Academic journal article Canadian Journal of Public Health

Civil Society? What Deliberative Democrats Can Tell Advocates about How to Build Public Commitment to the Health Promotion Agenda

Academic journal article Canadian Journal of Public Health

Civil Society? What Deliberative Democrats Can Tell Advocates about How to Build Public Commitment to the Health Promotion Agenda

Article excerpt


Closing the health inequity gap can be seen as an issue of justice, however what concretely best serves the interest of justice is in dispute. It is argued that standard policy-making mechanisms are inadequate to address this issue, and therefore more and better public dialogue is required. Drawing on deliberative democratic theory and practice, three public organizing considerations are offered: organizing within the state sphere, organizing within the public sphere, and using cross strategies. It is recommended that public resources be provided to involve the public in deliberations about population health promotion issues related to the wicked problem of health inequities.

Key words: Deliberative democracy; population health; health promotion; health inequity; advocacy; civil society


On peut considérer la réduction des inégalités en santé comme une question de justice, mais on ne s'entend pas sur les mécanismes qui, concrètement, servent le mieux les intérêts de la justice. Nous faisons valoir que les mécanismes habituels de formulation des politiques sont insuffisants dans ce cas, et qu'il faut tenir des discussions publiques plus nombreuses et plus éclairées. Nous proposons trois mécanismes possibles d'organisation du public, fondés sur la théorie et la pratique de la démocratie délibérative : l'organisation dans la sphère étatique, l'organisation dans la sphère publique et l'utilisation de stratégies transversales. Il est recommandé que l'État fournisse des ressources pour faire participer le public aux délibérations sur les questions de promotion de la santé des populations liées au problème épineux des inégalités en santé.

Mots clés : démocratie délibérative; santé des populations; promotion de la santé; inégalités en santé; revendication; société civile

Rhetorically, there may be general agreement that building a just society requires addressing health inequities. However, moving from rhetoric to reality means facing "wicked problems" with very difficult policy trade-offs. Wicked problems are social issues that defy resolution by one state* department or civil society action. They require the coordination of multiple departments and agencies to resolve the concerns at hand.1 Wicked problems challenge the ability of agencies to identify and connect with apparently conflicting interests and agendas of diverse publics. Driven by short-term budget and electoral cycles, agencies may simply "muddle through" without seeking any longer-term and deeper consensus on sustained program initiatives. This is especially so with health promotion where time horizons are generally long term. It is crucial then to have good ways of determining if there is real public support for such initiatives.

Broadly speaking, engagement processes strengthen democratic participation in governance and public agency activities, and have the ability to increase opportunities for education and awareness of population health promotion.3 More specifically, public dialogue offers the prospect of sustained discussion with the public on the direction in which we want to go as a society, and exposes perspective tensions between bureaucrats, scientists, academics and multiple publics. It offers structured environments to explore common ground among these groups and potential mechanisms for informing government and civil society directions in an explicit decision-making environment.3,4 Sustained public engagement has also been associated with increased knowledge on the topic under discussion, support for a given direction, and shifting perspectives due to deliberation.3

This manuscript examines how deliberative democratic advances can inform population health promotion education and advocacy efforts. Knowing where to target coordinating and advocacy efforts is shaped by three strategic considerations: when to align with government initiatives (state sphere); when to target efforts outside government mechanisms (public sphere); and key considerations during efforts to build combined inside/out engagement strategies (cross strategies). …

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