Village health, sanitation, and nutrition committee: Do the village level functionaries aware of their roles?

Background: National Health Mission intended to achieve decentralization and community participation through creating and supporting Village Health Sanitation and Nutrition Committees (VHSNCs). The services offered through VHSNC include maternal and child health, family planning, sanitation, communicable diseases and health promotion, and nutrition. The study was carried out to assess awareness on the implementation of the functioning of VHSNC implementation among village-level functionaries in the Dehradun district.
Methods: A community-based cross-sectional study was conducted in the Doiwala and Raipur blocks of Dehradun district from June 2019 to July 2019. Members of VHSNC with at least 3 months of membership were included in the study. A pretested semi-structured questionnaire was used to collect sociodemographic variables and questions about their awareness and responsibilities in implementing VHSNC. Data were collected by personal interviews using Epi-Collect and analyzed by SPSS 23. Result: Out of 69 members, 64 (92.4%) had formal education until high school. Only around 50% of members knew about the essential documents related to the VHSNC. Sixty-five members (98.48%) believed that the committee had the primary role in health-related services in the village, 54 (81.82%) members also marked providing safe drinking water as a function, 48 (72.73%) were in favor of access to clean public toilet and sanitation facilities while some others added role in Public Distribution System.
Conclusion: Around half of the members were partially or completely aware of the functioning of VHSNCs. Providing them with further awareness is required. Copyright:

Introduction

National Health Mission (NHM) envisioned that ownership of public health institutions could be effectively achieved by ensuring the public health personnel work in collaboration with the community’s involvement.[1] NHM intended to achieve decentralization and community participation through creating and supporting Village Health Sanitation and Nutrition Committees (VHSNCs). To achieve decentralization and community participation at the grassroots, NHM guidelines recommend constituting VHSNC under Gram Sabha through District Health Administration.[2] “People’s participation in health planning” and improving rural areas’ health care services are planned to focus on women and children. The services offered through VHSNC include maternal and child health, family planning, sanitation, communicable diseases and health promotion, and nutrition.[1]

It is already documented that village-level functionaries have poor structure and utilization of untied funds. Also, VHSNCs monitoring is reported as very weak.[3] The challenges faced in implementing this decentralized program include lack of interest and coordination among VHSNC workers, negligible community participation, and improper fund utilization.[4567]

Evidence from various studies conducted in India has already documented that awareness about VHSNC differs among various members like health workers, Panchayati Raj Institution members, accredited social health activists (ASHA), and self-help group members. Preventive and curative services offered near the doorstep will bring an effective change in the nutritional status and essential health services as envisaged in the principles of “Primary Health Care.” Awareness among the VHSNC will ensure proper referral and health-seeking toward Primary care physicians. The majority of the committee members were clueless regarding responsibilities and utilization of funds.[8] However, the perceived gaps in the implementation of VHSNC need to be identified to understand issues related to the effective functioning of VHSNC. Hence, this study is vital to understand the awareness regarding the responsibilities and functioning of VHSNC in Dehradun district, Uttarakhand. Thus, this study was conducted with the aim and objective to evaluate awareness regarding the responsibilities and implementation of the Village Health, Sanitation, and Nutrition committee among members in the Dehradun district.

Material and Methods

A community-based cross-sectional study was conducted in the Doiwala block and Raipur block of Dehradun district from June 2019 to July 2019. Members of the VHSNC committee with at least 3 months of membership were included in the study. All members of VHSNC were included in the study after obtaining informed consent. A pretested semi-structured questionnaire consisting of sociodemographic details and questions about their awareness and responsibilities in the implementation of VHSNC was used. Questions were prepared from “Handbook for members of Village Health Sanitation, and Nutrition Committee.”[9] Data were collected through personal interviews. Data collection was done using Epicollect 5.0,[10] which is open-access software for paperless data collection.

Data were analyzed using SPSS 23.0 for windows. A descriptive analysis was performed to calculate the responses. Statistical tests based on the nature and distribution of variables like the Chi-square test and Yates’ correction wherever applicable were applied to assess the significance of the study findings.

