHCs and villages is summarisedbelow:

For States with 15 to 29 districts: threepilot districts were selected.For States with 30 to 39 districts: fourpilot districts were selected.For States with 40 and above districts:five pilot districts were selected.

This will lead to a total of 36 districtsspread across these nine states. In eachdistrict, three blocks were identifiedgiving a total 108 blocks. In each of theseblocks, three PHCs were identified givinga total 324 PHCs. In each PHC area, fiverevenue villages were identified giving atotal 1620 villages.

Need for involving Civil SocietyOrganisations/ NGOs in theFirst Phase NGOs or Civil Society Organisations havebeen given crucial roles in the NRHM. It isenvisaged that besides providing services inselected areas, they will not only be membersin institutional arrangement at all levels, butwill also act as resource organisations andprovide support for evaluation, monitoringand social audit. These organisations had acrucial role to play in the first phase ofcommunity monitoring to ensure its success.Although state Health Departments wouldplay an extremely important role indeveloping community monitoringactivities, however the facilitation ofcommunity based monitoring was not left tostate Health Departments. Some of thereasons for this are as follows:

12

no similar community monitoring

activity, either inthe health sectoror in other socialsectors has beenimplemented on

a countrywidescale before

13


Figure-1 Geographical Spread

It is largely the Health Departmentfunctionaries themselves who would bemonitored; hence for the monitoring tobe robustly independent, it is notsufficient to leave the entire task ofdeveloping the monitoring frameworkto the Health department alone. For effective community monitoring,capacity building of a whole set of actorslike beneficiary representatives, CBOs,people’s movements, voluntaryorganisations and Panchayatrepresentatives - who will eventually dothe monitoring - is imperative. Hence,involvement of networks, organisationsand individuals with experience ofcommunity mobilisation and communitybased monitoring to facilitateinvolvement in the health system of thiswhole new set of actors is needed.To facilitate change in the balance ofpower in the health sector, in favour ofpeople. The exercise of communitymonitoring carries meaning only ifordinary people and theirspokespersons in form of bothPanchayat representatives and CBOs,gain a degree of authority to identifygaps and correspondingly proposepriorities and influence decisionmaking regarding the health system. The kind of capacity required to developa participatory community monitoringsystem is quite different fromprogramme implementation andtraining usually conducted by theHealth Department; hence involvingvoluntary sector agencies with someexperience of accountability buildingand health rights work would bedesirable to help facilitate this process.

Role of Civil Society Organisations inthe First Phase Civil Society Organisations i.e.Community Based Organisations (CBOs)and Non Governmental Organisations(NGOs) have three kinds of roles in theprocess of community based monitoring:

Members of monitoring committees:Social organisations working in close,regular contact with communities on

health related issues, especially from arights-based perspective, would be ableto present in various monitoringcommittees the community concerns,experiences and suggestions regardingimproving public health systemfunctioning.Resource groups for capacity building andfacilitation: NGOs and CBOs will havethe responsibility for overall facilitationof the initial process of committeeformation and capacity building ofcommunity monitoring committeemembers about the process ofcommunity based monitoring. It includesthe roles of members at different levels,including peripheral committees at PHCand village levels. Based on nationalmodel material, training modules andmaterials for orientation of communitymonitoring committee members wouldbe adapted and published at state leveland used for this capacity buildingprocess. All three types of members –Panchayat representatives, civil societyorganisations and health systemfunctionaries would benefit from suchcapacity building.Agencies helping to carry outindependent collection of information:NGOs and CBOs would contribute to thecollection of information relevant to themonitoring process at all levels from thevillage to state level. In these processes,an element of community mobilisationmay be involved. Specific teams woulddialogue with communities and wouldcollect and process community-basedinformation. These teams could be sub-groups drawn from the larger monitoringcommittee at specific levels, but couldalso include some persons from beyondthe monitoring committee. Formation ofsuch teams should be encouragedespecially at the PHC and block levels.Each team should include members fromone or more facilitating NGOs and PRImembers, and could also includerepresentatives from among the healthcare providers. Such teams shouldundergo a short orientation exercisebefore they undertake the communitymonitoring exercise.

14

facilitate change in the

balance of powerin the health

sector, in favourof people

17


Implementing the firstphase of CommunityMonitoringThe first phase of the community

monitoring process wasimplemented under the overall

supervision of the specially constitutedTask Group of the Advisory Group onCommunity Action. A NationalSecretariat was set up in Delhi throughthe collaboration of PopulationFoundation of India and Centre forHealth and Social Justice.

PREPARATORY PHASE The activities that were undertaken duringthe first phase and the persons responsibleat each level are given in the table below.The preparatory phase lasted from March2007 to June 2007.

State Mentoring Group The State Mentoring Group was formedinvolving representatives of the state HealthDepartment and state level health sector

voluntary networks. Based on experienceand demonstrated interest, the State MissionDirector and the state designated AGCAmembers suggested names for thismentoring team. This team had definiteresponsibilities to develop communitymonitoring in the state during the firstphase and beyond, which was clearly speltout. This team had seven to elevenmembers, of which at least four to sevenwere civil society representatives. Inaddition, the designated national AGCAmembers were permanent invitees to theState Mentoring Team.

State Nodal Organisation One of the state level NGOs withmembership in the State Mentoring Teamwas selected to work as the state nodalNGO during the first phase. This statenodal NGO worked under the direction ofthe State Mentoring Team.

SECTION-IV

Other state level activities that were carriedout in the preparatory phase are as follows:

A State Level Workshop was organisedby the State Mentoring Team, State NodalOrganisation and State Health Missioninvolving all stakeholders (State Missionofficials, District Health officials and PRIrepresentatives from selected districts,NGO networks and civil societyorganisations from these districts) alongwith NRHM GoI representatives. Theactivities of the first phase were sharedand the process finalised. Detailedtimetable for district level meetings,formation and orientation of committeeswas worked out in this two-day state

level workshop.A State level Training of Trainer s for

the facilitating teams from all pilotdistricts was conducted. It was heldprimarily by voluntary sector facilitatorsin the first phase, since governmentofficials may not have adequateexperience in community monitoringactivities. However state HealthDepartment officials were present andinvolved in these workshops, enablingthem to actively participate in furthersuch trainings.

