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Are village health sanitation and nutrition committees fulfilling their roles for decentralised health planning and action? A mixed methods study from rural eastern India

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Background: In India, Village Health Sanitation and Nutrition Committees (VHSNCs) are participatory community health forums, but there is little information about their composition, functioning and effectiveness. Our study examined VHSNCs as enablers of participatory action for community health in two rural districts in two states of eastern India - West Singhbhum in Jharkhand and Kendujhar, in Odisha. Methods: We conducted a cross-sectional survey of 169 VHSNCs and ten qualitative focus group discussions with purposively selected better and poorer performing committees, across the two states. We analysed the quantitative data using descriptive statistics and the qualitative data using a Framework approach. Results: We found that VHSNCs comprised equitable representation from vulnerable groups when they were formed. More than 75 % members were women. Almost all members belonged to socially disadvantaged classes. Less than 1 % members had received any training. Supervision of committees by district or block officials was rare. Their work focused largely on strengthening village sanitation, conducting health awareness activities, and supporting medical treatment for ill or malnourished children and pregnant mothers. In reality, 62 % committees monitored community health workers, 6.5 % checked sub-centres and 2.4 % monitored drug availability with community health workers. Virtually none monitored data on malnutrition. Community health and nutrition workers acted as conveners and record keepers. Links with the community involved awareness generation and community monitoring of VHSNC activities. Key challenges included irregular meetings, members' limited understanding of their roles and responsibilities, restrictions on planning and fund utilisation, and weak linkages with the broader health system. Conclusions: Our study suggests that VHSNCs perform few of their specified functions for decentralized planning and action. If VHSNCs are to be instrumental in improving community health, sanitation and nutrition, they need education, mobilisation and monitoring for formal links with the wider health system.
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R E S E A R C H A R T I C L E Open Access
Are village health sanitation and nutrition
committees fulfilling their roles for
decentralised health planning and action?
A mixed methods study from rural eastern
India
Aradhana Srivastava
1
, Rajkumar Gope
2
, Nirmala Nair
2
, Shibanand Rath
2
, Suchitra Rath
2
, Rajesh Sinha
2
,
Prabas Sahoo
1
, Pavitra Mohan Biswal
2
, Vijay Singh
2
, Vikash Nath
2
, HPS Sachdev
3
, Jolene Skordis-Worrall
4
,
Hassan Haghparast-Bidgoli
4
, Anthony Costello
4
, Audrey Prost
4
and Sanghita Bhattacharyya
1*
Abstract
Background: In India, Village Health Sanitation and Nutrition Committees (VHSNCs) are participatory community
health forums, but there is little information about their composition, functioning and effectiveness. Our study
examined VHSNCs as enablers of participatory action for community health in two rural districts in two states of
eastern India West Singhbhum in Jharkhand and Kendujhar, in Odisha.
Methods: We conducted a cross-sectional survey of 169 VHSNCs and ten qualitative focus group discussions with
purposively selected better and poorer performing committees, across the two states. We analysed the quantitative
data using descriptive statistics and the qualitative data using a Framework approach.
Results: We found that VHSNCs comprised equitable representation from vulnerable groups when they were
formed. More than 75 % members were women. Almost all members belonged to socially disadvantaged classes.
Less than 1 % members had received any training. Supervision of committees by district or block officials was rare.
Their work focused largely on strengthening village sanitation, conducting health awareness activities, and
supporting medical treatment for ill or malnourished children and pregnant mothers. In reality, 62 % committees
monitored community health workers, 6.5 % checked sub-centres and 2.4 % monitored drug availability with
community health workers. Virtually none monitored data on malnutrition. Community health and nutrition workers
acted as conveners and record keepers. Links with the community involved awareness generation and community
monitoring of VHSNC activities. Key challenges included irregular meetings, memberslimited understanding of
their roles and responsibilities, restrictions on planning and fund utilisation, and weak linkages with the broader
health system.
Conclusions: Our study suggests that VHSNCs perform few of their specified functions for decentralized planning
and action. If VHSNCs are to be instrumental in improving community health, sanitation and nutrition, they need
education, mobilisation and monitoring for formal links with the wider health system.
Keywords: Village health sanitation and nutrition committee, Community participation, Decentralized governance,
Planning, India
* Correspondence: sanghita@phfi.org
1
Public Health Foundation of India, Plot no. 47, Sector 44 Institutional Area,
Gurgaon, 122002 New Delhi, Haryana, India
Full list of author information is available at the end of the article
© 2016 Srivastava et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Srivastava et al. BMC Public Health (2016) 16:59
DOI 10.1186/s12889-016-2699-4
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
Strategies to strengthen community participation in
health vary greatly [1]. Many, however, involve commu-
nities prioritizing health needs and participating in the
design and monitoring of health services [15]. After
the 1978 Alma Ata Declaration, several countries includ-
ing Cuba, Tanzania, Zambia, the Philippines and India
created village-level health committees to fulfil these
roles [2, 68].
India has a long history of decentralised governance
and involvement of village committees in health plan-
ning. The 1946 Bhore Committee report suggested the
formation of village health committees to enhance com-
munity cooperationwith health authorities and address
local health issues [9]. Village health committees were
eventually implemented in India as part of the revival of
primary health care in the 1980s, to supervise local
health activities with the involvement of community
health workers [10].
In 2005 the National Rural Health Mission (NRHM)
programme brought sweeping changes to Indias health
system, including greater funding and decentralised
planning to improve the availability and quality of health
services, especially for the rural poor. The NRHM con-
ceptualized the Village Health and Sanitation Committee
(VHSC) as responsible for village-level health planning
and monitoring, formed within the overall framework of
the Gram Panchayat (village council), in which women,
village members from vulnerable groups and minority
communities should be adequately represented [11].
These VHSCs were tasked with preparing village-level
health and sanitation improvement plans based on local
priorities, and were given an untied fund of Indian Ru-
pees (INR) 10,000 (about US$ 161) per village annually
to undertake planned activities. In 2011, VHSCs were
renamed Village Health, Sanitation and Nutrition Com-
mittees(VHSNCs), to expand their role to address nu-
trition [12]. Committees are now required to maintain
data on the nutritional status of women and children,
refer severely malnourished children to rehabilitation
centres, prepare the nutritional components of the
village health plan, and educate community members
on nutritional issues [13]. Committees are also asked
to supervise Anganwadi Centres (AWCs), which are
village-level nutrition and pre-school education cen-
tres, and to monitor the Village Health and Nutrition
Day (VHND), a monthly event when midwives administer
immunisation, antenatal care and provide counselling
on recommended maternal and child health practices.
[12, 13]. The current strategy envisions VHSNCs as
peoples organisations for intersectoral planning and
action to address the social determinants of health,
and increase peoples utilisation of public health ser-
vices [14].
Little research exists on these committees, their
composition, functioning and effectiveness. Most
studies have used only qualitative methods to ex-
plore their functioning [1517], use of funds[1820]
and limitations [21]. One intervention study evalu-
ated a capacity building intervention to strengthen
VHSNCs in two districts of Karnataka, southern
India [22].
We aimed to understand the current structure and
functioning of VHSNCs for decentralised health plan-
ning and community action in health, nutrition and
sanitation in rural, underserved areas of India. We
also looked at factors that affected the functioning of
VHSNCs.
Methods
The study was nested within a cluster-randomised
controlled trial testing an intervention involving a
community-based worker focused on improving growth
in children under two, in two rural districts of eastern
India [23]. Strengthening of VHSNCs through a cycle of
six quarterly meetings over two years is being conducted
in both intervention and control arms as a minimum
common service that is sustainable beyond the trial
period, with no additional cost to local health services.
This data reported in this paper were collected as part of
the baseline study of VHSNCs, conducted between
December 2013 and February 2014.
Study population
The study was conducted in the districts of West
Singhbhum (Jharkhand) and Kendujhar (Odisha). Both
Jharkhand and Odisha are largely rural, with signifi-
cant tribal populations. Table 1 describes common
socio-demographic indicators for these two states.
Both are high focusstates, prioritised by the
National Health Mission. The two study districts have
a combined population of 3.3 million. Over 80 % of
their population lives in rural areas, and female liter-
acy rates in West Singhbhum and Kendujhar are 47
% and 58.7 %, respectively [24]. Over 40 % of resi-
dents in both districts are from Adivasi (meaning ori-
ginal inhabitant) communities, often referred to as
Scheduled Tribes. The two districts are representative
of other tribal-dominant districts and high-focus
states of India, and findings from these areas may
also be relevant to other low and middle-income
countries that have sought to support community-
based health planning and action in low literacy
contexts. The study area includes 120 geographical
clusters covering an estimated population of 121,531
across the two districts. Health services at the village
level are provided by three community health workers
(CHWs):
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an Anganwadi worker (AWW), who provides
supplementary nutrition to pregnant women,
lactating mothers and children aged three to six
years;
An Accredited Social Health Activist (ASHA), who
helps community members access essential health
services and promotes institutional deliveries; and
An Auxiliary Nurse Midwife (ANM), who provides
immunisations, essential medicines and antenatal
care.
