Garnering Support-Reinforcing Commitments: Working with the Village Health Sanitation and Nutrition Committee

SIFPSA's tryst with the Panchayati Raj Institutions began more than two decades back when SIFPSA, finding them to be ideally suited for implementation of the RCH program and integration of services at village level, took the onus of orienting the Pradhans and the Village Health, Sanitation and Nutrition Committee members, drawing many lessons. SIFPSA has successfully oriented the members of local self governance on reproductive, maternal, child health, newborn and nutritional issues, engaging them in improving the health seeking behavior of the community they represent, in turn improving the uptake of health and family welfare services provided by the National Health Mission in the state.

Panchayat or village level local body in India is an age-old institution for governance at village level, having given a constitutional status and responsibility for overall development of the village including health, hygiene, sanitation, nutrition and safe drinking water etc. SIFPSA considered the Panchayati Raj Institution ideally suited for implementation of the RCH program and integration of services at village level. The gram pradhan, head of the village panchayat, was recognized as the most influential person and one-third positions of the PRI members were reserved for women, providing an opportunity for greater involvement of women in program implementation.

However, many of the elected representatives did not have a clear understanding of their roles and responsibilities. Furthermore, their knowledge of health programs and functions of health units within their area was limited. SIFSPA considered it important to organize training programs for pradhans to encourage their participation in program implementation. The main objectives of the training programs were to make the pradhans aware of various health programs, particularly RH and FP; to strengthen the role of elected representatives as supervisors of health programs; to encourage pradhans to promote healthcare- seeking behaviour among villagers; and to elicit their cooperation and involvement in implementation of health activities at the panchayat level.

SIFPSA started engaging the PRI institutions way back in 1998 with the introduction of a comprehensive training program for Pradhans conducted in four phases in 35 selected districts during 1998 to 2004. To begin with, a three day training of trainers (ToT) program was conducted at the district level. The participants included three trainers from each block representing block level government officers such as the medical officer (MO) of the PHC, additional development officers (ADO) of blocks and ICDS officials. The ToT programs were conducted by the State Institute of Rural Development (SIRD) and Sahbhagi Sikshan Kendra, a leading NGO of the state. Topics covered in the ToT programs included introduction to SIFPSA, the 73rd Constitutional Amendment and the role of panchayats in RCH etc. Block health quarters in each district were selected as the training venues. To ensure participation of village pradhans, up-pradhans and block pramukhs were also invited; an invitation letter signed by the district magistrate was sent well in advance. The Pradhan Pati or the husbands of female pradhans were also invited to encourage participation of female pradhans. Duration of each program was one day and three to four programs, depending upon the village size, were conducted in each block to cover all selected PRI representatives. Each pradhan was given an information booklet to use and share with other members of the panchayat. The booklet contained information on synopsis of population policy, role of PRIs, gender equality and the role PRIs can play to promote it, RCH program, antenatal care (ANC) and nutrition, identification and referral of pregnant women, postnatal care (PNC) and immunization, RTIs, FP and services provided at RCH camps. A total of 28,594 pradhans, up-pradhans and block pramukhs were trained in four phases.

In addition to the PRI training programs, as a continued education model, SIFPSA developed eight pictorial comic books covering different RCH topics and circulated them among 30,000 village health committee members in three districts. Annual panchayat melas (fairs) were organized in each block once a year where communication material was exhibited, quizzes conducted, competitions held and folk performances organized to educate people on health issues. To recognize the efforts of the pradhans who were doing a commendable job of improving RCH services in their villages, pradhan forums, chaired by the district magistrate were organized.

With the launch of National Health Mission in 2005, under the decentralized program planning, the focus shifted on the development of a village health plan (VHP) expected to be prepared by the VHSC headed by the Pradhans. The Village Health Sanitation Committee (VHSC) was an important subcommittee functioning under the ambit of the Panchayati Raj Institutions (PRI) with a mandate to work on all health, sanitation and family welfare issues. This committee was headed by Pradhans or Up-pradhans. Later in 2011 'nutrition' was added to the mandate of the VHSC and the subcommittee was renamed 'Village Health Sanitation and Nutrition Committee' (VHSNC) to give due importance and focus to the nutritional status of women and children.

Efforts were made to augment and operationalize the VHSNCs according to the revised framework of the NHM. Each VHSNC is composed of selected panchayat members and co-opted members such as accredited social health activist (ASHA), auxiliary nurse mid-wife (ANM), anganwadi worker (AWW), members of self-help groups (SHGs), or teachers, amongst others, who would be nominated based upon the consent of the panchayat. The roles of VHSNCs were redefined to include community participation in government health programs; ensuring maximum possible utilization of government health facilities; contributing to preparation of area-specific village health plans (VHPs) and ensuring their effective implementation.

The VHSNCs are tasked with preparing village-level health, sanitation and nutrition improvement plans based on local priorities and are given an untied fund of Rupees 10,000 (INR) per village annually to undertake planned activities. Committees are also asked to supervise Anganwadi Centres (AWCs), which are village-level nutrition and pre-school education centres, and to monitor the Village Health and Nutrition Day (VHND), a monthly event when ANMs administer immunization, antenatal care and provide counseling on recommended maternal and child health practices. The current strategy envisions VHSNCs as people's organisations for intersectoral planning and action to address the social determinants of health, and increase people's utilization of public health services.

Based on the past experience of engaging with PRIs, SIFPSA formulated a project on capacity building of VHSNCs in order to strengthen them to develop and implement the village health plans. During 2005 and 2006, SIFPSA designed and implemented a project for training of VHSNC members in one block each of six districts of UP through funds from GoI's EAG scheme. In 2007, the VHSC training was scaled up for implementation at district level in Shahjahanpur and Kanpur Nagar districts through IFPS Project funds.

The key features of the project included designing a training module through participatory processes, developing guidelines for preparation of VHPs, conducting sensitization workshops on the roles and functions of VHSNCs, and implementing the three day training for VHSNCs to strengthen and build their capacities within a timeframe of six months. The module for training was quite comprehensive and included sections on the PRI structure, VHSNC roles and functions, RCH issues, PRA exercise, VHP development, and gender, amongst others. SIFPSA was the lead organization initiating these processes with support from District Health Society and divisional and district project management units.

Taking the onus of orienting the members on their roles and responsibilities and making them aware of the importance of the VHSNCs, SIFPSA has sensitized more than 1.74 lakh VHSNC members across 75 districts of the state. With PRI members elected every five years, the new set of members has assumed office after the recently concluded panchayat election in the state. Hence, SIFPSA has proposed to orient all newly elected VHSNC members from 25 High Priority Districts (HPDs) in the current financial year 2016-17, with funding support from NHM.