Introduction:
The NRHM framework of implementation mentions provision of VHSC in each revenue village that has to be formed within the overall framework of Gram Sabha with adequate representation of its members from disadvantaged and marginalized categories like women SC/ST/OBC/Minority communities.[1] VHSC is responsible for overall health of village. The roles and responsibilities assigned to VHSCs mainly include preparation of village health plan and village health register and organization of meetings and various health related activities like health camps, household survey, cleaning, sanitation drive, IEC activities etc., and creating awareness regarding national health programmes in the village. There is a provision of united fund of Rs 10,000 for each VHSC every year to undertake these activities. Moreover this fund can also be utilized for providing referral and transport facilities for emergency deliveries as well as immediate financial needs for hospitalization for the villagers in need. The NRHM also ensures training and capacity building of members of VHSCs to carry out activities expected to them.
Formation of VHSCs was started in Madhya Pradesh (MP)in 2007. In Indore district almost 89% VHSCs (487/552 villages) had already been formed at the time of commencement of this study. In MP, Panchayati Raj Institution (PRI) members and Accredited Social Health Activists (ASHAs) have been assigned as Chairpersons and secretaries respectively in the VHSCs. No specific study on VHSC component of NRHM has been undertaken in MP even after 3 years of its implementation. Also limited studies and reports are available allover India on VHSC which do not give enough information and a clear depiction on the functional status of the VHSCs.
There is a need to ascertain whether there is appropriate understanding among the members of VHSCs about their roles and responsibilities in the committee. There is also a need to ascertain the knowledge and awareness of different stakeholders of VHSCs regarding its various aspects viz. formation, functioning, training status and utilization of united funds.
Materials and Methods:
A cross sectional study was undertaken in 32 villages of all the four blocks of Indore district, from October 2010 to September 2011.
Sampling Design: Multistage
Selection of blocks and Villages with VHSCs:
- To give due representation to whole district, all the 4 blocks were included in the study viz., Hatod, Depalpur, Manpur and Sanver.
- Two PHCs (Primary Health Centers) were selected randomly from each block to cover more than 10% PHCs from each block. (Total 8 PHCs from all 4 blocks)
- From each selected PHC, 2 Sub centers were selected randomly (total 16 Sub centers from 8 PHCs); 16 Sub Centers covers more than 10% Sub Centers of the district, as a total of 111 Sub Centers were existing in the district at the time of commencement of study.
- From each selected Sub center 2 villages with existing VHSCs were purposively selected. One VHSC near (within 5 KMs) the Sub center or in the Sub center and one VHSC distant (5 Kms) from the Sub center were selected to include remote villages also in the study. So a total of 32 VHSCs from all the 4 blocks were selected in the study.
Selection of Study subjects
- DPM (District Programme Manager) of Indore district and all the 4 BMOs (Block Medical Officers) were included in the study as they are involved in releasing fund to VHSCs and in the monitoring of VHSCs as higher authorities.
- Four functionaries were selected from each selected VHSC. One Chairperson (PRI Member), one Secretary (ASHA), one ANM (Auxiliary Nurse Midwife) and one SHG (Self Help Group) member were purposively selected considering them as main stakeholder of VHSC at grassroots level as informed by DPM (District Programme Manager) in discussion. A total of 128 functionaries were selected from all the 32 VHSCs i.e. 4 from each.
- Total 133 study subjects were selected according to the sample designed.
Interviews and Record Reviews were used as study methods to collect data.
Study Tools:
- Pre designed semi structured Pre Tested Questionnaires were used to interview DPM, BMOs and Functionaries of VHSCs
- Checklist for record reviews
All the questionnaires were prepared taking into consideration the original guidelines issued by the Government of India, Ministry of Health and Family Welfare (MOHFW) regarding constitution, and functioning of village health and sanitation committees under NRHM frame work of implementation. The guidelines of Government of Madhya Pradesh State were also considered. The checklist for record review was prepared from standard guidelines on records to be maintained at VHSC issued by Government of India (MOHFW).
Data Analysis: The data collected by interviews, and record reviews is both Qualitative and Quantitative in nature. Quantitative data generated through interviews and record reviews were analyzed using SPSS Software. Qualitative data was analyzed manually using qualitative Qualifier. Two tailed Chi-square Test with Yat’s correction was applied wherever needed.
The data collected was analyzed separately for higher authorities and VHSC functionaries (members) owing to the difference in their jobs, education and socioeconomic status. This study particularly focuses on assessment of knowledge, awareness and opinion of different types of functionaries considered in the study as they are the main stakeholders in the VHSCs.
