• Stakeholder participation

Stakeholder participation

This paper discusses how to improve equity in health systems. In particular, it argues that social dimensions such as social networking, participation and governance are critical factors for vertical equity in health systems. Produced by EQUINET, the paper mainly draws from research work carried out in Zimbabwe, the conclusion from an EQUINET/TARSC/WHO/IDRC South African regional meeting on public participation in health, as well as from published literature.

The paper identifies three social dimensions that have a positive impact on equity in health systems: social networking, participation and governance. It discusses current issues relating to all these dimensions, namely the lack of access to social networks for the most destitute; the ambiguities surrounding different levels of participation; and the lack of a clear legal framework, information exchange or basic training in negotiation skills for good governance. It proposes measures to address these issues so as to enhance the social dimension of equity.

After establishing the importance of each of the three social dimensions in promoting vertical equity in health, the paper finds that:

• existing social networks such as churches, women’s organisations or residents’ associations should be extended so as to increase access for those with the greatest health needs (that is, the poorest and most vulnerable)

• levels of participation in health remain poor, especially when issues of financing and/or monitoring are being discussed

• certain measures such as user fees or cost-recovery policies aimed at increasing efficiency and equity in health systems have failed to deliver and have in fact had a negative impact on equity

• decentralisation, although designed to improve good governance in health systems through increased accountability and participation, has failed to deliver because it has not been substantiated by an adequate deployment of resources, or appropriate levels of training, and lacks a clear legal framework

• accountability at local level has come to be seen as a burden rather than an opportunity.

To address the above shortcomings of the social dimension to equity in health, the paper recommends:

• better networking to increase solidarity between various groups, and the extension of networking to include wider development or poverty reduction programmes dealing with health-related issues such as employment

• strengthening structures for participation, for instance via the representation of elected officials, civil groups, traditional elders and health professionals in meetings, and regular reviews, training and monitoring

• deploying resources to clearly define the legal frameworks for decentralisation

• facilitating a better exchange of information between communities, and between communities and health systems, and including community information in the design of policy

• giving people better access to participation through the building of their capacity to take part. Giving people a “chance” to participate can indeed end up being seen as lip service if more efforts are not made to enhance their ability to participate through training in negotiation, facilitation and general communication skills.

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