Ethical clearance

The study was ethically approved by the ethical committee of the institute (AIIMS/IEC/19/821). The study’s procedure and importance were briefed to participants before participation, followed by signed informed consent.

Results

The study included 24 different villages of Raipur and Doiwala blocks of the Dehradun district. VHSNCs of these villages were approached, and 69 members were successfully interviewed. The majority of committee members were ASHA workers, 31 (45%). Others were 8 anganwadi workers, 6 ward members, 5 village pradhan, 5 housewives, 4 ANMs, 3 shopkeepers, 3 water suppliers, 1 farmer, 1 news reporter, 1 ration distributor, and 1 teacher. Out of these, 8 were chairmen, 10 were secretaries, 3 were treasurers, 2 were ward members, and 46 were not holding any post. The mean age of the committee members was around 43.49 (±10.046) years. The average membership duration was found to be 54.09 (±50.139) months. The majority of members were members of the committee for around 60 months (5 years). The average monthly income of the VHSNC members was ₹ 8900 (±14144.044). Maximum members 25 (36%) had passed their intermediate exams, 17 (24.6%) had passed high school, 17 (24.6%) were graduates, 5 (7.2%) were postgraduates, and 4 (5.8%) were educated till middle school, while one of them was illiterate. The maximum number of members belonged to the Hindu religion 67 (97%) and general caste 44 (63.8%).

There was no fixed day for the meetings according to 66 members (95.70%) [Table 1]. Forty-seven (68.10%) members reported that the frequency of meetings is once a month, while 9 (13.0%) did not know about meetings. Out of the three members told there is a fixed day for the VHSNC meeting, one of them said it is on the 2nd Wednesday of every month, while the other two said it is on the first Saturday. It was found that the average number of meetings attended by the members of VHSNC was around 27.86 (+/−39.571) days. Out of the 69 members, only 25 (36.2%) attended all the meetings. Reasons given were 34 (77.3%) were busy at the time of the meeting, 9 (20.5%) were not aware, 15 (34.1%) were ill, and 2 (4.5%) had no response. Maximum members 24 (34.8%) and 23 (33.3%) considered pradhan and ASHA, respectively, should help to facilitate the meeting. Thirty-eight (55.10%) members were involved in the village health plan. Out of these 38 members, 18 (47.4%) participated in the village health plan once a month. Also, only 23 (33.30%) members actively participated in the Village Health Budget. The annual Village Health Budget is mainly utilized to provide sanitation and cleanliness-related services in the village. Around 25 (65.79%) members had no idea about Village Health Budget.

Table 1

Distribution of VHSNC members according to their knowledge regarding days and frequency of VHSNC meeting

Variables	Characteristics	Count (n)	Percentage
Frequency of VHSNC meetings	Once a month	47	68.10%
	Once a quarter	11	15.90%
	Once per annum	2	2.90%
	Do not know	9	13.00%
Fixed day for VHSNC meeting	No	66	95.70%
	Yes	3	4.30%
Participated in all the meetings conducted	No	44	63.8
	Yes	25	36.2
Reasons for nonparticipation in meetings*	Busy	34	77.27
	I did not get information regarding meetings	9	20.45
	Illness	15	34.09
	No response	2	4.55
Help in facilitating the meeting	ANM	4	5.80%
	ASHA	23	33.33%
	ASHA and Pradhan	12	17.39%
	Do not know	4	5.80%
	Pradhan	24	34.78%
	Health administration of the village	1	1.45%
	Unaware of the meetings	1	1.45%

*Multiple response table; percentages will exceed 100%

Table 2 shows that 41 (59.4%) members were not aware of any booklet provided for the functioning of the VHSNCs, and only 20 (29.0%) members had awareness regarding the booklet. Sixty-five members (98.48%) reported that VHSNC monitors general health-related services in the village. Fifty-four (81.82%) members told that providing safe drinking water was one of the essential functions of VHSNC, 48 (72.73%) were in favor of access to clean public toilet and sanitation facilities, and 21 (31.82%) members mostly utilized VHSNC services for providing ration from the public distribution system to the villagers. Gram pradhan was the chairperson of most VHSNCs (87.00%).

