NRHM- ROLE OF NGO

INTRODUCTION

The NRHM Framework for Implementation encourages partnerships with Non-

Governmental Organizations to improve the effectiveness of implementation and to make
health services and facilities accountable to citizens. The Mission provides for collaborations
with the voluntary groups/organizations for advocacy, building capacity at all levels,
monitoring and evaluation, delivery of health services and working together with community-
based organizations. The NRHM implementation framework articulates the Mission
provision for about 5% of the total NRHM outlay as the resource allocation to the voluntary
sector. Such an allocation provides an opportunity to build NGO capacity and leverage
community linkages to develop/strengthen people's organization for more active participation
in enabling improved health outcomes especially for the poor and marginalized.

NGOs have played a major role in shaping the design of the NRHM and in championing its
implementation. They have consistently expressed eagerness to participate in strengthening
public health systems, instead of becoming parallel to it, but in the absence of clear
operational guidelines, many NGOs have not found enough space.

Therefore, it is imperative to revitalize the NGO-NRHM Partnership in the 12th Five Year
Plan keeping in mind the potential for broadening the scope of NGO involvement in NRHM
so as to accelerate the achievement of RCH and NRHM goals.

The Department of Family Welfare introduced the Mother NGO scheme in the Ninth Five
Year Plan (1997-2002) under the Reproductive and Child Health Programme. Under the
scheme, grants were sanctioned to NGOs in allocated districts called Mother NGOs
(MNGOs), which in turn issued grants to smaller NGOs called Field NGOs (FNGOs) in the
districts. The broad objectives of the MNGO scheme as outlined in the RCH programme
were:

 Addressing the gaps in information on RCH services in the project area.

 Building institutional capacity at the State, district/field level.
 Advocacy and awareness generation.
The Ministry of Health and Family Welfare has a NGO Division which was originally
responsible for implementing a programme for support to NGOs.

FRAMEWORK

The revised framework for the NGO guidelines proposes that the programme will have the
following components:

1. NGO Interventions under the RCH and the NRHM flexible pools funds.

2. Existing NGO Interventions under various programmes like RNTCP, NPCB, and NLEP
etc.

The first component would be administered through the NGO division. For the second
component, various programme divisions have formulated their own guidelines. They would
continue with its approved system of approval, selection, fund release and monitoring and
evaluation. In case of new emerging programmes like tobacco control, mental health, control
of cancer, diabetes cardiovascular diseases and stroke, guidelines may be developed by the
concerned programme divisions or the NGOs may be involved through the Mission Flexible
Pool. The NGO interventions under the RCH and NRHM flexible pools would report to the
NGO division while NGOs under the National Disease Control Programmes and others
would report to the respective programme divisions.

Principles of the Revised NGO guidelines:

The existing model of Mother NGOs supporting Field NGOs would no longer apply. Instead,
NGOs with the required level of competence would be selected to work at the
National/State/District/ levels respectively. Under the revised NGO guidelines, for some
activities entire district can be covered and for others the district can identify the deficient
blocks and prioritize the engagement of NGOs in those blocks.

Under the guidelines, the scope of work of the NGOs would move beyond reproductive and
child health to a more comprehensive approach which would include community level
interventions under NRHM, disease control programmes, and other emerging issues. NGOs
would be selected at the National/State/District/ levels according to their competence and
experience in the field of work expected to be performed by them. At the National level, an
Apex Resource Centre housed within the existing National Health Systems Resource Centre
would provide technical assistance to the States and the RRCs.
The guidelines envisage a greater decentralization to the State and district level, with the
Centre playing a policy and guidance role. State and District Health Societies will be required
to play a more active role. In order to facilitate better synergy and coordination between the
NGO and the department of health, there would be a designated NGO Coordinator at the
State and district level respectively.

