Limitations in the functioning of Village Health and Sanitation Committees in a North Western State in India

Abbreviations: ANM: Auxiliary Nurse Midwife; ASHA: Accredited Social Health Activist; AWW: Aangan Wadi Worker; CBO: Community Based Organizations; ICDS: Integrated Child Development Services Scheme; MO: Medical Officer; MPHW: Multi Purpose Health Worker; MSW: Masters in Social Work; NGO: Non Government Organization; NRHM: National Rural Health Mission; OBC: Other Backward Class; PRI: Panchayat Raj Institution; SC: Schedule Caste; SHG: Self Help Group; SMO: Senior Medical Officer; ST: Schedule Tribe; UC: Utilization Certificate; UP: Uttar Pradesh; VHB: Village Health Board; VHF: Village Health Fund; VHND: Village Health and Nutrition Day; VHP: Village Health Plan; VHSC: Village Health and Sanitation Committees.


INTRODUCTION
Public healthcare services in India suffer from low quality and poor access.Despite significant efforts to raise government resources towards health sector, the health indicators remain very low. 1 One of the underlying purposes of NRHM is to improve public health services, Dr. Rajpal Singh, et al.: Limitations in the functioning of Village Health and Sanitation Committees in India especially in states with weak public health infrastructure and indicators. 2,3To achieve this, there has been a fair consensus among various stakeholders that local people must be given ownership and control.Such ownership can only be transferred with participation and control of local people (mainly from villages) over various aspects like planning of activities, prioritizing local problems, making money available to them and joint decision making in utilization of funds.With the idea of decentralization and empowerment of local people to achieve NRHM goal, one of the major initiatives under NRHM has been the introduction and formation of VHSC 4 .Such committees have been constituted at the village level with the idea of allowing more power and autonomy to local people so that it can lead to improved health status of the community. 5e definition of VHSC as conceptualized under NRHM is: "The VHSC is a facilitating body for all village level development programmes.It is a body that comprises of village level health workers, representative from PRI; representatives of various CBO including groups who are marginalised 2 ".
The main aim of VHSCs is to make people aware of the health programmes so that the utilization of services can be improved.Such committees have been constituted in the whole country.However, literature suggests some weaknesses in the formation and functioning of the committees. 6For example, in many places, the formation of committees has not been according to NRHM guidelines. 5 many places in India, committees were formed in the year 2007, but many committees were not clear about their aims and their roles and responsibilities.In addition, problems have also been reported in the selection of members of VHSC where the required number was less and composition was not according to the guidelines of NRHM. 2 Furthermore, no orientation trainings have taken place for its members and as a result the members were unaware about their roles as well as goals of the VHSC.The study also reported incomplete knowledge regarding utilization of VHF to the chairpersons, ANM and MO.
A study on rapid assessment of communitization processes of the NRHM in different states of India like Jharkhand, Orissa and Bihar found that the formation of committees was not according to NRHM guidelines and there were huge irregularities in meetings and the fund utilization was not according to guidelines. 6In most of places VHSC have either not been formed and even where they have been formed, most of the members were neither aware about their membership in VHSC nor about the use of VHF. 7 Studies also indicate that most of the members were unaware of their roles and responsibilities, did not prepare budgets, no trainings were given to members and monitoring and supervision part was poor. 6Another study in Bihar, Chhattisgarh, Jharkhand and Orissa in March 2008 showed that all states except Bihar did not have bank accounts. 8Yet another study in Uttar Pradesh in 2008-09 reported problems in the utilization of funds because of unavailability of guidelines or lack of understanding of these guidelines.The study also reported delay in the release of funds. 9wever, there have been some studies that show effective functioning of VHSCs.A study in Karnataka and UP reported that in UP, the level of community involvement in the planning and implementation phase was better due to NGO support. 10Similarly in Orissa, involvement of ASHA and PRI in VHSCs resulted in community action. 9In Maharashtra, VHSCs are fully functional and have received excellent involvement and cooperation of PRIs. 9 In Tamil Nadu, VHSCs meet regularly and the record of discussions is maintained and the untied funds are well utilized. 9n Kerala, Village Health and Nutrition Days are regularly observed and the untied funds of VHSC are being used.Absence of malaria, filarial and dengue in the state may indicate success of such activities. 9Therefore, the intersectoral convergence of PRIs with the VHSCs is very vital. 11e main objective of the study was to assess whether VHSC have been formed and function according to given NRHM guidelines and whether the VHSC members were aware of their roles and responsibilities.

