The Hindu Editorial Analysis
12 August 2025
Reviving civic engagement in health governance
(Source – The Hindu, International Edition – Page No. – 8)
Topic : GS Paper II: Governance
Context
As States deliver health care to doorsteps, communities must be engaged as active partners in shaping health systems.
Introduction
The ‘Makkalai Thedi Maruthuvam’ scheme in Tamil Nadu, launched in August 2021, and Karnataka’s Gruha Arogyascheme, introduced in October 2024 and expanded statewide by June 2025, aim to bring health care directly to the doorsteps of individuals with non-communicable diseases. Similar initiatives are being implemented in several other States, marking important progress in proactive health care delivery. However, these efforts also raise a critical question: while the system increasingly reaches citizens where they live, to what extent are citizens themselves able to access, participate in, and influence health governance at various formal levels?
The subject of citizen engagement
- Expanded Health Governance: Once solely government-led, health governance now involves civil society, professional bodies, hospital associations, and trade unions, functioning through both formal and informal social processes shaped by power dynamics.
- Value of Public Engagement: Essential for affirming self-respect, countering epistemic injustice, and upholding democratic values by enabling citizens to shape decisions affecting their health and health-care services.
- Impact of Inclusion: Inclusive participation boosts accountability, challenges elite dominance, and reduces corruption; without it, governance risks becoming oppressive and unjust.
- Benefits of Engagement: Fosters collaboration with frontline workers, improves service uptake, enhances health outcomes, and builds mutual trust between communities and providers.
- NRHM Initiatives: The National Rural Health Mission (2005) institutionalised public engagement via Village Health Sanitation and Nutrition Committees (VHSNCs) and Rogi Kalyan Samitis, designed for inclusivity and supported by untied funds for local initiatives.
- Urban Participation Platforms: Include Mahila Arogya Samitis, Ward Committees, and NGO-led committeesaimed at civic participation.
- Implementation Gaps: In some areas, these committees are non-existent, while in others they face ambiguous roles, infrequent meetings, underutilised funds, poor intersectoral coordination, and entrenched social hierarchies.
Where the problem lies
- Mindset Problem: A major challenge in India’s health system is the prevailing attitude toward public engagement, where communities are often seen as passive recipients rather than active participants.
- Target-Driven Approach: Programme success is measured through target-based metrics (e.g., number of “beneficiaries” reached) with little attention to implementation quality or community experience.
- Language Matters: The term “beneficiaries” frames citizens as objects of intervention, not as rights-holders or co-creators of health systems.
- Policy-Practice Gap: Although the National Health Mission promotes bottom-up planning through community involvement in Programme Implementation Plans, meaningful engagement remains rare.
- Medical Dominance: Health governance spaces are led mainly by medical professionals trained in western biomedical models, often without formal public health administration training.
- Leadership Structure: Promotions are largely based on seniority, reinforcing a medicalised and hierarchicalsystem disconnected from community realities.
- Resistance to Engagement: Scholarly research links resistance to fears of increased workload, accountability pressures, regulatory capture by dominant interests, and imbalances in governance power.
- Alternative Voices: In the absence of inclusive engagement platforms, citizens turn to protests, media campaigns, and legal action to express demands.
- Unmet Need: These alternative actions reflect a deep need for participation, voice, and accountability in India’s health governance.
The need for a shift
- Mindset Shift: Governance actors must undergo a fundamental change in perspective, recognising that community engagement is not just a tool to meet programme targets but a means to respect agency and dignity.
- Beyond Instrumentalism: Viewing people solely as a means to achieve health outcomes is reductive and undermines their participatory rights.
- Process Importance – Participatory processes hold equal value to the outcomes they aim to achieve.
- Empowerment: Actively empower communities by sharing health rights information, fostering civic awareness, reaching marginalised groups, and equipping citizens with knowledge, tools, and resources for effective participation in health governance.
- Early Engagement: Start civic education early to build a culture of active health governance participation.
- Marginalised Inclusion: Make intentional efforts to engage excluded or vulnerable populations in decision-making processes.
- System Sensitisation: Train health system actors to move beyond blaming poor awareness as the sole cause for low health-seeking behaviour and health-care utilisation.
Conclusion
Focusing too narrowly risks shifting blame onto individuals, further marginalising already vulnerable groups, while overlooking the deeper structural factors driving health inequities. Real progress demands that health professionals treat communities as active partners rather than passive beneficiaries, working together to tackle root causes. Public engagement platforms are an essential first step, but they must be strengthened, sustained, and made genuinely impactful.