Stakeholder engagement in the health policy process in a low income country: a qualitative study of stakeholder perceptions of the challenges to effective inclusion in Malawi

Abstract Background: Inclusive engagement in healthcare policies and decision-making, including with patients, non-government organisations and local government, is essential to address the needs of patients and communities, reducing health inequities and increasing the accountability of the government. In low income countries such as Malawi, with significant health challenges, stakeholder inclusion is particularly important to improve performance and service delivery. The 2017 National Health Plan II (NHP II) and accompanying Health Sector Strategic Plan II (HSSP II) aimed to improve the functioning of the healthcare system. The Ministry of Health for Malawi intended to involve all key health sector stakeholders in their development. This study explores the extent of stakeholder engagement in the health policy process through the perceptions of local level stakeholders of their engagement in the NHP II and HSSP II.Methods: A qualitative study design was used. Interviews were conducted with 19 representatives of organisations operating at the local level, such as civil society organisations and local government. Open questions were asked about experiences and perceptions of the development of the NHP II and HSSP II. Inductive content analysis was performed.Results: Stakeholders perceived barriers to inclusive and meaningful engagement in the health policy process. Three categories were identified: power (tokenistic involvement; stakeholder hierarchy; mutual distrust); representation (preferred stakeholders; open versus invited engagement); stakeholder-driven engagement. Conclusions: Local level stakeholders identified serious challenges to the meaningful and equitable engagement of stakeholder groups in the health policy process. Issues of trust, accountability and hierarchy in donor-citizen-government relations must be addressed to support stakeholder engagement. Engagement must go beyond tokenism to embed a range of stakeholders in the process with feedback mechanisms to ensure impact from their contributions. Local level stakeholders can be empowered to advocate for and participate in both invited and open stakeholder engagement exercises, and policy literacy increased but greater top-down efforts to engage stakeholders via diverse and inclusive methods are also required. These issues are not unique to Malawi or to health policy-making.