Canada has a rich history of public engagement in the health policy sector. However, current political, economic and social challenges call for critical reflection on this history, to assess whether current approaches to engaging Canadian publics are up to the task, and what adaptations or new approaches might be needed. If the persisting inequities in health systems across Canada are going to be addressed, it is imperative that those designing, developing and implementing policies find ways to reflect the needs and preferences of the communities and populations most adversely affected by these inequities in their decisions. The purpose of this special issue is to address this important topic through a series of research papers and commentaries. Our work is targeted to health policy makers across Canada who are seeking to engage with various publics on a wide array of health policy issues. We offer key insights into what more purposeful and equitable public engagement might look like, as well as common pitfalls in public engagement practices and how they can be avoided.

Introduction

Canada has a rich history of public engagement in the health policy sector. However, current political, economic and social challenges call for critical reflection on this history, to assess whether current approaches to engaging Canadian publics are up to the task, and what adaptations or new approaches might be needed.

The purpose of this special issue is to address this important topic through a series of research papers and commentaries. Our work is targeted to health policy makers across Canada – both federally and at the provincial and territorial levels – who are seeking to engage with various publics about a wide array of health policy issues relating to the governance, funding, organization and delivery of health services, programs and technologies. We offer key insights into what more purposeful and equitable public engagement might look like as well as common pitfalls in public engagement practices and how they can be avoided. If the numerous and persisting inequities in health systems across Canada are going to be addressed, it is imperative that those designing, developing and implementing policies find ways to reflect the needs and preferences of the communities and populations most adversely affected by these inequities in these decisions.

The contributions in this special issue are the culmination of a three-year Public Engagement in Health Policy (PEHP) project (hereafter “the Project”) led by an interdisciplinary team of scholars and practitioners who have wrestled with key concepts fundamental to addressing calls for more inclusive and transformative public engagement processes (Public Engagement in Health Policy Project n.d.). We have done this through descriptive, conceptual and empirical research, enhanced by opportunities for exchange with leading engagement scholars, practitioners and community partners.

In this introductory article, we present the work in the special issue and briefly describe some of our other project activities and outputs, including an equity-centred guide to public engagement resources for practitioners and community groups, a community fellowship program that supported innovative public engagement projects and a series of research fellowships that allowed an outstanding group of trainees to take a leadership role in designing and implementing various project activities. These fellowships were foundational to the Project, and so we turn to them first.

Research Fellowships, Community Leadership and Tools for Practitioners

A key aim of the Project was to build leadership and capacity in the field of public engagement in health policy. To achieve this goal, we funded six project fellowships for a mix of graduate and undergraduate students from McMaster University in Hamilton, ON. Project fellows conducted their own research activities mentored by senior faculty, while supporting the overarching objectives of the Project and learning more about public engagement. Several papers in the special issue are outputs of these activities, led by research fellows Roma Dhamanaskar, Joanna Massie and Jeonghwa You.

The Project also funded 11 fellowships to help community-based organizations conduct their own public engagement activities in the health and social care sector. Community-based organizations are uniquely poised to directly serve community needs and tackle policy problems at the local level, but they often operate with limited funds and resources. Our fellowships helped accelerate work that was already happening in community settings and prioritized front-line engagement activities that advanced the goals of inclusivity with a diverse range of populations. We see untapped potential here for relationship-building between community-based organizations, which have connections to equity-deserving groups, and policy makers looking to enhance the impact of public engagement processes on policy outcomes.¹

Throughout our work, we found that public engagement practitioners in government and community-based organizations alike were grappling with calls for more inclusive and equitable approaches to engagement. This prompted us to do an environmental scan of the resources currently available on the topic. We found many resources covering a variety of topics, ranging from defining principles and key concepts (like equity, diversity and inclusion) to making plans for equitable engagement to implementing strategies when conducting and facilitating engagement. Rather than recycling the ideas and approaches from the resources we found, we developed an equity-centred engagement guide (Ul Haq et al. 2023) that collected and organized existing resources into an actionable roadmap for engagement practitioners and those in policy advisory roles.

We discuss these non-traditional outputs here to highlight the potential for university-based research groups to conduct unique and meaningful activities that generate impact beyond convential academic research activities. Through our fellowships, we were able to directly support the next generation of engagement scholars as well as community-based organizations that are actively doing this work on the ground. Our equity-centred engagement guide (Ul Haq et al. 2023), as well as our Project blog and health policy podcast series through Matters of Engagement (2024), have helped make public engagement scholarship more accessible and disseminate our Project learnings outside academic settings and into policy making spaces.

Next, we delve more into our research contributions through this special issue.

Research Contributions

The contributions in this issue are structured around three phases of looking back, taking stock and moving forward in public engagement in Canadian health policy. The papers are intentionally diverse in their jurisdictional focus (pan-Canadian, Ontario), their form (empirical research, commentaries and oral histories), the populations they attend to (older adults, Black communities) and the issues they tackle (representation, recruitment, equity). They challenge prevailing understandings of public engagement and bring underrepresented communities to the foreground. They imagine a future for more ethical and reflexive engagement and propose public engagement as a tool for addressing ethically contentious policy problems facing Canadian health policy makers today. We hope these papers combined with our other Project outputs serve to inform discussion and debate about how more robust, equitable approaches to public engagement can strengthen current and future health policy decision making in Canada.

