Social participation in health decision-making is an essential pillar towards achieving equitable access to healthcare services and advancing the well-being of communities. The World Health Organization (2019) strongly advocates for participatory health governance; engaging the public in health reform planning contributes to the success of policies, among other factors. Moreover, the inclusion of local stakeholders in health system governance is a prerequisite for achieving equitable access to health (Fryatt, Benett, &amp; Soucat, 2017). While there is consensus on the critical role of participatory governance in achieving universal health coverage, the evidence on &ldquo;how best to institutionalize multi-stakeholder governance&rdquo; is still evolving (Rajan et al., 2019). A closeup on success stories with social participation from countries that have achieved or recently planned for realizing universal health coverage may provide valuable insight.
<h3>Tunisia&rsquo;s societal dialogue</h3>
In response to Tunisians&rsquo; aspirations for health sector reform, the Ministry of Health has, over the last decade, engaged the public, healthcare providers, professional associations, administrators, politicians, and international experts in a multi-phase policy dialogue on health policies, strategies, and plans. The first phase of Tunisia&rsquo;s Societal Dialogue aimed to build consensus among participants on the existing health system challenges and the possible approaches to reform. Its second phase culminated in the introduction of the &ldquo;National Health Policy&rdquo; in June 2019 to attain universal health coverage by 2030 (Comit&eacute; technique du dialogue soci&eacute;tal, 2014).
Tunisia&rsquo;s success in initiating and maintaining its Societal Dialogue on health is quite laudable. Officials calling for the dialogue harnessed the momentum for democratization and whole-of-society engagement in planning and policymaking following the recent radical political changes. Such push forward has kept the dialogue up and running despite fluctuation in political support due to frequent cabinet changes. Moreover, funding and technical guidance from multilateral and bilateral cooperation agencies afforded the country the state-of-the-art expertise for managing the dialogue. The new engagement mechanisms utilized, the high quality of deliberations, and the reliance on evidence in formulating the proposed policies in Tunisia attest to the crucial role of international agencies in supporting policy dialogue in emerging democracies. However, overreliance on external parties might threaten the sustainability of Societal Dialogue.
<h3>Thailand&rsquo;s national health assembly</h3>
The introduction of sociopolitical reform in the late 1990s in Thailand favoring &ldquo;citizen-state engagement&rdquo; has culminated in the passing of the National Health Act, establishing the National Health Commission headed by the Prime Minister, and paving the way for the first National Health Assembly (NHA) in 2008. By promoting inclusive, open deliberations, the NHA informs health decision-making by generating evidence harnessed from engagement with legitimate representatives of the public at all levels (Rajan et al., 2019).
The &ldquo;triangle that moves the mountain&rdquo; strategy (see the figure below) depicts how the NHA operates. The people&rsquo;s sector, including the public and civil society, engage with policymakers and administrative bodies, in the presence of think tanks and health researchers to thoroughly examine the provided evidence, inclusively listen to the diverse views, and freely debate the different policy options, including making decisions on proposals for resolutions, background papers drafting, dissemination of information, and public hearings (Rajan et al., 2019).
Figure 1:&nbsp;The &lsquo;triangle that moves the mountain&rsquo; strategy&nbsp;
<img style="display: block; margin-left: auto; margin-right: auto;" src="http://api-aps.aucegypt.edu/uploads/tinymce/1595432401imageFigure.jpg" alt="" width="500" height="250">
Source: Rosanathan et al., 2011
Thailand is a role model in participatory health governance among countries that have achieved universal health coverage for several reasons. First, supportive legislation and the direct involvement of the Prime Minister in the work of the National Health Commission have helped institutionalize and sustain the initiative. Second, technical and logistical support from the steering committee of the NHA enhances the quality and outcomes of the deliberations. A third factor is the inclusiveness of the NHA, as demonstrated by multi-sectoral participation.
Despite its commendable performance, the NHA is still challenged by the following: exclusion of marginalized, less articulate stakeholder groups; weak uptake of recommendations into national policies; inadequate participation of the more influential politicians; defensive behaviors during deliberations; and, sometimes, the lack of information on the discussed issues (Rajan et al. 2019).
<h3>Portugal&rsquo;s &ldquo;consultative health participatory spaces&rdquo;</h3>
Thanks to legislation passed in the 1990s, namely the Health Guidelines Law and the statute of the National Health Service, public participation in Portugal expanded by including service users in advisory committees to hospital boards and primary healthcare facilities. The Portuguese Republic then followed by establishing regional observatories, direct communication channels between providers and users, and formalized complaint systems to help strengthen the voice of the people (Matos &amp; Serapioni, 2017).
