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

Various attempts have been made in India with respect to decentralization, most significantly the 73rd Amendment to the Constitution of India (1993) which provided the necessary legal framework for decentralization to take place. However, the outcome has been mixed: an evaluation of the impact of decentralization in the health sector found virtually no change in health system performance and access to health services in terms of availability of health personnel or improvement in various health indicators, such as Infant Mortality Rates or Maternal Mortality Ratio. Subsequently, there has been a conscious effort under the National Rural Health Mission (NRHM)-launched in 2005-to promote decentralization of funds, functions and functionaries to lower levels of government; and Karnataka had a head-start since devolution of all 29 functions prescribed by the 73rd Amendment had already taken place in the state by the late 1990s. This study presents the findings of an on-going research effort to build empirical evidence on decentralization in the health sector and its impact on system performance. The focus here is on analyzing the responses of health personnel at the district level and below on their perceived 'Decision Space'-the range of choice or autonomy they see themselves as having along a series of functional dimensions. Overall, the data indicate that there is a substantial gap between the spirit of the NRHM guidelines on decentralization and the actual implementation on the ground. There is a need for substantial capacity building at all levels of the health system to genuinely empower functionaries, particularly at the district level, in order to translate the benefits of decentralization into reality.

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Decentralization and decision space in the health sector: a case study from Karnataka, India

There are several studies from different geographical settings and levels on maternal health, but none analyzes how accountability problems may contribute to the maternal health outcomes. This study aimed to analyze how accountability problems in public health system lead to maternal deaths and inequities in India. A conceptual framework was developed bringing together accountability process (in terms of standard setting, performance assessment, accountability (or answerability, and enforceability) —an ongoing cyclical feedback process at different levels of health system) and determinants of maternal health to analyze the influence of the process on the determinant leading to maternal health outcomes. A scoping review of qualitative and mixed-methods studies from public health sector in India was conducted. A narrative and interpretive synthesis approach was applied to analyze data. An overarching influence of health system-related factors over non-health system-related factors leading to maternal deaths and inequities was observed. A potential link among such factors was identified with gaps in accountability functions at all levels of health system pertaining to policy gaps or conflicting/discriminatory policies and political commitment. A large number of gaps were also observed concerning performance or implementation of existing standards. Inherent to these issues was potentially a lack of proper monitoring and accountability functions. A critical role of power was observed influencing the accountability functions. The narrative and interpretive synthesis approach allowed to integrate and reframe the relevant comparable information from the limited empirical studies to identify the hot spots of systemic flaws from an accountability perspective. The framework highlighted problems in health system beyond health service delivery to wider areas such as policy or politics justifying their relevance and importance in such analysis. A crucial message from the study pertains to a need to move away from the traditional concept of viewing accountability as a blame-game approach and a concern of limited frontline health workers towards a constructive and systemic approach.

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How do accountability problems lead to maternal health inequities? A review of qualitative literature from Indian public sector.

A multi-strategy community intervention, known as National Rural Health Mission (NRHM), was implemented in India from 2005 to 2012. By improving the availability of and access to better-quality healthcare, the aim was to reduce maternal and child health (MCH) inequalities. This study was planned to explore the perceptions and beliefs of stakeholders about extent of implementation and effectiveness of NRHM's health sector plans in improving MCH status and reducing inequalities. A total of 33 in-depth interviews (n = 33) with program managers, community representatives, mothers and 8 focus group discussions (n = 42) with health service providers were conducted from September to December 2013, in Haryana, post NRHM. Using NVivo software (version 9), an inductive applied thematic analysis was done based upon grounded theory, program theory of change and a framework approach. Almost all the participants reported that there was an improvement in overall health infrastructure through an increased availability of accredited social health activists, free ambulance services, and free treatment facilities in rural areas. This had increased the demand and utilization of MCH services, especially for those related to institutional delivery, even by the poor families. Service providers felt that acute shortage of human resources was a major health system level barrier. District-specific individual, community, and socio-political level barriers were also observed. Overall program managers, service providers and community representatives believed that NRHM had a role in improving MCH outcomes and in reduction of geographical and socioeconomic inequalities, through improvement in accessibility, availability and affordability of the MCH services in the rural areas and for the poor. Any reduction in gender-based inequalities, however, was linked to the adoption of small family sizes and an increase in educational levels.

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Impact of a Multi-Strategy Community Intervention to Reduce Maternal and Child Health Inequalities in India: A Qualitative Study in Haryana.

Maternal anaemia prevalence in Bihar, India remains high despite government mandated iron supplementation targeting pregnant women. Inadequate supply has been identified as a potential barrier to iron and folic acid (IFA) receipt. Our study objective was to examine the government health system’s IFA supply and distribution system and identify bottlenecks contributing to insufficient IFA supply. Primary data collection was conducted in November 2011 and July 2012 across 8 districts in Bihar, India. A cross-sectional, observational, mixed methods approach was utilized. Auxiliary Nurse Midwives were surveyed on current IFA supply and practices. In-depth interviews (n = 59) were conducted with health workers at state, district, block, health sub-centre, and village levels. Overall, 44% of Auxiliary Nurse Midwives were out of IFA stock. Stock levels and supply chain practices varied greatly across districts. Qualitative data revealed specific bottlenecks impacting IFA forecasting, procurement, storage, disposal, lack of personnel, and few training opportunities for key players in the supply chain. Inadequate IFA supply is a major constraint to the IFA supplementation program, the extent of which varies widely across districts. Improvements at all levels of infrastructure, practices, and effective monitoring will be critical to strengthen the IFA supply chain in Bihar.

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Identifying bottlenecks in the iron and folic acid supply chain in Bihar, India: a mixed-methods study

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.

Pramod Kumar Sah

Papers

Performance of village health, nutrition and sanitation committee: A qualitative study from rural Wardha, Maharashtra

Performance of village health, nutrition and sanitation committee: A qualitative study from rural