Proposal to facilitate on a pilot basis

Community based monitoring of Health services under NRHM
 

Section-I        : Suggested broad process of initial facilitation and capacity development

Section–II      : Suggested outline of the Community based monitoring activity

Section-III      : Role of civil society organisations in facilitating community based monitoring

Section IV      : Organisational responsibilities and timeframe

Section V       : Budget

 

I.        Suggested broad process of initial facilitation and capacity development

 

Introduction: overall relevance of community based monitoring and planning

The adoption of a comprehensive framework for community-based monitoring and planning at various levels under NRHM is an extremely positive development, which can place centre-stage community members and beneficiaries, community based organizations and NGOs working with communities, along with Panchayat representatives, allowing them to actively and regularly monitor the progress of NRHM interventions in their areas. Besides ensuring accountability, it would also promote decentralized inputs for better planning of health activities, based on the locally relevant priorities and issues identified by various community representatives.

This framework is consistent with the ‘Right to Health Care’ approach that has been mentioned in the latest NRHM framework document, since it places people at the centre of the process of regularly assessing whether the health rights of the community are being fulfilled. It could also be a step towards “Bringing the ‘Public’ back into Public health” by allowing community members and their representatives to directly give feedback about the functioning of public health services, including giving inputs for improved planning of the same.

This issue has been discussed by the NRHM Advisory Group for Community Action (AGCA) in its meetings on 28^th June 06, 27^th July 06 and 20^th December 06, with the circulation of specific draft notes by certain members on various aspects of facilitation of community based monitoring. Based on these suggestions, this proposal is being forwarded by AGCA to the NRHM, Union Ministry of Health and Family Welfare for consideration, as a demonstrative pilot, to help develop the process of Community monitoring under NRHM on a national scale.

Why is specific facilitation of Community monitoring essential?

Before discussing possible modes of facilitation, the first question that needs to be addressed is – why is any specific, additional facilitation of Community based monitoring involving inputs from the voluntary sector required at all? Cannot it be left to State health departments to put in place a system of community monitoring based on a reading of the existing framework document?

It needs to be recognized that while the State health departments would play an extremely important role in developing community monitoring activities, certain kinds of special, additional facilitation are necessary for this new and rather different kind of activity to flourish and develop in its most effective manner. Some of the reasons for this are as follows:

1. Effective Community monitoring is critically dependent on active intervention by, and capacity building of a whole set of actors outside the Health department. Unlike most other NRHM activities that would be implemented directly by the Health department, by definition Community monitoring cannot be ‘implemented’ by Health department officials alone. Rather this involves drawing in, activating, motivating and capacity building of a wide range of beneficiary representatives, community based organizations, people’s movements, voluntary organizations and Panchayat representatives – placing these actors, who form over two-thirds of the membership of all monitoring committees, at the centre of the monitoring process. Hence it would be desirable to involve networks, organizations and individuals with experience of community mobilization and community based monitoring to facilitate involvement in the health system of this whole new set of actors. For certain activities such as – helping the identification of organizations with experience and aptitude for monitoring kind of work; assisting the formation of committees in pilot areas; and building capacity of community and Panchayat representatives for monitoring and planning – such facilitation is considered important.

 

2. It is largely the Health department functionaries themselves who would be monitored; hence for the monitoring to be robustly independent, it is not sufficient to leave the entire task of developing the monitoring framework to the Health department alone. Rather, this will need joint facilitation where the Health department officials would play an important role, however agencies with experience of working with civil society groups and Panchayats would also need to play a facilitating role. Such joint facilitation could ensure emergence of a broadly representative, balanced and reasonably independent monitoring system, which can regularly give a range of fresh inputs from various sections of the community, not just a formal set of bodies appointed by the Health department, which uncritically comply with their actions and decisions.

 

3. Genuine community based monitoring and planning involves a change in the balance of power in the Health sector, in favour of people. It need not be reiterated that this entire exercise carries meaning only if ordinary people and their spokespersons in form of both Panchayat representatives and Community based organizations, gain a degree of authority to identify gaps and correspondingly propose priorities and influence decision making regarding the Health system.  It is difficult to imagine that this significant shift in balance of power – which involves making Health officials and functionaries directly accountable and answerable to people – can be carried out exclusively by the agency of the Health department without any additional facilitation, although their central involvement at every stage would of course be essential.

