Evaluation of village health sanitation and nutrition committee in Himachal Pradesh, India.

INTRODUCTION: Decentralization through introduction of Village Health Sanitation and Nutrition Committees (VHSNCs) was a key initiative introduced in 2007 under the National Health Mission (NHM), India to address local health and sanitation issues. This study was done to assess the functioning of the VHSNCs. AIMS AND
OBJECTIVES: 1. To assess the level of awareness among the VHSNC members about their roles and responsibilities 2. To assess the level of awareness among the community members about the committee and its functions. 3. To assess the pattern of disbursement and utilization of untied funds under VHSNCs.
METHODOLOGY: A cross-sectional study of 30 VHSNCs conducted in district Kangra of state Himachal Pradesh. Information was collected through a review of records and in-depth interviews with community and VHSNC members.
RESULTS: All committee members knew about VHSNCs but the level of awareness among community members was comparatively less (67%). Some members were confused about their roles and responsibilities. Most active members were the FHWs, AWWs, ASHAs, Mahila mandal representatives, and the female ward panch. A major chunk (65%) of the funds is utilized on the cleanliness activities. For the nutritional part, the majority of the work is already being undertaken by the AWCs so there is no clarity regarding the functioning of the committee on this aspect. Copyright:

Introduction

Decentralization to encourage people's participation is a key strategy for making health care services effective and addressing local problems. This has been highlighted in all significant documents articulating people's right to health such as the Bhore Committee report, Alma Ata declaration, and the NRHM (National Rural Health Mission) documents. A key initiative to achieve decentralization and empowerment of local people to achieve NRHM goal, was the introduction of Village Health Sanitation Committee (VHSC) in the year 2007.[1] These committees provide a platform to the community members to make decisions and action at a local level to maintain a clean environment and raise awareness about health and sanitation issues through organizing a monthly Village Health and Sanitation Day. There are monthly VHSC Meetings, there's no designated Village Health and Sanitation Day. Its either VHNDs or VHSNDs. Later in the year 2011, it was decided to expand the role of Village Health & Sanitation Committee (VHSC) to include 'Nutrition’ within its ambit with the active participation of anganwadi workers (AWWs), auxillary nurse midwives (ANMs), and Accredited Social Health Activists (ASHAs). The Committee henceforth was named as Village Health, Sanitation and Nutrition Committee (VHSNC).[2] In the state of Himachal Pradesh, VHSNCs were initially constituted in the year 2010. They functioned under the authority of Panchayati Raj Institutions (PRI) and in year 2016 they were reconstituted and brought under the health sector.

It was ensured that all VHSNCs were reconstituted according to the new guidelines. Committees were constituted in all villages where an ASHA worker was working. A bank account (with internet banking) in the name of the ASHAs was opened. Block medical officer was made the nodal officer of the concerned block.

To empower the VHSNCs and meet the needs of the community, untied funds of Rs. 10,000 per annum are given to the committee, to be utilized as and when required. This study was conducted to assess the level of awareness among the VHSNC members and community members regarding their roles and responsibilities and to understand the pattern of disbursement and utilization of untied funds under VHSNCs.

Methodology

A cross sectional study was conducted in district Kangra of state of Himachal Pradesh (HP) India. Kangra district is the most populous district of HP with highest number of villages (3698). Out of the 13 health blocks of the district, 3 blocks were randomly selected. A total of 10 villages were selected randomly from each of these blocks. Therefore, total 30 villages were selected to evaluate the VHSNCs.

All the members of the committee who were present on the day of the interview and gave consent to participate were included in the study. Among community, pregnant ladies, lactating mothers, and members of marginalized and poor families were randomly selected and interviewed.

Two semi structured and pre-tested sets of questionnaires, one each for VHSNC members and community members were used to gain insight on their level of awareness about the committee. Data about the allocation and current expenditure of the untied funds were collected through review of registers maintained by the committee. Data analysis was done using SPSS 20 software.

Ethical consideration

Institutional Ethics Committee of Post Graduate Institute of Medical Education and Research, Chandigarh, India, examined and cleared the protocol for the study 20-04-2017. Permission was taken from the National Health Mission, Himachal Pradesh as well for collection of data. A verbal informed consent was taken from all the participants.

Results

According to the national and state guidelines, VHSNCs must have a minimum of 15 members. Out of the 30 VHSNCs, 19 VHNCs had 15 members. In 9 out of 30 (30%) committees, yuva mandal representative was not a member due to absence of these representatives in the village. Similarly, in 6 (20%) committees, scheduled tribe representative was not there due to absence of these families in those areas. In 3 sub centres, there were no female health workers, so the male health worker was a member instead and was looking after these committees along with their respective chairpersons. The composition of the VHSNCs after reconstitution follows the guidelines of the committee given by the state [Table 1]. The gender compositions of the VHSNCs which have been formed are according to the state guidelines. All the 30 VHSNCs consisted of more than 50% female members. An average of 67% females and 33% males were members in the VHSNCs.

