Understanding the factors that make public participation effective in health policy and planning: a realist synthesis

Additional keywords: context–mechanism–outcome configurations, participation techniques, public involvement effectiveness, realist review.

Public participation has been a central theme in health policy reforms in the aim to be more responsive to the needs of the health system and priorities of the public. Health policymakers and practitioners have been using this approach to enhance accountability, improve trust and help cost-effective decision-making (Church et al. 2002). To realise these, a spectrum of methods or techniques to involve the public in the formulation of health policy and program planning has been used, such as citizen’s juries (Iredale and Longley 2007; Street et al. 2014), citizen’s panel, community meetings, public consultation, among others (Conklin et al. 2015). However, there has been a broad understanding of the concept of public participation, and it has been variously defined by several authors in the field of health policy and planning. Florin and Dixon (2004) broadly describe public participation as the involvement of the members of the public in the strategic decision-making about health services and policies from the local or national level, with the goal of increasing democratic input and responsiveness of services provided. From a sociological perspective, Contandriopoulos (2004) describes public participation as intrinsically concerned with power relation that requires redistribution of power to less powerful sections of the society. In some papers (e.g. Mitton et al. 2009; Conklin et al. 2015), public participation is a type of public involvement. However, in this paper, the term public participation was used interchangeably with public involvement and with public engagement.

Previous studies have focused on the role of context in health policy and program planning (Abelson et al. 2007; Boivin et al. 2014). Others also identified the possible outcome of public participation (Alborz et al. 2002; Restall and Kaufert 2011; Carman et al. 2015; Conklin et al. 2015). Although there has been an increasing number of studies of public participation in health policy and planning, no studies have focused on the factors that provide explanations on how and why effectiveness could be achieved in this field. Understanding these factors would help healthcare practitioners and decision-makers to maximize the benefits of public participation in the field of health policy and planning.

In the broader literature, some studies considered factors such as context and participation techniques – the process or instrument that enables involvement – as influential factors in the effectiveness of public participation. For instance, Delli Carpini et al. (2004) concluded in their review that the effect of deliberation and other forms of discursive politics is highly context-dependent; it varies with the subject under discussion, who participates and who the authoritative decision-makers are. Other reviews point to the appropriateness of the public participation technique to the context. Rowe and Frewer (2004) suggest that, by ensuring that the public participation technique matches the context – asking, ‘what works best, when?’ – the technique can become effective. And yet, although context and appropriate technique are considered essential, factors that influence effectiveness, why and how these lead to effectiveness, has not yet been sufficiently explained.

To understand how to enhance public participation effectiveness, the concept of ‘effectiveness’ must first be clearly defined. Rowe and Frewer (2004) stress:

Unless there is a clear definition of what it means for a public participation exercise to be effective, there will be no theoretical benchmark against which performance may be assessed [p. 517].

Effectiveness in general could simply denote, ‘the degree to which something is successful in producing a desired result’ (Oxford online dictionary, see http://www.oxforddictionaries.com/definition/english/effectiveness?q=effectiveness, accessed 10 January 2014). In the domain of public participation, unlike in the medical and natural sciences, Rowe and Frewer (2000) point out that effectiveness cannot be easily identified, described and measured, as it is not obvious, unidimensional or objective. Other authors use the words ‘good’ or ‘successful’ to denote effective public participation (Beierle and Konisky 2000; Webler et al. 2001); these, however, are insufficient descriptions because they mean different things to different people.

The complexity of evaluating effectiveness has been recognised early on. But Rosener (1978) pointed out that the lack of knowledge about how to evaluate effectiveness is probably related to how few have acknowledged its complexity – they have not taken into account the range of actors, objectives and issues that surround it. This problem was soon remedied, however, when the complex issues surrounding the evaluation of effectiveness were identified (Rowe and Frewer 2004; Abelson and Gauvin 2006).

Rowe and Frewer (2004) identified three issues in the practise of public participation. One is the diversity of aims and forms of public participation techniques that has made it difficult to create a consensus regarding what can be considered ‘effective’. Another issue is that the definition of the success of public participation depends on whose perspective is being considered and what this perspective entails. The last issue involves both the practical difficulty in identifying the endpoint of the public participation exercise, and the consequent difficulty of measuring the outcome criteria. Despite these problems, however, several authors have put forward ways to approach its evaluation by defining several criteria of effectiveness (e.g. Rosener 1978; Sewell and Phillips 1979; Crosby et al. 1986; Fiorino 1990; Webler 1995). Most of these criteria, however, were merely indicators or ‘rules of thumb’ rather than a comprehensive framework for evaluation. To address this, recent authors have developed several frameworks to evaluate public participation effectiveness (e.g. Chess and Purcell 1999; Rowe and Frewer 2000; Stephens and Berner 2011).

