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CAH Guidelines fo Programme Managers on Cmmunity Action for Health CAH |
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Guidelines
for Programme Managers on
Community Action for Health
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Acknowledgements
These guidelines are based on the tool used in over 1,600 villages and 300 facilities in the first phase of community
monitoring from 2007 to 2009. The guidelines were reviewed by a sub-group comprising representatives of civil society
organisations, the Advisory Group on Community Action, the National Health Systems Resource Centre and the Ministry of
Health and Family Welfare.
We acknowledge our sincere gratitude to Mr Manoj Jhalani, Joint Secretary (Policy) and Ms Limatula Yaden, Director,
National Health Mission, Ministry of Health and Family Welfare, and the AGCA members for their guidance.
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Message
Communitization has been envisaged as one of the five main approaches under the National Health Mission (NHM). The
Mission seeks to provide universal access to equitable, affordable and quality health care which is accountable and at the
same time responsive to the needs of the people. The inclusion of community based monitoring, now called Community
Action for Health, as one of the three processes within the accountability framework is a clear reflection of the Mission’s
commitment to community participation. The Advisory Group on Community Action (AGCA) was constituted by the Ministry
of Health and Family Welfare in 2005, almost immediately after the launch of the Mission. The AGCA comprises public
health and civil society experts and is mandated to advise the government on community action under NHM. Population
Foundation of India (PFI) hosts the AGCA Secretariat.
The first phase of the community based monitoring of health services was initiated under the guidance of the AGCA with
support from the Ministry of Health and Family Welfare (MoHFW). This phase was implemented in nine states-Assam,
Chhattisgarh, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Odisha, Rajasthan and Tamil Nadu between 2007
and 2009. An external evaluation of the initiative showed very positive results and recommended scaling it up to all states.
Subsequently, states have been including community based monitoring as a component of the state NHM programme
implementation plans (PIPs).
These guidelines for programme managers have been developed based on the cumulative experience and understanding
of all those working at national, state, district and sub-district levels. The guidelines include a comprehensive set of
principles for establishing and strengthening Community Action for Health as also the institutional mechanisms and
processes required for implementation. The document has been developed in consultation with various civil society
organisations under the guidance of the AGCA members.
I hope that the states will use these guidelines widely and guide programme managers at state, district and sub-district
levels in adapting the Community Action for Health processes to the state specific contexts for successful scale-up of the
implementation of Community Action for Health.
October 29, 2014
C K Mishra
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Foreword
The National Rural Health Mission, launched almost a decade ago, viewed community processes as central to its major
strategies. I am happy to note that the Advisory Group on Community Action (AGCA) supported through the NRHM, and
now the National Health Mission, has been able to demonstrate significant achievements in this area. The Guidelines for
Programme Managers and the User Manual for community and facility committees are important outcomes of their work.
I commend the commitment and guidance of the AGCA members and the hard work of the Secretariat in enabling the
development of the guidelines, manual and the accompanying tool.
Engaging civil society, community and the health system and bringing them on a common platform is no easy task. My
involvement in various AGCA processes validates this impression. The Guidelines, User Manual and the tool reflect the
dedicated involvement of the AGCA members. Community Action for Health is an evolving process. With renewed
commitment from the MoHFW, 22 States/Union Territories have initiated the process of rolling out the Community Action
for Health component by including it in the State Programme Implementation Plans (PIPs) with support from the AGCA.
However, consistent and sustained efforts are needed by the States to integrate and institutionalize the Community Action
for Health conponent to cover the entire country and fulfil the goals of NHM.
We urge the state governments to translate and adapt these Guidelines and User Manual and its tool as appropriate to
state contexts. We also encourage the states to partner with NGOs in order to rapidly scale-up Community Action for
Health and to ensure civil society representation in this important endeavour.
October 29, 2014
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Guidelines for Programme Managers on Community Action for Health 2014 | v
Structure of the Guidelines
The Guidelines are structured as follows: Section One includes lessons from the pilot phase and an overview of the key
features of the process. Section Two discusses the institutional mechanisms required to implement Community Action for
Health, including roles and responsibilities of different stakeholders. Section Three describes the application of the toolkit.
Section Four depicts the various levels of the planning process once the report card is generated, including feedback
mechanisms and inter-sectoral convergence. Section Five focuses on the process involved for capacity building of support
structures at various levels.
The programme guidelines draw on references which can be accessed at http://nrhm.gov.in/nhm/nrhm/guidelines/
nrhm-guidelines.html. The guidelines are intended for the use of programme managers responsible for community process
interventions at state, district and block levels and non government organisations (NGOs) who partner with the state in
the process of Community Action for Health.