 

4. The skills involved in developing participatory monitoring are different from usual programme related skills. The NRHM Framework for implementation document outlines the composition and broad roles of monitoring and planning committees at various levels. However, it naturally does not lay out how this entire process should be developed. This will require additional detailing and development at both national and state levels. The kind of capacity required to develop a participatory community monitoring system is quite different from programme implementation and training usually conducted by the Health department; hence involving agencies with some experience of accountability building and health rights work would be desirable to help facilitate this process.

 Why is a pilot phase essential?

Another issue which needs clarification is the suggestion that this process be initiated on a pilot basis in each state, before moving to generalization. Some reasons because of which it would be desirable to start with a pilot phase are as follows:

1. The need to pool expertise and build an initial critical mass: The number of organizations with experience in rights-based and accountability oriented work related to the Health sector may not be very large in many states. Similarly, expertise and commitment related to this activity within Health departments may also be limited to begin with. It would be desirable for facilitating agencies both within and outside the Health department to come together, share expertise, help launch pilots in a few areas, and analyse experiences, before going to scale at the state level. This would also strengthen ownership of the process within the Department. Starting directly with a widely generalized model would demand very extensive involvement of comparatively few facilitators from day one, they would have to immediately spread themselves thin – not allowing much space for initial development of methodologies and building a critical mass.

 

2. Learning from experiences and mistakes on a smaller scale, then moving to a larger scale: This is probably the first time in the country that the official health system is institutionalizing community monitoring of health services on a major scale. There is scope for many kinds of experiences and even deviation from objectives, regarding selection of appropriate organizations, formation of representative committees, and capacity building. It will be desirable to try out the process on a smaller scale and make corrections before moving to a state-wide scale.

 

3. A delicate process that needs to be handled carefully: It was rightly pointed out in the recent meeting of the Advisory Group for Community Action that the process of developing community monitoring is a delicate process that needs to be handled carefully. Community mobilization experiences in the Health sector show that the initial response of community representatives is often to assertively point out a whole range of problems, deficiencies, gaps and even alleged cases of denial of health care which may be quite difficult for the Health officials to digest and take in the right spirit – which could even at times, lead to a virtual breakdown of dialogue. Maintaining the vitality and authenticity of the process, but not allowing complete polarization which would disrupt the dialogue and convergence process itself is a delicate task. Starting by launching the community monitoring process all over the state on a large scale may conceivably lead to potentially disruptive situations and even demotivation of Health functionaries – which could be avoided by first working out the process in pilot areas and building appropriate checks and balances in the methodology before moving to generalization.

The relevance of special facilitation and piloting has been kept in mind, while giving suggestions regarding the facilitation of Community monitoring below.

 Possible role of Advisory Group for Community Action in initial facilitation of Community Monitoring process:

Supported by the Union Health Ministry, the State health departments obviously have a central role in developing the Community monitoring framework, and their ownership of the entire process is essential. However, as pointed out above, in combination with their important role, systematic additional facilitation will also be required. Here it is suggested that the Advisory Group for Community Action (AGCA) may play a role of pilot facilitation and support to capacity building at national level, working with the mentoring teams and organizations at state level.

Similar to the ASHA mentoring group which is supposed to contribute to developing the ASHA programme in various states, the AGCA along with organisations suggested by it, could give initial inputs for the community monitoring process at the national level in the following ways –

•      Working out the set of activities required for operationalisation of the present framework for Community based monitoring under NRHM

•      Specific members of AGCA could volunteer to support mentoring teams in  pilot states, along with suggesting for state mentoring teams the names of specific networks or organisations with relevant experience and approach. These State mentoring teams would support the initial process. They could also give initial advice to State governments about conceptualising and planning the process of community based monitoring.

•      Facilitating and helping to ensure in the initial stage, the involvement of diverse civil society networks and organisations at the state level in the Community Monitoring process.