There would be provision of one RRC per State to provide technical assistance and support
to the NGOs at the State/district level. In larger States (with more than 30 districts) there may
be two RRCs, while a group of smaller States/UTs could be covered by one RRC. At the
district level, the NGOs would be divided into two types based on function as follows:

➤ Field NGOs (FNGOs) which would carry out the activities like training and capacity
building, community monitoring, advocacy and community mobilization, planning, etc.

➤ Service NGOs (SNGOs) which would focus on service delivery especially in un-served
and underserved areas.

Role of NGOs:

Since health is State subject and decentralization is a priority, it is up to the States to

determine priority areas for partnerships with NGOs according to the local context and the
State's priorities. Further, different NGOs have a range of capabilities and areas of expertise
and thus the areas for NGO involvement also need to be broad based. A substantial proportion
of the support from NGOs would be for capacity building, and support for community
processes (the VHSNC, the ASHA programme, public participation in the RKS, public
participation in district planning and in community monitoring). The element of community
monitoring could be further expanded in areas such as improving data quality in HMIS and
MCTS, measuring availability of drugs, and monitoring support to JSSK.

Community monitoring which emerged as a viable strategy in the Eleventh Plan needs to be
built upon in the Twelfth Plan and scaled up. VHSNCs should develop the capacity to
undertake

monitoring. This is one area where NGOs can play an important role in capacity building and
support.

Some broad areas (indicative but not exhaustive) suggested for NGO involvement are:
1. Training of district, sub-district and field level personnel

2. Community Monitoring and Social Audits

3. Capacity Building and Training of community level bodies like PRIs, VHSNCS, RKS
members and SHGs etc.

4. Data analysis based on HMIS

5. Service delivery in un-served and underserved areas*

6. Community Mobilization and Advocacy

Key theme areas where NGOs can be effectively utilized are:

 Maternal Health
 Child Health - including Immunization and Newborn Care
 Sexual and Reproductive Health
 Adolescent health including School Health
 Malnutrition including anemia
 Communicable and Non Communicable diseases
 Declining sex ratio
 Inter sectoral Convergence

The roles and theme areas for NGO involvement are illustrative and the States may further
determine and define the role of NGOs as per their priorities. Thus, a State may engage a
consortium of NGOs to carry out various projects under NRHM in the State. While reflecting
the fund allocation for NGOs in the State PIP the role of the NGOs would also be defined by
the State.

Duration of a Project assigned to an NGO:

Duration of the project may be decided by the State based on the activity for which the NGO
is recruited. However, in case of Service NGOs the average project duration may be fixed for
3 years.

Monitoring, Evaluation and Reporting:

A monitoring and evaluation system is essential for effective, participatory and periodic
monitoring based on local situation and priorities. A system of periodic reporting, review, and
ongoing monitoring will be instituted for tracking NGO performance. This will enable the
NGOs to make mid-course corrections, if required, based on the findings of the review. It will
also ensure that the State's priorities and the goals of the project are being met. The
monitoring and evaluation system proposed is as follows:

A monitoring and evaluation system is essential for effective, participatory and periodic
monitoring based on local situation and priorities. A system of periodic reporting, review, and
ongoing monitoring will be instituted for tracking NGO performance. This will enable the
NGOs to make mid-course corrections, if required, based on the findings of the review. It will
also ensure that the State's priorities and the goals of the project are being met. The
monitoring and evaluation system proposed is as follows:

The performance of the NGO would be monitored on the basis of agreed indicators, which
will be clearly mentioned in the MoU signed between the NGO and the State government.
These indicators would be relevant and specific to the work undertaken by the NGO and not
be long- term impact indicators like reduction in IMR, MMR etc. that have multiple factors
affecting them. The agreement/MoU with the NGO should elaborate on the resources
extended by the districts, State and RRC.

The NGO will submit a detailed report of its activities in the prescribed format (financial and
physical) to the Chief Medical Officer (CMO) of the district through the designated NGO
Coordinator every month with a copy endorsed to the RRC, The NGO Coordinator/CMO
would give their suggestions and guidance after examining the report.

