Citizen Involvement in Health Policy (MK0154)

Which public problem is addressed is by the commitment? Countries in Southeast and Central Europe, which include the Republic of North Macedonia, are lagging behind the Western European countries in respect to key indicators of health and wellbeing. The fact that public institutions are closed and citizens have low awareness about their fundamental rights, coupled with lack of actual partnership between civil society organizations and public institutions, limit the process for improving public services and access thereto. In addition, technology development and digitalization opportunities in the world have encouraged governments in the region, including the Government of RNM, to initiate processes for digitalization of certain services and to introduce technologies for automated data publishing. Thus far, many of these initiatives concern development of products that would contribute to enhanced transparency of institutions, but significant share of them undermine the need for involvement of citizens and do not take into account their opinions, i.e. increased volume of data made publicly available under previous initiatives and intended to contribute towards increased engagement of citizens in decision-making, have not yielded the desired results. Two specific reasons have led to such situation: complexity of data published and citizens’ inability to understand them, as well as lack of two-directional communication mechanisms between those that publish data and intended users of such data. Lack of two-directional communication mechanisms between the Ministry of Health and citizens contributes to low trust among beneficiaries of its services and low response on the part of citizens, with focus on vulnerable groups and environments.

Main objective of the commitment Key and long-term objective of this commitment is to establish organized system and practice for two-directional communication between citizens and decision-makers in respect to creation, implementation and evaluation of healthcare policies and services.

How will the commitment contribute to addressing the public problem? Activities taken under this commitment will contribute to initiation of changes and establishment of positive practices at two levels: national and local, through cooperation between above named public institutions and civil society organizations. All activities will focus on establishment of mechanisms for involvement of citizens that are identified as beneficiaries of preventive healthcare programs, with focus on those intended for women and children. In particular, the commitment will be focused on: 1) establishing continuous cooperation between the Minister of Health/State Secretary responsible for planning, implementing and monitoring preventive healthcare programs and civil society organizations involved in this commitment, which would later continue such cooperation and engage in continuous work on developing target policies; 2) developing platforms for consultations and transparency and work with citizens from vulnerable groups, in order to familiarize them with their rights under these policies, collect their recommendations and opinions, and familiarize them with possibilities for future involvement in decision-making; 3) promoting the platforms developed with the general public in order to ensure broad use thereof, by direct involvement of persons responsible for public relations at the Ministry of Health/Cabinet of the Minister of Health and involvement of citizens in planning, monitoring and evaluating services in the relevant field; 4) improving policies/practices based on proposals received and citizens’ participation, by providing feedback on the status and steps taken in respect to their proposals.

How is the commitment relevant to OGP values? COMMITMENT IS IMPORTANT FOR TRANSPARENCY because it anticipates development and launch of tools and mechanisms for distribution of more information on budgeting and programming work by institutions that provide healthcare services to women, mothers and children. Also, the commitment works on improving quality and availability of existing and new information COMMITMENT IS IMPORTANT FOR CIVIC PARTICIPATION because it allows development of communication and consultation tools with target groups before and during adoption and implementation of policies in the relevant field and anticipates an approach for mobilizing and motivating citizens to active participate and use these tools. 50 COMMITMENT IS IMPORTANT FOR PUBLIC ACCOUNTABILITY as it enables establishment of mechanisms that will contribute to promoted accountability of public officials.

Additional information The commitment includes activities that imply establishment and use of mechanisms for civic involvement in decision-making pertaining to healthcare policies. Hence, all proposed solutions contribute to attainment of goals and actions defined by the Government of RNM after submission of the voluntary national review on implementation of SDGs at the HighLevel Political Forum on Sustainable Development in 2020. In particular, next step under SDG3: Ministry of Health will continue implementation of initiatives and activities from strategic documents and action plans and will start activities for development of the new National Strategy on Health by 2030. This strategy will provide direction for health system reforms at all levels. Link to UN Sustainable Development Goals Link to SDG16: Peace, Justice and Strong Institutions SDG target 16.6: Develop effective, accountable and transparent institutions at all levels. Measures under this commitment contribute to improved planning, implementation and monitoring of public services which, in turn, will contribute to greater satisfaction among citizens with public services delivered.

