Negotiating power relations, gender equality, and collective agency: are village health committees transformative social spaces in northern India?

Abstract

BackgroundParticipatory 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.MethodsOver 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 higher-level 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.ResultsVHSNCs 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.ConclusionsInterventions 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.

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

“…Despite these challenges, SEEK succeeded in forming and training VHSNCs across the 50 villages and was able to facilitate monthly meetings in most villages throughout the intervention period. Their support enabled female VHSNC members to participate and brought together community members from different caste and religious groups to seek improved health, nutrition, and water services . In this section, we describe the characteristics and strategies used by SEEK to achieve key intervention objectives.…”

“…3 | RESULTS 3.1 | Navigating a challenging context to implement the intervention SEEK encountered community hesitancy and poor responsiveness from government providers and officials (also discussed elsewhere 24,25 ). Community responses to the intervention were coloured by a widespread sense that the government was inaccessible, unfair, and uncaring.…”

“…Their support enabled female VHSNC members to participate and brought together community members from different caste and religious groups to seek improved health, nutrition, and water services. 25 In this section, we describe the characteristics and strategies used by SEEK to achieve key intervention objectives.…”

Building a transformative agenda for accountability in SRHR: lessons learned from SRHR and accountability literatures

“…Social scientists have long described critical consciousness and other reflective learning processes whereby women and other marginalised groups learn about their formal entitlements and reflect on their life experiences. 32,[52][53][54][55] An illustration of an intervention addressing accountability through strengthening community voice is provided by Scott et al, 20 which explains how government-supported Village Health Committees (VHCs) in Northern India provided opportunities for "micro-resistance"; women with percieved low status who normally have no opportunity to speak out leveraged the formal rules of the VHCs to voice their concerns. Structured opportunities to express voice and collaborate with others and decision-makers to improve policies and services can contribute to personal conscientisation and collective action.…”

“…We also analysed additional literature on accountability in health and development more broadly. [16][17][18][19][20] In keeping with the initial review, we limited our analysis to low-and middle-income countries. While our analysis draws upon literature from LMICs, much of our analysis is also likely to be relevant to high-income countries, where certain specific aspects of SRHR, such as access to safe abortion, might be widely contested.…”