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

Abstract

SummaryWhile 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.

Implementing social accountability for contraceptive services: lessons from Uganda

“…In the social accountability canon, dialogues are a central mechanism to counteract the hierarchical nature of the health services [14,20,22,23,41,[43][44][45]. Dialogues transform both how people perceive themselves and their ability to effect change, as well as how they perceive and interact with others, particularly those in socially advantaged and/or privileged positions.…”

“…In particular, social accountability, here defined as ongoing collective efforts to engage public institutions for accountability in the provision of public goods [26], has reportedly improved service provision and utilization, and health care provider behavior and responsiveness [5,6,22,25,40,42]. Studies have also documented enhanced rights literacy, improved social cohesion, and trust and mutual collaboration between communities and health workers [22,[43][44][45][46]. Learnings from across the health sector suggest that social accountability addresses local barriers to health care, particularly those related to inequitable access and quality of care [28].…”

Village Health Sanitation and Nutrition Committees: reflections on strengthening community health governance at scale in India

“…The NGO support staff worked closely with the VHSNC members in filing petitions with various authorities, attending monthly VHSNC meetings and ensuring follow-up. Notable successes in the Northern State included working with health authorities to deploy additional frontline health workers; working with other sectors to lay water pipes; and working with political authorities to grant one of the informal migrant settlement area the formal recognition of a ‘revenue village’, a formal administrative unit for which the state is mandated to ensure civic services 12…”

“…In the North Indian state, despite opening of bank accounts, non-release of funds by authorities was demotivating for committee members, and this remained unaddressed throughout the intervention period 12. In the South Indian state, although the annual funds were transferred, village health nurses and village heads continued to manage the funds with no change in the pre-existing pattern and without a significant role for lay members in determining how grants would be used.…”

“…While other papers report on research findings drawn from in-depth interviews, focus group discussions, ethnographic observation and process documentation,12–14 this paper in addition draws on the authors’ tacit and experiential knowledge based on multiple review meetings with project stakeholders to reflect on the lessons learnt on supporting community health governance at geographic scale. In particular, we reflect on three strategies in the revised guideline and institutional support package that respectively targeted three key groups of actors involved 11.…”