PATANG: Promoting Community Action for Health- A Co-Produced, Technology-Enabled Platform to Achieve National Goals.

GENERATING MOMENTUM TOWARDS COMMUNITY ROLES IN UNIVERSAL HEALTH COVERAGE: KEY OUTCOMES OF A SERIES OF STATE-CIVIL SOCIETY CONSULTATIVE PROCESSES

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.

The main challenge for a sustainability transition is to scale up successful solutions. Upscaling requires coalitions of public, private, and civil society actors who align their motivations. Pathways to upscaling may involve leveraging a dominant player's market power, integrating successful initiatives into public policy, or reinforcing government-led change with private efforts. Various actors agree to collaborate to take advantage of their complementary capabilities, e.g., government policies facilitate private action, market incentives reward progressive actors while government sanctions punish laggards, actors take up different tasks of the policy cycle, and large players absorb and disseminate pioneer efforts. To achieve durable impacts, the upscaling of solutions to reach sustainability must continually maintain a balance of incentives among key actors. We identify general lessons for successful upscaling that provide insights on the importance of motivating actors, designing collaborations for lasting success, and incorporating concerns of developing countries.

The role of civil society and community-based organizations in advancing universal health coverage and meeting the targets of the 2030 Agenda for Sustainable Development has received renewed recognition from major global initiatives. This article documents the evolution and lessons learnt through two decades of experience in India at national, state and district levels. Community and civil society engagement in health services in India began with semi-institutional mechanisms under programmes focused on, for example, HIV/AIDS, tuberculosis, polio and immunization. A formal system of community action for health (CAH) started with the launch of the National Rural Health Mission in 2005. By December 2018, CAH processes were being implemented in 22 states, 353 districts and more than 200 000 villages in India. Successive evaluations have indicated improved performance on various service delivery parameters. One example of CAH is community-based monitoring and planning, which has been continuously expanded and strengthened in Maharashtra since 2007. This involves regular, participatory auditing of public health services, which facilitates the involvement of people in assessing the public health system and demanding improvements. At district level, CAH initiatives are successfully reaching "last-mile" communities. The Self-Employed Women's Association, a cooperative-based organization of women working in the informal sector in Gujarat, has developed community information hubs that empower clients to access government social and health sector services. CAH initiatives in India are now being augmented by regular activities led and/or participated in by civil society organizations. This is contributing to the democratization of community and civil society engagement in health. Additional documentation on CAH and the further formalization of civil society engagement are needed. These developments provide a valuable opportunity both to improve governance and accountability in the health sector and to accelerate progress towards universal health coverage. Lessons learnt may be applicable to other countries in South-East Asia, as well as to most low- and middle-income countries.

BackgroundThe People’s Planning Campaign (PPC) in the southern Indian state of Kerala started in 1996, following which the state devolved functions, finances, and functionaries to Local Self-Governments (LSGs). The erstwhile National Rural Health Mission (NRHM), subsequently renamed the National Health Mission (NHM) was a large-scale, national architectural health reform launched in 2005. How decentralisation and NRHM interacted and played out at the ground level is understudied. Our study aimed to fill this gap, privileging the voices and perspectives of those directly involved with this history.MethodsWe employed the Witness Seminar (WS), an oral history technique where witnesses to history together reminisce about historical events and their significance as a matter of public record. Three virtual WS comprised of 23 participants (involved with the PPC, N(R)HM, civil society, and the health department) were held from June to Sept 2021. Inductive thematic analysis of transcripts was carried out by four researchers using ATLAS. ti 9. WS transcripts were analyzed using a realist approach, meaning we identified Contexts, Mechanisms, and Outcomes (CMO) characterising NRHM health reform in the state as they related to decentralised planning.ResultsTwo CMO configurations were identified, In the first one, witnesses reflected that decentralisation reforms empowered LSGs, democratised health planning, brought values alignment among health system actors, and equipped communities with the tools to identify local problems and solutions. Innovation in the health sector by LSGs was nurtured and incentivised with selected programs being scaled up through N(R)HM. The synergy of the decentralised planning process and N(R)HM improved health infrastructure, human resources and quality of care delivered by the state health system. The second configuration suggested that community action for health was reanimated in the context of the emergence of climate change-induced disasters and communicable diseases. In the long run, N(R)HM’s frontline health workers, ASHAs, emerged as leaders in LSGs.ConclusionThe synergy between decentralised health planning and N(R)HM has significantly shaped and impacted the health sector, leading to innovative and inclusive programs that respond to local health needs and improved health system infrastructure. However, centralised health planning still belies the ethos and imperative of decentralisation – these contradictions may vex progress going forward and warrant further study.

