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Query: Panchayats and Health Care System, from Foundation for Research in Community Health (Experiences).

 

Compiled by Alok Srivastava and Meghendra Banerjee, Resource Persons; additional research provided by Happy Pant, Research Officer and Aditi Banaa, Research Associate

30 June 2006

 

 

Original Query: By Rakhal Gaitonde, Foundation for Research in Community Health, Ralegan Siddhi (Maharashtra)

 

Posted: 11 June 2006

 

I am working on a project that is attempting to study the establishment of people-controlled health care system using the Panchayati Raj Institutions as basis.  As part of this I am working towards preparation of a proposal and collecting experiences / evidence of the effectiveness of village level committees in fulfilling the expectations of representativeness, equity and justice, gender equity and caste based equity.  I am, therefore, trying to gather experiences/data from all fields where village level committees have been tried as a strategy for increasing and deepening people's participation (whether within or without the Panchayati Raj Institutions) in various sectors of development.

 

Could members please send me their experiences from various sectors in this regard?  Any papers and references etc. that may be shared to throw further light on these issues will also be of help and will be duly acknowledged.

 

 

Responses were received, with thanks, from:

 

1.      Jayashree Raghunandan, Government of Tamil Nadu, Chennai

2.      Arunabha Majumder, All India Institute of Hygiene and Public Health (AIIHPH), Kolkata

3.      Venkatrao Ghorpade, SHIRDI Foundation, Bangalore

4.      Sidharth Dutta, Rajiv Gandhi Foundation, Faridabad

5.      Subhash Mendhapurkar, SUTRA, Solan, Himachal Pradesh

6.      Subash Ghosh, TISS, Mumbai

7.      Seema Kakade, Prayas, Pune

8.      Sadhu Charan Panda, VSS Medical College, Burla, Orissa

 

Further contributions are welcome!   

 

 

Summary of Responses

Comparative Experiences

Related Resources

Responses in Full

 

 

Summary of Responses

 

The query sought to collect experiences and evidences from across the country of people controlled health care systems based in village level committees, like Panchayati Raj Institutions (PRIs).  Generally concurring to the viewpoint that an effective way of addressing a broad array of issues corresponding to community interests is through the village committee approach, members provided a variety of experiences and lessons learned on village level participation to create an improved and equitable healthcare environment. Members underlined the key factors for the success of this approach and came up with suggestions to sustain such models. 

 

Members cited several examples of different implementation strategies adopted by communities in the health and water sectors. The Smart Parenthood Campaign project presented by members, offered an interesting model of local level participation for correcting the sex ratio imbalance by looking at issues of adolescent health, gender discrimination and population control. The achievements of the vibrant Village Health Committees (VHCs) formed under the project reflect the participatory effort of the community in their own development, not only with issues of health, but also education and gender. The National Rural Health Mission (NRHM), members pointed out, is also trying to involve VHCs in its efforts to improve rural healthcare.

 

Another experience shared by members was a community-based management project aimed at mitigating arsenic contamination. This highlighted the importance of the integrated role played by community groups in improving healthcare systems. Respondents pointed out how the active engagement of village level groups in awareness generation, and the operation and maintenance of arsenic removal unit coupled with constant facilitation and encouragement from project team produced high-quality results.

 

An experience of panchayat leaders’ participating in training workshops, threw light on the need for local governments to take a lead in attempts to improve healthcare systems. The panchayats facilitated identification of local health system problems followed by formulation of practical solutions by involving all key players. The exercise that brought out the felt needs of both their sides stressed on the power of dialogue between the affected parties. Members mentioned the Namadhu Gramam scheme, another example of how panchayat leadership in health initiatives results in improvement in health indicators. 

 

Additional research brought out the Janshala and PROUD project experiences, which illustrate that the success of an initiative depends largely on the degree of participation by the intended beneficiaries.

 

Stressing the importance of involving village level committees in social welfare programmes, specifically healthcare activities, respondents put forward several driving factors, they felt underpin vibrant and active community committees. Members pointed out result-oriented committees and/or PRIs tend to have the following features:

§         Need based- local committees/groups established on the basis of a felt need in the community to address certain issues generates interest and coordinated action by the community

§         Have proper orientation and understanding of situation- issue based training and participatory discussions can help committees to gain a better understanding of the issues as well as their roles and responsibilities

§         Diverse membership- ensuring representation of all sections of community, particularly women helps take into account issues affecting all sections

§         Active involvement of key stakeholders- to allow committees to gain from the stakeholders’ perspective

§         Flexible functioning- allows the group to collectively decide their working approach and ensure everyone is participating

 

Members noted that the specific health issues and problems vary from area to area. As the nature and role played by the village level committees and PRIs is the key to the success of an initiative, there is a need to assess, analyse and act according to the situation.