Outcomes of the Preparatory Phase:National Secretariat was established.State Community MonitoringMentoring Groups were established inall nine states. State Nodal Organisations wereestablished in all nine states.State level workshops were organised inall states.State level TOT was organised in allstates.Draft of materials, curriculum andmodules were prepared.State level adaptation of thepublications was begun.

DISTRICT LEVELIMPLEMENTATION PHASE Once the district and block level

18

Preparation of necessary Materials,Curricula and Modules.

National Secretariat Task Group

Meeting with state CSOs and identifyingState Nodal organization.

AGCA- Task Group National Secretariat

Meeting with State Health Secretary andNRHM Directorate and setting up StateCommunity Monitoring Mentoring Group.

AGCA- Task Group National Secretariat

Activity Responsibility Support from

Selection of districts and blocks for implementing the project.

State C MMentoring Group.

Task Group. National Secretariat.

Selecting organizations which willbe implementing activities at thedistrict and block level.


Task Group.National Secretariat.

State level workshop to finalise thedistricts and modalities of districtand block level activities.



State level TOT. State C MMentoring Group.


Adapting and translating materials,curricula and modules for the state.



Table-3 State Level Activities in the Preparatory Phase

Activity Responsibility Support from

Setting up Task Group. AGCA MoHFW, GOI

Setting up National Secretariat. AGCA- Task Group

Contacting State Secretaries in the 9 states. MoHFW, GOI

Contacting Civil Society Organisations inthe 9 states.

Task Group

Table-2 Activities in the Preparatory Phase

19


facilitating organisations were selected andtraind, the key activities shifted to thedistrict and block levels. The timeallocated for these activities was July 2007to December 2007 in the first phase.

The activities at the district and blocklevel proceeded in the following manner:

Getting Ready for Community Monitoring District processes were facilitated by NGOstaking responsibility in the first phasedistricts along with the District Health

officials and PRI representatives. A District Mentoring Team (includingrepresentatives of each of the threegroups) to facilitate the communitymonitoring process was put in place,which facilitated the orientation activitiesin this and subsequent stages. In eachdistrict, one NGO was needed to takeresponsibility as the District Nodal NGO.This NGO was assisted by other civilsociety organisations that would takespecific responsibility in various blocks.The process started with a District LevelWorkshop to share the concept, identify

Figure- 2 Organogram of Monitoring & Planning Committees

blocks and PHCs, involving key DistrictHealth officials, PRI members and civilsociety organisations. Three blocks withinthe district were selected for pilotimplementation. Block nodal civil societyorganisations took up the responsibilityfor specific blocks in coordination withthe District Nodal NGO.

There was need to conduct a block level training for at least a four memberBlock Community Monitoring FacilitationTeam, including at least two NGO/CBO members and half women. TheseBlock Facilitation Team members wereresponsible for the subsequent committeeformation and orientation processes. Itwas anticipated that these activities wouldbe completed in the month of July 2007.

Formation of Committees During the next four months (Aug– Nov2007), there was formation of committeesat village, PHC and block levels in theselected blocks (in that order), along withorganising primary orientation of theirmembers. Formation of communitymonitoring committees started fromvillage committees, PHC, block, and thendistrict committees. A few members fromVHCs were included in the PHCcommittee; similarly a few PHC committeemembers were included in the blockcommittee. Therefore it was important toconstitute the committees from villagelevel upwards in such a sequential order.CBOs/NGOs and Panchayatrepresentatives who had shown leadinginitiative in organising communitymonitoring activities at any level foundrepresentation in the next high-levelcommittees. Adequate representation ofwomen, dalits and adivasis was ensured invarious committees.

Following committee formation at theperipheral levels, the District LevelCommittee was also finalised and becamefunctional by November 2007. In the firstphase, at the state level, a provisionalcommittee was formed by December 2007.This would be given final shape only afterthe next phase of ‘Extendedimplementation’ is completed and at leasthalf of the districts of the state have the

Community Monitoring Committees inplace, which could send representatives tothe State Committee.

Community Monitoring The community monitored need,coverage, access, quality, effectiveness,behaviour, presence of health carepersonnel at service points, possible denialof care and negligence. The monitoringprocess included outreach services, publichealth facilities and the referral system.The community monitoring exercises andcollation of information was organisedvillage wise, PHC wise, block-wise anddistrict wise. In this way, these exercisesaggregated information upwards. Themonitoring results were also shared at thevillage level, block and district level in theappropriate PRI fora. Some of theframeworks on which communitymonitoring may be done, and which areincluded within the NRHM are as follows:

Village Health Plan, District Health Plan.Entitlements under the Janani SurakshaYojna.Roles and responsibilities of the ASHA.Indian Public Health Standards fordifferent facilities like Sub Centre, PHC,CHC.Concrete Service Guarantees.Citizen’s Charter and so on.

Activities that was undertaken at thevillage level for community monitoringhas already been outlined in Table 1-Section II, Page 9.

PHC and block level communitymonitoring exercises included a publicdialogue (‘Jan Samvad’) or public hearing(‘Jan Sunwai’) process by December 2007.Here individual testimonies andassessments by local CBOs/NGOs werepresented. Individual testimonies wereidentified through the adverse outcomerecording process. These public dialogueswere moderated/facilitated by the Districtand Block Facilitation Groups incollaboration with Panchayatrepresentatives and CBOs/NGOs workingon the issue of health rights.

The monitoring committee at each level

20

the monitoringresults were

also shared atthe village level,

block and districtlevel in theappropriate

PRI fora

21


Figure- 3 Process of Monitoring

reviewed and collated the summary reportsfrom the committees dealing with unitsunder it. This enabled it to make anassessment of the situation prevailing in allthe units under its purview, and to make areport at its level. For example, the DistrictCommittee would receive and review thereports from all block committees.

However monitoring committees didnot only rely on reports, but also directlyinteracted in the field situation and gotfeedback. Firstly, each committeeappointed a small sub-team drawn from itsNGO and PRI representatives who visitedon a regular basis, a small sample of units(say one facility or two villages) undertheir purview and directly reviewed theconditions. This enables the committee tonot just rely on reports but to also have afirst-hand assessment of conditions intheir area. For example, the PHCcommittee representatives would visit twovillages and conduct group discussions ineach trimester, selecting different villagesby rotation. Similarly, the BlockCommittee representatives would visit onePHC by rotation in each trimester.

