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Journal of Quality in Health Care & Economics Research Article 33 min read

Active Citizenship as an Integrating Axis between Health in All Policies and the Well-being Economy

Mandl Stangl J*
* Corresponding author
ISSN: 2642-6250  10.23880/jqhe-16000378  Received: April 09, 2024  Published: April 25, 2024
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Keywords
Citizen Participation Health in All Policies Well-Being Economy Community Social Capital
Abstract

The persistence of social inequities has affected the quality of life of the population in many countries for a long time. To counteract this situation, multinational agencies have proposed several political/technical alternatives among which Health in All Policies and the Well-being Economy stand out; in which the interaction of various sectors together with society at large is crucial to achieve the goals set in all areas. The aim of this review is to provide an overview of some of the main enablers that bring the two initiatives together, emphasising the active participation of citizens as a support for achieving the social justice and sustainable development goals of governments. In the research, we used an interpretative synthesis method in three phases: an exploration of the empirical work supporting Health in All Policies and its connection to Wellbeing Economy; a study of the theory of community social capital as a basis for building inclusive community participation; and finally, we analysed the fundamental elements that enable population groups, particularly the most vulnerable, to share power in making decisions that concern them according to their real and felt needs and problems. The results lead us to conclude that it is necessary for governments to privilege citizen power as a convergent strategic axis to strengthen their own institutions, both in the design and implementation of actions undertaken in the effort to mitigate social inequities through Health in All Policies and Well-being Economy.

Introduction

Nearly 25 years into the 21st century, a number of public policy initiatives have been designed and implemented to address social determinants to improve the health and well- being of people throughout their lives. Their development on a global scale has required an innovative, integrated, coordinated and evidence-based approach, new and different ways of thinking and working that incorporate multiple actors from all relevant policy areas; including the strengthening of equitable and mutually synergistic civil partnerships underpinned by values such as solidarity and co-responsibility, through the adoption of transdisciplinary approaches to address the root causes of inequity.One such initiative is Health in All Policies, a broadly agreed horizontal and complementary approach that systematically takes into account the Alma Ata principles [1], the Ottawa Charter [2], the Final Report of the Commission on Social Determinants of Health [3] and the Rio Political Declaration on Social Determinants of Health [4]; the core of the proposal is to intervene on determinants of health that are modifiable, but mainly controlled by policies in sectors other than health [5]. The other proposition we have considered is the Well-being Economy, expressed as a policy orientation and governance approach that aims to place people at the centre of decision- making for the expansion of economic opportunities, resilience and social mobility [6]. Both movements call for an inclusive and sustainable transformation in all policies where entrenched inequalities of power and vested interests are addressed and where the realisation of people‘s full potential through the enjoyment of their fundamental rights are central components [7].

Sustainable progress in these endeavours merits the inclusion of citizens to ensure that the inequities that affect individuals and families where they live, learn, work and play are addressed; and as such, it is vital that citizens are part of these processes and are not perceived as mere spectators waiting for the various government sectors to resolve their own social situations on their behalf. On the contrary, citizens are an integral part of government, and government can only access these junctures when communities actively participate as agents of change in the public policy-making process [8].

Despite the extensive literature on experiences at national, state and local levels of implementing Health in All Policies and Wellbeing Economics, there are few articles that highlight protagonist initiatives that enable citizens to truly influence the decision-making process in a direct, active and comprehensive manner, enabled through mechanisms accessible to key stakeholders. In this manuscript we aim to highlight the commitment of citizens to participate in the processes and activities of nation-states, especially with regard to their contribution in making critical decisions that affect their daily lives, in order to reinforce the legitimacy of Health in All Policies and Well-being Economy. The content has been divided into 3 sections with which we seek to analyse the key elements that characterise Health in All Policies and the Well-being Economy in its interaction with Community Social Capital and Active Citizenship as an Integrating Axis.

Method

To develop the manuscript, a scoping review Arksey H,et al. [9] encompassing original studies, conceptual articles, book chapters and reports (grey literature) was undertaken to examine the scope and nature of active citizen participation, determine the value of a comprehensive systematic review related to Health in All Policies and Well- Being Economy approaches, summarise and disseminate research outputs, and reflect on a complex concept to inform further research. The study was based on our initial question: how do we know when the power of the status-quo produces inequities if power is not shared with communities for the implementation of comprehensive health/wellbeing policies?

