Community Voices in Health Governance - Translating Public Participation Into Practice in a World of Pluralistic Health System
Department of Health and Social Care
University of Cape Town
India, Brazil and South Africa are countries with public health care systems, that assure some space, even if nominal, for citizen participation in its daily routines. This proposal focuses on ongoing changes in these systems, which increasingly rely on new ways of combining public and private provision, calling attention to the actual and potential role of institutionalized channels for public participation in contributing to system effectiveness. The central argument relies on the role of citizen participation in fostering the alignment of bureaucracies, politicians and health professionals around the goals of improving population health and wellbeing. The research program will produce a better understanding concerning: a) How citizen participation is working in these systems; b) How is it adapting to ongoing changes; c) What is needed in term of resources, institutional design, community involvement and public officials training to fulfill its potential contribution.   Since the 2000’s, large cities in these countries began to expand access to health care based on models of purchasing public health care. These experiences are growing, with private and philanthropic providers hired to manage public facilities and deliver public services. There is preliminary evidence suggesting that under certain conditions these experiences are contributing to a quick expansion and improved access to care in peripheral and poor areas of big cities (Coelho et al 2019, Seem, & NandraJ 2021, Schütz 2020).  Despite these initial positive results there is widespread resistance to this modality of pluralistic service provision, based on the idea that it introduces a private logic in the public system (England 2004; Witter et al 2012). Reynolds (2018) also caution that public servants lack the skills or experience to negotiate such contracts and that “unless substantial capacity is developed and mechanisms for monitoring — including by local health committees — established, the potential for dysfunctionality and fraud is great.”  From our perspective, pluralistic modalities of public service provision may contribute to the improvement of public administration agility, but at the same time may create a coalition between state and private actors to the detriment of population health interests. For us, the strengthening of the public health care system in LMIC countries will need to address deficiencies related to the six building blocks of the WHO model: infrastructure, human resources, technology, medicines, financial resources, and evaluation systems and will be facilitated once community governance mechanisms crosscut all the building blocks providing glue to ensure community voice is harnessed for health system responsiveness to citizens needs and equity.  In this scenario, we propose a multi country study focused on mapping and improving the state of community participation mechanisms in selected districts in the cities of Mumbai, Bengaluru, São Paulo, Fortaleza, Gqebhera and Cape Town, where pluralistic models of managing and providing services are either in place or in the making. This research seeks to understand the crucial role community participation can play in pluralistic health systems and how it could strengthen and enhance Universal Health System, helping to create an accountable health system with democratic governance. It seeks to identify a model for effective and meaningful participation within the pluralistic health system.
8.1 Organisation and delivery of services / GHPSR