No. Milestone Indicators Activity holder Start date End date 3.2.1 Establish a coordination body comprised of nine members: one representative from each civil society organization involved in this activity (5 in total, of which 1 from national organization and 4 from local organizations) and four representatives from the Ministry of Health, one responsible for preventive healthcare, one responsible for strategic planning, one representative from the Minister's Cabinet and one representative responsible for financial matters Coordination body is established (yes/no) MoH, Association ESE, in cooperation with 4 local CSOs: Station L.E.T. Romano Chachipe, Women's Forum and Mother January 2022 January 2023 51 3.2.2 Develop and launch electronic platform for information dissemination, monitoring and involvement of citizens in preventive healthcare programs and design mechanism for collecting, reviewing and providing feedback on proposals made by citizens Number of published documents/reports on implementation of healthcare programs Number of proposals for healthcare programs submitted made by citizens Number of inconsistencies and irregularities in implementation of preventive healthcare programs reported Number of positive comments/praise for healthcare programs Number of citizens' proposals taken as baseline to advance policies/practices (target: at least 25%) MOH, eHealth Administrati on and Association ESE, in cooperation with 4 local CSOs: Station L.E.T., Romano Chachipe, Women's Forum and Mother February 2022 December 2022 3.2.3 Conduct public information campaign on opportunities offered by the platform, by developing and implementing the communication strategy % of implemented activities from the communication strategy MoH, Public Relations / Minister’s Cabinet and Association ESE, in cooperation with 4 local CSOs: Station L.E.T., Romano Chachipe, Women's Forum and Mother January 2023 June 2023 3.2.4 Establish pilot cooperation with CSOs from Tetovo, Kumanovo, Shuto Orizari and Prilep to identify women and children from Number of mapped households for identification of women and children MoH, regional PHI from Tetovo, Kumanovo, Skopje and February 2022 June 2023 52 4 Program for Active Health Protection of Mothers and Children, Program for Early Detection of Malignant Diseases, Program for Systematic Examinations, Program for Exemption from Payment of Contribution Fees, Public Health Program that include services intended for vulnerable groups, with application of the multidisciplinary approach, such as facilitating expression of opinions and proposals by women and mothers before competent institutions using the platform developed. The pilot project will concern only programs intended for preventive healthcare of women, mothers and children. vulnerable groups in order to familiarize them with their rights arising from prevention healthcare programs4 from vulnerable groups (target: 250 per municipality) Number of meetings organized with identified households (target: 1 meeting per household) Number of surveyed citizens (target: 1000) Number of plans drafted to address problems affecting citizens (target 1) Prilep, and Association ESE, in cooperation with 4 local CSOs: Station L.E.T. Romano Chachipe, Women's Forum and Mother

Action Plan Review

Commitment 3.2: Preventive healthcare policies and services based on citizens’ priorities 

● Verifiable: Yes

● Does it have an open government lens? Yes

● This commitment has been clustered as: Public-service delivery based on citizen priorities (Commitments 3.1, 3.2, and 3.3 of the action plan)

● Potential for results: Substantial

Commitment cluster 2: Public-service delivery based on citizen priorities

(Employment Service Agency, Ministry of Health, Ministry of Education and Science, Association for Emancipation, Solidarity and Equality of Women)

For a complete description of the commitments included in this cluster, see Commitments 3.1, 3.2, and 3.3 in the action plan here.

Context and objectives:

This cluster establishes mechanisms for public participation in designing, implementing, and evaluating social policies. Commitment 3.1 addresses the employment sector. The Employment Service Agency (ESARNM) and the Association for Emancipation, Solidarity and Equality of Women (ESE) will establish a coordination body that will provide civil society the opportunity to discuss employment policies and assist in their implementation. The ESARNM will also develop an electronic platform for citizens to monitor the progress of employment policies and services and submit proposals. Finally, the ESARNM and ESE will work with CSOs from Kumanovo, Prilep, Shuto Orizari, and Tetovo to identify nonregistered, unemployed citizens and citizens from vulnerable groups to familiarize them about their rights and available services. Commitment 3.2 addresses the healthcare sector and includes the same activities and indicators as Commitment 3.1, to be implemented by the Ministry of Health and ESE. In cooperation with CSOs from the four municipalities listed above, the Ministry of Health and ESE will identify women and children from vulnerable groups to familiarise them about their rights under preventative healthcare programs.

Commitment 3.3 addresses the education sector and involves the Ministry of Education and Science and ESE. Although its objectives are similar to the other two, its activities mainly focus on improving transparency of education materials, and not participation in designing education policies. Milestone 3.3.3 involves establishing monitoring tools for students, parents, and teachers, but it is unclear if this activity will lead to the joint design and implementation of educational policies, as under Commitments 3.1 and 3.2. Similarly, Milestone 3.3.4 states that local and national institutions will discuss problems and solutions in the sector, but it is unclear if civil society and citizens will be involved. The IRM inquired with the Ministry of Education and Science to understand why the activities were designed differently from the other two commitments but did not receive a response at the time of writing this action plan review.

