Assessing the interactions of people and policy-makers in social participation for health: an inventory of participatory governance measures from a rapid systematic literature review.

Social participation, also termed stakeholder voice, is an important component of health system governance. Increased interactions between the community and policy makers could facilitate a more responsive health system that targets the needs of the community better. Recently, the World Health Organization (WHO) published a handbook on social participation that identified five key themes for ministries of health to consider when engaging the input of the community. In this rapid systematic literature review, we aimed to identify quantitative and qualitative measures that have been used to assess aspects of social participation involving people and policy makers. We identified 172 measures from 48 studies from countries in all six WHO regions. These measures were categorized by all five themes from the handbook on social participation and these measures are linked to 27 concepts. This rapid review found that the focus of measures is largely on the existence of participation-be it by the general population or specific vulnerable groups-rather than on the quality of their participation. The measures in this inventory may be useful for ministries of health and other key stakeholders to use when developing methods to assess and encourage social participation in their context.

The Tunisian experience of participatory health governance: the Societal Dialogue for Health (a qualitative study).

BACKGROUND: Tunisia has been engaged in the Societal Dialogue (SD) for Health process since 2012, a participatory health governance process aimed at bringing in people's voice into health policy-making. Its first success was the recently released National Health Policy 2030. This paper aims to document the SD process and to bring out the lessons learned to inspire other countries. METHODS: This study was based essentially on a qualitative analysis of semi-structured interviews with citizen jury members and health experts that took place from May to September 2018. The qualitative analysis adopted an inductive-deductive approach according to a cross-matrix between the themes of the interview of the two groups of interviewees. RESULTS: The qualitative analysis of the data highlighted that the Societal Dialogue created a health democracy dynamic with inclusive dialogue spaces for the population, communities, and civil society to participate in health system design. It constituted a multi-actor and multidisciplinary coordination platform to increase consensus building among actors. Initial government support and high levels of volunteer commitment allowed the process to achieve a certain level of sustainability. However, this process faced and still faces many challenges such as overreliance on volunteers; a crisis of trust; political instability and the lack of an effective communication strategy. These challenges negatively influence the policy uptake of recommendations made by the Societal Dialogue for Health. CONCLUSION: The Tunisian societal dialogue experience highlights both the successes and challenges of a structured participatory platform, as well as the effort and perseverance it takes to keep such a process functional and relevant. A key lesson from this study is that this model of participatory health governance eventually reaches a stage where population, community, and civil society participation needs to be more institutionalized within the government routine so that it can credibly feed into health policy review processes and inform decision-makers on a regular basis.

People's Voice and Civil Society Participation as a Core Element of Universal Health Coverage Reforms: Review of Experiences in Iran.

Health governance challenges can make or break universal health coverage (UHC) reforms. One of the biggest health governance challenges is ensuring meaningful participation and adequately reflecting people's voice in health policies and implementation. Recognizing this, Iran's Health Transformation Plan (HTP) lays out the country's blueprint for UHC with an explicit emphasis on the 'socialization of health.' 'Socialization' is seen as a key means to contribute to HTP objectives, meaning the systematic and targeted engagement of the population, communities, and civil society in health sector activities. Given its specific cultural and historical context, we sought to discern what notions such as 'civil society,' 'non-governmental organization,' etc mean in practice in Iran, with the aim of offering policy options for strengthening and institutionalizing public participation in health within the context of the HTP. For this, we reviewed the literature and analysed primary qualitative data. We found that it may be more useful to understand Iranian civil society through its actions, ie, defined by its motivation and activities rather than the prevailing international development understanding of civil society as a structure which is completely independent of the state. We highlight the blurry boundaries between the different types of civil society organizations (CSOs) and government institutions and initiatives, as well as high levels of overlaps and fragmentation. Reducing fragmentation as a policy goal could help channel resources more efficiently towards common HTP objectives. The National Health Assembly (NHA) model which was first launched in 2017 offers a unique platform for this coordination role, and could be leveraged accordingly.

Health system performance assessment: a primer for policy-makers

This policy brief is one of a new series to meet the needs of policy-makers and health system managers. The aim is to develop key messages to support evidence-informed policy-making and the editors will continue to strengthen the series by working with authors to improve the consideration given to policy options and implementation.

‘Build forward better’ must include heavy investment in government capacities to engage with communities and civil society

Civil society and community groups are active players in the COVID-19 response, providing support, advice and information where government reach is poor. Yet most governments have not managed to bring civil society’s perspectives, insights, and experiences into the COVID-19 response in a systematic way. If the world is to ‘build forward better’, more regular and systematised government-civil society engagement will need to underpin a shifttowards more inclusive health governance. Doing so successfully will require heavy investments in capacity-building for government actors to value and feel comfortable managing and sustaining participatory spaces and in skills to bring forward the kind of governance needed to build resilience against the next pandemic.

