Presented by: Programme Management Unit ASHA; Community Processes & Intersectoral Convergence SHS,...

Presented by: Programme Management Unit ASHA; Community Processes & Intersectoral Convergence SHS, NHM, J&K Community Based Monitoring & Planning (Proposal for NGO Involvement)

Introduction Panchayats in India are an age-old institution for governance at village level. States have to encourage all the steps to devolve greater powers and funds to Panchayati Raj Institutions. In Jammu and Kashmir, the roots of Panchayati Raj were planted by Maharaja Hari Singh in 1935 by promulgation of the Jammu and Kashmir Village Panchayat Raj. A special Department of Panchayati and Rural Development was created in 1936 to administer the 1935 Regulation which stated, it is expedient to establish in Jammu & Kashmir State the village panchayats to assist in the administrative, civil and criminal justice and also to manage the sanitation and other common concerns of the village.

By an amendment in 1941, the list of functions of the 1935 Regulation were widened. By an Act of 1951, the Panchayati Raj Institutions (PRI) was adopted to be re-established. The Jammu and Kashmir Government thereafter enacted the Village Panchayati Act in 1958 replacing the 1951 Act. The J&K state has been one of the pioneering states in the field of decentralized district planning with the introduction of an innovative initiative of Single Line Administration in 1976. The underlying objective of this model was to decentralize the authority with a view to accelerating the pace of developmental programmes and involve peoples participation in the process of development. This realization finally led to the introduction of Jammu & Kashmir Panchayati Raj Act 1989. This Act provides for a three tier system (village, Block and District level) for goverence at the grass roots. The institutions accordingly in J&K are called Halqa Panchayat, Block Development Council and District Planning and Development Board respectively.

In the Sate of J & K the devolution of powers to the PRIs pertaining to H & FW Dept. have been executed as in the following Govt. Order:-

In 1992, through the enactment of the 73 rd Constitutional Amendment, Panchayati Raj Institutions (PRIs) were strengthened as local government organizations with clear areas of jurisdiction, adequate power, authority and funds commensurate with responsibilities. Panchayats have been assigned 29 rural development activities, including several, which are related to health and population stabilization. The XI schedule includes Family Welfare, Health and Sanitation, (including hospitals, primary health centres, and dispensaries,) and the XII schedule includes Public Health. Thus the possible realm of influence of the Panchayats extends over a significant proportion of public health issues. The Gram Sabha, where empowered has the potential to act as a community level accountability mechanism to ensure that the functions of the village Panchayat in the area of public health and family welfare, actually respond to peoples needs.

Increasingly it is being realized that strategies for achieving low infant, under five and maternal mortality depend on a functioning continuum of high quality services from community to secondary and sometimes higher levels of care. In addition community support for such services comes through behaviour change to increase utilization as well as demand high quality services. In the RCH 2 implementation document, specific mention is made of plans to support PRI (and urban counterparts) in design, implementation, monitoring of RCH related interventions. This is also seen as a potential to address the social determinants of health through engagement with communities and PRI rather than a biomedical approach in isolation. It is expected that PRI involvement will increase community understanding of issues of accountability for quality and reliability of health care services. Thus there is opportunity for PRI involvement to address the non technical components of health care seeking, provided all PRI representatives are exposed to a perspective building exercise on health within the framework of gender and equity.

National Rural Health Mission, designed to integrate health and family welfare related interventions and address health from a holistic preventive, promotive and curative viewpoint takes a much more significant view of PRI engagement. The fulcrum of the NRHM programme is a social activist (ASHA) at the village level, who works with the village level resource team in providing preventive and promotive health care services. It is expected that she will be supervised and supported by the panchayats. One of the core strategies of the NRHM is to empower local governments to manage, control and be accountable for public health services at various levels.

