Context and Emerging Trends in Health Delivery

In recent years, several Indian states have launched innovative healthcare initiatives aimed at making health services more accessible and proactive. Among the most notable are Tamil Nadu’s Makkalai Thedi Maruthuvam scheme, initiated in August 2021, and Karnataka’s Gruha Arogya scheme, which was introduced in October 2024 and expanded statewide by June 2025. Both programmes prioritise the home-based delivery of healthcare services, with a particular focus on managing non-communicable diseases. While these efforts signify a commendable shift toward more responsive healthcare delivery, they also provoke an equally critical inquiry: as state systems work to physically reach citizens, to what extent are citizens enabled to actively engage with, influence, and shape the systems that govern their health?

The Imperative of Citizen Participation in Health Governance

India’s health governance has transformed from a centrally managed structure into a multifaceted ecosystem involving a range of actors, including civil society organisations, professional associations, hospital groups, and trade unions. This ecosystem operates through a blend of formal mechanisms and informal networks, often shaped by entrenched power dynamics that determine whose voices are prioritised. Genuine public engagement in this space is not merely a bureaucratic formality; it affirms individual dignity, combats epistemic injustice, and reinforces democratic ideals by allowing citizens to meaningfully contribute to decisions affecting their health and well-being.

Concrete Benefits of Inclusive Civic Engagement

Active and inclusive citizen participation enhances governance in tangible ways. It improves accountability and transparency across the system, challenges elite capture and reduces opportunities for corruption, and fosters constructive collaboration with frontline health workers, which in turn strengthens service uptake and health outcomes. Moreover, it cultivates mutual trust between communities and healthcare providers. Without such engagement, health governance risks becoming top-down, disconnected, exclusionary, and misaligned with community realities and needs.

Existing Participation Frameworks and Their Persistent Gaps

Efforts to institutionalise community engagement in healthcare began with the launch of the National Rural Health Mission (NRHM) in 2005. It established mechanisms such as Village Health Sanitation and Nutrition Committees (VHSNCs) and Rogi Kalyan Samitis, designed to include women and marginalised communities in health governance. These bodies were supported by untied funds intended for addressing local health needs. Urban counterparts such as Mahila Arogya Samitis, ward committees, and NGO-led groups were introduced to ensure similar engagement in city contexts.

Despite these frameworks, implementation remains patchy and inconsistent. In many areas, these bodies have never been constituted. Where they do exist, they are frequently undermined by irregular meetings, unclear mandates, and underutilised resources. Furthermore, poor intersectoral coordination and deeply embedded social hierarchies limit genuine inclusivity and participatory impact.

Structural and Perceptual Barriers to Engagement

A key barrier to effective civic engagement lies in the prevailing mindset among policymakers, administrators, and healthcare providers, who often perceive communities as passive recipients of care rather than as active participants in shaping the health system. This attitude reveals a subtle but persistent paternalism, treating citizens as subjects of state intervention instead of recognising them as rights-holders. Performance metrics tend to focus on quantifiable outputs such as the number of people reached, rather than assessing the quality of engagement or the lived experience of care delivery.

Health governance remains dominated by medical professionals, the majority of whom are trained in Western biomedical models and who often assume administrative responsibilities without formal training in public health. Career progression within this structure is largely based on seniority rather than merit or domain expertise, reinforcing a hierarchical and medicalised culture that often resists participatory approaches.

Charting the Way Forward

Overcoming these challenges requires a profound shift in both mindset and practice. Community engagement must be recognised not merely as a tool for achieving programme outcomes, but as an intrinsic element of democratic health governance. When people are reduced to instruments for improving health metrics, their dignity and agency are compromised. Participation should be valued not only for its instrumental benefits but as a fundamental right in and of itself.

Empowering communities requires widespread dissemination of accessible information about health rights and governance structures, along with sustained civic education beginning from an early age. Special effort must be made to reach and include marginalised populations, equipping them with the knowledge, skills, and resources necessary to engage meaningfully in governance processes.

Equally essential is the sensitisation of health system actors. This involves moving beyond simplistic explanations that attribute low service utilisation to community ignorance or apathy. Instead, health providers and administrators must be encouraged to understand and address the structural determinants of health disparities. By reframing the relationship between citizens and the state as a partnership of equals, health systems can evolve into more inclusive, just, and responsive institutions.