Background: We seek to highlight why population consultations need to be promoted more strongly as a powerful means to move health reforms towards Universal Health Coverage (UHC). However, despite this increasing recognition that the “population” is the key factor of successful health planning and high-quality service delivery, there has been very little systematic reflection and only limited (international) attention brought to the idea of specifically consulting the population to improve the quality and soundness of health policies and strategies and to strengthen the national health planning process and implementation. So far, research has done little to assess the significance of population consultations for the health sector and its importance for strategic planning and implementation processes; in addition, there has been insufficient evaluation of population consultations in the health sector or health-related areas.

Discussion: We drew on ongoing programmatic work of World Health Organization (WHO) offices worldwide, as most population consultations are not well-documented. In addition, we analyzed any existing documentation available on population consultations in health. We then elaborate on the potential benefits of bringing the population’s voice into national health planning. We briefly mention the key methods used for population consultations, and we put forward recent country examples showing that population consultation is an effective way of assessing the population’s needs and expectations, and should be more widely used in strategizing health. Giving the voice to the population is a means to strengthen accountability, to reinforce commitment of policy makers, decision-makers and influencers (media, political parties, academics, etc.) to the health policy objective of UHC, and, in the specific case of donor-dependant countries, to sensitize donor engagement and alignment with national health strategies.

Conclusions: The consequence of the current low international interest for population consultations probably has the most negative effect on resource-poor countries, as this analytical oversight comes with a high price. However, a population consultation has the potential to give more benefit and added value to contexts where resources are scarce and where planning processes pose a high extra burden, and should thus be promoted among international donor agencies.

Background

Governments and institutions worldwide are progressively increasing the involvement of the population in decision-making processes, aiming at strengthening transparency, legitimacy and the quality of health planning decisions (Catt et al. 2003). Giving voice to citizens in decision-making and policy-making processes (spaces formerly exclusively reserved to appointed or elected representatives) is now seen as a critical element of good governance (Department of Economic and Social Affairs 2008). The last session of the 2015 United Nations General Assembly adopted the sustainable development goals, promoting “responsive, inclusive, participatory and representative decision-making at all levels” (United Nations Department of Economic and Social Affairs 2015).

Specifically for the health sector, the importance of people’s involvement in defining their needs, expectations and opinions to feed into national planning processes is increasingly being recognized (Cornwall and Shankland 2008). The 1978 Alma Ata declaration on Primary Health Care laid the foundation for this, explicitly highlighting the right of people to participate in health planning and implementation (Declaration of Alma-Ata et al. 1978); this right was further reaffirmed through the World Health Organization (WHO)’s World Health Report 2008, where stronger participation of patients in health policy design processes was emphasized (WHO 2008). Subsequently, the WHO explicitly made the case for “social participation” (WHO 2015a) in connection with the debate around social determinants of health (WHO Commission on Social Determinants of Health 2008). Furthermore, when dealing with health services organization, the international focus has shifted to putting people at the centre, i.e., people-centred health services (WHO 2015b). From a legal perspective, participation and consultation are cross-cutting principles embodied in international human rights treaties and are part of the human rights-based approach to health (Potts 2010; UN 2012).

However, despite this increasing recognition that the “population” is the key factor of successful health planning and high-quality service delivery, there has been very little systematic reflection and only limited (international) debate and attention brought to the idea of specifically consulting the population for improving the quality and soundness of health policies and strategies and for strengthening the national health planning process and implementation. So far, research has done little to assess the significance of a population consultation for the health sector and its importance for strategic planning and implementation processes, and there has been insufficient evaluation of population consultation in the health sector or health-related areas.

In this paper, we debate and elaborate on why population consultation needs to be promoted more strongly by introducing it as a powerful means to move health reforms towards Universal Health Coverage (UHC). We examine the potential benefits of bringing the population’s voice into national health planning and briefly elaborate on the key methods used. We put forward recent country examples, with the aim of enriching the current international debate around participatory and inclusive health planning by making the case that more attention given to population consultation in the health sector can contribute to bringing a country closer to UHC.

Discussion

What is a population consultation?

Based on a OECD definition, a population consultation is: “… a two-way flow of information, which may occur at any stage of [the health planning process], from problem identification to evaluation of existing regulation. It may be a one-stage process or … a continuing dialogue. Consultation is increasingly concerned with the objective of gathering information to facilitate the drafting of higher quality regulation” (Cohen and Arato 1994; Rodrigo and Amo 2006).

