People-Centred Health Governance

12/08/2025

Why in the News?

Tamil Nadu’s Makkalai Thedi Maruthuvam (August 2021) and Karnataka’s Gruha Arogya (October 2024, expanded June 2025) are delivering healthcare at people’s doorsteps for non-communicable disease
Other States are implementing similar programmes, marking a major push for proactive healthcare delivery.
These developments raise a key governance question: as health systems reach people’s doorsteps, to what extent can citizens engage with and influence health governance formally?

Key Highlights

Importance of citizen engagement in health governance
1. Health governance now includes civil society, professional bodies, hospital associations, and trade unions.
2. Participation affirms self-respect, addresses epistemic injustice, and upholds democratic values.
3. Engagement strengthens accountability, challenges elite dominance, reduces corruption, fosters collaboration with frontline workers, and improves health outcomes.
Institutional mechanisms for participation
1. Under the National Rural Health Mission (2005), platforms like Village Health Sanitation and Nutrition Committees (VHSNCs) and Rogi Kalyan Samitis were created for inclusive decision-making.
2. Urban mechanisms include Mahila Arogya Samitis, Ward Committees, and NGO-led committees.
3. These aimed to include women and marginalised groups, with untied funds for local initiatives.
Gaps in practice
1. In some areas, committees are absent; in others, they suffer from infrequent meetings, unclear roles, underutilised funds, and poor intersectoral coordination.
2. Social hierarchies limit true inclusiveness.
Prevailing mindset as a barrier
1. Policymakers often see communities as passive “beneficiaries” rather than rights-holders or co-creators.
2. Programme success is measured mainly by target-based counts, not by quality of engagement.
3. Health leadership is dominated by doctors trained in biomedical models, promoted by seniority, lacking public health expertise.
4. Resistance stems from fears of workload, accountability, and dominance by medical/capitalist interests.
Need for a mindset and structural shift
1. Participation should be valued as much as outcomes; treating people as instruments for targets is reductive and disrespectful.
2. Two-pronged approach:
  1. Empower communities through awareness, inclusion of marginalised groups, and equipping them to participate in decision-making.
  2. Sensitise health actors to see beyond “poor awareness” and address structural determinants of health inequities.
3. Platforms must be established, activated, strengthened, and made meaningful.

Implications

Strengthening democracy in health governance
1. Meaningful engagement recognises citizens as partners, not passive recipients.
2. Helps dismantle hierarchical, top-down health decision-making.
Improved accountability and reduced corruption
1. Citizen participation challenges elite control and encourages transparent fund use.
2. Oversight ensures programmes serve intended communities.
Enhanced trust and service uptake
1. Collaboration between communities and providers improves mutual understanding and service use.
2. Especially critical for NCD care.
Shift from output-based to process-based success
1. Move beyond beneficiary counts to assess quality of participation.
2. Recognise participatory processes as equally important to health outcomes.
Addressing health inequities
1. Inclusion of marginalised groups tackles structural and social determinants of poor health.
2. Prevents victim-blaming and ensures community-informed solutions.

Challenges and Way Forward

Challenge	Why it matters	Immediate(0-12 months)	Long-term actions (1-5 years)
Committees not constituted or inactive	No formal channel for community voice or local planning.	Mandate reconstitution, publish membership lists, hold training.	Audits of committee functioning; link funding to participation metrics.
Ambiguous roles and tokenistic participation	Allows co-optation and reduces effectiveness.	Issue clear role descriptions and operating procedures.	Embed roles in guidelines with accountability clauses.
Framing citizens as beneficiaries	Limits authority and reduces dignity.	Conduct sensitisation workshops for programme managers.	Use rights-based language and require participatory planning evidence.
Medicalised leadership	Leaders lack governance or participation skills.	Provide short courses in public health and governance.	Create career paths rewarding community engagement outcomes.
Social hierarchies and exclusion	Reproduces inequities, silences key voices.	Require outreach and reserved representation for women/marginalized.	Invest in civic education and fund community organisations.
Under- utilisation of untied funds	Missed local solutions, reduced trust.	Publicise fund balances; fast-track local projects.	Introduce participatory budgeting and social audits.
Target- focused metrics	Ignores quality and dignity of delivery.	Add process indicators like meeting frequency and fund utilisation.	Redesign evaluation to weigh citizen feedback equally with targets.
Resistance from providers	Pushback can stall reforms.	Incentivise facilitators of participation.	Reform job descriptions; provide facilitation staff.

Conclusion

The expansion of doorstep healthcare is a positive step toward accessible services, but without genuine citizen participation, governance will remain top-down and potentially unjust. True transformation lies in empowering communities with knowledge, tools, and representation to shape health systems, while sensitising providers to value partnership over paternalism. Strengthened platforms, inclusive practices, and a rights-based approach are essential to building accountable, equitable, and trusted health governance.

Ensure IAS Mains Question

Q. Doorstep healthcare delivery schemes have improved physical access to services, but meaningful civic engagement in health governance remains limited. Discuss the challenges in ensuring participatory health governance and suggest measures to strengthen citizen involvement at all levels. (250 words)

Ensure IAS Prelims Question

Q. Which of the following committees/platforms was/were institutionalised under the National Rural Health Mission (NRHM) to promote community participation in health governance?

1. Village Health Sanitation and Nutrition Committees (VHSNCs)

2. Rogi Kalyan Samitis

3. Mahila Arogya Samitis

Select the correct answer using the code given below:

a) 1 and 2 only

b) 2 and 3 only

c) 1 and 3 only

d) 1, 2 and 3

Answer: a) 1 and 2 only

Explanation:

Statement 1 is correct: The Village Health Sanitation and Nutrition Committees (VHSNCs) were set up under the National Rural Health Mission (NRHM) to institutionalise community participation in rural health governance, particularly involving women and marginalised groups, and were given untied funds for local initiatives.

Statement 2 is correct: Rogi Kalyan Samitis (also called Hospital Management Committees) were also part of NRHM’s strategy to enhance participatory governance at health facilities, enabling local decision-making and fund utilisation.

Statement 3 is incorrect: Mahila Arogya Samitis are urban health platforms designed for community engagement in urban areas, particularly under the National Urban Health Mission (NUHM), not NRHM.