Study design
The study, using a mixed methods design, involved two
phases of data collection [25]. In the first phase we con-
ducted a cross-sectional quantitative survey of all 169
VHSNCs in the study area (91 in West Singhbhum,
Jharkhand, and 78 in Kendujhar, Odisha), in order to ob-
tain information on their composition, training of mem-
bers, fund availability and activities. We then conducted
ten focus group discussions (FGDs) with VHSNC mem-
bers to gain an in-depth understanding of membersper-
ception of their roles and functions, levels of participation
in planning and activities, and recommendations for im-
proving the committeesfunctioning. Qualitative data was
collected to explore in-depth the areas covered by quanti-
tative data collection. In the study we first present the
quantitative finding and then utilize the qualitative data to
analyse the particular aspect in further detail.
In order to guide the design of quantitative and quali-
tative data collection tools, as well as data analysis, we
used a conceptual framework for community participa-
tion in health and described the VHSNC as an enabling
mechanism linking the community, community health
workers and the health administration (Fig. 1). Listed
with each element are the factors that influence the
VHNSCseffectiveness. Our conceptual framework was
adapted from the health governance framework of Brin-
kerhoff and Bossert [26] and the framework for the de-
terminants of health facility committee performance
offered by McCoy et al. [27]. Four main elements are
depicted in relation to the Indian context:
1) The VHSNC is conceptualized as a platform to
foster community participation in health. In order
for this to happen, members need to be clear about
their roles and the committees functions, mandate
and authority. They also need to have the required
capabilities and resources, and must put in place
accountability mechanisms.
2) Health administration provides guidelines, resources,
capacity building and supportive supervision to the
committee. The health administrations relationship
with VHSNCs is influenced by the attitude,
perception and skills of staff in the health system, as
well as the availability of resources.
3) Community health workers, who are members of
the VHSNC, facilitate its functioning, and are in
turn monitored and supported by the committee in
performing their functions in the village. Their
attitudes, perceptions, knowledge and skills also
influence their effectiveness.
4) The community, who is the primary beneficiary of
the committees activities, participates in planning
and implementation and also monitors the
committees performance. The community is also
the recipient of mobilisation and awareness
generating activities carried out by the VHSNC.
Links between the VHSNC and community are
influenced by the overall socio-political, cultural and
economic context.
Based on a typology of community participation in
health programmes, we situated VHSNCs within the
community developmentor empowermentapproach,
in which health is defined as a human condition and
participation as the planning and management of health
activities by the community using professionals as re-
sources and facilitators [28, 29]. Community participa-
tion is classified on the basis of how people participate,
whether as beneficiaries, in conducting programme ac-
tivities, in implementing health programmes, in moni-
toring and evaluating programmes, or in planning and
managing health programmes [29].
Quantitative methods: cross-sectional survey
The purpose of the survey that covered all 169 VHSNCs
in the study area was to understand VHNSCs formation
Table 1 Jharkhand and Odisha: demographic and health
indicators
Indicators Odisha Jharkhand India
% rural population
a
83 76 69
% tribal population
a
23 26 9
Female literacy rate
a
64 56 66
Infant Mortality Rate
b
53 38 42
Maternal Mortality Ratio
c
235 219 178
% institutional deliveries
d
76 40 73
% children aged 1223 months
fully immunized
d
60 60 67
% children under five who are stunted
e
45 50 48
% households covered by improved
sanitation facility
e
16 15 31
a
Census of India 2011
b
SRS Bulletin, Oct 2013
c
SRS estimates 201012
d
Annual Health Survey, 201213 (Odisha and Jharkhand); Coverage Evaluation
Survey 200910 (India)
e
DLHS-3, 200708
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and composition, meeting frequency, supervisory
mechanisms and activities. Survey respondents were
multiple VHSNC members including ASHAs, AWWs,
Presidents, Treasurers, Ward members and other mem-
bers. The study team met with the ASHA and asked her
to identify other committee members whom the team
then contacted for the survey. All members agreed to par-
ticipate in the survey. The study field team met with re-
spondents by appointment. They explained the study
objectives and purpose of data collection, and sought ver-
bal consent for collecting the data. Data were collected
using a structured questionnaire about each VHSNCs
composition, the quantity and type of training received,
receipt of supportive supervision, untied fund utilisation,
and activities related to maternal, newborn, child and nu-
trition services in the last 12 months. Consensus answers
to all questions were noted in the responses. The ques-
tionnaire was translated into the local or indigenous lan-
guages spoken in the study areas; Hindi, Oriya and Ho.
Information from the survey was also supplemented and
verified wherever possible by examining VHSNC records,
such as the meeting and expenditure registers. The survey
data were entered in Microsoft-Excel. We examined
the data for completeness and accuracy using range
checks and frequencies, and analysed it using descrip-
tive statistics.
Qualitative methods
Focus group discussions aimed to gain information
about VHSNCs composition; membersperception of
the committees role and responsibilities; CHWs roles in
the committee; the frequency of meetings, attendance
and issues discussed; activities conducted; and record
keeping systems. Members were also asked about the
challenges and facilitators in VHSNC functioning. Using
the cross-sectional survey data, we prepared a list of bet-
ter and comparatively poorer performing VHSNCs based
on the regularity of meetings and expenditure of com-
mittee funds (better performing committees met with
greater regularity and were able to utilize a higher pro-
portion of their funds as compared to poorer performing
ones). VHSNCs for the FGDs were selected purposively
from this list to include relatively better or poorer func-
tioning ones. Each FGD included between eight and 10
VHSNC members. The details of VHSNC members in
the selected committees were already available from the
quantitative survey. The study team visited the selected
villages, informed all members and invited them for the
Enabling mechanism (VHSNC)
-Clarity in roles & functions
-Clarity on mandate & authority
-Accountability arrangements
-Capabilities & resources
Health Administration
-Attitudes and perceptions
-Skills
-Resources
Community
-Socio-political
factors
-Socio-cultural
factors
-Socio-economic
factors
Community Health Workers (CHW)
-Attitudes and perceptions
-Skills, efficiency
- Responsiveness to
community needs
- Monitoring by community
Guidelines,
resources,
training,
supervision
- Facilitation by CHW
- Oversight & support
by VHSNC
Fig. 1 Conceptual Framework for enabling community participation in health through VHSNCs. Note: Adapted from the health governance
framework of Brinkerhoff and Bossert (2008)
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FGD. The discussion was held once there were eight or
more participants. Care was taken to ensure participa-
tion of key office bearers, including two community
health workers (ASHA and AWW) and the village head-
man, who was also often the President or Secretary of
the committee. We developed semi-structured topic
guides with open-ended questions to guide the FGDs,
using our conceptual framework and the official guide-
lines relating to VHSNC structure and functions.
Trained facilitators with knowledge of local languages
(Ho and Oriya) carried out the FGDs in village meeting
places. Each facilitator was accompanied by a researcher
who noted important discussion points and helped re-
focus the discussion on to the guide when required. Fa-
cilitators explained the objectives of the study, read an
informed consent sheet and requested written consent
from participants. Facilitator also encouraged all partici-
pants to join the discussion, restraining dominant and
encouraging quieter participants. Differences in partici-
pation across gender and ethnicity were not significant
as most groups were homogenous consisting mostly of
women and of tribal and vulnerable social caste groups.
Each FGD lasted between 50 and 60 minutes. Discussion
of other relevant issues that emerged was also encour-
aged. At the end of each FGD, the researchers com-
pleted a section on notes and observations, intended to
capture information on any challenges in conducting the
FGD, the ability of respondents to speak freely, and any
other relevant observations. All FGDs were recorded
using a digital voice recorder and transcribed by a re-
searcher in the local language before translation into
English.
The analysis was based on the Framework approach
[30]. Three levels of thematic codes were developed and
applied to the data. Initially one researcher listed a priori
themes based on the FGD guide. Following this, four re-
searchers from the study team jointly identified a set of
emerging themes from the transcripts. Finally a third
layer of themes was developed, based on synthesis and
cross-comparison of data from different groups of re-
spondents in the two study states. Atlas TI software was
used to systematically review and code the data. In order
to triangulate findings from the quantitative survey and
qualitative discussions, we present these results together.
