World Health & Population
Public health consultations are a fundamental part of public health policy design and implementation. However, one cannot assume that these consultations will automatically be inclusive, that their inputs will indeed influence policy makers, and that this will lead to progress towards UHC. Assessing how public consultations can be more inclusive and influential for stronger results needs to be part of the consultation design. This commentary offers some suggestions on how to do so.
The milestone Alma-Ata Declaration of 1978 with its pledge of “Health for All” noted that “people have a right and duty to participate individually and collectively in the planning and implementation of their health care.”1 Nearly 40 years later, the lead paper titled “Population consultation on needs and expectations” in the WHO-published handbook for strategizing national health in the 21st century reminds us of the importance of this, and it focuses on the ways populations can be consulted both in planning and implementation for Universal Health Care (UHC).
The lead paper presents an overview of different population consultation methods (Rohrer et al. 2017), with some brief snapshots of a wide range of recently conducted consultations for health planning and implementation. Evidence of the effect of consultations on the decision-making process or the implementation stage is anecdotal. However, the variety of examples shows that, in many different contexts, consultations did succeed in raising awareness of issues that were not central to the discussion before, and engaged a broad range of stakeholders, including vulnerable groups, in health discussions.
Rohrer, Rajan and Schmets (2017) note that consultations can be relevant at different points in policy development or a program cycle, whether it is to improve planning, mid-term course correction or impact evaluations. Various purposes can be prioritized, such as getting vital information from excluded and vulnerable social groups at the planning stage or focusing on using citizen feedback for monitoring, evaluating and making public health programs accountable.
The Tunisia case is particularly interesting, with the Societal Dialogue launched in 2012 as a combined effort by the government, international partners and different sections of the media (TV, regional radio, print media) to mobilize people to participate in the first-ever citizens’ meetings on health.
This lead paper (Rohrer et al. 2017) is a useful introduction to the consultation process in health for those in the ministries of health or in NGOs who are interested in learning what such processes entail and what they can bring.
What it lacks is a frame for assessing under which circumstances consultations will be the most effective in bringing in a broad range of perspectives and influencing public health programs towards universal health coverage.
To do so, we need to challenge a few assumptions that are implicit in the paper. In fact, although many examples provided in Rohrer et al. (2017). are fascinating and even convincing, they do not go beyond anecdotal evidence in showing that (1) consultations succeed in reaching out to a broad range of stakeholders, representing various views and groups; (2) stakeholders’ inputs were taken into account by policy makers and the inputs did inf luence policy and/or implementation beyond a statement of intent; (3) this led to progress towards UHC; and (4) the population was aware of this and satisfied with the process.
Political economy considerations of stakeholder management can often be a motivational driver of consultative processes in practice, aimed at building a support base for a particular reform measure. Although it is important that the consultation be seen as unbiased, if it is to be effective and credible, it is equally often the reality that there are existing (or perceived) biases and incentives driving consultations. The lead paper takes an apolitical stand in giving the guidance to make explicit from the beginning that stakeholders should not attempt to influence the process of the consultation. In reality, stakeholders are bound to be driven by their interests, incentives and preferences.2
In a 2015 publication, we unpack the drivers of citizen action and state action relevant for effective social accountability, highlighting also the important role of information, civic mobilization and the nature of the citizen– state interface (Grandvoinnet et al. 2015). Figure 1 has some relevance to further understand when and why population consultations have shown results for public health in specific cases, and why often not as well, and we will use some of its findings to discuss three key questions below.
What Will Make the State Engage in Consultations and use their Conclusions?
First, we need to acknowledge and address government apprehensions that consultations become more a forum for criticisms of well-known failures of health systems, rather than the normative ideal that the lead paper highlights. In this case, the state might just choose not to engage in any form of consultations.
Second, assuming consultations do take place, the quality of the consultation will matter, and this is closely linked with the attitudes of officials towards a consultative process and the shifts in mindsets of officials required for a productive engagement. How can beliefs and incentives be changed such that an engagement is not perceived as an imbalanced one between the powerful state officials or the educated elite on the one hand, and a vulnerable “hard-to-reach” population on the other?
Third, a consultative process requires a wider enabling ecosystem to ensure that citizens’ inputs are taken into account and that there is feedback to citizens as to how their inputs were taken into account (and if not, why) following consultative processes. Experience suggests this is where implementation has been the weakest. Rohrer et al. (2017) indicate that such follow-up is important; what is as relevant is to discuss the various reasons why such follow-up does not happen. More guidance is needed on mitigating against such risks, by unpacking the reasons that explain lack of responsiveness from the state (whether it is linked to a choice of priorities, capacity, incentives, etc.).
Figure 1. Unpacking the drivers of citizen action and state action for effective social accountability
Fourth, the nature of the interface for the consultations can be critical in determining the credibility of the consultative process, including the role of interlocutors. In an interesting case of discussions that the China, Hong Kong SAR initiated on a Health Protection Scheme, the lead paper further observes that a public consultation can end up going in unexpected directions. Although the need for consultations is evident again in this case, we need to still better understand why governments or other initiators of consultations (including NGOs and donors) can be more open to such unexpected directions that consultations can foster.
