While various services under National Rural Health Mission (NRHM) have been launched in Rajasthan and community participation promoted through Village Health, Sanitation and Nutrition Committees (VHSNC), there has been hardly any convergence achieved with the constitutionally mandated Panchayati Raj system in rural areas. With support from UNFPA and Government of Rajasthan, PRIA intervened in this regard over a three year period during 2010-13. This Policy Brief analyses the results achieved and the efficacy of interventions deployed.

1. www.pria.orgPRIA POLICY BRIEF NOV 2013
Delivering Convergence in
Maternal Health
Promoting Panchayat Engagement in Service Delivery in Rajasthan
ajasthan has long been weak in
promoting gender equity in
general, and in matters of health,
in particular. The status of delivery
of maternal health services in the state
has been rather disappointing till
recently; sex-selective abortions and
maternal mortality rates have
remained comparatively high. While
various services under National Rural
Health Mission (NRHM) have been
launched in Rajasthan and community
participation promoted through Village
Health, Sanitation and Nutrition
Committees (VHSNC), there has been
hardly any convergence achieved
with the constitutionally mandated Panchayati Raj system in rural areas. With support from
UNFPA and Government of Rajasthan, PRIA intervened in this regard over a three year period
during 2010-13. This Policy Brief analyses the results achieved and the efficacy of interventions
deployed.
Within this short span of three years, several
interesting results have begun to be visible in
improving the delivery of maternal health
services in Rajasthan.
1. Better Usage of Existing Health
Facilities
An important aspect of improving maternal
health service delivery is to enhance the
rate of institutional delivery. Data from the
health record of village Panchayats show
that there has been an overall 7% increase
in institutional delivery in the intervened
blocks of the 13 districts of the state during
the period 2009-10 to 2012-13 (see Table 1
below). In some districts of western
Rajasthan, the increase in institutional
delivery has been substantial. Some
Panchayats (like Ranjitpura in
Hanumangarh district) have moved to 100%
institutional delivery.
R
PRIA POLICY BRIEF NOV 2013
1. Results Achieved

2. www.pria.orgPRIA POLICY BRIEF NOV 2013
Table – 1: indicating the increasing trend of institutional delivery
S.No Name of district Total
number of
delivery
% of
institutional
delivery
Total
number of
delivery
% of
institutional
delivery
2009-10 2012-13
1 Banswara 360 90.55 482 94.81
2 Baran 350 81.71 329 93.31
3 Bharatpur 619 89.98 688 97.96
4 Bikaner 934 38.86 786 66.53
5 Dausa 827 91.05 772 89.89
6 Jaipur 1462 97.60 1420 99.64
7 Hanumangarh 100 99.00 554 96.75
8 Jaisalmer 129 32.55 428 58.17
9 Jhalawar 484 73.96 480 86.66
10 Jhunjhunu 382 97.12 261 98.08
11 Nagaur 371 90.02 459 88.23
12 Sawaimadhopur 1022 90.90 911 98.57
13 Sirohi 670 95.07 592 100
Total 7710 84.07 8162 90.93
Source: Data from Panchayat health records
Similar pattern of improvements in usage of
maternal health services can be noticed in
several blocks. A sample of improvements in
the performance of health staff and
utilisation of basic services can be gleaned
from the data collected by the VHSNC of
Dattani Gram Panchayat of Sirohi district
below (Table 2).
Table - 2: Health indicators data of VHSNC Dattani-district Sirohi:
S. No. 2009-10 2010-11 2011-12 2012-13
(Til Jan.2013)
1 ANC 16 18 22 24
2 PNC 9 11 13 21
3 ANC Registration 18 19 24 24
4 Home Delivery 1 00 00 00
5 Intuitional Delivery 11 16 21 22
6 Private Hospital 4 2 1 2
7 Condom Distribution 156 201 278 330
8 Oral Pills 9 12 18 40
9 Immunization 71% 73% 78% 82%

