|Year : 2017 | Volume
| Issue : 4 | Page : 290-296
Assessment of village health sanitation and nutrition committees of Chandigarh, India
Reetu Passi1, Sonu Goel2, Sangeeta Ajay3
1 Ph.D. Scholar, Department of School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Additional Professor, Department of School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Nodal Officer, National Health Mission, Chandigarh, India
|Date of Web Publication||6-Dec-2017|
School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Village Health, Sanitation and Nutrition Committees (VHSNCs), one of the key interventions introduced by National Rural Health Mission, are an important mechanism to ensure community participation and ownership for decentralized health planning. Objectives: To assess the implementation status of VHSNCs and analyze the issues regarding their implementation in the villages of Chandigarh. Methods: A cross-sectional mix method study was conducted in the year 2015 in all 22 VHSNCs of Chandigarh. The data of VHSNCs' members were obtained using interview schedule and in-depth interview checklist, while record review checklist was used to assess functioning of VHSNCs. A scoring sheet was developed based on sociodemographic profile, public services monitoring, training status, untied funds utilization, and regularity of monthly meetings. The comparison of VHSNC indicators was done between villages under Panchayat and Municipal Corporation (MC). Results: Most VHSNCs' members are trained (except medical officers) and had their joint bank account (95.4%). Maximum fund is utilized for administrative purposes, leaving less for health and nutrition-related activities. Most villages (68.9%) got 25–30 score depicting that implementation status of VHSNCs under these villages is “promising,” while one and six villages were “low performing” and “good performing,” respectively. Public service monitoring indicator's implementation was better in villages under Panchayat as compared to those under MC. Conclusion: The performance of most villages having VHSNCs under Chandigarh was satisfactory. Few areas such as training of medical officers and supportive supervision of VHSNCs needs strengthening for achieving mandate of National Rural Health Mission regarding community ownership and decentralizing health sector.
Keywords: Community ownership, decentralization, National Rural Health Mission, village health, sanitation and nutrition committees
|How to cite this article:|
Passi R, Goel S, Ajay S. Assessment of village health sanitation and nutrition committees of Chandigarh, India. Indian J Public Health 2017;61:290-6
|How to cite this URL:|
Passi R, Goel S, Ajay S. Assessment of village health sanitation and nutrition committees of Chandigarh, India. Indian J Public Health [serial online] 2017 [cited 2019 Oct 14];61:290-6. Available from: http://www.ijph.in/text.asp?2017/61/4/290/220058
| Introduction|| |
Accessibility and availability to healthcare in India, especially in rural areas, is a continuing cause of concern for policymakers even today. Despite numerous efforts, the gap between the aspiration – providing quality healthcare on an equitable, accessible, and affordable basis across all regions and communities of the country – and today's reality still remains. Vertical health and family welfare programs in India have limited synergy at operational levels and lack of community ownership of public health programs impacts levels of efficiency, accountability, and effectiveness.
The launch of National Rural Health Mission (NRHM) in 2005, now renamed National Health Mission (NHM), has provided the Central and the State Governments with a unique opportunity for carrying out architectural corrections and necessary reforms in the health sector to bring forth the agenda of community involvement in better public health planning. The thrust of the mission is on establishing a fully functional, community-owned, decentralized health delivery system with intersectoral convergence at all levels, so as to ensure simultaneous action on a wide range of determinants of health. N (R) HM has clearly envisaged community action as the only guarantee for the right to health care by putting community pressure on the health system. Moreover, it is widely understood and accepted that for services to maintain quality and to be effective, people must have ownership and control.
Village Health and Sanitation Committee, later renamed as Village Health, Sanitation and Nutrition Committee (VHSNC), was formed for each village under N(R) HM by providing untied grant for village level activities. As the name suggests, this committee is expected to take collective action on issues related to health and its social determinants at the village level. The concept of constituting VHSNCs lies in the fact that decentralized health services by the community for the community will provide inputs to ongoing healthcare activities at the local level and thus cater to local context and healthcare needs.
A decade has passed since the launch of NRHM; it is now imperative to look into the operationalization of its core strategies such as VHSNCs. Few studies were conducted to assess its operationalization; a comprehensive study to see VHSNCs as a unique instrument to drive local health agenda was missing. A study on rapid assessment of communization processes of the N(R)HM in states of Jharkhand, Orissa, and Bihar showed that N(R)HM guidelines for VHSNCs were not being followed religiously. Other studies indicated that most of the members of the committee were unaware of their roles and responsibilities mainly due to lack of proper orientation. In contrast, some states such as Kerala, West Bengal, Maharashtra, and Gujarat have shown effective functioning of VHSNCs.
