Under the National Rural Health Mission (NRHM) 2005, decentralization of functions, functionaries, and funds was identified as an important tool to improve the service delivery of the public health system. The mission was optimistic that this will result in more effective management of health programs as it facilitates the accommodation of the local context, subsequently improving the region’s health outcomes. Decentralization of power across different administrative levels was expected to provide a more accountable and robust service delivery system that accommodates the voices of people across multiple levels.
However, several years down the line, the optimism with which the NRHM had conceptualized decentralization has not borne fruit. According to Seshadri and Parab, various factors impeded the successful decentralization of health governance: political and bureaucratic resistance to sharing resources and power, lack of funds, and minimal clarity about the responsibilities of administrative units. They further argue that to ensure effective decentralization there is a need to emphasize the “political will to devolve funds and powers to lower levels of government” and “substantial capacity building at all levels of the health system to genuinely empower functionaries” (Seshadri, Parab, and Kotte). Parallelly, there is a need to ensure decision space for the functionaries across different levels to truly experience decentralization’s benefits.
The following figure represents the decentralization of health governance as proposed in the NRHM:
The Village, Health, Sanitation, and Nutritional Committees
The Village, Health, Sanitation, and Nutritional Committee is the most local-level administrative unit that facilitates, plans, and monitors the health needs of a village. The committee performs many functions. It supports service providers, mobilizes beneficiaries, and develops village plans that are specific to local contexts. Ultimately, the VHSNC is to promote “community action for health” by being a platform of mobilization and action. As an administrative unit, it is also assumed to address the social determinants of health. VHSNC members identify problems faced by the community to access health, nutrition, and sanitation services and find local solutions through discussions and meetings.
In my experience of working with India Health Action Trust in Madhya Pradesh’s Shahdol district, I came across villages with different models of VHSNCs. There were villages where the committee was active and regular, showing promising health outcomes due to this platform. There were also villages where these existed on paper, without performing any of the mandated functions.
Understanding the role of the VHSNC in improving the village’s MNCH services, my organization decided to conduct a pilot initiative that sought to reactivate and revamp the VHSNC in one village in Jaisinghnagar block in Shahdol. The village was chosen as it had performed poorly on several MNCH indicators in a baseline survey conducted by the organization.
Revamping the VHSNC – The Pilot Experience
The team began by collaborating with the Block Program manager and the Block community manager of the health department to discuss the pilot initiative. The positive reception encouraged us to begin the task enthusiastically. The intervention village had a population of 2100 and had four ASHAs. Though the village had a VHSNC committee previously, it became dysfunctional during the time of COVID in the absence of funds. Furthermore, the composition of this committee was not representative of all the social groups or geographical regions in the village. Emphasizing the representation of community members from distant geographies within the village was significant to ensure that the ASHA had a support system even in places that were away from the main roads.
In the preparatory phase, the team created ASHA area maps with the four ASHAs of the village to understand different tolas(regions) within each ASHA area. Information regarding the socio-economic profile of the population, the number of households, estimated pregnancies in each area, hard to access geographies were understood through these micro-level ASHA area maps. Transect walks were conducted in all four ASHA areas to identify the tolas being left behind and understand the community’s access to health services. The team facilitated coordination between the Panchayat and the frontline workers of the village. At each stage, suggestions from the Panchayat, frontline workers, and the block health officials were incorporated, carrying the initiative forward.
After facilitating the coordination between different stakeholders, the VHSNC reactivation and revamping meeting were conducted in February. Representatives of the Panchayat, frontline workers, and community members were part of this meeting.
After a discussion on the importance and role of VHSNC members, a newly elected VHSNC committee was announced. The newly formed committee with 25 members had representation from all ASHA areas and SC, ST, and OBC communities. 76% percentage of the committee members are women. 44% of the committee is composed of members from scheduled tribes.
Each ASHA presented her ASHA area map to the Panchayat and the committee members. The ASHA and the Anganwadi worker in each area raised the obstacles they faced in functioning. This was followed by discussion and finding solutions in coordination with the secretary and president of the village. The meeting concluded with an oath-taking to reaffirm the commitment of all VHSNC members to being leaders and guardians of their village.
Learnings and going forward
The experience was a learning process. Bringing frontline workers and key decision-makers of the community together to ensure effective actions on problems was the main objective. Instituting a VHSNC committee is only step one in the processes of health governance. Ensuring they have funds, autonomous decision-making power, equal opportunities, etc. are all factors that should be followed to ensure that the committee functions to its best ability. This requires capacity building, support from government officials, regular funding, and unwavering determination. While this pilot taught me the effort required to ensure equal representation in local-level committees, it also showed the collective labour and collaboration required to arrive at this.
What drives the initiative to strengthen community platforms like this is the belief that together we can achieve so much more. As one ASHA who has been running the VHSNC for more than a decade told me during a conversation, “The perk of having such a community platform is everyone does a little bit that is in their capacity.” It is these little actions that go a long way in making an impact on the well-being of the community.
References
Seshadri, Shreelata Rao, et al. “Decentralization and Decision Space in the Health Sector: a case study from Karnataka, India.” Health Policy and Planning (2016): 171-181.
