ABSTRACT
Global evidence suggests community participation is crucial in strengthening public health systems and ensuring the availability, accessibility, and acceptability of quality health services at healthcare facilities, through mechanisms that hold public health systems accountable to the community. Community participation in public health is not new, and examples are traceable back to the early 20th century. The Alma-Ata Declaration in 1978 marked a significant turning point in advancing community participation as a key aspect of global health. In the Indian context, although community participation in national health programmes featured in the National AIDS Control Programme (NACP) phase-2 in 1999, the National Rural Health Mission (NRHM) in 2005 institutionalised communitisation in public health. The National Health Mission’s (NHM) programme Community Action for Health (CAH) identifies communitisation as one of its key pillars, placing communities at the centre of public health systems to ensure their health needs and entitlements are met. The Ministry of Health and Family Welfare (MoHFW), Government of India, issued a government order to constitute an advisory group on community action (AGCA), comprising eminent public health experts from civil society organisations as its members and with a secretariat housed in the Population Foundation of India. The AGCA secretariat provided technical support to state governments to implement CAH processes under the NHM from 2005 to 2023. Integral to this was the continuous and well-informed guidance received from the AGCA. This chapter presents the experience of CAH and revisits the evolution of communitisation as a strategy. The chapter unpacks the implementation of the CAH programme by highlighting its key outcomes, challenges, learnings, and the way forward. It reflects on the 18-year journey of CAH (2005–2023) within the larger NHM framework, including its evolution, institutionalisation, and scaling up. We have identified and analysed the challenges and opportunities for moving forward with communitisation. The chapter draws inferences from the desk review on community participation and engagement in health, social accountability in health, and an in-depth review and analysis of published literature on communitisation within the scope of NHM. CAH provided a pathway for empowering communities and integrating their voices into the national programme’s design and implementation, thereby enhancing citizen’s participation in the public health systems. The CAH process, which started as a pilot project between 2007 and 2009 in nine Indian states, expanded to 25 states by 2023, covering over 230,000 villages across 450 districts and 145 cities. It has established processes for proactive community participation, moving away from tokenistic engagement. This expansion has resulted in positive outcomes, such as building trust between communities and health systems, improving coverage of health services, creating community awareness on health entitlements and rights, generating demand for health services, supporting frontline health workers to overcome service delivery constraints, facilitating local and need-based planning, ensuring appropriate planning and utilisation of untied funds, facilitating the deputation of doctors at healthcare facility, reducing demands for informal payments, ensuring timely and complete payments of incentives, and significantly reducing outside prescriptions, thereby reducing out-of-pocket expenses. The journey of communitisation underscores the unique value it adds by offering a model of community participation through a meaningful partnership at scale between the government and civil society across the country.