Table 1: Qualifiers used for Open ended questions. |
| Proportion of Respondents |
Adjectives used |
<10 % Functions of VHSCs stipulated in the guidelines |
Very few |
10-30 % Functions of VHSCs stipulated in the guidelines |
Some |
30-50 % Functions of VHSCs stipulated in the guidelines |
Approximately half |
51-70 % Functions of VHSCs stipulated in the guidelines |
Majority/Over half |
71-90 % Functions of VHSCs stipulated in the guidelines |
Most |
>90 % Functions of VHSCs stipulated in the guidelines |
Almost all |
Results:
In the present study 5 higher authorities (1 DPM and 4 BMOs) and 128 VHSC functionaries (members) of four different categories were interviewed. Among higher authorities, only one (20%) authority knew about correct percentage of women in the formation of VHSC. All the 5 (100%) authorities knew about theprovision of training for VHSC members but none had undertaken any capacity building initiative for VHSC members in their blocks. All the 5 (100%) authorities mentioned that functioning of VHSCs was being undertaken through verbal instructions given to Accredited Social Health activist (ASHAs) and ANMs at their block level meetings. None of the authorities were found to be aware of all the functions of VHSC stipulated in the guidelines. Three (60%) higher authorities have been found to be aware of most of the functions of VHSC. Only 1 (20%) authority correctly knew about all the areas of utilization of united fund stipulated in the guidelines. All the 5 (100%) authorities had opined that the amount being provided to VHSCs was not sufficient to carry out the activities stipulated in the guidelines.
Among VHSC members (functionaries), 118 (92.18%) were females and 10 (7.82%) were males (n=128). Thirty four (26.56%) VHSC functionaries were illiterates (n=128). These illiterates were either from the category of PRI members or SHG members. Maximum 52 (40.6%) members of VHSCs were from Other Backward Castes (OBC), 41 (32%) members were from Scheduled Castes (SC), 31 (24.2%) were from general and only 4 (3.12%) members were from Scheduled Tribes (ST) (n=128). [Table 2]
Table 2: Socio-demographic profile of Stakeholders of VHSCs |
| Category |
Stakeholders |
Chairpersons
(PRI Member)
(n=32) |
Secretaries
(ASHAs)
(n=32) |
ANMs
(n=32) |
SHG Member
(n=32) |
Higher Authorities
(DPM/BMOs)
(n=5) |
Mean Age |
Mean Age of Functionaries of VHSCs is found to be 39 years |
Mean age 42 years |
Sex |
Males (%) |
Among All functionaries 10 (7.81%) were males (n=128) |
4 (80%) |
Females (%) |
118 (92.81%) were females (n=128) |
1 (5%) |
Education |
Illiterate |
17 (53.1%) |
Nil |
Nil |
17 (53.1%) |
Nil |
1st- 5th (Primary) |
4 (12.5%) |
9 (28.1%) |
Nil |
5 (15.6%) |
Nil |
6th- 8th (Middle) |
2 (6.2%) |
11 (34.3%) |
Nil |
7 (21.8%) |
Nil |
9th-10th (High School) |
2 (6.2%) |
11 (34.3%) |
Nil |
2 (6.2%) |
Nil |
11th -12th (High Sec.) |
2 (6.2%) |
1 (3.2%) |
22 (68.7%) |
1 (3.2%) |
Nil |
Graduate |
5 (15.6%) |
Nil |
6 (18.7%) |
Nil |
Nil |
Post graduate |
Nil |
Nil |
4 (12.5%) |
Nil |
Nil |
Professionals |
Nil |
Nil |
Nil |
Nil |
5 (100%) |
Caste |
Scheduled Tribes |
2 (6.2%) |
1(3.1%) |
0 |
1(3.1%) |
Nil |
Scheduled Castes |
7 (21.8%) |
11(34.3%) |
13(40.6%) |
10(31.1%) |
1 (20%) |
Other Backward Castes |
17 (53.1%) |
11(34.3%) |
7 (21.8%) |
17(53.1%) |
1 (20%) |
General |
6 (18.7%) |
9 (28.1%) |
12 (37.5%) |
4 (12.5%) |
3 (60%) |
None of the SHG members and only 3 (9.3%) of all the PRI knew about NRHM and only 2 (6.2%) SHG members and 15 (46.8%) PRI knew about the concept of VHSC. A statistically significant association between knowledge about NRHM and concept of VHSC and type of stakeholder have been found in SHG members and PRI members (?2= 42.6, p=0.000). [Table 3]
