Scott Kerry, George Asha S, Harvey Steven A, Mondal Shinjini, Patel Gupteswar, Ved Rajani, Garimella Surekha, Sheikh Kabir
Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America.
Public Health Foundation of India, New Delhi, Delhi National Capital Territory, India.
PLoS One. 2017 Aug 24;12(8):e0182982. doi: 10.1371/journal.pone.0182982. eCollection 2017.
Health committees are a common strategy to foster community participation in health. Efforts to strengthen committees often focus on technical inputs to improve committee form (e.g. representative membership) and functioning (e.g. meeting procedures). However, porous and interconnected contextual spheres also mediate committee effectiveness. Using a framework for contextual analysis, we explored the contextual features that facilitated or hindered Village Health, Sanitation and Nutrition Committee (VHSNC) functionality in rural north India. We conducted interviews (n = 74), focus groups (n = 18) and observation over 1.5 years. Thematic content analysis enabled the identification and grouping of themes, and detailed exploration of sub-themes. While the intervention succeeded in strengthening committee form and functioning, participant accounts illuminated the different ways in which contextual influences impinged on VHSNC efficacy. Women and marginalized groups navigated social hierarchies that curtailed their ability to assert themselves in the presence of men and powerful local families. These dynamics were not static and unchanging, illustrated by pre-existing cross-caste problem solving, and the committee's creation of opportunities for the careful violation of social norms. Resource and capacity deficits in government services limited opportunities to build relationships between health system actors and committee members and engendered mistrust of government institutions. Fragmented administrative accountability left committee members bearing responsibility for improving local health without access to stakeholders who could support or respond to their efforts. The committee's narrow authority was at odds with widespread community needs, and committee members struggled to involve diverse government services across the health, sanitation, and nutrition sectors. Multiple parallel systems (political decentralization, media and other village groups) presented opportunities to create more enabling VHSNC contexts, although the potential to harness these opportunities was largely unmet. This study highlights the urgent need for supportive contexts in which people can not only participate in health committees, but also access the power and resources needed to bring about actual improvements to their health and wellbeing.
卫生委员会是促进社区参与卫生工作的常见策略。加强委员会的努力通常侧重于技术投入，以改善委员会的形式（如具有代表性的成员构成）和运作（如会议程序）。然而，松散且相互关联的背景环境也会影响委员会的有效性。我们运用一个背景分析框架，探究了在印度北部农村地区促进或阻碍村庄卫生、环境卫生和营养委员会（VHSNC）发挥功能的背景特征。我们在1.5年的时间里进行了访谈（n = 74）、焦点小组讨论（n = 18）并开展了观察。主题内容分析有助于识别和归类主题，并对子主题进行详细探究。虽然干预措施成功加强了委员会的形式和运作，但参与者的叙述揭示了背景影响对VHSNC效力产生作用的不同方式。妇女和边缘化群体在社会等级制度中周旋，这限制了她们在男性和有势力的当地家庭面前维护自身权益的能力。这些动态并非一成不变，先前存在的跨种姓问题解决方式以及委员会为谨慎违反社会规范创造机会的做法都说明了这一点。政府服务中的资源和能力不足限制了卫生系统行为者与委员会成员建立关系的机会，并引发了对政府机构的不信任。行政问责制分散，使得委员会成员在改善当地卫生状况时承担责任，却无法接触到能够支持或回应其努力的利益相关者。委员会有限的权力与广泛的社区需求相悖，委员会成员难以让卫生、环境卫生和营养部门的各种政府服务参与进来。多个并行系统（政治分权、媒体和其他村庄团体）提供了创造更有利的VHSNC环境的机会，尽管利用这些机会的潜力在很大程度上尚未实现。本研究强调迫切需要有利的环境，使人们不仅能够参与卫生委员会，还能获取实现自身健康和福祉切实改善所需的权力和资源。