METHODS
This was a cross sectional study.The data collection was done during April to June, 2010.The study was done in 17 VHSC from one block in a North Western state, India.The study district and block were purposively selected.The reason for choosing known district and block was to identify deficiencies in the formation and functioning of VHSC and provide concrete and feasible recommendations as it was authors own work district.The main reason for selecting only one block was the limited duration of the study and lack of resources available for data collection.Under the selected block, 25% of the VHSC (17 VHSC from a total of 66) were randomly selected.
The respondents of the study included all the members of the VHSCs including Sarpanchs (chairman), ANM, ASHA workers, PRI members, AWW, MPHW, retired persons, teachers and NGO representatives.All the members from the selected VHSCs who were present during the study and willing to participate were included in the study.According to the NRHM guidelines, the actual number of members in each VHSC should be at least 11.Hence we were expecting to interview nearly 11*17=187 members.However in the field, we could only find 6 members (on an average) per VHSC.In total, out of 104 members from the 17 committees, we could talk to 94 members.We were able to talk to all the Chairpersons, ASHA, MPHW, Ex Servicemen, NGO members; 13 out of 17 ANMs; 25 out of 28 PRI members; 4 out of 5 retired persons; 22 out of 23 AWW while no one from the SHG as there was only 1 member from SHG who could not be followed up.
Primary data was collected with the help of an instrument that was designed to capture the study objectives.The secondary data was collected using a separate check list that included observation of records of ANMs; documents from district and block level NRHM branches; maintenance registers and other records maintained at the VHSC; records of ANM and VHF released by district to VHSCs during 2008-09 and 2009-10.The primary data collection tool was pre tested in some another block which was not part of the study.
The study maintained all research ethics.A verbal informed consent was taken from the participants.The identity of participants was kept confidential during the entire study and was not disclosed either directly or indirectly to anybody.For ethical purpose, the name of the district, block and VHSC selected under study have not been disclosed in the manuscript.

RESULTS AND DISCUSSION
This section reports the findings of the 17 VHSC's visited.The findings indicate the actual situation of VHSC in comparison to what has been prescribed under NRHM guidelines.

NUMBER OF VHSCS EXISTING:
According to the NRHM guidelines, VHSCs should be constituted in all revenue villages.The study findings indicate that the VHSC's existed in all the 17 selected villages under study.

COMPOSITION OF VHSCS:
According to NRHM guidelines the VHSCs should have at least one member from each of the following categories: SC and ST, PRIs, School Teacher, retired person, ASHA worker, Women groups like SHG, ex-servicemen, AWW, ANM, MPHW and NGO representative.The number of members may however go up.
According to the study findings, none of the VHSC had school teacher as its member, only 4 had retired persons; 13 had AWW's, only 2 VHSCs had ASHA workers; only 1 with representation from SHG and ex-servicemen and only 4 with NGO representatives.This indicates that the constitution of VHSCs in terms of its members from various areas does not confirm to the NRHM guidelines.(See Table 1 for details) The main reason given by most of the respondents for not having ASHA as a member was that VHSCs were formed in Sept 2007 whereas selection of ASHA was done in February 2008.However, despite the selection of ASHA in February, 2008, they were not in place until June 2010 in 15 VHSC.
Guidelines: Under NRHM, the guidelines for the constitution and orientation of VHSCs are provided to each VHSC.However according to the study findings, none of the VHSC (and its members) were provided with any guidelines.Most of the ANMs responded that only verbal guidelines were given by SMO in monthly meetings.However, they shared that some written guidelines were only provided in February 2009, nearly one and a half years after the formation of such committees.Non availability of guidelines was a major reason given by the respondents for committee's non conformity with NRHM guidelines.

AWARENESS AMONG PARTICIPANTS ABOUT GUIDELINES:
Despite the guidelines that were provided to all ANMs and chairpersons in Feb 2009, only 6 chairpersons were aware of a book being received.However all the six did not know that the books were actually the guidelines.Out of total 17 ANMs, 8 initially responded to have not received any such guidelines.However, when probed differently, 13 of them responded that they received a book with Dr. Rajpal Singh, et al.: Limitations in the functioning of Village Health and Sanitation Committees in India pink cover printed called 'Disha-Nirdesh' (guidelines).However, none of them really knew that these were guidelines.The other members of the committees were not aware about the guidelines being provided to them or their committees.(See Table 2 for details)

CASTE AND GENDER PROFILE OF VHSC:
According to guidelines of NRHM, there should be at least one member of SC/ST/OBC categories among the PRI participants and at least 50% women should be included in the VHSCs.All the VHSCs fulfil the guidelines for inclusion of SC/ ST/ OBC and 50% women for the existing number of members.However, as discussed above, the minimum number of members required for committee is not complete for most of the committees.
Hence, what remains to be seen is whether VHSC's after having minimum number of members will have 50% women representation or not.