The objectives of a population consultation on health-related matters are to capture a population’s demands, opinions and expectations; improve national health strategizing and planning; and increase the health system’s responsiveness (Provincial Health Assembly in Trang Province Thailand 2014). Examples presented in this paper show that a population consultation is a unique feature in the planning process: it provides a key information source for policy makers; it increases the population’s ownership; it strengthens accountability and transparency (OECD 2015); and it reinforces monitoring and evaluation mechanisms (Jadoo et al. 2014). Thus, a population consultation complements a situation analysis, a health needs assessment and/or a health sector review, but it should not be confused with any of those. A population consultation goes beyond facts and figures and incorporates qualitative and non-expert information, such as current opinions and future expectations, on health-related matters.

Understanding the political context of a population consultation

The country examples presented in this paper show that the democratic and social set-up of countries making use of population consultations varies greatly. The interest in a population consultation is thus not necessarily tied to the type of governance or the source of legitimacy of the government. With this in mind, we highlight that the term “population” is not to be confounded with “civil society,” which is directly linked to the types and qualities of democratic social interactions (Cohen and Arato 1994; Rodrigo and Amo 2006).

That being said, even though democracy is not a direct prerequisite for population consultations, in reality, democratic countries tend to better enable successful population consultations by inherently placing greater value on the factors which provide a fertile ground for them, such as the following:

• an interest in continuous dialogue between the government, decision-makers, other stakeholders’ representatives and the population;
• accountability and transparency;
• population ownership;
• involvement of a multiplicity of stakeholders in policy making; and
• independent media coverage informing and questioning the issues and the outcome of the consultation.

Population consultation is a crucial tool on the path towards UHC

An increasing number of countries have adopted UHC as a national health sector goal (WHO 2017). However, the suggested UHC reforms usually face the huge challenge of attempting to reconcile scarce resources with the need to provide a comprehensive package of high-quality health services to the whole population. More effective health planning is thus critical, given such limited resources, to ensure that UHC is the ‘final destination’ of the health sector (Kutzin 2013). We expand in more detail below on how a consultation of the population can support UHC-oriented health planning.

One of the key features of a UHC-oriented health system is the ability to ensure good health for marginalized and vulnerable communities (Brearly et al. 2013). A population consultation is an extremely powerful means to increasing the ability of a country to assess and respond to inequities in access to healthcare as described with country examples below.

Even though health financing reforms are definitely critical to UHC, the “other” side of the UHC coin, often ignored due to its complexity, is health service delivery reforms. We argue with concrete examples that a population consultation can improve health services and service provision methods, which better enable a country to march forward towards UHC.

A population consultation can thus help policy- and decision-makers in the following different ways:

1. Increasing the effectiveness of national health planning, given limited resources, by:
   • Capturing needs, demands and expectations: Governments and ministries of health usually have high technical expertise and information and evidence on normative needs. They may, however, have limited knowledge of the expectations and demand of the population they serve. A population consultation allows for a much more comprehensive situation assessment that reflects also the demand for services and, consequently, better health planning, which is closer to people’s expectations.

   
   

   In Guinea, for example, the “Etats Généraux de la Santé” (EGS) (2014) (pre-Ebola), provided timely and necessary complementary information to the technical analysis of the health system by thematic groups, coordinated by the MoH. The EGS in Guinea brought together approximately 250 participants coming from all sections of society. The EGS did not intend to duplicate or “validate” the technical analysis, but to go beyond and complement it by bringing in other points of view and a more system-wide perspective. The EGS enabled a wide range of external stakeholders to contribute to the debate in a political and personal way, rather than in a technical way. In addition, the EGS provided a forum whereby the population could express their expectations of the health sector and produce useful recommendations to be included in the National Health Development Plan.

    
   • Going beyond the health sector: Many health sector challenges might not lie uniquely within the sphere of the health sector. A well-organized consultation provides a more holistic view of the social and economic burden the population is facing, thus encouraging the MoH to build bridges to other sectors – thereby improving the effectiveness and quality of health planning.

   
   

   The recently published report “Nothing about us without us: Citizens’ voices for women’s, children’s and adolescent’s health” on 19 countries’ citizens’ hearings recounted how citizens called for more comprehensive linkages between health and other sectors such as education, nutrition, water and sanitation (WASH), and agriculture (White Ribbon Alliance Uganda 2015).