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vi | Guidelines for Programme Managers on Community Action for Health 2014
Acronyms
AGCA
AF
ANM
ANC
ASHA
AWW
AWC
BCM
CBMP
CBO
CMO
CMHO
CHC
ICDS
NGO
MoHFW
MTA
NHM
PFI
PTA
PHC
PMC
RKS
SC
VHND
VHSNC
Advisory Group on Community Action
ASHA Facilitator
Auxiliary Nurse Midwife
Antenatal Care
Accredited Social Health Activist
Anganwadi Worker
Anganwadi Centre
Block Community Mobiliser
Community Based Monitoring and Planning
Community Based Organisation
Chief Medical Officer
Chief Medical Health Officer
Community Health Centre
Integrated Child Development Services
Non Government Organisation
Ministry of Health and Family Welfare
Mother Teacher Association
National Health Mission
Population Foundation of India
Parent Teacher Association
Primary Health Centre
Planning and Monitoring Committees
Rogi Kalyan Samiti
Sub Centre
Village Health Nutrition Day
Village Health, Sanitation and Nutrition Committees
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Guidelines for Programme Managers on Community Action for Health 2014 | vii
Contents
Message
iii
Foreword
iv
Structure of the Guidelines
v
Acronyms
vi
Section I
Background, Components and Key Features
1
Section II
Institutional Structures and Composition
6
Section III
The Community Action for Health Tool
9
Section IV
Sharing of Report Cards and Follow up Process
14
Section V
Capacity Building
16
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2 Pages 11-20 |
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I Background, Components
Section and Key Features
Community Action for Health, earlier known as Community Based Monitoring and Planning (CBMP) of health
services, is a key strategy under the National Health Mission (NHM). It is envisaged as an important pillar of
NHM’s Accountability Framework in order to ensure that the services reach those for whom they are intended. The
accountability framework proposed in the NRHM is a three-pronged process that includes internal monitoring, periodic
surveys and studies and community based monitoring. Community monitoring is also seen as an important aspect
of promoting community led action in the field of health. The provision for Monitoring and Planning Committees has
been made at the Primary Health Centre, Block, District and State levels. The adoption of a comprehensive framework
for community-based monitoring and planning at various levels places people at the centre of the process of regularly
assessing whether the health needs and rights of the community are being fulfilled.
In 2005, the Ministry of Health and Family Welfare (MoHFW) constituted an Advisory Group on Community Action
(AGCA) under the National Rural Health Mission (NRHM). This group was mandated to advise NRHM on community
action including community monitoring initiatives. It comprises eminent public health professionals and civil society
representatives. The Population Foundation of India (PFI) hosts the Secretariat of the AGCA.
A pilot phase of community based monitoring of health services was implemented under the guidance of the AGCA in
nine states covering 36 districts and 1600 villages. The initiative was supported by the MoHFW. The processes included
capacity building of Planning and Monitoring Committees (PMCs) and Village Health, Sanitation and Nutrition Committees
(VHSNCs) to undertake community enquiry and assessment of a set of services provided through outreach and various
facilities. An external evaluation of the pilot demonstrated positive outcomes of the CBMP process towards improving
health services under NRHM1. Key findings included:
1Population Foundation of India 2010. Reviving Hopes Realizing Rights: A Report on First Phase of Community Monitoring under NRHM. New Delhi
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2 | Guidelines for Programme Managers on Community Action for Health 2014
Increased awareness among communities for health service provision
and health entitlements.
Greater community involvement and support in local planning
resulting in reduction of service delivery constraints of front line health
workers.
Significant increase in utilization of village-level untied funds based on
local priorities identified by VHSNCs.
Improvements in the availability, range and quality of services,
especially during the Village Health Nutrition Day (VHND) following
regular review and dialogue.
Significant improvements in timely and full disbursals of the Janani
Suraksha Yojana (JSY) benefits and a considerable reduction in the
number of providers demanding informal payments.
Community Action for
Health, earlier known
as Community Based
Monitoring and Planning
(CBMP) of health services,
is a key strategy under the
National Health Mission
(NHM). It is envisaged
as an important pillar of
NHM’s Accountability
Framework
A platform for dialogue with service providers through public sharing of health report cards and paving the way for
corrective action and planning. Actions included reduction in the practice of prescribing medicines from private shops,
provision of unavailable essential medicines through Rogi Kalyan Samiti (RKS) funds.
Increase in the number of people availing services from primary health centres in some areas.
Display and provision of Citizen's Health Charter, suggestion boxes, list and availability of essential medicines at
facilities.
Operationalization of non-functional laboratory facilities in some districts.
Involvement of adolescents (12-17 years of age) in VHSNCs of some blocks to raise issues related to children and
adolescents in the meetings.
Approval of a mobile medical unit under one of the PHCs on community's demand.
Community Action for Health ensures that people’s health rights are being met through a process of active engagement of
the community in assessing the availability and quality of the services they are entitled to.
Community Action for Health Process
The Community Action for Health process has the following essential components:
Creating community awareness on NHM entitlements, roles and responsibilities of the service providers
Formation and strengthening of Planning and Monitoring Committees (PMCs) at Primary Health Centre (PHC), block,
district and state levels
Strengthening of Village Health, Nutrition and Sanitation Committees (VHSNCs) at the village/ Gram Panchayat level to
undertake the Community Action for Health process
Training of VHSNC and PMC members at all levels
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Guidelines for Programme Managers on Community Action for Health 2014 | 3
Undertaking community enquiry and facility assessment on a biannual basis using structured tools in order to monitor
community and facility based health services
Using periodic Jan Samwad (Public Dialogue) for advocacy with key stakeholders to highlight gaps and find solutions
Developing village, block and district health plans for aggregation into state-level planning processes.
