Key Message

9: Deepening participation takes time, consistent presence and capacities

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Whatever the practices, building participatory interaction between communities and services in a manner that is empowering for communities is not achieved in a single step or two. It takes time to let models evolve, to identify where and how best to contribute and for work to remain grounded. 

Time and consistent presence is needed to embed mentoring and capacity building and enable horizontal connections and spread across communities. While demanding of time and often facing opposing power, growing social power and trust and shared strategic review with those involved, including employees and community members, helps to build and sustain the work. 

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Story of Change
CHD Murska Sobota

Building institutional mechanisms and capacities for participation in health and development in Pomurje region, Slovenia

Beznec P, Maučec G, Nemeš S, Nemeš D, CHD, TARSC 2018

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The global financial crisis in 2008 hit Pomurje region Slovenia hard, with unemployment, falling levels of education and entrepreneurship and an exodus of youth and experienced workers. This added to other health challenges and high levels of inequality in health. In Slovenia regional development agencies co-ordinate stakeholders and municipalities plan and manage development and public services, including for healthcare. There are, however, no formal mechanisms for direct public participation in decisions on health policies. The public express their views through debates, parliamentary discussions, media, social protests, people’s initiatives and referendums, municipal representatives, patient agents, councils, websites and the media.

In 2001, Programme Mura initiated an investment in health approach to support the region’s economy and reduce health inequalities. The goal to identify and prioritise actions that would improve health equity led to agriculture, tourism, health and environment being prioritised.  Click on the second photo adjacent to see a video that describes some of this work. While the institutional resources to deliver the interventions were already in place, the co-ordination mechanisms to make them happen were not. So an inter-ministerial working group was set up to co-ordinate, guide and support the work, a Regional Action Group (RAG) formed to enable wide participation of various groups and Programme Council Mura and the Centre for Health and Development (CHD) founded as technical agencies.

 After mapping stakeholders a “RAG Mura was established for cross-sectoral and stakeholder collaboration, involving state sectors, social organisations, associations of pensioners, people with disabilities, Roma community, civil society associations, long-term care organisations, local universities and media. Participants are delegated by their institutions, sign a letter of intent to work within the RAG and participate as full members in each of its four working groups. The decision-making body is the assembly, where each member has one vote. CHD staff provide a secretariat including to support co-ordination with between higher levels of the systems.

Using a Health Equity 2020 toolkit  the priorities are identified as actions that support health equity and local economic and social development. Four key action areas were identified, that link participation in decision-making to participation in health and in economic activities:

  1. Health and healthy lifestyles, involving physical activity programmes, infrastructure, accessibility for vulnerable groups; healthy diet in kindergartens and schools; healthy ageing; mental health and social inclusion.
  2. Agriculture, involving healthy food; fruit and vegetables production, diverse quality food; local food supply, short food supply chains and social enterprises in quality food production and processing.
  3. Healthy tourism, involving hiking, biking, Nordic walking, active tourism (programmes, infrastructure); local healthy food and sustainable tourism in a ‘healthy tourist offer’.
  4. Environment, involving active mobility; water resources; renewable energy sources and efficient energy use.

Hence, for example, the local farm community now supplies schools and kindergartens in the area with locally grown produce, incentivised by public procurement systems that are oriented towards preferring healthier choice. In the healthy tourist offer programme, local foods are sold in tourist sites, generating jobs in food processing and gastronomic sectors, and also creating jobs in local construction and maintenance of an infrastructure that is used not only by tourists, but also by local inhabitants for healthier lifestyles. Various measures have also been implemented on healthy environments, ranging from building long- distance heating systems based on biomass, to efficient energy use (insulation of buildings to reduce energy consumption), use of renewable energy and promotion of active mobility and physical activity.

Results of National Health Monitoring Surveys carried out from 2001 to 2008 indicate positive changes in lifestyle in the region in terms of increased consumption of fresh fruits and vegetables, reduced use of animal fats in cooking, and reduced smoking and consumption of unhealthy foods such as fried foods, sweets, beverages, and salt, and an increase in recreation activities and exercise.

The RAG has provided a means for the continuity needed in participation, capacity building and action that these changes demand, as well as for engaging with formal decision making bodies. Decisions and outputs from four working groups (one on each of the four priority areas) and from the RAG assembly are developed into formal proposals by CHD with the relevant stakeholders, and presented to the Regional Development Agency and Regional Development Council (RDC). The RAG proposals have been integrated into programmes of the RDC and through CHD the RAG has been officially designated as the expert body for priorities in regional development for improvement of health and social inclusion. 

These processes have been supported by a range of features. Consistent interactions have built awareness, trust and confidence. They draw attention to good practice, changing participants’ way of thinking, including about their own role in health co-production, and sustaining the work and partnership over time. To avoid wish lists and dispersed projects that may not have impact or be feasible, evidence on the conditions and health equity impacts is explained in an accessible way through The Health in the Municipality programme, contributing to decision-making, justifying the choices when presented to the RDC, and supporting the setting of shared goals. While funding is a key factor, the informal, flexible nature and methods of the RAG have enabled and sustained it. The work has also benefited from national incentives, such as green procurement.

The RAG Mura approach was facilitated by social cohesion and capacity building of all stakeholders in social determinants of health backed by evidence from assessments. The sustained commitment of CHD for its processes was key, and the support from institutions and policy actors at local, regional and national levels and from WHO reinforced the work. These sustained processes call for visible gains to boost confidence, and the recognition of RAG proposals in the regional development plan in the regional development council was important for this, as were the visible changes in the community.

From a case study  by P Beznec, G Maučec, S Nemeš, D Nemeš  Photos: Producing food in a sustainable way. © CHD 2014; video Health Inequalities - Social Determinants of Health Film (Slovenia) NSM Centre 2010: and Inaugural meeting of the RAG © CHD 2012

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