Improving policy responsiveness through participatory spaces

This article is written by Lara Brearley, Dheepa Rajan, Charlotte Poulussen, Katja Rohrer-Herold and Kira Koch – World Health Organization.

• The problem: Whilst all governments have endorsed the principle of participation, implementation remains insufficient.
• Why it matters: Social participation, which entails bringing in people’s voices into policymaking and decision-making processes, can make health policies and programmes more responsive to the needs and lived experiences of vulnerable communities, whilst also promoting trust, transparency and accountability.
• The solution: As laid out in the WHO Handbook on social participation for Universal Health Coverage, there are clear steps that all countries can take to move towards institutionalising social participation in decision-making processes.

The Covid-19 crisis has exposed the fragility of the population’s trust in government at a time when public health has perhaps never been a more popular agenda. Lack of trust affects the success of public policies from adherence to virus suppression measures and confidence in officially published Coronavirus statistics, to vaccine uptake. It demonstrates the disconnect between those who make decisions and those for whom decisions are made.

This article focuses on a key reason for this disconnect: the routine absence of people’s voices in health decision-making processes. There are clear actions government can take to address this:

1. Investing adequate, stable and predictable financial resources for participation

Without stable funding, participatory mechanisms are likely to be more ad-hoc and peripheral to the health system modus operandi. Funding shortfalls can also lead to an over-reliance on volunteers or intermediaries whose interests may not always align with public health goals. These characteristics – of being stable and predictable – are perhaps more important than high levels of budget allocation to social participation.

There are various ways to protect and sustain funding for social participation – for instance, through legal endorsement or earmarked funding. In Thailand, for instance, the statutory nature of the National Health Commission Office (NHCO) – a publicly funded parastatal body, mandated to implement the National Health Assembly (NHA) each year – ensures the stable allocation of funding. Revenue for ThaiHealth – the health promotion foundation – comes from a 2% surcharge of excise taxes on tobacco and alcohol, which makes it less susceptible to waning political support. ThaiHealth supports civil society organisations with core funding for health promotion activities.

Ministries of Health may have an important role in funding community and civil society’s participation and resourcing and/or facilitating capacity strengthening for meaningful involvement. This may require leveraging legal provisions for civil society to receive funding or advocating for these to exist in their absence.

2. Building government capacities to design and implement meaningful participation and facilitating the capacity strengthening of participants

Regular and systematised participatory interaction can only come about when there is adequate government capacity to convene, communicate and listen. While most government health institutions are well-endowed with medico-technical skills, they often lack the expertise necessary to design and manage a participatory space that fosters meaningful participation. This task is not as simple as it may seem – see the table below for some of the design considerations for which capacities must be built:

Specific skills are also required for ensuring that participation influences the decisions made. This includes linking participatory processes with the right decision-making authority, framing the policy question so that it addresses policymaker concerns, and ensuring that participants are seen as legitimate. Capacities need to be built and maintained, particularly in light of staff turnover.

Governments hold a critical role in facilitating and/or funding the capacity strengthening of populations, communities and civil society to legitimately represent their constituencies, build coalitions and effectively interact with governments on an equal level. Such activities should be “owned” by the communities themselves.

3. Establishing and/or strengthening mechanisms for sustained regular participation as opposed to ad-hoc interaction

Opportunities for regular interaction help foster a culture of participation through a deeper understanding of how to dialogue and how to find solutions; they allow relationships to be built on mutual respect and understanding to be strengthened.

Governments can move towards more regularised participatory engagement over time through a variety of strategic and synergistic actions. These include:

• Building long-term partnerships with civil society and community groups

• Securing legal and/or institutional frameworks to sustain social participation

• Providing protected time within policy processes for adequate engagement as well as for evaluating participation to learn and improve.

Legislative frameworks that mandate a specific public entity to implement social participation mechanisms can facilitate regular and sustained engagement over time (although they may not be strictly necessary or immediately possible in all settings). For example, the National Health Council in Portugal and the Consultative National Committee on Bioethics in France are backed by legal provisions. Health ministries have a role in advocating for and shaping such legislation. Key considerations for legislative frameworks include:

• Representation and selection processes

• Roles and responsibilities in participatory spaces

• Funding modalities

Ideally, all three aspects should be addressed concomitantly to ensure meaningful participation.

4. Monitoring and using data routinely

What gets measured, gets done – the implementation of participatory spaces, but also the quality of how they are implemented, and crucially, their impact on the health policy and planning decisions that are made. These metrics should be integrated into existing monitoring systems where possible to reduce the burden on health ministries, and considered in national sector review processes to secure political attention.

We want to hear from you

Various countries are pursuing a World Health Assembly resolution to secure political commitment to social participation. WHO has drafted a Technical Background Paper – based on the Handbook – for stakeholder consultation, to inform Member State priorities to institutionalise social participation in health decision-making processes. Please complete this survey on whether the Technical Background Paper aligns with your expertise and country experiences. Thank you.

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