    
   • Strengthening planning capacity: In countries with strong resource limitations, health planning capacities tend to be weak; in this case, a consultation improves the planning process and potentially makes the outcome of a situation assessment sounder.

   
   

   In Haiti, for example, a consultative workshop (which was also termed an “états généraux de la santé” – EGS) was undertaken in 2012 to prepare for a new overarching National Health Plan post-earthquake, which would serve as a reference document for the health sector (Rapport des Etats Généraux de la Santé 2012). The EGS was preceded by intense organized debate and deliberation within the 10 administrative (geographic) departments of the country. These departmental discussions were more technical in nature and were conducted mainly by external health and/or policy experts, acknowledging that MoH only may not have all the solutions to the nation’s health problems. Suggestions and proposals from the EGS helped steer the development of a new National Health Policy and a National Strategic Health Plan 2012–2022.

    
   • Enlarging the information base for decision-making: Direct responses from the population on the current health situation or on proposed decisions and reforms expand the information base for health policy making, thereby strengthening the ability of policy makers to make informed decisions, and consequently, use available resources more effectively.

   
   

   The 1999 “états généraux de la santé” in France allowed policy makers to focus on new and emerging issues, such as a patient’s right to health and youth health, which may not have gotten the same level of attention otherwise (Brücker and Caniard 1999).

    
   • Improving monitoring and evaluation: A population consultation provides essential information on the population’s opinions and expectations, which strengthen the monitoring and evaluation processes by directly linking policy decisions to the assessment of health system performance for the population.

   
   

   For example, Turkey’s health sector reform (“Health Transformation Programme” – HTP) was assessed in 2013 via a survey of almost 500 households spread across seven regions (Jadoo et al. 2014). Respondents were questioned on their views regarding the Turkish health system before and after the HTP reform. Over 75% of the respondents preferred the current health system and were more satisfied with health services now compared to that previously. The Turkish Statistics Institute’s (TURKSTAT) Life Satisfaction Survey reported 39.5% overall population satisfaction with health services in 2003, just before the launch of the HTP. In 2010, that number had dramatically increased to 73% (Turkish Statistics Institution Data base 2013). Both surveys helped lend legitimacy to the HTP and gave backing to continue with the reform.

    
   • Improving accountability: Accountability and transparency can be increased through the direct interaction and elevation of the population as a participating stakeholder.

   
   

   In Tunisia, the “dialogue societal” has pushed the government to take into account the results of the population consultation in their high-level National Health Conference in 2014, independent of government and regime changes (WHO Tunisia Country Office 2017).

    

2. To increase the ability to assess and respond to inequities in access to healthcare by:
   • Ensuring inclusiveness: A population consultation is an instrument that addresses the full social and political spectrum of a country. This opportunity of including the voice of marginalized population groups will have benefits for equitable health planning.

   
   

   In the dialogue societal programme in Tunisia, vulnerable and marginalized population groups were targeted for focus group discussions, as they did not turn up in large numbers during the regional “Citizens’ Meetings on Health.” This enabled a heightened awareness and improved buy-in from these groups for the process of health sector reform currently on-going (WHO Tunisia Country Office). The following population groups were targeted: patients living in remote areas; patients living in poor urban zones; single mothers; families living in impoverished regions; isolated senior citizens; and families living in polluted industrial areas.

    
   • Highlighting sub-national or social differences and the need for tailored and diversified approaches: A consultation enables decision-makers to better tailor policies and reforms to the needs of different sub-sections of the population and thereby improve equity among different parts of the population.

   
   

   In Thailand, National Health Assembly (NHA) resolutions helped raise the visibility of equity-related issues. For example, NHA resolutions have covered the following equity-focused topics: stateless people’s access to basic public healthcare; disabled people’s fair access to health services; well-being of informal workers; occupational health and safety of workers in industrial and service sectors; and southern regional development initiatives that may be unresponsive to the eco-culture and people’s need (NHA Resolutions available at https://en.nationalhealth.or.th/). The National Health Commission acknowledges that it is too soon to measure the achievement of NHA in improving equity; however, actions such as a Cabinet resolution in 2010 announcing that basic public healthcare, including health promotion, treatment, rehabilitation and prevention, will cover stateless people and demonstrate that the inequity problems that were raised at the NHA are being addressed. In addition, the National Disabled Commission was created in 2012 in line with the NHA 2010 resolution on the disabled. The NHA thus plays a crucial role in bringing issues of inequity to the attention of the public and decision-makers, to better tailor policies and reforms to disadvantaged and marginalized sub-sections of the population (National Health Commission Office of Thailand 2017; Department of Foreign Affairs and Trade 2013).