No such literature is available for northern region of India. The local context of villages of Chandigarh (located in proximity to urban region) is different from other villages of country that are situated at huge distances from the urban areas. This study was conducted to assess the implementation status of VHSNCs in villages of Chandigarh and therefore to identify the bottlenecks related to the implementation of VHSNCs.
| Materials and Methods|| |
The Union Territory of Chandigarh is a northern Indian city with a population of 1.5 million (census 2011). There are a total of 22 villages in Chandigarh, nine under the control of Chandigarh Municipal Corporation (MC) while 13 under the jurisdiction of Chandigarh administration governed by elected gram Panchayat. The demographic, socioeconomic, and health profile is almost similar across villages of Chandigarh. One auxiliary nurse midwife (ANM) looks after one village of Chandigarh.
Study design and population
A cross-sectional mix method study was conducted between January and May 2015 using universal sampling technique in all (n = 22) VHSNCs of Union Territory of Chandigarh. A mixed methods research design is a technique for collecting, analyzing, and “mixing” both quantitative and qualitative methods in a single study to understand a research problem. The population of villages catered by one ANM ranges from 4000 to 49,554. Simple random technique (lottery method) was used to select one Anganwadi center (AWC) and one Government High school from each village. Similarly, members of VHSNCs of villages, namely, one ANM, one Anganwadi Worker (AWW), 2 members of other categories (Sarpanch, NGO member, Resident, Trained Dai), and Principal of the Government schools of each village were randomly enrolled in the study.
For data collection, two tools were used – in-depth interview schedule (for VHSNC members) and records review checklist. The interview schedule for VHSNC members was developed after consultation of experts and extensive literature review. It contained questions regarding composition of the VHSNC, bank account details, fund position, training of the members, and monthly meetings. An observation checklist was prepared for the assessment of VHSNCs on the basis of Guidelines for Community Processes by NRHM. This included review of records regarding public services monitoring tools, birth/death registers, VHSNC monthly meeting register record, VHSNC monthly meeting minutes, cash book for VHSNC, and VHSNC statement of expenditure.
Pretesting of data collection tools was done in one village after which the tools were modified and finalized for the study. The primary data were collected from the members of VHSNCs through in-depth interview schedule administered by the trained researcher. The secondary data were obtained through the records maintained by the VHSNC office and selected AWC of the respected village using the predesigned observation checklist. Data from one government high school were collected after getting the permission from the principal.
Data entry was done in MS Excel, and frequency tables and percentages were obtained. Scoring sheet was developed based on five major domains related to VHSNCs, namely, sociodemographic profile of members, public services monitoring, training of members, bank account-untied funds, and monthly meetings. All the items under each major domain were categorized from 0 to 2 based on their performance. 0 meant poor performance, whereas 2 referred to good performance [Table 1]. Later, score of each indicator was added to obtain an overall score of the indicators. Furthermore, total score of each village was obtained by adding score of individual indicators. Later, the villages were color coded based on their performance. The poor performing village (score <25) was given red color, promising village (score 25–30) was given yellow color, and the good performing village (score >30) was given green color. The comparison of VHSNC indicators was done between villages under Panchayat and villages under MC.
|Table 1: Scoring of Village Health, Sanitation and Nutrition Committees on the basis of key indicators|
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The data collected through in-depth interviews (IDIs) were summarized and a structure was built with the statements of the interviewees categorized under major themes such as funds/resources related issues, administration-related issues, responsibilities/participation of members, and village problems.
The permission of administrative authorities of NHM, Chandigarh was obtained for data collection and publication of information. Besides, informed written consent was also obtained from the VHSNC members enrolled in the study. The permission from Institute Ethics Committee of Punjab University was obtained before conduction of study.
| Results|| |
All (n = 22) villages in Union Territory of Chandigarh having VHSNCs were assessed. Thirteen out of 22 villages come under Panchayat and rest (n = 9) is under MC. About 46% VHSNCs were formed in the year 2010, and 27% VHSNCs were formed each in years 2009 and 2011.
