Scope and Limitations of Municipal Health Councils: A Case Study

• Author: Carla A. A. Ventura,Marcela J. Miwa,Mauro Serapioni,Márjore S. Jorge
• Published date: 01 March 2018
• DOI: http://doi.org/10.1002/wmh3.259
• Date: 01 March 2018

Scope and Limitations of Municipal Health Councils:

A Case Study

Carla A. A. Ventura, Mauro Serapioni, Marcela J. Miwa ,

and M

arjore S. Jorge

This case study analyzed citizen participation at the Municipal Health Council (MHC) of Ribeir~

ao

Preto, in the state of S~

ao Paulo (Brazil), using a qualitative approach with a phenomenological basis

and methodological triangulation: (i) analysis of the minutes of the meetings, (ii) passive

observation, and (iii) semi-structured interviews with councillors. The interviews were analyzed

using content analysis and categorized according to three themes: (i) challenges and limitations of

participation in the MHC, (ii) representativeness of the councillors, (iii) the Council and its

inf‌luence on local health-care policies. Problems with infrastructure and the organizational logistics

of the MHC, as well as relational diff‌iculties among members occupying varied roles and having

different levels of knowledge about health, inf‌luenced the quality of the deliberative process. In

contrast to studies that indicate poor participation by health-care service users in spaces of dialogue

around health-care policies, this study found the users actively engaged and committed.

KEY WORDS: citizen participation, health councils, Brazil

Introduction

Internationally, citizen participation has been increasingly on the agenda in

discussions on the process of health-care reforms. In recent years, the demand for

greater participation of civil society has increased, and political and social

scientists have taken a growing interest in analyzing the social practice of

participation that leads to active citizenship and high-intensity democracy

(Santos, 2002).

Arguments in favor of citizen participation in health-care decision-making

processes include: (i) the experiential knowledge of health-care service users

improves the quality of decisions (Barnes et al., 2008; Rojatz & Forster, 2017); (ii)

public health care is most effective when decisions are shared with those affected

(Scutchf‌ield, Hall & Ireson, 2006); (iii) community health needs must be aligned

with health-care services (Abelson et al., 2003); (iv) the users’ perspectives should

be valued in the decision-making process (Charles & De Maio, 1993); (v) the

World Medical & Health Policy, Vol. 10, No. 1, 2018

65

doi: 10.1002/wmh3.259

#2018 Policy Studies Organization

participation of users and citizens increases the legitimacy and accountability of

health-care services (Tritter & McCallum, 2006); (vi) the voice of users is an

important strategy in overcoming the growing “democratic def‌icit“ nature of

health-care systems, particularly after the managerial reforms of the 1990s

(Cooper, 1995).

However, the question of how participation in health-care systems should be

designed and implemented remains. Experience in this f‌ield shows that, despite

good intentions and efforts, results have been modest (Abelson et al., 2003;

Conklin, Morris, and Nolte, 2015; Li, Abelson, Giacomini, & Contandriopoulos,

2015). In recent years, deliberative methods have been considered by policy-

makers as an innovative strategy to improve interaction between decision makers

and service users. Deliberative democracy aims to foster decision-making

processes by promoting discussions and analyses—preferably in small groups—

in which participants can freely express different points of view in a democratic

environment (Dryzek, 2009). Deliberation is considered an important aspect of

democracy, and occurs when discussion, explanation, and justif‌ication replace

consensus and voting as conceptual cores of legitimacy (Gr€

onlund, B€

achtiger, &

Set€

al€

a, 2014).

The benef‌its of deliberative processes include: greater citizen participation in

health-care policies, the potential to change participants’ opinions, the ability to

increase tolerance and understanding between groups holding different points of

view, and being a qualif‌ied means of reaching collective decisions (Mitton, Smith,

Peacock, Evoy, & Abelson, 2009). Lehoux, Daudelin, Demers-Payette, and Boivin

(2009) recommend adopting deliberative processes because of their potential to

maximize mutual learning both within expert groups and between experts and

lay people.

The deliberative approach has gained increasing ground in health-care

systems in several countries that understand the need to create participatory

forums and spaces that encourage dialogue between different actors of the health-

care system.

However, it is also important to mention some critical aspects of deliberative

exercises identif‌ied in the literature, such as the problem of representativeness

(Bispo Ju

´nior & Gerschman, 2015), the potential for inf‌luence (Conklin et al., 2015)

and the unavoidable power imbalance between the sponsor of the deliberative

process and the participants (Gooberman-Hill, Horwood, & Calnan, 2008).

The Citizens’ Jury is one of the most widely used deliberative methods in the

British health-care system (Parkin & Paul, 2011). In Canada, dialogue sessions

(Choice Work Dialogue) with representatives of the public have been adopted to

learn about the views of the Canadian population on health-care policies

(Maxwell, Rosell, & Forest, 2003). In the Netherlands, Health Councils and Client

Councils include user organizations in decision making on policies and on the

organization of health-care services (Bovenkamp, Trappenburg, & Grit, 2009). In

Italy, the Emilia–Romagna Region has set up Mixed Advisory Committees

(Comitati Consultivi Misti), with representatives from user associations, health-care

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