Table 3: Knowledge awareness and perception of village level functionaries (members) of VHSCs regarding formation of VHSCs and situation existing regarding formation and training in these VHSCs |
|
Chairperson
(PRI Member)
(n=32) |
Secretary
(ASHAs)
(n=32) |
ANMs
(n=32) |
SHG Member
(n=32) |
Total (n=128 ) |
No. |
% |
No |
% |
No |
% |
No |
% |
No |
% |
Know about NRHM |
3 |
9.3 |
19 |
59.3 |
32 |
100 |
Nil |
0 |
54 |
42.1 |
Know about Concept of VHSC |
15 |
46.8 |
30 |
93.7 |
32 |
100 |
2 |
6.2 |
79 |
61.7 |
Received Guidelines for formation of VHSCs |
0 |
Nil |
6 |
18.7 |
24 |
75 |
0 |
Nil |
30 |
23.4 |
Verbal instructions from authorities for the formation of VHSCs |
21 |
65.6 |
32 |
100 |
32 |
100 |
0 |
Nil |
85 |
66.4 |
Could not tell anything regarding basis of formation |
11 |
34.3 |
0 |
Nil |
0 |
Nil |
32 |
100 |
43 |
33.5 |
Know at least half of the guidelines regarding formation of VHSC |
0 |
Nil |
21 |
65.6 |
23 |
71.8 |
0 |
Nil |
44 |
34.3 |
Formal Training on VHSC Received |
0 |
Nil |
0 |
Nil |
0 |
Nil |
0 |
Nil |
0 |
Nil |
Training not Received |
32 |
100 |
32 |
100 |
32 |
100 |
32 |
100 |
128 |
100 |
Any kind of instructions on VHSC functioning |
0 |
Nil |
32 |
100 |
32 |
100 |
0 |
Nil |
64 |
50 |
Detail Training is needed |
32 |
100 |
32 |
100 |
32 |
100 |
32 |
100 |
128 |
100 |
None of the PRI members and SHG members received any guidelines for the formation of VHSCs. All the 32 (100%) ASHAs and ANMs and 21 (65.6%) PRI members mentioned verbal instructions from block level authorities (BMOs, Block Education Extensors and Block Programme Managers) as the basis of formation of VHSCs in their areas. All the 32 (100%) SHG members were totally ignorant about formation process of VHSC and many of them came to know about their membership only at the time of study. Twenty three (71.8%) ANMs and 21 (65.6%) ASHAs knew about at least half of the guidelines regarding formation of VHSC. None of the PRI members and SHG members knew about at least half of the guidelines regarding formation of VHSC. A statistically significant association between knowledge about formation of VHSC and type of member has been observed (χ2= 67.3, p=0.000). Formal training specifically on VHSC has never been imparted to any member of any VHSC considered in the study, although all the 32 (100%) ASHAs and ANMs had been received verbal instructions regarding functioning of VHSC. All the 128 (100%) members wanted to undergo training to understand functioning of VHSCs. [Table 3]
None of the stakeholders knew about all the functions of VHSC. Thirty (93.7%) of SHG members and 7 (21.8%) PRI members could not tell any function of VHSC. A statistically significant relation between knowledge on roles and responsibilities of VHSC and type of member has been observed; knowledge about functions of VHSC being least among SHG members followed by PRI members (χ2= 85.5, p=0.000). None of the members were found to be aware of the term village health plan which is a specially mentioned activity in the guidelines of VHSC. None of the SHG members were aware of provision of monthly meeting for VHSCs. Forty six (35.9%) members mentioned that the monthly meeting was organized regularly in their respective VHSCs while 24 (18.7%) members mentioned that monthly meeting was not organized in their respective VHSCs. Fifty eight (45.3%) members mentioned that they knew whether the meeting was organized or not in their respective VHSCs (n=128). All the 32 (100%) SHG members and 21 (65.6%) PRI members were ignorant about whether household survey was conducted by their committees or not. PRI and SHG members were unaware about VHND. Thirty two (100%) SHG members and 25 (78.1%) PRI members were ignorant about whether records of birth and deaths were kept by their respective VHSCs or not. Public dialogue was not organized at any VHSC. [Table 4]