•      Supporting development of model orientation material for capacity development and monitoring tools by suggesting an organisation or group of organisations, which could develop national model material for adaptation and use by State health departments.

Some initial steps for development of the community monitoring process on a pilot basis are briefly indicated below.

National preparatory phase (Mar.-May 07)

Tools for Community Monitoring, a model curriculum for Trainings, materials for trainings and workshops, design and contents of workshops, awareness and promotional materials and documentation formats (including review and revision at the end of the pilot project) could be prepared during this period by a sub-group of the AGCA along with some additional consultants, and approved by the Union MoHFW/NRHM.

State preparatory phase (Apr. 07 to June 07)

1. Designated AGCA members for each pilot state would make a visit to the state and along with the State Mission Director, State Health Dept., Panchayati Raj Dept. officials and state level NGO network representatives could conduct a preparatory meeting, to plan the State level workshop. A brief mapping exercise may be conducted to identify coalitions and organisations already involved in monitoring and health rights activities in the state. A short list of districts, which have a strong presence of civil society organisations capable of community monitoring of Health services, would be prepared (about 5-8 districts) based on suggestions from the participants in this preparatory meeting. A final selection of pilot districts would be done after this preparatory meeting by the designated AGCA members and State Mission Director based on clearly defined criteria.

 

2. Following the preparatory meeting, a State Mentoring team would be formed involving representatives of the State Health department and state level Health sector voluntary networks. Based on experience and demonstrated interest, the State Mission Director and the state designated AGCA members would suggest the names for this mentoring team. This team would have definite responsibilities to develop community monitoring in the state during the pilot phase and beyond, which would be clearly spelt out. This team would have upto seven members, of which at least four would be civil society representatives. In addition, the designated national AGCA members would be permanent invitees to the State mentoring team. One of the State level NGOs belonging to the State mentoring team would be selected to work as the state nodal NGO during the pilot phase; this state nodal NGO would work under the direction of the State mentoring team.

 

3. Translation and adaptation of material required for the community monitoring process would be initiated at the earliest, to enable key drafts to be available by the time of the State level training of trainers.

 

4. A State level workshop organised by the State mentoring team and State Health Mission would then be held involving all stakeholders (State Mission officials, District health officials and PRI representatives from selected districts, NGO networks and civil society organizations from these districts) along with NRHM GoI representatives, where the pilot process would be concretized. Detailed timetable for District level meetings, formation and orientation of committees could be worked out in this two-day State level workshop.

 

5. State level Training of Trainers for the facilitating teams from all pilot districts would need to be conducted primarily by voluntary sector facilitators in the pilot phase, since Government officials may not have adequate experience in community monitoring activities. However State Health department officials would be present and would be involved in these workshops, enabling them to actively participate in further such trainings.

The details of the further steps beyond this will need to be worked out at the state level. However an indicative possible framework is suggested here to give an idea of the approximate overall timetable and activities that might be required.

Pilot implementation in the Districts (July to Dec. 07)

1. Further district processes would be facilitated by NGOs taking responsibility in the pilot districts along with the District health officials and PRI representatives. A District mentoring team (including representatives of each of the three groups) to facilitate the Community monitoring process would need to be put in place, which would facilitate the orientation activities in this and subsequent stages. In each district one NGO would need to take responsibility as the District nodal NGO. This NGO would be assisted by other civil society organisations that would take specific responsibility in various blocks. The process could start with a District level workshop to share the concept, identify Blocks and PHCs, involving key district health officials, PRI members and civil society organisations. Three blocks within the district could be selected for pilot implementation. It would be desirable that Block nodal civil society organisations take up responsibility for specific blocks in coordination with the District nodal NGO.

 

2. There would be a need to conduct a Block level training for at least a four member Block Community Monitoring facilitation team, including at least two NGO/CBO members. Preferably half of the Block team should be women. These Block facilitation team members would be responsible for the subsequent committee formation and orientation processes. 