To further advance public participation in health policymaking, Portugal recently created &ldquo;consultative health participatory spaces&rdquo; for representatives of the public, civil society, academia, and medical practice associations to exchange views with decision-makers on health system transformation (de Freitas, 2017). One such example was the &ldquo;More Participation, Better Health&rdquo; forum, in response to the 2012-2016 National Health Plan&rsquo;s call for promoting &ldquo;health citizenship,&rdquo; a movement whereby each citizen was encouraged to become &ldquo;an ally in transforming the system&rdquo; (de Freitas, 2017). For individuals who could not participate in similar events (e.g., people with disabilities), other innovative means like think tanks and social forums have been introduced (de Freitas, 2017).
The significance of this case of social participation in Portugal goes beyond being supported by favorable legislation. This Southern European country with universal health coverage is motivating its citizens to assume an active role in health policymaking by introducing various types of &lsquo;spaces,&rsquo; which are better catering to the different population groups while serving the same purpose of boosting participatory health governance. Nevertheless, health policymaking in Portugal has been struggling with power imbalance due to the &ldquo;strong influence of structured interest groups&rdquo; and the reduced participation of citizens, thus calling for a review of representation criteria and selection practices (Matos &amp; Serapioni, 2017).
<h3>A roadmap to institutionalize participatory health governance in Egypt</h3>
Egypt&rsquo;s Vision 2030 highlights the need to establish &ldquo;an integrated, accessible, high quality, and universal healthcare system&rdquo; (Central Agency for Mobilization and Statistics, 2016). This commitment was further demonstrated by the passing of the 2018 Universal Health Insurance Law (Devi, 2018). Since participatory governance is indispensable for achieving universal health coverage (Fryatt, Benett, &amp; Soucat, 2017), strengthening social participation in health policymaking would ensure Egypt&rsquo;s health system reform is in line with citizens&rsquo; needs and expectations. Evidence suggests a sustainable, well-funded, inclusive, participatory mechanism in Egypt would support public engagement in health policymaking and the realization of national health reform goals.
Has Egypt made enough progress in this regard? The Egyptian Initiative for Personal Rights, a civil society organization working in Egypt since 2002, has recently concluded its community-based assessment of the Universal Health Insurance pilot program in Port Said governorate. The study noted the lack of a mechanism for social accountability and called for establishing an independent higher health council charged with national planning and policymaking and including representatives from all involved stakeholders and service users (The Egyptian Initiative for Personal Rights, 2019). The roadmap towards institutionalizing social participation in Egypt should thus consider the below guidance.
<ul>
<li>Political will&nbsp;at the highest level is needed to trigger the process and ensure better uptake of the agreed recommendations by policymakers. Supportive legislation is also crucial to institutionalizing social participation in health policymaking at the national and local levels. Moreover, legislation should include securing necessary funding and appointing a special health commission to manage the policy dialogue and provide technical and logistical support. The role of international cooperation agencies is indispensable, and a clear policy for synergizing aid provided by the different parties needs to be in place.</li>
<li>The inclusion of all involved health sector stakeholders&nbsp;is critical and sometimes challenging. With decades of mistrust and political tensions, Egypt needs to communicate its willingness to promote a healthy environment for participatory governance and create and announce the set of stakeholder engagement principles it intends to adopt. Invited parties should include representatives from laypeople and experts/researchers, civil society and patient interest groups, professional associations and syndicates, healthcare providers including those affiliated with universities and the military, faith-based organizations, politicians and parliamentarians, healthcare-related industries, as well as government officials charged with health policymaking.</li>
<li>The challenge of representativeness needs to be carefully addressed, especially when marginalized population groups, whether based on socioeconomic status, geographical location, religious beliefs, political convictions, or disability status, are excluded. Mechanisms for soliciting feedback from all stakeholders should be varied and tailored to their skills and health literacy level. Moreover, power balance during discussions should be carefully controlled by having independent, competent facilitators in place, as well as clear rules for participation.</li>
<li>Another evidence-based prerequisite for kicking off the policy dialogue is&nbsp;the awareness and capacity building of the different stakeholder groups. This includes improving health literacy among participants, enhancing their negotiation skills, and making sure they recognize each other&rsquo;s valuable contributions and maintain such a positive attitude even when conflicts of interest arise during deliberations. Participants&rsquo; capacity to periodically review the process and evaluate the outcomes of the policy dialogue ensures continuous improvement.</li>
</ul>
It&rsquo;s about time to pave the way for participatory health governance in Egypt!