Search Strategy and Inclusion Criteria

First, we searched Google Scholar and relevant bibliographies in English and Spanish for quantitative, qualitative or mixed methods research addressing the topic of our review. This process generated a total of 909 archives. Subsequently, using Covidence software, the following information was extracted from each article: research objective, main findings and supporting evidence, study limitations, and recommendations for public health practice, policy and future research; for qualitative studies, additional information related to the conduct of focus group discussions, coding methodology and theoretical frameworks used in the research was also extracted. This generated the following combined search terms: /inequities/citizen participation, policies for well-being/civic engagement, community social capital/citizen empowerment and, healthy communities/ economy of well-being. This process resulted in the selection of 79 manuscripts.

Data Integration

Second, all titles and abstracts of the 79 manuscripts were coded using Atlas.ti in order to extrapolate constructs from the results sections to develop categories that captured the various results as succinctly and efficiently, but also as comprehensively as possible, of findings related to: (1) the level or stage of civic engagement, (2) social determinants influencing Health in All Policies Well-Being Economy, and (3) relevance to population health/wellness practice.

Formulation of A Synthesis Argument

Thirdly, the sources included were analysed based on the principles of the descriptive analytical method as an interpretative approach to increase knowledge and understanding of the phenomenon under investigation; more specifically, we investigated how citizen interaction contributes to the design and implementation of Health in All Policies and the Wellbeing Economy. Thus, we synthesise the main elements identified in order to draw generalised conclusions about the practical approach to social and political participation in both initiatives, which we subsume under the label of Active Citizenship as an Integrating Axis.

Between Health in All Policies and Well-being Economy: People First

Many of the health inequity problems facing society today require collective action, which poses the challenge of how to change and impact on social determinants by implementing long-term, broad, multisectoral strategies that simultaneously involve and engage the whole of government and society to provide a basis on which various response actions can be explained, developed and utilised [10, 11, 12, 13]. This policy approach dominated the World Health Organization‘s Declarations when it defined health in all policies as a public policy approach that systematically considers the implications of decisions for health, seeks synergies where connections and interactions between positive health outcomes and policies within other sectors are highlighted and, in doing so, identifies the co-benefits for all sectors‘ agendas for healthier, more caring, equitable and resilient populations [14, 15, 16, 17].

Despite the substantial adoption of Health in All Policies in several countries worldwide, its implementation has not been easy. Most of the cases discussed in this review remain anchored in an unrealistic view, treating policy making as a biomedical exercise and ignoring power relations and politics as a social determinant of health. From this perspective it can be interpreted in different ways by other sectors - even within the sector itself - and working across these boundaries requires dedicated and sustained efforts to challenge existing powerful social, political, commercial and economic interests and dominant ideologies [5, 18, 19, 20, 21].

Secondly, the relevance and the way in which information is processed and analysed for decision-making depends on several different mutually supportive factors, including a diverse workforce that recognises and embraces social determinants in public health, adequate training and educational opportunities, and an enabling political and policy context that fosters a broad perspective on health [20]. Health leaders must not miss this opportunity to build a common language of goals and solutions to compare trade-offs within and across sectors to address current and upcoming challenges, as well as to encourage institutions to synthesise, build and share knowledge about which health policies work and which do not, rather than trying to duplicate actions [21]. We start from a conception of Health in all Policies as a management model characterised by a sequence of integrated and sustainable public policies, the product of multisectoral and transdisciplinary processes of social mediation to ensure that all members of society have fair and equitable opportunities to participate in decisions that allow changes in the determinants of health inequities and, therefore, in the conditions and quality of life of the population, Mandl Stangl J [22]; In this sense, a promising option is strong citizen participation, political will for intersectoral action in favour of health and equity, strong leadership and policy development that includes communities, political and institutional actors, truly capable of undertaking the actions and activities they wish to carry out in order to promote social and health benefits in a fairer society [23, 24].

