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Improving Health System and Strengthening NRHM through Community Action Experiences, Lessons Learnt, Challenges and Way Forward. AGCA Secretariat Population Foundation of India December 24, 2013. Outline. The accountability framework under NRHM

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Improving Health System and Strengthening NRHM through Community Action Experiences, Lessons Learnt, Challenges and Way Forward

AGCA Secretariat

Population Foundation of India

December 24, 2013

  • The accountability framework under NRHM
  • Community action under NRHM – process, experiences and gains
  • Challenges
  • Way forward – status of implementation in states
community action in nrhm
Community Action in NRHM
  • Mechanisms to improve accountability and enable better delivery of services
    • Builds community awareness on health entitlements
    • Provides a platform for community feedback and dialogue with service providers
    • Initiates corrective action and planning with community engagement

Leads to improved coverage and accessibility of health services

In essence brings ‘public’ back into public health

accountability framework under nrhm
Accountability Framework under NRHM
  • A three pronged process:
    • community based monitoring,
    • external surveys and
    • routine program monitoring
  • Communitization of the health institutions
    • Prominent display of information on funds received, medicines in stock, health right entitlements
  • Public reports on Health at the State and district levels to report progress to the community
advisory group on community action agca
Advisory Group on Community Action (AGCA)
  • Group of civil society experts constituted by the MOHFW in 2005 with Population Foundation of India (PFI) as the Secretariat
  • Mandate :
    • Advise on developing community partnership and ownership for the Mission
    • Provide feedback based on ground realities, to inform policy decisions
    • Develop new models of Community Action and recommend for further adoption to the national / state governments
cah immediate outcomes
CAH - Immediate Outcomes

Community Based Planning and Monitoring


programme in

Bihar - India

first phase of community monitoring 2007 09
First phase of Community Monitoring (2007-09)

9 States, 36 districts, 1620 villages

  • Assam
  • Chhattisgarh
  • Jharkhand
  • Karnataka
  • Madhya Pradesh
  • Maharashtra
  • Orissa
  • Rajasthan
  • Tamil Nadu













W Bengal










1. Education and awareness :

  • Community awareness on health entitlements
  • Training of Village Health Sanitation and Nutrition Committees (VHSNC) and Rogi Kalyan Samities (RKS) members
  • Display of Citizen’s charter and service guarantees
  • Monitoring and information sharing
  • Collection of information and sharing of report cards, community experiences of health services
  • Multi stakeholder Monitoring and Planning Committees at PHC, Block and District levels
  • Public dialogue
  • Periodic public dialogue (Jan Samvad) - Engagement with providers based on community evidence
community action under nrhm experiences and gains
Community action under NRHM - experiences and gains

Five Tangible benefits:

1. Construction work completed

2. Improvements in status of delivery of health services

3. Enhanced trust and improved interaction

4. Community based inputs in planning and action

5. Reduction in out of pocket expenditure

1 construction of sub centre completed
1. Construction of Sub-Centre completed

Story of change - Maharashtra

  • In Jamshet village, Thane district, construction of a sub-center was incomplete for over two years
  • Village health committee members discussed the issue in a series of Gram Sabha meetings and in Block monitoring committee meetings
  • A large group of community members went to the sub-centre to ‘complete’ the construction through ‘Shramdaan’
  • The sub-center building got completed and is fully functional
2 performance of health services improves rajasthan sep 2008 oct 2009
2.Performance of health services improves -Rajasthan (Sep 2008-Oct 2009)

Number of Villages




key outcomes
Key outcomes

3. Enhanced trust and improved interaction between provider and community

  • Improvement in service delivery - ANC, PNC, immunization,
  • Responsiveness of provider to community needs
  • Improved provider attitude and behavior

4. Community based inputs in planning and action

  • Active involvement of PRI members in planning and functioning of health facilities
  • Appropriate planning and utilization of untied funds at VHSC, PHC and CHC
key outcomes1
Key outcomes

5. Reduction in out of pocket expenditure

  • Reducing demands for informal payments
  • Ensuring timely and full payments of Janani Surksha Yojana
  • Significant reduction on outside prescription
key challenges
  • Capacity constraints to institutionalize and scale up community monitoring
  • Allocation of adequate resources
  • Mechanisms to address systemic gaps emerging from CBMP process and feeding into the planning process

- vacancies/ posting, procurement and distribution of drugs and supplies, training of health functionaries

  • Institutionalizing minimum service guarantees, grievance redressal mechanisms
implementation status
Implementation status
  • Scaled up - Maharashtra, Tamil Nadu, Jharkhand, Chhattisgarh
  • Modified – Karnataka, Chhattisgarh
  • Re/Initiated – Odisha, Rajasthan, Assam and Bihar
  • In FY 2013-14, 15 States / UTs CAH component has been approved
  • AGCA has provided support to Assam, Jammu and Kashmir, Maharashtra, Madhya Pradesh and Uttar Pradesh in developing their state PIP
way forward role of agca
Way forward – Role of AGCA

Technical Support proposal approved by GOI

National level

  • Revise CAH tools and share with states for adoption
  • Development of RKS guideline and training manual (in consultation with NHSRC and MoHFW)
  • Report on review of  approaches/models on grievance redressal
  • Processes developed for selection of NGOs to support implementation of CAH
way forward role of agca1
Way forward – Role of AGCA

State Level

  • Support constitution and orientation of State AGCAs
  • Development of state plans – visioning for scale up
  • Orientation of Nodal Officers and state institutions - SHRC, ARC, RRC, SIRD etc
  • Regular mentoring and review