 

 

Comparative Experiences

  

West Bengal
 

Community Based Management System (from Arunabha Majumder, AIIHPH, Kolkata)

To mitigate the problem of arsenic contamination in ground water in affected districts, the All India Institute of Hygiene and Public Health undertook a project of community based management. It identified NGOs and community groups, which spread awareness about deleterious effects of arsenic, testing of all water sources and O&M of hand pump attached Arsenic Removal Unit (provided under the project) at the fee of Rs 5-10 per beneficiary family.    
 
Tamil Nadu
 
Namadhu Gramam (from Jayashree Raghunandan, Government of Tamil Nadu, Chennai)
Health is one of the sectors under the Namadhu Gramam scheme its goals are 100% immunization and institutional delivery, reduction of IMR and MMR, and prevention of STIs/HIV. As the scheme provides for an incentive to the panchayat for progress towards the goals, success has been high with regard to involvement of panchayat president about ensuring better health care in panchayats. See more
 
Haryana
 

Importance of Participation of Panchayat Leaders in Workshops (from Subhash Mendhapurkar, Sutra, Solan, Himachal Pradesh)

Upon intervention of the BDO’s office panchayat leaders cultivated interest in WCD training workshops. They voiced problems relating to poor primary health care services, ANMs, male health workers charging fees etc. This feedback was built into the socio-economic mobility mapping exercise to identify the cause and solution of the problem.  It brought SHGs into picture who took up the responsibility of motivating Panchayat leaders to spend money for routine upkeep of health sub-centre.
 

Smart Parenthood Campaign (SPC) (from Sidharth Dutta, RGF, Faridabad)

The Rajiv Gandhi Foundation is implementing the SPC in Kurukshetra District, aiming to improve imbalance sex ratio. It formed 100 VHCs in the project area with about 20 members, drawn from PRIs, religious groups, service providers (i.e. ANMs, schoolteachers and AWWs), community leaders and social activists. VHCs acted as pressure groups to involve community in taking up issues like stopping child marriage and female feticide, and closing liquor shops.  
 
All India
 
National Rural Health Mission (from Alok Srivastava, Resource Person)

The Mission adopts a synergistic approach by relating health to determinants of good health viz. segments of nutrition, sanitation, hygiene and safe drinking water.  Among many other things the Plan of Action includes reducing regional imbalance in health infrastructure, integration of organizational structures, and most importantly decentralization and district management of health programmes and community participation. (see more at http://mohfw.nic.in/nrhm.html)

 

Accredited Social Health Activist (ASHA) (from Venkatrao Ghorpade, SHIRDI Foundation, Bangalore)

The NRHM’s calls its new cadre of rural health functionary ASHA. One ASHA per 1,000 people would create awareness on health and its social determinants, mobilize the community towards local health planning and increased utilization of the existing health services. She would educate villagers on nutrition, women’s health during and after pregnancy, correct breast-feeding, etc., and interact with village level committees and get the Panchayats involved in health programmes. See More

 

Several States

 

From Happy Pant, Research Officer

 

Janshala 

Janshala is a joint programme of the U.N. and the GoI. Various states carried out micro-planning activities to identify problems like out-of-school children, school infrastructure and awareness generation. Following this, the project formed Village Education Committees (VECs) in about 20,000 habitations. The VECs are actively involved in school improvement, activities to promote universal enrolment and retention of children in primary and alternative schools. See More
 
People's Responsible Organization for United Dharavi (PROUD) 
The people of Dharavi, Mumbai (Asia’s largest slum) came together to solve their collective problems. They formed an organization called PROUD with its structure derived from the Chawl Committees' issue-solving processes. PROUD is composed of chawl residents, has office bearers, monthly meetings and planning process. If a local problem which cannot be solved by the local chawl committee it is taken to the Executive Committee. See More 
 
 
Related Resources

 

Recommended Documentation

 

From Jayashree Raghunandan, Government of Tamil Nadu, Chennai

 

Namadhu Gramam

http://www.tn.gov.in/gorders/rd-e-140-2004.htm

Illustrates how the scheme envisions participation of people in sustainable development of villages by focusing on sectors specific goals; health, sanitation, water and education, etc.