Similarly, a Well-Being Economy has been proposed as an alternative approach to mainstream economic design, which aims to achieve social justice through a better understanding of possible economic solutions, including achieving social equity and improving people‘s quality of life/health, by adopting a holistic approach to decision-making; it is a term that encompasses a wide range of ideas and actions and is co-created by and for the communities it is meant to serve and pursues inclusive and sustainable development [25, 26]. The implication of this perspective for policy makers is that the economy serves social and environmental well-being, rather than positioning people‘s well-being as necessary for economic outcomes; In this context, the performance of societies is not measured by any traditional economic indicator (such as Gross Domestic Product, GDP), but by five principles that focus explicitly on building healthier societies: 1) establishing a harmonious relationship between society and nature; 2) aligning economic, political and organisational goals with people‘s needs; 3) ensuring a fair distribution of resources to address economic inequity; 4) encouraging more participatory decision-making and; 5) supporting healthy and resilient people and communities [27, 28].

A transition to a sustainable Well-Being Economy has been supported by a growing number of governments and international organisations, forming strong partnerships to accelerate progress towards enabling people to enjoy health and well-being as a fundamental human right, where local neighbourhoods represent the basic unit of exchange, care and democratic empowerment; this requires interdisciplinarity, greater governmental awareness and attention, as well as specific training and capacity building for diverse technical actors and empowerment of the collective in their own well- being [29, 30, 31].

Health is a beneficiary of well-being economy as it promotes healthier populations and, in turn, is a driver of well-being economies, as healthier populations and health systems contribute to greater social cohesion and economic development [26]; in that sense, we agree that Health in All Policies and Well-being Economy are interconnected agendas. To conclude this section, we summarise some common elements between the two approaches that are reflected in the literature:

  • The design of an equitable economy that serves human development within planetary and local ecological limits and the development of healthy public policies for the common good are key strategic actions for moving towards wellbeing societies. These interconnections between the Economy of Well-being and Heath in All Policies have been recognised by the World Health Organisation, in the Geneva Charter [32, 33].
  • The principles and functions that underpin Health in All Policies, such as the joint formulation of policies that guarantee human rights for all, can be useful for the transition to a Well-being Economy that considers addressing social determinants to address growing social inequity; similarly, a Well-being Economy aims to create policy incentives that increase the importance of social outcomes, such as greater social cohesion, environmental sustainability and health [34].
  • The development of Health in All Policies and a Well- Being Economy depends on a multidisciplinary and inclusive understanding of health/well-being policies and their importance as a fundamental social goal and can only be achieved through collaborative approaches within and across sectors, as well as strong community engagement [35, 36].
  • A Well-Being Economy requires multiple inputs to enable the holistic vision of a healthy and sustainable population. Health in All Policies is a useful way to help consolidate the multi-sectoral resources needed to ensure those responsible for implementing activities that support an Economy of Wellbeing [37].
  • While the potential synergies between Well-Being Economy and Health in All Policies are exciting, it is important to point out some key risks and areas of weakness that are mentioned as strategies but poorly developed in practice: a) conceptually, Well-Being Economy refers to the theoretical aims and objectives of policy rather than policy instruments and tends to provide fuzzy explanatory models of how economics operates within Health in All Policies; b) achieving true Health in All Policies with a Well-Being Economy in mind destabilises many powerful interests who view the association with public health promotion with suspicion; it would be extremely naïve to believe that they will not continue to fight against such progress which depends more on political will and leadership than on technical vision; c) the role of communities as active participants in the governance of the Well-being Economy and Health in All Policies is not clearly defined: strategies to develop community resources and capacities, strategies to assess changes in health/equity according to the needs and conditions of vulnerable groups, changes in the structural determinants of health, the views of community members, and the effectiveness of co-design methods with political and governmental actors [38].