In the literature on public participation, there are various criteria used to evaluate effectiveness. These include the following: public influence (Lauber and Knuth 1999; Petts 2001; Rowe and Frewer 2000; Butterfoss 2006), consensus (Bass et al. 1995; Innes 2004), increased understanding (Petts 1995; Laurian 2009), improved quality of decision (Laurian 2009; Brown and Wei Chin 2013) and increased trust (Wang and Wan Wart 2007; Laurian 2009). Other effectiveness criteria are also identified in the literature, such as representativeness (Crosby et al. 1986; Rowe and Frewer 2000), complete information exchange (Crosby et al. 1986; Rowe and Frewer 2000), independence (Lauber and Knuth 1999; Rowe and Frewer 2000), transparency (Lauber and Knuth 1999; Drew et al. 2004) and cost-effectiveness (Rowe and Frewer 2000; Involve 2005). The other effectiveness criteria, however, could be considered as processes to achieve effectiveness. Table 1 shows a summary of these effectiveness criteria that are considered as outcomes, rather than processes of public participation.

Table 1.  Effectiveness criteria in the public participation literature

The purpose of this paper is to identify the factors that generate these effectiveness criteria by identifying the underlying mechanisms within health policy and planning, and by considering the possible mechanisms derived from various disciplines. In this paper, a literature synthesis using a realist approach was performed – adding new knowledge by providing specific explanations as to what makes public participation effective in health policy and planning, while clarifying the contextual factors and underlying mechanisms that lead to it. The discussion of the concept of effectiveness in public participation was followed by an explication of the realist synthesis approach, and an outline of how studies were selected. The underlying mechanisms or causes of public participation effectiveness, and the contextual factors that trigger these mechanisms, were then subsequently presented. By uncovering an underlying mechanism from the field of health policy, and proposing the possible mechanisms derived from various disciplines, advocates and healthcare practitioners can better understand how to optimally involve the public in health policy and program planning. This could encourage the use of public participation in health policy-making by dispelling the prevailing scepticism surrounding its value – a scepticism due to the dearth of evidence supporting its effectiveness (Draper et al. 2010; Preston et al. 2010), and the claim by several health practitioners and policymakers that it is time-consuming and costly (Foley and Martin 2000).

In acknowledging the complexity of public participation, it is necessary to use a methodological approach suited to address this complexity – and the realist approach used here serves this purpose. Burton et al. (2006) have proposed this approach to evaluate public participation; they consider its potential in bringing to the surface key assumptions about how public participation is expected to make a difference. The appropriateness of this realist approach has been demonstrated by its use in the evaluation of complex systems such as complicated interventions and programs (Marchal et al. 2010).

This fairly new approach to literature synthesis has been increasingly used to understand programs or interventions, with the primary argument that no one particular intervention fits all situations because of its contextual dependence. Pawson (2006) clarifies the relationship of the intervention – in this case, the public participation technique – to the context. He argues that the intervention used does not independently produce effectiveness, but rather the context provides opportunities for this intervention to work. Although the contextual factors and the match between techniques and context may influence the outcome of the public participation exercise, they neither directly nor primarily cause public participation effectiveness.

The realist inquiry is based on a realist philosophy of science that seeks to explain a certain complex phenomenon by uncovering the underlying reason that generates an outcome. Understanding the underlying cause of a particular outcome of interest – in this case, effective public participation in health policy-making – requires the need to look beyond the observable (i.e. context and participation technique) and delve into the underlying reasons or so-called causal mechanisms (Pawson and Tilley 1997) – the underlying entities, forces or powers that actually directly cause the outcome (Pawson 2006). The use of a realist approach allows researchers to look at the interconnection between context and outcome, and explains their connection through an underlying reason or mechanism. Through the realist approach, it becomes clear that the underlying mechanism that leads to the outcome is only turned on when the context is appropriate to the participation technique used.

Realist synthesis involves an iterative process of synthesising the existing literature. The systematic search is not only limited to the use of the identified search terms but also progressively searched for evidence through snowball searching (e.g. identifying possible additional papers after reading initial papers). The following sections will outline, step-by-step, the process of how we arrived at the underlying mechanisms of effective public participation, thus offering an explanation as to how and why they succeed.

In order to identify relevant studies, a comprehensive search strategy was developed based on the focus of this paper: what generates public participation effectiveness within health policy and planning? Accordingly, four main terms were identified for the search, namely: participation, decision-making, effectiveness and health policy. Concepts related to each of these four terms were also determined, giving four sets.

The first set included the following: ‘community participation’, ‘community involvement’, ‘community engagement’, ‘citizen’s participation’, ‘citizen involvement’, ‘citizen engagement’, ‘public participation’, ‘public involvement’ and ‘public engagement’. The second set included: ‘participatory forum’, ‘citizen jury’, ‘public consultation’, ‘public deliberation’, ‘participatory decision-making’, ‘public hearing’, ‘council meeting’, ‘advisory panel’, ‘health facility committee’ and ‘advisory board’. The third set included: ‘effectiveness’, ‘successful’, ‘good’, ‘active’, ‘efficient’, ‘productive’, ‘challenges’ and ‘facilitate’. The fourth set included: ‘health policy’, ‘health planning’ and ‘health priority-setting’.

A series of literature searches was conducted on several databases, including Scopus, Proquest Central, CINHAL, Medline (Ovid), MEDLINE, PsycINFO, Sociological Abstract, Wiley Online Library and Web of Science. A librarian was consulted to identify the most appropriate databases in relation to the research question. The search was primarily conducted in January and February 2013, and a subsequent progressive search through a snowball approach in April and May 2013 was also done. The search was significantly updated in May 2015 and in February 2016. These searches were conducted mainly through online sources, particularly for journal articles written in English, as these are the most accessible sources.