    
   • Empowering the population in making their voice heard: A well-organized population consultation, with methods and tools adapted to the needs and living conditions of all sections of society, can enable the consulted population to feel more comfortable in voicing their needs and expectations more confidently and freely.

   
   

   Community consultations undertaken in eight Victorian local governments (Australia) in 2008 aimed at capturing the needs and views of their citizens to be included in local policy making. The consultations tried specifically to address marginalized population groups to achieve more inclusive and representative consultation results, in addition to the general public, which is easily accessible through mainstream media and usually considered as active citizens. Results showed that consulting marginalized population groups and tailoring consultation methods to their specific needs and circumstances increased the likelihood of their participation and increased the inclusiveness of the consultations (Brackertz and Meredyth 2008).

    
   • Identifying specific needs of marginalized groups: The consultation process could be a first step in improving the sustainable involvement of marginalized and hard-to-reach population groups in policy making processes. It enables policy makers to design specific tailored policies better accepted by the full population and potentially improve the equity orientation of health systems performance.

   
   

   The NHAs in Thailand mentioned above, for example, have succeeded in involving those who are often marginalized in policy making, with subsequent improved buy-in by these very groups (Rasanathan et al. 2012).

    

3. To improve services and service provision methods by:
   • Gauging the quality of services as perceived by the population: A population consultation can give deep insights into the perceived quality and acceptance of the services provided.

   
   

   In 2012, the European Commission (EC) set up an independent and multidisciplinary “Expert Panel on Effective Ways of Investing in Health” (EXPH) to advise the EC on health system issues. Many of the EXPH expert opinions are deemed “preliminary” in nature, as they are then subject to public consultations before becoming “final.” The EXPH started its work in July 2013 and has since provided the EC with their expert opinion on a variety of topics. In 2015, the EXPH launched a public consultation on their preliminary expert opinion on “Access to health services in the European Union.” European Union citizens and stakeholders were requested to submit their comments, suggestions, views and contributions regarding specific aspects of the EXPH report. Following this public consultation, a final opinion is to be prepared by the EXPH. All comments and suggestion received through the consultation are made publicly accessible. The EXPH will comment on each submission and provide feedback and information if the submission was taken into consideration. If a submission was not taken into consideration, the EXPH will elaborate on the rationale. This process shows the careful handling of public opinion on access to health services and is exemplary in the way insights from the public on health services can be used to advise decision-making institutions like the EC (Directorate General for Health and Food Safety 2016).

    
   • Guiding policy makers in designing strategies to improve health service delivery: Policy makers can obtain a more comprehensive picture of service quality by looking at quantitative and qualitative data. Epidemiological data, when complemented by qualitative parameters elicited from a population consultation, can help better comprehend the links between service quality and health status, with more leads for service improvement strategies.

   
   

   In Uganda, a citizen petition led to a parliamentary health committee visit to the concerned district with the aim of listening more closely to citizen concerns on healthcare. The citizen feedback prompted the parliamentary health committee to actually visit the district health facilities, to see for themselves the state of the local health system. What they saw corroborated with the citizens’ assessment on healthcare quality and has led to tailored measures, which have significantly improved health service delivery in the district (White Ribbon Alliance Uganda 2015).

    

Overview of methodologies and approaches

Each methodological approach to a population consultation requires country-specific preparation that may involve evidence- and information-gathering, targeted dialogue with special population groups or a variety of other activities. The most common approaches to a population consultation include the following:

1. Face-to-face dialogue with large population sample(s)

   The essence of this approach is a large-scale, organized series of public debates. Its main characteristic is that it captures the population’s opinions and expectations through structured face-to-face debates between the organizers and the population and among citizens themselves. Its purpose is to inform the priority-setting process and/or the decision-making process. Its strength comes from the level of evidence-based technical preparation of the topics to be discussed: from a simple, short and easy-to-understand way of presenting the topics to an excellent structuring of the debates so as to lead to a clear formulation of opinions and expectations.