Figure 1: Steps of the Community Action for Health Process
Community
Awareness
Formation
of Planning
& Monitoring
Committees
Constitution/
Strengthening
of VHSNC
Training of
VHSNC &
Planning &
Monitoring
Committees
Community
Enquiry
Village level
Health Plans
Jan Samwad
Key Features
1. The process of community action ideally needs to be facilitated by an agency with a degree of independence
from the health care delivery system. At state, district and block levels there is a need for an agency, independent
from the health department with a functional role in implementation, and not merely an advisory role. This
agency will also play an advocacy role if response from the system does not emerge.
2. Such implementation agencies need to be supported by officials working in the health system, and the process
needs to be mentored by multi-stakeholder advisory bodies at district and state levels. Nodal civil society
organizations/consortia or group of civil society organizations with demonstrated capacity and credibility are
needed to support this process. The roles of the nodal civil society organization/group at each level will be to
undertake capacity building of members of the planning bodies, facilitate implementation of key activities and
undertake advocacy.
3. Planning & monitoring committees (PMCs) at PHC, block, district and state levels need to be set up to enable planning based
on feedback from each successive level. Where MPCs are not formed, regular review meetings at block and district levels may
be considered, and existing mechanisms may be used to feed into the planning process.
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4 | Guidelines for Programme Managers on Community Action for Health 2014
4. Oversight of implementation will be through multi-stakeholder advisory groups at district and state levels – State and
District Mentoring and Advisory Groups for Community Action. These could either be established independently from
the State ASHA Mentoring Group which provides support to community process interventions in the state, or be part of
the existing structures.
5. Spaces for multi-stakeholder dialogue are necessary. Such multi-stakeholder involvement includes health officials
and providers, Panchayati Raj Institution members, community members and civil society groups. These include
existing bodies at local level (VHSNC and Rogi Kalyan Samiti) as well as additional bodies at higher levels.
Co-convenors of dialogue bodies may be from facilitating civil society organisations to ensure regularity. Such
meetings should be held at least once a quarter. Gaps highlighted through community feedback process should
be discussed and follow up action ensured.
6. Dialogue spaces must encompass inter-sectoral representatives and become a fulcrum of integrated action on various
social determinants of health. The multi-stakeholder committee at each level needs to have representation from other
sectors to ensure necessary expertise and capacity for action on social determinants. At the block and district levels,
officials from the general administration, ICDS, water supply and sanitation and other relevant departments along
with Panchayati Raj representatives should be on the multi-stakeholder committees (such as monitoring and planning
committees). Training and capacity building of all participants for effective inter-sectoral action (moving beyond vertical,
fragmented action) needs to be planned.
7. There needs to be a clear commitment of the health system to respond to the issues emerging from the monitoring
and planning process. Otherwise, it is unethical and wasteful to set such processes in motion. Community
needs that emerge from planning sessions could be supported by governments, other than through the use of
untied funds.
8. Community Action for Health processes must be operationalized simultaneously at all levels of the health system with
effective linkages between them. Community action for health cannot be effectively operationalised only through
community-
level activities.
9. Unresolved issues must be systematically raised and discussed at the next level in the health system. Decisions taken at
various levels need to be fed back to the lower levels through instituting feedback systems and regular Action
Taken Reports.
10. The functioning of the programme should be actively supported by the ASHA support structures, and facilitate
involvement of ASHAs in the Community Action for Health process. The VHSNC and RKS are integral to the mandate
of Community Action for Health. These need to be activated, oriented and may have to be expanded to ensure active
community representation. Structures established for support to the community interventions component, need to be
facilitated by civil society organizations and actively incorporate community based suggestions.
There is a great diversity in states and districts in terms of training of members of VHSNCs and PMCs, support systems
including partnerships with NGOs, and community awareness on entitlements. Therefore, each question in the formats is given
a level. States have the discretion to customize the tool depending on the a) functionality of the health system (b) capacities
and handholding by implementation organisations and (c) duration of implementation of the Community Action for Health
programme. Three levels are identified based on a set of criteria. These levels are:
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Guidelines for Programme Managers on Community Action for Health 2014 | 5
The Characteristics of the Regions:
LEVEL I
• Resources for capacity building: Training infrastructure in terms of a pool of trained resource persons as well
as support structures for ASHAs, RKS etc is weak or absent.
• Presence of civil society organisations: Weak civil society organisations/ NGOs in the area.
• Status of the public health system: Remote and inaccessible areas where the public health system is weak
in terms of infrastructure and manpower.
At this level, Community Action for Health will focus on availability of the core entitlements and basic quality aspects
such as cleanliness, the behaviour of the health staff and display of OPD timings. In areas under this level, the Community
Action for Health process will focus on building demand for service and highlighting the critical gaps in the availability of
services so that the system can respond and fill these gaps.