 

Care for Mother and Child at Village Health Center

http://www.solutionexchange-un.net.in/decn/cr/res24060601.pdf (Size: 70 KB)

Lists five successful case studies showcasing the leadership demonstrated by panchayat Presidents in achieving health targets under Namadhu Gramam

 

Quality of Care in Health Services and Role of Gram Panchayat (from Subhash Mendhapurkar, SUTRA, Solan, Himachal Pradesh)

http://www.solutionexchange-un.net.in/decn/cr/res24060602.doc  (Size: 3,921 KB)

The UNFPA developed module is to be used for orienting panchayat leaders in quality of care in health care delivery in general and sexual and reproductive health, in particular.

From Happy Pant, Research Officer

 

Why Some Village Water and Sanitation Committees are Better than Others: : A Study of Karnataka and Uttar Pradesh (India)  

Water and Sanitation Programme, South Asia; 2001

http://www.wsp.org/publications/sa_ybetter.pdf (Size: 464 KB)

Demonstrates the effectiveness of village committees under the project on ‘sustained water services for rural poor’ with regard to planning, implementation, maintenance of schemes

 

Community Groups and Planning Action 

http://www.gdrc.org/uem/doc-comparti.html
Case study illustrates participation methodology adopted by residents of Dharavi and the committees formed to solve local problems.

 

Recommended Organizations
 

From Subhash Mendhapurkar, SUTRA, Solan, Himachal Pradesh

 

Department of Women and Child Development, Government of Haryana 

http://wcdhry.gov.in/
Functioning since 1992, the Department is responsible for streamlining the activities in different sectors of social welfare to give impetus for holistic development of women and children.

 

UNFPA, India

http://www.unfpa.org.in/
Supports government’s policies and programmes on population particularly in quality of services, infrastructure development, technology transfer, MIS, training and IEC.
 
Society for Social Uplift Through Rural Action (SUTRA), Solan, Himachal Pradesh
http://www.indianngos.com/s/sutra.htm
The NGO has been engaged in areas of health, gender sensitization, women’s empowerment focusing on integrating panchayat’s role in above sectors.
 

From Arunabha Majumder, AIIHPH, Kolkata

 

All India Institute of Hygiene and Public Health (AIIHPH), Kolkata 

http://mohfw.nic.in/kk/95/ib/95ib0y01.htm

With an objective of developing health work force, it provides post-graduate training facilities, conducts research in health problems in the community, provides support services.

 

India Canada Environment Facility, New Delhi 

http://www.icefindia.org/
Works to enhance environmentally sound development, with focus on building institutional and related management capability in natural resource and environmental management

 

Rajiv Gandhi Foundation (RGF), New Delhi (from Sidharth Dutta, RGF, Faridabad)

http://www.rgfindia.com
RGF acts as catalyst promoting sustainable programmes in various sectors including projects to make women and children full participants of the development process.
 
Sambhav, Gwalior (from Happy Pant, Research Officer)

http://www.sambhavindia.org/

A voluntary organization working in the areas of child education and   women empowerment, it ensures participation of panchayat and Village Health Committees in related programs. 

 
Recommended Website
 

National Rural Health Mission (NRHM) (from Venkatrao Ghorpade, SHIRDI Foundation, Bangalore)

http://mohfw.nic.in/nrhm.html

Provides detailed guidelines on roles/responsibilities, selection procedure and other institutional arrangements of ASHA

 

 

Responses in Full

 

Jayashree Raghunandan, Government of Tamil Nadu, Chennai

 

In Tamil Nadu, we have been implementing a scheme called ‘Namadhu Gramam’ meaning ‘our village’, which focuses on people’s participation for development with panchayat playing a key role for that. Health is one of the sectors which are addressed as part of the holistic and sustainable development of the panchayat and improvement to quality of life indicators. The goals under Health that the scheme looks at are:

§         100% immunization

§         100% institutional delivery

§         Reduction of IMR & MMR

§         Making village malnourishment free

§         Prevention of STD & HIV infection

 

The scheme also provides for an incentive to the panchayat for progress towards the goals.

 

Success has been seen especially with regard to involvement of Panchayat President and attention given in panchayats to ensure better health care in panchayats. Some success stories are also enclosed.

 

Results would be far far better if the Health Department would themselves adopt this strategy and IEC methodology and work in a converged manner.

 

In fact one of the active Master Trainers and officials involved in its planning, implementation and monitoring who is from the Health Department (Block Extension Educator) has this to say –

 

‘My work in achieving my targets in Health Department has become so easy with Namadhu Gramam. I as a field functionary fully support Namadhu Gramam and consider it the best scheme to get panchayats and people involved’ .