Table 4: Knowledge and Awareness of different stakeholders regarding roles and responsibilities of VHSCs. (n=32 in each group of stakeholders) |
Knowledge Variable
(on functions of VHSC) |
Chairperson
(PRI Member) (n=32) |
Secretary
(ASHAs) (n=32) |
ANMs (n=32) |
SHG Member (n=32) |
No. |
% |
No. |
% |
No. |
% |
No. |
% |
Could tell almost all the functions stipulated in the guidelines |
Nil |
0 |
Nil |
0 |
Nil |
0 |
Nil |
0 |
Could tell Most of the functions |
Nil |
0 |
22 |
68.7% |
23 |
71.8% |
Nil |
0 |
Could tell half of the functions |
5 |
15.6% |
32 |
100% |
32 |
100% |
Nil |
0 |
Could tell some functions |
20 |
62.5% |
32 |
100% |
32 |
100% |
2 |
6.25% |
Could not tell any function |
7 |
21.8% |
Nil |
0 |
Nil |
0 |
30 |
93.7% |
Know about Village Health Plan |
0 |
Nil |
0 |
Nil |
0 |
Nil |
0 |
Nil |
Know about provision of monthly meeting |
19 |
|
32 |
100 |
32 |
100 |
0 |
Nil |
Committee organizes monthly meeting |
7 |
|
22 |
|
17 |
|
0 |
Nil |
Conduct household survey to identify health issues of the village |
7 |
|
22 |
|
28 |
|
0 |
Nil |
Know about VHND |
0 |
Nil |
32 |
100 |
32 |
100 |
0 |
Nil |
Committee keeps record of every birth and death of the village |
7 |
21.8 |
30 |
93.7 |
32 |
100 |
0 |
Nil |
Committee organizes public dialogue |
0 |
Nil |
0 |
Nil |
0 |
Nil |
0 |
Nil |
SHG members were totally ignorant regarding provision, amount and account holders of united fund. Ninety six (75%) functionaries did not receive any written guidelines for united fund utilization and all these mentioned that they got verbal instructions from the concerned authorities to use the united fund. All these findings are statistically significant with respect to SHG members (p<0.05). Cleanliness and environmental sanitation drives were the most common activities undertaken by all the 32 (100%) VHSCs during the previous year, followed by emergency transportation of patients to health facility, including antenatal cases for delivery. [Table 5]
Table 5: Knowledge, Awareness and Perception of functionaries about united fund |
|
Chairperson
(PRI Member)
(n=32) |
Secretary
(ASHAs)
(n=32) |
ANMs
(n=32) |
SHG Member
(n=32) |
Total (n=128) |
No. |
% |
No |
% |
No |
% |
No |
% |
No |
% |
Know about provision of funds for VHSC |
32 |
100 |
32 |
100 |
32 |
100 |
2 |
6.2 |
98 |
76.5 |
Know about amount of fund received by VHSC |
32 |
100 |
32 |
100 |
32 |
100 |
2 |
6.2 |
98 |
76.5 |
Know about account holder for receiving united grant of VHSC |
32 |
100 |
32 |
100 |
32 |
100 |
2 |
6.2 |
98 |
76.5 |
Received written guidelines to use fund |
0 |
Nil |
11 |
34.42 |
26 |
42.42 |
0 |
Nil |
37 |
28.9 |
Received verbal instructions from some authorities regarding use of united fund |
32 |
100 |
32 |
100 |
32 |
100 |
0 |
Nil |
96 |
75 |
Know at least half of the functions or activities as per the guidelines for which united fund could be utilized |
3 |
9.3 |
32 |
100 |
32 |
100 |
0 |
Nil |
67 |
52.3 |
Noticed some improvement after formation of VHSC in the village |
17 |
53.1 |
27 |
84.3 |
21 |
65.6 |
0 |
Nil |
65 |
50.7 |
Opine that present amount is sufficient |
0 |
Nil |
0 |
Nil |
0 |
Nil |
0 |
Nil |
0 |
Nil |
In record review only record of united fund has been found available at all the 32 VHSCs.
Discussion:
The present study focuses on knowledge, awareness and perception of different types of stakeholders of VHSCs regarding various aspects of VHSC.
