Reviving civic engagement in health governance

The Hindu

3 days ago

The 'Makkalai Thedi Maruthuvam (Medicine at people's doorstep') scheme, introduced in Tamil Nadu in August 2021, and the Karnataka's Gruha Arogya scheme, launched in October 2024 and expanded to all districts in June 2025, aim to deliver health care at doorsteps for persons with non-communicable diseases.
Several other Sates are implementing similar programmes. While such initiatives represent significant strides toward proactive health care, they also prompt a profound question: as the system strives to reach people's doorsteps, to what extent are citizens themselves able to reach, engage with, and influence health governance at different levels formally?
The subject of citizen engagement
Health governance, once a government-led function, now includes diverse actors such as civil society, professional bodies, hospital associations and trade unions. It operates through formal and informal social processes, with power dynamics shaping participation and influence. Public engagement in health policy processes is essential because it affirms self-respect, counters epistemic injustice and upholds democratic values by enabling people to shape decisions affecting their health and health-care services.
Inclusive participation strengthens accountability, challenges elite dominance and reduces corruption. Without it, health governance risks becoming oppressive and unjust. Moreover, engaging communities fosters collaboration with frontline workers, improves service uptake, and supports better health outcomes. It also builds mutual understanding and trust between communities and providers.
The National Rural Health Mission (NRHM), launched in 2005, institutionalised public engagement in India's health governance through platforms such as Village Health Sanitation and Nutrition Committees (VHSNCs) and Rogi Kalyan Samitis. These were designed to be inclusive, particularly of women and marginalised groups, and supported by untied funds for local initiatives. In urban areas, key platforms for civic participation include Mahila Arogya Samitis, Ward Committees, and non-government organisation-led committees. Despite their potential, in some areas these committees have not been established, while in others where they do exist, they face persistent challenges such as ambiguous roles, infrequent meetings, underutilisation of funds, poor intersectoral coordination, and deeply rooted social hierarchies.
Where the problem lies
A major challenge in India's health system lies in the prevailing mindset toward public engagement. Policymakers, health administrators and providers often view communities as passive recipients of care rather than as active participants in shaping health systems. Programme performance is typically measured through target-based metrics, such as the number of 'beneficiaries' reached, with little reflection on how programmes are implemented or experienced on the ground.
The use of the term 'beneficiaries' itself signals a deeper issue: it frames citizens as objects of intervention, not as rights-holders or co-creators of health systems. Although the National Health Mission promotes bottom-up planning, including community participation in Programme Implementation Plans, such engagement is rare in practice.
Health governance spaces remain dominated by medical professionals, predominantly trained in western biomedical models. Health administrative leadership, across national, State, district, and sub-district levels, is typically held by doctors who are expected to learn public health administration on the job. Promotions are often based on seniority rather than public health expertise, reinforcing a medicalised and hierarchical system that remains disconnected from community realities.
Scholarly work on health policy suggests that resistance to public engagement often stems from concerns over increased workload, greater accountability pressures, regulatory capture by dominant medical and capitalist interests, and the absence of a level playing field in governance processes.
In the absence of functional or inclusive engagement platforms, citizens often resort to alternative channels, such as protests, media campaigns, and legal action to make their voices heard. These responses reflect a deep and unmet need for participation, voice and accountability in health governance in India.
The need for a shift
A fundamental mindset shift is needed among governance actors. Community engagement must no longer be seen as merely to achieve programme targets. Treating people as instrumental to health outcomes is not only reductive but also deeply disrespectful to their agency and dignity. Participatory processes are as important as the outcomes they seek to achieve.
To enable meaningful community engagement in health governance, we must adopt a two-pronged approach. First, this involves actively empowering communities: disseminating information about health rights and governance platforms; fostering civic awareness early; making intentional efforts to reach marginalised groups; and equipping citizens with knowledge, tools, and resources needed to participate effectively in health care decision-making processes.
Second, we must sensitise health system actors to move beyond framing poor awareness as the sole reason for low health-seeking behaviour and health-care utilisation among people.
This narrow approach risks individualising blame, further victimising already vulnerable populations, and ignoring the structural determinants of health inequities. True transformation requires that health professionals view communities as partners, not passive recipients, and that they work collaboratively to address root causes. Establishing platforms for public engagement is a necessary starting point, but these platforms must be activated, strengthened, and made meaningful.
Meena Putturaj is a public health researcher based in Bengaluru