Public Participation, Vulnerable Population and Health Inequality

The benefits of public participation (PP) in health systems (HS) have been extensively discussed in the literature. There are many arguments that legitimize the PP, such as increasing accountability and transparency, improves the quality of the decisions, strengthening health promotion activities, and improving the representation of underrepresented groups, thus reducing health inequalities. However, central investigation has highlighted some critical points affecting the quality and the effectiveness of PP in the HS. One of the most noteworthy is the deficit of representativeness in participatory forums and the failure to prioritize the involvement of socially disadvantaged groups, such as migrants, homeless people, mental health patients, etc. In this context, it is important to point out that there are still few articles reporting the participation of vulnerable groups and indicating which groups are involved in participatory spaces. In fact, health institutions still are criticized for not providing appropriate opportunities and mechanisms to citizens who lack the economic and social resources to participate in decision-making processes. The World Health Organization has repeatedly supported and promoted PP as a strategy to reduce health inequalities. The post-pandemic scenario has certainly contributed to further deepen the dynamics of social and health inequality, especially of vulnerable groups, making PP (and not only the participation of experts) in HS even more relevant. This article discusses some important PP experiences carried out in the HS of Brazil and Southern European countries (Italy, Spain and Portugal) in recent years, with the aim of identifying the strengths and weaknesses of the participatory mechanisms adopted, as well as the main barriers that determine the underrepresentation of socially disadvantaged groups. The result of the study points to the following barriers: lack of health literacy, communication difficulties, financial constraints, few channels for expressing the interests of vulnerable groups, among others.