Ethical approvals
The Institutional Ethics Committee of the Public Health
Foundation of India (June 2013, TRC-IEC-163/13),
reviewed the protocol and approved the study. An
Independent Ethics Committee linked to Ekjut (May
2013), and University College LondonsResearchEthics
Committee (June 2013, reference 1881/002) also granted
ethical approval to the study. All data collection was con-
ducted following informed consent recorded on paper
(signed by all participants) after explaining the purpose of
the study. Verbal consent was taken from a few partici-
pants who were apprehensive about giving anything in
writing, though they agreed to participate in the study.
Confidentiality of all participants was assured during the
data analysis and quotes are given with pseudonyms.
Results
Formation and composition of VHNSCs
Most VHSNCs (98 %) in Jharkhand were formed in
2007, and in Odisha, most (81 %) between 2008 and
2010. VHSNCs included an average of nine members
in Odisha (Range: 512) and an average of 16 (Range:
1035) in Jharkhand. Table 2 describes the character-
istics of VHSNC members by state. Most members
werewomen(justover75%inOdishaand65%in
Jharkhand) and from vulnerable groups - Scheduled
Castes, Tribes or Other Backward Castes,withmany
more Scheduled Tribe members in Jharkhand. As per
Government guidelines, the community health workers
(ASHA and AWW) were members of VHSNC in both
states, while a Panchayat representative (Ward Member
or Pradhan/Mukhiya) was the President. In Jharkhand,
ASHAs organised meetings and kept records, while in
Odisha record keeping was the role of AWW.
Our qualitative data indicated that VHSNCs were
formed according to state-level guidelines in both
Jharkhand and Odisha.
Regularity of meetings and attendance
VHSNCs struggled to hold meetings regularly and with
full attendance. Six VHSNCs (two in Jharkhand and four
in Odisha) of the ten who participated in qualitative dis-
cussions reported holding monthly meetings, but faced
irregular attendance. It was difficult to agree on a time
convenient to all, resulting in either delayed meetings or
poor attendance.
Members who could not attend regularly were agricul-
tural or casual labour; finding time for the meeting im-
plied loss of wages. Attendance was especially thin in
the harvest season, when members had to work in the
fields. Sometimes members migrated out for seasonal
labour; that also led to low attendance.
People want some money when they attend the
meeting as they lose their wage for that day. FGD1,
Jharkhand.
Other members not attending meetings regularly in-
cluded poor and illiterate members and those living in
distant hamlets.
We call people from distant hamlets to attend
meetings; but they dont come. Hence we dont call
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them frequentlynow we avoid them. We also call
youth but they also dont attend so we take decisions
within the smaller group, FGD5, Jharkhand.
Linkages with health authorities
Training
Guidelines in both states stipulate that VHSNC
members should receive a days training on their
roles and VHSNC functions. Very few members in
either Odisha or Jharkhand had received any training
related to VHSNC activities in the past 12 months.
In Odisha, 13 members out of the 857 who partici-
pated in the quantitative survey had received train-
ing. In Jharkhand, only two out of 1286 members
had received any training on VHSNC roles and
responsibilities.
In our FGDs, all members reported receiving some
training on their role as VHSNC members or the com-
mittees functions, though the quality of this training
varied widely.
Four VHSNCs in Odisha and two in Jharkhand
recalled that they were oriented on their roles and func-
tions as VHSNC members by block-level officials.
All members got one day of training in the village.
During the training we were told to clean the village
ponds, roads and bleach wells. And we are doing it
through our VHSNC. FGD2, Odisha
We were given information on health, diseases among
childrenwe were told that annually we will receive
fundevery month we willdiscuss on how to prevent
diseases. FGD 5, Jharkhand.
Members noted that ASHAs and AWWs were usually
the recipients of detailed training about the VHSNC,
while other members, at the most, received only a brief
orientation, which many probably did not regard as
training.
Participants in all FGDs expressed the need for further
training in order to improve their knowledge and help
them perform their roles as VHSNC members more ef-
fectively. Areas for desired training spanned members
roles and functions, management of VHSNCs, planning
and financial record keeping to technical knowledge that
they could use for awareness building, such as malaria
and diarrhoea prevention and food and nutrition.
We would like to get some training on the role and
responsibility of the VHSNC, utilisation of funds and
annual planning. We definitely want to know more
about VHSNC functions. The more we know about
VHSNC, the more it will help us to improve our
village. FGD1, Odisha.
Supportive supervision and monitoring
The block and district health administration is re-
quired to provide supportive supervisionto VHSNCs,
which implies monitoring their activities as well as
helping committees improve their performance by ad-
dressing any issues that may occur. According to
VHSNC guidelines, district or block level administra-
tors must visit VHSNC meetings at least once every
two months to assess their functioning and offer
guidance as required. In Odisha, our cross-sectional
survey found that only 5.5 % VHSNCs reported any
visit by district or block level officials in the previous
year to discuss record keeping and expenditure on
health activities. In contrast, 96 % VHSNCs in Jhar-
khand reported visits in the past year by block level
officials, most reporting 23 visits. Financial audit of
VHSNCs by district-level NRHM officials was negli-
gible, though financial reporting to block-level NRHM
staff appeared to be robust. In Odisha, 90 % of VHSNCs
had reported on their untied fund expenditure, compared
with 85 % of VHSNCs in Jharkhand.
In the qualitative discussions, none of the VHSNCs
reported any regular supervisory visits by district or
block-level officials. In a few instances the ANM,
who visited the village weekly for immunisation
sessions and VHNDs, also made enquiries about
VHSNC functioning.
District and Block officials never come but the ANM
comes to our village two to three times. Sometimes she
attends our meetings. FGD2, Jharkhand
Table 2 Characteristic of VHSNC members, by state
Odisha (N= 857) Jharkhand (N=1286) All (N=2143)
Sex Male (%) 24.7 35.2 31.0
Female (%) 75.3 64.8 69.0
Social category Scheduled Tribe (%) 55.1 74.4 47.6
Scheduled Caste (%) 7.4 6.7 26.0
Other Backward Class (%) 36.9 18.9 26.1
Other (%) 0.7 0.0 0.3
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Linkages with community health workers
Oversight and support
The VHSNC is mandated by NHM to provide over-
sight and support to community-level health services
and health workers to ensure smooth functioning
and better coordination between them. Table 3 de-
scribes the services monitored by VHSNCs. The
majority of VHSNCs in Odisha were active in moni-
toring the AWC, VHND, the mid-day meal scheme
(providing meals to primary and upper-primary stu-
dents in government schools) and services provided
by the ASHA and AWW. On the other hand, only
10 % reported monitoring the Sub-Centre and 4 %
reported checking drug availability with community
health workers. In Jharkhand, most VHSNCs moni-
tored the work of ASHAs, referral of severely acutely
malnourished (SAM) children by AWWs, and VHND
services including the ANMs attendance. Only 17 %
monitored AWCs and 3 % checked the Sub-Centre.
Most of the 'supervision' was informal and no
written records were maintained. Differences were
statistically significant (p< .001) except for the mon-
itoring of Sub-Centres and ANMs attendance in
VHNDs.
However, the FGDs revealed that members were not
regularly monitoring community health services. Rea-
sons included lack of awareness of this role, or trust in
the work of the ASHA and AWW. Sometimes male
members hesitated to visit the VHND, as only women
and children attended them. Only one VHSNC out of
the ten where we held FGDs were regularly monitoring
the AWC and VHND.
We never participate in any VHND programme.
AWW and ANM have more knowledge than us, so we
never interfere in their work. Our ASHA, AWW &
ANM have good cooperation between themselves.
FGD5, Odisha.
Participation and facilitation by CHWs
Community health workers such as ASHAs and AWWs
play very specific roles in the VHSNC. ASHAs convene
the VHSNC meetings and maintain records in Jharkhand,
while the AWWs perform the same role in Odisha.
ASHA is the convener. It is her duty to call meetings
and maintain register. FGD4, Jharkhand.
AWW call the meetings and if someone misses she
briefs them about it. FGD2, Odisha.