Secondly, monitoring committees atPHC, block and district level would beinvolved in six-monthly or annual JanSamvads or Public hearings at theirrespective levels, where committeemembers would get direct feedback of thesituation, including possible presentationof cases of denial of health care. Similarly, itis suggested that the State Health Missioncould conduct an annual public meetingopen to all civil society representatives

where the State Mission report andindependent reports would be presentedand various aspects of design andimplementation of NRHM in the state,including state specific health schemes,would be reviewed and discussed enablingcorrective action to be taken.

Screening Civil Society Organisationsfor involvement in CommunityMonitoringIn order to screen civil society organisationsfor their capacity to partner in communitymonitoring activities, and to participate inmonitoring committees at various levels, asimple questionnaire was used. Suchorganisations may include CBOs (includingSelf-Help Groups and people’sorganisations) as well as NGOs working atthe respective level, with documentedactivity in the area since at least three years.In addition to other questions about theorganisation, the following issues will beincluded in the questionnaire.

On the basis of their responses to theirquestionnaire, the following screeningtable will be used and any organisationhaving at least one entry in all the fouraspects (with brief report of the activitycarried out in that aspect) may beconsidered as having qualified. Anyorganisation with demonstratedexperience of monitoring public services;organising public dialogues or publichearings should be given priority toparticipate in the community monitoringcommittees.

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Table-4 Criteria for NGO selection

Activity Profile CommunityMobilisation

Women’sEmpowermentActivities

WomeRights basedActivities

A1- Income GenerationA2 - Environment /Natural ResourceMgmtA3 - EducationA4- Health

C1- Self Help GroupsC2- Village LevelCommitteesC3- FederationsC4- CommunityLeadership trainingC5- Work with PRIsC6 – Village basedorganisation andmobilisation on specificissues

W1- Village levelwomen’s groupsW2 – Women’sleadershipdevelopment andtrainingW3 – Women andPRI

R1- Right to HealthcareR2- Right to FoodR3- Right to InformationR4- Right to EmploymentR5- Livelihood rights e.g.rights related to Forest,Land, Wages, Displacementetc. (specify)

monitoring committees didnot only rely onreports, but also

directlyinteracted in the

field situationand got feedback

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Key Considerations during SelectionTo ensure wide participation, diversegroup of civil society networks andorganisations involved in promotion ofhealth rights and monitoring should beinvolved at various levels.

The process of selecting civil societyorganisations to be involved inmonitoring committees at all levels couldbe facilitated by the mentoring team of therespective level, with guidance from thementoring team of the higher level. Forexample, the District Mentoring Teamcould suggest the names of civil societyorganisations to be involved in the DistrictMonitoring Committee, with inputs fromthe State Mentoring Team as relevant. Thisshould be a participatory processincluding various civil society networksand organisations. It should not be limitedto NGOs, and should also definitelyinvolve CBOs and people’s organisations

Civil society involvement inmonitoring should not be focussed onlyon ‘mother NGOs’ which are often deeplyinvolved in implementation and who maynot always be the most objective monitorsof work which they themselves areinvolved in implementing. Particularly forthe community monitoring process inNRHM, it is imperative that the idea is notconfined to just ‘leave it to mother NGOs.’Rather, organisations with experience ofrights based activities and accountabilityenforcing activities should be givenadequate space and responsibility at alllevels.

Process Documentation and Review Since the first phase of the communitymonitoring process was a learning phase, itincluded process documentation andreview as an important component. Thisincluded the following three distinct stages:

Process DocumentationTo ensure uniformity of recording theactivity, each activity of the project that hasbeen mentioned above included adocumentation procedure. Thesedocuments were filled in by the responsibleagency at different levels and collated at thestate level. The State Mentoring Team wasresponsible for analysing these documentsand prepared a review report on the stateimplementation, reporting whatinterventions worked and why andsuggesting changes.

Evaluation of the State LevelInterventionThere was an independent evaluation ofthe different interventions and theirimpact on different stakeholders by a teamof five experts. The evaluation includedreview of the documentation process,interviews with different stakeholders,including members of the community in alimited number of locations across each ofthe nine states.

State Level Review Workshops The third component of the review processcomprised of an end line workshop withthose involved in implementing the firstphase to review the process in each state.

Table-5 Format for NGO Selection

Name of CSO Activity Profile Community Mobilisation Activities Women’sEmpowermentActivities

Rights basedActivities

A1 A2 A3 A4 C1 C2 C3 C4 C5 W1 W2 W3 W4 W5 W6

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OrganisationalResponsibilities

The entire range of activities duringthe first phase were needed to besupported by NRHM Mission

Directorate from the Union HealthMinistry level for rapidity of execution,given the compressed timeframe available.Responsibilities for handling funds andensuring activities at various levels wereallocated as follows:

NATIONAL LEVELAt the national level, the Task Group of the

Advisory Group on Community Action(AGCA) facilitated the entire process ofcommunity action in consultation with theMinistry of Health and Family Welfare. ThePopulation Foundation of India is theSecretariat for the AGCA.

AGCA-TAG (Sub-group of AGCA)Conceiving and planning the entireintervention.Periodic review.Support the relationship building with

SECTION-V

Table 6: Organisational Responsibilities at Different Levels

Level Responsibility

National Overall facilitation by AGCA (in consultation with NRHM officials). Financialresponsibilities and coordination handled by AGCA Secretariat along with sub-group of AGCA.

State State Nodal NGO under guidance of State Mentoring Team (which wouldinclude State Mission Director).

District District nodal NGO under guidance of District Mentoring Team (which wouldinclude District Health Officer).

Block and below Block nodal civil society organisation (in coordination with District Nodal NGO).

the state government.Support the formation of State CMMentoring Group.Identify State Level Nodal Organisation.Technical inputs. Generate training designs.Framing Community MonitoringProtocol.Jan Samvad protocols etc.Distil lessons learnt.

National Secretariat on CommunityAction – NRHMA National Secretariat was set up under theleadership of PFI along with Centre forHealth and Social Justice at New Delhi.The Secretariat undertook specialfacilitation of the community monitoringprocess at the national level inconsultation with the MoHFW and NRHMMission. The National Secretariatfunctioned within the frameworkformulated by the AGCA for communitybased monitoring of programmes underNRHM.