 

Encl.: Success stories http://www.solutionexchange-un.net.in/decn/cr/res24060601.pdf

 

 

Arunabha Majumder, All India Institute of Hygiene and Public Health (AIIHPH), Kolkata

 

In West Bengal 79 Blocks in 8 Districts are affected by Arsenic contamination in ground water. In 1983 it was first detected in West Bengal. One of the steps for mitigation of Arsenic problem in drinking water is to supply Arsenic safe water after removal of arsenic from ground water. Water quality monitoring, awareness and motivation are also components of mitigation program. AIIH&PH (All India Institute of Hygiene and Public Health), Kolkata has undertaken a Project Funded by ICEF (India Canada Environment Facility) to mitigate the arsenic problem through community -based management system.

 

In affected villages, the village people were made aware of the deleterious effect of arsenic on human health. Community groups were formed. All water sources in the villages were tested. 

 

The Community groups were told to select technology (System) for Hand- Pump attached Arsenic Removal Unit. They were shown different functional models in Technology Park (established for the project) and also operation and maintenance.  After selection, Arsenic Removal Units (hand pump attached) were provided in the villages from the project fund. The community groups are presently operating and maintaining the ARU. Each beneficiary family is paying between Rs. 5 and Rs. 10 for O&M. Funds are kept at Post Offices / Gramin Bank / Cooperative Bank. The groups (Committees) decide on functioning of the Units. Success rate - 80%.

 

AIIHPH selected NGO partners for implementation of the program.

 

I worked with the Project for 5 years (till 31.1.2006). The project will be completed in 2006.

 

 

Venkatrao Ghorpade, SHIRDI Foundation, Bangalore

 

To support such a programme one necessarily requires the help of a coordinator, who can sit with the village level committee and interact with the beneficiaries.

The National Rural Health Mission has created anew cadre of rural functionary called ASHA - Accredited Social Health Activist. The general norm would be one ASHA per 1000 population. They will educate villagers on nutrition hygiene, counsel women on pregnancy, breast feeding etc.

 

ASHA could interact with village level committees coming in their jurisdiction and get the Panchayats involved in such health programmes.

 

 

Sidharth Dutta, Rajiv Gandhi Foundation, Faridabad

In response to your query regarding the effectiveness of village level committees as a strategy for increasing peoples' participation in various development sectors, I would like to share my experience of highly vibrant village health committees (VHCs) formed under the Smart Parenthood Campaign project of the Rajiv Gandhi Foundation in Kurukshetra District of Haryana.

Based on the diffusion of innovation theory of development communication, the smart parenthood campaign has been conceptualized and designed by the Foundation for improving imbalance sex ratio and for stabilising population by addressing the issue of female foeticide, reproductive and sexual health of youth, gender discrimination and the issue concerning population control.

Diffusion of innovation is the process through which innovations, new ideas, concept of social relevance spreads via different channels over time among the members of a particular social system. The issues are addressed at societal, family and individual level. In this project, the issues related to imbalance sex ratio and growing population have been effectively covered using different channels- community based channels which include VHCs/Panchayats, Institutional based channels including schools, universities, Smart Parenthood Clinics, Primary Healthcare delivery system and the communication channel involving folk as well as print media to bring an attitudinal change amongst the masses. 

Started in June 2005, the project has been piloted in Kurukshetra District. The major strategies employed include:

A total of 100 VHCs with 15 to 20 members in each have been formed in the project area. A VHC comprises of PRI members, religious leaders, service providers at village level (ANM, AWW, School teacher), community leaders, youth, social activists and other interested community member. Equal representation of the women has been ensured in each of the committees. The purpose of forming the committees is to create a pressure group and involve the community in improving its own health.

Results have been highly encouraging with lot of community driven initiatives. Some of the decisions taken by VHCs have been

There are many more such examples which reflect the participatory effort of community in their own development through these VHCs. In a period of less than a year, these committees have come up as strong community level institutions working towards sustainable development.

The driving factors which I think have contributed in such a vibrant VHCs include

I hope this information will be of use.

 

 

Subhash Mendhapurkar, SUTRA, Solan, Himalaya Pradesh

 

We, with support from UNFPA and WCD of Haryana, tried this in Rewari district of Haryana.

 

At the beginning, the experience was very frustrating as far as involvement of Panchayat leaders was concerned. The panchayat leaders shall not attend the Training Workshops as invitation from WCD was of no concern to them. After involving the BDO office we started getting some response, but as the word spread, more and more Panchayat leaders started attending the Workshop. So the first thing is to convince the Panchayat leaders that they must get exposed to other areas such as Health apart from filling muster rolls training of RD.

 

Once they got motivated, they spoke lot about non-availability of primary health care services to villagers and especially the non existence of ANMs, and cases of some male health workers working as ‘doctors’ and charging fees. We took this feed back to the Workshops of ANMs and male Health Workers which wasn't received well but there was agreement that the ANMs and Male Health Workers were not taking Panchayat leaders in confidence due to ‘class’ biases - the functionaries felt that all the Panchayat leaders are corrupt and have nothing else to do apart from politicking.