Record keeping
The VHSNC is mandated to maintain a record of the vil-
lage population, especially vulnerable groups (pregnant
women, children, malnourished children), and events such
as births and deaths. ASHA and AWW routinely main-
tained VHSNC records as well as other records for births,
deaths and malnourished children. Record keeping is also
essential to maintaining transparency and accountability
in VHSNC functioning. In 82 (90 %) VHSNCs in Odisha,
AWWs were solely responsible for maintaining VHSNC
records, while in 9 (10 %) VHSNCs, AWW and ASHA to-
gether maintained records. In Jharkhand, almost all
VHSNCs reported having a meeting register maintained
by the ASHA. 53 (64 %) VHSNCs in Jharkhand also
Table 3 Village health services monitored by VHSNCs
Services monitored Odisha Jharkhand P*
(N= 91) (N=78)
Anganwadi Centre, n(%) 75 (82.4) 13 (16.7) .000
Sub-Centre, n(%) 10 (11.0) 2 (2.6) .061
Village Health and Nutrition Day, n(%) 81 (89.0) 22 (28.2) .000
ASHA accompanying women for ID, n(%) 52 (57.1) 66 (84.6) .000
Referral of SAM children by AWW, n(%) 58 (63.7) 29 (37.2) .000
Presence of ANM at VHND, n(%) 62 (68.1) 43 (55.1) .057
Presence of drugs with ASHA/ANM/AWW, n(%) 4 (4.4) - .000
Mid-day meals in school, n(%) 68 (74.7) - .000
Children reported by VHSNCs for treatment/rehabilitation, (n)
1 child 11 4
23 children 24 3
More than 3 children 20 1
VHSNCs with hamlet-wise malnutrition records, n(%) 18 (20) 3 (4) .001
VHSNCs with information on malnourished children, n(%) 55 (60) 8 (10) .000
*Pvalue obtained through Chi-square test
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Content courtesy of Springer Nature, terms of use apply. Rights reserved.
maintained a separate cashbook to record fund utilisation,
and 17 (22 %) VHSNCs maintained a survey register con-
taining village demographic, health and nutrition status
information, recorded and updated by ASHAs. However
only nine VHSNCs in Odisha and three in Jharkhand car-
ried out a listing of vulnerable families, pregnant women
and young children in the last one year.
Linkages with the community
Planning, fund utilisation and mobilisation for health
activities
One of the core functions of the VHSNC is to prepare
village-level health plans on the basis of local priorities.
Table 4 describes the VHNSCsactivities in relation to
planning and the use of untied funds. 83 % of VHSNCs
in Odisha reported preparing village health plans, com-
pared with only 8 % in Jharkhand.
However, in practice, few of the VHSNCs who partici-
pated in group discussions had ever prepared an annual
health plan, though most seemed to be aware of it.
Members in six VHSNCs had no knowledge on how to
prepare a health plan. They recalled receiving some
orientation on preparing plans and formats for recording
them, but the process has not been followed. The untied
fund was spent according to the fund utilisation guide-
line provided to them, without any proper plan in place.
No we do not prepare any plan for utilisation of
untied fund. We got a guideline on utilisation of funds,
like how much we can spend for bleaching powder,
how much to spend for road cleaning, pond cleaning
and referral, etc. Accordingly we spend the fund.
FGD3, Odisha
Although our quantitative survey showed that 83 %
committees in Odisha made a village health plan, the
qualitative findings show that this is not always the case,
and that the purpose of the plan was not always
understood. Members were either unaware of this re-
sponsibility, or complained of a lack of knowledge of the
planning process. In one FGD, members blamed com-
munity health workers for not facilitating the process.
The annual plan is not prepared; ASHA, AWW &
Ward Member should take a lead on this but they
dont, hence [the planning process] has not been
initiated. FGD1, Odisha.
In another FGD, members complained that they were
not able to implement plans due to late arrival of untied
funds.
Whatever plans we develop never work out as untied
funds reach late every year; Government transfers
money in the ninth month of the year and asks us to
spend it within the next three months, which causes
many problems for us. FGD2, Odisha.
Use of untied funds
Each VHSNC is provided with an annual untied fund of
INR 10,000 for carrying out community health, nutrition
and sanitation-related activities. All VHSNCs must have
bank accounts to be able to receive funds allocated to
them to carry out their activities. All 91 VHSNCs
surveyed in Odisha had a bank account, while 17 %
VHSNCs surveyed in Jharkhand were yet to open one.
97 % VHSNCs with bank account in Odisha and 57 % in
Jharkhand reported spending their untied fund in the
last one year. On average, VHSNCs reporting expend-
iture in Odisha spent 53 % of their INR 10,000 (USD
160) untied fund last received, while in Jharkhand
VHSNCs spent 83 % of their untied funds.
As shown in Table 5, most VHSNCs in both states
spent their untied funds on health and sanitation activ-
ities (detailed in the qualitative responses discussed
below). Only 23 (14 %) VHSNCs reported spending
funds on nutrition. The Othercategory had significant
amount of expenditure allocated to it, which mainly in-
cluded spending on meetings, furniture and other items
for the VHSNC itself. MannWhitney U tests indicated
Table 4 Planning and fund utilisation by VHSNCs
Odisha N=91 Jharkhand N=78 P*
VHSNCs that prepared village plan, n(%) 76 (83) 6 (8) .000
VHSNCs that made a list of vulnerable population groups, n(%) 9 (10) 3 (4) .109
VHSNCs that have a bank account, n(%) 91 (100) 64 (83) .000
VHSNCs with bank account that reported expenditure of untied fund
in last 12 months, n(%)
88 (97) 39 (57) .000
Amount of untied fund spent (INR) Mean (SD)** 5267.4 (1923.3) 8297.8 (2251.5) .000
#
% of total untied fund (INR 10,000/-) spent annually** 53 83
*Pvalue obtained through Chi-square test
#
Pvalue obtained through t-test
**For VHSNCs that reported expenditure
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Content courtesy of Springer Nature, terms of use apply. Rights reserved.
significant difference in mean expenditures between the
two districts on health (p<.001) and nutrition (p= .009),
but not in sanitation (p= .053).
Our qualitative data indicated that members were
aware that they would get an annual fund and knew how
it shouldbe utilised.
We were told that ten thousand [INR] will come to our
village. Health fund will be spent for cleaning of drains,
referring malnourished children to hospital, preparing
banners, display boards and wall writings. Maximum
fund will be spent for cleanliness. FGD5, Jharkhand
Members reported utilising the annual untied VHSNC
fund on a wide range of activities related to health, nu-
trition, village sanitation and hygiene and also to meet
the needs of the committee itself. They discussed and
took decisions jointly on fund utilisation in meetings.
Generally in every meeting we discuss health and
sanitation in the village, cleaning of the village road,
bleaching of tube well, insecticide spray, night
assistance to pregnant mothers, supplying drinking
water in summer season, organizing health camps,
bank passbook update. FGD2, Odisha
We have talked about repairing the tube well, cleaning
the village and financial assistance to patients.
[We also discussed] care of pregnant mothers and
institutional delivery, [the need to] spread awareness
about pregnant mothers diet, how to prevent diseases
in children. FGD5, Jharkhand
Monitoring by the community
The linkage between a VHSNC and the community is
meant to be operationalised through Gram Sabhasor
village council meetings, in which the community col-
lectively reviews the VHSNCs performance. We found
very little evidence of a formal system of community
monitoring of VHSNCs. In our cross-sectional survey,
only 22 % of VHSNCs in Odisha and 31 % of VHSNCs
in Jharkhand reported the community ever asked about
their activities. In our qualitative discussions, all five
VHSNCs in Odisha and one in Jharkhand reported
sharing the details of untied fund expenditure with
the community, when asked. Quantitative data shows
that in 30 % VHSNCs in Jharkhand and 22 % in Odisha
reported a Gram Sabha (village council) meeting being
held in their area to review VHSNC functioning.
Villagers also monitor the progress and utilisation of
money. Sometime we present the expenditure details in
front of villagers when they require it. FGD2, Odisha.
Mobilizing community members for health activities
One of the responsibilities of VHSNC members is to
raise awareness and educate community members on
key health, nutrition and sanitation issues within the
community. Participants highlighted several activities in-
cluding counselling women to access antenatal care, ad-
vising pregnant women and mothers about diet and
nutrition, discouraging alcohol consumption and coun-
selling families on malaria prevention through the use of
mosquito nets and keeping surroundings clean.
Last year, we visited all the households and educated
them about the use of mosquito nets and cleaning of
surroundings [for malaria prevention]. FGD5, Odisha
Among health activities, VHSNCs focused significantly
on helping people to access healthcare. This included
helping pregnant women access institutional delivery
Table 5 Untied fund expenditure by VHSNCs that reported expenditure in the past 12 months
Odisha Jharkhand P*
% of VHSNCs spending
funds N=88
Average amount spent (INR)
median (Interquartile range)
% of VHSNCs spending
funds N=37
Average amount spent (INR)
median (Interquartile range)
Health
a
99 1000 (500) 73 500 (1319) .000
Nutrition
b
25 0 (25) 3 0 (0) .009
Sanitation
c
93 1000 (200) 89 2350 (3000) .053
Public Works
d
5.6 0 (0) 22 0 (0) .003
Literacy
e
0 0 (0) 11 0 (0)
Other
f
96.6 2600 (1587) 100 5000 (4500) .000
*Pvalue for the difference in mean amount spent in INR, obtained through the MannWhitney U test
Some examples of activities included under the above categories:
a
Health: Assistance to pregnant mothers for institutional delivery, insecticide spray, organizing health camps and other events for awareness generation
b
Nutrition: Referring malnourished children to hospital
c
Sanitation: Bleaching and paving of wells and tube wells, cleaning village roads and drains
d
Public Works: Any construction for public infrastructure/civic services, augmenting drinking water supply
e
Literacy: Assistance to local schools
f
Others: Meeting expenses, durable and non-durable items for the committee itself, room for committee meetings, display boards, wall painting etc
Srivastava et al. BMC Public Health (2016) 16:59 Page 9 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
and supporting elderly and poor patients in accessing
healthcare. The committee also assisted patients with
specific conditions like tuberculosis and accessing treat-
ment for diarrhoea. Pregnant women and mothers were
also counselled on antenatal care and nutrition. Activ-
ities for malaria control and environmental hygiene were
also significant, and included insecticide spraying and
cleaning of roads, waterlogged areas and bushes.
