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Authors – Sweta Dash, Shayari Nag, Pushpa V and Menaka MB In Sandeep Layout, Bengaluru, the Mahila Arogya Samiti (MAS) experimented with something simple but meaningful for effective realisation and celebration of community participation in urban health systems: organising a collective event that brings together different stakeholders including community members, frontline health workers, local leaders, The George Institute of Global Health India’s research team and their partner organisations. The idea for this celebratory event did not emerge from a formal event plan made in silos. Instead, it emerged during the MAS meeting in September where our thematic discussion was around the elements of the proposed intervention for the NIHR-COMPLUS research project aimed at strengthening how community participation in urban health systems works in practice. The George Institute’s team of researchers had synthesised findings, observations, and learnings from MAS meetings in the last 2 years, to arrive at a proposed intervention with distilled elements and a theory of change that duly reflected the realities and needs on ground. As a part of the team’s attempt to incorporate participatory approaches and centre co-production, the proposed intervention plan has been shared with MAS members in all 17 groups that the team has been working with. Two themes in particular sparked strong interest among the women. The first was building and improving interpersonal relationships between frontline health workers (FHWs) and MAS members. The second focused on ensuring stronger linkages with higher-level governance structures so that community concerns could travel upward and receive responses. As these ideas were discussed, MAS members began reflecting on their own experiences engaging with officials and health workers. The MAS group had been active in addressing issues like sanitation, drainage, and public services. As a MAS member recalled, “Because we all went and spoke at BBMP and the local leaders, the road and drainage work is in process.” Yet, there were missed opportunities and unaddressed concerns which they felt could have been sorted out with better relationships and communication mechanisms with all the relevant stakeholders. That discussion led to a practical suggestion from them to organise an event coinciding with their two-year anniversary. Their idea was to use the occasion to invite FHWs, municipal representatives, local leaders, and neighbouring MAS groups. The gathering could celebrate the group’s journey so far while also creating space to build relationships, share experiences, and strengthen connections with institutions that influence local governance and health systems. It was being planned as a platform where the MAS members can speak about their work, interact directly with stakeholders, and make their presence visible within the local governance ecosystem. In doing so, the celebration became part of the intervention itself. Rather than treating community participation as something abstract, the MAS members attempted to collaborate and create a concrete moment where relationships could be built, conversations could happen, and new linkages could emerge. As preparations moved forward, the focus remained on collective ownership. The MAS members took charge of designing the agenda, inviting guests, and coordinating logistics. With the support of our community mobiliser, Pushpa, they negotiated with the local leader to secure access to a venue for the event despite the