Every quarter, a review meeting will be held at the district involving NGOs, CMO, District
NGO Coordinator, the RRC and the Block Medical Officer. The District Collector will chair
these review meetings. At the meeting, the NGO will report on progress as well as constraints
faced in the field. These meetings will serve as a forum for discussing any problems faced by
the NGOs in the project implementation, the inputs and support required from the
government machinery etc. The District level meeting should be held before or in the
beginning of the financial year to sanction the projects approved for NGO involvement in the
District Health Action Plan (DHAP). The first tranche of funds should be released to the
NGOs by 31 ^ (st) May. The review of the NGO performance could be as per the following
schedule:

First review: in October

Second review: in January

The State and the Centre could commission external evaluations as and when required to
understand and improve the programme. The State NGO Coordinator would be empowered
to conduct external evaluation of upto 5% NGOs to be selected on a random basis.

It is imperative that the State Health Department should engage with NGOs for effective and
efficient service delivery and outreach. States will identify 2-3 Nodal NGOs forming a State
level committee with government officials to identify key health issues for NGO engagement
based on health indicators, community needs and State's priorities. There should be provision
for flexible support to NGOs in special cases like LWE affected districts, disaster prone areas
etc.

The proposed structure is a 3-tier system scaling up from the district to the national level.
The structure, function and constituency at each tier are given in the following paragraphs.
One of the important points of the structure is that it aims at obliterating the demarcation
between the MNGOs and FNGOs that so far was restricting NGO capacities to reach out for a
wider role in the health sector.

National Level:

Apex Resource Centre

The current NGO Division is the National Programme Management Unit with the role of
policy guidance and providing technical support to the programme. Fund allocation and
release to RRCs is done through the NGO division, which would also coordinate with the
State NGO cells.

While the engagement with NGOs will be operationalized in a decentralized manner, the
Centre may offer some direct grants to upto five national level NGOs for innovative projects.
5% of the funds allocated for partnerships with NGOs will be retained at the National level
with the NGO division for funding RRCs and the innovative projects. The NGO Division will
also perform the following functions:

 Coordination with various divisions for implementation

  Capacity building of States for implementation
 Monitoring, Evaluation of the NGO performance
 Providing technical support on NGO matters to the States
 Release of funds to the RRCs and their performance evaluation

Apex Resource Centre (ARC)

The NGOs must be given technical support in order to build their capacity in areas that are
not their areas of expertise. Instead of establishing a separate technical body it is proposed to
utilize the services of the existing National Health Systems Resource Centre (NHSRC). The
Apex Resource Centre would function as the technical arm of the NGO Division and would
be housed within the NHSRC for providing technical support to NGOs, coordinate and
support country wide NGO assisted interventions, provide support, develop capacity and
monitor performance of NGOs. The Apex Resource Centre will report to the Joint Secretary
in charge of the NGO Division at the Ministry of Health & Family Welfare. The concerned
technical divisions in NHSRC would be utilized for mentoring and training of NGOs and
RRCs. In addition, the expertise of the NIHFW would also be employed for training and
capacity building for which necessary funds may be provided by the NGO Division.

State Level

The organizational structure proposed at the State level is as follows:

 State Selection Committee

 Regional Resource Centre (RRC)

State Selection Committee:

The State selection committee would select the institutions to undertake external evaluation
of NGOs. In addition, the committee would also select NGOs at the State level for
undertaking state level activities including training of master trainers and for carrying out
innovative projects in the State. The committee will be constituted by:

 State Health Secretary

 Mission Director NRHM
  Director SIHFW
 Representatives of two State level NGOs nominated by the State Health Secretary
 State NGO Coordinator
 RRC Project Director
 Regional Director of MoHFW
 Representative of the MoHFW - from the NGO division

The roles and responsibilities of the State Selection Committee would also include:

 Overall guidance to the NGO programme under NRHM in the State

 Review of performance of State and District level NGOs
 Review the work of the RRC
 Ensure regular Monitoring and Evaluation of the NGO programme.
 Internal and external evaluation after completion of one year
 Share views and experiences with all stakeholders in the State and National advisory
group

District NGO Committee:

The District Health Society would constitute a committee called District NGO Committee.
This Committee will be responsible for selection of NGOs in the district. The members of the
committee would include:

 District Collector or his nominee

 CMO of the District
 ICHC in-charge
 District Social Welfare Officer (incharge of WCD)
 Representative of the RRC
 District Programme Manager
 District NGO Coordinator will be the Member Secretary
 State NGO Coordinator may be included as a special invitee.

Functions of the District NGO Committee:

Representative of the RRC

District Programme Manager

District NGO Coordinator will be the Member Secretary

State NGO Coordinator may be included as a special invitee.

Functions of the District NGO Committee:

 Selects district level NGOs

 Facilitate the signing of MoU between the NGO and the District Health Society
 Undertakes review meetings to assess performance of NGOs
 Facilitates training programmes by NGOs
 Keep the State Health Society and NGO Division, Gol informed about the selection
and release of funds to NGO.

Selection of NGOs:

NGOs would be selected at National, State and District level, depending on its area of
operation. Those NGOs which are already functioning under NRHM or those that have
functioned satisfactorily in the past would be preferred for selection.

At the National level, the NGO Division would be involved in the selection of the Regional
Resource Centres as well as the NGOs for national level innovative projects.

Criterion for selection:

Selection process of NGOs should be a 2 stage bid model NGOs should fulfill the following
eligibility criteria:

1. Registration:

NGO should be registered under the Societies Registration Act/Indian Trust Actv Indian
Religious and Charitable Act Companies Act or the State counterparts of such acts for more
than three years.

2. Experience:

At least 10 years’ experience for national level projects, 5 years for State level projects and 3
years for district level projects in the sector and/or in the commensal social sector is
education, vows community dualization health service micro-planning Clo segment.

3. Financial:
Annual turnover of at least 50 lakh for awarding national level, Rs 25 lakh for State Level
and Rs 10 lakh for district level projects

The NGO should have good financial stability, having infrastructure in shape of land,
building or corpus fund amounting to Rs 20/10/2.5 lakh for NGOs applying for projects at the
National/State/District level respectively in the name of the organization.

Procedures for selection:

The District Health Society shall be the authority, which would select and appoint NGOs at
the district and sub-district level. The district health society shall observe the following
guidelines for appointing NGOs:

The DHS will initiate the process for NGO selection through a process of open
advertisement in 2 leading newspapers one in English and the other in the regional language.
The district NGO Coordinator will conduct the desk review and inform the applicants about
the status of their applications. The names of the selected NGOs would also be displayed on
the website of the State/District Health Department.

The DHS will initiate the process for NGO selection through a process of op advertisement
in 2 leading newspapers one in English and the other in the regional language The district
NGO Coordinator will conduct the desk review and inform the applicants about th status of
their applications. The names of the selected NGOs would also be displayed on the website of
the State/District Health Department.

The DHS would enter into a MoU with the NGO, which would detail the key roles and
responsibilities of each. These MoUs would be subject to central review and be the basis of
audit and programme monitoring. The whole selection process should normally take 60 days.
The period of appointment of the NGO would be based on the project duration which would
vary depending on the nature of the project. Service NGOs would ordinarily be appointed for
a period of three years. The project would be evaluated bi-annually and based on the
evaluation the district or State health society would recommend further release of grant to the
NGO or its discontinuation.

Similar selection procedure would be followed for selection of NGOs at the State level with
the State Health Society as the selecting authority.
After the selection, the NGO would be given orientation training of three days duration by
the RRC where its duties, responsibilities, manner of reporting and performance indicators
etc. would be explained. For the training the expertise of the NHSRC may also be utilized
where needed.