The National Secretariat had thefollowing roles and responsibilities:

Coordinating activities of the nationalpreparatory phase, which includesdeveloping tools, model curriculum,workshops, awareness materials anddocumentation formats for theprogramme.Assist the AGCA members and the stateNRHM Directorates and NGO networksfor the state preparatory stage.Facilitate process documentation andreview of the pilot implementation phasein consultation with AGCA members.Develop a website on community basedmonitoring of processes and access toservices under NRHMManage the financial responsibility ofthe pilot programme Prepare progress reports, field visits andthe national dissemination workshopsof the programme at the national levelConduct quarterly review of AGCA forreview of the pilot programme.

Staffing: The National Secretariat wasmanaged by two programme officers

responsible for the overall programmaticand financial coordination of theprogramme. The officers reported to theTask Group of AGCA.

STATE LEVELAt the state level, there was the StateCommunity Monitoring MentoringGroup, State Resource Pool and the StateNodal Agency.

State CM Mentoring GroupCoordinate with the State Government.Prepare state level plan/design andbudgets.Identify districts and blocks.Identify NGOs for district and blocklevel.Review progress at the state level.Distil lessons learnt from the state levelexperiences.

State Resource PoolAdaptation of manuals, protocols andmaterials for the state level situation.Translation of materials, manuals andprotocols.Provide training and facilitationsupport for events – trainings andworkshops.

State Nodal AgencyAssist in implementing the decisionstaken at the CM Mentoring Team.Arrange for technical and resourcesupport to district/block level NGOs.Support the process of adaptation,translation and publication state levelmaterials/manuals.Supervise community leveldocumentation processes.Maintain documentation of state levelprocesses.Provide progress, process and financialreports and documents to the NationalSecretariat on a regular basis.Financial support and disbursement todistrict level and block level processes.Maintain state level accounts.Supervise progress and supportprocesses/activities at the district, blockand community levels.

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a NationalSecretariat was

set up under theleadership of

PFI along withCentre for Healthand Social Justice

at New Delhi

Ministryof Health

and FamilyWelfare

(GoI)- NRHM

Advisory Group on

Community Action(AGCA)

National Secretariat onCommunity

Action- NRHM

State Monitoring and PlanningCommittee

State Mentoring Team

State Nodal NGO(Out of the state mentoring team, one

NGO Member will designated as State NodalNGO)

District Mentoring Team(This team will include PRI representatives, district Health

Officials and NGO representatives)

District Nodal NGOThe District level and Block level funds in the first phase in each state

would be given to designated District nodal NGO to enable a fast start-up and adequate flexibility in the process)

District Monitoring and Planning Committee

Block Nodal Civil Society Organizations(The District nodal NGO would collaborate with Block nodal civil society

organisations for execution of activities in specific blocks)

Block Community Monitoring Facilitation Team(Responsible for subsequent committee formation and orientation processes)

Block Monitoring and Planning Committee

PHC Monitoring and Planning Committee

Village Health and Sanitation Committee

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Figure-4 Organogram

DISTRICT LEVELAt the district level, there is the DistrictCommunity Monitoring Mentoring Groupand the District Nodal Agency.

District CM Mentoring GroupCoordinate with the State and districtlevel government.Prepare district level plan/design andbudgets.Coordinate with blocks and providestechnical support. Review progress at the district level andbelow.Distil lessons learnt from the districtlevel and below experiences.Identify NGOs for district and blocklevel for implementing the communitymonitoring programme.

District Nodal AgencyAssist in implementing decisions takenby mentoring group.Arrange for technical and resourcesupport to district/ block level NGOs.Support process of adaptation,translation and publication state levelmaterials/manuals.Supervise community leveldocumentation processes.Coordinate with State Nodal Agency.Coordinate with district officials - ChiefMedical Officer; Zilla Parishad, DistrictMentoring Team.Mobilisation and capacity building atdistrict level.Collation of records and reports.Financial management.Mobilisation and capacity building atdistrict and block level.Facilitate balance of power betweenstakeholders - liaison with differentstakeholders.Declaring, dissemination - healthentitlements within rights basedapproach.Reflect community/spokespersons ofcommunity concerns, experiences.Form committees at the village, PHCand block if such committees have notbeen formed.

BLOCK LEVEL AND BELOWAt the block level, there is a Block NodalAgency in coordination with DistrictNodal NGO. The block level NGOs willappoint block facilitators for the executionof community monitoring.

Block Nodal AgencyCollaborate with District Nodal Agencyfor execution of activities in block.Mobilisation and capacity building atblock level.Form committees at the village, PHCand block if such committees have notbeen formed. Coordinate with- Block Medical Officer;village Panchayat, Panchayat Samitis,District Mentoring Team.Supervise block facilitators for theexecution of the CommunityMonitoring at block and village level.Community mobilisation at villagelevel.Financial management at the blocklevel.Encouraging participation of allstakeholders in community monitoringprocess. Conduct Jan Samvad at village, PHCand block level.Supervise community leveldocumentation processes. Organise VHSC trainings.

Handholding of VHSC members forcommunity inquiry and preparation ofreport card

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AnnexuresANNEXURE 1: NRHM STRATEGIES

(a) Core Strategies:Train and enhance capacity of Panchayati Raj Institutions (PRIs) to own, control andmanage public health services.Promote access to improved healthcare at household level through the female healthactivist (ASHA).Health Plan for each village through Village Health Committee of the Panchayat.Strengthening sub centre through an untied fund to enable local planning and actionand more Multi Purpose Workers (MPWs).Strengthening existing PHCs and CHCs, and provision of 30-50 bedded CHC per lakhpopulation for improved curative care to a normative standard (Indian Public HealthStandards defining personnel, equipment and management standards).Preparation and Implementation of an inter-sectoral District Health Plan prepared bythe District Health Mission, including drinking water, sanitation & hygiene andnutrition.Integrating vertical Health and Family Welfare programmes at national, state, block,and district levels.Technical support to National, State and District Health Missions, for public healthmanagement. Strengthening capacities for data collection, assessment and review for evidence basedplanning, monitoring and supervision.Formulation of transparent policies for deployment and career development of humanresources for health.Developing capacities for preventive health care at all levels for promoting healthy lifestyles, reduction in consumption of tobacco and alcohol etc.Promoting non-profit sector particularly in under served areas.