LEVEL II
• Resources for capacity building: There are fairly well developed training resources in terms of infrastructure
and a pool of trainers. The support structures for ASHAs and RKS exist, and are functional. While the training
capacity is present, supportive supervision requires further strengthening.
• Presence of civil society: There is a strong civil society presence, with experience in community-level training
but not yet optimally utilised by the district/state.
• Status of the public health system: There are adequate number of functional PHCs, moderate availability of
human resources, trained and functional ASHAs, moderately regular organisation of VHSND and regular visits by
ANMs.
At this level, in addition to aspects covered in Level-I, the Community Action for Health process will go beyond availability to
focus on the quality of the services delivered. These will include counseling services, infection prevention and other protocols.
LEVEL III
• Resources for capacity building: There is an efficient and mature system of capacity building in terms of
infrastructure, trained resource persons and manuals. There is adequate capacity for supportive supervision
as well.
• Presence of civil society: Strong civil society organisations/NGOs are available and being used by the system
for Community Action for Health.
• Status of the public health system: The region has trained and functional ASHAs, regular VHSND and visits
by the ANM, functional PHCs and SCs, wide coverage of the Janani Suraksha Yojana and Janani Shishu Suraksha
Karyakram. Overall the public health system is functional, efficient and service provision goes beyond Maternal
and Child Health (MCH) services.
In addition to aspects covered in Level-I and Level-II, the Community Action for Health process at this level will be based
on a broader definition of health – it will go beyond Maternal and Child Health and focus on educational components of
the services.
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II Institutional Structures
Section and Composition
The composition of committees at different levels is given below:
Table 1. Structure and composition of different committees
Structure
Composition
30% of total members to be elected representatives, belonging to the state legislative body
(MLAs/MLCs)
15% to be non-official members of district committees, by rotation from various districts of different
regions of the state
State Level
Planning &
Monitoring
Committee
20% members to be representatives from the state health NGO coalitions working on health rights,
involved in facilitating community based monitoring
25% members belong to the State Health Department. These would include the Secretary, Health
and Family Welfare; Commissioner, Health; relevant officials from the Directorate of Health Services
(including the NHM Mission Director) along with technical experts from the State Health System
Resource Centre / Planning cell
10% members to be officials of other related departments and programmes such as Women and Child
Development, Water and Sanitation and Rural Development.
Chairperson: One of the elected members (MLAs)
Executive Chairperson: Secretary, Health and Family Welfare
Secretary: One of the NGO/civil society representatives
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Guidelines for Programme Managers on Community Action for Health 2014 | 7
30% members to be representatives of the Zilla Parishad
25% members to be district health officials, including the District Health Officer /Chief Medical Officer
and Civil Surgeon or officials of equivalent designation
District
Level
Planning &
Monitoring
Committee
15% members to be non-official representatives of block committees
20% members to be representatives from NGOs/CBOs and people’s organisations working on health
rights and regularly involved in facilitating community based monitoring at other levels (PHC/block) in
the district
10% members to be representatives of Hospital Management Committees in the district
Chairperson: A Zilla Parishad representative
Executive Chairperson: CMO/CMHO/DHO or officer of an equivalent designation
Secretary: One of the NGO / CBO representatives
30% members to be representatives of the Block Panchayat Samiti (Adhyaksha/Adhyakshika of the
Block Panchayat Samiti or its members, with at least one woman
20% members to be non-official representatives from the PHC health committees in the block, with
annual rotation to enable representation from all PHCs over time
Block Level
Planning &
Monitoring
Committee
20% members to be representatives from NGOs/CBOs and people’s organisations working on
community health and health rights in the block, and involved in facilitating monitoring of health
services
20% members to be officials such as the Block Medical Officer, the Block Development Officer,
selected Medical Officers from PHCs of the block
10% members to be representatives of the CHC-level Rogi Kalyan Samiti
Chairperson: Block Panchayat Samiti representative
Executive Chairperson: Block Medical Officer
Secretary: One of the NGO/CBO representatives
30% members to be representatives of Panchayat Institutions (Panchayat Samiti members from the
PHC coverage area)
20% members to be non-official representatives from the village health committees
PHC
Planning &
Monitoring
Committee
20% members to be representatives from NGOs/CBOs and people’s organisations working on
community health and health rights in the area covered by the PHC
20% members to be health and nutrition care providers, including the Medical Officer – Primary Health
Centre and at least one ANM working in the PHC area
10% members to be from the PHC-level Rogi Kalyan Samiti
Chairperson: Panchayat representatives, preferably Panchayat Samiti member from the PHC coverage area
Executive Chairperson: Medical Officer of the PHC
Village
Health
Sanitation
Nutrition
Committee
Gram Panchayat members from the village
ASHA, Anganwadi Worker, ANM
Self Help Group Leader, Parent Teacher Association (PTA)/Mother Teacher Association (MTA)
Secretary, village representative of a community based organisation working in the village, user-group
representative
Chairperson: Panchayat member (preferably woman or SC/ST member)
Convenor: ASHA; where ASHA is not in position, it could be the Anganwadi worker of the village