In the present study, all the authorities, all the ANMs and 30 (93.7%) ASHAs have been found to be knowing about concept of VHSC. Similar findings were obtained in another study by Mohanti et al.[3]
In the present study, maximum members (40.6%) were found to be from OBC. Mohanti et al[3] reported 69% (maximum) members from OBC. Knowledge on formation of VHSC has been found in none of the PRI members and SHG members in the present study, in contrast to the finding of Mohanti et al[3] where knowledge on formation has been found to be in 50% SHG members and 16% of PRI members. Only 34.3% members have been found to be knowing about formation of VHSC in the present study. Another study[4] showed that only 39.5% members were knowing about the formation of VHSC. In the present study 76.5% members had not received any guidelines regarding formation of VHSCs. Mohanti et al[3] also reported that none of the members received any guidelines regarding formation of VHSCs. All (100%) ASHAs and ANMs mentioned that they were verbally instructed by concerned authorities to form VHSCs in their areas. Mohanti et al[3] found 50 % ASHAs and ANMs had mentioned verbal instructions from seniors as the basis of formation VHSCs in their areas. The present study shows that none of the members of VHSCs had been imparted any specific training on VHSC. Only ASHAs and ANMs have been found verbally instructed by BMOs, BPMs and BEEs of their respective blocks regarding functioning of VHSCs but none of the PRI members and SHG members had been given any training or instruction on functioning of VHSCs. Mohanti et al[3] also observed that only ASHAs and ANMs were given training but none of the PRI members and SHG members were given any training on VHSC.
In the present study 100% respondents wanted to undergo detailed training on all aspects of VHSC to work properly in the committee. Mohanti et al[3] also reported the same opinion from all the 100% respondents.
In the present study, 76.5% respondents were knowing about provision of united fund for VHSC. Another study[5] also reported knowledge about provision of fund for VHSCs in 85.71% respondents. In this study, 93.7% of all SHG members were found to be unaware about provision of united fund for VHSCs. Mohanti et al[3] reported that 100% SHG members were unaware about provision of united fund for VHSCs.
In the present study 76.5% of all stakeholders of VHSCs were found to be correctly knowing about the amount of united fund provided to VHSCs every year. Similar findings were revealed by Kesri et al.[5] In the present study 76.5% of all members were found to be knowing correctly about the account holders of VHSC fund. Similar findings were obtained in anotherKesri et al.[5]
Awareness about activities for utilization of untied fund was found in 52.3% members. Kesri et al[5] reported 41.6% members were aware about utilization of united fund.
Conclusions:
The present study reveals that the efficiency and impact of VHSCs appears to be very limited. No capacity building initiative for the members of VHSCs has been undertaken so far by programme implementers. The functions of VHSCs have been implemented through verbal instructions by the concerned authorities. It appears that programme implementers (DPM and BMOs) themselves have not been clearly explained regarding the programme guidelines. Significant association between type of stakeholder and knowledge on various aspects of VHSCs has been observed as PRI members and SHG members have been found to be totally ignorant about many aspects of VHSC.
The involvement of VHSC members in the activities laid down in VHSC guidelines has been found to be limited and negligible with regard to SHG members and PRI members. ASHAs and ANMs also have inadequate knowledge about functions of VHSC and they have been found to be limited mainly to the function of sanitation.
There is no involvement of other members except ASHAs and PRI members in budget planning and subsequent expenditure and also members are not involved in budget tracking activities. SHG members are not even aware of provision and amount of annual grant provided to VHSCs.
Acknowledgements:
The authors are grateful to all the participants in the study who extended their full cooperation in the study. We would like to thank our team and we sincerely acknowledge Dean and HOD (PSM) of MGM Medical College, Indore, for their support for this work.
References :
- National Rural Health Mission Documents/Guidelines of untied funds NRHM. Ministry of Health and Family Welfare, Government of India. Available from: http://mohfw.nic.in/NRHM/Documents/Guidelines_of_untied_funds_NRHM.pdf (Last accessed on 2012 April 15).
- National Rural Health Mission (programme implementation plan 2006-2012) document of State health mission Department of health & family welfare, Government of Madhya Pradesh Bhopal. Available from: http://www.mp.gov.in/nrhm/pip-nrhm.pdf. (Last accessed on 2012 August 17 )
- Mohanti et al. Rapid Appraisal of Functioning of Village Health and Sanitation Committees (VHSCs) under NRHM in Orissa. Available from http://nihfw.org/pdf/RAHI-I%20Reports/Kalinga/Kalinga.pdf. (Last accessed on 2013 June 15).
- SMS Foundation. Capacity-building needs of Village Level Health Committees (VLC) cum Village Health and Sanitation Committee (VHSC) - A report on study undertaken by Institute of Rural Research and Development (IRRAD) in the 13 villages of 4 blocks of Mewat district of Haryana state in 2010. Available from http://www.smsfoundation.org/pdf/Report%20on%20Capacity-Building%20Needs-VLC%20cum%20VHSC.pdf. (Last accessed on 2013 June 18th).
- Kesri VR et al. Assessment of knowledge and utilization of untied fund provided to VHNSCs in selected villages of 5 sub centre area of PHC, Anji in Wardha district. The Journal of Mahatma Gandhi Institute of Medical Sciences March 2011;16:30-32.
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