Once VHSNC members helped [ASHA] take a
pregnant lady to hospital at night. They arranged
money and vehicle to take her to hospital. The
VHSNC donated INR 300.00 to that mother. We also
once referred a tuberculosis patient and three
malnourished children to hospital through VHSNC
fund after discussion with members. FGD3, Odisha
VHSNC is getting ten thousand rupees per year and
we spend the money for referral of poor people to
hospital, treatment of patients, road cleaning, tube
well cleaning and also insecticide spray. FGD2,
Jharkhand
With respect to nutrition, the main activity for VHSNCs
in both districts was referring severely malnourished chil-
dren to hospitals. Some members also reported counsel-
ling women on nutrition during pregnancy and lactation,
and for young children.
If we identify a child with low weight we register it
and refer [to health centre for treatment]. We referred
a low-grade [malnourished] baby and its mother to
hospital [and] gave [them] INR 200; now both mother
and baby are fine. We referred two children with low
weight this time. FGD2, Odisha
Sanitation and hygiene works included cleaning roads,
drains and water sources like ponds and wells, and lining
them with bleaching powder to prevent infections.
Expenditure on VHSNCs own requirements included
purchasing furniture, utensils, sheets, lights, banners and
display boards for the meeting venue, and snacks to be
served during meetings.
We have spent more money on purchasing of some
items for committee. We spent on purchasing of
polythene [sheet] and lights. Now we have [around]
INR 3000 unspent amount and we are planning [to
procure] a welcome board and display boards. FGD3,
Jharkhand
Discussion
While committees have been generally constituted ac-
cording to the guidelines in both districts, their training
and compliance with planning and specified functions
was very weak. Clarity in roles and functions, mandate
and authority are the prerequisites for an effective
VHSNC and greater health system support and supervi-
sion enable stronger community health committees [4].
Our study found relatively weak linkages between the
VHNSCs and the health system, particularly in Jhar-
khand. This could be on account of overall weaker local
governance in the state. Weak supportive supervision of
VHSNCs by the health system was common to both
states as reported in other studies [19, 21]. VHSNC
members in both states were unclear about their roles,
with the exception of the CHWs, who have specific roles
in the committees as conveners. This has been observed
in other studies in India [15, 16, 18, 20, 31]. Few mem-
bers received formal training in VHSNC functioning as
found by VHSNC members interviewed in a study in
Maharashtra [16]. Though socially and geographically
marginalised groups were represented in the com-
mittees, their participation was irregular. This has
equity implications, as frequently absent members
were completely excluded from the VHSNC process
over time [21].
Our study had strengths and limitations. It covered a
large number of VHSNCs in a quantitative survey and
also used qualitative methods for an in-depth investiga-
tion. Having data from two adjacent districts across two
states provides useful lessons to share. However, our
findings cannot be generalised to the states in their en-
tirety, or to other parts of India. Our self-reported data
in both our quantitative survey and group discussions
may have been subject to social desirability bias, as
members may have felt pressured to report adhering to
government guidelines. In FGDs, group dynamics could
have influenced responses as participation was not uni-
form and some members were more vocal than others.
The community health workers had a tendency to pro-
ject a more positive picture of the committee as its func-
tioning reflected on their effectiveness in coordinating it.
We could infer from this that findings relating to any
challenges in participation and decision making may
have been missed or inadequately reflected. These biases
could explain discrepancy between quantitative and
qualitative responses for some aspects like monitoring of
community health services and making of annual plans
by VHSNCs. Lastly, owing to time and resource limita-
tions, the study focused exclusively on the committees
themselves, and did not explore the perspectives or the
health authorities or community at large regarding these
committees, which could have strengthened some of our
inferences.
Our comprehensive analysis of all VHSNCs in two
districts of India adds to the global evidence on the ef-
fectiveness of village-level committees for decentralised
Srivastava et al. BMC Public Health (2016) 16:59 Page 10 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
health planning and action. Existing evidence on village-
level health committees, largely drawn from African
studies, shows these structures often suffer from weak
community linkages and participation, even when they
operate within well-established systems [2, 7, 32]. This is
mainly on account of a lack of inclusive membership,
poor community engagement and weak support from
the health authorities. Having a longstanding tradition of
centralised governance is also thought to weaken partici-
patory community-level bodies [8].
Studies highlight the need to ensure inclusive par-
ticipation and community mobilisation [2, 7]. Strong
committees are well supported by district or regional
health system, work with relative autonomy, free from
political interference and enjoy community confidence
[2, 4, 33, 34]. Inadequate support in terms of infra-
structure, resources, support and training prevents
committees from performing to their potential [32].
Sustained engagement, advocacy and education of
committee members and the larger community was
suggested to improve role clarity, enhance member
skills and activate the committees to perform their
functions [8]. These suggestions have strong relevance
in India too.
Our quantitative data from questionnaires were often
contradicted by focus group discussions. In question-
naires members report that they undertake diverse
health-related activities for the community, but the
group discussions show that activities focus only on vil-
lage sanitation works, facilitating treatment of patients
and organizing health awareness camps. Most untied
funds, are spent on environmental sanitation and other
expenses. Similar lack of focus on mandated activities
by VHSNCs has been reported in other studies [20].
Findings reveal that CHWs were strongly linked to the
VHSNCs, fulfilling their roles as conveners, facilitators
and record keepers of the committees. They were also
monitored by the block level health authorities on their
performance of this role. However, there were gaps in
the monitoring by VHSNCs of community health ser-
vices provided by CHWs. The VHSNCslinks with com-
munity health workers are guided by the district and
state health administration. Better guidance from the
health authorities in Odisha led to better linkages of
VHSNCs with CHWs, with members more actively in-
volved in Village Health and Nutrition Day and monitor-
ing of the Anganwadi centers. In some committees
where monitoring was lax, members expressed full faith
in the CHWs. Research evidence from Africa has found
that CHWs often dominate committees as they have
more knowledge and power compared to other members
[35, 36]. In our setting, this was evidenced through the
tendency of CHWs to dominate discussions in some of
the FGDs. Though not explicitly stated by the members,
this could be a possible factor preventing them from
monitoring services provided by CHWs. Other studies
have also found that CHWs often resent and object to
the monitoring by committees [36], but this aspect was
not explored in our study.
Community mobilisation and health awareness activ-
ities were supported by VHSNCs in both states.
However, there was little evidence of any systematic
monitoring of VHSNC by the community, with mem-
bers only mentioning that they shared VHSNC details
with the community when asked. Linkage with the
community has been explored in other studies on
VHSNCs only from the point of view of participation of
Panchayati Raj institutions and not the village commu-
nity as such [21, 31]. Community participation is heavily
influenced by prevalent socio-cultural norms, political
and economic relations, as they determine the dynamics
of interaction and participation within the community
[37]. A recent review of the NHM has suggested that
training should be undertaken for VHSNCs at state and
district levels, with trainers specializing in social mobil-
isation. Greater state support is also recommended for
village health planning, community monitoring of com-
munity health services and local collective action for
health promotion. This will enhance the participatory
nature of VHSNCs [13].
Conclusion
VHSNCs offer an opportunity for bottom-up planning
in community health. Our study has highlighted com-
prehensive weaknesses among VHSNCs that must be
urgently addressed. Health authorities must train and
help VHSNCs through supportive supervision. Members
require orientation regarding their roles and responsibil-
ities, technical aspects of health, nutrition and sanitation,
and participatory processes related to making plans and
using untied funds. Local non-governmental organisations
could help with training and encouraging community par-
ticipation to make them more accountable. VHSNCs need
assistance to plan effectively, in order to allocate their
funds rationally between health, nutrition and sanitation
activities in the community. Well-designed annual health
plans could be integrated into block and district-level
health plans, thereby strengthening the decentralised
health planning process recommended by Indiasnational
guidelines.