Source: NRHM Framework for Implementation, 2005-2012
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8 | Guidelines for Programme Managers on Community Action for Health 2014
Table 2 - Roles and responsibilities of different stakeholders for community enquiry at different levels
Stakeholder
State ASHA/Community Process
Resource Centre/State Nodal NGO
District Community Mobiliser/District
Programme Manager/District Data
Assistant/District NGO
Block Medical Officer/Nodal Officer/
Block Community Mobiliser/ASHA
Facilitators/Block NGO
Village Health Sanitation Nutrition
Committee/Members of PRI /SHGs/
CBOs
Role & Responsibility
Adapt the formats for community enquiry and facility surveys based on
classification of levels (described in Section I under Key Features–Levels)
Translate the tool in local language
Identify and train a pool of state and district trainers
Organise trainings of district trainers
Orient district planning and monitoring committees
Support in collection, collation and analysis of data from District Hospital/
Sub District Hospital/Community Health Centre
Facilitate Jan Samwad
Ensure follow up action on issues/gaps identified
Collate block level plans and use that to inform the District Plan
Train VHSNC members
Support supervision to VHSNC & ASHA facilitators for preparation of
report cards for facility and village levels
Mentor VHSNCs during their monthly meetings
Orient block planning and monitoring committees
Support in data collection, collation and analysis
Facilitate Jan Samwad
Ensure follow up action on issues/gap identified
Collate village level plans to develop block level plan
Conduct community enquiry and facility surveys facilitated by ASHA/
ASHA Facilitator/NGO/CBO
Prepare report card
Share report card with the community and identify issues for redressal at
the PHC level.
Present denial of care/adverse outcome cases with service providers
Prepare village health plan based on the findings of the report card
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III The Community Action
Section for Health Tool
The community enquiry and facility assessment processes require the structured tool to be used on a bi-annual
basis. The tool is meant to enable community representatives understand service delivery standards, entitlements
and service guarantees envisaged under the National Health Mission (NHM). This, in turn, leads to an informed
interaction with health personnel on availability of staff, drugs, amenities, quality of services, and access to entitlements
and services. Service guarantees under the National Health Mission as well as additional guarantees provided by the states
are updated periodically and vary from one state to the other. It is critical to identify and list all guarantees within the
state and use the information to mobilise communities and adapt the tool for community and facility enquiry. The AGCA
Secretariat will work closely with the states in the identification and adaptation process.
The formats included in the Community Action for Health tool facilitate community members to collect and collate data on
a range of issues. Experiences from different states in utilising pre-designed tool for community monitoring are summarised
in Annexure I.
Components of the tool kit
There are two sets of formats—one for the Community and the other for the Health Facilities (See Table 3). The
community-level formats cover entitlements under maternal and child health, adolescent programme, general health
services in the village and ICDS. The facility formats cover services provided at different levels – the Sub Centre, Primary
Health Centre (PHC), Community Health Centre (CHC) and the Anganwadi Centre (AWC). The formats and details on how
they will be used are given in the companion User Manual for members of VHSNCs and PMCs at PHC, block and district
levels.
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10 | Guidelines for Programme Managers on Community Action for Health 2014
Table 3- The tool with formats and methodology for data collection at the community and facility level
Community-level formats
S. No. Format
Methodology Respondents
Number
Format
Number
1
Maternal
Individual
health services interview
Mothers who have
5 per village (3 from
Format No-1
delivered in the last six marginalised and 2 from general
months
population)
2
ASHA support Individual
services
interview
ASHA
All ASHAs in a village
Format No-2
3
Adolescent Focus Group
health services Discussion
In-school and Out- of-
school children of 11-19
year age group (8 per
1 per village
group). mixed group
Format No-3
4
Village health Focus Group
services
Discussion
A mixed group of 10-12
men and women
2 per village (one from
marginalised and one from the
general population)
Format No-4
5
Child health
services
Individual
interview
Mothers of children
aged 0-2 years
5 per village (3 from
marginalised and 2 from general
population)
Format No-5
6
ICDS services
Focus Group
Discussion
Mothers of children in
the age group of 0-6
years
1 per village (one more group
discussion to be conducted if
there is a marginalised group)
Format No-6
7
Anganwadi
Centre (AWC)
Individual
interview/
Observation
AWW
1 per AWC
Format No-7
Mid day
8
meal and
Focus Group
school health Discussion
programme
5-10 students (6-14
years)
1 per school
Format No-8
Facility-level formats
Individual
9 Sub Centre Interview/
ANM
Observation
1 per Sub Centre
Format No-9*
10
Primary Health
Centre (PHC)
Individual
interview/
Observation
Medical Officer
1 per PHC
Format No-
10*
Community Individual
11 Health Centre interview/
(CHC)
Observation
Senior medical staff
1 per CHC
Format No-11
12
Exit Interview Individual
at facility
interview
Patient/attendant
5 per facility—include at least Format No-12
three women
* As per the Guidelines for Community Processes 2013, Ministry of Health and Family Welfare, Government of India
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Guidelines for Programme Managers on Community Action for Health 2014 | 11
How to use the tool
The tool is a set of formats that comprise questions on various services and entitlements at the community and facility
levels. The community feedback on services is obtained through individual interviews and Focus Group Discussions.
