A mixed-method study to evaluate the knowledge and marshalling of untied funds in rural area

INTRODUCTION

With the launch of the national rural health mission (NRHM) in 2005, it was envisioned that PHCs in India would be upgraded to 24x7 PHCs providing basic emergency obstetric and newborn care (BEmONC), with two doctors and three nurses, facility-based newborn care (FBNC), and operating around the clock.^1,2 It was also planned to strengthen CHCs, SOHs, and OHs as first referral units (FRU) offering critical emergency obstetric and newborn care (CEmONC), complete with a fully functional operation theatre, blood bank/blood storage units, sick newborn care units (SNCU), and malnutrition treatment centres (MTC).³ Aside from funds for the upkeep/improvement of health facilities, human resources (contractual appointments), equipment, supplies, and medicine, training, and capacity building, NRHM provides health facilities with unlimited flexible funds to improve the quality of care.^4-6 Untied funds (to be used at the discretion of the facility in charge, primarily as a contingency fund), annual maintenance grant (given only to facilities operating in government buildings and to be used for routine maintenance and upkeep of health facilities) and Rogi Kalyan samiti grants (meant for facility development wherever management societies are formed at the facility level in the form of Rogi Kalyan Samiti-RKS. Each subcenter receives 10,000 INR as untied fund for urgent but discrete activities.⁴

The funds are held in a joint account by the ANM, the medical officer in charge, and the sarpanch/village Head.^6,7 Various studies conducted throughout India revealed that untied funds were underutilised.⁸Knowledge of how to use Untied funds is insufficient. Our review of the literature revealed that there have been very few studies conducted in Rajasthan. Underutilization can be caused by a variety of root-cause issues.^9,10 This study was carried out to better understand the financing approach, knowledge, facilitators, and barriers to underutilization of Untied funds.¹⁰

Aim and objectives

Aim and objectives of current study was to investigate the various aspects of the utilisation of Untied funds provided to health centres, to assess the availability of Untied funds to various health centres, to determine whether the Untied funds are being used in accordance with the NRHM guidelines, to determine the most important area of spending, determine the process and individuals responsible for expenditure prioritization, to identify issues with the use of Untied funds and to make recommendations to programme managers on how to better use Untied funds.

METHODS

Study pattern, setting and sample size

A mixed-methods study was carried out (after obtaining ethical permission from the institutional ethical board) to determine the utilisation patterns and knowledge of health workers regarding untied fund. A qualitative study that used a grounded theory approach to identify the facilitators and barriers to effective use of untied funds. RHTC-Mandawar and its six subcenters were included in our study. For the quantitative portion, a random sample of all 27 healthcare workers was used.

Inclusion and exclusion criteria

All front-line health workers and PRI’s as part of committee under untied fund resource pool like ANM, VHSNC and ASHA were included. Block chief medical officers, nodal officers, CMHO's, and MO I/C were excluded as respondents.

Sampling technique

Purposive sampling was used for the qualitative portion, which included all of the Untied Fund's stakeholders. The entire duration of the study concerning fund utilisation in the previous year based on records. Using multistage sampling method, the blocks were selected.

Study tool

Following a thorough literature review and using findings from previous studies and empirical literature, a semi-structured questionnaire was developed. It was distributed to assess knowledge of areas where Untied funds can be used. In-depth interviews were conducted to assess various stakeholders' perceptions of the use of untied funds.

Data collection

The entire duration of study was one year. The data was collected from November 2021 to October 2022 in form of record review and staff interview. Consenting respondents were interviewed for primary data. Secondary data was gathered by reviewing records at subcenters. All documentary evidence of fund flow and use was scrutinised.

Data analysis

Collected data was collected, entered and coded electronically in MS Excel 10. Pearson’s Chi square test was applied through SPSS software 26.0 as the test of significance, depending upon the sample size, p value <0.05 was considered insignificant.

RESULTS

Majority of the subcenters selected for study did not have manpower who were formally trained. As per the records, majority of subcenters have received regular fund flow.

Only two subcenter out of six has used the funds properly, according to the observed trend. The remaining subcenters have spent no money. According to the records, the median unspent amount is 6789 INR, while health workers estimate it to be 1560 INR.

Untied funds are mostly used for IEC, ASHA rewards, cleaning, consumables, bills, repair, and contingencies at the subcenter level. A few other items are also included. Multiple facilitators were also identified like availability of written material, direct transfer of funds. Concerning health-care workers' understanding of the proper use and timely expenditure of the united fund. When compared to the guidelines, the mean average answers were significantly less correct. The health-care workers lacked proper and comprehensive knowledge. The barriers to incomplete knowledge included a lack of refresher training, a lack of human resources, and overburdened health workers.

DISCUSSION

The vast majority of respondents were recruited three to five years ago and have remained active members of committees since then. The average age was 34.21 years old. The vast majority of them were men. There were numerous gaps discovered. At the majority of subcenters, funds can be used more effectively.⁹ However, we identified numerous barriers, such as a lack of training, which resulted in a lack of awareness regarding the use of funds. There was no transparency in the use of Untied funds.

The sole decision maker for utilisation was identified as ANM. Only 11% of respondents said the decision was reached through a common consensus meeting. The new guidelines recommend that PRI members and ASHA maintain a joint account in a bank for the handling of untied funds, but they continue to follow the old ones.¹¹ This trend jeopardises community goals such as ownership and monitoring. Shah et al.¹² discovered the same phenomenon when they discovered that the majority of members were unaware of areas where funds were used and that the secretary decided on fund use without consulting other members. According to these findings, there is a clear lack of transparency in the use of funds that are more tied than untied. One limitation of the study is low sample size; thus, generality of the study is impacted.

CONCLUSION

The funds are not handled by local community leaders like VHSNC, but they are still under the control of ANM. The study reveals a need for member sensitization and capacity building in order for Untied funds to be used effectively.

Recommendations

Based on the foregoing findings, the following recommendations are made for the prudent and priority-based use of Untied funds. Participation of all designated members in regular meetings with an adequate quorum so that funds could be used properly. Refresher training for staff to educate them on the objectives and priorities for utilising Untied funds, as well as their responsibilities as members of the committee. Recruiting more personnel to relieve the burden on existing personnel.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

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