Navnirman trust and Karnataka State Health Systems Resource Centre (KSHSRC)
The National Rural Health Mission (NRHM) hopes to achieve its goal of providing universal access to equitable, affordable and quality health care, especially for the poor and vulnerable communities in rural areas, through greater involvement of the Panchayat Raj Institutions (PRI). The initial pilot of community monitoring has been institutionalized by creating Village Health and Sanitation Committees (VHSC) at the village level. According to the Government of India guidelines, these committees are recommended to have 50% women representation and representation by Scheduled castes, Scheduled tribes and other backward classes. This committee also receives an annual untied fund of Rs. 10,000/- for specific activities.
The current study was undertaken in Bagalkote and Chikmagalur districts. A semi-structured questionnaire was administered to the VHSC chairpersons, VHSC members, ASHAs, ANMs and PHC medical officers.
68% of the people interviewed were aware of the guidelines for VHSC formation, 50% were unaware if the guidelines were being followed. The government of India recommendation of 50% representation of women in VHSC has been followed. The guidelines do not mention a quota of representation of SC/ST communities in these committees so SC representation ranged from 7 to 33% with only one VHSC having one ST member.
VHSC members were aware of functions such as ensuring ambulance facilities, support for pregnant and antenatal care, care of children with malnutrition, anemia treatment, immunization, prevention of epidemic disease, sanitation, safe drinking water and encouraging people to build toilets. However there was no awareness about raising awareness about health rights and entitlements, village health plans, village health registers, health information boards and annual health reports.
Although VHSC trainings have taken place in 30 districts, the department has not been actively involved in monitoring, implementation, formulation of guidelines or in capacity building. Monitoring of VHSC functioning was also felt to be inadequate. District authorities were not involved in most of the processes.
Participation by women in trainings is much more than that of men. It was felt that more seriousness had to be given to conducting and participation in these training programs and to give more practical applications rather than theory.
It is important that the VHSC has a good representation of members of the SC/ST communities, with specific focus on including the most marginalized communities such as the Madigas.
The state and district government machinery should be used in all decision making, monitoring and capacity building of the VHSC. This would lead to a more sustainable model than having a fragmented approach with out-sourcing of different services to different agencies.
Monitoring the quality and effectiveness of training is important. Gaps in capacity should be regularly identified and filled.
The VHSC meetings should follow basic guidelines and clear outputs defined. These should be revisited at subsequent meetings to see if they were implemented or not.
There is a need for more involvement of VHSC members in identifying health problems in the community and identifying specific solutions, rather than multiple and random activities.
The motivation of VHSC members to attend training is important. This training should be regularly conducted. Non participatory members should be removed after a period of time.
There is a need for more intensive training needs assessment before rolling out the second level of training. A larger study should be conducted to understand the training needs of VHSC members. The organizations that conduct these trainings should have good capacity and understanding of field realities.
This study brings out the need for the VHSC members to be adequately trained and informed about their collective roles and responsibilities. They should also be supported to move beyond the routine and simple health education activities to more complex tasks. There is also a need for ongoing and regular update and orientation to service providers about the untied fund and its effective utilization. Printed and clear guidelines on untied funds should be provided as well as timely disbursal of funds.
The VHSC was constituted to institutionalize community participation in key health related issues and is an important move to decentralize. It is important that the VHSC be strengthened to ensure that the true spirit of community participation is ensured. This requires skilful planning, regular monitoring and support.