This study investigates the complex dynamics of state and civil society cooperation in Ukraine since the February 2022 Russian invasion. The study relies on in-depth interviews with senior representatives of civil society and state actors in Ukraine and examines the performance of key actors in terms of addressing immediate wartime needs. The research identifies crucial stages in state decision-making where Civil Society Organizations (CSOs) play a pivotal role, emphasizing their contributions, especially to problem identification, information collection, alternative identification, and result evaluation. Furthermore, it assesses the sustainability of civil society-state actor cooperation during the conflict, emphasizing financial stability, flexibility, communication, and trust as pivotal factors. Lastly, it explores shared challenges, including divergent priorities, politicization, security concerns, and collaboration reluctance, proposing strategies centered on open dialogue, collective problem-solving, and expert advice incorporation. In summary, this research provides nuanced insights into civil society-state actor collaboration during enduring conflict, offering lessons on fostering cooperation and resilience in the face of foreign invasion.

A comprehensive examination of the European public sphere must consider Europeanization from below, of, and by civil society. As Jurgen Habermas argues, civil society has a key role to play in a democratic public sphere: civil society actors at the periphery of the formal political arena have the potential to bring new groups of citizens into the political debate and to highlight problems that may become central to the agenda (Habermas 1996c). If this potential were undermined, it would seriously exacerbate the democratic deficit in the European Union (EU) (Habermas 2006c). This chapter takes stock of the European public sphere with a focus on organized civil society and civil-society actors’ digital communication beyond the mass media. Earlier studies have found that civil society is weakly represented in the European public sphere, leading to concerns about the lack of broad public engagement or citizen-level political contention. When the capacity of the (national) mass media to employ Europeanized frames and attend to transnational issues or actors is analyzed, the picture that emerges is an issue-driven European sphere in which a few issues or claim makers may reach different national media using similar frames during common periods. However, there is little civil society in this picture: claims are overwhelmingly made by elites who communicate to largely passive audiences. For example, when the European financial crisis erupted in 2010, national papers across the EU were filled with similar pronouncements from various officials, including national leaders such as German Chancellor Angela Merkel and EU officials such as the head of the European Central Bank. Civil society tends to be sketched in terms of voters in Greece or demonstrators in Spain, with few concrete authoritative claims attached. Beyond demonstrations and elections, there is little in the way of media characterizations of broader public engagement with the crisis and other policy issues that cut across both EU and national-governance processes. The question is whether civil society engagement in European public spheres is weak in itself or whether it is simply not captured in these analyses of mass-media content. We suggest that part of the answer may be the latter possibility. To analyze civil society dimensions of European public spheres, it makes sense to look beyond the mass media to the increasingly common alternative forms of public communication that civil society actors utilize.

Having transformed its hinterland to become a major exporter of agricultural commodities, Brazil has, since the mid-2000s, set up a range of South–South cooperation (SSC) initiatives to export its agri-food policies and technologies to othe countries, mainly in Latin America and sub-Saharan Africa. Both the domestic agricultural policies and SSC have been scrutinised and shaped by interactions with civil society actors, from peasant associations and trade unions to rights-based non-governmental organisations. This article explores modes of interaction and interdependence between different civil society and state actors in the context of SSC relating to food security and agricultural development. It analyses changes and continuities in civil society engagement, and mobilisation and de-mobilisation dynamics. Recently, the government’s de-prioritisation of the South–South agenda has been accompanied by very limited civil society activism. The article discusses why this needs attention and the challenges that need to be considered to reinstate productive state–civil society dynamics.

This article sketches the process of democratization in Thailand, focusing on shifting relations between civil society and state actors. Environmental discourse and conflicts about natural resources, specifically forests, during the last two decades, have been one of the main fields of social controversy and change. In the context of these controversies, civil society actors, in resistance to and alliance with state agencies, drove forward democratization by intruding into power domains of the state. State agents, increasingly forced to justify their actions according to democratic norms in the expanding space of public debate, had to search for allies and majorities within civil society. The successful establishment of public debate as an integral part of political decision making, on the one hand, resulted in a diversification of civil society, on the other hand, forced powerful segments of society to organize and defend their interests within the new public political space. Strategies of exclusion, referring to nationalism and ethnicism, have become an important instrument to secure positions and power, threatened in the process of democratization and emancipation of discriminated social groups.