ESE initiated Commitments 3.1 and 3.2 during the co-creation process, and these commitments were jointly developed with the relevant institutions. According to ESE, before the start of the co-creation, there was a consensus with the institutions on the focus of the activities. ^[96] There were discussions to include these commitments in previous action plans and ESE was content that these commitments are now included in the fifth plan. A representative from the ESARNM agreed that the process was inclusive and that ideas were actively exchanged during the formulation of Commitment 3.1. [97] According to the ESARNM, Commitment 3.1 is not technically connected to the other two commitments. ^[98] However, ESE notes that although the public services present their own challenges, the commitments have shared goals and methodologies. Thus, examining them together can provide a broader insight about citizens’ access to and participation in these important public services. All three commitments are relevant to the OGP values of transparency, by providing citizens with information about the progress of social services and policies. They are also relevant to civic participation, as civil society will be directly involved in designing and assisting in employment and health policies (for Commitments 3.1 and 3.2) and parents and students will be involved in designing educational policies. The milestones for Commitments 3.1 and 3.2 are verifiable with measurable targets and indicators, but Commitment 3.3’s milestones are comparatively less specific.

Potential for results: Substantial

Commitments 3.1 and 3.2 offer ground-breaking changes to the way citizens and civil society can oversee the design and delivery of critical public services. There are currently no mechanisms in North Macedonia that allow citizens to participate in an organised manner in the design of employment and health services and policies, nor are there platforms where citizens can express their opinions, concerns, or complaints based on their experiences with public-service delivery. According to ESE, many unemployed persons do not register with the ESARNM because they believe that the services offered won’t help improve their circumstances. ^[99] Further, persons who do register are often unemployed for long periods of time, suggesting a lack of efficacy. Regarding healthcare, ESE has noticed that people have limited information on the scope of existing programmes and rarely use related services. ^[100] The feedback and experiences of citizens who have used services are not included in annual plans and programmes, and it has been difficult to include proposals for changes based on citizens’ needs.

The coordination bodies under Commitments 3.1 and 3.2 will offer novel opportunities for civil society to become directly involved in the overseeing policies and services in employment and healthcare. As the bodies will consist of both national and local CSOs, they could result in services that are more responsive to the needs of citizens. Furthermore, cooperation with local CSOs could result in employment and health services that are more accommodating to the needs of socially vulnerable groups who are often left out from these services. Although these are pilots and cover only four municipalities, their targeted samples are large: mapping 250 households per municipality to identify unemployed persons (ESARNM) and women and children from socially vulnerable groups (Ministry of Health) and surveying 1,000 citizens to address identified problems in public-service delivery. Cooperation with local CSOs indicates a willingness on the part of the public institutions to reach socially vulnerable citizens. According to ESE, local CSOs often have better access to these groups than public institutions. ^[101] ESE disseminated a questionnaire on the experiences of unemployed citizens in the four municipalities for Commitment 3.1. [102] A similar survey will be conducted for Commitment 3.2 in relation to health services. Based on these questionnaires, the public institutions and local CSOs will gather opinions from citizens that use the agency’s services. ^[103] ESE, the ESARNM, and the Ministry of Health will develop educational materials for each mapped household to inform citizens about available services. ^[104] The plans will be adopted based on the data gathered from the questionnaires and other information that CSOs have collected. ^[105]

In terms of transparency, the electronic platforms will allow citizens to see who is using certain employment and healthcare services. ^[106] ESE has started working with ESARNM (and plans to work with the Ministry of Health) to identify the data that these institutions already have and to discuss which data will be made publicly available and in which form. ^[107] The IRM researcher has seen a draft version of the ESARNM’s platform. [108] The platforms will allow users to monitor the regional and national distribution of assets, with data downloadable in Excel format. ^[109] Each measure from the ESARNM’s and Ministry of Health’s annual plans will be covered, including activities, services, and measures, how many people applied, how many received funds for all measures, how much has been allocated, and data on gender, age, and minority group status. This could help ensure a more equitable distribution of services and uncover potential corrupt practices in their delivery, such as whether certain health services are prioritised for acquaintances of health sector employees. As North Macedonia looks to recover from the COVID-19 pandemic, these platforms could also help ensure that public services (particularly health) are provided efficiently and equitably to all communities. 

Commitment 3.3 seeks to make education policies and services more responsive to citizens’ needs. However, the planned activities focus mostly on improving the transparency of and access to educational materials. For example, the Ministry of Education and Science plans to publish information on the websites of national institutions, municipalities, and schools and establish mechanism for mandatory publication of open educational resources. While these activities could be beneficial to citizens and educators, there are no details on what materials and information will be published. The commitment also has a target for municipalities to publish only least two-thirds of the required information. Although it includes milestones for citizens (parents, teachers, and students) to help define priorities for education policies, these commitments do not mention if they will involve the same attributes of the other two commitments in the cluster, namely the coordination bodies and the engagement with local CSOs. Thus, it is difficult to accurately assess the potential of this commitment.

