9 research outputs found
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 âsocial spaces,â and the âdiscourses of
responsibilityâ 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 âdiscourse of responsibilityâ: 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
Comprehensive Primary Health Care in South America: contexts, achievements and policy implications
Assessing participation in a community-based health planning and services programme in Ghana
Background Community participation is increasingly seen as a pre-requisite for successful health service uptake. It is notoriously difficult to assess participation and little has been done to advance tools for the assessment of community participation. In this paper we illustrate an approach that combines a 'social psychology of participation' (theory) with 'spider-grams' (method) to assess participation and apply it to a Community-based Health Planning and Services (CHPS) programme in rural Ghana. Methods We draw on data from 17 individual in-depth interviews, two focus group discussions and a community conversation with a mix of service users, providers and community health committee members. It was during the community conversation that stakeholders collectively evaluated community participation in the CHPS programme and drew up a spider-gram. Results Thematic analysis of our data shows that participation was sustained through the recognition and use of community resources, CHPS integration with pre-existing community structures, and alignment of CHPS services with community interests. However, male dominance and didactic community leadership and management styles undermined real opportunities for broad-based community empowerment, particularly of women, young people and marginalised men. Conclusion We conclude that combining the 'spider-gram' tool and the 'social psychology of participation' framework provide health professionals with a useful starting point for assessing community participation and developing recommendations for more participatory and empowering health care programmes