10.B. Round table: Strengthening health sector governance in plural health systems through community participation

Abstract Health systems are moving towards a more plural model of healthcare delivery with growing private service provision. Without adequate governance, duplication, service gaps, provider opportunism, and rising costs often prevail. Community participation in health governance is a potential coordinating mechanism to promote accountability, provide local knowledge about services and determinants of ill-health, and rebalance power relations, contributing to more inclusive, responsive health systems. But this potential is under-explored empirically. In this workshop, efforts from India, South Africa, and Brazil to strengthen community participation in the governance of urban primary care will stimulate discussion around the potential and pitfalls of community participation in plural health systems. The workshop begins with an introduction to the NIHR-COMPLUS, project. Presentations from each country follow. The Brazilian COMPLUS team works with health councils, municipalities, and healthcare providers in São Paulo and Fortaleza to coproduce citizen-centred indicators measuring care access and quality. This is an attempt to move away from the current centrally designed evaluation system which lacks community input and neglects stark urban inequalities, partly because Brazil's community health councils are sidelined by local governments and private providers. The indicators and the process of coproducing them could foster accountability and the development of more equitable, responsive care. In South Africa, the team collaborates with public sector health committees in Cape Town and Gqeberha. We examine how communities can meaningfully participate in a plural health system envisioned under the recently enacted National Health Insurance (NHI) through testing and strengthening inclusive participatory governance mechanisms, including establishing user committees at private facilities similar to public health committees, advocating for policy changes to ensure participation in NHI governance structures, capacitating health and user committees, and disseminating knowledge about the NHI. These strategies aim to foster an equitable, responsive and accountable health system with universal health coverage (UHC). The Indian team works with Mahila Arogya Samitis (MAS) -women's health committees- to co-produce nine interlinked elements for an intervention aimed at strengthening community voice. We discuss the participatory and iterative process of the development of these elements through sustained dialogue with MAS members, frontline health workers, health department officials, and civil society actors- centering lived experience and addressing everyday exclusions. The second half invites the audience to reflect on how to meaningfully involve citizens in governance for more inclusive, responsive and transparent plural health systems, focusing on power relations; policy and evaluation frameworks; local determinants of health; and community capacities. Key messages • Participatory mechanisms could help plural health systems become more equitably governed and deliver more responsive services - but implementation is complex. • Insights from three countries suggest context-sensitive strategies and co-production methods to strengthen community participation through addressing enablers and barriers. Speakers/Panellists Zoheb Khan The Brazilian Center of Analysis and Planning, Sao Paulo, Brazil Jith Jagajeevan Remadevi The George Institute for Global Health, Thiruvananthapuram, India Therese Boulle University of Cape Town, Gqeberha, South Africa