A river, frontline families, and the double-edged sword of community participation: how nutrition interventions are shaped at the village level in Dhubri, India

This paper explores how top-down health interventions engage with and reshape communities at the village level, focusing on nutrition interventions as tracers to examine the functioning of local health systems. Drawing on 28 in-depth interviews and 6 focus group discussions conducted in Dhubri district, Assam, the study investigates how such interventions are delivered through a health system constituted of both formal structures and informal arrangements, deeply influenced by the ecology of the Brahmaputra River. Using an exploratory qualitative approach, the study surfaces five key themes. First, seasonal disruptions linked to the river significantly affect service continuity, revealing the inadequacy of existing policies to respond to environmental vulnerability. Second, the creation of 'frontline families'-where the personal lives and unpaid labour of frontline health workers' households are drawn into service delivery-reflects systemic dependence on invisible support. Third, community participation emerges as a double-edged sword, simultaneously enabling programme reach and generating unrealistic demands and burdens on frontline actors. Fourth, informal spaces and interpersonal relationships underpin much of the operational success of interventions, compensating for gaps in formal governance and infrastructure. Finally, symbolic campaigns, detached from local material realities, often foster alienation rather than awareness. The findings call for a rethinking of intervention design and delivery that take account of embedded social, ecological, and institutional realities. The paper argues that building just and sustainable health systems requires recognising and supporting the informal, relational, and contextual dimensions that currently remain overlooked in dominant policy frameworks.