Sociodemographic profile of village health, sanitation and nutrition committee members
None of the VHSNCs in Chandigarh are following the Government of India (GOI) mandate of constituting committee with 15 members. The women representation in all VHSNCs was encouraging with women constituting over 50% of the total members of committee. The Schedule Caste member's representation in all VHSNCs was unsatisfactory [Table 2].
|Table 2: Sociodemographic profile of Village Health, Sanitation and Nutrition Committee members in study area|
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Public services monitoring indicators of villages
Overall AWCs were found to be deficient in regular attendance of children aged 3–6 years (42.5%) and ensuring complimentary feeding to 6–12-month-old children (59.9%). The other services such as child growth monitoring and child vaccination were being delivered to satisfactory level. Village Health Nutrition Day (VHND) was celebrated every month on the same day as VHSNC meeting in 19 out of 22 villages (86.4%). Free ration and old age pensions were being given in all villages. Cases of childhood marriages and violence against women were not registered by ANMs in any village. Individual household latrines were constructed and government water supply was being provided in every village. Cases of home deliveries were reported in 16 villages (72.7%) ranging from 1 to 13 (mean = 4.25, standard deviation = 2.1) in study period of 6 months (July–December 2014). No records were available in schools of 5 villages regarding attendance of 6–14-year-old girls. Birth/death registers and village health registers were maintained properly by the ANMs of each village. The implementation of AWC services under the ambit of Panchayat were found better than that of AWC of MC [Table 3].
|Table 3: Comparison of public services monitoring indicators between villages under Panchayat and Municipal Corporation, Chandigarh|
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Status of training and monthly meetings of village health, sanitation and nutrition committee members
More than three fourth (77.8%) of VHSNC members had got orientation training. Training for VHSNC was however not provided to the medical officers.
Merely 6 villages (27.3%) had regular monthly meeting of VHSNCs. “Members busy,” “members not interested,” and “poor weather conditions” were the common reasons found for cancellation of meetings. Health, hygiene, and water-sanitation issues were discoursed during the meetings in more than two-third of the VHSNCs. However, nutrition-related issues were never discussed in any of the VHSNC except three; thus, defeating entire purpose of adding nutrition component in the existing mandate of VHSNC [Table 3].
Details of bank accounts untied fund of village health, sanitation and nutrition committee
Almost all VHSNCs (95.4%) had joint bank accounts, and funds were received in financial year 2014–2015 by 21 VHSNCs (95.4%). Utilization of funds was a major area of concern since 14 (66.7%) of the VHSNCs were not able to utilize even 50% of the funds. Status of VHSNCs under Panchayat regarding the presence of bank account, receipt of funds for the financial year 2014–2015, availability of cash book, and utilization of funds were better than that of VHSNCs under MC. Most of the ANMs were satisfied with the amount of fund received annually [Table 3].
Activities for which untied funds were used by village health, sanitation and nutrition committee
In most of the villages, the maximum fund utilization (31.2%–100%) was reported for the activities categorized under “administrative expenses” such as cleaning of subcenter, whitewashing, buying utensils, repair of electricity stuff and furniture, buying stationary, and other such material. Only two VHSNCs had spent funds on water and sanitation activities and that too very low (2.1%–4.2%). For activities related to health and nutrition, only four villages had spent funds ranging from 10.5% to 65.6% of total expenditure and 15 out of 22 villages reported “Nil” expenditure. Two VHSNCs (9.1%) had expenditure more than that of expected for 6 months (Rs. 5000.00) while five VHSNCs (22.7%) reportedly had no expenditure at all in the study period of 6 months (from July to December 2014).
Scoring of villages
Fifteen villages (68.2%) got 25–30 score (out of a maximum score of 40) depicting that implementation status of VHSNCs under these villages is “promising”. Six villages out of 22 (27.3%) have shown good performance (score over 30) and only one village comes under the category of low performance (score <25). The major contributing factor toward low performance of the same was nonutilization of untied funds. Only one AWC got maximum score as far as attendance of children aged 3–6 years was concerned. None of the villages satisfied the criteria of having minimum number of scheduled caste (SC)/scheduled tribe (ST) members in VHSNCs. The villages showed good performance regarding the nutritional status of children aged 0–3 years but performance of providing complimentary feeding to children of age 6–12 months was average. In case of monthly meetings, all the villages were in the category of average performance while villages under MC performed better on training status [Table 4].