2. Consultative methods with invited participants from different population groups

   The two predominant types of consultative methods are the consultative meeting and the focus group.

   • Consultative meetings bring together stakeholders who are informed about, have a view on and/or are experienced in a particular area, for the purpose of voicing their opinions and assessments for a particular objective. These meetings are smaller in number than the larger face-to-face consultations mentioned above. Usually, the participants are carefully selected from different population groups to ensure adequate representativity – for example, professional associations, patient groups, district health authorities and others are typical participants of these types of gatherings. Technical experts from government, development partners and civil society are usually present as well and may provide specific technical inputs on an issue.
   • Focus group interviews are usually done with small, relatively homogeneous groups (6–12) of people with similar backgrounds and experience. The homogeneity and the much smaller size of the groups are the main differences from consultative workshops. The group interviews provide a platform to discuss a specific topic freely and interactively, with the help of a moderator. The moderator uses general guidelines and protocol such as introducing the subject, keeping the discussion flowing while using subtle probing techniques and preventing a few participants from dominating the discussions. Focus group discussions allow a more in-depth exploration of stakeholder opinions, similar or divergent points of view and judgements, as well as information on behaviours, understanding and perceptions of an initiative. They are also extremely useful for gathering information on tangible and intangible changes resulting from an initiative.
3. Survey types and survey tools with invited/selected population groups and one-on-one individual survey types and tools

   Like the face-to-face dialogue with large population samples and consultative workshops, the purpose of a survey is to capture the opinion of the population and its expectations. However, the methodology is different and leads to different results: in surveys, debates do not take place; randomly selected citizens answer questionnaires prepared by technical experts and statisticians, or answer interviews guided by professional interviewers. A multiplicity of methods exists to survey the population, with specific advantages and challenges. As these methods are extensively documented elsewhere, this paper will refrain from entering into those details (Table 1).

Conclusion

Bridging the knowledge gap: Where should research focus?

Despite the growing call for more population involvement in planning, the actual use of a consultation and its benefits for sustainable health planning needs to be further analyzed and evaluated. It is of note that much of the information we were able to access on the population consultation mentioned in this paper was via people directly involved with the process. The following documentation and academic analyses would greatly assist countries to bridge the knowledge gap:

• A sound collection of lessons learned in various contexts to feed national planning and nurture international discussions.
• An in-depth analysis on the benefits and potentials of a population consultation for strategizing in the health sector.
• An analytical framework aimed at generating generalizable conclusions, based on a good documentation and analysis of experiences.
• Increased analytical engagement in research related to priority setting and evaluation methods that explicitly include interaction with the population.

The consequence of the current low international interest for population consultations has probably the most negative effect on resource-poor countries, as this analytical oversight comes with a high price. A population consultation has the potential to give more benefit and added value to contexts where resources are scarce and where planning processes pose a high extra burden, and should thus be promoted among international donor agencies.

How can stakeholders give population consultation a more prominent and sustainable role in health policy making?

This paper has shown that a population consultation is a means to support reforms oriented towards UHC by increasing the effectiveness of national health planning, given limited resources; by increasing the ability of a country to assess and respond to inequities in access to healthcare; and by highlighting ways to improve health services quality, coverage and access. The health ministries and their national and international partners, including academics, should follow up on this and take a closer look at the use of population consultations for national health planning.

National engagement from health ministries is needed

Ministries of Health should be courageous enough to undertake population consultations on a regular basis and, if necessary, seek international support or capacity-building. Initiatives from sub-national level or from non-governmental organizations to bring a population consultation onto the table should be taken seriously by the central government.

It must be acknowledged that a population consultation does come with costs. First and foremost, domestic resources must be mobilized or earmarked for this sort of exercise. In low-income countries with high donor engagement, the international community and donors must be called upon to include population consultation in their funding areas. Donor countries and agencies that are supporting the planning process should put a strong emphasis on the benefits of population consultation processes.

Increased international support is needed

Support for a population consultation from international actors is essential. Even though donor policies are less politically driven than those during the 1980s and 1990s, there is still a tendency to decide on funding priorities outside the country context. Global Health Initiatives, often influencing countries’ priorities through funding prospects (World Health Organization 2014), would do well in supporting population consultation.

A special role for international institutions, especially WHO, would be to include the topic of population consultation stronger in debates, workshops and capacity-building mechanisms around health planning and governance and promulgate its proliferation.

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