Health Systems and Citizenship: Public Participation in Southern Europe

Governance, Participation, And Citizenship: The Sphere Of Health

Nowadays, the assumption of “good” governance increasingly requires strengthening the mutual interdependence of actors in participatory mechanisms in order to competently solve public problems and to improve the quality of decisions. For the last 20 years, deliberative approaches based on citizen participation in decision-making contexts have been considered essential for the development of democracy. Accordingly, initiatives of participation launched by civil society were multiplied. Those initiatives are pressing the public sector to redesign the social rights system, that is no longer understood as the right of access to services provided by the State (Marshall, 1973), but as a demand for greater involvement of citizens in the definition of public policies.

This new concept of citizenship highlights the relevance of community and the obligations of the individual, as well as promotes a model of active citizen participation in institutions and public services (Habermas, 1992; Crouch, 1999; Santos, 2003). In this sense, participation is still perceived not only as the subject of rights, which gives people the ability to act, but as the right to participate in the political life, aiming at promoting a more active form of citizenship – citizenship understood as practice – based on citizen involvement strategies, in this case in the health system, and aiming to strengthen co-responsibility and transparency of public services (Lister, 1998). Being a citizen means to be able to enjoy the proper means to participate in social and political life. Moreover, citizenship also becomes associated with the promotion and development of personal empowerment rights (Wharf Higgins, 1999).

Even though citizen participation is widely recognized as a fundamental dimension of citizenship, the results in the health domain have been modest. Not all citizens have the proper means to enforce their rights and benefits and, besides that, those who are often seen as the main beneficiaries of participation in health care are still less likely to engage in such initiatives. In this context, Boaventura de Sousa Santos states that the introduction of participatory mechanisms and the consequent intensification of active citizenship becomes more urgent “in a public space in which State coexists with interests and non-governmental organizations” (2006: 344-345) .

This debate, very intense since the 1980s, has proved to be very fruitful when applied exactly to the area of health, being of great vitality specifically the debate on citizen participation in health systems. In fact, one of the central themes of health reform processes of the past 20 years emphasizes the recognition of the centrality of the users, the importance of their voice and their perspective in the organization of health care system and in the health provision services.

Much of the research conducted in this area has stressed that the incorporation of users’ knowledge and experience not only improves the quality of decisions of the professionals as it improves the provision of health services (Barnes et al., 2008; Bovenkamp et al., 2009). To strengthen users’ voice, therefore, represents an important strategy to overcome the growing “democratic deficit” (Cooper et al., 1995) that characterizes many of the health systems. That need to strengthen accountability and transparency of health services through bodies favoring users’ involvement has been widely emphasized.