The Village Health, Sanitation & Nutrition Committee (VHSNC), the standing committee of the Gram Panchayat (GP) is expected to provide oversight of all NRHM activities at the village level and supposed to be responsible for developing the Village Health Plan with the support of the ANM, ASHA, AWW and Self Help Groups. For this there is an immense need to train and enhance capacity of Panchayati Raj Institutions (PRIs) to own, control and manage public health services which though is evolving a lot is still needed to be done to maximize the function of PRIs. The Village Health, Sanitation & Nutrition Committee (VHSNC) forms the link between the Gram Panchayat and the community. The VHNC is responsible for working with the Gram Panchayat to ensure that the health plan is in harmony with the overall local plan. It is anticipated that this committee will prepare a Village Health Plan and maintain village level data, supervised by the Gram Panchayat. Engaging the Gram Sabha and other groups in planning and monitoring the Village Health Plan will presumably enforce transparency and accountability.

Under the NRHM, untied funds of Rs. 10,000 are placed with the VHSNCs to meet unanticipated expenditures. A Joint account has been opened with the Sarpanch and ASHAs for operationlization of the activities planned. So after considering the functioning of VHSNCs to put in place the gaps identified, a need is felt to undertake the subsequently mentioned strategy on priority to achieve the objective of involvement of PRI as per mandate of NRHM.

Proposed Community Based Monitoring and Planning (CBMP) Program in Jammu and Kashmir Update on communitization initiatives The following initiatives have been taken by the Jammu and Kashmir State Health Society (SHS) in implementing the communitization component through the National Health Mission (NHM): 1. Village Health Sanitation Nutrition Committees (VHSNC) have been formed in all 6881 villages of the state in 2011-12. 2. Subsequently, VHSNCs have been re-constituted to include the newly elected members of the Panchayati Raj Institutions (PRI's) through a government order in September, 2011. 3. First instalment of village untied funds (total amount of Rs 3.25 crores) has been released to 5817 VHSNCs in 2011-12. The second instalment of funds for FY 2012-13 is 1.09 crore to 6881 committees. Total funds released till date is 4.35 Crores.

4. Interaction meetings/Melas with VHSNC members have been organized at the district and block level to orient them on the various components of NHM and their roles and responsibilities. Approx 34000 VHSNC members have been reached through about 350 block and district meetings. But as per new guidelines VHNSC should have 12-15 member in which case we may have to orient around one lac members in the reconstituted committee. Constitution of VHSNC:- Gram Panchayat Members from the village ASHA, AWW, ANM SHG Leader The PTA/ MTA Secretary Village representative of any Community based organization working in the village

5. Rogi Kalyan Samities (RKS) have been constituted in health facilities at the PHC, CHC and district level. The governing body of these committees are chaired by the local Member of Legislative Assembly (MLA) and include officials from the departments of Health, Integrated Child Development Scheme (ICDS), Public Health Engineering Department (PHED), Education, along with NGO representatives. 6. SHS has developed a diary which covers various aspects of NHM, including roles and responsibilities of ASHA and VHSNC members. This has been printed and distributed to 4000 Gram Panchayats in the state. 7. SHS has prepared a booklet on 'Guidelines for Devolution of Functions to PRIs in Health'. This booklet has been distributed to all line departments and PRI members in the state.

Proposed plan for initiating CBMP The State proposes to initiate Community Based Monitoring and Planning (CBMP) in NHM State PIP for 201314. In the first year the programme is proposed to be implemented in six districts (Jammu, erstwhile Doda and Rajouri in Jammu division; Ganderbal, Anantnag and Budgam in Kashmir division) covering 19 blocks. The Advisory Group on Community Action (AGCA) would provide overall guidance and technical support to the SHS in implementing CBMP programme. The key program components would include; 1. Formation and strengthening of State Advisory Group on Community Action (SAGCA) and State Technical Advisory Group (STAG) to guide the implementation of CBMP;

2. Adaptation and translation of VHSNC and RKS guidelines, training manuals and CBMP tools; 3. Formation and orientation of planning and monitoring committees at the district, block level; and 4. Identification and orientation of Nodal NGO's to manage the implementation of CBMP at the district and block level; 5. Initiating implementation of CBPM in 1123 villages in 19 blocks covering 14 CHC and 70 PHC across 6 districts. The details of program scale proposed in Year-1 (2014-15) is enclosed in Annexure 1.