In this synthesis, the search within the field of health policy and planning were presented first. Synthesis of papers within this field drew some findings but showed fairly limited explanations about the mechanisms that generate public participation effectiveness. Unpacking explanations of public participation effectiveness and adding explanations from broader sources provided valuable insights. The findings derived from the broader literature were then presented. These disciplines that commonly use a public participation approach in policy or program development includes community development, public administration, environmental science, science and technology, and health care and social work.

Literature that met the following criteria were selected: (a) studies that relate to participatory practices in decision-making such as policy-making, public consultation or deliberation, planning or budgeting; (b) articles with major discussions about any form of improving or sustaining the effectiveness of public participation; and (c) reviews and theoretical articles, and original researches. For the search within health policy and planning, we added a fourth criterion that is relevant to this particular field. Theoretical articles were included because they provide the conceptual basis for their interpretation of the data. Review articles were included because their focus is different from the primary studies they reviewed, and therefore provided another perspective.

The keywords search generated 32 papers within the field of health policy and planning (Fig. 1). The search across disciplines generated 1324 references (Fig. 2). After assessing the article titles and abstracts, many were excluded. These excluded articles were teaching guides, government reports, poster presentation abstracts, conference session presentations and book reviews. Approximately 40 duplicates were also excluded. Full texts of the remaining articles were assessed for relevance and more articles were excluded. A further extensive search through a snowball process was conducted by using modified search terms relevant to the initially identified contexts, mechanisms and outcome components, and by looking at the references of the previous articles. The total number of papers included for the selection of papers for the health and policy and planning was 15, whereas the total number for papers selected across disciplines was 62 papers. Figs 1 and 2 show the selection process of relevant studies: Fig. 1 shows the selection process of papers for the health policy and planning field; and Fig. 2 shows the selection process of relevant papers across disciplines.

Fig. 1.  Selection process of relevant studies from health policy and planning.

Fig. 2.  Selection process of relevant papers across disciplines.

Articles from peer-reviewed journals were initially chosen. These were further winnowed down to those that focused on decision-making and on ways to enhance public participation. Original studies were used, but some secondary studies that supported and clarified the original studies were also included. These studies were judged on their relevance and the robustness of their data for the purpose of answering the specific questions within the overall review question. Although the process of appraising the literature is fairly flexible, which resulted in the generation of several studies particularly for the broader literature, the intention is to do reconnaissance or mapping of the literature to provide possible explanations of the factors that make public participation effective, which are unclear in the field of health policy and planning.

To uncover the underlying mechanism that generates effective public participation, identified as criteria of public participation effectiveness (Table 1), data were extracted from the selected articles for explanations of how and why a particular evidence of public participation effectiveness was achieved. To illustrate using the broader literature, the mechanism of ‘political commitment’ was found to generate effectiveness criteria of ‘public influence’, ‘consensus’ and ‘increased understanding’. This mechanism was initially articulated in some articles as the ‘willingness of government leaders to support public participation exercise’; others articulated it as ‘capacitating the public for public participation’. Through an iterative process of coding and thematizing text extracts of articles that explain a direct link to any of the outcomes or criteria of public participation effectiveness, the underlying mechanisms were drawn from these studies. Following a similar process, specific contextual factors were also extracted from the selected studies that have shown to activate the distinct underlying mechanism. Data extractions are shown in the Supplementary material (Tables S1 and S2 of the Supplementary material). Detailed descriptions of the underlying mechanisms and contextual factors are presented in the next section.

Using the realist approach to outline the context-mechanism-outcome configuration (CMOc), ‘political commitment’ was uncovered as the underlying mechanism that generates public participation effectiveness in the field of health policy and planning. The succeeding subsection is a discussion of this mechanism.

This mechanism relates to the impetus of health policymakers and public participation organisers in achieving public participation goals. In the organisational commitment literature, Mowday et al. (1979) relate commitment to three behaviours: (1) a strong belief in and acceptance of the organisation’s goals and values; (2) a willingness to exert considerable effort on behalf of the organisation; and (3) a strong desire to maintain membership in the organisation.

This review of the health policy and planning literature reveals some elements of the mechanism of political commitment. Li et al. (2015) described ‘willingness to listen’ as the openness of the policymakers to communicate with the public and consider their input irrespective of its substance. Though they present this as a signal to the public that political leaders are disposed to do something with the public input, indications of translating this into concrete action would be indispensable. Other studies provide evidence to support this element. For instance, Boivin et al. (2014) articulate that officials pro-actively seek advice from the public and promote policies that are important to them. Kitzhaber (1993) further emphasised the importance of assembling the results of public participation exercise into reports, and having the decision-makers actively use this document. Public inputs in its raw form, however, may not be ‘digestible’ to be useful for policy formulation. The necessity of faithfully transforming public inputs into clear policy priorities is necessary. This requires the involvement of mediating bodies (Tenbensel 2002; Li et al. 2015) to interpret information to be translated to policy priorities. This element is described as ‘partnership brokering’. Support of public participation designers and policymakers to this mediating or brokering process facilitates public input to be translated to policy decision, thus allowing public influence on policy decisions.