3. www.pria.orgPRIA POLICY BRIEF NOV 2013
One of the key foci of intervention was to
reduce sex-selective abortion and thereby
contribute to improved female-male sex
ratio. The recent data from the
Government of India’s Annual Health Survey
(AHS) 2010-11 (data released in the year
2013) indicate that several of the intervened
districts have begun to narrow down the
gender gap in 0-5 age group (see Table 3
below).
Table - 3: Births of Boys and Girls in Intervened Districts
S.No Name of district Year 2009-10 (%) 2011-12 (%) 2012-13 (%)
Boys Girls Difference Boys Girls Difference Boys Girls Difference
1 Jaipur -1 57.2 43.37 13.83 53.23 46.09 7.14 50.1 49.89 0.21
2 Banswara 52.47 47.52 4.95 53.42 46.57 6.85 49.17 50.82 -1.65
3 Baran 50.29 49.7 0.59 50.03 46.96 3.07 53.08 46.91 6.17
4 Bharatpur 54.16 46.62 7.54 51.76 48.5 3.36 54.73 45.56 9.17
5 Bikaner 51.49 48.5 2.99 50.69 49.3 1.39 50.63 49.36 1.27
6 Dausa 55.18 44.81 10.37 57.25 42.74 14.51 55.76 40.09 15
7 Hanumangarh 56 44 12 48.39 51.6 -3.21 51.74 48.25 3.49
8 Jaisalmer 53.9 46.09 7.81 52.37 47.62 4.75 51.78 48.21 3.57
9 Jhalawar 53.06 46.93 6.13 51.92 48.07 3.85 56.52 43.47 13.05
10 Jhunjhunu 53.35 47.64 5.71 53.74 46.25 7.49 68.87 45.13 23.74
11 Nagaur 55.4 44.59 10.81 55.06 44.93 10.13 55.37 44.62 10.75
12 Sawaimadhopur 57.54 42.54 15 54.99 45.4 9.59 55.42 44.57 10.85
13 Sirohi 55.42 44.28 11.14 48.47 51.77 -3.3 48.41 51.75 -3.34
Total 54.54 45.43 9.11 52.67 47.26 5.41 52.75 47.68 5.07
As can be seen from this table, over the
three time periods---2009-10, 2011-12 and
2012-13---there has been a significant
reduction in the gap in percentage
between girls and boys in districts of Jaipur,
Banswara, Hanumangarh, Jaisalmer and
Sirohi. On the other hand, the gender gap
has increased in the districts of Baran,
Bharatpur, Dausa, Jhalawar and Jhunjhunu.
These data are early figures as the
intervention was completed in April 2013
only. The reduction in gender gap needs to
be monitored further, and causes for
uneven results need to be investigated in-
depth.
2. Improved Sex ratio

4. www.pria.orgPRIA POLICY BRIEF NOV 2013
1. New Facilities Built
As a result of these interventions, several
new facilities are being developed to
improve the delivery of maternal health
services in the village level. An 8 bed
maternity ward has been constructed in the
PHC at Etava Gram Panchayat (district
Govindgarh) with the initiative of Panchayat
leadership. Likewise, Panchayats in other
places uses their own funds to construct
boundary walls (for privacy and security of
patients) and approach roads for health
centres, bought weighing machines and
other medical aids to improve maternal
health care.
2. Social Recognition
The positive reinforcement to girl child
friendly behaviours has been initiated in
several Panchayats in the districts of
Nagaur, Sirohi, Govindgarh, Sawai
Madhopur and Banswara. Block panchayat
Parbatsar (Nagaur district) began issuing
‘badhai patra’ (congratulatory notes) to
parents who gave birth to a girl. Increased
social recognition of gender parity has
begun to be visible in many Panchayats.
During the period of intervention, several
deliverables have been accomplished
which significantly contributed to the
achievement of the above results.
Through active involvement of several
stakeholders, the intervention generated 70
Gram Panchayat level health plans focusing
especially on maternal health service
delivery in the intervened districts. With the
active coordination of Panchayats and
health department at district, block and
village levels, detailed plans for the five year
and one year period were prepared to
improve the delivery of maternal health
services and other health issues in the
villagers.
3. Rapid Implementation of the Plans
Nearly two-thirds of most of these plans
were already being implemented by now.
The progress of implementation was rapid as
shown in Table 4 below as on 31st July 2013.
Table: 4
Status of health plan implementation (in percentage)
S.No Districts
Implemented
(%)
In Progress
(%)
Needs Support
(%)
Total
1 Bharatpur 71.1 21.7 7.2 100.0
2 Jhunjhunu 50.0 0.0 50.0 100.0
3 Hanumangarh 77.4 22.6 0.0 100.0
4 Sirohi 87.2 12.8 0.0 100.0
5
Sawai
Madhopur 33.3 46.7 20.0 100.0
6 Banswara 32.1 67.9 0.0 100.0
7 Jaisalmer 62.9 0.0 37.1 100.0
8 Jaipur 39.3 53.6 7.1 100.0
9 Baran 50.0 45.7 4.3 100.0
10 Dausa 41.4 58.6 0.0 100.0
3. Outputs Delivered

