Bringing the perspectives of citizens, including the most marginalized, into health policy processes remains a challenge. Doing so requires great effort and patience, and it can be a long and difficult road, but one that will lead to transformative change as well as bring health for all.
First of all, what is health for all? In simple words, it means to bring health and well-being to everyone regardless of where they live, and which ethnicity, group, caste or social status they belong to. Health and well-being is not only about having health care services available, but is about ensuring that all people lead a socially and economically productive life. Health for all is an aspiration.
Policy debates in the past have often revolved around the supply side of health care, and the availability of health care facilities. For example, this is reflected in the emphasis of international efforts on increasing the number of health care facilities, along with a focus on childbirth at the facilities. While this has certainly improved health outcomes (such as higher immunization coverage and reduced child and maternal mortality), there has been relatively less focus, and as a result less progress worldwide, on improvements to access and quality of health care. This is particularly true for the marginalized.
I have seen this firsthand. With the IDRC’s research award, I spent four months in a rural community of Nepal studying needs of women. One of the questions I had planned to ask pregnant women I would interview was: why don’t you go the health facility for prenatal care during pregnancy, since the service is available? During the fieldwork however, after hiking for 3 hours to get to a community, I could no longer ask this question to a 17 year old in her third trimester. How could I expect her to walk 6 hours, up and down the hill, to access the health facility? During my stay in the community, it became clear to me that not all the knowledge on local context (such as how community members access health care, and their experience with and expectations of the quality of these services) is known to those of us, researchers, who do not live there. Such knowledge can be understood and shared by engaging those community members. A three year study done in Nepal, for example, found that the maternal mortality ratio decreased significantly and women were more likely to have prenatal care where citizens were engaged in the project planning and intervention processes.
Citizen engagement & community empowerment
The importance of citizen engagement and community empowerment in policy processes and development projects has been widely discussed by academics. Educators, economists, scholars and activists such as Paulo Freire, Amartya Sen, Gita Sen, Robert Chambers, Lawrence W Green have argued for many years that development and health policies thrive with community-driven approaches and local empowerment. Along with the theoretical work, there is ample evidenceto suggest that engaging citizens in decision-making processes improve population health. Involving citizens in discussing root causes of health issues and deriving solutions that speak to them and their social determinants is essential, and it works.
Given the extensive evidence and experience now available, I believe it is now time to listen, reflect, act, and turn development on its head to construct development from the bottom up. The aid world, which plays a pivotal role in achieving health for all, needs to stop working for the poor and marginalized and work with them. The processes must provide space for citizens to lead and not take over their lives and their ability to make decisions.
The global goals to achieve health for all
A study undertaken by the Participate Initiative, with evidence from 84 participatory studies on progress toward meeting the Millennium Development Goals (MDGs), finds that the most marginalized are often not reached by development projects. With the Sustainable Development Goals (SDGs) at hand, the opportunity is ripe to build structures that ensure inclusive decision-making processes and move forward with community engagement. The SDGs, which embraced an inclusive process of goal setting, present an opportunity to radically transform conventional public policy processes. Such transformations can provide space for citizens to exercise their power to shape the decisions that affect their health and well-being.
Citizens can identify the root causes of health problems and barriers to health care access. When they participate in research and discussions and contribute in generating evidence and solutions -this leads us closer to attaining health for all, and in understanding the mechanisms for how to get there.