“Sandwich strategies” are interactive processes in which reformers in government take tangible measures that reduce the risks of citizen action from below, driving virtuous circles of mutual empowerment between pro-accountability actors in state and society. This case study is one of a set of 18 published here, which are among those included in comparative analyses of whether and how sandwich strategy initiatives drive institutional change.

In 2000, the creation of the new Indian state of Chhattisgarh triggered a reformist bureaucrat in the health department to provide financial, technical, and social support to organize women from marginalized groups to secure their rights to healthcare. This case study documents the government-run Mitanin program, which created a semi-autonomous agency to use an activist approach to support and train elected community women volunteers (Mitanins) from socially excluded groups.

These Mitanins numbered almost 70,000, covering almost all of the rural hamlets in the state. In coordination with the support agency, Mitanins consistently adopted roles that went far beyond health program-specific interventions, raising awareness on rights to food, nutrition, and employment; forest rights; and about violence against women.

The case study discusses the con­tributing factors that led to the development of the Mitanin program, and the strategies used by state and civil society actors to design and implement pro-poor health policy reform and mobilize collective action to strengthen public health systems. It describes how state and civil society actors used openings from above and learned from existing community health worker experiences to include disenfranchised social groups, and promote mutually reinforcing interactions between state and civil society.