Recent schemes like Tamil Nadu’s Makkalai Thedi Maruthuvam and Karnataka’s Gruha Arogya reflect a shift toward doorstep care for non-communicable diseases, yet they raise a critical question on citizens’ ability to actively engage with and influence health governance.
PWOnlyIAS Extra Edge:
About Non-Communicable Diseases (NCDs)
- Definition: These are those diseases not caused by infectious agents and not transmissible from person to person. They are typically of long duration and slow progression.
- Major Types of NCDs (WHO classification): Cardiovascular diseases (CVDs) – e.g., coronary heart disease, stroke, Cancers, Chronic respiratory diseases – e.g., COPD, asthma & Diabetes (Other emerging NCDs include mental health disorders, chronic kidney disease, osteoporosis)
Recent Data on NCDs in India
- Prevalence – NFHS-5 Findings: A large-scale study (NFHS-5, adults 30+) shows one in three Indians has hypertension, and nearly one in five has diabetes.
- Moreover, 43% of diabetics also have hypertension, and over 25% of hypertensives also have diabetes—underscoring the twin epidemic.
- Market Indicators – Rising Drug Sales: Between June 2021 and June 2025, cardiac medication sales surged 50%, reflecting a growing cardiovascular disease burden; cardiovascular diseases now account for 27% of all deaths.
- Government Response – 75/25 Initiative: The government’s “75/25” initiative aims to provide standardized care to 75 million individuals with hypertension and diabetes by December 2025.
- As of March 5, 2025, 42.01 million treated for hypertension and 25.27 million treated for diabetes, achieving 89.7% of the target.
Health Governance: State Primacy and Union Role
- Health governance is the system of rules, policies, and institutions that guide the planning, delivery, and oversight of health services, ensuring accountability, equity, quality, and citizen participation in improving public health outcomes.
- A State Subject: Health is a State subject as listed in Entry 6 of the State List of the Seventh Schedule of the Indian Constitution. This gives state governments the primary responsibility for public health, hospitals, dispensaries, and sanitation.
- Union Government’s Role: While states lead on healthcare delivery, the Union Government plays a crucial and influential role in several areas:
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- Central Health Policies and Schemes: The Union Government frames national policies and funds large-scale health schemes like the National Health Mission (NHM) and Ayushman Bharat, which provide financial protection and access to healthcare for millions.
- Medical Education and Drugs: The Union Government regulates medical, dental, and other health-related education. It also controls the quality and standards of drugs and medicines.
- Inter-state and International Health Issues: The Union Government handles health matters that affect multiple states or have international implications, such as agreements on health-related trade and disease surveillance.
- Quarantine and Epidemic Control: Under the Epidemic Diseases Act, 1897, and more recently the Disaster Management Act, 2005, the Union Government can take necessary measures to prevent the spread of infectious diseases across the country.
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About Civic Engagement in Health Governance
- Refers: The active participation of citizens, civil society organisations (CSOs), community health workers, patient groups, and local governance bodies in decision-making, monitoring, and evaluation of health systems.
- Scope: Involves planning health interventions, community monitoring of health facilities, public grievance redressal, and co-production of services with the government.
- Key Mechanisms in India:
- Rogi Kalyan Samitis (Patient Welfare Committees)
- Village Health Sanitation and Nutrition Committees (VHSNCs)
- Jan Sunwai (public hearings)
- Community Based Monitoring and Planning (CBMP) under NHM
Constitutional & Legal Basis
- Directive Principles of State Policy (DPSPs):
- Article 38: Promote welfare of the people.
- Article 39(e) & (f): Protect health of workers, ensure healthy development of children.
- Article 47: Duty of the State to raise nutrition levels and improve public health.
- 73rd & 74th Constitutional Amendments: Empower Panchayats and Urban Local Bodies to plan and monitor local health services.
- Right to Health: Implicit in Article 21 (Right to Life) — affirmed by various Supreme Court judgments.
- Parmanand Katara vs. Union of India (1989) – SC held that right to emergency medical care is part of the Right to Life, obligating all doctors, public or private, to provide immediate treatment.
