Abstract
BackgroundInclusive engagement in healthcare policies and decision-making is essential to address the needs of patients and communities, reduce health inequities and increase the accountability of the government. In low income countries such as Malawi, with significant health challenges, stakeholder inclusion is particularly important to improve performance and service delivery. The 2017 National Health Plan II (NHP II) and accompanying Health Sector Strategic Plan II (HSSP II) aimed to improve the functioning of the healthcare system. The Ministry of Health for Malawi intended to involve all key health sector stakeholders in their development. This study explores the extent of stakeholder engagement in the health policy process through local level stakeholders’ perceptions of their involvement in the NHP II and HSSP II.MethodsA qualitative study design was used. Interviews were conducted with 19 representatives of organisations operating at the local level, such as CSOs and local government. Open questions were asked about experiences and perceptions of the development of the NHP II and HSSP II. Inductive content analysis was performed.ResultsStakeholders perceived barriers to inclusive and meaningful engagement in the health policy process. Five categories were identified: tokenistic involvement; stakeholder hierarchy; mutual distrust; preferred stakeholders; no culture of engagement.ConclusionsSerious challenges to the meaningful and equitable engagement of local level stakeholder groups in the health policy process were identified. Issues of trust, accountability and hierarchy in donor-citizen-government relations must be addressed to support stakeholder engagement. Engagement must go beyond tokenism to embed a range of stakeholders in the process with feedback mechanisms to ensure impact from their contributions. Local level stakeholders can be empowered to advocate for and participate in consultation exercises alongside greater top-down efforts to engage stakeholders via diverse and inclusive methods. These issues are not unique to Malawi or to health policy-making.
Highlights
Inclusive engagement in healthcare policies and decision-making is essential to address the needs of patients and communities, reduce health inequities and increase the accountability of the government
As health stakeholders, every interviewee expressed a desire to be heard and to use their knowledge to influence central government health policy-making, ‘as an organisation that deals with health issues, there ‘should have been some form of involvement for us to input into the documents’ (P11, Civil Society Organisation (CSO))
They felt that being involved in policy decision-making would communicate the policy needs of their members and the communities they serve, helping hold those responsible for policy implementation to account: ‘[Name of organisation] is the mouthpiece of what happens on the ground regarding Human immunodeficiency virus (HIV) and AIDS in Malawi
Summary
Stakeholder engagement throughout the policy development cycle (problem identification, agenda setting, policy formulation, adoption, implementation, evaluation) is essential for understanding the needs of different groups and communities, such as civil society organisations and donors who may have different priorities, and for increasing equity in policy [1,2,3]. It can give additional legitimacy by providing evidence to support and shape policies and increase accountability of the government to stakeholders achieving greater policy implementation [4,5,6]. The engagement process is shaped by political will, established cultures of stakeholder engagement, hierarchical social relationships, lobbying by some stakeholders (but not others) for inclusion, poor understanding by stakeholders of policy processes and institutions (policy literacy), and limited resources, meaning that equitable and inclusive consultation is often difficult to achieve [5, 10]
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