(b) Supplementary StrategiesRegulation of private sector including the informal rural practitioners to ensureavailability of quality service to citizens at reasonable cost. Promotion of Public Private Partnerships for achieving public health goals. Mainstreaming AYUSH -revitalising local health traditions. Reorienting medical education to support rural health issues including regulation ofmedical care and medical ethics.Effective and viable risk pooling and social health insurance to provide healthsecurity to the poor by ensuring accessible, affordable, accountable and good qualityhospital care.

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ANNEXURE 2: MONITORING AND EVALUATION

Health MIS to be developed upto CHC level, and web-enabled for citizen scrutiny.Sub centres to report on performance to Panchayats, hospitals to Rogi Kalyan Samitisand District Health Mission to Zila Parishad.The District Health Mission to monitor compliance to Citizen’s Charter at CHC level.Annual District Reports on People’s Health (to be prepared by Govt/NGOcollaboration).State and National Reports on People’s Health to be tabled in Assemblies, Parliament.External evaluation/social audit through professional bodies/NGOs.Mid-course reviews and appropriate correction.

(From: NRHM Mission Document)

Monitoring Outcomes of the MissionRight to health is recognised, as inalienable right of all citizens as brought out by therelevant rulings of the Supreme Court as well as the International Conventions towhich India is a signatory. As rights convey entitlement to the citizens, these rights areto be incorporated in the monitoring framework of the Mission. Therefore, providingbasic Health services to all the citizens as guaranteed entitlements would be attemptedunder the NRHHM. Preparation of household specific health cards that record information on: Record ofbirths and deaths, record of illnesses and disease, record any expenditure on healthcare, food availability and water source, means of livelihood, age profile of family,record of age at marriage, sex ratio of children, available health facility and providers,food habits, alcohol and tobacco consumption, gender relations within family, etc, (byASHA/AWW/Village Health Team). Preparation of habitation/village health register, on the basis of the household healthcards (by the Village Health Team).Periodic health facility survey at SHC, PHC, CHC, district levels to see if serviceguarantees are being honoured (by district/block level Mission Teams/research andresource institutions). Formation of Health Monitoring and Planning Committees at PHC, block, district andState levels to ensure regular monitoring of activities at respective levels, along withfacilitating relevant inputs for planning. Sharing of all data and discussion at habitation/village level to ensure full transparency. Display of agreed service guarantees at health facilities, details of human and financialresources available to the facility. Sample household and facility surveys (by external research organisations/NGOs). Public reporting of household and health facility findings and its wider disseminationthrough public hearings and formal reporting.

(From: NRHM Framework for Implementation)

ANNEXURE 3: COMMUNITY MONITORING FRAMEWORK

We have discussed the overall monitoring framework in an earlier section (IV). The basicchange that NRHM wishes to bring about in the monitoring framework is to involve localcommunities in planning and implementing programmes with a framework that allowsthem to assess progress against agreed benchmarks. While external institutions will alsoassess progress, they will do so on benchmarks that have been agreed with localcommunities and health institutions. The intention is to move towards a community basedmonitoring framework that allows continuous assessment of planning and implementationof NRHM. Besides the issues already mentioned earlier on the monitoring framework, thebroad principles for community based monitoring are listed below:

Given the overall objective that people should have complete access to rational,appropriate and effective health care, community based monitoring shouldpreferably fulfil following objectives:

It should provide regular and systematic information about community needs, whichwould guide related planning. It should provide feedback according to the locally developed yardsticks for monitoringas well as key indicators. This would essentially cover the status of entitlements,functioning of various levels of the public health system and service providers,identifying gaps, deficiencies and levels of community satisfaction, which can facilitatecorrective action in a framework of accountability. It should enable the community and community-based organisations to become equalpartners in the planning process. It would increase the community sense ofinvolvement and participation to improve responsive functioning of the public healthsystem. The community should emerge as active subjects rather than passive objects inthe context of the public health system. It could be used for validating the data collected by the ANM, Anganwadi worker andother functionaries of the public health system.

Ownership of Community Monitoring Process The Health Department functionaries need to be involved in the preparation andmobilisation phase of the initiative so as to enable ‘ownership’ of the process andoutcomes among the providers and users. PRIs, community based organisations and NGOs, along with Health Departmentfunctionaries should be involved in the preparation and mobilisation phase of theinitiative so as to enable ownership of the process and outcomes among the providersand users. The government can enable such interactive processes through issuing relevantGovernment Orders, and by ensuring effective communication to all levels of publichealth functionaries.All the members of any committee that is formed (for example the Village HealthCommittee) must have their roles and responsibilities clearly defined and articulated.

Power(s) and Capacity Building The committees that are formed at various levels must have concomitant authority i.e.they must have the power to initiate action. The capacities of the members of a villagelevel committee have to be built continuously for them to be able to functioneffectively. This would require allocation of resources and capacity building inputs. Thisprocess must begin with full and ready access to information. The intent of the newly launched NRHM as mentioned in the core strategy is that itwill promote community ownership and decentralised planning from village to district

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level. This is supposed to be through participatory processes, by strengthening evidencebased effective monitoring and evaluation. In order to actually do so it will beimperative that: The government should enable such interactive processes by issuing relevantGovernment Orders. One example of such orders is the one passed by the Governmentof Rajasthan for the formation of Convergence Committees at the district and PHClevel. A similar example is the response of the Gujarat Government to the NationalHuman Rights Commission, wherein coordination bodies at various levels of the PublicHealth System are proposed for operationalising a state level health services monitoringmechanism. All the members of any committee that is formed must have their roles andresponsibilities clearly defined and articulated. Effective and quality monitoring requires institutional mechanisms at various levelsbeginning at the community and going upwards. Adequate investment (time andresources) must be made in capacity development at various levels. Analysis of the collected information must be undertaken at various levels so as toenable prompt action and corrections. The committees that are formed at various levelsmust have concomitant authority i.e. they must have the power to take action. The monitoring system must be directly linked to corrective decision making bodies atvarious levels. The information and issues emerging from monitoring must becommunicated to the relevant official bodies responsible for taking action (from PHCto state level) so that monitoring results in prompt, effective and accountable remedialaction.