The community level formats will be administered by VHSNC members, whereas the facility level formats will be
administered by members of the PMCs of the respective facility at each level. For each question, response is coded as
follows:
Good–Green
Average–Yellow
Poor–Red
While conducting individual interviews, the members of VHSNC/PMC will record by placing a tick mark against the
appropriate color box based on the response. In a group interview, members should be encouraged to decide collectively
on the response regarding performance. The rankings are validated in a larger community-level meeting.
The enquiry should be conducted on a bi-annual basis. The timing of the enquiry should preferably be synchronized with
the preparation of the Programme Implementation Plan (PIP) process. This would enable inputs from the CBMP/Community
Action for Health process to be incorporated into the PIP2.
Compilation of Village and Facility Level Report Card
The data collected through the process of such enquiry would be collated as follows:
Village Health Report Card (the outline is in Table 5)
Facility Report Card (the outline is in Table 6)
The collation of data will be done by VHSNC or Planning and Monitoring Committee members based on the number of
boxes of different colours that have been ticked. The scores derived from the formats for different services will be collated
and presented in a Report Card (see Table 5 & 6). The collation will be done on the basis of the criteria given in Table 4.
Table 4- Collation criteria
Criterion
Number of boxes ticked GREEN is more than 75%
Between 50 to 74% boxes have been tickmarked GREEN; Or
If number of GREEN boxes are less than 50%, but the total number of GREEN and YELLOW boxes
are more than those ticked RED
The total number of GREEN and YELLOW boxes are less than the number of RED
Final color
GREEN
YELLOW
RED
After the report card has been filled in for each village; these are collated as cumulative report cards at PHC, block and
district levels. A similar process is followed for facility report cards.
2The main rationale behind this is to have a balance between regular monitoring, planning and follow up activities that will sustain the community’s interest in the
process versus giving the system time to respond to the issues brought up by the community. The key issue is for the process to be timed in such a way that the
plans that emerge from the process are able to feed into the district and state processes of evolving PIPs.
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12 | Guidelines for Programme Managers on Community Action for Health 2014
Table 5- Village Health Report Card
S.No Sub -Tool/issue
1 Maternal health services
Antenatal care
Delivery
Post natal care
Family planning
Janani Suraksha Yojna (JSY) entitlement
Janani Shishu Suraksha Karyakram (JSSK)
2 Adolescent health services
3 ASHA support services
4 General health services
Quality of care
Disease surveillance
Curative services
Untied fund
5 Child health services
Immunisation
Childhood illness
6 ICDS services
Nutritional guarantees
Growth monitoring
Referral services
Other services
Participation of community
Discrimination
7 Mid-day meal & school health
Mid-day meal services
School health
8 Perception of ASHA functioning3
Good
Average
Poor
3It may be noted that perception of ASHA functioning will be captured from maternal health, adolescent health, general health and child health service formats.
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Guidelines for Programme Managers on Community Action for Health 2014 | 13
Table 6- Facility Report Card
S.No
1.
2.
3.
4.
Tool/issue
Community Health Centres (CHC)
Maternal health services
Family planning services
Curative services
Outreach services
Infrastructure
Availability of drugs and non-medical supplies
Human resources
Accountability
Maternal and Infant Death Review
Primary Health Centres (PHC)
Availability of infrastructure
Availability of staff
General services
Availability of medicines
Availability of curative services
Availability of reproductive and maternal health services
Child care & immunisation services
Laboratory & epidemic management services
Sub Centre
Availability of staff
Availability of infrastructure
Availability of services
Quality of Care (Exit interview)
Good
Average
Poor
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IV Sharing of Report Cards
Section and Follow-up Process
After the preparation of community and facility report cards, a meeting is to be organised by the VHSNC at the Gram
Sabha level. All residents, including members of community based organisations and Self Help Groups, the ASHA,
ANM and AWW need to be present. The VHSNC Chairperson will share the findings of the report cards, discuss
gaps areas and identify the steps for corrective action. This is then formulated as a plan. A draft template for the plan is
provided in Table 7.
Plan for follow up:
The locally developed action plan needs to be followed up at the village level. This can be done during the monthly
meeting of the VHSNC.
The issues not resolved at the village level would be taken up at the PHC level for resolution and included in the block
level plan.
Table 7- Planning Sheet
Gaps (marked as Red &
Yellow in Report card)
a.
b.
C
Reasons for Possible
gaps
Solution
Responsibility Timeline
Support
Required
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Guidelines for Programme Managers on Community Action for Health 2014 | 15
Some issues can be solved at the local level. However, some cannot be
solved locally and need referral to the next level. For example-
(a) Specific gaps in local service delivery – Issues such as irregular visits
by the ANM, limited package of services at VHND, not reaching all
women and children in the village, irregular availability of food at the
AWC, etc, can be solved at the field level itself.
(b) Problems specific to infrastructure /drug /equipment related issues
like sub centres in poor condition, BP apparatus not functional would
entail minor funding, which can be sanctioned from the untied funds.