- National Health Mission (NHM) Framework: Provides for VHSNCs, Rogi Kalyan Samitis, and community monitoring.
- RTI Act, 2005: Enables citizens to seek health-related information and hold service providers accountable.
- National Health Policy, 2017: Recognises community participation as a guiding principle.
Forms of Civic Engagement in Health Governance
- Participatory Policy & Planning:
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- Representation in Committees: Citizens, NGOs, and elected representatives participate in State & District Health Committees.
- Co-Designing Health Plans: Platforms like Village Health Sanitation & Nutrition Committees (VHSNCs) develop integrated plans for health, sanitation, and nutrition.
- Rogi Kalyan Samitis (RKS): Facility-level bodies with community members managing hospital resources and improving service delivery.
- Integrated National Health System: As proposed by the Public Health Foundation of India (PHFI), including universal health insurance, decentralised governance, and legislation guaranteeing health as an entitlement.
- Indian Medical Service (IMS): It proposed a national cadre, similar to the Indian Administrative Service (IAS), for structured and accountable health administration, enabling systematic citizen–state coordination in health policy and service delivery.
NGO Case Studies on Civic Engagement in Health Governance
- SEWA (Self Employed Women’s Association) empowers women in the informal sector by advocating for their health rights and involving them in local health planning, significantly improving access to maternal care and sanitation.
- The Jan Swasthya Abhiyan (JSA), a national coalition, actively promotes the Right to Health through community monitoring, social audits, and public hearings, influencing key health policies like the National Health Policy 2017.
- Globally, Partners in Health (PIH) emphasizes community health worker empowerment and patient inclusion in governance, leading to better treatment adherence and trust in underserved communities.
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- Community Monitoring & Accountability:
- Community-Based Monitoring & Planning (CBMP): Under the NRHM, communities track availability, quality, and equity of health services, submitting reports to higher bodies.
- Social Audits: Adaptation of MGNREGA-style reviews to assess fund utilisation and programme outcomes in public health.
- Citizen Charters: Public display of entitlements, services, and grievance redressal channels at health facilities.
- Public Hearings (Jan Sunwai): Open forums where citizens present grievances and demand action.
- Benefit Incidence Analysis (BIA): It reveals that inpatient care spending in public health facilities is more pro-poor, while outpatient care spending is more pro-rich—particularly in urban areas—whereas rural areas perform better in pro-poor allocation, highlighting the need for stronger local monitoring to address urban bias and ensure equitable resource distribution.
- Public Mobilisation & Advocacy:
- Health Campaigns: Citizen participation in initiatives like Pulse Polio Immunisation and Swachh Bharat Mission.
- Patient Rights Movements: Advocacy for transparency in treatment costs, ethical medical practices, and informed consent.
- Civil Society Engagement: NGOs, SHGs, and media networks (e.g., PATH, SEWA, PRADAN) influencing health priorities and mobilising communities.
- Digital & Feedback Platforms
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- Digital Engagement: Citizens share feedback via portals and mobile apps such as e-Sanjeevani, the National Health Helpline, and social media health campaigns.
- Grievance Portals: Online systems enabling real-time reporting of service issues and tracking resolution progress.
| PWOnlyIAS Extra Edge:
International Best Practices for Civic Engagement in Health Governance
- Brazil – Participatory Health Councils:
- Mechanism: National, state, and municipal health councils with 50% representation from civil society.
- Functions: Approve health budgets, monitor implementation of the Unified Health System (SUS), and hold periodic “Health Conferences” open to the public.
- Impact: Institutionalised citizen oversight ensures budget transparency and pro-poor allocation.
- Thailand – National Health Assembly (NHA):
- Mechanism: A formal forum bringing together government, academia, and civil society to deliberate on national health policies.
- Legal Backing: National Health Act, 2007.
- Impact: Recommendations from the NHA are binding for integration into health strategies, ensuring policy co-creation.
- United Kingdom – Healthwatch England & Local Healthwatch Bodies:
- Mechanism: Independent statutory bodies representing patients’ voices at national and local levels.
- Functions: Conduct surveys, inspect facilities, and escalate complaints directly to the Care Quality Commission (CQC).