5. www.pria.orgPRIA POLICY BRIEF NOV 2013
11 Jhalawar 55.4 16.1 28.6 100.0
12 Bikaner 73.9 26.1 0.0 100.0
13 Nagaur 41.5 46.2 12.3 100.0
Total 53.3 35.2 11.5 100.0
Source: primary data on implementation of 70 GP Health Plans - as on 31st July 2013
Most of the problems (nearly 53%) mentioned in
the village health plans related to coordinated
response had been solved in the first six months
itself. Vacant positions of ANMs, ASHA and
Anganwadi workers were being rapidly filled up.
Utilisation of budgeted resources for delivery of
various services had gained momentum with the
implementation of village level plans.
4. Regularly Functioning VHSNCs
As a result of sustained interventions, more than
300 VHSNCs have been energized to function
effectively and regularly. As a result of the
interventions, Panchayat-based Social Justice and
Social Welfare Committees (SJSWC) began to
coordinate with VHSNCs around improved
maternal health services as they have over-
lapping mandates. Field workers, members of
these committees and their leadership are
involved in problem-solving arising out of the
implementation of the plans made for service
delivery.
The strategy of intervention designed to deliver
convergence between Panchayats and NRHM
was based on a three-pronged approach:
mobilising demand, sensitizing supply and
enabling interface. The basic assumption made in
this strategy is that both demand and supply side
interventions are critical for improving the
convergence of services. Enabling interface
between demand and supply can further
facilitate convergence of service delivery. A
number of specific activities were undertaken in
each component of the strategy, as described
briefly below.
1. Mobilising Demand
It was felt necessary that the issues related to
maternal health and adverse female ratio need
to be made the focus of community mobilisation
and awareness. Several types of activities were
launched to mobilise demand of maternal health
services.
2. Pre-Election Voters Gender Awareness
Campaign
At the start of the intervention in early 2010, a
public awareness campaign with specific focus
on gender issues related to health was launched
in the entire state. More than 300 civil society
organisations were brought on a common
platform to prepare and launch this campaign
with support of State Election Commission (SEC).
More than 5000 contestants were oriented during
the campaign to sign a pledge to focus on
gender inequities in health, should they get
elected. Use of pamphlets, posters, radio and TV,
along with folk forms of communication,
throughout this campaign ensured increased
public awareness of these issues.
3. Orienting Gram Panchayats
After the Panchayat elections were completed,
second phase of demand generation focused on
the orientation of elected representatives on
issues of gender inequities in health in their area
and the roles of Panchayats in addressing this
challenge. Special focus was given to the
formation and functioning of Social Justice and
Social welfare Committees (SJSWC) of the Gram
Panchayats. During this phase, focused
intervention was limited to 13 districts where 2380
elected panchayat representatives, including
4. Strategy of Interventions

6. www.pria.orgPRIA POLICY BRIEF NOV 2013
1758 women representatives were oriented in this
manner.
4. Facilitating Gram Sabhas
One of the most significant features of
Panchayats is the recognition of Gram Sabha
(Village Assembly) comprising of all adult voters. In
most cases, Gram Sabhas have not functioned
effectively. Issues of gender inequity and delivery
of maternal health services have hardly been an
agenda of any Gram Sabha meetings. Facilitating
discussion on maternal health issues and
availability of services in this regard during the
Gram Sabha meetings has been an integral part
of this demand mobilisation. More than 300 Gram
Sabhas were directly facilitated, and about 500
Gram Sabhas was facilitated by the Panchayat
functionaries.
5. Mobilising Media
A major activity in mobilising demand during the
entire period was mobilisation of media to focus
reporting on this set of issues at all stages of the
interventions. A media advisory committee set up
for this purpose helped to guide this mobilisation
of media in all the various forms and channels.
More than 600 media reports appeared during this
period which kept the public awareness focused
on this set of issues.
6. Sensitizing supply
Sensitization of the health delivery system to
address the gaps in service delivery with active
participation of the community was a key
component of the overall strategy. Several
specific activities were undertaken in this regard.
7. Capacity building
A major activity undertaken in this period was
building the capacity of the functionaries of
health system and members of Panchayats and
their standing committees.
Understanding the system of Panchayati Raj
Institutions and the nature of mandates of its
Social Justice and Social Welfare Committee was
a major focus of such capacity building effort.
8. Energising VHSNCs
The programme implementation structure of
NRHM includes a community participation
mechanism called VHSNCs. These committees
have not been functioning adequately, and
many have not even been formed properly. As a
result, the community engagement structure
which is supposed to act as a bridge with the
functionaries had not been operational. During
the course of the intervention, 3154 members of
VHSNCs in the intervened 13 districts were trained
to understand their roles and to act in ways that
improve delivery of maternal health services.
9. Enabling Interface
A major component of the strategy was to
facilitate interface between demand and supply
so that convergence of responses can occur.
Several activities were undertaken to make such
an interface meaningful.
10. Interfacing SJSWC and VHSNC
Despite overlapping and shared mandates, the
two local committees meant to ensure
community participation had barely known each
other, let alone interacted. VHSNC remained