|Table 4: Scoring of implementation status of Village Health, Sanitation and Nutrition Committees in Chandigarh|
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A total of 12 IDIs were conducted with 2 members of each category comprising of ANMs, AWWs, Sarpanch, resident members, trained dais, and NGO members. The responses of participants were categorized into four major themes, namely, funds or resources; administrative issues; roles and responsibilities; and village problems. The [Box 1] enlists the key issues under the themes and verbatim expressed by members pertaining to the functioning of VHSNCs.
| Discussion|| |
Decentralization of the planning process in N(R)HM is envisaged through community participation and ownership on various local public health issues. Thus, VHSNCs are set up at the revenue village level to undertake local action and to ensure that public health activities at village level receive priority action through organized community participation.
The year of formation of maximum number of VHSNCs (45.4%) in the present study was 2009–2010 which was in contrary to few studies conducted in India which showed maximum VHSNCs were formed in the period of 2006–2008., The reason for delayed formation of VHSNCs in study area could be due to multiplicity of reasons such as lack of mandatory implementation, lack of training, late opening of the bank accounts, and frequent transfers of ANMs who were present during the formation of the committees.
Similar to Uttarakhand and Tamil Nadu, over 3/4th members of VHSNCs were females in the current study, which fulfill the criterion of GOI guidelines of having minimum 50% women members., More representation of females in the studies across country is an encouraging sign and points toward more empowerment and ownership of village-related issues among the fairer gender.
The majority (85.8%) of members in our study were general caste category while only few (14.2%) were from SC category and none from STs. A study conducted by Semwal et al. (2013) in Nainital district of Uttarakhand also showed that 70.9% participants belonged to general category, 27.3% belonged to SC category, and no member belonged to ST category. The reason behind no ST category member found in our study is that there are no tribes found in this region. However, Chandigarh has the highest proportion of SC population (17%) among all Union Territories of India and ranks overall 8th in India in terms of proportion of schedule caste, but their representation in VHSNC is quite dismal. The present study has maximum proportion of AWWs and Gram Pradhans in VHSNCs which was in sharp contrast to other studies conducted in North Eastern and North Western states.,
In this study, it was found that all the VHSNCs have their joint bank accounts opened except for one VHSNC. These results were similar to the study by Regional Resource Centre for North Eastern States (RRC, NE) in 2013 which showed that all the VHSNCs in Meghalaya and Tripura have opened their joint bank account with Panchayati Raj Institution member/Headman and the ASHA/AWW as joint signatories. Almost all the VHSNCs of our study had received Rs. 10000.00 as untied fund for the financial year 2014–2015 which was in contrast to a study conducted in Uttar Pradesh (2008–2009).
In contrast to study by Ganesh et al. (2013) in a district of Tamil Nadu, majority (72.7%) of ANM in the current study were satisfied with the funds. Our study also found that decision taken to utilize this fund was made collaboratively by all members which was in accordance with a study conducted in Jamnagar (2013) and in contrast to few studies showing that only ANM or secretary takes this decision without consulting other members.,,
The activities conducted during VHND in the present study such as community toilet cleaning, cleaning of village, notice board for health information, medicine purchase, instruments purchase, or helping poor patient were found to be similar to the study conducted in North Eastern states (2013). However, in another study conducted in North Western state (2012), very few of such activities were conducted primarily due to lack of awareness among VHSNC members and absence of budget allocation.,
As far as monthly meetings and training of the members are concerned, many studies have revealed that neither meetings nor training was being conducted to the satisfactory level.,,,, However, results of our study were contrary to them as 54.6% VHSNCs had 10–12 monthly meetings in the year 2014 and 77.8% of the members had received training conducted by National Health Mission, Chandigarh.
| Conclusion and Recommendations|| |
The performance of most VHSNCs under Chandigarh is satisfactory, still few areas such as training of medical officers and monitoring of VHSNCs need more emphasis. It is suggested that focus should be on training and supportive supervision of VHSNCs so that they can plan their activities effectively and utilize funds as per GOI guidelines.
Limitations and strength of the study
Due to time constraints, all members could not be interviewed and the perspective of the villagers was also not taken into consideration. However, it is a first study of its kind which comprehensively assessed the implementation of all 22 VHSNCs in Chandigarh by taking almost all indicators as envisaged under VHSNC guidelines of GOI.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]