Table 2

Distribution of VHSNC members according to their awareness regarding the booklet of VHSNC functioning and services provided by VHSNC

Variables	Characteristics	Count (n)	Percentage
Awareness about any booklet related to the functioning of VHSNC (n=69)	Yes	20	29.0%
	No	41	59.4%
	Do not know	8	11.6%
Copy of any booklet related to the functioning of VHSNC (n=20)	Yes	12	60.0%
	No	8	40.0%
Recollect name of the booklet provided (n=12)	Do not remember	10	83.300%
	Mahila Sashaktikaran Svasthya Mission	1	8.3%
	Rashtriya Swasthya Mission, Uttarakhand	1	8.3%
Awareness on the eligible person as chairperson of VHSNC (n=69)	Gram Pradhan	60	87.00%
	Do not know	4	5.80%
	ASHA	1	1.40%
	Not aware	4	5.80%
VHSNC can monitor certain services at the village level (n=69)	Yes	66	95.70%
	No	3	4.30%
Services monitored by VHSNC*	Health services	65	98.48%
	Access to clean toilet	48	72.73%
	Drinking water	54	81.82%
	AWC services	27	40.91%
	MGNREGA	16	24.24%
	Mid-Day Meal	15	22.73%
	Ration from the Public Distribution System	21	31.82%
	Others	7	10.61%

*Multiple response table; percentages will exceed 100%

As shown in Table 3, 42 members (62.90%) knew about the meeting’s attendance register. Forty-two members (62.90%) were aware of bank cash book and 50 (72.50%) knew about the bank passbook. Forty-three (62.30%) had information regarding the statement of expenditure, and while 50 (72.50%) were aware of a village health register. Thirty-one members (44.90%) knew about the public services monitoring tool and register. Sixty-six (95.70%) were aware of the death register and 67 (97.10%) were aware of the birth register maintained by the committee. Sixty-six members (95.70%) believed that VHSNC could monitor specific health, sanitation, and nutrition-related services of the village. The maximum number of members, 55 (79.70%), were aware of the budget provided to the VHSNCs. Forty-seven members (87.00%) reported that the budget was ₹ 10000 per annum. According to the maximum number of members, 30 (54.5%), the fund was used mainly for sanitation and cleanliness services in the village, and 20 (36.4%) members reported that the fund utilization was decided by Gram pradhan alone.

Table 3

Distribution of VHSNC members according to their awareness regarding various registers and records maintained by VHSNC

Variables	Yes	No	Never heard or read about
Awareness regarding the record of meetings with attendance signatures	42 (60.9)	16 (23.2)	11 (15.9)
Awareness regarding cash book	42 (60.9)	16 (23.2)	11 (15.9)
Awareness regarding bank pass book	50 (72.5)	12 (17.4)	7 (10.1)
VHSNC Statement of Expenditure	43 (62.3)	12 (17.4)	14 (20.3)
Village Health Register	50 (72.5)	16 (23.2)	3 (4.3)
Public Services Monitoring Tool and Register	31 (44.9)	27 (39.1)	11 (15.9)
Death Register	66 (95.7)	2 (2.9)	1 (1.4)
Birth Register	67 (97.1)	2 (2.9)	69 (100.0)

According to Table 4, 52 (75.4%) members reported that Village health nutrition day (VHND) was conducted mainly for providing counselling on nutrition and health. Most of the members, 26 (37.7%), helped arrange the meeting and gather people for VHND. Twenty (29.0%) members helped in counseling of nutrition and health for adolescents and women. Thirteen (18.8%) members had some role in vaccination, while 20 (29.0%) members were either unaware of the VHND or had no role.

