14 research outputs found
Government helper and citizen advocate? A case study of the multiple roles and pressures facing a nongovernmental organization contracted by government to strengthen community health in northern India
While nongovernmental organizations (NGOs) can potentially
strengthen valuable citizen political engagement, NGOs that are
increasingly oriented towards donor and government contracts may
instead contribute to depoliticizing development. Amidst competing
pressures, NGO experiences and agency in managing multiple roles
require examination. We present a qualitative case study of an NGO
implementing a government‐designed intervention to strengthen
Village Health, Sanitation, and Nutrition Committees (VHSNCs) in
rural north India. Despite a challenging context of community
scepticism and poor government services, the NGO did successfully
form VHSNCs by harnessing its respected interlocutor status,
preexisting relationships, and ability to “sell” the VHSNC as a
mechanism for improving local well‐being. While the VHSNC enabled
community members to voice concerns to government officials,
improvements often failed to meet community expectations. NGO
staff endured community frustration on one hand and rebuffs from
lower‐level officials on the other, while feeling undersupported by
the government contract. Consequently, although contracted to
strengthen a community institution, the NGO increasingly worked
alongside VHSNC members to try to strengthen the public sector.
Contrary to assumptions that NGOs become “tamed” through taking government contracts, being contracted to deliver inputs for
community participation was intertwined with microlevel political
action, though this came at a cost to the NGO
Doing implementation research on health governance: a frontline researcher’s reflexive account of field-level challenges and their management
BACKGROUND: Implementation Research (IR) in and around health systems comes with unique challenges for
researchers including implementation, multi-layer governance, and ethical issues. Partnerships between
researchers, implementers, policy makers and community members are central to IR and come with
additional challenges. In this paper, we elaborate on the challenges faced by frontline field researchers,
drawing from experience with an IR study on Village Health Sanitation and Nutrition Committees (VHSNCs).
METHODS: The IR on VHSNC took place in one state/province in India over an 18-month research period.
The IR study had twin components; intervention and in-depth research. The intervention sought to
strengthen the VHSNC functioning, and concurrently the research arm sought to understand the contextual
factors, pathways and mechanism affecting VHSNC functions. Frontline researchers were employed for data
collection and a research assistant was living in the study sites. The frontline research assistant experienced
a range of challenges, while collecting data from the study sites, which were documented as field memos
and analysed using inductive content analysis approach.
RESULTS: Due to the relational nature of IR, the challenges coalesced around two sets of relationships (a)
between the community and frontline researchers and (b) between implementers and frontline researchers.
In the community, the frontline researcher was viewed as the supervisor of the intervention and was
perceived by the community to have power to bring about beneficial changes with public services and
facilities. Implementers expected help from the frontline researcher in problem-solving in VHSNCs, and
feedback on community mobilization to improve their approaches. A concerted effort was undertaken by
the whole research team to clarify and dispel concerns among the community and implementers through
careful and constant communication. The strategies employed were both managerial, relational and
reflexive in nature.
CONCLUSION: Frontline researchers through their experiences shape the research process and its outcome
and they play a central role in the research. It demonstrates that frontline researcher resilience is very
crucial when conducting health policy and systems research.Scopu
Negotiating power relations, gender equality, and collective agency: are village health committees transformative social spaces in northern India?
BACKGROUND: Participatory health initiatives ideally support progressive social change and stronger collective agency
for marginalized groups. However, this empowering potential is often limited by inequalities within communities and
between communities and outside actors (i.e. government officials, policymakers). We examined how the participatory
initiative of Village Health, Sanitation, and Nutrition Committees (VHSNCs) can enable and hinder the renegotiation of
power in rural north India.
METHODS: Over 18 months, we conducted 74 interviews and 18 focus groups with VHSNC members (including female
community health workers and local government officials), non-VHSNC community members, NGO staff, and higherlevel
functionaries. We observed 54 VHSNC-related events (such as trainings and meetings). Initial thematic network
analysis supported further examination of power relations, gendered “social spaces,” and the “discourses of
responsibility” that affected collective agency.
RESULTS: VHSNCs supported some re-negotiation of intra-community inequalities, for example by enabling some
women to speak in front of men and perform assertive public roles. However, the extent to which these new gender
dynamics transformed relations beyond the VHSNC was limited. Furthermore, inequalities between the community
and outside stakeholders were re-entrenched through a “discourse of responsibility”: The comparatively powerful
outside stakeholders emphasized community responsibility for improving health without acknowledging or correcting
barriers to effective VHSNC action. In response, some community members blamed peers for not taking up this
responsibility, reinforcing a negative collective identity where participation was futile because no one would work for
the greater good. Others resisted this discourse, arguing that the VHSNC alone was not responsible for taking action:
Government must also intervene. This counter-narrative also positioned VHSNC participation as futile.
CONCLUSIONS: Interventions to strengthen participation in health systems can engender social transformation. However
they must consider how changing power relations can be sustained outside participatory spaces, and how discourse
frames the rationale for community participation.ISIScopu
Beyond form and functioning: Understanding how contextual factors influence village health committees in northern India
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.IS
Methodological gaps and opportunities for studying multisectoral collaboration for health in low- and middle-income countries
The current body of research into multisectoral collaborations (MSCs) for health raises more questions than it answers, both in terms of how to implement MSCs and how to study them. This article reflects on current methodological gaps and opportunities for advancing MSC research, based on a targeted review of existing literature and qualitative input from researchers and practitioners at the 2018 Health Systems Research (HSR) Symposium in Liverpool. Through framework analysis of 205 MSC research papers referenced in a separately published MSC \u27overview of reviews\u27 paper, this article identifies six broad MSC question domains (\u27meta questions\u27) and applies content analysis to estimate the relative frequency with which these meta questions and the research method(s) used to answer them are present in the literature. Results highlight a preponderance of research exploring MSC implementation using case study methods, which, in aggregate, does not seem to adequately meet policymakers\u27 and practitioners\u27 needs for generalizable or transferable insights. The content analysis is complemented by qualitative insights from HSR Symposium participants and the authors\u27 own experience to identify six key methodological gaps in research on MSC for health. For each of these gaps, we propose areas in which we believe there are opportunities for methodological development and innovation to help advance this field of study, including: better understanding the role of power dynamics in shaping MSCs; development of a classification framework (or frameworks) of governance arrangements; exploring divergence of perspective and experience among MSC partners; identifying or generating theoretical frameworks for MSC that work across sectors and disciplines; developing intermediate indicators of collaboration; and increasing transferability of insights to other contexts. Collaboration with researchers outside of the health sector will enhance efforts in each of these areas, as will the establishment and strengthening of pluralistic MSC evidence networks also involving policymakers and practitioners