However, in case of major amounts involved such as for repair of
building, allocation of drugs, the issue could be put into the Programme
Implementation Plan.
Once the village level
sharing meeting has been
held, the next step is to
share the PHC and block
report cards (cumulative
village report card and
facility report card) at the
Jan Samwad that is held at
the block level.
Once the village level sharing meeting has been held, the next step is to share the PHC and block report cards (cumulative
village report card and facility report card) at the Jan Samwad that is organised at the block level. Details about how to
conduct a Jan Samwad are provided in the User Manual.
Feedback Mechanisms
Based on the feedback and information obtained from the report card, corrective measures can be taken. The following
steps need to be followed –
Sharing of the report cards and follow up action at various forums like meetings of VHSNCs, Gram Sabha, Planning and
Monitoring Committees at PHC, block and district levels, Rogi Kalyan Samities and District Health Society.
Triangulation of data, generated through this process, with HMIS and survey data by programme managers at block
and district levels.
Representation of departments such as Nutrition, Water and Sanitation, and Education in the PHC, block and district-
level planning and monitoring committees as the tool also captures information related to their services.
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V
Section Capacity Building
The capacity building plan will be developed based on the structures that are finalised at the state level for rolling out
Community Action for Health. Training will be conducted at multiple levels.
A team of state trainers will be trained at the state level by the national AGCA secretariat.
A team of trainers at the district level, drawn from the block level (three for each block), will be identified and trained
by the state-level trainers
The district-level trainers would conduct trainings for Block Community Mobiliser (BCM), ASHA facilitators and selected
ASHAs at the sub district level.
The basic level of
implementation,
would be the
systematic application
of the public service
monitoring tool
which is a part of the
Community Processes
Guidelines
The district trainers would then conduct the training for a team of five
members from every VHSNC supported by the BCM, ASHA facilitator (AF)
and ASHA.
State and district trainers will be trained at the state training sites designated
for ASHA and VHSNC training. Training for BCM, AF and ASHA would take
place at sub district/ block levels. State and district trainers can be drawn from
NGOs. The training can also be undertaken in partnership with credible NGOs.
There is a great diversity in states regarding the training of members of
VHSNCs and PMCs, and support systems including partnerships with NGOs.
The basic level of implementation be would be the systematic application
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Guidelines for Programme Managers on Community Action for Health 2014 | 17
of the public service monitoring tool which is part of the Community Processes Guidelines. This tool is meant to be
administered by the VHSNC with support from the ASHA and ASHA Facilitator. The application of the public service
monitoring tool will serve as a learning platform for communities and the system. As states progressively strengthen the
Community Action for Health component, they can include appropriate formats as listed in Table 3.
In remote and inaccessible areas with poor public health facilities, insufficient health workforce, poor training for ASHAs
and VHSNCs, no credible NGOs/CBOs, fledging support systems for community processes, and evidence that entitlements
and service guarantees are sporadically met, the Community Action for Health mechanisms would need to be gradually
introduced. At this level, the purpose of Community Action for Health would be to build demand for services, and highlight
critical gaps in their availability, so that the system can respond and take corrective action.
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18 | Guidelines for Programme Managers on Community Action for Health 2014
Annexure I
Some Examples of Community Action Programmes
Community Action for Health, Tamil Nadu
In the pilot phase, the Community Action for Health programme in Tamil Nadu was implemented by SOCHARA (Society for
Community Health Awareness, Research and Action), and covered 446 panchayats of 14 blocks in five districts.
VHSNCs members were trained on the community enquiry tool. The information collected through the monitoring process
was collated into a Panchayat-level Report Card and presented to the Gram Panchayat. VHSNC members monitored
the facilities available at the Health Sub Centres and the Primary Health Centre once in six months. In addition, an exit
interview was held at the Primary Health Centre. Patients coming to the facility were asked to put in a coloured token
based on their level of satisfaction with the services – a green coloured token for satisfactory services and a red coloured
one for unsatisfactory services. These were then collated in the presence of elected representatives and block/district level
health officials, and the report presented to the medical officer in charge of the facility. Patients were also asked to write
their feedback on pieces of paper that were used as a basis for planning improvements in the facility. In some districts,
this exercise extended to cover taluk-level hospitals and the district hospital too. On Panchayat Health Planning Day
(once every six months), the Panchayat Report Card was presented to the president, panchayat ward members and other
community members. Health care providers, including the Village Health Nurse and PHC medical officer, were invited to this
meeting. A discussion based on the coloured grades awarded to various services was held. The objective of the planning
exercise was “to change Red to Green in six months”. Out of the list of areas identified as needing improvement, two or
three were chosen in consultation with everyone present, and plans were made to find solutions for the issues. These plans
were filled into a format that spells out responsibilities and time frame.