ACTIVITIES AND PROCESSES UNDER VHSC:
Meetings: According to NRHM guidelines each VHSC should have at least one meeting every month.However, according to findings, there were only 3 committees who conducted three to five meetings during 2008-09 and two to six meetings during 2009-10.Rest 14 committees did only one meeting per year.(See Table 3 for details) Most of the ANMs reported that the meetings were only on papers.One   of them said that "There were no proper meetings because the chairpersons and other PRI members are not responsive towards the meetings.Every time there is a meeting they say that they have no time to attend the meetings as they are busy with other panchayat meetings."Another ANM said "The PRI members and chairpersons are not cooperative".Most of the ANMs felt that it is a burden on them and it should be shifted to PRIs.According to most of the ANMs, there has not been a single occasion where all the committee members were present together for the meeting.According to them this is one of the biggest reasons why members of a committee do not know each other.
Other activities conducted by VHSCs: None of the VHSC's selected under study conducted any awareness campaign during their work.All the VHSCs also failed to perform the most important activity of preparing the VHP.Since, VHPs were not prepared; VHSCs also failed to do any budgeting for the future year.The monitoring and inspection part of the VHSC's also seemed to be very weak with no VHSC having done any inspection of ANM's and MPHW's work and none of the VHSC did any monitoring and control to check the records maintained by ANM, MPHW and AWW in that area.
Furthermore, none of the VHSC in past sent activity reports to higher authority.Furthermore, none of the VHSC maintained any registers or records of the activities done by them.In addition to this, none of the VHSC's chairperson or any other PRI member attended a VHND, one of the most important activities of the VHSCs.Also, there were no evaluations of VHSCs work with the involvement of the community (See Table 4 for details).Some of the common reasons that emerged for not doing the activities were unawareness among the committee members; lack of adequate training and meetings and absence of supervision and monitoring system.The only activity that all the VHSC's were able to do successfully do was display of VHB at common places in villages.

AWARENESS LEVEL OF PARTICIPANTS ABOUT CHAIRPERSON OF THE COMMITTEE AND ABOUT THEIR
OWN MEMBERSHIP: Out of the total 94 members interviewed, 79 VHSC members knew that they were part of the committees while 15 members did not know about being members of VHSCs.However, only 63 of the 94 members were aware about who was chairman of their respective committee.

AWARENESS OF THE MEMBERS ABOUT THE AREAS OF UTILIZATION OF VHF /UNTIED GRANT:
According to NRHM guidelines, every committee duly constituted and oriented would be entitled to an annual untied grant or VHF of Rs. 10,000.The VHF can be broadly used under nine areas.Based on the awareness of utilization of funds under the those areas, we categorized respondents as Nearly 72% of the participants had partial knowledge; 20% had little knowledge and nearly 8% had no knowledge about VHF utilization.The chairpersons, despite being the signing authorities for utilization of fund, knew only partially about areas where such fund could be utilized.Moreover it was observed from the records in one of the VHSCs that nearly half of the fund was used for cleanliness drives of the villages but no verification of the activities was done by anybody.In one village 90% of the total untied fund was spent on cleanliness while the amount spent on vector control measures was negligible (See Table 5 for details).

AVAILABILITY AND UTILIZATION OF VHF:
The VHF was available to all the VHSCs during respective financial year but it was not received in time.For example, for financial year 2008-09, the fund was released in the end of January 2009.According to one of the chairperson "It was very difficult to use the fund in just two months.If it was received in time, it could have solved a few problems that exist before fund was received".For the next financial year, the funds were released during the month of August, which was late by four months but improved as compared to fund received during 2008-09.

ACCOUNTABILITY:
As observed from the record available, there was no evidence of checking the records or attendance register of ANMs, AWWs, MPHWs and others by the chairperson of any VHSC.
There were no proper meeting registers; no VHPs available; no periodic reviews done by higher authorities; no feedbacks received from higher authorities; no evidence of supervision and monitoring of VHSC activities.One of the failures to do such activities was unawareness of the VHSC members and chairpersons about their Roles and Responsibilities.

This is what one of the Block Development Programme
Officer had to say about the training."No trainings have been provided to the VHSC members".One of the Chairpersons of the Block Panchayat Samiti said "We are not receiving any report from the VHSCs.They are only reporting to the MOs".But on the other one of the MO of the same Block Panchayat said "We are only receiving UC (Utilization Certificate) and no other reports from the VHSCs".
Most of the ANMs felt that this was an additional burden on them.An ANM said "This is burden on me.Please free me from this and transfer all this work to Panchayat".One of the chairpersons of the VHSC's said "Money is so less there is nothing available so what is the purpose of meetings".The other chairperson said, "If someone provides training, only then we can do something".
FACILITATION AND SUPPORT: According to the underlying concept of VHSCs, there should be community and NGO involvement in monitoring the activities of VHSC and its members must be given support.However the study findings indicate no evidence of supportive supervision of VHSCs by higher authorities; no capacity building programmes for VHSC members; no regular meetings of VHSCs staff with higher authorities for providing supportive supervision to the staff and there were no reports sent to Block Panchayats or District Health Society.

