Public participation in regional health policy: a theoretical framework

Abstract

How best to involve the public in local health policy development and decision-making is an ongoing challenge for health systems. In the current literature on this topic, there is discussion of the lack of rigorous evaluations upon which to draw generalizable conclusions about what public participation methods work best and for what kinds of outcomes. We believe that for evaluation research on public participation to build generalizable claims, some consistency in theoretical framework is needed. A major objective of the research reported on here was to develop such a theoretical framework for understanding public participation in the context of regionalized health governance. The overall research design followed the grounded theory tradition, and included five case studies of public participation initiatives in an urban regional health authority in Canada, as well as a postal survey of community organizations. This particular article describes the theoretical framework developed, with an emphasis on explaining the following major components of the framework: public participation initiatives as a process; policy making processes with a health region; social context as symbolic and political institutions; policy communities; and health of the population as the ultimate outcome of public participation.

We believe that this framework is a good beginning to making more explicit the factors that may be considered when evaluating both the processes and outcomes of public participation in health policy development.

Introduction

In the 1990s, participation became internationally a key part of the discourse in the health sector. Participation was central to the concept of primary health care introduced in the 1970s [1] but has moved beyond that to a broader inclusion in health policy development. Participation is also a major tenet of health promotion and is encapsulated in its 1986 Ottawa Charter definition: “Health promotion is the process of enabling people to increase control over and to improve their health” [2]. Fostering public participation was one of three strategies for health promotion encouraged in early policy documents from the Canadian government [3]. Participatory action-research [4], participatory research [5] and participatory development [6] are just some of the activities thought to improve the chances of success in health promotion. More recently, in Canada, health sector reforms focused on acute care have taken place under the banner of increasing public input [7], [8], [9], [10].

Other factors have also brought increased attention to participation in all parts of the health sector. Recognition that the broad determinants of health [11] and sectors other than health influence the health of populations has increased the demand for intersectoral action [12], [13]. Partnerships between organizations have become a popular technique of participation and have been posed as solutions to many health problems [14], [15], [16], [17]. Citizen juries, deliberative panels, and round tables [18] are other examples of techniques for increasing public participation.

Despite the popularity of participation, there is little consensus about what it means in practice, and the literature on participation is fraught with inconsistency [1], [19], [20], [21]. The term partnerships, for instance, is used to represent many different relationships and understandings [22] such as coalitions, networks, coordinating committees, and work groups to name a few. The public participation framework of one regional health authority acknowledges a range of participation from information exchange to delegation of authority [10], based on the work of Arnstein [23] and others. Abelson et al. [9] identify that “current activity seems largely focused on efforts to design more informed, effective and legitimate public participation processes with a strong evaluation component” (p. 239).

Evaluation research requires a clear articulation of the program logic model, program theory [24], outcome line [25], or program coherence [26]. “In the absence of a clearly articulated programme theory, it may be necessary to bound the programme… that is, to specify which activities, services, targets, results, and parts of the environment are understood to ‘belong’ to the program in question. This at first seems simplistic; however, when one considers the complexity of social change organizations and projects, it is important to make this distinction” of what belongs to the program [27] (p. 36). In our experience in health program evaluation, often one of the most challenging activities is articulating the program components and intended outcomes [28], [29], [30], and this is true in evaluating public participation. The diversity of meanings and activities, as well as resulting differences in how or which outcomes are specified, makes integration of findings difficult across studies.

One of the areas of confusion is differentiating between public participation as an initiative or intervention encapsulating a process and a means to an end and public participation as the intended outcome or end in and of itself. The focus on processes is often on “how best” to involve citizens in the decisions that affect them [9], [31]. In discussing deliberative public participation initiatives used in the health sector, Abelson et al. [9], for instance, at times imply that the outcome of interest is the decision or recommendation of the participants after their deliberation; at other times they imply that it is how this decision or recommendation is used by a health authority.¹ Abelson et al. [9] also state that the ‘decisions’ or policy issues that are to be affected by participants range from identification of public values to allocation of resources to general governance of the health sector. Public values may, however, be one of the factors that go into a decision to allocate resources. In this paper we will use the term public participation initiatives to refer to the whole set of activities and processes, and public participation techniques to refer to the methods chosen to engage people. As we see participation, a number of processes (e.g., setting up the management group, choosing the participants) may be involved in any initiative and any technique.

Abelson et al. [9] note the “paucity of rigorous evaluations” (p. 249) available to those who want to draw generalizable conclusions on public participation. They call for the use of “clearly defined and agreed upon criteria” (p. 249), presumably of effectiveness. Similarly, Church et al. [32] identify the need for more research on the many ways that citizens can influence decision-making in the health sector. We argue that for evaluation research on public participation to build generalizable claims, some consistency in theoretical framework is needed. A framework that encourages clear articulation of an initiative would help describe its components, specify the public participation techniques (e.g., advisory councils, public forums, citizen juries, partnerships), the resources used, the objectives pursued, as well as the target of change or desired outcomes, and the environment in which that target is situated. Research based on this framework would make integration of findings more possible. The research reported on here used grounded theory to develop a theoretical framework for understanding public participation in the context of regionalized health governance.