Swasth Panchayat Yojana, Chhattisgarh
Under the Swasth Panchayat Yojana, monitoring of the village health status is done along a pre determined set of 29
questions, and a birth and death register is maintained. Based on this monitoring, two to three issues are identified for
action every month, their causes analysed, possible solutions planned along with clear delineation of responsibilities and
time frame. In addition, approximately 12-16 VHSNCs are brought together under one cluster and they meet once every
month. This space is used to identify problems that are common to several villages that may require coordinated action by
higher officials in various departments. In order to take the processes at the village and cluster level to the block, public
dialogues or Swasth Panchayat Sammelans are held annually at the
block level.
The State Health Resource Centre (SHRC) also conducts annual surveys (Swasth Panchayat surveys) that assess the health
situation of each village and panchayat. The data is collected by Mitanin trainers on 10 indicators through house-to-
house surveys at the hamlet level and hamlet-level meetings. In order to reduce bias, the Mitanin trainers do not carry
out the survey in their own district. This information is filled into a panchayat-level score card that is then presented to
the Sarpanch of the panchayat. This enables the Sarpanch to identify specific aspects that need to be improved. In
addition, the hamlet-level data is centrally analysed to arrive at consolidated panchayat-level indicators and the
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Guidelines for Programme Managers on Community Action for Health 2014 | 19
composite panchayat-level Health and Human Development Index. Panchayats are then ranked block-wise based on
these indices and the top ranking panchayats are given cash awards to encourage good performance.
Community Based Planning and Monitoring Programme, Bihar
The Community Based Planning and Monitoring Programme (CBPM) is being implemented with support from the
State Health Society, Bihar, and in partnership with civil society organisations under the National Rural Health
Mission since May 2011. It covers 300 villages across five districts.
The Village Planning Monitoring Committee (VPMC) members monitor services provided on the Village Health
Sanitation and Nutrition Day (VHSND). In addition, a pre-designed tool has been used by the VPMC members
to monitor health services in specific pre-determined domains. This is collated into a report card at village and
panchayat levels to arrive at a colour code that grades services as good (green), average (yellow) and poor (red).
These report cards are then presented both at village and panchayat level meetings, and discussed with the
community for possible improvements. These community-level enquiries are supplemented by facility surveys that
assess the availability and quality of services at the sub health centre and primary health centre. In addition, as part
of increasing engagement between the communities and the public health system, Jan Samwads - facilitated public
dialogues between people, local governments and health care providers - are being held at block and PHc levels.
Monitoring of Maternity Homes, Karnataka
The Public Affairs Centre (PAC), Bengaluru has used innovative methods to monitor the quality of maternity services
in Bengaluru’s municipality-run health centres. In 2000, PAC undertook a Citizen Report Card survey of maternity
homes. The survey showed poor quality of services and a high degree of corruption. As a follow up, in 2009, PAC
along with its partner NGOs took up a repeat monitoring of the facilities to understand the current status of
services provided.
The first round of Citizen Report Cards in 2010 covered 12 maternity homes in Bengaluru municipal area and
included interviews with health care providers, users and the Board of Visitors (a forum of users). Data from the
above interactions was centrally entered, analysed and collated to form the Citizen Report Card. The findings were
then shared with the Bengaluru municipality authorities to advocate for change.
Following this, and based on interactions with users of these facilities, indicators for a Community Score Card were
developed. These Community Score Cards were filled in three maternity homes, as a group exercise with users and
the health care staff. The findings of the Community Score Cards were then discussed at an interface meeting that
brought together the staff of the maternity homes, higher authorities from the Bengaluru municipality and users of
the facility. This resulted in a discussion along with plans for action to improve the services.
Source: Excerpt from Unpublished Monograph -Community Action for Health Experiences, Learning and Challenges, Population
Foundation of India
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20 | Guidelines for Programme Managers on Community Action for Health 2014
Community Based Monitoring and Planning in Maharashtra
The Community Based Monitoring and Planning (CBMP) process was implemented in maharashtra as a pilot in five
districts during 2007-09. Currently, CBMP is being implemented in 13 districts, covering 37 blocks, 150 PHCs and 680
villages. Support for Advocacy and Training to Health Initiatives (SATHI) is the state nodal agency. About 25 civil society
organizations (CSOs) are involved collaboratively in implementing the CBMP.
Community feedback/assessment of health services are compiled through data collection and preparation of report cards.
The experience and feedback of community members are collected using specific tools– in-depth interview, focus group
discussion, case studies and review of records.
The report card has three colour codes on the basis of the status of implementation of various activities and delivery
of services. (Green - 75=100% activities completed or services delivered; Yellow - 50=74% activities completed or
services delivered; Red - 1=49% activities completed or services delivered).
Data is collated and analysed at different levels so as to present in the Citizen Report Card (prepared at village, sub-
centre and PHC levels).
Planning and monitoring committees send periodic reports to the committees above their level to ensure action on
issues which they cannot resolve.
For further information, please visit: http://www.nrhmcommunityaction.org/
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Advisory Group on Community Action (AGCA)
Secretariat
Population Foundation of India
B-28 Qutab Institutional Area,
New Delhi- 110 016, India
Telephone: + 91-11-43894100; Fax: +91-11-43894199
E-mail: info@populationfoundation.in
www.nrhmcommunityaction.org
National Health Mission
Ministry of Health and Family Welfare
Government of India
New Delhi