Participants of public participation exercise should necessarily have a good appreciation and understanding of the design of the exercise and the health problem under question to contribute adequately in the deliberation process. Kitzhaber (1993) points to another significant element of this mechanism and asserts that designers of public participation exercise should have the ‘dedication to educate’ the public on health policy choices and its consequences. Molster et al. (2013) consider that the achievement of deliberative principles is attributed to the information provided before and during the deliberation process that is considered fair, balanced and useful for learning about policy issues and the perspective of others. This element fulfils the educative purpose of a public participation exercise in particular, which is primarily a responsibility of the organisers.

Involving the public in health policymaking also requires allocation of adequate resources. For instance, Molster et al. (2013) and Alborz et al. (2002) highlight that effective public participation could be achieved when the sponsoring institution allocate significant human and financial resources to the deliberation forum. Outcomes that address the meso-, micro- and macro-level social structures could also be achieved when adequate resources are allocated to implement related strategies (Restall 2015). The cost of implementing public participation exercise, however, should not outweigh the benefits in implementation.

Li et al. (2015) present another important element of this mechanism – signalling use through a ‘feedback loop’. Participants of a deliberation exercise ideally appreciate responses on how ideas and suggestions of the public are used internally by the organisation or externally by relevant stakeholders. More specifically, Li et al. (2015) noted that some organisations provide detailed feedback through reports and responses on what inputs of the public have been considered or accepted, as well as reasons for rejecting recommendations. By signalling use through a ‘feedback loop’, public officials indicate a gesture of transparency and accountability to public participation exercise. Molster et al. (2013) agree on the importance of making the forum design and translation of output into publicly available policy. Li et al. (2015), however, noted conflicting evidence on the tracking tools to respond to the use of public inputs.

In this review, we found that public officials who have a strong belief and consideration for the principles of public participation exercise, and who are willing to exert considerable efforts for its success, would consistently act for public input in health policy and planning. Many policy actors have always regarded political commitment as the reason for success in any political undertaking; the absence of which is always regarded as a reason for failure of the implementation of a program or policy. The concept of political commitment could be synonymous with political will (te Lintelo and Lakshman 2015). In the organisational commitment literature, there is a growing body of knowledge that could be relevant to public participation. For instance, in the notion of ‘consistent lines of activity’, Becker (1960) refers to commitment as a consistent behaviour and persistent support through engagement of people in a quite diverse types of activities necessary in the pursuit of a particular goal. Evidence from this review is also consistent with affective commitment, as described in this body of literature; though other types of commitment such as continuance and normative commitment (Meyer et al. 2002) are also relevant. Affective commitment denotes an emotional attachment to, identification with, and involvement in the organisation, and continuance commitment denotes the perceived costs associated with leaving the organisation; the perceived obligation to remain in the organisation is called the normative commitment (Meyer and Allen 1984). This indicates that politicians can engage in ‘consistent lines of activities’ and can be responsive to public participation when they are aware how this exercise works, when it complements their political goals or when they have a personal connection to the exercise.

In this synthesis, we found that the mechanism of political commitment works when the health problem identified affects the common good, when it is considered a priority of the users (Crawford et al. 2003; Carman et al. 2015) and when the identified health problem is clear and specific (Abelson et al. 2003; Crawford et al. 2003). Intangible outcomes of public participation brought about by broadly defined issues promote the notion that nothing comes out of it. For example, the issue of teenage pregnancy could generate a more tangible public participation outcome than issues of determinants of health such as income, which is broader. It is also necessary that plans and decisions should be enacted with broad-based support (Molster et al. 2013; Whitty and Littlejohns 2015) and with the involvement of mediating bodies to ensure effective translation of public input (Tenbensel 2002; Li et al. 2015). This should be accompanied by the presence of a political mandate where policies are enforced that make public involvement a requirement (Kitzhaber 1993; Crawford et al. 2003) in health policy development and program planning.

Several studies show that public participation indeed increased the knowledge on the topic and helped the participants realise the processes involved (Abelson et al. 2003; Goold et al. 2005; Guttman et al. 2008; Carman et al. 2015). However, in ethical decision-making in health policy, Mullen (2008) doubts if the public participation process increases the defensibility of decisions. Further, although Molster et al. (2013) argue that complete consensus is unlikely, it is possible that participants mutually agree, especially when the issues are clear and specific (Abelson et al. 2003; Boivin et al. 2014). The role of mediating bodies contributes significantly for the public to influence policy (Tenbensel 2002; Li et al. 2015), as they enhance the rationality and legitimacy of the decision. Fig. 3 below shows a summary of the CMOc of political commitment, as derived from the field of health policy and planning.

Fig. 3.  Mechanism of ‘political commitment’ in health policy and planning.

The synthesis of the health policy and planning literature that uncovered the mechanism of ‘political commitment’ shows a significant explanation of what makes public participation effective in this field. This, however, could not explain the other public participation effectiveness criteria, as presented in Table 1. Although there are an increasing number of studies that explore the factors affecting effectiveness, findings in this field cannot sufficiently explain the various factors that generate effectiveness. It would be insightful to ask – what evidence can we draw from the broader literature that presents potential explanations of the effectiveness of public participation in the health policy and planning field?