initial opposition from the local leader. They also ironed out their own interpersonal differences and worked together to execute this event. In October, the event eventually brought together more than 80 participants from the neighbourhood and nearby areas. Representatives from the Bruhat Bengaluru Mahanagara Palike (BBMP), FHW, local leaders, and members of neighbouring MAS groups also attended the programme. Several invited guests used the platform to engage with the community. Shanthi, a BBMP representative, spoke about the importance of formally registering women’s self-help groups so they could better access government schemes. Shivakumar, a local Congress representative, spoke about the state government’s welfare schemes and encouraged women to make full use of available public services and facilities. Local leaders Munikrishnappa and Venkatesh also addressed the gathering, congratulating the MAS members for organising the event and encouraging them to continue working with local institutions. Lakshmi, the president of the MAS group from Ambedkar Colony, shared examples from her own community’s work, including efforts to address water supply issues and strengthen awareness around public health services. Manohar Yelavathi and Nisha Gulur from Sangama spoke about the role MAS groups can play in strengthening community voices within public health systems. Shayari from the George Institute for Global Health acknowledged the effort the women had put into organising the gathering and highlighted the importance of platforms where community experiences can inform decision-making processes. For the MAS members of Sandeep Layout, the event was both a celebration and an experiment in building connections. In effect, the event became part of the intervention being tested and created spaces where MAS members could meet, speak, and begin building relationships with stakeholders, making participatory governance possible. ಸಮುದಾಯದ ನೇತೃತ್ವದಲ್ಲಿ ಬದಲಾವಣೆಯ ಯೋಜನೆ: ಬೆಂಗಳೂರಿನ ಸಂದೀಪ್ ಲೇಔಟ್‌ನ MAS ಸಂಭ್ರಮಾಚರಣೆಯ ಹಿಂದಿನ ಪರಿಕಲ್ಪನೆ ಲೇಖಕರು: ಶ್ವೇತಾ ದಾಶ್, ಶಾಯರಿ ನಾಗ್, ಪುಷ್ಪ ವಿ ಮತ್ತು ಮೇನಕಾ ಎಂ.ಬಿ. ಬೆಂಗಳೂರಿನ ಸಂದೀಪ್ ಲೇಔಟ್‌ನಲ್ಲಿ, ನಗರದ ಆರೋಗ್ಯ ವ್ಯವಸ್ಥೆಯಲ್ಲಿ ಸಮುದಾಯದ ಪಾಲ್ಗೊಳ್ಳುವಿಕೆಯನ್ನು ಗುರುತಿಸಲು ಮತ್ತು ಆಚರಿಸಲು, ಅಲ್ಲಿಯ ಮಹಿಳಾ ಆರೋಗ್ಯ ಸಮಿತಿಯು (MAS) ಒಂದು ಸರಳ ಹಾಗೂ ಅರ್ಥಪೂರ್ಣ ಪ್ರಯತ್ನವನ್ನು ಮಾಡಿತು. ಇದಕ್ಕಾಗಿ ಸಮುದಾಯದ ಸದಸ್ಯರು, ಆರೋಗ್ಯ ಕಾರ್ಯಕರ್ತೆಯರು (Frontline Health Workers – FHWs), ಸ್ಥಳೀಯ ನಾಯಕರು, ಜಾರ್ಜ್ ಇನ್‌ಸ್ಟಿಟ್ಯೂಟ್ ಆಫ್ ಗ್ಲೋಬಲ್ ಹೆಲ್ತ್ ಇಂಡಿಯಾದ ಸಂಶೋಧನಾ ತಂಡ ಮತ್ತು ಅವರ ಪಾಲುದಾರ ಸಂಸ್ಥೆಗಳನ್ನು ಒಳಗೊಂಡ ಒಂದು ಸಾಮೂಹಿಕ ಕಾರ್ಯಕ್ರಮವನ್ನು ಆಯೋಜಿಸಲಾಯಿತು. ಈ ಸಂಭ್ರಮಾಚರಣೆಯ ಆಲೋಚನೆಯು ಯಾವುದೋ ಒಂದು ಮುಚ್ಚಿದ ಕೋಣೆಯಲ್ಲಿ ಸಿದ್ಧಪಡಿಸಿದ ಔಪಚಾರಿಕ ಯೋಜನೆಯಲ್ಲ. ಬದಲಾಗಿ, ಇದು ಸೆಪ್ಟೆಂಬರ್ ತಿಂಗಳ MAS ಸಭೆಯಲ್ಲಿ ಮೂಡಿಬಂದ ವಿಚಾರ. ಆ ಸಭೆಯಲ್ಲಿ ನಾವು ನಗರದ ಆರೋಗ್ಯ ವ್ಯವಸ್ಥೆಯಲ್ಲಿ ಸಮುದಾಯದ ಪಾಲ್ಗೊಳ್ಳುವಿಕೆಯನ್ನು ಪ್ರಾಯೋಗಿಕವಾಗಿ ಹೇಗೆ ಬಲಪಡಿಸಬಹುದು ಎಂಬ ಗುರಿಯನ್ನು ಹೊಂದಿರುವ ‘NIHR-COMPLUS’ ಸಂಶೋಧನಾ ಯೋಜನೆಯ ಬಗ್ಗೆ ಚರ್ಚಿಸುತ್ತಿದ್ದೆವು. ಜಾರ್ಜ್ ಇನ್‌ಸ್ಟಿಟ್ಯೂಟ್‌ನ ಸಂಶೋಧನಾ ತಂಡವು ಕಳೆದ ಎರಡು ವರ್ಷಗಳ MAS ಸಭೆಗಳ ಅನುಭವ, ಅವಲೋಕನ ಮತ್ತು ಕಲಿಕೆಗಳನ್ನು ಒಟ್ಟುಗೂಡಿಸಿ; ಇವುಗಳಿಂದ ತಿಳಿದುಬಂದ ಪ್ರಮುಖ ಅಂಶಗಳನ್ನು (Distilled elements) ಮತ್ತು ಸ್ಥಳೀಯ ವಾಸ್ತವಗಳು , ಜನರ ಅಗತ್ಯಗಳನ್ನು ಪ್ರತಿಬಿಂಬಿಸುವ ‘ಬದಲಾವಣೆಯ ಸಿದ್ಧಾಂತ’ವನ್ನು (Theory of Change) ಆಧರಿಸಿದ ಒಂದು ಸುಧಾರಣಾ ಯೋಜನೆಯನ್ನು (Intervention Plan) ಸಿದ್ಧಪಡಿಸಿತ್ತು.ಸಮುದಾಯದ ಸಹಭಾಗಿತ್ವಕ್ಕೆ ಹೆಚ್ಚಿನ ಆದ್ಯತೆ ನೀಡುವ ನಿಟ್ಟಿನಲ್ಲಿ, ಈ ಯೋಜನೆಯನ್ನು ತಂಡವು ಕೆಲಸ ಮಾಡುತ್ತಿರುವ ಎಲ್ಲಾ 17 MAS ಗುಂಪುಗಳ ಸದಸ್ಯರೊಂದಿಗೆ ಹಂಚಿಕೊಳ್ಳಲಾಗಿದೆ. ಮುಖ್ಯವಾಗಿ ಎರಡು ವಿಷಯಗಳು ಮಹಿಳೆಯರಲ್ಲಿ ಹೆಚ್ಚಿನ ಆಸಕ್ತಿ ಮೂಡಿಸಿದವು. ಮೊದಲನೆಯದು, ಆರೋಗ್ಯ ಕಾರ್ಯಕರ್ತೆಯರು (FHWs) ಮತ್ತು MAS ಸದಸ್ಯರ ನಡುವಿನ ಪರಸ್ಪರ ಸಂಬಂಧವನ್ನು ಬೆಳೆಸುವುದು ಹಾಗೂ ಸುಧಾರಿಸುವುದು. ಎರಡನೆಯದಾಗಿ, ಉನ್ನತ ಮಟ್ಟದ ಆಡಳಿತ ವ್ಯವಸ್ಥೆಗಳೊಂದಿಗೆ ಬಲವಾದ ಸಂಪರ್ಕವನ್ನು ಹೊಂದುವುದು; ಇದರಿಂದ ಸಮುದಾಯದ ಸಮಸ್ಯೆಗಳು ಮೇಲಧಿಕಾರಿಗಳ ಗಮನಕ್ಕೆ ತಲುಪಿ, ಸೂಕ್ತ

