The adoption of a comprehensive framework for community-based monitoring and planning at various levels under NHM 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 NHM 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 NHM 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 NHM Advisory Group for Community Action (AGCA) in its meetings on 28th June 06, 27th July 06 and 20th 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 NHM, Union Ministry of Health and Family Welfare for consideration, as a demonstrative pilot, to help develop the process of Community monitoring under NHM on a national scale.

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:

• 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 NHM 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, peoples 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.
• 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.
• 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.
• The skills involved in developing participatory monitoring are different from usual programme related skills. The NHM 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.

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:

• 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.
• 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.
• 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.

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 NHM
• 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.

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/NHM.

• 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.
• 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.
• 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.
• 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 NHM 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.
• 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.

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

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 NHM 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.

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

• Preparation of model Community monitoring tools, training, orientation and awareness materials and documentation formats at national level
• State Preparatory meetings and Workshops
• State mentoring team formation, finalization of state appropriate frameworks
• 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.
• District workshop one in each district. Formation of District mentoring teams.
• Block level training for four members of a Block Community Monitoring team, including at least two civil society members.
• Community mobilization and formation of Community Monitoring committees at different levels starting from village level.
• Orientation of members of Community Monitoring committees at all levels.
• 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.
• Process documentation, state evaluations and end phase state workshops in all states

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

• 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 20th 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.
• 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.
• In each district identify three blocks (total 90 pilot blocks)
• Identify three PHCs in each of these blocks (total 270 pilot PHCs)
• 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 :

Materials

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