The current evidence from the broader literature across disciplines shows potential mechanisms that generate some of the effectiveness criteria that could be pertinent to health practitioners and health policymakers. The process of generating evidence within the broader literature was similar to the process conducted in the field of health policy. The only difference is the exclusion of the search term ‘health policy’ and its related terms. A brief discussion of these possible underlying mechanisms follows.

Four possible mechanisms were theorised from the broader literature as the underlying mechanisms of public participation effectiveness that could be relevant in health policy-making and program planning. These are, namely, ‘political commitment’, ‘partnership synergy’, ‘inclusiveness’ and ‘deliberativeness’.

In the broader literature, the mechanism of ‘political commitment’ refers to the willingness of politicians and public participation organisers to take action to achieve public participation goals. Although public participants should also exemplify willingness, the focus on politicians and organisers in the literature suggests the decisive role that this group plays in the design of the public participation exercise and achieving effectiveness. In particular, the mechanism of ‘political commitment’ generates public participation effectiveness in terms of ‘public influence on decision’ and ‘increased understanding’.

Most of the articles that have shown evidence on this mechanism relate to the active support of the agency (especially the government), in terms of building local leaders’ capabilities, strengthening the community health sector and providing resources (Neudoerffer et al. 2001; Church et al. 2002; Frankish et al. 2002; Leach 2006; Yassi et al. 2013). Providing information to and developing the technical skills of participants are considered essential for effective public participation (Burroughs 1999; Loubier et al. 2005; Calland and Nakhooda 2012). Capacitated participants who have a certain level of understanding of the issue can articulate their arguments more effectively and may see the different aspects of the issue. For instance, Mendoza et al. (2007) use an innovative outreach model of a ‘Knowledge Exchange Train’ as an effective means of broadening the participation of local leaders and stakeholders in planning for sustainable development. Sharing of recent research findings among sustainable development practitioners through this model led to public awareness, which in turn enabled local leaders and other stakeholders to hold a dialogue and debate with decision-makers.

These capabilities and resources are essential to enable participants to perform their tasks and to conduct situation assessment properly. Further, decision-makers and organisers should be willing to understand the views and circumstances of the stakeholders (Mustajoki et al. 2004; Dalton 2005; Burkardt and Ponds 2006; Webler and Tuler 2006; Baggett et al. 2008; Avard et al. 2010; Sevenant and Antrop 2010; Agger 2012; Lehoux et al. 2012). It is necessary that citizens’ resources and capacities are appraised, and that clarity about their viewpoints and expectations of the process are achieved. This includes the identification of who should participate, and how they can participate. This knowledge is essential to guide the organisers of the participatory exercise with regard to the identification of the appropriate type and extent of public involvement. Knowledge about the contexts where participatory practices are implemented is another important element of this mechanism (Abelson et al. 2007; Sneddon and Fox 2007; Boote et al. 2010; McCoy et al. 2012). The analysis of the political, social and cultural conditions, including the role of power, enables public participation practitioners to situate efforts in making public participation contribute to the social development process. It also shows that public participation outcomes vary in different settings. As these authors point out, context matters in public participation and it is essential to create the context that is favourable for participation to achieve its desired goals.

Other authors argue that willingness to yield power is a prerequisite when organisational structures need to be created, as well as a fundamental change in the politician’s perception of their traditional role (North and Werko 2002). Likewise, this mechanism relates to the public officials’ openness to ceding genuine voice to the stakeholders and to creating a decision-making environment, so they can weigh the value of the different responses being presented.

The mechanism of political commitment is triggered in circumstances where a public participation initiative is consistent with government policies and programs, such as ‘devolution’ – described as the shift of the approach of governance from the traditional top-down process to a bottom-up process, or decentralisation of health governance, and the incorporation of public participation as an essential aspect of health reforms (Church et al. 2002; Frankish et al. 2002; North and Werko 2002; Sevenant and Antrop 2010). Complementarily, organised public participants could also contribute in activating this mechanism. For instance, Yassi et al. (2013) observed that in a unionised working environment, it is more likely that management will pay attention to recommendations made by the health and safety committees. The CMOc for political commitment drawn from the broader literature is shown in Fig. 4.

Fig. 4.  Context-mechanism-outcome configuration (CMOc) for the possible mechanism of political commitment.

The mechanism of ‘partnership synergy’ was found to operate in collaborative processes that generate consensus among participants. This mechanism is considered an underlying factor in the resolution of differences and conflicts among diverse groups who usually have polarised views, as well as different capacities. Synergy could be described as the ability to work together by combining resources in order to produce an output that cannot otherwise be achieved by single agents (Lasker et al. 2001).

