Tue, Apr

Public Health Dialogue: The Role of Citizen Engagement. Image Courtesy of The Maternal And Child Survival Program

Thoughts From Afar
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Having citizens at the decision-making table also affords policymakers the opportunity to have conversations around what is feasible and what is not. It provides the citizens with the option of challenging the rationale...

“We define our identity always in dialogue with, sometimes in the struggle against, the things our significant others want to see in us. Even after we outgrow some of these others—our parents, for instance—and they disappear from our lives, the conversation with them continues within us as long as we live.”

Conversations around health in Ghana always fascinate me. In most instances, they are conducted as though the citizens who often are not health professionals are simple beneficiaries of decision making. For all intent and purpose, our society behaves as though health is not a fundamental human right. It takes a simple observation of the mannerism of a chief or town elder when they crave the indulgence of political office holders, requesting for basic healthcare amenities for their society to come to a conclusion. Often their tone and demeanour is a semblance of a plea. In many cases, these requests are not backed by any research, evidence or reasoning, they are simply based on what the community think they want, rather than what the community really needs. In the end, politicians mindful of optics tend to provide the said wants if they come with political capital; without pausing to access the real needs.

In many countries, however, citizen’s participation in health policy and decision making is aggressively sought. In the view of many who work in the area of health policy, “the legitimacy and sustainability of any major policy decision increasingly depend on how well it reflects the underlying values of the public.” In the year 2000, The Council of Europe declared that the right of the public to be involved in the decision-making processes affecting health care is a basic and essential part of any democratic society. The benefits this participation brings can be seen in these countries where innovation has improved the reach and access to health. Continuing with our approach would only see the world leave us behind and countries that embrace this new approach with similar health challenges to us, pass us by. Why then has our country failed to embrace this approach to planning for our healthcare needs?

To answer this I have looked at our culture and the impact of our high power distant traditions. Often many who work or lead in the area of healthcare seem as mini-gods who hold the key to life and death. As a result, they must be spoken to and accorded the utmost respect. In the eyes of many, it is even detrimental to question their actions or motives. This attitude is by default extended to those in charge of health policy including appointed and technocratic leaders. Unfortunately, such differing makes many in these positions feel they can and must provide answers to our health needs, with us acting only as compliant subjects when health has long moved to a collaborative approach based on concordance.

Invariably, the result is that things go wrong consistently, policies that are not needs but mere wants are proposed and in some instance implemented, leading to unintended suffering by the citizenry when they require health care. Consequentially, when such failings affect a citizen with influence, all hell breaks loose with the middle classes shouting and baying for blood. In the end, scapegoats are found often amongst the very health professionals who are seen as gods and the matter is made to rests only to reappear, often with vengeance. This vicious cycle sees us seething with rage but hapless to act, we surely can do better.

In a country where democracy has been practised for close to three decades, my view is the time has come for us to democratise how decisions in health are arrived at. Such an approach will bring legitimacy, ensure transparency and provide a sense of accountability. To start with, the citizens are the majority actors in this and most other areas of our society. Secondly, they bear the brunt of the actions and inactions of policy bureaucrats and are best placed to articulate these. Without them being at the table at the formulation stage or being involved in the review of the fallout of these policies, how then can they get their grievances heard?

Having citizens at the decision-making table also affords policymakers the opportunity to have conversations around what is feasible and what is not. It provides the citizens with the option of challenging the rationale behind say the construction of a new hospital, to question the availability of funds, human resources and strategy. If done properly it would also diminish the tendency of political actors hoodwinking Ghanaians with structures that tend to further their political gain with no long-term community gains. Overall it would eliminate the top-down approach to policy-making which frowns on collaboration and scrappers citizen buy-in whilst rendering implementation a nightmare.

Ultimately, it will open healthcare up to inclusion, dispel the belief that health professionals pull rank in situations where medical negligence may have occurred and will bring innovation to the table. However, this new approach will not come without a fight. It will be ludicrous if we thought that having cultivated positional leaders, who value titles and status ahead of performance for most of our independent life, the current crop will welcome input from lesser beings willingly. Especially when many have had to join the civil service queue and wait for their time or used their political contacts to get their jobs. We must remember, “No turkey votes for Christmas.”

This is where citizen advocacy in health has a role. We should begin to agitate and demand a place at the table. We can commence by pushing back and rejecting projects that are simply imposed on us through announcements by political players and request that our views be heard first.

Some may find this laughable and think we lack the power to do so. For those who are of this ilk, I have a bit to say. There is a reason why patient and citizen groups exist in countries with thriving healthcare systems but don’t exist in ours. This reason is the basis of why we lack transparency and trust when things go wrong in our healthcare system. It is also why committees can be set up to investigate health failings but the reports kept away from the very citizens who were at the receiving end of these failings. These reasons will not disappear unless we sit up and begin to adopt good practice and shed the cloak of pompous power distance. It is in our interest if we did.

It is not for nothing that sixty-two years after independence many hospitals use paper files and analogue health record keeping when computers exist with apps and software in abundance. A similar argument can be made for why most pharmacies scribble instructions for medicines on boxes when labelling software exist. Likewise, it’s not for nothing that health facilities litter our country at various stages of completion with no end in sight. The first two which border on medical health and safety has led to much harm to patients with no data available to quantify the extent. The third is a manifestation of a waste of taxpayer funds that could have gone into the provision of a service industry for our health care based on digital innovation but has ended up as a sunk cost. All these are the culmination of citizen apathy. We cannot continue to sit on the sidelines and watch as decisions are made for us, we must be involved. As it is said, “patients not only have a right to engage in discussions on decision making about priorities (the political stance), their input is also needed because they have a specific, relevant type of knowledge: their ‘experiential knowledge’” and the value of this expertise cannot be ignored.

Brazil went down this route and the evidence of their experiment point to equitable distribution of public health services and significant entrepreneurial infused innovation. For the sake of our children and to ensure our conversations are impactful, we must demand the same too.

Feature Image Courtesy of The Maternal And Child Survival Program

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