ABSTRACT:
Community participation (CP) is widely recognised as a cornerstone of responsive and accountable health systems. However, in practice, health systems often operate with and rely on dominant epistemologies of technical rationality and/or clinical objectivity, leaving little room for the lived-experience-based knowledge and emerging felt needs of marginalised communities. Consequently, efforts to engage with marginalised communities through CP mechanisms are often implemented in a top-down manner, with limited spaces for community voices to fit into, often only within pre-approved templates. Our work with Mahlia Arogya Samitis (MAS) - Women's Health Committees - in Bengaluru attempts to adopt an approach that centres the community voices to develop a ground-up intervention. The study employed sustained engagement and focused observation, including participant observation of MAS meetings, in-depth interviews with MAS members, frontline health workers (ASHAs, AWWs), and civil society actors, alongside iterative stakeholder dialogues. Observations and reflections were systematically documented using a structured “thinking table,” enabling collective sense-making across all actors. Emerging findings were distilled into potential intervention elements. These were further refined by analysing overlaps, resulting in 9 core elements. For each element, a theory of change was developed, stakeholders were mapped, and components were reorganised into a phased intervention design. The intervention elements the co-production process resulted in include: building trust and interpersonal relationships; challenging gendered expectations of participation; addressing sexual and reproductive health concerns including gender-based violence; bridging information gaps in navigating urban health systems; enabling community-led agenda setting; ensuring flexibility to address non-health grievances; addressing communication and language barriers; establishing feedback loops with higher-level governance; and securing accessible physical spaces for participation. This paper contributes methodological insights on operationalising co-production as an ethical imperative and offers practical lessons for designing bottom-up, contextually grounded interventions that strengthen community voice and accountability in urban health systems.