Some studies suggest that a quality working relationship, trust and a degree of shared identity are the essential elements of this mechanism (Carr et al. 1998; Hartz-Karp et al. 2010; Poetz 2012). By investing resources in long-term relationship building – before, during and after – the quality of interaction can be improved and misunderstandings can be reduced (Poetz 2012). A synergistic collaborative process also relies on the level of trust among participants, which enables individual interests to be transcended when searching for a group solution (Carr et al. 1998). Despite differences in their backgrounds, the emergence of a shared identity or friendship, a belief in fairness, and determination in the face of adversity are vital for enhancing the participants’ understanding of the ‘common good’ (Hartz-Karp et al. 2010). This mechanism serves as the stimulus for a more fruitful and meaningful collaborative process, which explains why consensus is achieved.

This mechanism works best in a context wherein diversified stakeholders are able to recognise the existence of heterogeneity within and between communities (Poetz 2012), and acknowledge the existence of inherent conflicting cultural and political vantage points in a pluralistic society (Hartz-Karp et al. 2010). The other contextual factors that activate this mechanism are the presence of legislation that requires public participation (Carr et al. 1998) and the interest of fostering democratic discourses and discussions (Bryner 2001). Further, specific conditions are necessary to achieve consensus such as clear and binding rules, leadership by the agency and the presence of a facilitator who manages conflict and keeps the process going (Bryner 2001). In Fig. 5, we present the CMOc for partnership synergy.

Fig. 5.  Context-mechanism-outcome configuration (CMOc) for the possible mechanism of partnership synergy.

‘Inclusiveness’ relates to the accommodation or consideration of a broad range of views and values in a public participation exercise. The most common manifestation of this mechanism relates to the involvement of multiple publics and groups with a special attention to minority groups (Summers and McKeown 1996; Kashefi and Mort 2004; Brackertz and Meredyth 2009; Menon and Stafinski 2011; Griebler and Nowak 2012). These minority groups include those who have a marginalised voice and those who are not usually inclined to participate; that is, ‘hard-to-reach’ stakeholders. One way to increase participation from the poor and marginalised is by restructuring the public participation process, which initially separates the deliberations of the poor from that of the powerful, and only later comes together to a final combined plenary session (Sultana and Abeyasekera 2008).

Web-based approaches to public participation are essential to minimising power dynamics because they circumvent the normal reticence of the public to speak in front of large audiences (MacMillan 2010; Klenk and Hickey 2011). However, Evans-Cowley and Hollander (2010) argue that technology-based public participation works best as part of a broader public participation process. This suggests that public participation should happen at different levels and with different methods; for example, the use of a combination of techniques that may provide balance between breadth and depth, leading to a more rounded understanding of public situations or increased understanding (Mullen 2008; del Rio and Levi 2009; Mitton et al. 2009; Aditya 2010; Evans-Cowley and Hollander 2010; Mandarano et al. 2010; Fredericks and Foth 2013). However, Oliver et al. (2009) point out that the development of such methods of involvement should be a shared task with lay people, to allow them to be more proactive rather than being merely required to comply with methods developed by professionals alone.

Although participation of all stakeholders may not be possible in many public participation exercises, it is suggested that representatives should at least ensure constant communication with their constituents through reporting and consultation – in order to access their views and feedback, thus ensuring broader public participation (Oliver et al. 2008; Griebler and Nowak 2012).

The important contextual factors that drive inclusiveness were pointed out in the literature; these included the diversity of participants that requires the inclusion of varied interests or opinions and the recognition of varying degrees and levels of participation (Webler et al. 2001; Litva et al. 2002; Mustajoki et al. 2004; Webler and Tuler 2006; Burkardt and Ponds 2006; Baggett et al. 2008; Agger 2012). Similarly, in many instances, the use of a single participation technique inadequately involves the stakeholders. This requires the use of diversified participation techniques and use of different methods to involve the public (Rowe and Frewer 2005). It is also essential that the participation techniques should allow an interactive and iterative process of deliberation (del Rio and Levi 2009; MacMillan 2010). In Fig. 6, we present the CMOc for inclusiveness.

Fig. 6.  Context-mechanism-outcome configuration (CMOc) for the possible mechanism of inclusiveness.

The mechanism of ‘deliberativeness’ refers to the quality of the dialogue and debate over issues under question. The literature primarily relates this mechanism to the quality of the communication process in the actual decision-making – a practical, interactive deliberation free from compulsion and allows the stated proposal to be questioned (Khisty and Leleur 1997; Johnson and Dagg 2003; Hamlett and Cobb 2006; DesRoches 2007; Lamers et al. 2010; Rossmann and Shanahan 2012). One essential strategy to achieve good communication is the use of a professional facilitator. For instance, high-quality facilitation skills are essential to avoid what is called the ‘polarization cascade’ (Hamlett and Cobb 2006); that is, the adoption of the opinion of others on the basis of cosmetically persuasive arguments or simply because the minority can come up with only a few ideas. Another significant indication of deliberativeness is the quality of the information provided as requisites for discussion, such as balanced, simplified and relevant informational materials (Del Furia and Wallace-Jones 2000; Berry et al. 2011; Molster et al. 2013).

