Context

• In recent years, Indian states have experimented with ambitious initiatives aimed at bringing health care directly to people’s doorsteps.
• Tamil Nadu’s Makkalai Thedi Maruthuvam scheme, launched in August 2021, and Karnataka’s Gruha Arogya scheme, introduced in October 2024 and expanded statewide in June 2025, are notable examples.
• These programmes focus on delivering services, particularly for non-communicable diseases, directly to citizens’ homes.
• While such measures mark significant progress toward proactive health care delivery, they raise an equally important question: as health systems strive to reach citizens physically, to what extent can citizens themselves reach into, engage with, and influence health governance?

The Imperative of Citizen Engagement and Its Benefits

• The Imperative of Citizen Engagement
  • Health governance in India has evolved from a government-led domain into a more complex ecosystem involving civil society organisations, professional bodies, hospital associations, and trade unions.
  • It functions through both formal and informal processes, where power dynamics influence whose voices are heard.
  • Meaningful public engagement is not just a procedural nicety, it affirms dignity, counters epistemic injustice, and upholds democratic principles by enabling citizens to shape decisions affecting their health.
• Tangible Benefits of Inclusive participation
  • It strengthens accountability and transparency.
  • It challenges elite dominance and reduces the scope for corruption.
  • It develops collaboration with frontline workers, improving service uptake and health outcomes.
  • It builds mutual trust between communities and providers.
  • Without such engagement, health governance risks becoming exclusionary, oppressive, and disconnected from community realities.

Existing Frameworks for Participation and Persistent Challenges

• The National Rural Health Mission (NRHM), launched in 2005, institutionalised community participation through platforms like the Village Health Sanitation and Nutrition Committees (VHSNCs) and Rogi Kalyan Samitis.
• Designed to be inclusive, especially of women and marginalised groups, these bodies were supported by untied funds for local health initiatives.
• Urban parallels include Mahila Arogya Samitis, Ward Committees, and NGO-led committees.
• However, despite their promise, these platforms face persistent challenges. For example, in some areas, they have never been established.
• Where they do exist, meetings are irregular and roles are poorly defined and funds are underutilised.
• Intersectoral coordination is weak and deep social hierarchies undermine inclusivity.

Structural and Mindset Barriers

• A fundamental obstacle lies in how policymakers, administrators, and providers perceive communities.
• Too often, citizens are viewed as passive beneficiaries rather than active co-creators of health systems.
• This language signals an underlying paternalism: citizens are framed as objects of intervention rather than rights-holders.
• Performance metrics typically prioritise the number of people reached rather than the quality of engagement or the lived experience of service delivery.
• Health governance structures remain dominated by medical professionals, mostly trained in western biomedical models, who often acquire administrative responsibilities without formal public health training.
• Promotions are seniority-based rather than expertise-driven, entrenching a hierarchical and medicalised culture.

The Way Forward

• The Need for a Mindset Shift
  • Addressing these challenges requires a fundamental shift in mindset. Community engagement should not be reduced to an instrumental strategy for achieving programme targets.
  • Treating people merely as a means to better health statistics diminishes their agency and dignity.
  • Participatory processes should be valued in their own right, not only for the outcomes they produce.
• Empowering Communities
  • Disseminate accessible information on health rights and governance structures.
  • Develop civic awareness from an early stage.
  • Intentionally reach marginalised groups.
  • Equip citizens with the tools, skills, and resources to participate meaningfully.
• Sensitising Health System Actors
  • Move beyond the narrative that low health service utilisation is simply due to poor awareness.
  • Avoid individualising blame for systemic issues.
  • Recognise and address structural determinants of health inequities.
  • Develop collaborative relationships where communities are treated as equal partners.

Conclusion

• Doorstep health delivery programmes such as those in Tamil Nadu and Karnataka demonstrate the capacity of the Indian health system to innovate in service provision.
• Yet, without corresponding progress in citizen engagement, such initiatives risk reinforcing a top-down model of care.
• True transformation demands that communities are not only reached by services but are also empowered to shape them.
• By investing in inclusive, functional, and participatory governance platforms, and by shifting the attitudes of health system actors, India can move from a model of medicine at people’s doorsteps to one of democracy in health governance.