Community Action for Health in India's National Rural Health Mission: One policy, many paths

•Community based accountability was a key aspect of the National Health Mission in India.•Following a centrally sponsored pilot the state governments took diverse paths.•Divergences were due to changing opportunity structures and balance of forces.•Divergences were due to agreement on some but not all key components of interventions.•Trust played a role in helping go beyond entrenched institutional perspectives.

Community participation as a strategy for health system strengthening and accountability is an almost ubiquitous policy prescription. In 2005, with the election of a new Government in India, the National Rural Health Mission was launched. This was aimed at 'architectural correction' of the health care system, and enshrined 'communitization' as one of its pillars. The mission also provided unique policy spaces and opportunity structures that enabled civil society groups to attempt to bring on to the policy agenda as well as implement a more collective action and social justice based approach to community based accountability. Despite receiving a lot of support and funding from the central ministry in the pilot phase, the subsequent roll out of the process, led in the post-pilot phase by the individual state governments, showed very varied outcomes. This paper using both documentary and interview based data is the first study to document the roll out of this ambitious process. Looking critically at what varied and why, the paper attempts to derive lessons for future implementation of such contested concepts.