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Source: The Hindu

Context

As states continue to deliver health care directly to homes, initiatives must be taken to engage communities as active partners in designing health systems.

Civic Engagement in Health Governance Civic engagement in health governance refers to the active participation of community members, civil society organisations, and local groups in the planning, decision-making, implementation, and monitoring of health services and policies. Key features include: Inclusion of marginalized groups such as women, the poor, and vulnerable populations to ensure equitable health outcomes. Formation of local committees and platforms (e.g., Village Health Sanitation and Nutrition Committees, Rogi Kalyan Samitis) that empower communities to voice their health needs. Collaboration between government, NGOs, and community stakeholders to improve health service delivery. Utilization of untied funds that allow local bodies to address specific health priorities. Strengthening accountability and transparency in health programs through grassroots participation.

Significance of Civic Engagement in Health Governance

• Public involvement in health policy ensures respect for individuals and that their voices are heard.
  
  
• It protects democratic values by allowing people to participate in decisions affecting their health and services.
  
  
• Inclusive participation makes the health system more accountable and reduces the influence of a small elite group, helping to prevent corruption.
  
  
• Without public participation, health governance risks becoming unfair and oppressive.
  
  
• Collaboration with communities builds trust between health workers and people.
  
  
• This trust increases the use of health services and results in better health outcomes for all.

Recent Initiatives in Healthcare Delivery

• Indian states have introduced ambitious healthcare schemes aimed at delivering services directly to people’s doorsteps.
  
  
• Tamil Nadu’s Makkalai Thedi Maruthuvam, launched in August 2021, is a prominent example of such a program.
  
  
• Similarly, Karnataka’s Gruha Arogya scheme started in October 2024 and was expanded statewide in June 2025.
  
  
• Both schemes focus on proactive healthcare delivery by providing services at home, especially for non-communicable diseases (NCDs) like diabetes, hypertension, etc.
  

Significance of These Schemes

• These initiatives represent a shift from reactive to preventive care by bringing health services closer to citizens.
  
  
• They aim to reduce the burden on hospitals and improve early diagnosis and treatment at the community level.
  
  
• The schemes help in increasing accessibility and affordability of healthcare for vulnerable and remote populations.
  

Governance and Citizen Engagement

• While physical access to healthcare is improving, an important question arises:
  
  
• To what extent can citizens engage with and influence health governance?
  
  
• Active citizen participation is critical for ensuring accountability, transparency, and better outcomes in health programs.
  
  
• Strengthening citizen involvement can help health systems respond better to local needs and challenges.

Health Governance in India: Evolution and Structure

• Traditionally, health governance in India was primarily a state-led function, with governments responsible for planning, implementation, and regulation of health services.
  
  
• Over time, the governance model has expanded beyond the government to include civil society, professional associations, hospital groups, and trade unions.
  
  
• These stakeholders operate through both formal committees and informal networks, broadening the scope and inclusiveness of health governance.
  

National Rural Health Mission (NRHM) and Community Participation

• The launch of the National Rural Health Mission (NRHM) in 2005 marked a significant turning point in India’s health governance.
  
  
• NRHM institutionalised community participation by creating decentralized platforms to involve local populations in health decision-making.
  
  
• Key platforms under NRHM include:
  
  
• Village Health Sanitation and Nutrition Committees (VHSNCs)
  
  
• Rogi Kalyan Samitis (RKS)
  
• These bodies are aimed at empowering local communities, ensuring women and marginalised groups are part of health governance.
  
  
• They are supported by untied funds, which allow these committees to address local health needs flexibly and promptly.
  

Urban Health Governance Platforms

• In urban areas, community participation is encouraged through platforms like:
  
  
• Mahila Arogya Samitis
  
  
• Ward Committees
  
  
• NGO-led platforms and committees
  
  
• These bodies also emphasize inclusion of women and marginalised sections, strengthening grassroots engagement in urban health planning and delivery.

Citizen Engagement in Health Governance

• Health governance in India has transformed from a purely government-led system into a complex ecosystem including civil society organizations, professional bodies, hospital associations, and trade unions.
  
  
• It operates through both formal and informal processes, where power dynamics affect whose voices are heard.
  
  
• Meaningful public engagement is essential,not just a formality, because it:
  
  
• Affirms the dignity of citizens
  
  
• Counters epistemic injustice (unfair exclusion of knowledge or perspectives)
  
  
• Upholds democratic principles by allowing citizens to influence decisions about their health
  

Benefits of Inclusive Participation

• Strengthens accountability and transparency in health governance
  
  
• Challenges elite dominance, reducing chances of corruption
  
  
• Encourages collaboration with frontline workers, which improves service uptake and overall health outcomes
  
  
• Builds mutual trust between communities and healthcare providers
  
  
• Without citizen engagement, health governance risks becoming exclusionary, oppressive, and disconnected from community needs

Existing Frameworks for Community Participation

• The National Rural Health Mission (NRHM), launched in 2005, institutionalised community participation in health governance.
  
  
• Key platforms created include Village Health Sanitation and Nutrition Committees (VHSNCs) and Rogi Kalyan Samitis.
  
  
• These platforms are designed to be inclusive, especially encouraging participation of women and marginalised groups.
  
  
• They are supported by untied funds to enable local health initiatives.
  
  
• In urban areas, similar bodies exist such as Mahila Arogya Samitis, Ward Committees, and NGO-led committees.
  

Persistent Challenges in Participation

• Despite the promise, many areas lack establishment of these committees altogether.
  
  
• Where present, meetings are often irregular, and the roles of members are poorly defined.
  
  
• Funds remain underutilised, limiting impact.
  
  
• Intersectoral coordination between different government departments is weak.
  
  
• Deep-rooted social hierarchies hinder inclusivity, especially affecting marginalised groups.
  

Structural and Mindset Barriers

• A key obstacle is the perception of communities by policymakers, administrators, and providers.
  
  
• Citizens are often seen as passive beneficiaries rather than active co-creators of health systems.
  
  
• This paternalistic view treats people as objects of intervention, not as rights-holders.
  
  
• Performance metrics focus more on numbers reached than on quality of engagement or user experience.
  
  
• Health governance is dominated by medical professionals trained mostly in Western biomedical models.
  
  
• These professionals often assume administrative roles without public health training.
  
  
• Promotions are based on seniority, not expertise, reinforcing a hierarchical, medicalised culture.
  

The Way Forward

The Need for a Mindset Shift

• Community engagement should not be seen only as a tool to meet programme targets.
  
  
• Treating people just as means to improve health statistics reduces their agency and dignity.
  
  
• Participatory processes must be valued for their own sake, beyond just the results they bring.
  

Empowering Communities

• Share accessible information on health rights and governance structures widely.
  
  
• Build civic awareness from an early age to foster active participation.
  
  
• Make special efforts to include marginalised groups.
  
  
• Provide citizens with the right tools, skills, and resources to engage meaningfully in health decisions.
  

Sensitising Health System Actors

• Move past blaming low health service utilisation solely on poor awareness.
  
  
• Avoid blaming individuals for larger systemic issues.
  
  
• Understand and address structural determinants that cause health inequities.
  
  
• Foster collaborative relationships where communities are treated as equal partners in health governance.

Practice Question Q. Community participation is the backbone of accountable and equitable health governance in India. Critically evaluate.