Table 1

Composition of VHSNCs

MEMBERS	Yes (%)
Chairperson-Up-Pradhan	100
Mahila Mandal Representative	96.4
Yuva Mandal Representative	76.8
IPH Members	96.4
Anganwadi worker	100
School teacher (primary)	92.3
Female Health Worker	95.9
ASHA	100
Female Ward Panch	100
S.C Representative	100
S.T Representative	88.1
OBC Representative	97.4
BPL Representative	100
Self Help Group Representative	100
Pregnant Lady	100

All committee members were aware that they are a part of the committee and 94% knew about NHM, 91% knew about the guidelines of the committee and 94% knew about their roles and responsibilities. However, 16% of them had never attended the VHNDs. Among the community members, 78% had heard about NHM and only 67% knew about VHSNCs [Table 2].

Table 2

Awareness and knowledge about NHM and VHSNCs among VHSNC Members in district Kangra

	Yes (%)
Know that they are member of VHSNC	100
Know about NHM	93.9
Know about guidelines of VHSNCs	91.2
Know about their roles and responsibilities	94.3
Know about VHNDs	93.9
Attended VHNDs	84

About 55% community members said that work done was related to cleanliness and nutrition and 65% said that awareness groups were being organized. Only 50% had been part of the activities organized by the committee. About 60% said that committee spread awareness related to health programs. Display of village health plan in common places in village was confirmed by 47% community members and 56.4% respondents said that VHSNC meetings were held to discuss issues and problems of the village [Table 3].

Table 3

Awareness and knowledge about NHM and VHSNCs among Community members

	Yes (%)
Know about NHM	77.7
Know about VHSNC	67
Work done related to cleanliness or nutrition	54.8
Awareness camps organized by committee	64.9
Been part of any activity done by committee	50.6
Awareness about any health program	60.1
Display of Village Health Plan in common places in village	47.3
VHSNC meetings held related to issues and problems of the village	56.4

It was observed that 84% committee members and 74% community members had attended the VHNDs. The 16% committee members who had not attended the meetings comprised mainly the up-pradhans, teachers, and female ward panch. Knowledge about registration of malnutrition cases among committee and community members in all the VHSNCs was less (54.6% and 49.4%, respectively). Measurement of weight of children in AWCs was done every month and was confirmed by 96.4% members and 84.1% community members. About 88% committee members and 74% community participants said that food is distributed in cooked form every day [Table 4].

Table 4

Awareness about Activities related to Nutrition among VHSNC Members (M) and Community Members (CM)

	Yes (%)
	Committee Members	Community Members
Registration of Malnutrition/severe malnutrition cases	54.6	49.4
Measurement of weight of children in AWCs	96.4	84.1
Distribution of cooked food at AWCs	88.1	74
Take home rations to children during VHND (6 months-6 yrs)	97.8	92.9
Take home rations to adolescent girls during VHND	99.4	92.1
Take home rations to pregnant ladies during VHND	100	98.6
Take home rations to lactating mothers during VHND	98.2	95.7

Take-home rations to children (0-6 yrs), adolescent girls, pregnant ladies, and lactating mothers were provided during VHNDs and this was confirmed by more than 95% of the committee members and more than 90% community members.

Out of 30 committees, only 18 had untied fund registers. In one of the VHSNCs, it was observed that the register had not been maintained for the past 5 years. The registers which were found during the visit dated back to 2012.

Figure 1 shows the different activities on which the untied funds were spent. As it is evident, more than 60% fund is spent on activities related to cleanliness like cleanliness of water sources like wells, bawdis, village areas like grounds, roads, bushes cutting, garbage cleaning, etc., 25% funds are used for cleanliness of wells which is a water source in various villages. Similarly, 25% funds are spent on cleaning another water source that is, bawdis of the village. Totally, 15% funds are used for the cleanliness of gathering areas like grounds.

Figure 1

Activities on which untied funds were spent

A total of 20% of the funds are spent on providing water campers either to AWCs or panchayats. Expenditure of the VHSNC untied fund is decided by presenting a proposal in the VHSNC meeting and when all the members reach a consensus related to a particular issue, then the activity is carried out.

About 8% of the funds go into awareness camps. The expenditure includes the material for camps like hoardings, pamphlets, refreshments for the camp, etc., and 5% of the expenditure goes into the refreshments of the VHSNC and VHND meetings.

Apart from these, the other activities include making of a garbage ditch, where the whole village can dump their garbage and buying emergency medicines.

