12 August 2025
(Mains: Editorials Simplified)

CITIZEN PARTICIPATION IN HEALTH GOVERNANCE

Recent initiatives like Tamil Nadu’s Makkalai Thedi Maruthuvam and Karnataka’s Gruha Arogya reflect a paradigm shift towards proactive, doorstep healthcare delivery. It makes it important to highlight that effective health governance must go beyond service delivery to incorporate meaningful public participation, ensuring accountability, inclusiveness, and responsiveness.

Background

• Historically, health governance was a top-down government function. But it has evolved to include civil society, professional bodies, and community groups, emphasizing participatory decision-making.

• India’s National Rural Health Mission (NRHM) institutionalised public engagement via platforms like Village Health Sanitation and Nutrition Committees (VHSNCs) and Rogi Kalyan Samitis to enable bottom-up planning.

• Urban areas have similar forums such as Mahila Arogya Samitis and Ward Committees. Yet these platforms often remain underutilized due to poor coordination, social hierarchies, and unclear mandates.

• Despite policy frameworks promoting citizen involvement, real empowerment and meaningful participation remain limited, reflecting systemic challenges in governance structures and mindsets.

Challenges in Health Governance Participation

• Citizens as Beneficiaries: Policymakers often treat citizens as passive beneficiaries rather than rights-holding partners, focusing on target achievement over participatory processes.

• Medicalised Governance: Health system leadership is dominated by medically trained professionals, often selected by seniority rather than public health expertise, leading to hierarchical and disconnected governance.

• Resistance to Engagement: Concerns about accountability pressures, workload increases, and entrenched interests contribute to reluctance in embracing genuine community participation.

• Weak or Inactive Platforms: Many formal engagement mechanisms exist only in name, hindered by infrequent meetings, poor fund utilization, and lack of inclusivity, especially for marginalized groups.

• Alternative Expression of Voice: In the absence of functional engagement, citizens resort to protests, media advocacy, and legal recourse to claim their rights, reflecting gaps in institutional responsiveness.

Approaches for Meaningful Community Involvement

• Empowering Communities: Systematic dissemination of information on health rights, governance structures, and civic education targeting marginalised populations is essential.

• Capacity Building: Equip citizens with knowledge and tools to actively participate in health decision-making processes, fostering confidence and agency.

• Strengthening Institutions: Activate and strengthen existing platforms with clear roles, regular functioning, adequate resources, and inclusive representation to ensure meaningful engagement.

• Fostering Collaboration: Promote partnership models where health professionals and communities co-create solutions, bridging gaps between service delivery and lived realities.

• Accountability Mechanisms: Develop transparent systems that allow community feedback to influence policy adjustments and resource allocations effectively.

Conclusion

India’s doorstep healthcare initiatives mark important progress but are insufficient without embedding citizen engagement at the heart of health governance. A transformative shift in attitudes among policymakers and health administrators, coupled with empowered citizens and strengthened institutions, is critical for realizing inclusive, responsive, and just health systems.

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EVOLUTION OF THE RULES-BASED INTERNATIONAL ORDER

The post-World War II rules-based international order has historically underpinned global governance, trade, and security through a network of institutions largely shaped by U.S. leadership. Recent geopolitical shifts have tested the resilience and adaptability of this system. The central question is how this order will transform under pressures from coercive policies, shifting alliances, and emerging multipolar dynamics.

Background

• The rules-based order emerged post-1945, driven by U.S. initiatives such as the Marshall Plan, aimed at reconstructing Europe and stabilizing global politics under a unipolar framework.

• Institutions like the WTO, IMF, World Bank, and the United Nations were created to embed norms, regulate economic flows, and curb rival powers.

• The order balanced American dominance with openings for developing nations, allowing controlled participation in global governance.

• Asia’s rapid economic rise unfolded within this framework, shaped both by U.S. leverage and the autonomous agency of Asian states.

Defining Key Concepts

• Rules-Based International Order: A system of global governance structured around agreed norms, laws, and institutions to regulate state behaviour and international relations.

• Pax Americana: The period of relative peace and stability maintained by U.S. economic, political, and military dominance post-World War II.

• Washington Consensus: Economic policy prescriptions promoting liberalization, privatization, and market reforms endorsed by institutions like the IMF and World Bank.

• Multipolarity: The emergence of multiple influential global or regional powers, diluting unipolar dominance.

Challenges and Transformations

• U.S. Coercive Policies: Use of economic sanctions and trade restrictions against Asian and developing economies challenges the collaborative spirit of the order.

• Asian Agency: Asian nations have asserted growing autonomy and regional cooperation, complicating unilateral U.S. dominance and introducing systemic flexibility.

• Erosion of European Stability: The U.S. withdrawal of support from NATO destabilizes a key pillar of the global order, with consequences for European security architecture.

• Geopolitical Realignments: U.S. alliances, such as close ties with Israel, reshape Middle East politics and impact global diplomatic networks.

• Institutional Fragmentation: Global bodies face weakening legitimacy amid increasing bilateralism, undermining cooperative problem-solving mechanisms.

• Technological and Military Shifts: Growing reliance on drones, AI, and proxy conflicts reflects a changing nature of conflict and power projection.

Navigating the Emerging Global Landscape

• Recognize Multipolar Realities: Embrace Asia’s rise and diversified power centres as integral to the evolving international framework.

• Strengthen Multilateralism: Reinvigorate global institutions to mediate conflicts, enforce norms, and facilitate equitable cooperation despite geopolitical frictions.

• Balance Bilateral and Regional Engagements: While bilateral agreements gain prominence, fostering inclusive regional cooperation remains vital for stability.

• Promote Inclusive Global Governance: Ensure emerging and developing economies have meaningful participation in decision-making to preserve legitimacy.

• Adapt to Technological Change: Develop international norms for emerging technologies in warfare and security to prevent escalatory dynamics.

• Mitigate Institutional Erosion: Support reforms that increase transparency, responsiveness, and resilience of international organizations.

Conclusion

The rules-based international order shaped by Pax Americana is undergoing profound transformation. For India and other emerging powers, navigating this evolving landscape requires strategic engagement, strengthening multilateralism, and safeguarding sovereign interests within a fluid international system.

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