 

3. During the next four months (Aug. – Nov. 07), there would be formation of committees at Village, PHC, and Block levels in the pilot blocks (in that order), along with organising primary orientation of their members. Formation of Community Monitoring committees would start from village committees, then PHC, then Block, and then District committees. A few members from VHCs would be included in the PHC committee; similarly a few PHC committee members would be included in the Block committee. Therefore it would be important to constitute the committees from village level upwards in such a sequential order. CBOs / NGOs and Panchayat representatives who have shown leading initiative in organising community monitoring activities at any level should find representation in the next higher level committees

Similarly, the Community Monitoring exercises and collation of information should be organised village wise, PHC wise, Block-wise, District wise and then at the State level. In this way these exercises should aggregate information upwards. The monitoring results should also be shared at the Village level, Block and District level in the appropriate PRI fora.

It may be considered that in the pilot phase, five revenue villages may be selected for committee formation from each PHC area. Adequate representation of women, dalits and adivasis should be ensured in various committees.

4. Following committee formation at the peripheral levels, the District level committee could also be finalised and would become functional by Nov. 07.

5. In the pilot phase, at the state level a provisional committee could be formed by Dec. 07. This would be given final shape only after the next phase of ‘Extended implementation’ is completed and at least half of the Districts of the state have in place Community monitoring committees, which could send representatives to the State committee.

6. PHC and Block level community monitoring exercises would include a public dialogue (‘Jan Samvad’) or public hearing (‘Jan Sunwai’) process by Dec. 07. Here individual testimonies and assessments by local CBOs / NGOs would be presented. Individual testimonies could be identified through the adverse outcome recording process. These Public dialogues should be moderated / facilitated by the District and Block facilitation groups in collaboration with Panchayat representatives and CBOs / NGOs working on the issue of Health rights.

 

Process documentation and review (July. 07 – Jan. 08)

This will include the following three distinct stages:

Process Documentation: Each activity of the project that has been outlined above will include a documentation protocol, which will be developed in the National Preparatory phase. The activity will be documented in these protocols and this will allow uniformity of recording the activity. These documents will be filled in by the responsible agency at different levels and collated at the state level. The state mentoring team will be responsible for analyzing these documents and will prepare a review report on the state implementation, reporting what interventions worked and why and suggesting changes.

Evaluation of the state level intervention: In addition to the report of the process documentation there will be an independent evaluation of the different interventions and their impact on different stakeholders by a team of two experts. The evaluation will include review of the documentation process, interviews with different stakeholders, including members of the community in a limited number of locations across each of the 8 states.

State level review workshops: The third component of the review process will comprise of an endline workshop with those involved in implementing the pilot phase to review the process of the pilot in each state.

It should be emphasised that this entire timetable is only indicative and the actual timetables would obviously need to be worked out in each state keeping in mind the specific situations and constraints. It may be noted that this timetable is also quite compressed, considering the fact that village level processes including meetings and participatory processes to facilitate formation and to orient Village health committees usually take time. However given the NRHM deadlines for Community monitoring, such a comparatively rapid progression of activities is being suggested.

Further it is envisaged that the process of orientation and capacity building of committees would be periodic and ongoing; the timelines indicated here only refer to the primary orientation required to start off the committees and make them initially functional.

Summary of Major activities in preparatory and pilot phase

 Given the outline suggested above, major events / exercises with organizational and budgetary implications in the preparatory and pilot phase would be as follows:

1. Preparation of model Community monitoring tools, training, orientation and awareness materials and documentation formats at national level
2. State Preparatory meetings and Workshops
3. State mentoring team formation, finalization of state appropriate frameworks
4. State Training of trainers – one state level workshop for Facilitators. Training of Community Monitoring teams at different levels will be conducted by NGO facilitators in the pilot phase.
5. District workshop – one in each district. Formation of District mentoring teams.
6. Block level training for four members of a Block Community Monitoring team, including at least two civil society members.
7. Community mobilization and formation of Community Monitoring committees at different levels starting from village level.
8. Orientation of members of Community Monitoring committees at all levels.
9. Block and district level community monitoring exercises would include a public dialogue (‘Jan Samvad’) or public hearing (‘Jan Sunwai’) process once or twice in the year in each PHC and Block.
10. Process documentation, state evaluations and end phase state workshops in all states