The mechanism of deliberativeness is most possible to be activated in circumstances where there are policies or legislations that provide the opportunity for the public to express their needs and opinions (Del Furia and Wallace-Jones 2000; Johnson and Dagg 2003). The other condition is equal participation of all members, which includes safeguards against any form of internal exclusion (De Vries et al. 2010). One specific example, suggested by Higgs et al. (2008) in their study about public participation in a wind farm development, is the use of a deliberative structure that combines multi-criteria decision analysis (MCDA) and a geographical information system (GIS). Through a GIS, participants can explore different aspects of the problem based on the landscape visualisations of project sites. MCDA provides a structured environment for investigating the sources and intensity of conflict among diverse participants, and it promotes communication. These tools ultimately permit a greater degree of interaction and allow stakeholders to contribute to decision-making more effectively.

Another condition is the presence of a trusting relationship between the participants of the deliberative forum. Such relationships allow for a more meaningful public participation, as it engenders a willingness to work, to listen, and to live with the decision jointly arrived at. Parkins and Mitchell (2005), however, elaborate that some guarantees for the public should be present; assurance of their safety and assurance that their voices will be heard. They further point out that in a deliberative process, the focus is on an institutional level of trust rather than interpersonal trust, as the latter may depoliticise the public process and limit the quality of critical debate.

The last condition is the presence of a structured process that emphasises reasoned and informed discussions. In the Gooberman-Hill et al. (2008) study, a citizens’ jury enabled participants to develop a deep engagement with the topic in question, which resulted in the commitment of the participants to, and their continued interest in, the process. In the same study, it was further found that the participants’ continuing interest and engagement was also a product of a belief in their ability to shape decisions, not just of the calm deliberative nature of the negotiation. This mechanism of deliberativeness is shown to generate increased understanding and improved quality of decision.

In summary, this synthesis of the health policy and planning literature and its comparison with the broader literature shows that the mechanism of political commitment is consistently uncovered. This mechanism generates public influence, increased understanding and reached consensus. The broader literature suggests three other possible mechanisms of partnership synergy, inclusiveness and deliberativeness that could be relevant to the field of health policy and planning. These generate effectiveness such as increased understanding, consensus and improved quality of decisions. However, this synthesis was unable to show the specific mechanism that generates specific effectiveness criteria, such as increased trust.

Moreover, these mechanisms come into operation within appropriate contextual conditions. These contextual conditions can be broadly classified as public participant’s features, health system features and health problem features. For example, diversity of stakeholders and organised groups are classified as public participant’s features. Decentralised governance and public participation as part of the health system reform are classified as health system features. Health problems that affect the common good and priority of the public are considered as health problem features. The concurrent presence of some of these specific contextual features could activate a particular mechanism to generate a particular effectiveness criterion, as described in Figs 4–7. Fig. 8 shows a summary of the review findings.

Fig. 7.  Context-mechanism-outcome configuration (CMOc) for the possible mechanism of deliberativeness.

Fig. 8.  Summary diagram of the context-mechanism-outcome configuration (CMOc) of public participation effectiveness.

This realist synthesis of 15 papers from the health policy and planning literature, and 62 papers from the broader literature, offers a new way of understanding the complexity of public participation effectiveness.

The mechanism of political commitment that is consistent with both health policy and planning and the broader literature highlights the impetus of public officials in achieving public participation effectiveness. This is consistent with the observation made by Crawford et al. (2003) on the central role that managers and staff play in determining the effect of public participation exercise. It indicates that in achieving various public participation effectiveness, it is imperative to consider the critical role of public participation sponsors and public officials (Abelson and Gauvin 2006), especially that ultimately, the policymakers will decide whether to incorporate the public inputs in policy decisions (Milewa et al. 2002). Further, as the mechanism of political commitment primarily focuses on public officials, this review finding is relevant to the observation of Boswell et al. (2015), whereby ‘invited’ spaces, or those state-initiated arenas for public participation, have more direct effect or influence on policy decisions and decision-making processes compared to those participation spaces in which the citizens created themselves – or the so-called ‘invented’ spaces. It is essential, therefore, to recognise and utilise the state institutional support to sustain such spaces for public participation. However, public participants and organisers of such exercises should acknowledge that policymakers will not always take on board the proposals derived from the collective decision-making processes; and policymakers ultimately rely on their judgement of its political cost and benefits (Zalmanovitch and Cohen 2015). Success of public participation initiatives relies heavily on the political leaders’ commitment and authority. As such, building genuine political commitment is so important in achieving public participation effectiveness, such as public influence on policy decisions, consensus and improved decision quality.

Although this synthesis highlights the primary role of policymakers and organisers of public participation exercise, a dynamic interaction of the public officials and the public is indispensable in a democratic process. To leave the question of public participation effectiveness to public officials alone is inappropriate because there are circumstances where power differential persist, and politicians and organisers have limited perspectives. As such, the public may not expect a significant public participation. In this situation, the argument made by Contandriopoulos (2004) that public participation as intrinsically related to power relations, shows that the willingness of political leaders to yield power to the public could be another possible element of the mechanism of political commitment. A significant amount of power should be provided to the public, especially for those who usually do not have the opportunity to be heard, such as Indigenous peoples, elderly, youth and the disabled. Although this is not highlighted in this synthesis, Yassi et al. (2013) described the importance of an organised group to negotiate with the political leaders in influencing the outcome of public participation. The operation of the mechanism of political commitment to the public participants is obviously very much relevant. Public participants, who are pro-active, willing to participate, willing to allocate time and resources, and consistently engaged in public participation exercises, are equally important in the success of such an initiative.