Authors: Pushpa V, Sweta Dash, Shayari Nag, Jith JR As a research team that had just started working with Mahila Aarogya Samitis (MAS) to strengthen community participation in the urban health system in Bengaluru, we realised the pertinent need for better relationships between the community members and the frontline health workers like the Accredited Social Health Activist (ASHA). On one hand, our MAS members expressed the lack of awareness about the roles and responsibilities of ASHAs and said they did not have access to proper information channels to understand and claim entitlements with their support. On the other hand, the ASHA workers shared how they are overworked and overburdened with increasing workloads, and said they felt demotivated because the community members were not cooperative enough with them.  On a hot summer afternoon in June 2024, with our partner organisation in Bengaluru, Sangama, we organised a meeting with 13 ASHAs. This meeting was intended to allow open and honest dialogues between the MAS members and the ASHAs. In the process, we realised, all over again, that the ASHAs form the backbone of community health but are not even recognised as ‘workers” in the eyes of the State. Who is the ASHA?  In 2005, community health workers employed by the Ministry of Health and Family Welfare (MoHFW) of India were recognised as the ASHAs with the idea that they would act as the bridge between the marginalised population and the health care system. One ASHA is expected to cater to every 1000 and 2000 people in rural and urban areas, respectively. In Karnataka, ASHAs were recruited and trained under the health department from 2008-09. According to the National Health Mission, Karnataka, over 40,000 ASHAs work in the state. According to the National Health Mission, the role of the ASHAs includes, but is not limited to, “promoting universal immunization, referral and escort services for Reproductive & Child Health (RCH) and other healthcare programmes, and construction of household toilets”; “create awareness on health and its social determinants and mobilise the community towards local health planning and increased utilisation and accountability of the existing health services”; promote good health practices and provide a minimum package of curative care; “provide information to the community on determinants of health such as nutrition, basic sanitation & hygienic practices, healthy living and working conditions, information on existing health services and the need for timely utilisation of health & family welfare services”; “counsel women on birth preparedness, importance of safe delivery, breast-feeding and complementary feeding, immunisation, contraception and prevention of common infections including Reproductive Tract Infection/Sexually Transmitted Infections (RTIs/STIs) and care of the young child.” Importantly, the ASHAs are selected from the same marginalised communities that they serve. An ASHA emerges from these disadvantaged areas as a woman who not only serves her family but also raises her voice on behalf of the community.  