 

Overall scale of activity

The State Pilot for Community Monitoring could develop this activity with the following pilot sample:

1. Eight pilot states to be selected, drawn from all regions of the country, with varying levels of health development. Based on discussions in the AGCA on 20^th Dec. 06, in consultation with the Additional Secretary, Ministry of Health and Family Welfare, the following states are being suggested for this national pilot:

·        Assam

·        Chhattisgarh

·        Jharkhand

·        Madhya Pradesh

·        Maharashtra

·        Orissa

·        Rajasthan

·        Tamil Nadu

It is also desirable to include the states of Karnataka and Uttar Pradesh if any of these states are not included, or if a slightly larger pilot is possible.

2. Three to five districts in each state would be identified, with a minimum of 3 districts per state.

Criterion for number of pilot districts per state:                     

States with 15 to 29 districts: 3 pilot districts

States with 30 to 39 districts: 4 pilot districts

States with 40 and above districts: 5 pilot districts

This amounts to a total of 30 pilot districts spread across these eight states.

 

3. In each district identify three blocks (total 90 pilot blocks)
4. Identify three PHCs in each of these blocks (total 270 pilot PHCs)
5. Identify five revenue villages in each PHC area identified (total 1350 pilot villages)

Based on this, the following scale of activities is suggested for this large pilot activity:

Activity	Number of unit activity
Model tools, orientation material, curricula to be prepared	Single set of model material at national level
State Mentoring teams to be formed, visit by AGCA member(s), conduct one preparatory meeting to plan state workshop	8
State level workshop (2 days)	8
State Training of trainers (5 days)	8
District workshop – one in each district	30
Block level trainings of facilitators	90
Formation of Community Monitoring committees
·        Village	1350
·        PHC	270
·        Block	90
·        District	30

 

Orientation of members of Community Monitoring committees
·        Village	1350
·        PHC	270
·        Block	90
·        District	30
Conduction of one Jan Samvad in each of the pilot PHCs and blocks
·        PHC Jan Samvad	270
·        Block Jan Samvad	90
State process documentation, evaluation and end phase workshops	8

 

Materials

The following kinds of materials would need to be developed to carry out the required activities:

Level	Type of material
National	Preparation of Models: Tools for Community Monitoring / Curriculum for Trainings / Materials for Training and Workshop / Workshop design and contents / Awareness and Promotional materials / Documentation formats including review and revision at the end of the pilot project
National, State and Dist. level (For programme managers)	Publication of guidelines, prototype tools, framework for community monitoring and facilitation process
District / block / PHC / village committee members	Main implementation guidelines booklet including all Community monitoring tools (questionnaires and checklists)
District / block / PHC / village committee members	Level specific pamphlets (Separate pamphlets for each level - District, block, PHC, village)
Block, PHC and village trainers	Guidelines for training of Block facilitators
	Manual for training of Block committee members
	Manual for training of PHC committee members and VHC members
General public	Awareness material and public records (Posters on mandated health services, Health services calendars)

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Section–II: Suggested outline of the Community based monitoring activity

We are envisaging an interactive system of monitoring, where more than one level of committee looks into the functioning of each level. The underlying concept is:

 

1. The Monitoring committee at each respective level reviews and collates the records coming from all the committees dealing with units immediately below it. This enables it to make an assessment of the situation prevailing in all the units under its purview, and to make a report at its level.
2. This Monitoring committee also appoints a small sub-team drawn from its NGO and PRI representatives who visit a small sample of units (say one facility or two villages every trimester) under their purview and review the conditions there. This enables the committee to not just rely on reports but to have a first-hand assessment of conditions in their area. For example, the PHC committee representatives would visit 2 villages and conduct FGDs there, in each trimester by rotation. Similarly the Block committee representatives would visit one PHC by rotation in each trimester.
3. The monitoring committees at PHC / Block / District levels would make an assessment of the functioning of the major Health care facility at their respective level (PHC / CHC / District Hospital). This obviates the need for a separate committee to look into Health care facilities.
4. The Monitoring committee sends a periodic report (Quarterly for Village, PHC, Block and District levels; Six monthly for State level) to the next higher level committee enabling it to collate the report at that level.

