Journal Article

How communitization begets and endures sarkarikaran: a witnessed history of community action for health in India’s national rural health mission

Nambiar, Devaki, Chadha, Neymat

2025

Overview

The legacy of Community Action for Health (CAH) in India traces back to the global momentum for primary health care galvanized by the Alma Ata Declaration and post–World War II social movements. In 2024, the World Health Assembly endorsed a resolution on institutionalising CAH and other forms of social participation as a core pillar of health reform. The Indian experience of institutionalising CAH under its erstwhile National Rural Health Mission offers an example of sustained national-scale implementations of CAH globally, yet its lessons—both successes and blind spots—remain under-analysed. This paper aims to fill that gap by critically examining the trajectory of CAH since 2005 and exploring its implications for the operationalization of the SPH Resolution. In 2021, two virtual Witness Seminars and four in-depth interviews were conducted with leaders of Civil Society Organizations (CSOs), program implementers, and policy decision-makers involved in the institutionalization of Community Action for Health (CAH) under the National Rural Health Mission (NRHM). Participants included. Seminars and interviews explored key events, actors, processes, and contextual factors that shaped the evolution of CAH. All sessions were fully transcribed and analysed using ATLAS.ti (version 22). Our analysis of the evolution of CAH in India suggests four phases – leading to and flowing away from governmentality. While initially communitization involved collaborative dialogue, debate and system redesign, pilots of CAH rolled out across Indian states with varying strategies, ownership, and stakeholdership. Roles of community began to shift into that of agents and providers as part of “sarkarikaran” or governmentalization of community processes. A final phase suggests that like flowing water, CAH may continue to reconfigure state-society relations in the wake of emerging challenges, less formalised, more embedded interactions. This suggests that institutionalising, standardizing and centralising CAH is neither lasting, nor desirable. Highlights Community action for health has a vaunted legacy and remains highly relevant across contexts today. Witness seminar methodology can help understand how community action for health models have evolved in a decentralized social democratic context like India’s. Analysis reveals four (nautical) phases in the evolution of community action for health in India: building the ship, setting sail, floundering waters, and flowing where there’s space (or even when there’s not). In the current context, where institutionalization of social participation for health is being called for, understanding these histories and trajectories offers many insights.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Accountability / Advocacy / Bureaucrats / Citizen participation / Civil society / Community action / Community action for health (CAH) / Community Participation / Decision making / Evaluation / Health Administration / Health aspects / Health care policy / Health care reform / Health Informatics / Health policy and systems research (HPSR) / Humans / India / Interviews as Topic / Medical policy / Medicine / Medicine & Public Health / Mortality / National health mission (NHM) / Nursing Research / Oral history / Planning / Political aspects / Public Health / Rural health / Rural Health Services - history / Rural Health Services - organization & administration / Sanitation / Social aspects / Social participation