Overall Points to be ConsideredEffective community monitoring would change the status of community membersfrom passive beneficiaries to active rights holders, enabling them to more effectivelyaccess health services. One must be realistic in setting indicators and planning activities. Communities needfew and simple indicators for monitoring, and the time devoted by members, especiallycommunity representatives involved in various committees, must be utilised optimally. Community monitoring must be seen as an integral part of the Public Health Systemat all levels and for all activities, and not as a stand-alone process. Panchayati Raj Institutions are not synonymous with the community. For communityownership and effective monitoring, even if PRI representatives are involved, one stillneeds to involve user groups and beneficiaries, and to include CBOs.

Involvement of the General Public by Means of Regular ‘Public dialogue’ or Publichearing (Jan Samvad / Jan Sunwai)

Most of the public participation in the monitoring process would be mediated byrepresentatives of the community or community-linked organisations. However, to enableinterested community members to be directly involved in exchange of information, andto improve transparency and accountability of the health care system, ‘Public dialogues’(Jan Samvad) or Public hearings (‘Jan Sunwai’) would be need to organised at regularintervals (once or twice in a year, depending on the initiative of the local organisations)at PHC, block and district levels (see section IV page 21).

What Should the Community Monitor? The community and community-based organisations should monitor demand/ need,coverage, access, quality, effectiveness, behaviour and presence of health care personnel atservice points, possible denial of care and negligence. This should be monitored related tooutreach services, public health facilities and the referral system.

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ANNEXURE 4: COMPOSITION, ROLES AND RESPONSIBILITIES OF MONITORING COMMITTEES

Village Health CommitteeThis Committee would be formed at the level of the revenue village (more than one suchvillages may come under a single Gram Panchayat).

Composition The Village Health Committee would consist of:

Gram Panchayat members from the village. ASHA, Anganwadi Sevika, ANM. SHG leader, the PTA/MTA Secretary, village representative of any Community BasedOrganisation working in the village, user group representative.

The chairperson would be the Panchayat member (preferably woman or SC/ST member)and the convener would be ASHA; where ASHA not in position it could be the AnganwadiSevika of the village.

Roles and ResponsibilitiesCreate public awareness about the essentials of health programmes, with focus onpeople’s knowledge of entitlements to enable their involvement in the monitoring. Discuss and develop a Village Health Plan based on an assessment of the villagesituation and priorities identified by the village community.Analyse key issues and problems related to village level health and nutrition activities,give feedback on these to relevant functionaries and officials. Present an annual healthreport of the village in the Gram Sabha.Participatory Rapid Assessment to ascertain the major health problems and healthrelated issues in the village – Estimation of the annual expenditure incurred formanagement of all the morbidities may also be done. The mapping will also take intoaccount the health resources and the unhealthy influences within village boundaries.Mapping will be done through participatory methods with involvement of all strata ofpeople. The health mapping exercise shall provide quantitative and qualitative data tounderstand the health profile of the village. These would be village information(number of households – caste, religion and income ranking, geographical distribution,access to drinking water sources, status of household and village sanitation, physicalapproach to village, nearest health facility for primary care, emergency obstetric care,and transport system) and the morbidity pattern. Maintain village health register and health information board/calendar – The healthregister and board, put up at the most frequented section of the village will haveinformation about mandated services, along with services actually rendered to allpregnant women, new born and infants, people suffering from chronic diseases etc.Similarly, dates of visit and activities expected to be performed during each visits byhealth functionaries may be displayed and monitored by means of a Village healthcalendar. These will be the most important document maintained by the villagecommunity about the exhibition of health status and health care services availability.This will also serve as the instrument for cross verification and validation of data. Ensure that the ANM and MPW visit the village on the fixed days and perform thestipulated activity; oversee the work of village health and nutrition functionaries likeANM, MPW and AWW. Obtain a bi-monthly health delivery report from health service providers during theirvisit to the village. Discuss the report submitted by ANM and MPW and takeappropriate action.

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36

Consider the problems of the community and the health and nutrition care providersand suggest mechanisms to solve it. Discuss every maternal death or neonatal death that occurs in their village, analyse itand suggest necessary action to prevent such deaths. Get these deaths registered in thePanchayat. Manage the village health fund.

Power (s) of the CommitteeThe convener will sign the attendance registers of the AWWs, Mid-Day MealSanchalak, MPWs, and ANMs. MPWs and ANMs will submit a bi-monthly village report to the committee along withthe plan for next two months. Format and contents of the bi-monthly reports wouldbe decided village health committee. The committee will receive funds of Rs.10, 000 per year. This fund may be used as perthe discretion of the VHC.

Yardsticks for Monitoring at Village Level Village Health Plan. NRHM indicators translated into Village health indicators.

Tools for Monitoring at Village LevelVillage Health Register.Records of the ANM.Village health calendar. Infant and maternal death audit.Public dialogue (Jan Samvad).

PHC Health Monitoring and Planning Committee The PHC Health Committee would function as the health monitoring and planning armof the Panchayats coming under the PHC area. It is recommended that the PHCCommittee have the following broad pattern of representation, including members fromPanchayats, health care service providers and civil society:

Composition 30% members should be representatives of Panchayat Institutions (Panchayat Samitimember from the PHC coverage area; two or more sarpanchs of which at least one is awoman).20% members should be non-official representatives from the village healthcommittees, coming from villages under the jurisdiction of the PHC, with annualrotation to enable representation from all the villages.20% members should be representatives from NGOs/CBOs and people’s organisationsworking on Community health and health rights in the area covered by the PHC.30% members should be representatives of the health and nutrition care providers,including the Medical Officer – Primary Health Centre and at least one ANM workingin the PHC area.

The chairperson of the PHC committee would be one of the Panchayat representatives,preferably a Panchayat Samiti member belonging to the PHC coverage area. The executivechairperson would be the Medical officer of the PHC. The secretary of the PHC committeewould be one of the NGO/CBO representatives.