 

Keeping this in mind, outlined below are a broad suggested framework for activities at various levels, and a complementary suggested framework of organisation of information for the Community based monitoring activity.

Suggested framework of activities according to levels

Level	Agency	Activity (Quarterly for Village, PHC, Block and District levels; Six monthly for State level)
Village	Village Health and Sanitation Committee	a. Reviews Village Health register, Village health calendar b. Reviews performance of ANM, MPW, ASHA c. Sends brief three monthly report to PHC committee
PHC	PHC Monitoring and Planning Committee	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 (including CHC)	Block Monitoring and Planning Committee	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 (including District hospital)	District Monitoring and Planning Committee	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 RKS members, makes observations c. Visits District hospital and reviews records, discuss with RKS members c. Send brief three monthly report to State committee
State	State Monitoring and Planning Committee	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

 

Suggested framework to organise information

Level	Main issues for monitoring	Reference documents	Who	When	Tools
Village level	i.           ANM / MPW services incl. maternal, infant and child health services at village level; ASHA activities ii.          Availability of key services at local health facilities iii.        Selected adverse outcomes like maternal death iv.        Denial of health care	i.                Village Health Plan ii.               Charter of Citizens Health Rights for Sub-centre and PHC iii.             NRHM schemes – ASHA, JSY, Untied fund expenditure etc.	i.  Village Health and Sanitation Committee (incl. ASHA+ ANM +AWW+SHG) ii. Responsibility  for facilitating FGDs and interviews in sample villages –local CBO / NGO	Quarterly	i.  Standard agenda items for VHSC meeting ii. Village Health register iii.Village Health calendar iv. ANM / MPW records v. Village FGDs  vi. Interviews of ANC/ PNC beneficiaries vii. ASHA interview viii. Protocol for cases of denial of health care
PHC level	i. Overview of village level health services ii. Staffing, Supplies and services availability at PHC iii. Quality of care at the PHC from people’s perspective iv. Implementation of the National Health Programmes; State specific health schemes v. Selected adverse events, denial of health care	i.           PHC Health Plan ii.          Charter of Citizens Health Rights for PHC iii.        IPHS for PHC iv.        NRHM schemes – ASHA, JSY, Untied fund expenditure etc. v.         Standard Treatment Guidelines vi.        Guidelines for National health programmes and Family Planning Insurance Scheme	i.  PHC monitoring and planning committee – incl. PRI members, members of selected VHSCs, NGOs / CBOs, ii. PHC RKS members iii. Facilitation by NGO / CBO	Quarterly	i.  Standard agenda items for PHC committee meeting ii.  Reports from VHSCs iii. Record of select village FGDs iv. Interview of the MO PHC v.  Exit interview of PHC patients v.  Records of cases of Health care denial related to PHC vi. Interviews of RKS members vii. Objective findings in PHC         viii. Adverse outcomes viii. Protocol for cases of denial of health care ix. PHC level Public hearing

 