Participation/Deliverance as Central Axis to Well-being

If the strengthening of community social capital is equivalent to the building of bridges, links and connections to counteract the excess of technicality in the implementation of Health in All Policies and the Welfare Economy; the active participation of citizens - a logical consequence of this process - becomes the integrating axis that permeates the political dialectics of these initiatives, providing them with greater legitimacy and sustainability on the part of the actors involved. Active and inclusive citizen participation emerges as the main strategy for social inclusion and empowerment of vulnerable sectors to co-create feasible solutions together with public institutions, and thus overcome the existing structural gaps that determine the prevalence of inequalities in society. Inclusive and meaningful participation of citizens and community networks has the potential to better align policies with people‘s lived experiences, enabling greater acceptability and the achievement of better equity and efficiency outcomes, while increasing resilience to respond to adverse events [13, 63, 64, 65]. Today, participation as a dimension of social capital not only provides communities with greater opportunities for cooperative behaviours among themselves and diverse actors in pursuit of common social benefits, but is also the key driver that fosters a more proactive associative life, increasing awareness and recognition of the rights of vulnerable groups; and transforming the most fragile people into agents and protagonists of the policies, plans and programmes that concern them through new collective knowledge that contributes to equitable outcomes in levels of well-being [66]. 67] In that sense, the arguments in favour of citizen participation variously emphasise the advantages for individuals, families, organisations and society, including increased knowledge, authority, power and problem-solving capacity.

An agenda to promote citizen participation should include: the adoption of a participatory institutional culture; the inclusion of the entire population in the different stages of the policy process (diagnosis, planning, implementation, and monitoring and evaluation); the establishment of partnerships with other sectors (supported by joint commitments, data sharing and joint implementation); and the development of a culture of monitoring and evaluation. Participatory processes should therefore be organised by the organisations promoting them, with the initial objective of establishing a space for communication and decision-making that allows for reflection on how to define and address problems. Subsequently, the decisions taken are put into practice, with the involvement of the actors who participated in the previous discussions; therefore, participation also means inclusion in planning, implementation, monitoring and evaluation [67]. However, its effectiveness depends on understanding its instrumental/technical and political character, so that in activating it, each actor contributes on their own terms and according to the specific needs of the public problem to be solved; it is about deliberative mechanisms that enable people to: identify their interests and values, contribute ideas and acquire a greater degree of autonomy to design comprehensive action plans together with the government, such as public hearings, public meetings, citizen advisory boards, online platforms for feedback and consultation, participatory budgeting and collaborative governance structures [68].

These mechanisms aim to create opportunities for citizen stakeholders to benefit from a better understanding of the changing nature of public opinion on policy and the need for other stakeholders to consider the citizen as a stakeholder and not simply a policy target. Evidence suggests that deliberative mechanisms have the potential to help in both respects, thus giving citizens a central place in the decision- making process [69, 70, 71, 72].

We consider that the key elements that contribute to successful citizen participation are: a) an organisational culture that is supposed to support citizens‘ ideas and initiatives by incorporating people into the political process, developing their social capacities and political rights, and opening spaces that ensure the inclusion of groups with different social interests and cultural values within the processes of change. In this sense, the role of the state consists fundamentally in guaranteeing the set of conditions (social, political, economic and cultural) that constitute the social basis for the development of capacities to live in citizenship; b) the management of citizen participation as a key cross- cutting element in the management of administrative and operational aspects, such as organisational practices and processes; where the role of political leaders (e.g. mayors) as a bridge between citizens and public policy makers is highlighted. The state and its competent bodies must be prepared to institute a legal framework that strengthens this process as a shared responsibility; c) having adequate resources to enable the development of policies as fair and reasonable through citizens‘ perceptions. From this perspective, the outcome of citizen participation is the granting of legitimacy and the ratification of government policy decisions by society [73, 74].

However, citizen participation faces a number of challenges that can hinder its effectiveness and inclusiveness: (a) political apathy is a major obstacle, as it leads to disengagement and lack of interest in public affairs; (b) lack of resources and information poses a challenge, as not all citizens have equal access to training, information or the means to participate effectively; c) barriers to access, such as physical or social barriers, language barriers or restrictive participation procedures, further limit the ability of certain groups to participate; d) distrust of the political process, fuelled by corruption, scandals or broken promises, can also deter citizens from participating; e) the digital gap exacerbates disparities, as unequal access to digital technologies and internet connectivity limits the ability of some people to participate in online platforms and methods of digital participation. The implementation of various inclusive strategies and processes can help overcome barriers to participation by: a) promoting public awareness, these campaigns sensitise people to actively participate in public affairs; b) broadening access to information; c) promoting inclusive dialogue and engagement and creating spaces for constructive debates; d) fostering a culture of active citizenship [14].