Policy dialogue as a collaborative tool for multistakeholder health governance: a scoping study.

INTRODUCTION: Health system governance is the cornerstone of performant, equitable and sustainable health systems aiming towards universal health coverage. Global health actors have increasingly been using policy dialogue (PD) as a governance tool to engage with both state and non-state stakeholders. Despite attempts to frame PD practices, it remains a catch-all term for both health systems professionals and researchers. METHOD: We conducted a scoping study on PD. We identified 25 articles published in English between 1985 and 2017 and 10 grey literature publications. The analysis was guided by the following questions: (1) How do the authors define PD? (2) What do we learn about PD practices and implementation factors? (3) What are the specificities of PD in low-income and middle-income countries? RESULTS: The analysis highlighted three definitions of policy dialogue: a knowledge exchange and translation platform, a mode of governance and an instrument for negotiating international development aid. Success factors include the participants' continued and sustained engagement throughout all the relevant stages, their ability to make a constructive contribution to the discussions while being truly representative of their organisation and their high interest and stake in the subject. Prerequisites to ensuring that participants remained engaged were a clear process, a shared understanding of the goals at all levels of the PD and a PD approach consistent with the PD objective. In the context of development aid, the main challenges lie in the balance of power between stakeholders, the organisational or technical capacity of recipient country stakeholders to drive or contribute effectively to the PD processes and the increasingly technocratic nature of PD. CONCLUSION: PD requires a high level of collaborative governance expertise and needs constant, although not necessarily high, financial support. These conditions are crucial to make it a real driver of health system reform in countries' paths towards universal health coverage.

Revenue-raising potential for universal health coverage in Benin, Mali, Mozambique and Togo.

Increasing overall fiscal space is important for the health sector due to the centrality of public financing to make progress towards universal health coverage. One strategy is to mobilize additional government revenues through new taxes or increased tax rates on goods and services. We illustrate how countries can assess the feasibility and quantitative potential of different revenue-raising mechanisms. We review and synthesize the processes and results from country assessments in Benin, Mali, Mozambique and Togo. The studies analysed new taxes or increased taxes on airplane tickets, phone calls, alcoholic drinks, tourism services, financial transactions, lottery tickets, vehicles and the extractive industries. Study teams in each country assessed the feasibility of new revenue-raising mechanisms using six qualitative criteria. The quantitative potential of these mechanisms was estimated by defining different scenarios and setting assumptions. Consultations with stakeholders at the start of the process served to select the revenue-raising mechanisms to study and later to discuss findings and options. Exploring feasibility was essential, as this helped rule out options that appeared promising from the quantitative assessment. Stakeholders rated stability and sustainability positive for most mechanisms, but political feasibility was a key issue throughout. The estimated additional revenues through new revenue-raising mechanisms ranged from 0.47-1.62% as a share of general government expenditure in the four countries. Overall, the revenue raised through these mechanisms was small. Countries are advised to consider multiple strategies to expand fiscal space for health.

Il est important d'accroître l'espace budgétaire global alloué à la santé en raison du caractère crucial du financement public pour accomplir des progrès en faveur de la couverture sanitaire universelle. Une stratégie consiste à mobiliser des fonds publics supplémentaires par le biais de nouvelles taxes ou d'une augmentation des taux d'imposition applicables aux biens et aux services. Nous expliquons comment les pays peuvent évaluer la faisabilité et le potentiel quantitatif de différents mécanismes de mobilisation de fonds. Nous examinons et synthétisons les processus et les résultats d'évaluations nationales menées au Bénin, au Mali, au Mozambique et au Togo. Ces études ont analysé la mise en place de nouvelles taxes ou la hausse de taxes sur les billets d'avion, les appels téléphoniques, les boissons alcoolisées, les services touristiques, les transactions financières, les billets de loterie, les véhicules et les industries extractives. Les équipes chargées des études au sein de chaque pays ont évalué la faisabilité des nouveaux mécanismes de mobilisation de fonds à l'aide de six critères qualitatifs. Le potentiel quantitatif de ces mécanismes a été estimé en définissant différents scénarios et en formulant des hypothèses. Des consultations ont été menées auprès des parties prenantes au début du processus afin de sélectionner les mécanismes de mobilisation de fonds à étudier et de discuter des résultats et des options à un stade ultérieur. Il était essentiel d'étudier la faisabilité, car cela a permis d'écarter les options qui semblaient prometteuses à partir de l'évaluation quantitative. Les parties prenantes ont jugé la stabilité et la durabilité positives pour la plupart des mécanismes, mais la faisabilité politique a été une question clef tout au long du processus. Nous avons estimé que la part des fonds supplémentaires générés par les nouveaux mécanismes de mobilisation de fonds dans les dépenses générales de l'État allait de 0,47 à 1,67% dans les quatre pays. Dans l'ensemble, les fonds générés par ces mécanismes étaient de faible ampleur. Il est conseillé aux pays d'envisager plusieurs stratégies pour augmenter l'espace budgétaire alloué à la santé.

