What ails community participation for healthcare in urban contexts in India? Examining collective action theory and practice in two Indian cities

Objective:  Participation—community action directed to obtain improved public services--remains central to renewed calls by the World Health Organization to strengthen local health services. However, in urban India, mobilizing communities for healthcare has been challenging, in contrast to apparently more robust efforts by groups to procure other public services such as water and sanitation. To explain why, this study examines factors theorized to undergird collective action at individual, community, and health system levels.

Methods: Key-informant interviews were conducted with 11 community-based and advocacy organizations involved in participatory initiatives for healthcare in two neighboring cities, Mumbai and Pune, following a review of literature documenting participation for a range of public services--water, sanitation, and healthcare—in urban India.

Findings: Preliminary analysis shows that individual incentives to participate for healthcare are overwhelmed by the routine urgency of everyday needs such as water. Community ties within ethnically diverse and unstable urban settlements are weak, but seem tractable impediments for collectives for other public services. A more fundamental challenge is the structure of the urban health system. An avid and largely unregulated private sector enables the poor to avoid under-resourced state facilities, and deflects ‘grievance’—perception of an inadequacy in need of redress--about the deficiencies of healthcare.

Conclusion: Urban contexts in India exhibit a fragility of collective demand for healthcare alongside a rapidly evolving health services market. Mobilizing urban communities for improved healthcare will require addressing popular perceptions of quality of medical care as well as wider public dialogue about the social goals of the health system.