To summarise this section, for participatory/deliberative processes to be truly practical for the development of health in all policies and a welfare economy, they are needed:

  • Empowered citizens who have the skills, knowledge and attitudes to participate, including the capacity to organise.
  • Legal basis based on effectively implemented social, economic and political rights (laws, regulations and executive orders) that allow for direct participation in participatory decision-making and accountability.
  • Willingness to incorporate citizens‘ needs and suggestions into policies and commitment to genuine inclusive participation of government (political leadership and government agencies) and citizens.
  • Identification, understanding and participation of all relevant social groups, in particular vulnerable populations.
  • A well-planned participatory process with clear/ actionable clear/feasible objectives and sufficient allocation of resources (financial and human) by all stakeholders.
  • Transparent government and communities where trust prevails between public/private bodies and citizens.

Conclusions

Two of the policy approaches most promoted in recent years by multilateral agencies are Health in All Policies and Well-Being Economy, whose interconnected agendas depend on a multidisciplinary and inclusive understanding of health/economy/well-being policies and their importance as a fundamental social goal to address the challenges that give rise to social inequities; this can only be achieved through collaborative approaches within and across sectors that share power with communities, especially those in vulnerable situations. Active citizen participation has become an important policy strategy to advance these initiatives; as a construct of social capital it has a wide range of connotations, including organisational capacity; the ability to identify and understand problems related to inequities of individuals, social groupings and institutions that affect the quality of life and behaviour of others and alter the decision- making environment; and the competence to promote social roles, customs and ethical norms that permeate institutional power to achieve courses of action in accordance with their needs.

A number of promising innovative interventions have been developed in various countries, highlighting the voice of people at the centre of decision-making through public consultations or dialogues, the implementation of participatory laws and regulations, the determination of priorities through participatory problem/solution analysis and participatory budgeting, employment levers to improve community economic circumstances, the fostering of solidarity and a sense of collective action and/ or a good balance between inclusiveness and policy design [75, 76, 77]. These initiatives reflect core commitments to health promotion by seeking to create the social conditions necessary to enable all people to realise their aspirations, meet their needs and build resilient individuals, communities and societies. The creative approaches represented by these initiatives work to ensure collaboration, participation and investment in health and well-being outcomes [78].

Despite these advances in both initiatives, the issue of active citizen participation - often mentioned as part of the political discourse - in practice there is still a lack of alignment between the ideas of participation and the policies, priorities or plans of governments. In some experiences, the limited possibilities of fostering successful participation processes are mainly due to lack of awareness or understanding, inadequate use of communication channels, resource constraints, cultural and linguistic differences; but fundamentally because there is no countervailing power to counterbalance established power due to the polarised context surrounding the political sphere, as well as low trust in state institutions and the divergence of economic/ commercial power from social power [79].

For this participation to be of greater interest, governments must invest resources to strengthen the sense of community, collective efficacy, community capacity and competencies of their people, and identify the political factors that can oxygenate their potential. This can be significantly enhanced through integrated and comprehensive commonwealths that are equitable, fair and open to different groups in diverse cultural contexts.

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@article{mandl2024,
  title   = {Active Citizenship as an Integrating Axis between Health in All
Policies and the Well-being Economy},
  author  = {Mandl Stangl J},
  journal = {Journal of Quality in Health Care & Economics},
  year    = {2024},
  volume  = {7},
  number  = {2},
  doi     = {10.23880/jqhe-16000378}
}
Mandl Stangl J (2024). Active Citizenship as an Integrating Axis between Health in All
Policies and the Well-being Economy. Journal of Quality in Health Care & Economics, 7(2). https://doi.org/10.23880/jqhe-16000378
TY  - JOUR
TI  - Active Citizenship as an Integrating Axis between Health in All
Policies and the Well-being Economy
AU  - Mandl Stangl J
JO  - Journal of Quality in Health Care & Economics
PY  - 2024
VL  - 7
IS  - 2
DO  - 10.23880/jqhe-16000378
ER  -