Abbreviations
ANM: auxiliary nurse midwife; ASHA: accredited social health activist;
AWC: Anganwadi centre; AWW: Anganwadi worker; CHW: community health
worker; FGD: focus group discussion; INR: Indian rupee; NHM: National health
mission; NRHM: National rural health mission; SAM: severely acutely
malnourished; VHND: Village health and nutrition day; VHSC: Village health
and sanitation committee; VHSNC: Village health sanitation and nutrition
committee.
Srivastava et al. BMC Public Health (2016) 16:59 Page 11 of 12
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Competing interests
The authors declare that they have no competing interests.
Authorscontributions
AS was responsible for drafting the article. AP helped in the literature search
to identify similar articles and contributed to drafting, reviewing and editing
the article. SB also contributed to drafting and reviewing of the article. RG,
ShR, SR, PS, PMB, VS, VN, AS and SB contributed to field data collection and
analysis. NN, RS, HPSS, JSW, HHB and AC contributed to reviewing and
editing the manuscript. All authors read and approved the final manuscript.
Acknowledgements
We are grateful to the funders for supporting this work. This work was
supported by UK Medical Research Council (MR/K007270/1), the Wellcome
Trust (099708/Z/12/Z) and the Department for International Development
(DfID) under their joint Global Health Trial scheme. The funders were not
involved in the study design, data collection, analysis, and interpretation or
in the writing of the manuscript.
Author details
1
Public Health Foundation of India, Plot no. 47, Sector 44 Institutional Area,
Gurgaon, 122002 New Delhi, Haryana, India.
2
Ekjut, Chakradharpur,
Jharkhand, India.
3
Sitaram Bhartia Institute of Science and Research, New
Delhi, India.
4
Institute for Global Health, University College London, 30
Guilford Street, London WC1N 1EH, UK.
Received: 23 July 2015 Accepted: 6 January 2016
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... Health facility in charges or health facility staff have also been mentioned to be a member of the HFGCs who in many committees become HFGC secretaries [26,28,32,37,38,42]. Village governments or members of the local government in some countries are included in the HFGCs, as has been highlighted by the governing guidelines [26,28,40,42,45]. Gender representation has not been left out in the composition of HFGCs in many countries, this is evidenced by the special requirement of gender representation among community representatives in the HFGCs [26,28,40,45,48]. ...
... Village governments or members of the local government in some countries are included in the HFGCs, as has been highlighted by the governing guidelines [26,28,40,42,45]. Gender representation has not been left out in the composition of HFGCs in many countries, this is evidenced by the special requirement of gender representation among community representatives in the HFGCs [26,28,40,45,48]. ...
... The HFGCs were found to have been devolved with many responsibilities and roles to fulfill in the course of governing and administering primary health facilities, according to the extracts investigations. Some of the responsibilities include managing and overseeing facility operations [23,25,26], to articulate community interest and address community health matters [23,26,30,33,37,42], participating in planning and budgeting [23,26,31,38,42,45,49,50]. Other common functions of HFGCs are to mobilize facility resources such as funds and other materials [23,25,26,33,37,38], managing the performance of health workers, including hiring and firing [23,26,40] and facilitate feedback to community and health facilities [23,26,31,33,38]. ...
Article
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BACKGROUND Health facility governing committees (HFGCs) were established by lower and middle-income countries (LMICs) to facilitate community participation at the primary facility level to improve health system performance. However, empirical evidence on their effects under decentralization reform on the functionality of HFGCs is scant and inconclusive. OBJECTIVE This article reviews the effects of decentralization on the functionality of HFGCs in LMICs. METHODS A systematic literature review was conducted using various search engines to obtain a total number of 24 relevant articles from 14 countries published between 2000 and 2020. Inclusion criteria include studies must be on community health committees, carried out under decentralization, HFGCs operating at the individual facility, effects of HFGCs on health performance or health outcomes and peer-reviewed empirical studies conducted in LMICs. RESULTS The study has found varied functionality of HFGCs under a decentralization context. The study has found many HFGCs to have very low functionality, while a few HFGCs in other LMICs countries are performing very well. The context and decentralization type, members’ awareness of their roles, membership allowance and availability of resource to the facility in which HFGCs operate to produce the desired outcomes play a significant role in facilitating/limiting them to effectively carry out the devolved duties and responsibilities. CONCLUSION Fiscal decentralization has largely been seen as important in making health committees more autonomous, even though it does not guarantee the performance of HFGCs.
... It also tests the widespread understanding that a key reason for the failure of decentralization in the health sector is the lack of awareness and capacity of functionaries working in the field. Several studies have documented efforts to build the capacity of VHSNCs to strengthen their functioning and bolster their impact on health outcomes at the community level (Mohan et al., 2012;Srivastava et al., 2016;Ved et al., 2018). Their findings indicate a mixed picture; while capacity building has been found to be effective in improving the performance of VHSNCs, there are indications that (i) these improvements may be difficult to sustain in the absence of intense support from either an external agency or from higher levels of the health system; and (ii) the effectiveness of village-level entities (including VHSNCs) depends critically on their relationship with the higher-level political and administrative levels . ...
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Abstract: While India has made progress in achieving important health sector goals, there is still a long way to go. The Government of India has adopted decentralization or devolution with the objective of promoting greater equity and supporting people-centered, responsive health systems. We report on a study that problematizes the idea of strengthening health sector governance through decentralization and that explores the intersection of the political goal of enhanced local-level autonomy and the programmatic goal of more responsive health service delivery. The study examines the extent to which both political and programmatic decentralization are functional at the village level; looks at the design and objectives of decentralization at the village level; and considers whether sustained and supportive capacity building can create the necessary conditions for more genuine de facto decentralization and empowerment of village-level functionaries. Our methodology included semi-structured interviews with village-level functionaries in two districts of Karnataka, based on which we designed an Action Research to strengthen coordination and synergy between the functionaries responsible for political and programmatic decentralization. We found that both political and programmatic decentralization at the village level are at risk due to a lack of convergence between the political and programmatic arms of the government. This is substantially due to problems inherent in the design of the decentralization mechanism at the district level and below. Sustained capacity building can contribute to the more effective application of decentralization mechanisms, but systemic issues regarding the decentralization mechanisms need to be addressed alongside. We were also able to identify some spaces where coordination between village-level functionaries is possible, and the steps that need to be taken to build on this potential. Keywords: Decentralization; National Health Mission; Village Health Sanitation and Nutrition Committee (VHSNC); Community Health Worker (CHW); Karnataka health sector
Article
Community Health Committees (CHCs) are mechanisms through which communities participate in the governance and oversight of community health services. While there is renewed interest in strengthening community participation in the governance of community health services, there is limited evidence on how context influences community‐level structures of governance and oversight. The objective of this study was to examine how contextual factors influence the functionality of CHCs in Kajiado, Migori, and Nairobi Counties in Kenya. Using a case study design, we explored the influence of context on CHCs using 18 focus group discussions with 110 community members (clients, CHC members, and community health volunteers [CHVs]) and interviews with 33 health professionals. Essential CHC functions such as ‘leadership’ and ‘management’ were weak, partly because Health professionals did not involve CHCs in developing health plans. Community Health Committees were active in the supervision of CHVs, reviewing their household reports, although they did not utilise these data for making decisions. Resource mobilisation and evaluation of health programs were affected by the lack of administrative and operational support, such as training. Despite having influential membership, CHCs could not provide leadership and management functions. Health system actors perceived the roles of CHCs as service providers rather than structures for governance and oversight. Insufficient awareness of CHC roles among health professionals, lack of training and operational support for community‐based activities constrained CHCs' functionality and thus their role in community participation. While there are efforts to institutionalise community‐level governance structures for health at sub‐national level, there is a need to scale‐up these efforts countrywide. We recommend that community‐level governance structures be empowered, mandated, and provided with resources to take on the responsibility of overseeing community health services and exacting accountability from health providers. Selection of elite persons in community‐level health committees does not enhance the leadership roles in these committees. Legislation on community‐level health governance committees could enhance community participation in planning and managing health programs. Implementation of vertical health programs without the community participation contributes to missed opportunities for incorporating local knowledge into these programs. Community members and health professionals who implement community health services still do not understand the importance of community participation in making decisions in community health programs. Selection of elite persons in community‐level health committees does not enhance the leadership roles in these committees. Legislation on community‐level health governance committees could enhance community participation in planning and managing health programs. Implementation of vertical health programs without the community participation contributes to missed opportunities for incorporating local knowledge into these programs. Community members and health professionals who implement community health services still do not understand the importance of community participation in making decisions in community health programs.