7. www.pria.orgPRIA POLICY BRIEF NOV 2013
confined to health department and SJSWC in
Panchayat department. One of the first interfaces
to be enabled was to bring the members and
leaders of these two committees together, village-
by-village. Facilitating mutual understanding and
interactions between them was critical for
convergence.
11. Local Planning with Gram Panchayats
Despite the mandates and guidelines, planning of
annual and six monthly activities of NRHM
programme barely included active engagement
of Panchayats at the village and block levels.
Preparation of Gram Panchayat level service
delivery plans in response to locally relevant
priorities helped create this interface. These plans
were shared and approved by Gram Sabha to
ensure broader understanding and ownership. As
a result, both Panchayats and health department
functionaries developed joint ownership of these
village plans, and concrete implementation could
follow.
1. Multi-stakeholder Dialogues
After the village level plans were developed
based on local needs, a multi-stakeholder
dialogue was convened in each of the 13 districts.
These dialogues brought district level functionaries
of health department and Zila Parishad
leadership, along with block and village level
personnel, to deliberate on the plans and evolve
a shared and clear commitment for
implementation.
2. State Level Advisory
In order to secure greater support from the state
level officials and planning agency, a state level
advisory committee functioned throughout the
programme, under the leadership of Deputy
Chairman of the State Planning Board. It enabled
interface, interactions and coordination between
health and Panchayat departments and their
functionaries at the state level. It also provided the
necessary political and technical support to the
interventions at the district and below levels.
The results of this intervention to improve
convergence between Panchayats and health
service delivery system at the village, block and
district level has shown that a lot can be achieved
through sustained strategic interventions. With
very limited resource support provided by UNFPA,
civil society in the state got mobilized to work
together on delivery of maternal health issues.
Intensive interventions were confined to 13 districts
after the state-wide voters’ gender awareness
campaign carried out in 2010 due to limited
resources available. The efficacy of this strategic
intervention to deliver convergence in maternal
health services has been demonstrated from the
above.
The next big question is how to sustain a scaled-up
intervention to achieve deeper results and to be
able to institutionalize the convergence
processes.
3. Further scaling-up would require strong
political support at the level of state
government. With the formation of a new
government after the assembly elections in
Rajasthan, it is imperative that the findings of
this experience are shared at the highest
5. Scaling Up Interventions

8. www.pria.orgPRIA POLICY BRIEF NOV 2013
political levels (Chief Minister, Health
Minister, Health Secretary, Panchayat
Minister and Secretary, Legislative Sub-
Committee on health etc) to secure their
commitment to scale-up and sustain this set
of interventions.
As has been demonstrated, PRIA’s
facilitation roles were critical in mobilising
demand, sensitizing supply and enabling
interface over the period of intervention.
Such catalytic and facilitation roles are
essential for further scaling up the
convergence efforts in maternal health. An
independent agency like PRIA was able to
play this role because of its expertise,
credibility and human and institutional
capacity. Providing flexible resources to
such an independent facilitator agency
would be critical to ensure scaling up
efforts.
Finally, institutionalization of convergence
mechanisms would entail expansion of
interventions in all the districts. Based on this
phase of results, sharing of methodology
and outcomes in state level consultations
can be enabled to promote similar efforts
throughout the state. Since convergence
requires changes in attitudes and
behaviours of several actors at district and
below levels, sustaining such activities over
3-5 year period would be necessary.
PRIA
42, Tughlakabad Institutional Area,
New Delhi-110062
Tel: +91-11-29960931-33
Fax: +91-11-29955183
E-mail: info@pria.org; Web: www.pria.org
Rajesh Tandon is a Co-Founder & President of PRIA. He is
pioneer in innovative methodologies in participatory
research, participatory planning, monitoring &
evaluation. E-mail: rajesh.tandon@pria.org
Manoj Rai is a Director in PRIA. He has worked
extensively to strengthen Panchayats and Participatory
Rural Development. Currently he is leading action
research initiatives on Urban Govrnance & Uran Poverty.
E-mail: manoj.rai@pria.org
This Policy Brief is a product of the community
participation in Health Delivery System in Rajasthan
promoted through Village Health, Sanitation and
Nutrition Committees (VHSNC). With support from
UNFPA and Government of Rajasthan, PRIA intervened in
this regard over a three year period during 2010-13.
This Policy Brief analyses the results achieved and the
efficacy of interventions deployed.
THE AUTHORS
THE PROJECT