Focus Areas The CBMP process would focus on activating and building capacities of VHSNC, RKS and Panchayat representatives to monitor and provide feedback on the functioning of public health services, including inputs for improved planning on issues such as: a) demand/ need b) coverage and access c) quality of services d) behaviour and presence of health care personnel at service delivery points/ health facilities, and e) identify possible denial of care and negligence. A grievance redressal mechanism will also be put in place to resolve the issues/ gaps emerging from the CBMP process at the block and district level.

Key programme components The key components outlined above will be implemented by a team of professionals based in SHS in partnership with NGOs at the District and Block level. A. State Level 1. Formation of State Advisory Group on Community Action (SAGCA) and State Technical Advisory Group (STAG) to guide the implementation of CBMP A State Advisory Group for Community Action (SAGCA) will be constituted for providing advisory support to the state for implementing CBPM. The SAGCA will be chaired by the Secretary Health and Family Welfare and comprise senior officials from the State Health Society, Departments of Health and Family Welfare, Panchayati Raj, Women and Child Development and NGO representatives. Representatives from the national level AGCA will also be included as SAGCA members. SAGCA members will be oriented to the CBMP processes as implemented in the pilot phase and in other states. Subsequently, meetings will be organized to strategize and work out a broad plan of action for rolling out the CBMP programme in the state over the next three years. PFI/AGCA members will facilitate the orientation and planning exercise.

A Technical Assistance Group (TAG) will also be formed to provide technical support to the process. The STAG will comprise representatives from NGOs working on health and rights based approaches. It will also have representatives from the State Health Society and its meetings will be convened by the Nodal Officer designated by the MD NHM. The AGCA will support in developing Terms of Reference (TOR) and conduct orientation of the SAGCA and STAG members. 2. Identification and orientation of NGOs/ CBOs to manage the implementation of CBMP; A mapping exercise would be undertaken to identify potential NGOs/ CBOs with capacities and field presence to implement the CBMP program. Subsequently, NGOs/ CBOs will be selected/ nominated through a due diligence process. Existing Mother NGOs (MNGOs) and Field NGOs (FNGOs) will be given preference, on the basis of their performance in implementing the Regional Resource Center (RRC) scheme. The NGOs staff will be trained by the AGCA with support from the team based at the SPMU.

3. Adaptation of state level guidelines, training manuals, formats for VHSNC and RKS members The TAG will adapt the VHSNC and RKS guidelines, training modules to suit the state context. Selected MNGOs and ASHA trainers will also be invited contribute to the process. A sub-group will be formed to work on the details of the guidelines, modules and tools, including translation of the manuals into Urdu, Dogri and adapting the Hindi version to make it easier to understand. 4. Formation and orientation of planning and monitoring committees at the district, block and PHC level Orientation meetings will be organized at the district level for key officials from the Health, ICDS, PHED departments. The meeting would help in developing an understanding among the stakeholders on the CBMP program and seeking their support in the implementation processes.

District and Block Level 1. Formation and orientation of DPMC and BPMC members DPMC and BPMC will be formed 19 blocks across 6 districts. This will be followed by an orientation meeting of the committee members on the CBPM process, including developing an understanding on their roles and responsibilities. Subsequently, meetings of these committees will be organized on a quarterly basis to discuss and resolve issues emerging from the community monitoring and planning processes. 2. Orientation of RKS members A state level notification would be issued to reconstitute/ expand the membership of the RKS to enable inclusion of PRI members and NGO/ CBO representatives. Subsequently, structured orientation of the committee members will be organized.

Village level 1. Community meetings would be organized to generate awareness on NHM entitlements and CBMP process. IEC/ BCC materials (including wall writings) would be developed and distributed among the VHSNC members. 2. Training of VHSNC members- Two rounds of structured trainings would be organized for the VHSNC members. In the current FY, a) basic orientation one day would be organized for all VHSNC members at the village level b) followed by a two day orientation of selected members (around 5 members) will be organized at the Gram Panchayat/ PHC level. The second round of training for VHSNC members would be organized in the next FY. In addition, orientation meetings of the ASHA, ANM and Anganwadi Workers (AWW) will be organized to develop their understanding on the roles and responsibilities of VHSNC. This would be done through their ongoing monthly review meetings organized at the PHC / Block level. 3. Focus will be organizing VHSNC meetings and introducing tools for monitoring services at the village and health facility level. Subsequently, village and facility score cards would be generated and shared with service providers to facilitate dialogue and corrective action.