 

After first round of ventilation, the ANMs and MHWs started getting around the issue of not able to reach to all the ‘people’. We followed this with socio-economic mobility mapping of families under their coverage area. This mapping helped the ANMs and MHWs to understand how the poorest and most vulnerable families leave their homes early morning for ‘jobs’ and return in late evening, whilst the functionaries are in the village between 10 to 5.

 

Once this was identified as ‘gap’ in the service provision, solutions were looked for and one of the solution that came out was the ANMs agreed to reach out to these families provided they get support from SHGs or women's collectives.

 

This Brought the SHG members in picture. During the Workshops with SHGs, we again encountered the negative feelings towards functionaries, we gave enough space for expressing this and once this was done, we concentrated on how the SHGs and ANMs/MHWs can join hands to work together - especially in community need assessment and based on this, developing programs.

 

The SHGs readily agreed to provide support and participation in the workshops at village level for asserting the community need assessment.

 

During this the role of Panchayats came up for discussion and the SHGs took up the responsibilities for motivating Panchayat leaders to spend money for minor repairs and upkeep of Health Sub-center. This was one of the most felt needs of the ANMs, as they never felt physically secure at Health Sub-centers which are constructed away from localities, mostly with filthy surroundings. So they would sit at their relatives’ house and wait for the clients to approach them. Due political and caste rivalries, many families were not able to access the services.

 

UNFPA has developed a training manual for Panchayat leaders (for induction in health service provision) and the manual is available with Ms Dhanashri Brahme, Program Officer, UNFPA, 53 Jor Bagh, New Delhi.

 

Some wonderful things have happened since the SHGs, Service Providers and Panchayat leaders joined hands (for detail please contact Director, WCD, Government of Haryana) or write to SUTRA@sril.com.

 

 

Subash Ghosh, TISS, Mumbai

 

I was a Medical Officer in Nowrangpur District, one of the backward districts of Southern Orissa. When I joined there I had great difficulties in getting along with PRI leaders as well as my staffs, who were not exactly in good books of each other. The problems the health and ICDS staff faced were mainly of communication, supplies and lack of participation from the panchayat, health was always the last topic in their agenda. We organized joint trainings of the panchayat members, and invited the health & ICDS teams as resource persons. The training had group work on delivering mock health services and the panchayat members also had ample opportunity to interact with the health, ICDS and Block Extension Officers – this somewhat cleared the confusion and started a dialogue. The feedback of the training was followed up with a series of multisectoral meetings with all the relevant departments, who surprisingly enough, neglected health as an agenda in their routine plans.

 

At a district level, this regular sharing of concerns and joint planning helped to clarify the roles and more importantly responsibilities however, issues like sectoral planning and accountability and appraising the panchayat members performance in health care delivery – is still under debate.

 

 

Seema Kakade, Prayas, Prayas, Pune

 

This is interesting. We, in Maharashtra are exploring one idea, sharing about it here seems relevant.

 

There are ample success stories and ample educative material on PRIs. While reviewing this material, we felt that it is necessary to go a step ahead, to understand the strategies to ensure enablers as well as strategies to overcome hindrances and bottlnecks. It is essential to understand these strategies from the viewpoint of people, especially women, who are evolving and utilising these strategies. Some of these strategies may be theme specific, while some may be generic.

 

This will provide insights on 'utilising spaces in the mainstream effectively', from the view point of users. Thus, these will go beyond the typical success stories. These insights can be developed as 'best practices' to be used and adopted at various spaces. We have initiated this process in Maharashtra, in collaboration with PRI movements of women, which are spread in all parts of rural Maharashtra.

 

We will be able to share these insights in near future.

 

 

Sadhu Charan Panda, VSS Medical College Burla, Orissa

 

I want to share my experience with you – when I was working as an M.O. Additional PHC, in Mahichala, Kalahandi District, Orissa.

 

I served a village with a Sarpanch belonging to a backward class. My presence, as an upper caste, was not really welcomed. After a lot of efforts and special sessions with the people of the village, not only the backward class but also the upper class, I could convince them that as a service provider I do not and cannot differentiate among the classes; and it is equal for all.

 

So the summary is issues and problems from area to area are different. We should assess, analyse and act accordingly. Once we gain the confidence of leaders of the community through equitable service, then they become “health” friendly and take ownership of the service delivery, in this case the Health Centre.

 

 

 Many thanks to all who contributed to this query!

 

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