Challenges for change

Posted on 10 March 2009

‘Medicine prices are too high!’

‘‘Donors gave lots of money for medicines, but where has the money gone? There are no medicines at the health centre!’

‘We can’t trust the quality of medicines on the market.’

These are just three of the frequently heard cries from civil society groups active on access to medicines in countries around the world. However, what would they say if they were not campaigning for change from the outside, but were sitting round the table with government policy makers, senior researchers, staff from international agencies and donors, and business leaders looking for solutions to these and other problems?

That’s what MeTA is trying to find out in seven countries as it encourages the development of multi-stakeholder dialogue to improve access to medicines. This, as Dr Tim Evans, Assistant Director General of the World Health Organization (WHO – a key MeTA partner) said recently (Evans, 2009), is part of the changing nature of negotiation around international development issues. He stressed the importance of ‘ensuring an inclusive process that engages the views of diverse stakeholders. The era of “command and control” leadership in health is increasingly a relic of the last century – a new era of “steer and negotiate” leadership is upon us.’

This “steer and negotiate” process enables shared learning and collaborative action among all stakeholders to dialogue about and agree directions for health and is the kind of innovative approach that is needed to deal with the demands of increasingly complex health systems.

However, Mark Pieth from the Swiss-based Basel Institute on Governance (Pieth, 2006) suggests that for civil society, these types of multi-stakeholder initiatives can prove difficult ‘since its representatives are often the main initiators and motivators of the initiatives, at least in its early stages. If the initiatives do take off, civil society is rapidly considered as superfluous, even though the initiative will change its character without them. On the other hand, the means of civil society groups to set these processes in motion are frequently weak, sometimes crude and the outcome is usually uncertain.’

Minu Hemmanti and her colleagues (Hemmanti, et al, 2002) note that among civil society actors ‘there is a widening split between those who seek to engage with other stakeholders and those who define their role outside the conference room.’ Civil society representatives often have concerns over co-option, of losing independence, and being in a situation where the political and economic power of other participants in a multi-stakeholder process might divide civil society or dilute the strength of its voice and its advocacy for change.

However, Hemmanti argues that an essential part of any multi-stakeholder process is dialogue, and that dialogue leads to real opportunities for change. ‘Learning to engage in dialogue means to move from hearing to listening. It means taking one step beyond fighting, beyond adversarial, conflictual interaction. Dialogue is the foundation for finding consensus solutions which integrate diverse views and generate the necessary commitment to implementation. It can form the basis to take us one step beyond talking towards common action.’

What’s the difference among debate, dialogue and discussion?
Debate means to discuss or examine a question by presenting and considering arguments on both sides. Debates do not lead to an integration of views.

Discussion is the consideration of a question in open and usually informal debate. It may explore the benefits and disadvantages of different views, but is not focused on mutual understanding that leads to consensus-building.

Dialogue is a conversation or exchange of ideas and opinions between two or more people that is aimed at resolution of differences. It requires listening to each other’s views to develop mutual understanding not only of the ideas, but of each other’s value base, interests, goal and concerns. It is not about ‘winning’ an argument, but about finding common ground.

Thus, debate and discussion may air views without leading to any change among the participants; dialogue seeks real change.

The MeTA multi-stakeholder process is very much about change and transformation. It seeks to:

• shift some decision-making power to consumers
• put greater competitive pressure on suppliers
• promote better governance and more appropriate resource allocation by public purchasers
• improve the functioning of the pharmaceutical market
• encourage innovative and responsible business practices.

Helping to shape the agenda of the dialogue, learning about what solutions are possible, and working together to encourage change are strong incentives for civil society to engage in the multi-stakeholder process.

What do you think? We’d like to hear from civil society representatives (and others) about your thoughts on the advantages and disadvantages of engaging in multi-stakeholder processes, and your experience. Join the MeTA Dialogue

References

Evans, T. 2009. Primary Health Care, Social Determinants of Health and Health Public Policies: Indispensable Agents for Equity in Health. Keynote Speech delivered at Prince Mahidol Award Conference, Bangkok, Thailand. 

Pieth, M. 2006. Multistakeholder Initiatives to Combat Money Laundering and Bribery. Basel: Basel Institute on Governance.

Minu Hemmati, M. et al. 2002. Multi-stakeholder Processes for Governance and Sustainability: beyond deadlock and conflict. London: Earthscan.