Not an Easy Task ASHAs are the first point of contact for healthcare for the marginalised communities in rural and urban areas. The medical personnel from the Primary Health Centers (PHC), for instance, rarely leave their workplaces to visit the communities to raise health awareness and provide health services such as immunisation drives. It is the ASHAs who eventually handle the cumbersome task of keeping stock of identification of mothers and children, tracking logistics, bringing children and women to the PHC, fetching the necessary vaccines, and ensuring online and manual data entry. In our work in Bengaluru, we realised that the responsibility of the MAS is also on the ASHAs. They are expected to form the groups for the women to have a space to discuss their problems, find solutions, and raise their voices. In doing so, these ASHAs facilitate a safe space for the women where the topics that were once considered ‘private’ and ‘individual’ get to be heard and discussed collectively. Thereafter, the ASHAs convey the discussions to the PHC as per their reporting templates, and follow up with medical staff to escalate matters to other appropriate levels for resolution as deemed fit. None of this is an easy task, especially considering the paltry honorarium of Rs 5000 per month. Many of these ASHAs are the primary or at least the most significant breadwinner of their households. And, given the cost of living in urban settings, it is difficult to sustain with this amount.   Overburdened and Unheard The ASHAs have seen a dramatic rise in workload since the National Rural Health Mission’s launch in 2005. Originally expected to work just two hours a day, ASHAs now handle extensive responsibilities, from maternal and child health services to vaccination drives and data collection, to learning palliative care, reporting domestic violence cases, providing mental health support, and more. Despite their essential role, they are overworked and often expected to function without rest. The relentless nature of their work takes a severe toll. Many ASHAs report exhaustion, inadequate food intake, and chronic sleep deprivation. A survey conducted during the COVID-19 pandemic in Phanda block of Bhopal found 13% of ASHAs go without food during work hours, while nearly half reported insufficient sleep and rest. This overexertion not only harms their health but also diminishes the quality of healthcare they provide.  Systemic challenges compound their burden. ASHAs frequently face caste- and gender-based discrimination, along with mistreatment from superiors. Some are denied entry into households due to caste bias, while others endure derogatory remarks when interacting with the male community members. Some of them reported that they find it challenging to raise their voice or advocate for better implementation of rules and policies because they fear they will be met with the threat of termination. These experiences contribute to mental stress and an unsupportive work environment. When asked why they chose this profession, many of them answered that it was due to poverty.  Their husbands often did not work, leaving them to take responsibility for the household expenses and care work. They asked, “If the government ignored those who served society, how were they supposed to survive?” They further

COMPLUS undertakes a range of study activities including landscape analysis, in-depth qualitative research, and tracking of selected indicators from available secondary data, to investigate the implementation of the intervention across the three country contexts emerging from the research, and their linkages with outcomes. It employs use of ‘tracers’, which are specific service delivery areas of importance that can be used as examples to guide and allow investigators to focus their inquiry on tangible outcomes. We are using Tuberculosis and Non-Communicable diseases (diabetes) as tracers to study different types of aspects of utilisation and responsiveness of health services.