Restriction of civic space is widely understood as a condition that constrains the autonomous role of civil society organizations. However, this conceptualization is delimiting. This paper explores civic space as constituted in the dynamics between civil society organizations and state actors, contributing to an emergent shift to a more processual, relational and agential understanding of civic space, involving a redefining of civil society roles by state and civil society actors acting and reacting within their everyday work. We explore the case of India. Based on 36 interviews with state and civil society actors, the paper. shows how the state marginalizes civil society through three pathways: delegitimation, displacement and repurposing. A fourth pattern, however, qualifies this marginalization: political roles for civil society continue to be sought and found, depending on situations and the specific actors involved, based on their interpretations and political advantages at stake for them. The broader significance of these findings is, first, that everyday understanding and experience of civic space may prominently revolve around changes in civil society roles. Second, these changes in roles may best be understood at the level of concrete cases of relating and political contention, doing justice to the agency of the actors involved.

Pursuing accountability under authoritarian rule: Thailand's National Human Rights Commission and community struggles for justice

Restricting NGOs: From Pushback to Accommodation

Purpose This study examines the role of a semi-state actor in developing an agrifood multi-stakeholder initiative (MSI) and its related sectoral accounting and reporting in response to the grand challenge of environmental sustainability in the agrifood industry. The paper also explores how an national environmental protection agency and environmental non-governmental organizations (NGOs) challenge the initiative’s performance. The concepts of dialogic accounting and accountability provide the theoretical framework for the study. Specifically, the study empirically assesses and extends existing theorisations of accountability-based accounting systems to the context of an MSI. Design/methodology/approach The study involved extensive documentary data collection, discussions with the semi-state staff, NGOs and sector experts, attendance at events and seminars and regular monitoring of media reports on the sector. This enabled an examination of the role of state, semi-state and civil society actors in the creation and evolution of the MSI and the related accounting and accountability processes. Findings The study finds that state, semi-state and civil society actors have diverse and often conflicting roles in addressing environmental sustainability in the agrifood sector and reveals the dynamic and complex nature of dialogic accounting and accountability in the context of an MSI. In particular, the study finds that the responsibility network around an MSI can create their own disclosures to challenge and critique an MSI’s performance and its incomplete and aspirational accounting. They can also seek to extend the accountability space beyond the MSI to include the sector as a whole and related government policy. Research limitations/implications For practitioners, NGOs and policymakers, the study illustrates the value of accounting practices and disclosures that extend beyond corporate entities. These practices and disclosures can form part of an overall process of dialogic accountability, holding a sector or part of a sector to account for their environmental impacts and highlighting deficiencies in performance. In this way, NGOs and other actors can support progress towards enhanced environmental sustainability in a sector. The study encourages accounting scholars to consider how their research can support this type of accountability and these civil society actors. Originality/value The study provides insight into the role of diverse actors including state and civil society groups in enhancing accountability for environmental sustainability. It contributes to our understanding of how a variety of actors engage within and around MSIs. It adds to the literature on sustainability accounting and accountability that comes in a form and space other than corporate reports and press releases.

Global Business and Local Struggle: Chapter 7, Key Findings

BackgroundThere are increasing calls for developing robust processes of community-based accountability as key components of health system strengthening. However, implementation of these processes have shown mixed results over time and geography. The Community Action for Health (CAH) project was introduced as part of India’s National Rural Health Mission (now National Health Mission) to strengthen community-based accountability through community monitoring and planning. In this study we trace the implementation process of this project from its piloting, implementation and abrupt termination in the South Indian state of Tamil Nadu.MethodsWe framed CAH as an innovation introduced into the health system. We use the framework on integration of innovations in complex systems developed by Atun and others. We used qualitative approaches to study the implementation. We conducted interviews among a range of individuals who were directly involved in the implementation, focusing on the policy making organizational level.ResultsWe uncover what we have termed “dissonances” and “disconnects” at the state level among individuals with key responsibility of implementation. By dissonances we refer to the diversity of perspective on the concept of community-based accountability and its perceived role. By disconnects we refer to the lack of spaces and processes for “sense-making” in a largely hierarchically functioning system. These constructs we believe contributes significantly to making sense of the initial uptake and the subsequent abrupt termination of the project.ConclusionsThis study contributes to the overall field of policy implementation, especially the phase between the emergence on the policy agenda and its incorporation into the day to day functioning of a system. It focuses on the implementation of contested interventions like community-based accountability, in Low- and Middle-income country settings undergoing transitions in governance. It highlights the importance of “problematization” a dimension not included in most currently popular frameworks to study the uptake and spread of innovations in the health system. It points not only to the importance of diverse perspectives present among individuals at different positions in the organization, but equally importantly the need for spaces and process of collective sense-making to ensure that a contested policy intervention is integrated into a complex system.