Level	Main issues for monitoring	Reference documents	Who	When	Tools
Block Level	i.  Overview of health services (incl. outreach and PHC based services) in the block ii. Staffing, Supplies and services availability at CHC iii. Quality of care at the CHC from people’s perspective iv. Implementation of the National Health Programmes and support by CHC to outreach services; State specific health schemes v. Selected adverse events, denial of health care	i.  CHC Health Plan ii. Charter of Citizens Health Rights for CHC iii. IPHS for CHC iv. NRHM schemes – ASHA, JSY, Untied fund expenditure etc. v.  Standard Treatment  Guidelines vi. Guidelines for National health programmes and Family Planning Insurance Scheme	i.  CHC monitoring and planning committee – incl. PRI members, members of selected PHC committees, NGOs / CBOs ii.  CHC RKS members iii. Facilitation by nodal NGO / CBO	Quarterly	i.  Standard agenda items for CHC committee meeting ii. Reports from PHC committees iii. Records of visits to select PHCs iv. Interview of the MO incharge CHC  v. Exit interview of patients vi. Records of cases of Health care denial related to CHC vii. Interviews of CHC RKS members viii. Objective findings in CHC         ix. Adverse outcomes x.  Protocol for cases of denial of health care xi. Block level Public hearing
District Level	i. Overview of all public health services in the District (except for services provided by municipal bodies), including implementation of all aspects of NRHM, State specific health schemes ii. Quality of care at District Hospital and sub-divisional hospitals	i.  District health plan ii. Charter of Citizens Health Rights for District hospital and sub-divisional hospitals iii. IPHS for District hospital iv. NRHM schemes – ASHA, JSY, Untied fund expenditure etc. v. Standard Treatment Guidelines vi. Guidelines for National health programmes and Family Planning Insurance Scheme vii. PPP and related regulations viii. District health budgets	i.  District Health Monitoring and planning committee ii. Public Hearing Facilitator team iii. Inputs from DPMU, CMO,  Collector, ZP	Six -monthly	i.  Standard agenda items for District committee meeting ii. Reports from the block health committees iii. Records of visits to select sub-divisional hospitals / CHCs iv. Report of the district health mission v.         District Public Hearing vi.        District People’s Rural Health Watch report

 

Level	Main issues for monitoring	Reference documents	Who	When	Tools
State level	All issues of Rural public health services / NRHM in the state including State specific health schemes	i.  State Health Plan, State PIP ii. NHRC  recommendations and State Govt. component of NHRC National Action Plan iii All NRHM schemes – ASHA, JSY, Untied fund expenditure etc. iv. IPHS and functioning of various level facilities v. National Health Programmes and Family Planning Insurance Scheme vi. PPP and related regulations vii. State health budget and expenditure	i.  State Health Monitoring and Planning committee ii. State People’s Rural Health Watch report / citizen’s report by civil society groups iii. Public meeting of State mission with civil society representatives.	Six monthly committee meetings   Annual independent reports, public meetings	i.  Reports from the District Health committees ii.  Records of visits to select districts iii. Report of the State Health Mission iv. Reports of District Public Hearings v.  Independent reports

Note: Reports refer to information received by a committee from other bodies; records refer to information collected by the committee itself

While operationalising this framework, the following mode of functioning may be kept in mind:

5. The Monitoring committee at each level would review and collate the summary reports coming from the committees dealing with units immediately below it. This enables it to make an assessment of the situation prevailing in all the units under its purview, and to make a report at its level. For example, the District committee would receive and review the reports from all Block committees.
6. However Monitoring committees would not only rely on reports, but would also directly interact in the field situation and get feedback. Firstly, each committee would appoint a small sub-team drawn from its NGO and PRI representatives who would visit on a quarterly / six monthly basis a small sample of units (say one facility or two villages) under their purview and directly review the conditions there. This enables the committee to not just rely on reports but to also have a first-hand assessment of conditions in their area. For example, the PHC committee representatives would visit two villages and conduct Group discussions there, in each trimester selecting different villages by rotation. Similarly the Block committee representatives would visit one PHC by rotation in each trimester.

Secondly, monitoring committees at PHC, Block and District level would be involved in six-monthly or annual Jan Samvads or Public hearings at their respective levels, where committee members would get direct feedback of the situation including possible presentation of cases of denial of health care. Similarly, it is suggested that the State health mission could conduct an annual public meeting open to all civil society representatives where the State mission report and independent reports would be presented and various aspects of design and implementation of NRHM in the state, including State specific health schemes, would be reviewed and discussed enabling corrective action to be taken.

Tools for monitoring:

1. Format for Village Health register

2. Format for Village Health Calendar

3. Guideline for information to be collected in Village group discussion

4. Schedule of ASHA Interview

5. Interview format for MO PHC / CHC

6. Format for Exit interview (PHC / CHC)

7. Format for independent additional observations regarding PHC / CHC

8. Documentation of testimony of denial of health care

9. Guidelines for organising public hearing

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