The broad range of effectiveness, as shown in the public participation literature, indicates that it is not only through public influence on policy decisions where public participation could be considered as effective. Rowe and Frewer (2004) argue that various players of such exercise could achieve certain outcomes. Effectiveness depends on whose perspective is being considered and what this perspective entails. For example, effectiveness for marginalised groups may mean inclusion of their views and opinions into policies or decisions. To the policymakers, effectiveness may mean a decision that balances the people’s needs and their own political goals.

In contrast, political commitment should not be viewed as simply an intention to act and expression of support to public participation initiatives, but should also indicate evidence of sustained action. ‘Willingness to listen’, as an important element of political commitment drawn from this synthesis, could be complemented by concrete actions, such as evidence of utilisation of public inputs as well as evidence of translating the public inputs through support to mediating bodies. Similarly, ‘dedication to educate’ should also be supported by corresponding persistent actions relevant to the public participation exercise, such as providing adequate resources for the preparation and actual delivery of educational activities, as well as knowing what educational activities works and what does not. In this way, stakeholders are allowed to learn more effectively the topic of interest and process of public deliberation. Rather than just leaving the responsibility of capacity building for public participation as a main responsibility of the public participants, it is argued here that this is the main responsibility of the state as an important element of political commitment to incorporate public voice in health policy and program planning. This review finding supports the argument that political commitment is a concept that is not separate from or precedes actions on the ground (te Lintelo and Lakshman 2015). Similarly, the notion of ‘consistent line of activity’ indicates a sustained engagement of political leaders in organisational initiatives including public participation in health policy and planning.

The other possible mechanisms identified in the broader literature, namely ‘partnership synergy’, ‘inclusiveness’ and ‘deliberativeness’, also offer a more structured understanding of the merits of participation within particular contexts. This review presents potential explanations to be considered in the practice of public participation in health policy and planning, but more evidence should be derived from the literature when considering these potential mechanisms to this field.

The use of the realist approach in public participation allows researchers and healthcare practitioners in this field to understand the interaction between the specific contextual factors, underlying causal mechanisms and specific desired outcome. As has been shown, both the context and the match between participatory technique and context are undeniably essential for effectiveness. In this synthesis, we argue that understanding the actual interaction between context, mechanism and outcome presents a more systematised explanation for how effectiveness is achieved, and thus can aid policymakers and health practitioners. The question posed by Rowe and Frewer (2004) and other researchers – ‘what works best when?’ – can be reformulated in a realist way as ‘what works, for whom, in what circumstances and why?’ By looking at the interaction between context, mechanism and outcome, we have provided a framework for understanding how to achieve specific effectiveness outcomes, such as public influence, consensus, better understanding and representativeness. The current assumption in the literature that the public participation technique should match the context for it to be effective could be further systematised by uncovering the actual causal mechanisms that link this match directly to its effectiveness.

Based on the findings of this review, we suggest that the mechanism of political commitment is decisive in aiming for public participation effectiveness. To achieve various effectiveness criteria for public participation exercise, the organisers as well as the participants should prioritise nurturing political commitment. This could be done by building the willingness and confidence to act, and sense of responsibility of policymakers, advocates as well as the public, towards a meaningful public participation exercise. These efforts could be facilitated when emphasis is given in strengthening the willingness of public officials to listen and to provide feedback to the public. Efforts should also ensure the active interpretation and translation of public inputs to policy priorities, as well as increasing the political leader’s amenability to yield power to the public. Apart from consistently engaging the public officials or their representative in the processes of this exercise, working on their political interest and possible political gains by involving the public in health policymaking may help build their political will for public participation. Sharing the good practices of other localities about the practice of public participation in health issues has also been observed as helpful.

Although there are circumstances where public participation may not be necessary, such as in emergency, in many situations, public participation could generate various outcomes or effectiveness criteria. We have shown in this synthesis that the use of the realist perspective could provide clarifications on how best to involve the public rather than debating on whether to involve the public when drafting health policies and programs. Uncovering the mechanism of political commitment and other possible mechanisms provides significant evidence that shows that effective public participation can indeed be achieved. Further studies are recommended to explore the possible mechanisms that were drawn from the broader literature and uncover the new mechanisms that may concretely contribute in generating the other effectiveness criteria for public participation.

Our hope is that public participation will be fully accepted by those who are sceptical about its value. The current scarcity of studies on the effectiveness of public participation has contributed to this scepticism. Further studies that strive to understand the effectiveness of involving the public in drafting health policies and programs by focusing on the underlying mechanisms linking context to participation techniques should serve as an appropriate remedy.

C. P. Pagatpatan initially conceptualised this research, which was further developed with P. R. Ward. C. P. Pagatpatan conducted the systematic search and appraisal of the literature. P. R. Ward provided comments and guidance during the entire process and substantially contributed to the analysis of the findings. C. P. Pagatpatan wrote the initial draft report, on which this manuscript is based. P. R. Ward commented and provided further refinements of the manuscript. Both authors have read and agreed on the final manuscript.

The authors declare that they have no conflicts of interest.