In the issue's lead article, Roma Dhamanaskar and colleagues trace the history and key trends in public engagement in Canadian health policy from 2000 to 2021, providing a reference point for subsequent papers (Dhamanaskar et al. 2024). From their review of more than 100 cases of government-initiated public engagement at the federal, pan-Canadian and provincial government levels, several broad trends emerge that reinforce long-standing critiques noted in the public engagement literature. Most notably, government-initiated public engagement activities were dominated by self-selection recruitment methods and feedback-style engagement, limiting opportunities for more sustained and thoughtful engagement with the public. This potentially explains another troubling finding from the review – only about 1 in 10 activities mentioned prioritizing equity-deserving populations.

The next three papers examine these critiques in greater depth. Joanna Massie and Katherine Boothe tackle the topic of recruitment for public engagement, reflecting on the Project's own public engagement workshop with community members, engagement practitioners and researchers (Massie and Boothe 2024). They echo other scholars' critiques of “recruitmentology” (Massie and Boothe 2024: 38) where disproportionate attention is given to the technical aspects of recruitment to the detriment of other factors that shape engagement, like trust, community building and power relations, and grapple with the practical challenges of applying these critiques to an actual recruitment process. They describe important trade-offs and key lessons when making decisions about recruitment that will be especially helpful for those attempting to foster inclusive and equitable engagement.

Jeonghwa You and colleagues explore the theme of representation and the role of intermediaries who are seeking to represent the interests of others, particularly those who are unable to advocate for themselves (You et al. 2024). Drawing on a set of interviews with residents or family members of residents in long-term care facilities in Ontario, this paper offers important insights about who can and should represent this group in policy making, what contributes to their legitimacy as representatives for others and how this might help to build public trust and support for policy making in a sector that relies heavily on intermediaries. Although the research was carried out in Ontario, the insights shared in this work will be relevant to other provincial and territorial jurisdictions engaged in policy development work in the long-term and community care sectors.

Rhonda C. George and Alpha Abebe centre Black communities in their exploration of how Black community leaders and advocates influenced policy before, during and since the COVID-19 pandemic, often through community-led, bottom-up initiatives (George and Abebe 2024). This challenges the prevailing narrative of top-down, government-led and formalized public engagement structures that many in the field have become familiar with, opening the door to more community-driven approaches. The paper describes the sense of responsibility and collectivist leadership approaches that Black leaders embody, allowing them to influence policy change despite structural barriers.

The last two papers in the issue look ahead to the transformative potential of public engagement. Roma Dhamanaskar and Julia Abelson propose public deliberation – a type of engagement that emphasizes sustained dialogue between members of the public – as an essential strategy for ethical policy making for medical assistance in dying (MAiD) (Dhamanaskar and Abelson 2024). They describe how Canada can use its rich history and leadership in public engagement in tandem with key lessons from other countries to engage the public about ethically complex MAiD policies.

Finally, Jamila Michener brings researchers into the fold in her description of “scholarly public engagement” (Michener 2024: 94). She calls for more reflexive and values-driven approaches to public engagement led by researchers who want to make a change in the world. She describes four pitfalls that limit the potential for transformative public engagement and brings her own lived experiences as a public engagement scholar to discuss how these pitfalls may be avoided and addressed.

This special issue is enriched by two oral histories by community leaders, Camille Orridge and Lanre Tunji-Ajayi, who share their perspectives as health advocates from and for communities that are often underrepresented in public engagement initiatives (Orridge 2024; Tunji-Ajayi 2024). Camille Orridge details her 50-year history as an advocate for Black communities and offers important lessons for designing equitable health systems through collaborative efforts. She calls for caution and reflection when using increasingly popular public engagement methods, like co-design, which may produce exclusionary effects. Lanre Tunji-Ajayi describes her advocacy for patients with sickle cell anemia, a condition that disproportionately impacts Black communities. She identifies persistence as a hallmark for success when engaging policy makers while also discussing the personal toll this can take when compounded with structural forms of anti-Black racism.

Overall, this special issue explores the potentials and pitfalls for Canadian public engagement in the health policy sector. We engage with questions that the public engagement field has been grappling with for years – inclusivity, equity, recruitment and representation. We find a sustained interest from health policy makers in engaging the public over the past 20 years; however, we also note some important deficiencies in current practices. As approaches to engaging the public continue to evolve to meet current needs, we hope that some key messages from this special issue can help shape future practices. These include moving beyond recruitment when designing inclusive engagement activities, appreciating communities that engage with policy makers outside formalized engagement structures and ensuring engagement is rooted in core values like democracy and equity. Transformation takes time; this special issues offers some next steps toward more purposeful public engagement in Canadian health policy.

Correspondence may be directed to Julia Abelson by email at abelsonj@mcmaster.ca.

Participation du public aux politiques canadiennes de la santé: rétrospective, bilan et tracé de l'avenir

Résumé

Le Canada a une longue histoire de participation du public dans le secteur des politiques de santé. Cependant, les défis politiques, économiques et sociaux actuels exigent une réflexion critique sur cette histoire afin d'évaluer si les approches actuelles pour mobiliser le public canadien sont à la hauteur de la tâche et pour savoir quelles adaptations ou nouvelles approches pourraient s'avérer nécessaires. Si on veut s'attaquer aux inégalités persistantes dans les systèmes de santé au Canada, il est impératif que ceux qui conçoivent, élaborent et mettent en œuvre les politiques puissent trouver des moyens de refléter dans leurs décisions les besoins et préférences des communautés et des populations les plus touchées par ces inégalités. Le présent numéro spécial a comme objectif d'aborder cet important sujet grâce à une série de commentaires et d'articles de recherche. Notre travail s'adresse aux décideurs canadiens en matière de santé qui cherchent à engager la discussion avec divers publics sur un large éventail d'enjeux en matière de politiques de la santé. Nous offrons des renseignements clés sur ce que pourrait être une participation plus ciblée et équitable du public, ainsi que sur les pièges courants et la façon de les éviter.

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