El aumento del espacio fiscal general es importante para el sector de la salud debido al carácter central de la financiación pública para avanzar hacia una cobertura sanitaria universal. Una estrategia consiste en movilizar fondos públicos adicionales mediante nuevos impuestos o aumentar los tipos impositivos sobre los bienes y servicios. A continuación se ilustra cómo los países pueden evaluar la viabilidad y el potencial cuantitativo de los diferentes mecanismos de recaudación de fondos. Se han revisado y sintetizado los procesos y los resultados de las evaluaciones nacionales en Benin, Malí, Mozambique y Togo. Los estudios analizaron nuevos impuestos o la subida de los impuestos sobre los billetes de avión, las llamadas telefónicas, las bebidas alcohólicas, los servicios turísticos, las transacciones financieras, los billetes de lotería, los vehículos y las industrias de extracción. Los equipos de estudio de cada país evaluaron la viabilidad de nuevos mecanismos de recaudación de fondos mediante seis criterios cualitativos. El potencial cuantitativo de estos mecanismos se estimó mediante la definición de diferentes escenarios y el establecimiento de supuestos. Las consultas con las partes interesadas al comienzo del proceso sirvieron para seleccionar los mecanismos de recaudación de fondos que se estudiarían y posteriormente examinar las conclusiones y las opciones. Era esencial explorar la viabilidad, ya que ayudaba a descartar opciones que parecían prometedoras de la evaluación cuantitativa. Las partes interesadas calificaron la estabilidad y la sostenibilidad como positivas para la mayoría de los mecanismos, pero la viabilidad política fue una cuestión clave en todo momento. Los fondos adicionales estimados por medio de los nuevos mecanismos de recaudación oscilaron entre el 0,47 % y el 1,62 % de los gastos de las administraciones públicas de los cuatro países. En general, los fondos recaudados mediante estos mecanismos fueron reducidos. Se aconseja a los países que consideren múltiples estrategias para ampliar el espacio fiscal para la salud.

Out-of-pocket expenditure and financial protection in the Chilean health care system-A systematic review.

BACKGROUND: Protection against financial risk due to medical spending is an explicit health guarantee within Chile's AUGE health reform. This paper seeks to analyze the degree to which out-of-pocket expenditure still expose Chilean households to financial catastrophe and impoverishment, and to explore inequalities in financial protection. METHODS: A systematic literature review was conducted to identify empirical studies analyzing financial protection in Chile. The search included databases as well as grey literature, i.e. governmental and institutional webpages. The indicators are based on the conceptual framework of financial protection, as portrayed in the World Health Report 2013. RESULTS: We identify n=16 studies that fulfill the inclusion criteria. Empirical studies indicate that 4% of Chilean households faced catastrophic health expenditure defined as out-of-pocket expenditure exceeding 30% of household's capacity to pay, while less than 1% were pushed into poverty in 2012. In contrast to prior studies, recent data report that even publicly insured who should be fully protected from co-payments were affected by catastrophic health expenditure. Also in the private insurance system financial catastrophe is a common risk. CONCLUSION: Despite health reform efforts, financial protection is insufficient and varies to the disadvantage of the poor and vulnerable groups. More research is required to understand why current mechanisms are not as effective as expected and to enable according reforms of the insurance system.

Revenue-raising potential for universal health coverage in Benin, Mali, Mozambique and Togo

Increasing overall fiscal space is important for the health sector due to the centrality of public financing to make progress towards universal health coverage. One strategy is to mobilize additional government revenues through new taxes or increased tax rates on goods and services. We illustrate how countries can assess the feasibility and quantitative potential of different revenue-raising mechanisms. We review and synthesize the processes and results from country assessments in Benin, Mali, Mozambique and Togo. The studies analysed new taxes or increased taxes on airplane tickets, phone calls, alcoholic drinks, tourism services, financial transactions, lottery tickets, vehicles and the extractive industries. Study teams in each country assessed the feasibility of new revenue-raising mechanisms using six qualitative criteria. The quantitative potential of these mechanisms was estimated by defining different scenarios and setting assumptions. Consultations with stakeholders at the start of the process served to select the revenue-raising mechanisms to study and later to discuss findings and options. Exploring feasibility was essential, as this helped rule out options that appeared promising from the quantitative assessment. Stakeholders rated stability and sustainability positive for most mechanisms, but political feasibility was a key issue throughout. The estimated additional revenues through new revenue-raising mechanisms ranged from 0.47­1.62% as a share of general government expenditure in the four countries. Overall, the revenue raised through these mechanisms was small. Countries are advised to consider multiple strategies to expand fiscal space for health