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Roles and ResponsibilitiesConsolidation of the village health plans and charting out the annual health actionplan in order of priority. The plan should clearly lay down the goals for improvementin health services and key determinants. Presentation of the progress made at the village level, achievements, actions taken anddifficulties faced followed by discussion on the progress of the achievements of thePHC, concerns and difficulties faced and support received to improve the access tohealth facilities in the area of that particular PHC. The discussion could include: Sharing of reports of Village Health Committees. Reports from ANM, MPW about the coverage of health facilities. Any efforts done at the village level to improve the access to health care services. Record and analysis of neonatal and maternal deaths. Any epidemic occurring in the area and preventive actions taken. Ensure that the Charter of citizens’ health rights is disseminated widely and displayed outside the PHC informing the people about the medicine facilities available at the PHC,timings of PHC and the facilities available free of cost. A suggestion box can be kept forthe health care facility users to express their views about the facilities. These commentswill be read at the coordination committee meeting to take necessary action. Monitor physical resources like, infrastructure, equipments, medicines, water connectionetc at the PHC and inform the concerned government officials to improve it. Discuss and develop a PHC Health Plan based on an assessment of the situation andpriorities identified by representatives of village health committees and communitybased organisations.Share information about any health awareness programme organised in the PHC’sjurisdiction, its achievements, follow up actions, difficulties faced etc. Coordinate with local CBOs and NGOs to improve the health scenario of the PHC area. Review functioning of sub-centres operating under jurisdiction of the PHC and takingappropriate decisions to improve their functioning. Brief minutes of the meeting at the end of the meeting along with the action planemphasising the actions to be taken by different committee members, which will beshared at the District Level Committee. The minutes will also serve as a reference point,while sharing the progress done between two committee meetings. Initiate appropriate action on instances of denial of right to health care reported orbrought to the notice of the committee; initiate an enquiry if required and table reportwithin two months in the committee. The report may become a part of theperformance appraisal of the concerned staff member. The committee may recommendcorrective measures to the next level (block/district). The decisions taken in thecommittee need to be forwarded to higher concerned officials and a copy to thecorresponding health committee of that level who will be responsible to take necessarydecision for action to be taken on the inquiry within a period of three months.

Power(s) of the committeeContribute to annual performance appraisal of Medical officer/other functionaries atthe PHC. Take collective decision about the utilisation of the special funds given to PHC (sayRs.25, 000) for the repairs, maintenance of equipments, health education etc and anyother aspects, which will facilitate the improvement of access to health care services.The MO can utilise this fund after the discussion and approval from the committee.

Yardsticks for Monitoring at PHC level Charter of Citizens Health Rights. IPHS or similar standards for PHC (this would include continuous availability of basic

outpatient services, indoor facility, delivery care, drugs, laboratory investigations andambulance facilities). PHC Health Plan.

Tools for Monitoring at PHC level Village health registers / calendars.PHC records.Discussions with and interviews of the PHC committee members.Public dialogue (Jan Samvad) or Public hearing (Jan Sunwai).Quarterly feedback from village Health Committees.Periodic assessment of the existing structural deficiencies.

Block Health Monitoring and Planning Committee The committee constituted at the block level would be consistent with CHC. Thiscommittee would have members drawn from service providers, representatives of VHSCsand PPMCs, representative of panchayts. A local civil society organization will serve as itsmember secretary. The block CMO & HO will be the convener of this committee and itwill be chaired by the Pradhan of Panchayat Samiti.

Composition 30% members should be representatives of the Block Panchayat Samiti (Adhyaksha/Adhyakshika of the Block Panchayat Samiti or members of the Block Panchayat samiti,with at least one woman).20% members should be non-official representatives from the PHC healthcommittees in the block, with annual rotation to enable representation from allPHCs over time.20% members should be representatives from NGOs / CBOs and People’s organizationsworking on community health and health rights in the block, and involved infacilitating monitoring of health services.20% members should be officials such as the Block Medical Officer, the BlockDevelopment Officer, selected Medical Officers from PHCs of the block.10% members should be representatives of the CHC level Rogi Kalyan Samiti. Thechairperson of the Block committee would be one of the Block Panchayat Samitirepresentatives. The executive chairperson would be the Block medical officer. Thesecretary would be one of the NGO / CBO representatives.

Roles and ResponsibilitiesConsolidate PHC level health plans and charting out of the annual health action planfor the block. The plan should clearly lay down the goals for improvement in healthservices. Review progress made at the PHC levels, difficulties faced, actions taken andachievements made, followed by discussion on any further steps required to be takenfor further improvement of health facilities in the block, including the CHC. Analyse records on neonatal and maternal deaths; and the status of other indicators,such as coverage for immunisation and other national programmes. Monitor physical resources like, infrastructure, equipments, medicine, waterconnection etc at the CHC; similar exercise for the manpower issues of the healthfacilities that come under the jurisdiction of the CHC. Coordinate with local CBOs and NGOs to improve the health services in the block. Review functioning of sub-centres and PHCs operating under jurisdiction of the CHCand taking appropriate decisions to improve their functioning. Initiate appropriate action on instances of denial of right to health care reported orbrought to the notice of the committee; initiate an enquiry if required and table report

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within two months in the Committee. The Committee may also recommend correctivemeasures to the district level.

Power(s) of the committee Contribute to annual performance appraisal of Medical officer/other functionaries atthe PHC and CHC. Take collective decision about the utilisation of the special funds given to CHC for therepairs, maintenance of equipments, health education etc and any other aspects,which will facilitate the improvement of access to health care services. The CMO canutilise this fund after the discussion and approval from the committee.

Yardsticks for Monitoring at Block level IPHS or similar standards for CHC (this would include continuous availability of basicoutpatient services, indoor facility, community outreach services, referral services,delivery and antenatal care, drugs, laboratory investigations and ambulance facilities). Charter of Citizens Health Rights for CHC.Block Health Plan.

Tools for Monitoring at Block level PHC and CHC records.Discussions with and interviews of the CHC RKS members.Report of Public dialogue (Jan Samvad).Quarterly feedback from village and PHC Health Committees.Periodic assessment of the existing structural and functional deficiencies.

District Health Monitoring and Planning Committee The committee constituted at the district level would contribute to the development ofDistrict Health Plan. This committee would have members drawn from service providers,representatives of VHSCs, PPMCs, BPMCs and representative of panchayts. Thechairperson of the District Committee would be one of the Zilla Parishad representatives,preferably convenor or member of the Zilla Parishad Health committee. The executivechairperson would be the CMO/CMHO/DHO or officer of equivalent designation. Thesecretary of the PHC committee would be one of the NGO/CBO representatives.