- Impact: Provides formal grievance redressal and data-driven advocacy.
- Rwanda – Community Health Worker (CHW) Cooperative Model:
- Mechanism: Each village elects CHWs responsible for preventive care, maternal health, and early disease detection.
- Integration: CHWs are linked to primary health facilities through digital reporting tools.
- Impact: Dramatic reductions in maternal and child mortality through grassroots ownership
- Canada – Indigenous Health Partnerships:
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- Mechanism: Co-governance agreements between indigenous communities and provincial health ministries.
- Example: First Nations Health Authority in British Columbia.
- Impact: Ensures culturally appropriate care, integrating traditional knowledge into mainstream services.
Global Initiatives on Civic Engagement in Health Governance
- World Health Organization (WHO) — Health Promotion and Community Engagement: Advocates for empowering communities to participate in health decision-making through frameworks like the Ottawa Charter for Health Promotion (1986) and Health in All Policies (HiAP) approach.
- Supports Community Health Worker (CHW) programs globally to enhance local ownership and responsiveness.
- Global Fund to Fight AIDS, Tuberculosis and Malaria: Requires community and civil society participation in country coordinating mechanisms (CCMs) for oversight and resource allocation.
- Promotes patient and key population involvement in program design, implementation, and monitoring.
- Gavi, the Vaccine Alliance: Engages communities in vaccination campaigns and feedback mechanisms to improve vaccine uptake and address hesitancy.
- Supports country-led social mobilisation strategies involving local leaders and civil society.
- UHC2030 (Universal Health Coverage Partnership): Promotes inclusive health governance by fostering multi-stakeholder platforms where citizens, governments, and partners co-create health policies.
- Emphasises accountability and transparency as central pillars of UHC progress.
- People’s Health Movement (PHM): A global network advocating for the right to health and community control over health systems.
- Organises campaigns, social audits, and forums to amplify marginalized voices.
- UN Sustainable Development Goals (SDGs): Particularly Goal 3 (Good Health and Well-being) and Goal 16 (Peace, Justice, and Strong Institutions) promote inclusive, participatory governance and accountability in health systems.
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Need for Civic Engagement in Health Governance
- Bridging Trust Deficit: Many communities perceive public health institutions as corrupt, neglectful, or inaccessible. Regular public consultations, budget disclosures, and facility visits by VHSNC members restore credibility by making governance transparent.
- Reducing Inequities in Service Delivery: Local monitoring ensures proportionate allocation of resources to underserved rural, tribal, and marginalised groups, countering the urban bias in healthcare spending.
- Early Detection of Service Gaps: Civic monitoring can identify absentee staff, drug stock-outs, and malfunctioning equipment before they escalate into systemic crises, enabling timely interventions.
- Combating Health Misinformation: Community-led campaigns (via Accredited Social Health Activists (ASHAs), SHGs, influencers) effectively address vaccine hesitancy, nutritional myths, and unsafe health practices, often outperforming centralised advisories.
- Ensuring Cultural Sensitivity: Participation from local communities helps design health interventions that respect socio-cultural norms (e.g., culturally appropriate maternal care in tribal areas).
- Democratic Imperative: Engagement affirms self-respect, counters epistemic injustice, and strengthens citizens’ agency as rights-holders rather than passive beneficiaries.
- Community Health Worker (CHW) Model: One Community Health Worker per 40,000 population, linked to a 75-bed district hospital. Uses mobile technology and electronic health records to detect gaps early and escalate them to higher health facilities.
Importance of Civic Engagement in Health Governance
- Improved Accountability: Mechanisms like Community-Based Monitoring and Planning (CBMP) and Rogi Kalyan Samitis (RKS) create continuous feedback loops, discouraging fund misuse and increasing responsiveness.
- Better Resource Utilisation: Ground-level feedback ensures spending targets real needs rather than politically motivated or duplicate schemes, enhancing cost-effectiveness.
- Strengthened Primary Healthcare: VHSNCs, ASHAs, and Mahila Arogya Samitis improve immunisation, maternal care, and early disease reporting.
