Abstract
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.