Obtaining public input for health‐systems decision‐making: Past experiences and future prospects

Abstract: Interest in finding more effective methods for public involvement in decision‐making about health systems is more widespread than ever in Canada since significant aspects of health‐care decision‐making were devolved from provincial governments to regional health authorities. Involving the public can be risky business, however, as the accountability and legitimacy of decisions made by governing authorities are often assessed against the nature and degree of interaction that occurs with the public. Consequently, decision‐makers in a variety of policy domains routinely struggle with questions about when it is appropriate to involve the public, what the most effective means are for doing this, and how to measure their success. The authors analysed these issues by documenting the experiences of health‐systems decision‐makers in two Canadian provinces (Ontario and Quebec) with public consultation and participation over the past decade. Their findings illustrate that despite the different roles and responsibilities held by Ontario and Quebec decision‐makers, decisions to consult with their communities are driven by the same basic set of objectives: to obtain information from and to provide information to the community; to ensure fair, transparent and legitimate decision‐making processes; and to garner support for their outcomes. Decision‐makers also acknowledged the need to rethink approaches for involving the public in decision‐making processes in response to the perceived failure of past public participation and consultation processes. While these experiences have clearly left some participation practitioners feeling beleaguered, many are approaching future community consultation processes optimistically with plans for more focused, purposeful consultations that have clear objectives and more formal evaluation tinged with a healthy dose of pragmatism. Sommaire: L'intérêt que I'on porte à trouver des méthodes plus efficaces pour inciter le public à participer à la prise de décisions au sujet des systèmes de santé ne cesse de grandir au Canada depuis que les gouvemements provinciaux ont transféré aux autorités régionales la responsabilité d'importants aspects de la prise de décisions dans ce domaine. Cependant, faire intervenir le public peut être une affaire délicate, car la transparence et la légitimité des décisions prises par les autorités existantes sont souvent évaluées par rapport à la nature et au degré d'interaction qui se produit avec le public. C'est pourquoi, les décideurs dans divers domaines de politiques ont généralement de la difficultéà déterminer quand il convient de demander I'avis du public, quels sont les moyens les plus efficaces pour le faire et comment mesurer leur succès. Nous avons analysé ces questions en documentant les expériences que les décideurs des systèmes de santé de deux provinces canadiennes (l'Ontario et le Québec) avaient eues en ce qui concerne les efforts de participation et de consultation publique au cours de la derniére décennie. Nos conclusions démontrent qu'en dépit des divers rôles tenus et diverses responsabilités assumées par les décideurs de I'Ontario et du Québec, leur déision de consulter leurs communautés est guidée par les mêmes principaux objectifs: obtenir de I'information de la communauté et lui en foumir; assurer des processus de prise de déisions justes, transparents et légitimes et obtenir I'aval de leur décision. Les décideurs ont également reconnu le besoin de repenser les approches visant à faire participer le public aux processus de prise de décisions suite à I'échec perçu des expériences antérieures de participation et de consultation du public. Alors que certains partisans de la participation ont été clairement découragés par ces expériences, un grand nombre envisagent avec optimisme les processus de consultation communautaire. Ils croient que les consultations pourraient être plus focalisées et plus déterminées visant des objectifs clairs et une évaluation plus formelle et empreinte d'une bonne dose de pragmatisme.     

Reviews

Kaunda's Zambia, 1964 ‐ 1991. A Select and Annotated Bibliography compiled by Naomi Musiker.

South African Institute of International Affairs, Bibliographical Series No. 26, Johannesburg. 1993. viii plus 426pp.

Environment, Employment and Development edited by A.S. Bhalla. International Labour Office, Geneva, 1992. x plus 177pp. including bibliography.

Poverty in Developing Countries: A Bibliography of Publications by the International Labour Office World Employment Programme, 1975–91. International Labour Office Bibliography No 12. International Labour Office, Geneva, 1992. viii plus 152pp.

The South African Tripod: Studies in Economics, Politics and Conflict by B. Oden, T. Ohlson, A. Davidson, P. Strand, M. Lundahl, and L. Moritz. Scandinavian Institute of International Studies, Uppsala, 1994. 281pp. including tables and graphs.

Tears of the Dead, the Social Biography of an African Family by Richard Werbner. Baobab Books: Harare and Edinburgh University Press, 1991. xi plus 211pp. including genealogies and illustrations.

The Politics of the National Arts Festival by Kenneth Grundy. Occasional Paper, No. 34, Institute of Social and Economic Research. Rhodes University, Grahamstown. 66 pp. including notes.

The Agrarian Question in Southern Africa and Accumulation from Below: Economics and Politics in the Struggle for Democracy by Michael Neocosmos. Research Report No. 93, The Scandinavian Institute of African Studies, Uppsala, 1993. 79 pp. including notes and bibliography.

The Bushman Myth: The Making of a Namibian Underclass by Robert J. Gordon. Boulder, Westview Press, Colorado and Oxford, 1992. xiv plus 304 pp. including maps, tables, notes, references and index.

A Bed Called Home: Life in the Migrant Labour Hostels of Cape Town by Mamphela Ramphele. David Philip: Cape Town, 1993. vii plus 152pp. including illustrations, appendix, bibliography and index.

The Small and the New in Southern Africa: The Foreign Relations of Botswana, Lesotho, Namibia and Swaziland since their Independence. A Select and Annotated Bibliography compiled by L.E. Andor. South African Institute of International Affairs, Bibliographical Series No. 25, Johannesburg, 1993. x plus 526pp.     

Preadjudicatory detention in a large metropolitan juvenile court

While the use, and possible abuse, of detention by the juvenile court has been the subject of heated controversy in recent years, this issue has received very little systematic empirical attention. A few studies of detention have been conducted, but they have produced mixed findings, which may be a result of the different locations and time periods considered, and the different methodologies employed. To shed additional light on this important question, we examine in this investigation the effect of a variety of legal, extralegal, and other case characteristics on the preadjudicatory detention practices of a large metropolitan juvenile court. Over 60,000 cases disposed of by the court during a seven-year period (1969–1975) were considered in a detailed multivariate analysis of detention outcomes (detained/not detained). The analysis produced no evidence that the court operates on a double standard—discriminates—along sexual, racial, or socioeconomic lines in the use of detention. Both additive and interaction statistical models considering the extralegal variables showed a youth's sex, race, and social class to be largely independent of detention decisions. In contrast, a legal factor—a youth's previous court experience—was found to be an important predictor of detention. This factor better accounts for detention outcomes than any, or all, of the other legal, extralegal, and other case history variables considered in the analysis.