Also, maintenance of sub-centre was also done using this untied fund. In one sub-centre, the fund was utilized to tile the floor of the sub-centre. In another sub-centre, VHSNC fund was used to buy chairs for the sub-centre. Electrical faults were also repaired through these funds.

The disbursal of funds was irregular. Out of the 18 VHSNCs, 50% had received their untied funds in the previous year while 27% had not received their funds in the past two years and 16% had not received funds from past three years. One of the VHSNC, had not received any funds in the previous 5 years [Figure 2].

Figure 2

Disbursement of the Untied funds

Discussion

The committees were reconstituted in all villages where an ASHA worker was working. The composition of the VHSNCs after reconstitution follows most of the guidelines of the committee given by the state even though there was non-availability of written guidelines in one block. Yet the composition followed the guidelines as most of the committees had an average of 15 members (14–16) and the committees comprised of more than 50% females. Nongdrenkhomba also noted the VHSNC constitution in three states that is Manipur, Meghalaya, and Tripura, generally followed the national guidelines. However, the norms for establishing VHSNCs were modified as per the state needs.[3] In Manipur, the norm was based on number of ASHAs rather than number of revenue villages.[3] This adjustment led to more number of VHSNCs and therefore, more grant in terms of resources.[3] The validation of the composition of the committees was done by reviewing the records of the committee and VHSNC registers.

Majority of committee members (92%) had heard about NHM but only 78%community members had heard about NHM before and knew very less about NHM in detail. They had only heard about it through television commercials or radio advertisements and some had seen the name on the hoardings which were there in the hospitals or public health facilities. Nandan (2007), observed that most of the ANMs, ASHAs, and majority of self-help group members knew about the NHM, but only 50% PRI members knew about NHM.[4]

All committee members knew about VHSNCs but the level of awareness among community members was comparatively less (67%). Sha (2013) in Wardha also observed that all the ANMs, most of the ASHAs and majority of the AWWs (secretary) knew about the VHNSC.[5]

Some committee members were confused about their roles and responsibilities because neither had they received any official training regarding the committee nor were the guidelines available with them. Sharma et al. (2016) also observed that majority of the members in the study VHSNCs had not received any formal training.[6] Singh et al. also observed similar results where guidelines were absent and stated that under NHM, 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.[7] In our study also, VHSNCs of one block did not have the guidelines with them.

Majority of the work regarding supplementing nutrition is already being undertaken by the AWCs and there is lack of clarity on this aspect. The VHSNCs and the AWCs work in tandem to improve the nutritional status of their respective villages. Most 93.9% committee members knew about Village Health Nutrition Days (VHNDs), an activity supported by the VHSNCs and 84% committee members had attended these. Johri et al. (2019) mentioned in their study that in the 30 villages randomly selected for inclusion, 36 VHNDs were scheduled but four (11.1%) were cancelled.[8]

About 56% respondents said that VHSNC meetings were held to discuss issues and problems of the village and they had attended these. Bathula, Sripada & Choudhury (2020) observed that only 8% of the households have reported to be contacted by VHSNCs to understand health-related problems, little less than 5% have attended VHSNC meetings in last one year.[9]

The major chunk (65%) of the funds is utilized on the cleanliness activities which include cleaning of water sources like bawdis, wells and common village areas and clearing of bush and shrubs, etc., The main functions, therefore, according to all committee and community members were to clean the village areas, water sources, drains, etc., Semwal (2013) observed similar findings where they found that maximum responses were for cleaning village environment.[10] In a study by Ahmed (2017), Majority of the funds received by VHSNCs was utilized for sanitation and cleanliness of the village.[11] Provision of campers, chairs, tables, etc., to the AWCs was also done using VHSNC funds.

Few members (8%) like Up-Pradhan and FHWs said that they wanted to make public toilets in the market of their villages but as they were not sure that they could utilize the VHSNC funds for the provision of public toilets, so these were not utilized.

Conclusion

This article attempts to renew the focus on this seemingly important, yet neglected, area of healthcare that is Village Health Sanitation Nutrition Committees. These committees are an opportunity which must be utilized to attain the vision of universal health coverage through decentralization. These committees can easily use an integrated approach as its composition hails from different sectors like health, PRI, SHGs, AWCs, education, etc., to achieve primary health care. These committees are helpful in primary prevention, early diagnosis, preventive care, and educational purposes through awareness regarding health programs. The community can learn about health issues and preventive measures in their own comfort zones since the people teaching them are from amongst themselves. The committees also give an opportunity of home-based care for the community. Through formal training and provision of the guidelines, hesitation to utilize funds can be reduced. The levels of knowledge among the committee and community members vary which can be improved by holding the VHSNC meetings regularly and by involving the community members more just like the VHNDs.

Declaration of participants consent

The authors certify that they have obtained all appropriate participants consent forms. In the form the participants has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.