What will Motivate Citizen Action, and in this Case, What Will Make Citizens Participate in Consultations?
If the main motivating aim of a population consultation is to draw upon the population’s expectations and demands, we need to be sure our assumptions that (1) citizens care; (2)citizens are informed; and (3) citizens can inform the specific areas of health service planning, beyond known generalities all hold in the particular country/local context and on the focal issue. Processes beyond a consultation are needed, aimed at information and civic mobilization, to raise awareness and salience of health-related issues among citizens, build citizen trust and their efficacy to effect policy or a program. It is important that we build our knowledge base of why consultations have failed or succeeded, not because of the consultation method alone (i.e., focus group or survey), but because of these additional activities to stimulate meaningful citizen action.
We know that accessibility of information is crucial (and accessibility needs to cater to different audiences), as well as its frame and trustworthiness of the provider of the information. This will mean different things for information inciting people to participate in consultations or for information provided during such consultations. One interesting avenue for research is how to embed the use of new information and communication technology (ICT) in such consultations to broaden their reach and make them more agile.
We also know that two critical factors will matter for citizens to engage with the state: (1) the nature of the interface (and whether the consultation platform is perceived as credible and accessible), and (2) the existence and quality of interlocutors that mediate the consultation.
Finally, yet importantly, most consultations will involve some form of mediation by civil society organizations. Understanding their interests and viewpoints on some of the issues up for debate will be important, as well as their weight in the dialogue, to ensure that consultations are not captured by a narrow group of organizations with very specific interests that could be at odds with public interest.
Assumptions that those participating do not genuinely represent or appreciate the collective interest of the population may remain relevant, if a population consultation is not universal in coverage or adequately targeted to cover the heterogeneity of ethnicities, religion, gender, income and age. Rohrer et al. (2017) are correct to prioritize consultations with the excluded and marginalized; it is worth noting that it is precisely such consultations that might require additional efforts and costs.
Will Consultations always Lead to Better UHC?
Rohrer et al. (2017) seem to assume that asking a broad range of stakeholders their viewpoint on universal health coverage would bring more weight to this effort. This may not automatically be the case, for the following reasons.
At the planning stage, much will depend on the view over UHC in the consulted population. Although one might assume a universal desire to get access to quality healthcare, discussions might become more heated if issues such as financing of such healthcare come into play, or financing of particular needs that may be at odds with specific beliefs (support to the fact-based evidence of the benefits of family planning might be opposed, for instance, on religious grounds).
In the implementation stage, although identifying gaps and inefficiencies is a crucial first step, it stops short of solving them. When ignorance of such gaps and inefficiencies is the main impediment to progress, consultations may have a direct beneficial impact on UHC. In cases where inefficiencies are also linked to capacity, incentives or beliefs, the link will be much less straightforward.
The population needs to have a say in health. Consultations can be a supportive element for this, but these need to focus, in each particular case, on specific objectives and how to support a constructive process that will lead to meaningful progress for UHC.
A follow-up to the WHO Handbook lead paper could take up more examples of population consultations in health, looking at the practical challenges of citizen commitment and awareness to engage, and the types of costs and incentives on the part of the initiators of the consultation, to discuss how to best use this instrument to support UHC. Although the lead paper concludes that consultation “will always have positive effects on the interaction between policy makers and the population,” we are likely to find in practice that there are cases where such consultations can raise expectations of the participating population that are not fulfilled, or be perceived as not inclusive by sections of society, creating more harm than good. How to avoid such occurrences is part of the goal.
- Declaration of Alma-Ata, 1978; <https://www.who.int/publications/ almaata_declaration_en.pdf?ua=1>.
- The importance of interests, preferences and incentives is discussed most recently in the World Development Report 2017: Governance and the Law. Washington, DC: World Bank.
About the Author(s)
Shomikho Raha, Senior Public Sector Specialist, World Bank*, Washington, DC
Helene Grandvoinnet, Lead Governance Specialist, World Bank*, Washington, DC
Correspondence may be directed to: Helene Grandvoinnet; E-mail: firstname.lastname@example.org
Shomikho Raha; E-mail: email@example.com
Grandvoinnet, H.M., G. Aslam and S. Raha. 2015. Opening the Black Box: The Contextual Drivers of Social Accountability. New Frontiers of Social Policy. Washington, DC: World Bank.
Rohrer, K., D. Rajan and G. Schmets. 2017. “Population Consultation: A Powerful Means to Ensure that Health Strategies are Oriented Towards Universal Health Coverage.” World Health & Population 17(2): 5–15. doi:10.12927/ whp.2017.25157.
Footnotes*Any views expressed in this commentary are the views of the authors and do not represent the views of the World Bank group.
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