Opportunities, challenges, and recommendations during implementation

At the time of this review (March 2022), the activities related to the employment sector (Commitment 3.1) are largely completed. Regarding healthcare, even though there have been changes to the management at the Ministry of Health, this is unlikely to affect Commitment 3.2, as ESE will work with employees at the ministry. ^[110] According to ESE, the aim is to eventually formalise the coordination bodies as a matter of procedure, but decisions still need to be made regarding their frequency and what information they will gather and process. ^[111] Another aim is to include additional organisations beyond the pilots, though this would require additional funds for these coordination bodies to function. Ultimately, the coordination bodies’ sustainability and their cooperation with local CSOs will determine the extent of how employment and health services are designed and delivered. ESE and the public institutions should try to formalize these mechanisms within the ESARNM and the Ministry of Health so that collaboration in shaping services becomes a matter of routine, rather than one-time initiatives.

The IRM recommends the following both during and after the implementation of this cluster:

● Develop clear procedures for the coordination bodies and ensure that feedback is adequately considered and responded to by the ESARNM and Ministry of Health. Participating CSOs and public sector representatives should clearly articulate the role that the coordination bodies will have in shaping and monitoring North Macedonia’s employment and health policies and services. The coordination bodies should be afforded the greatest possible influence in shaping employment and health policies and services. It is also important for ESARNM and the Ministry of Health to respond to the feedback from the coordination bodies. Preferably, the ESE and the public institutions should develop guidance on how the institutions will respond to the coordination bodies’ suggestions, particularly from civil society members. The ESARNM and Ministry of Health could publish summaries on their webpages on how they accounted for these suggestions in the design and implementation of their services and policies.

● Develop similar consultation structures for shaping other public services, such as education. North Macedonia could adopt similar consultation structures for citizens and civil society to shape other public services. Commitment 3.3 could be expanded to include the establishment of a coordination body for the education sector. While implementing this commitment, the Ministry of Education and Science could provide opportunities for parents and students to audit and report on school performance, supplies, and management. As an example, Mongolia implemented a commitment in its 2016–2018 action plan where parents, teachers, and students were invited to raise concerns about education services and work directly with local self-governments to improve schools. [112] Another area might be reducing excessive bureaucracy in the public sector. Romania’s 2020–2022 action plan involves establishing a government-civil society working group to evaluate the central public administration for excessive bureaucracy and publishing its findings. [113] Estonia’s 2016–2018 action plan included a commitment to crowdsource proposals on reducing bureaucracy in the country’s business sector, many of which were implemented in collaboration with the relevant institution. [114]

● Consider knowledge sharing among government institutions with support from implementing CSOs. Given the similarities in the commitments in this cluster, there could be opportunities for collective learning across the three government institutions. This could help address practical implementation issues that the institutions face and collectively discuss how to best leverage participation inputs. Supporting CSOs, particularly ESE, could help facilitate informal knowledge sharing among the three institutions. This could result in the Ministry of Education adopting some of the more far-reaching approaches from Commitments 3.1 and 3.2.

● Institutionalize citizen participation in developing and implementing public services and consider country-wide consultations on public-service delivery. North Macedonia could build on these commitments to further institutionalize citizen consultations in public-service policy development and implementation. The long-term goal should be to support public servants in routinely involving citizens in public-service delivery. One possibility could be to expand the coordination bodies into more formal citizen assemblies. For example, in its 2018–2020 action plan, Scotland piloted a variety of participatory methods to consult citizens in designing public services. [115] North Macedonia could also consider holding broader, country-wide consultations on important policies. For example, in its 2021–2023 action plan, Germany is holding country-wide public consultations to develop its National Action Plan on Education for Sustainable Development. [116] In its 2016–2018 action plan, Uruguay launched a dialogue on the National Water Plan where nearly 2,000 citizens, academics, and government representatives contributed ideas for the plan and its implementation. [117]

● Work directly with the access to justice centres to reach socially vulnerable groups in municipalities and expand to more municipalities. Three of the four municipalities involved in Commitments 3.1 and 3.2 (Prilep, Shuto Orizari, and Tetovo) saw the openings of centres for access to justice as part of North Macedonia’s 2018–2020 action plan. [118] These centres are managed by local CSOs and provide legal and paralegal assistance to citizens, particularly socially vulnerable groups. There is strong overlap in the objectives of Commitments 3.1 and 3.2 with the work of these centres (e.g., they provide marginalised groups with information about their healthcare rights and available legal tools). ESE and the implementing public institutions could work with these centres when conducting surveys in order to reach a wide variety of citizens and to tailor the delivery of employment and healthcare services to their needs. Finally, if successfully carried out in the four municipalities, these activities could be expanded to additional municipalities in North Macedonia.