Table 4

Distribution of VHSNC members according to their awareness regarding village health and nutrition day activities

Variables	Characteristics	Count (n)	Percentage
Awareness about activities done on Village Health and Nutrition Day (VHND)*	Counseling of nutrition and health	52	75.36%
	Vaccination	35	50.72%
	Weight and height of children	14	20.29%
	Food supplement distribution	13	18.84%
	Unaware	8	11.59%
	ANC check-up	3	4.35%
Role of members in Village Health and Nutrition Day (VHND)*	Arranging the meeting and gathering people	26	37.68%
	Counseling of nutrition and health	20	28.99%
	Unaware	20	28.99%
	Vaccination	13	18.84%
	Weight and height of children	8	11.59%
	Food supplement distribution	2	2.90%
	ANC check-up	2	2.90%

*Multiple response table; percentages will exceed 100%

Discussion

In India, strategies to strengthen community participation have been taken up for a long time, which is important to ensure affordable, reachable, and quality primary healthcare, particularly the susceptible and vulnerable sectors of society.[11] World Health Organization (WHO) also suggests that “development in health should be more people-centric” and encourage participation.[12] India also has a long history of decentralized governance involving communities in designing and planning health services via various village health committees. Such village health committees were formed in India for health planning, enhancing health activities, addressing local issues, and enhancing cooperation between community and health authorities.[11] In 2005, National Rural Health Mission (NRHM), retitled as National Health Mission (NHM), introduced the Village Health and Sanitation Committee under Gram Panchayat (village council) to ensure the availability of quality health services to mainly rural poor.[11] Later in 2011, Village Health Sanitation Committee (VHSC) was renamed “Village Health Sanitation Nutrition Committee” to expand services in nutrition. NHM has laid a strong emphasis on the inclusion of “Panchayati Raj Institutions” in the functioning of VHSNC to make it more community-centric.[13] Functions of VHSNC include planning for health and sanitation on village priorities and issues using untied funds. Also, keeping records on community members’ nutritional status, especially women and children increases awareness on nutritional matters. It also organizes “Village Health and Nutrition Day (VHND)” along with Anganwadi Centers (AWCs).[11] To summarize, VHSNC of the Gram Panchayat acts as a platform by addressing various determinants of health by increasing knowledge and access to health services, developing village health plans based on local needs and issues, and increasing people’s utilization of public health services.[1314]

Semwal et al.[6] conducted a similar study in the Nainital district of Uttarakhand and reported that the average age of the members was 39.01 ± 8.5 years and the maximum subjects (32.8%) were qualified up to intermediate, followed by 26.4% graduates. The same study had 16.4% gram pradhan, 9.1% female health workers, 18.2% ASHAs, and 13.6% anganwadi workers. When seen on aspects of monthly meetings, Das et al.’s study in the rural areas of the Kamrup district, Assam[4] reported that monthly meetings were not regular; only 16.67% of the VHSNCs conducted 10–12 meetings in 1 year. More than half of the members mentioned that meetings are conducted for discussing issues of the villages and proposing and budget approval for activities to be conducted in the village.[15] Inadequate and improper record keeping is reported for the meetings.[16] A study from rural eastern India reported that the work of the members of the committees centered around on consolidation of village sanitation, conducting health awareness activities, and assisting in medical management for sick, malnourished children and pregnant women.[11] Awareness among the members of VHSNC is the key to idea of placing “People’s participation in health planning” and ensuring the Universal Health Coverage in India. However, attempts should be made to ensure implementation and developing a monitoring framework for VHSNC. This study gives an insight into awareness among the village level functionaries and their understanding of the VHSNCs.

Conclusion and Recommendations

Village level functionaries of VHSNC of the selected blocks of Dehradun district had partial awareness of the committee’s functioning. Most of the committees used the fund for basic health services, sanitation facilities, and helping poor patients in their treatment and transport to the hospital. Further awareness is required in the committee members to improve the function.

Financial support and sponsorship

Indian Council of Medical Research Short Term Studentship 2019 for financial support

Conflicts of interest

There are no conflicts of interest.