- Resilient Health Systems: Community-led responses (e.g., ASHA-led COVID-19 contact tracing) demonstrate adaptability during crises.
- Inclusive Decision-Making: Active involvement of women, SC/STs, minorities, and marginalised groups ensures health policies reflect diverse needs.
- Behavioural Change and Ownership: Co-ownership of health initiatives promotes sustainable lifestyle changes, such as hygiene practices and balanced diets.
- Trust Building & Collaboration: Engagement strengthens relationships between communities and frontline workers, improving service uptake.
- Technology as a “Glue”: Linking Community Health Workers, doctors, and hospitals to create seamless and accountable healthcare delivery.
- District-to-State referral Linkages: Ensuring each state has a world-class tertiary care facility (e.g., All India Institute of Medical Sciences – AIIMS-type), improving coordinated citizen-led health responses.
Challenges lies for Civic Engagement in Health Governance
- Mindset Barriers: Policymakers often see communities as passive beneficiaries, not partners. Engagement is valued only for target achievement.
- Tokenism: Consultations may exist only on paper, with minimal implementation of community recommendations.
- Capacity Gaps: VHSNC and CSO members often lack knowledge of health rights, budgeting, and monitoring.
- Information Asymmetry: Many citizens are unaware of entitlements under NHM, Ayushman Bharat, or state health schemes.
- Medicalised Governance: Leadership dominated by biomedical professionals with little public health training; promotions based on seniority reinforce top-down approaches.
- Political Interference: Local health committees sometimes prioritise electoral gains over community health needs.
- Low Institutional Support: Feedback from CBMP/VHSNCs is often ignored or delayed.
- Digital Divide: Rural/poor communities are excluded from e-health consultations, grievance portals, and monitoring tools.
- Volunteer Fatigue: Over-reliance on unpaid or underpaid volunteers reduces sustained participation.
- Social Hierarchies & Exclusion: Marginalised voices may be silenced in committee discussions due to entrenched power dynamics.
- Fragmented Public Health Education: No national standard for the Master of Public Health (MPH) degree.
- Gaps in training for public health engineering, behavioural science, and health technology.
- Limits the ability of VHSNCs, ASHAs, and Civil Society Organisations (CSOs) to interpret health data and influence governance effectively.
Way Forward
- Institutionalise Community Monitoring: Expand CBMP beyond pilot states (Maharashtra, Chhattisgarh) to all NHM districts, with regular public reports.
- Legal Backing: Enact a statutory Right to Health with provisions for citizen oversight, mandatory representation of marginalised groups, and grievance redressal rights.
- Capacity Building: Structured training for VHSNC members, ASHAs, SHGs, and CSO representatives on governance, budgeting, and data analysis.
- Data Transparency: Create real-time public dashboards showing facility budgets, medicine stocks, service utilisation, and health outcomes.
- Leverage Digital Tools Inclusively: Develop mobile-based grievance and telemedicine systems with offline facilitation in low-connectivity areas.
- Adapt Community Health Worker (CHW) technology-enabled models for low-connectivity areas so rural participation is not excluded.
- Incentivise Participation: Provide honorariums, public recognition, and inclusion in district health planning boards.
- Integrate Community Feedback into Policy: Require at least 50% of inputs in annual health action plans to come from community forums and monitoring reports.
- Mindset Change in Health Administration: Sensitise officials to view communities as co-creators; prioritise participatory processes alongside health outcomes.
- Integrate Benefit Incidence Analysis (BIA) into local health planning – making equity audits part of annual district health reviews.
- Reform the Master of Public Health (MPH) Curriculum: Standardised, interdisciplinary training to strengthen grassroots engagement.
- Formalise the Indian Medical Service (IMS) Cadre: Ensure permanent, skilled leadership for community engagement and decentralised health governance.
Conclusion
Civic engagement in health governance, rooted in Article 21 (Right to Life), Article 47 (public health duty), and the 73rd & 74th Amendments, is vital for ensuring participatory, transparent, and equitable health systems that address inequities and strengthen citizens’ role as rights-holders in healthcare.
12 Aug 2025
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