Our study contributed to the little evidence available on the assessment of community health governance in one of the largest democracies of the world, India. In our study, most of the VHSNCs in Rajasthan and Odisha started more than six years ago compared to Uttar Pradesh. This could probably be because VHSNCs were non-active in Uttar Pradesh for many years, or the respondents did not have the previous records . The number of members in VHSNCs in most of the studies, including our study, are in accordance with the guidelines except Odisha [14,15]. On the contrary, some studies reported that the VHSNCs did not have a minimum number of members in the committee . Not just the numbers, the VHSNC guidelines set forth the recommendation to have representatives from the marginalized classes in the committee. However, most studies echoed that marginalized classes are poorly represented or heard or taken seriously even if represented in such committees [15,16,17]. This poor representation of the marginalized classes in the meetings connotes the caste and power dynamics in villages.
Unlike most of the studies, we reported that VHSNC meetings occurred regularly [10,14-18]. However, similar to ours, another study from Maharashtra reported regular VHSNC meetings . Studies acknowledged reasons such as bad weather conditions or the busy schedule of VHSNC members for irregular meetings . In our study, most of the VHSNCs had a fixed date for holding the meetings. We argue that a fixed date of meeting every month may prompt the members to attend it regularly. Furthermore, proper records of all the meetings should be entered in the registers with key discussion points, actions to be taken, and members present in the meeting.
In other studies, most of the VHSNCs received funds but more than 50% did not spend half of its amount . A lot of funds had been spent on administrative purposes and not on the activities. In fact, some studies highlighted that the frontline workers were pressured to spend funds on personal use of Sarpanchs [10,17]. Furthermore, records and registers were not updated as per the norms of all the meetings [9,14,15]. Our study echoed the previous findings that funds were limited, and there was a delay in payments to VSHNCs . Despite the delay in receiving the funds, most of the VHSNCs utilized them well [9,14,15]. We found that limited balance was left in the accounts of the VHSNCs as most of it had been spent on the activities. However, the documentation of untied funds in the registers was poor. Most of the studies highlighted that the registers were not updated [9,20]. The accountability and transparency of the expenditures are crucial pillars of good governance and means to bring reforms in public health. Within the ambit of good governance, the limited resources can be used judiciously, and services are provided efficiently and effectively . To encounter delays in the payments or release of funds, the government is planning to start the financial year from 1st January .
Like other studies, Sarpanch’s involvement in the meetings was poor and not regular in most places [15,17,18]. Different reasons identified for the poor engagement of Sarpanchs in the VHSNC meetings include since members did not get any remuneration for organizing the VHSNC meetings, they were not interested in doing it. Secondly, most of the Sarpanchs were not well educated or illiterate, so they could not envisage the benefits of organizing VHSNC meetings for making annual health plans of villages, community events for health promotion, etc. Thirdly, Sarpanchs were more interested in organizing such meetings in closed groups to negotiate with people for votes . On the contrary, the workload and hassle of record-keeping of the meetings discouraged ANM from participating in these meetings regularly [15,17].
Cleanliness drive and awareness generation were the common activities performed by VHSNC [9,15]. The scope of VHSNC work was limited to a few activities and there has been an emerging need to broaden the horizon of its work, especially post COVID-19 . VHSNC members, particularly Sarpanchs, were not aware of their roles and responsibilities; some of them did not even know if they were the members. While members had not been trained on VHSNCs guidelines in many places, the training was inadequate at other places [15,19]. Many were uninformed about how to spend the untied funds . Most of the trainings for VHSNC members work on a cascade model that trains only frontline workers, primarily ASHA, who are supposed to conduct training for other members. Similarly, the guidelines propose repeated trainings at regular intervals, all of which are not implemented effectively at the ground level, resulting in most members being unaware of their roles and responsibilities [2,6]. Furthermore, repeated training needs to be emphasized as Sarpanchs are elected representatives that change every 4-5 years .
VHSNCs are involved in organizing VHSND, but they were not organizing it regularly as described in our study. Likewise, it has been reported in other studies that VHSNDs were held inconsistently [15,17]. VHSNDs are established by the government as a unique platform to bring a convergence of health, nutrition, and sanitation services at a primary care level on a monthly basis. Furthermore, VHSNDs are proposed to deliver a package of services, including registration of pregnant women, immunization and growth monitoring of under-5, family planning service provision, and health education [24,25]. Irregular and improperly organized VHSND can defy the purpose and may leave many children deprived of basic health and nutrition services.
Village health plans were not routinely made by VHSNC, and some studies highlighted that the involvement of Sarpanchs/PRI members in the development of village health plans was limited [9,15,17]. The members were unaware of such plans, and documentation of the plans is weak [9,15,19]. Village health plans are important and need micro-financial planning at the village level. This would ensure that the health and nutrition needs of the communities are raised and adequately addressed in the annual district or state health plans.
We found inadequate supportive supervision and monitoring visits by the government officials, such as medical officers, child development project officer, etc. Supportive supervision is an evidence-based strategy to improve the professional competence of the workers, thereby, the quality of services. This two-way communication process helps health workers identify problems, find appropriate solutions, optimize resource allocation, and promote teamwork . The process of supportive supervision needs inter-sectoral convergence wherein the child development project officer from the department of women and child development would coordinate with the medical officer from the department of health and family welfare to improve the functioning of VHSNC by Sarpanchs (answerable to Ministry of Panchayati Raj).
Our study’s results should be interpreted considering the following limitations. Firstly, VHSNC of the selected geographies were selected as the study was a part of an intervention. This limits the generalizability of the findings to all the VHSNC across the country. Secondly, we lacked data on three crucial parameters, which have been captured in many studies, including representation of members from different social backgrounds in VHSNC, education status and gender of the Sarpanch, and the awareness of the roles and responsibilities among VHSNC members. Lastly, community-perspectives on the functioning of VHSNC were not collected. Though the additional data on these parameters would have given a 360-degrees perspective to the analysis, due to limited resources and time, we could not obtain them in our study. However, we propose to overcome these shortcomings in future research.