THE CONTEXTS AND COMPLEXITIES OF COMMUNITY PARTICIPATION: STRENGTHENING VILLAGE HEALTH, SANITATION, AND NUTRITION COMMITTEES IN RURAL NORTH INDIA by Kerry Scott A dissertation submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Philosophy Baltimore, Maryland February 2016 © 2016 Kerry Scott All Rights Reserved Abstract The Indian government’s Village Health, Sanitation, and Nutrition Committee (VHSNC) program seeks to improve rural access to the fundamental entitlements of public health. Although over 500,000 VHSNCs have been officially formed, they have so far failed to serve as viable local bodies. In 2013, the government introduced guidelines to invigorate VHSNCs. This dissertation examines the contexts that facilitate and hinder VHSNC functionality, and explores the impacts of VHSNCs on marginalized communities and the non-governmental organizations (NGOs) that support them. The study draws on longitudinal qualitative research from rural north India. The study found that contextual features at the community, health facility, health administration, and societal level were often at odds with VHSNC functionality. Despite challenges at the community level, inclusive VHSNCs were formed, and the members received training, held monthly meetings, and attempted to improve local public services. However, barriers in the other contextual spheres undermined committee capacity to bring concrete improvements (chapter 5). VHSNCs created some opportunities for participants to re-negotiate power inequalities within the community, particularly around gender. Power inequalities between the communities and outside actors (e.g. government officials) were ii manifest in a “discourse of responsibility,” whereby outsiders sought to assign broad responsibility for improving public services onto VHSNCs. Some community members accepted this discourse and then blamed their peers for failing to take action, entrenching a negative collective identity. Others rejected the discourse, and positioned participation in the VHSNC as futile, since responsibility lay beyond VHSNC control (chapter 6). The NGO that implemented the VHSNC-intervention played a crucial role in building community capacities to engage with government and helped overcome many community-level barriers to participation. These beneficial processes were made possible by the NGO’s “in-between status” as community advocate and government helper. Yet this role came at a high cost for NGO staff, who found themselves promoting VHSNCs with little control over key factors that influenced the program (chapter 7). 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. iii Readers and advisors Katherine Smith, Committee Chair Associate Professor, Health, Behavior & Society, School of Public Health Steven Harvey, Thesis Advisor Assistant Professor, International Health, School of Public Health Nicole Warren, Reader Professor, Department of Community-Public Health, School of Nursing Asha George, Reader Assistant Professor, International Health, School of Public Health Alternate readers Peter Winch Professor, International Health, School of Public Health Robert Lawrence Professor, Environmental Health Sciences, School of Public Health iv Acknowledgements The research was made possible by funding from the World Health Organization’s Alliance for Health Policy and Systems Research through the Implementation Research Platform Secretariat and the Government of Canada’s International Development Research Centre. My gratitude first and foremost goes to the respondents in northern India, who welcomed me and my colleagues into their lives and shared their chai, time, and insights. I am thankful to the NGO staff who worked assiduously to strengthen these committees and the broader systems in which they operate, and whose dedication continues to inspire me. My sincere gratitude to the Public Health Foundation of India Health Governance Hub family for their intellectual, emotional, and logistical support, and specifically to the study team: Kabir Sheikh, for his leadership and guidance, Shinjini Mondal, Gupteswar Patel, T. Sharanya, Surekha Garimella, and Raman VR, who all worked tirelessly on this project. In addition, I wish to thank Rajani Ved and John Porter, who both provided encouragement and wisdom throughout. The Johns Hopkins School of Public Health (JHSPH) International Health Fellowship gave me the privilege of studying as a PhD student in the Social and Behavioral Interventions program. I am deeply grateful for the faith in my work that this fellowship expressed and for the life-changing financial support. It has been an honor to be part of the JHSPH family and to be taught and inspired by the passion v and intellect of the faculty and fellow students. I would like especially to thank: Steve Harvey, my advisor, for the constant support, humor, and mentorship; Peter Winch and Elli Leontsini for welcoming me to the SBI family; and Asha George, whose intellectual rigor challenged me to think more critically and whose kindness bolstered me. I would not have been a part of this study if it were not for you. I am thankful to the Canadian public educational institutions that I have been fortunate enough to have attended: From my little primary school OOOPS in Toronto, where Mrs. Fonck taught compassion above all else, to JGA and MCI, where the teachers pushed us to care about the world beyond our neighborhood, to my undergraduate program, Arts and Science at McMaster University, for teaching the students to ask the critical question: “Who benefits?” Thank you especially to Jean Wilson, Gary Warner, Dr. Kubursi, and Marshal Beier. I am also deeply thankful to Catherine Campbell and the MSc Health, Community and Development program at the London School of Economics. The focus on social justice, power, and marginalization directed my interests towards community participation in health. Cathy, your enthusiasm, encouragement, and brilliance inspired me to take up this PhD and gave me many of the tools I’ve used to complete it. I am thankful to my friends in Bangalore, Toronto, Baltimore, Hamilton, Ottawa, Singapore, Pune, and many places in between. To my wonderful family, especially my parents Sara Street and Ian Scott, for their boundless support (including throughout several tumultuous visa processes) and love. Mum, I hope to someday vi write as well as you, but thank you for getting me this far. Dad, you showed me that a thriving, accountable public sector is worth fighting for. My Grandma, June Scott, who is currently mobilizing to resettle Syrian refugees at the age of 91, and my Grandpa, David Scott, and Nana, Sheila Street, both of whom I was so lucky to know and learn from for so many years. My in-laws, my aunts and uncles, and my brother Adam and sister-in-law Nary: for all the encouragement and welcome distraction, thank you. And to Siddhant, my husband, who gets me to and from airports, train stations, and bus stands at all hours so I can travel to the field, who is always curious and endlessly insightful about this research, and who makes it all fun. Thank you. vii Table of contents Chapter 1. Introduction......................................................................................................... 1 1.1 Introduction .................................................................................................................................. 1 1.2 Study aims ...................................................................................................................................... 3 1.3 Organization of the dissertation ............................................................................................ 4 Chapter 2. Literature Review ............................................................................................... 5 2.1 Community participation in health ...................................................................................... 5 2.2 Health committees ...................................................................................................................... 9 2.2.1 Evidence linking health committees to health and health system outcomes ......... 10 2.2.2 Contextual factors influencing health committees ............................................................. 12 2.2.3 Health committee roles and activities in LMIC health systems .................................... 16 2.2.5 Health committees in India .......................................................................................................... 19 Chapter 3. Research context ............................................................................................... 23 3.1 Indian economic growth and social indicators ............................................................. 23 3.2 The health care situation in India ...................................................................................... 26 3.3 Public service structure in rural India ............................................................................. 29 3.4 Village Health, Sanitation and Nutrition Committees in India ................................. 32 3.5 The research area .................................................................................................................... 38 Chapter 4. Methods ...............................................................................................................