Community Voices in Health Governance - Translating Public Participation Into Practice in a World of Pluralistic Health System

The overarching research question is “How community participation, framed as a human right, can facilitate the promotion of population health and wellbeing in pluralistic health systems?” In this proposal pluralistic health systems refer to the presence of state and non-state actors providing public health care. Private sector providers in plural systems are generally regulated through contractual arrangements by the state and through professional regulatory standards and private quality assurance systems, rather than directly through human rights law, which applies to State duties to their citizens. This poses a health system design question. If States, to whatever extent they can or do, comply with their human rights obligations to ensure meaningful social participation in health, how then, do they negotiate extending the purview of such systems to non-state providers? Participation and pluralization grew in the 1990’s across Brazil and India and more recently in South Africa, being currently embedded in their public health care system. Both share the promise of promoting access, quality, and efficiency, but their proposed strategies to achieve these aims prioritize different actions. The former stresses the importance of democratizing the policy process, while the later stresses the importance of improving managerial capacities. For us, both strategies have strengths and may come to reinforce each other. Finding adequate mechanisms to bring them closer will represent a decisive contribution to strengthen both community participation - as it would have a clearer mandate in the implementation process-, and the contracting process - as communities’ views, needs and perceptions of health service adequacy would be more adequately incorporated into contracts. Case studies were selected in 4 highly unequal urban settings in Brazil, India and South Africa. Relying on an actor-centred implementation analysis and complex adaptive systems approaches, researchers will work to understand the contexts and identify the mechanisms that impede or facilitate intensified community engagement in pluralized health systems aimed towards UHSs. In year 1, it is planned to collect and generate evidence across the three countries on the policy context. The focus will rely on both urban health committees and other “claimed spaces”, and the processes of evaluating and contracting public health care providers. This mapping together with the development of collaborative partnerships should allow the recognition of opportunities for strengthening community participation in the policy cycle. In years 2 and 3 it is planned to co-develop, test, and implement participatory approaches pilots to empower community voice in the policy cycle. In years 3 and 4, activities of capacity building and evaluation of the implemented pilots will happen. In year 4, it is planned to compare, synthesize and disseminate findings. As outcomes it is expected to generate structured and meaningful opportunities for communities to voice their input to decision-making in plural health systems. Services will be more accountable to citizen needs, helping to promote positive health outcomes and reduced health and social inequalities. Service providers will be supported to facilitate rather than feel threatened by community participation. A culture of using health research to strengthen health system accountability and responsiveness will be strengthened.