Proposed Operational Mechanism and Human Resource Structure A. State Level The AGCA would provide technical support and guidance to the SHS team in rolling out the CBMP program. This would include: 1. Developing the Terms of Reference (TOR) and support in constituting the State Advisory Group on Community Action (S-AGCA) and Technical Assistance Group (S-TAG); 2. Developing guidelines, criteria and processes for selection of NGOs; 3. Co-facilitating trainings and orientation of implementing partners; 4. Adaptation of guidelines, training modules for VHSNC and RKS; 5. Adaptation tools for community enquiry and facility surveys; and 6. Periodic review and guidance for implementation of the CBMP programme To manage implementation of the CBMP program a team of professionals will be hired. This will include a State Project Officer and 2 Divisional Project Officer(one each in Jammu and Kashmir division) to implement and manage the CBPM component. In addition adequate secretarial assistance will be provided to these units.

B. District Level In each district, an NGO/ CBO will be identified to implement the program at the district level. Their role would include: a) formation and strengthening of District Planning and Monitoring Committees (DPMC), Block Planning and Monitoring Committee (BPMC) b) facilitate training of VHSNC and RKS members c) compilation and analysis of community enquiry data and facility surveys. Each organization would have two (2) staff, a District Project Officer and a Training Officer. To manage the finances, costs for a part time Accountant will also be provided.

C. Block Level In each block, an NGO/CBO will be identified to implement CBMP activities at the village level and block level. Their role would include: (a) extension / reconstitution of VHSNC (b) organizing community meetings to raise awareness on NRHM entitlements (c) training of VHSNC members (d) organizing regular meetings of VHSNC (e) initiation of community level enquiry to assess the availability, access and quality of health services. In each block, a Block Coordinator along with a team of Community Facilitators (each covering around 7-10 villages) will be in place. Difficult to reach districts will have 1 facilitator for 7 villages and plain districts will have 1 facilitator for 10 villages. To manage the finances, costs for a part time Accountant will also be provided.

Scale up plans The processes initiated in Year-1 (FY 2014-15) would help the state in developing a robust implementation mechanism to support the scale up in the next FYs. The details of the scale up plan in the subsequent would include: Year 2 (FY 2015-16) 1. Covering remaining blocks from the districts covered in year one plus few more blocks in identified districts, upto a total 48 blocks in year two. 2. Creating a pool of master trainers (from existing NGOs/ CBOs) to roll out structured training for VHSNC and RKS members across the 6 districts. 3. Undertaking a mapping exercise to identify potential NGOs/ CBOs in the blocks to covered in year two. 4. Selection of NGO/ CBO in the additional districts (across all blocks). Year 3 (FY 2016-17) Completion of remaining blocks across the pending districts.

District Jammu S NoBlockVHSNCPHCCHC 1Kot Bhalwal10740 2Dansal10630 3Akhnoor9182 4Marh9031 Total394183 Erstwhile District Doda S NoBlockVHSNCPHCCHC 1Assar (Doda)4120 2Kishtwar (Kishtwar)8220 3Batote (Ramban)4521 Total16861 Rajouri District S NoBlockVHSNCPHCCHC 1Sundarbani4231 2Nowshehra6151 Total10382 Details of Programme Scale

District Ganderbal S NoBlockVHSNCPHCCHC 1Ganderbal2141 2Laar2530 3Kangan7471 Total120142 District Anantnag S NoBlockVHSNCPHCCHC 1Achabal3431 2Bijbehera4861 3Mattan5221 Total134113 District Budgam S NoBlockVHSNCPHCCHC 1Beerwah7481 2Magam5021 3Soibugh4021 4Khag4010 Total204133

CUMULATIVE TOTAL Districts6 Blocks19 VHSNC1123 PHC70 CHC14 Of the six districts only Rajouri and Erstwhile Doda being hard to reach districts, shall have 1 facilitator for 7 villages; rest of the 4 districts will have 1 facilitator for 10 villages. Budget Sheet Budget Sheet

Presented by: Programme Management Unit ASHA; Community Processes & Intersectoral Convergence SHS,...

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