CONCLUSION AND RECOMMENDATIONS
STRENGTHEN THE FORMATION AND COMPOSITION: One of the basic problems with the formation of VHSC has been its inappropriate composition.All VHSCs under study did not have the minimum number of required members as per the NRHM guidelines.The shortages were particularly severe for school teachers, NGO representative, ASHA worker and Ex-servicemen.ASHA is one of the most important parts of these committees.The envisaged role of ASHA under NRHM is very crucial in providing basic healthcare to rural population.Therefore all efforts must be made to include ASHA and other members in such committees.
According to NRHM guidelines, the VHSC members should be selected in the meeting of the Gram Sabah with the help and guidance of District Health Society in a fair and transparent manner.But according to the views of the ANM, many members were added by the chairpersons and skipped the process of selection through Gram Sabah.Therefore it is recommended that the composition should be corrected and platform of Gram Sabha should be used to make the selection process more transparent.

COMPREHENSIVE ORIENTATION AND TRAINING OF MEMBERS TO IMPROVE KNOWLEDGE AND SKILLS:
As evident from the study, the awareness and knowledge regarding various activities of VHSC was poor among the majority of the members.Therefore during the time of formation of VHSC, a strong orientation programme of all the VHSC is recommended.This should cover the basic philosophy of VHSC; the process to be followed during formation and composition of VHSC; roles and responsibilities of various members; various activities under VHSC.Each member should also be provided with a written guidelines.Once this is done, a periodic training should be conducted to train people on various aspects like how to utilize VHF; how to maintain accounts and registers.
Such training programmes should be held periodically to update knowledge of the participants.The involvement of PRI in the entire process is highly recommended.

MAINTAIN RECORDS AND CONDUCT REGULAR MEETINGS:
The findings suggest that no committee held any regular meeting.The only purpose ANMs were meeting the Chairpersons was regarding the use of funds.So, there should be sensitization and training of the members on how to maintain records and registers.Such activities and records must be the supervised by someone from the local level.Again, active involvement of chairperson (who is a member of PRI) is recommended.In addition to this, there is a great need to strengthen the reporting system.The committees should first be made aware that they need to prepare activity reports and these must be regularly submitted to the chairperson of the committee.There should also be a feedback system in place to provide feedback on reports.
EFFECTIVE SUPERVISION AND MONITORING: Supervision and monitoring did not exist in any of the VHSC visited.To make the VHSCs perform and function effectively, it is recommended that the supervision and monitoring committees be constituted and make them responsible and accountable.Such committees should focus on continuous monitoring and evaluation system of committees.

COMMUNITY EDUCATION AND INVOLVEMENT OF ASHA, PRI
AND NGO: There needs to be strong efforts in the area of IEC so that community can be educated on the provisions and entitlements of VHSC under the NRHM.This can be done with active participation of all the members of VHSC, especially of ASHA, PRI and NGO's.

EFFECTIVE DELEGATION AND LEADERSHIP:
The chairperson of the committees must help the other members of VHSC to be effective in their roles.The committee's chairperson should have enough freedom to exercise his power in matters concerning VHSC.However this must not mean that the chairpersons become task obsessive and insensitive to the needs of his teammates.The delegation of work must be done in such a way so that it does not seem to be a burden on any members.

PRI, DEPARTMENT OF HEALTH AND ICDS TO FUNCTION
AS A TEAM: As discussed earlier, the biggest problem with the VHSCs has been lack of team work.Therefore more emphasis should be given to team building aspects like effective collaboration and decision making.This is because unless all the team members of VHSC (who represent various departments and background) come together, the joint goals of VHSCs cannot be achieved.

INVOLVING MANAGEMENT OR SOCIAL WORK GRADUATES:
To address some of the management related issues, it is recommended that Masters in Social Work (MSW) can be recruited at a block level.They should ensure effective formation and functioning of VHSCs in all areas.Their recruitment should particularly address the following areas where VHSCs have been weak:

1 .
Regular Meetings to improve the overall communication within VHSC teams as well as outside VHSC 2. Documentation of various processes at the time of formation and function of VHSC 3. Identifying training needs for each group and providing training in required areas

Table 4 : Status of all activities done by VHSCs according to NRHM guidelines
Dr. Rajpal Singh, et al.: Limitations in the functioning of Village Health and Sanitation Committees in India having: Complete knowledge (if they knew about all the nine areas); Partial Knowledge (if they knew about more than three areas); little knowledge (if they know one or more than one but less than four); and No Knowledge