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This paper employs the policy capacity framework to develop a multidimensional and nested policy analysis that is able to examine how different types of capacity—analytical, organizational, and political from different related levels of the health system—have contributed to both policy success and failure during the implementation of a politically significant national community health worker (CHW) program in India. Directed toward rural and urban marginalized populations in India, this CHW has become the world’s largest CHW program. Launched in 2006, it has targeted communitization, strengthening of the primary health-care system, and universal health-care coverage, ultimately receiving an international award in 2022. We argue that, in a context of capacity deficits and tensions between different capacity domains, the individual political capacity has been more critical to policy success and strengthening. The analysis not only clarifies the ways in which the government took some initiatives to build up capacity but also highlights capacity deficits along different competency dimensions. This approach demonstrates the value of understanding and creating awareness concerning complex poor-resource settings and low organizational capacity while concomitantly building up the capacities needed to foster (workforce and leadership) strengthening.
Article
India is home to the largest population of indigenous tribes in the world. Despite initiative of the National Rural Health Mission, now National Health Mission (NHM) and various tribal development programmes since India's Independence, disparity in healthcare for Scheduled Tribes (STs) prevails. The constitution of Village Health Sanitation and Nutrition Committees (VHSNCs) in 2007 by the NHM is a step towards decentralized planning and community engagement to improve health, nutrition and sanitation services. VHSNCs are now present in almost all States of the country. However, several reports including the 12th Common Review Mission report have highlighted that these committees are not uniformly following guidelines and lack clarity about their mandates, with no clear visibility of their functioning in tribal areas. We therefore conducted a review of studies to assess the participation of the VHSNCs in tribal dominated States in order to know in detail about their functioning and gaps if any that require intervention. Several deviations from the existing guidelines of NHM were identified and we concluded that in order to sustain and perform well, VHSNCs not only require, mobilization and strict monitoring but also motivation and willingness of its members to bring in a radical change at the grassroot level. With continuous supervision and support from both the Government and various non-governmental organizations, handholding, strategic deployment of workforce, community participation and sustained financial support, VHSNCs would be able to facilitate delivery of better healthcare to the indigenous population.
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Community participation is one of the founding pillars of primary health care. However, due to various reasons, we are yet to achieve complete integration of this component into the health system functioning in India. The objective of our study was to do a formative assessment of community participation in a rural healthcare setting by adopting participatory learning action (PLA). technique. The study participants included frontline health workers and members from local governing institutions of rural areas. The study design is qualitative in nature with a participatory approach. A number of three PLA techniques have been used as a part of this study to recognize available resources for community participation, address its barriers and facilitators, and finally devise a time-line-based action plan. Based on the this, a conceptual framework for community participation pertaining to the rural healthcare system has been developed. This study highlights the importance of understanding the psychosocial aspects of community participation among various stakeholders involved in rural health care. Lessons learned from this PLA study will be helpful in the integration of community-based participatory approach within grassroot level healthcare planning and service delivery.
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Background: National Health Mission intended to achieve decentralization and community participation through creating and supporting Village Health Sanitation and Nutrition Committees (VHSNCs). The services offered through VHSNC include maternal and child health, family planning, sanitation, communicable diseases and health promotion, and nutrition. The study was carried out to assess awareness on the implementation of the functioning of VHSNC implementation among village-level functionaries in the Dehradun district. Methods: A community-based cross-sectional study was conducted in the Doiwala and Raipur blocks of Dehradun district from June 2019 to July 2019. Members of VHSNC with at least 3 months of membership were included in the study. A pretested semi-structured questionnaire was used to collect sociodemographic variables and questions about their awareness and responsibilities in implementing VHSNC. Data were collected by personal interviews using Epi-Collect and analyzed by SPSS 23. Result: Out of 69 members, 64 (92.4%) had formal education until high school. Only around 50% of members knew about the essential documents related to the VHSNC. Sixty-five members (98.48%) believed that the committee had the primary role in health-related services in the village, 54 (81.82%) members also marked providing safe drinking water as a function, 48 (72.73%) were in favor of access to clean public toilet and sanitation facilities while some others added role in Public Distribution System. Conclusion: Around half of the members were partially or completely aware of the functioning of VHSNCs. Providing them with further awareness is required.
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Background COVID-19 pandemic and the subsequent national lockdown in India compelled the health system to focus on COVID-19 management. Information from the field indicated the impact of COVID- 19 on the provision of maternal health services. This research presents users' and providers' perspectives about the effect of the pandemic on maternal health services in select districts of Assam. Methods The study was undertaken to understand the status of maternal health service provision and challenges faced by 110 pregnant and recently delivered women, 38 health care providers and 18 Village Health Sanitation and Nutrition Committee members during COVID-19 pandemic. Telephonic interviews were conducted with the users identified through simple random sampling. Healthcare providers and the community members were identified purposively. Results Most of the interviewed women reported that they could access the health services, but had to spend out-of-pocket (for certain services) despite accessing the services from government health facilities. Healthcare providers highlighted the lack of transportation facilities and medicine unavailability as challenges in providing routine services. The study revealed high proportion of Caesarian section deliveries (42.6%, n = 32) and stillbirths (10.6%, n = 8). Discussion This research hypothesizes the supply-side (health system) factors and demand-side (community-level) factors converged to affect the access to maternal health services. Health system preparedness by ensuring availability of all services at the last mile and strengthening existing community-reliant health services is recommended for uninterrupted good quality and affordable maternal health service provision.
Article
Purpose The authors intend to assess the village health sanitation and nutrition committees (VHSNC) on six parameters, including their formation, composition, meeting frequencies, activities, supervisory mechanisms and funds receipt and expenditures across nine districts of the three states of India. Design/methodology/approach The cross-sectional study, conducted in the states of Uttar Pradesh (five districts), Odisha (two districts) and Rajasthan (two districts), used a quantitative research design. The community health workers of 140 VHSNCs were interviewed using a semi-structured questionnaire. The details about the funds' receipt and expenditures were verified from the VHSNC records (cashbook). Additionally, the authors asked about the role of health workers in the VHSNC meetings, and the issues and challenges faced. Findings The average number of members in VHSNCs varied from 10 in Odisha to 15 in Rajasthan. Activities were regularly organized in Rajasthan and Odisha (one per month) compared to Uttar Pradesh (one every alternate month). Most commonly, health promotion activities, cleanliness drives, community monitoring and facilitation of service providers were done by VHSNCs. Funds were received regularly in Odisha compared to Rajasthan and Uttar Pradesh. Funds were received late and less compared to the demands or needs of VHSNCs. Research limitations/implications This comprehensive analysis of VHSNCs' functioning in the selected study areas sheds light on the gaps in many components, including the untimely and inadequate receipt of funds, poor documentation of expenditures and involvement of VHSNC heads and inadequate supportive supervision. Originality/value VHSNCs assessment has been done for improving community health governance.
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Background This is the sixth of our 11-paper supplement entitled “Community Health Workers at the Dawn of New Era”. Expectations of community health workers (CHWs) have expanded in recent years to encompass a wider array of services to numerous subpopulations, engage communities to collaborate with and to assist health systems in responding to complex and sometimes intensive threats. In this paper, we explore a set of key considerations for training of CHWs in response to their enhanced and changing roles and provide actionable recommendations based on current evidence and case examples for health systems leaders and other stakeholders to utilize. Methods We carried out a focused review of relevant literature. This review included particular attention to a 2014 book chapter on training of CHWs for large-scale programmes, a systematic review of reviews about CHWs, the 2018 WHO guideline for CHWs, and a 2020 compendium of 29 national CHW programmes. We summarized the findings of this latter work as they pertain to training. We incorporated the approach to training used by two exemplary national CHW programmes: for health extension workers in Ethiopia and shasthya shebikas in Bangladesh. Finally, we incorporated the extensive personal experiences of all the authors regarding issues in the training of CHWs. Results The paper explores three key themes: (1) professionalism, (2) quality and performance, and (3) scaling up. Professionalism: CHW tasks are expanding. As more CHWs become professionalized and highly skilled, there will still be a need for neighbourhood-level voluntary CHWs with a limited scope of work. Quality and performance: Training approaches covering relevant content and engaging CHWs with other related cadres are key to setting CHWs up to be well prepared. Strategies that have been recently integrated into training include technological tools and provision of additional knowledge; other strategies emphasize the ongoing value of long-standing approaches such as regular home visitation. Scale-up: Scaling up entails reaching more people and/or adding more complexity and quality to a programme serving a defined population. When CHW programmes expand, many aspects of health systems and the roles of other cadres of workers will need to adapt, due to task shifting and task sharing by CHWs. Conclusion Going forward, if CHW programmes are to reach their full potential, ongoing, up-to-date, professionalized training for CHWs that is integrated with training of other cadres and that is responsive to continued changes and emerging needs will be essential. Professionalized training will require ongoing monitoring and evaluation of the quality of training, continual updating of pre-service training, and ongoing in-service training—not only for the CHWs themselves but also for those with whom CHWs work, including communities, CHW supervisors, and other cadres of health professionals. Strong leadership, adequate funding, and attention to the needs of each cadre of CHWs can make this possible.