<hr>
References
<ul>
<li style="font-size: 10pt;">
Central Agency for Public Mobilization and Statistics. (2016, July 12). <a style="color: #333333;" href="https://www.arabdevelopmentportal.com/sites/default/files/publication/sds_egypt_vision_2030.pdf">Sustainable Development </a>
</li>
<li style="font-size: 10pt;">
<a style="color: #333333;" href="https://www.arabdevelopmentportal.com/sites/default/files/publication/sds_egypt_vision_2030.pdf">Strategy (SDS): Egypt Vision 2030.</a>
</li>
<li style="font-size: 10pt;">
Comit&eacute; technique du dialogue soci&eacute;tal. (2014).&nbsp;<a style="color: #333333;" href="http://www.hiwarsaha.tn/upload/1409046285.pdf">Pour une meilleure sant&eacute; en Tunisie : Faisons le </a><a style="color: #333333;" href="http://www.hiwarsaha.tn/upload/1409046285.pdf">chemin ensemble.</a>de Freitas, C. (2017). <a style="color: #333333;" href="https://doi.org/10.1016/j.pbj.2017.01.001">Public and patient participation in health policy, care and research</a>.&nbsp;Porto Biomedical Journal,2(2), 31&ndash;32.
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<li style="font-size: 10pt;">
Devi, S. (2018). <a style="color: #333333;" href="https://doi.org/10.1016/s0140-6736(18)30091-6">Universal health coverage law approved in Egypt.</a>The Lancet,&nbsp;391(10117), 194.
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Fryatt, R., Bennett, S., &amp; Soucat, A. (2017). <a style="color: #333333;" href="https://doi.org/10.1136/bmjgh-2017-000343">Health sector governance: should we be investing </a><a style="color: #333333;" href="https://doi.org/10.1136/bmjgh-2017-000343">more?&nbsp;</a>BMJ Global Health,&nbsp;2(2).
</li>
<li style="font-size: 10pt;">
Matos, A. R., &amp; Serapioni, M. (2017). <a style="color: #333333;" href="https://doi.org/10.1590/0102-311x00066716">The challenge of citizens&rsquo; participation in health systems </a><a style="color: #333333;" href="https://doi.org/10.1590/0102-311x00066716">in Southern Europe: a literature review</a>.&nbsp;Cadernos de Sa&uacute;de P&uacute;blica,&nbsp;33(1).
</li>
<li style="font-size: 10pt;">
Rajan, D., Mathurapote, N., Putthasri, W., Posayanonda, T., Pinprateep, P., de Courcelles, S., &hellip;&amp; Schmets, G. (2019). <a style="color: #333333;" href="https://doi.org/10.1136/bmjgh-2019-001769">Institutionalising participatory health governance: lessons from nine years of the National Health Assembly model in Thailand.</a>BMJ Global Health,&nbsp;4(Suppl 7).
</li>
<li style="font-size: 10pt;">
Rasanathan, K., Posayanonda, T., Birmingham, M., &amp; Tangcharoensathien, V. (2011, February1).&nbsp;<a style="color: #333333;" href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1369-7625.2010.00656.x">The &lsquo;triangle that moves the mountain strategy</a>.&nbsp;[Figure].
</li>
<li style="font-size: 10pt;">
The Egyptian Initiative for Personal Rights. (2019). التشغيل التجريبي للتأمين الصحي الشامل في بورسعيد- تقييم مجتمعي للمرحلة واصلاحات واجبة. Retrieved from <a style="color: #333333;" href="https://eipr.org/sites/default/files/reports/pdf/port_said_report_for_web.pdf">https://eipr.org/sites/default/files/reports/pdf/port_said_report_for_web.pdf</a>
</li>
<li style="font-size: 10pt;">
World Health Organization. (2019, September 23). <a style="color: #333333;" href="https://www.who.int/activities/promoting-participatory-governance-social-participation-and-accountability">Promoting participatory governance, social </a><a style="color: #333333;" href="https://www.who.int/activities/promoting-participatory-governance-social-participation-and-accountability">participation and accountability.</a>
</li>
</ul>

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