Composition 30% members should be representatives of the Zilla Parishad (esp. convenor andmembers of its Health Committee).25% members should be district health officials, including the District HealthOfficer/Chief Medical Officer and Civil Surgeon or officials of parallel designation,along with representatives of the District Health Planning Team includingmanagement professionals.15% members should be non-official representatives of block committees, with annualrotation to enable successive representation from all blocks.20% members should be representatives from NGOs/CBOs and people’s organisationsworking on Health rights and regularly involved in facilitating community basedmonitoring at other levels (PHC/block) in the district.10% members should be representatives of Hospital Management Committees in thedistrict.

Roles and ResponsibilitiesDiscuss on the reports of the PHC health committees.Financial and solving blockages in flow of resources if any. Assess infrastructure, medicine and health personnel related information and

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necessary steps required to correct the discrepancies. Review progress report of the PHCs emphasising the information on referralsutilisation of the services, quality of care etc. Contribute to development of the District Health Plan, based on an assessment of thesituation and priorities for the district. This would be based on inputs fromrepresentatives of PHC health committees, community based organisations and NGOs. Ensure proper functioning of the Hospital Management Committees. Discuss on circulars, decisions or policy level changes done at the state level; decidingabout their relevance for the district situation.Take into cognisance of the reported cases of the denial of health care and ensureproper redressal.

Yardsticks for Monitoring at District Level Charters of Citizens Health Rights. District Action Plan.NRHM guidelines.Indian Public Health Standards.

Tools for Monitoring at the District Level Report from the PHC Health committees.Report of the District Mission committee.Public Dialogue (Jan Samvad).

State Health Monitoring and Planning Committee The committee constituted at the state level would contribute to the development ofState Health Plan. This committee would have members drawn from service providers,representatives of VHSCs, PPMCs, BPMCs, DPMCs and representative of panchayts. Thechairperson would be one of the elected members (MLAs). The executive chairpersonwould be the Secretary Health and Family Welfare. The secretary would be one of theNGO coalition representatives.

Composition30% of total members should be elected representatives, belonging to the Statelegislative body (MLAs/MLCs) or Convenors of Health committees of Zilla Parishads ofselected districts (from different regions of the state) by rotation. 15% would be non-official members of district committees, by rotation from variousdistricts belonging to different regions of the state.20% members would be representatives from State health NGO coalitions working onHealth rights, involved in facilitating community based monitoring. 25% members would belong to state Health Department.Secretary Health and Family Welfare, Commissioner Health, relevant officials fromDirectorate of Health Services (incl. NRHM Mission Director) along with technicalexperts from the State Health System Resource Centre / Planning cell.10% members would be officials belonging to other related departments andprogrammes such as Women and Child Development, Water and Sanitation, Ruraldevelopment.

Roles and Responsibilities Discuss the programmatic and policy issues related to access to health care and tosuggest necessary changes. Review and contribute to the development of the State Health Plan, including the planfor implementation of NRHM at the state level; the committee will suggest and reviewpriorities and overall programmatic design of the State Health Plan.

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Discuss Key issues arising from various district health committees, which cannot beresolved at that level (especially relating to budgetary allocations, recruitment policy,programmatic design etc) and initiate appropriate action initiated by the committee.Also discuss administrative and financial level queries, which need urgent attention. Institute a health rights redressal mechanism at all levels of the health system, whichwill take action within a time bound manner. Review summary report of the actionstaken in response to the enquiry reports.Operationalise and assess the progress made in implementing the recommendations ofthe NHRC, to actualise the right to health care at the state level. Take proactive role to share any related information received from GOI and will alsowill share achievements at different levels. The copies of relevant documents will beshared.

Power(s) of the committee Ensure that the different levels committees are properly constituted and they meetregularly and transact their mandates in letter and spirit

Yardsticks for Monitoring at State Level NHRC recommendations and National Action Plan on Right to Health Care; responsesof state Health Departments and actions to which the State Government hascommitted itself.NRHM state level plan and the State Health Mission guidelines.IPHS.

Tools for Monitoring at State Level Reports of the district health committees.Periodic assessment reports by various taskforces/ state level committees about theprogress made in formulating policies according to IPH Standards, NHRCrecommendations and its implementation status etc.

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ANNEXURE 5: CONCRETE SERVICE GUARANTEES

Concrete Service Guarantees that NRHM will provide: Skilled attendance at all births.

Emergency obstetric care.

Basic neonatal care for new born.

Full coverage of services related to childhood diseases/health conditions.

Full coverage of services related to maternal diseases/health conditions.

Full coverage of services related to low vision and blindness due to refractive errorsand cataract.

Full coverage for curative and restorative services related to leprosy.

Full coverage of diagnostic and treatment services for tuberculosis.

Full coverage of preventive, diagnostic and treatment services for vector bornediseases.

Full coverage for minor injuries/illness (all problems manageable as part of standardoutpatient care upto CHC level).

Full coverage of services inpatient treatment of childhood diseases/health conditions.

Full coverage of services inpatient treatment of maternal diseases/health conditionsincluding safe abortion care (free for 50% user charges from APL).

Full coverage of services for blindness, life style diseases, hypertension etc.

Full coverage for providing secondary care services at sub-district and DistrictHospital.

Full coverage for meeting unmet needs and spacing and permanent family planningservices.

Full coverage of diagnostic and treatment services for RI/STI and counselling for HIV– AIDS services for adolescents.

Health education and preventive health measures.

visitwww.nrhmcommunityaction.org

Published on behalf ofAdvisory Group on Community Action (AGCA)

byNational Secretariat on Community Action - NRHM

Centre for Health and Social Justice (CHSJ) Population Foundation of India (PFI) Flat 3C, H Block, First Floor, Saket B-28, Qutab Institutional AreaNew Delhi - 110017 Tara Crescent, New Delhi - 110 016Phone: + 91-11-40517478, 26511425, Fax: 26536041 Phone: + 91-11-42899770, Fax: 42899795E-mail: [email protected] E-mail: [email protected] Website: www.chsj.org Website: www.popfound.org

(2005-2012)

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