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Background: The NRHM framework supports decentralized planning and monitoring upto the grass root level. Therefore, it was decided to entrust village level committees of the users group for the planning, monitoring and implementation of NRHM activities into villages of the country. Objectives: To study awareness regarding constitution and responsibilities among the VHNSC members; to study the current role of VHNSC in healthcare delivery at village level and preparation of village health action plan; and to understand the composition and process within VHNSC during conduct of a meeting, decision-making, resource management and conflict resolution. Methodology: Qualitative research methods (focus group discussion and in-depth interview) were conducted with VHNSC members during January to April 2011. The study was conducted in the selected villages of five sub-centres of PHC Anji, Wardha district of Maharashtra state. In each sub-centre, two villages were identified; one sub-centre village and another village purposively selected from among rest of the villages where the VHNSC was constituted and functional. Data was analyzed manually and transcripts were prepared using thematic analysis framework. Results: Awareness about VHNSC, its roles and responsibilities was highest among ANMs and AWWs. Awareness about objectives of VHNSC was highest among ANMs followed by AWWs, and least among panchayat members, ASHAs and SHG members. Most of the members were unaware of their roles and responsibilities and admitted to having received no formal training, before being made members of these committees. Regarding use of fund, majority of the VHNSC members were unaware about the areas where the funds were utilized. Most of VHNSC members said that either president or secretary decided about use of the funds without consulting other members. Conclusion: Capacity-building program of VHNSC members regarding rationale of VHNSC and its role in healthcare delivery should be considered towards better performance of NRHM.
Article
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Background: The Village Health Sanitation and Nutrition Committee (VHSNC) is one of the major initiatives under National Rural Health Mission (NRHM) to decentralize and empower local people to achieve NRHM goal. Limited studies have been conducted to assess the VHSNC in India. Objective: To assess the composition of VHSNC and find out the deviations, if any, from the prescribed framework of guidelines, awareness of VHSNC members about their roles and to assess the functioning of VHSNC. Methodology: The cross-sectional study was carried out from July 2012 to June 2013 in two selected blocks (out of eight) in Nainital district of Uttarakhand. A total of 18 VHSNCs were studied, nine from Haldwani and nine from Bhimtal covering 48 revenue villages, 31 in Haldwani and 17 in Bhimtal block respectively. Out of 139 members in 18 VHSNC, 110 members were interviewed. Results: Mean age of the study subjects was 39.01 ± 8.5 years. Out of the 110 members studied maximum 73 (66.4 %) were female and 37 (33.6%) were males. Maximum subjects, 35 (32.8%) were qualified up to intermediate followed by 29 (26.4%) graduates. Maximum 78 (70.9%) participants belonged to Others (General) category, 30 (27.3%) belonged to scheduled caste and only two (1.8%) belonged to OBC category. There were no subjects belonging to scheduled tribe. Out of the 110 members interviewed there were 18 (16.4%) Gram Pradhans, 10 (9.1%) Female Health Workers, 20 (18.2%) ASHAs and 15(13.6%) Anganwadi Workers. There was very low awareness among the members about role of the committee. Maximum, 93 responses were for cleaning village environment which were given by all 18 Gram Pradhans, 16 ASHAs and ward members.
Article
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Childhood stunting (low height-for-age) is a marker of chronic undernutrition and predicts children’s subsequent physical and cognitive development. An estimated 52 million children in India are stunted. There is a broad consensus on determinants of child undernutrition and interventions to address it, but a lack of operational research testing strategies to increase the coverage of these interventions in high burden areas. Our study aims to assess the impact, costeffectiveness, and scalability of a community intervention involving a government-proposed community-based worker to improve growth in children under two.
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Mixed methods research offers powerful tools for investigating complex processes and systems in health and health care. This article describes integration principles and practices at three levels in mixed methods research and provides illustrative examples. Integration at the study design level occurs through three basic mixed method designs-exploratory sequential, explanatory sequential, and convergent-and through four advanced frameworks-multistage, intervention, case study, and participatory. Integration at the methods level occurs through four approaches. In connecting, one database links to the other through sampling. With building, one database informs the data collection approach of the other. When merging, the two databases are brought together for analysis. With embedding, data collection and analysis link at multiple points. Integration at the interpretation and reporting level occurs through narrative, data transformation, and joint display. The fit of integration describes the extent the qualitative and quantitative findings cohere. Understanding these principles and practices of integration can help health services researchers leverage the strengths of mixed methods.
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Introduction Primary health care approach is aimed at community participation in understanding the health needs of the community. To address the community participation in institutionalized health services in India, Village Health Sanitation and Nutrition Committees (VHSNC) werer formed at village level under the National Rural Health Mission (NRHM). About 421,892 VHSNCs have been constituted across the country at the village level. The internal program implementation review mechanism has highlighted the lack of clarity over roles and responsibilities of VHSNCs and has stressed upon a detailed research for better understanding. The study presented in this abstract was conducted during the period March to July 2011 in the three of the eight North Eastern states: Manipur, Meghalaya and Tripura. Methods The strata of three districts were selected from Manipur and Meghalaya, and of two districts from Tripura. Furthermore, listing of all VHSNCs in these districts was made along with their village names. Of this list, 10% of VHSNCs were selected based on systematic random sampling method. A pretested semi-structured interview schedule was used for data collection. The indicators were relating to registers, fund management, community interaction through meetings, interaction with public health institutions, and their experience of importance of VHSNCs. The key informants for the study were the members of the Panchayati Raj Institutions (local elected bodies) and Accredited Social Health Activists (ASHA: female community health workers) who are presidents and member secretaries of VHSNC respectively. The information provided by interviewee was validated through interacting with other members of the VHSNCs. A VHSNC would have about six to seven members. The data validation also included physical verification of registers/records, meeting minutes and schedules at the village. Results The VHSNC constitution in the study state generally followed the national guideline. However the norms for establishing VHSNCs were revised as per the state needs. In Manipur, the norm was based on number of ASHAs rather than number of revenue villages. This dilution led to more number of VHSNCs and therefore more grant in terms of resources from the center. For the ease of financial management, all VHSNCs had to have a bank account in the name of the VHSNC. Only 60% of VHSNCs in the Chandel district of Manipur had opened bank accounts. The funds from the bank were withdrawn at one point of time and this was observed mainly among most VHSNCs in Manipur and Meghalaya state. Overall, utilization of funds was found to be good in all VHSNCs studied. However, the grants that were allocated were erratic and this hampered the activities of VHSNCs on ground. Community level monthly meeting is one of the core activity of VHSNC and the results showed that about 84% of VHSNCs in Manipur, 36% in Meghalaya and 68% in Tripura had organized these meetings regularly. To overcome the resource constraint, many VHSNCs had generated funds through voluntary donations. In Manipur, About 11.4% of VHSNCs in the district were engaged in fund generation activities, ranging from INR 3,000 to INR 8,000.The funds were utilized for construction of community toilets, furniture, safe drinking water, health awareness campaigns and cleanliness activities in the village. Lack of orientation about the roles and responsibilities have also been highlighted by all VHSNCs members interviewed. Discussion We observed that the states had revised the norms related to constitution of VHSNCs taking into account the geo-politico-social context. As a result the number of VHSNCs varied across the states. Secondly, having a bank account for each of the VHSNCs is an important aspect as it can provide details about the number of VHSNCs and the financial transactions. The major drawback in term of financial management is the lack of capacities of VHSNC members to produce finance utilization certificates for the money received on an annual basis. VHSNC model is solely driven by active leadership role assumed by the people’s representatives at the grassroots level. From this study we also realized that some of the VHSNCs had involved in fundraising activities and other involved in providing safe drinking water. All these activities highlight the people’s representatives’ sensitization towards heath needs of the village. We therefore suggest that grassroots level sensitization as well as capacity-building of the members of the committee is essential in successful functioning of VHSNC model.
Article
After years of deterioration of the health care system, due to the declining economy and the World Bank Structural Adjustment Programs of the 1980s, Zambia has initiated a health reform entailing a radical decentralization of the health care system. The reform combines neoliberal tendencies of the 1980s with a renewed focus upon the development of human resources and community participation. Participation now carries connotations of "ownership" and "responsibility" rather than "democracy" and "empowerment" as it did in the 1970s, and the goal of the reform is to achieve equal access to health through increased cost-effectiveness of the health care system. This article explores how some of these policy terms translate into concrete social interactions around health units. Rather than attempting to measure the extent to which participation is achieved, we discuss how social relations are altered due to activities implemented as part of the reform. We explore what these social interactions teach us about the direction in which the Zambian health care system is moving and raise questions about some of the assumptions in prevailing global health policies. In particular we wish to draw attention to the crucial but often neglected role of health workers.