There is a consensus that health systems challenges are complex development issues. Therefore, a systematic approach is needed to develop a holistic understanding of the issue at hand and to propose the most effective, efficient, and inclusive solutions possible. The process of bringing stakeholders together to facilitate a conversation where they first collectively define the issue at hand, brainstorm evidence-based policy design solutions, and draw up a roadmap for their implementation with measurable benchmarks and objectives we refer to as process facilitation.
This blog is the result of a literature review conducted by the African Collaborative for Health Financing Solutions to understand what experts, in various development sectors, have said about process facilitation, the outcomes it seeks to achieve, determinants for its success, and how the process can be evaluated. The purpose of such an exercise is to identify ways to sharpen the tools and approaches development practitioners use in their work relative to Health Systems Strengthening (HSS) where process facilitation is a keystone element.
Meaningful collaboration is a keystone element to process facilitation
Per the literature, the most important aspect of process facilitation is its collaborative nature. To fully grasp the essence of meaningful collaboration in process facilitation, the concepts of diversity and inclusion are critical. Diversity consists of bringing different people together to create changes regarding the current state of affairs. Inclusion, on the other hand, consists of empowering different representatives within the decision-making process, and creating an enabling environment for all participants to be heard. Thus, because process facilitation seeks to support broad engagement and participation to ensure a collaborative decision-making and implementation process, it draws on the tenets of inclusion to proactively empower a diverse set of stakeholders. The key takeaway is that for process facilitation to work, powerholders need to be intentional about inclusivity and provide all participants with the tools they need to meaningfully contribute to the process.
Another important learning from the literature is to break down the “collaboration status quo” to ensure that all involved parties are able to fully participate and voice their concerns. For this to occur efficiently and effectively, there need to be two levels of collaboration. Level 1 is a decentralized form of collaboration where each stakeholder group holds a “mini process facilitation exercise” internally to ensure their views are harmonized and made as strong as possible to feed into a broader collaborative process.
For instance, as representatives of the people, civil society organizations (CSOs) would need to hold consultations with the people they represent as well as other CSOs to ensure they bring a strong and unified voice that speaks authentically to the views of all subgroups within their circle. A similar exercise should be conducted by all other stakeholder groups.
Level 2 then houses the centralized collaboration approach where the representatives of all stakeholder groups, armed with the insights of their peers collected at level 1, interact with other stakeholder groups in an attempt to ensure their concerns are taken into account when defining the problem and suggesting potential solutions.
Figure 1. Decentralized Collaboration
Process facilitation oils the wheels of policy design and implementation at the country level
Successful process facilitation tends to be effective when a legitimate and neutral third-party organization or actor plays a facilitation role among country stakeholders to collaboratively determine country priorities and serve as a bridge between national stakeholders and technical and financial partners.
However, for this blog, the emphasis is placed on the facilitation that happens at the country level with national stakeholders.
By focusing on this facet of process facilitation, the literature review revealed three insights:
1. Process facilitation ensures cohesion among national stakeholders and limits foreign influence
When national stakeholders gather to discuss what their country’s priorities are vis-à-vis a given focus area (i.e. public health, education, national security, etc.) they are better able to portray themselves as a unified body speaking with one voice. Traditionally, in development projects, there is almost always a foreign donor who tends to have a lot of influence on the design of policies. On that note, process facilitation allows for a better definition of the problem by taking into account different perspectives and simultaneously ensuring that whatever is suggested as a way forward reflects the views of the national stakeholders. Furthermore, since the process includes both stakeholders who design policies as well as those in charge of carrying them out and beneficiaries, the execution of policies is more inclusive and less likely to face implementation issues given they reflect the realities on the ground.
2. Process facilitation promotes systems thinking and more creative policies
When policies only focus on one aspect of a complex, multifaceted issue without investigating its impeding factors, it can negatively impact the proposed solution(s) to the challenge. However, when diverse stakeholders with different perspectives and roles in the system related to the challenge are brought together, the issue is dissected and analyzed more systemically; that notion is known as systems thinking. The underlying assumption of systems thinking is that a structure has different components and each component is a system by itself. A change in different components can change the broader system in various ways. Therefore, when seeking to alter the system as a whole, all components need to be taken into consideration to avoid unintended changes and to achieve intended sustainable outcomes. By bringing together different stakeholders with different perspectives, priorities, and expertise, process facilitation creates an environment conducive to more creative and sustainable policy design and implementation.
3. Process facilitation sets the stage for stronger accountability mechanisms
Process facilitation structures collaboration among country stakeholders to ensure that there is a harmonized definition and shared understanding of the issue to be tackled as well as the collective development of a sustainable solution. Process facilitation also sets the stage for creating or strengthening accountability mechanisms. In the realm of public policy, a given context could be said to have a strong accountability mechanism if all stakeholders are guaranteed the following: 1) Access to information about the process as well as the role and responsibility of each actor, 2) Ability to express their concerns without repercussions, 3) Ability to influence the decision-making process, and 4) Ability to possibly activate institutions that enforce consequences depending on each stakeholder conduct. The collaborative aspect of process facilitation creates an environment where all stakeholders have all the information that they need to keep each other accountable. However, it is the structure of the process itself that brings together all the components necessary for a strong accountability mechanism.
Walking the evaluation tightrope
There is a noticeable gap in evidence in the literature on effective methods to evaluate process facilitation exercises or collaborative efforts. Most literature focuses on evaluating the structure of the collaborative work rather than the outcomes of the process. Generally, evaluation publications on process facilitation are satisfaction surveys attempting to elicit perspectives on the approach by showing how satisfied participants were to partake in such an effort, rather than showing the value-add of adopting such an approach.
It is important to note that there are a few publications that demonstrate ways of gauging the value-add of process facilitation. These mainly focused on increasing learning among stakeholders as the principal objective of process facilitation. Several publications looked at increased connections across stakeholder groups as the ultimate value-add of the process facilitation exercise.
In other words, we posit that there is merit in going beyond evaluating the level of learning and the magnitude of connections created among stakeholders as the value-add of process facilitation.
However, more work is needed to follow the long-term outcomes of process facilitation, how sustainable those outcomes are compared to less collaborative approaches, and what — if any — long-term change process facilitation has on a system. Upcoming blog posts will focus on segmenting the process facilitation process, exploring how much collaboration each segment needs, and proposing a potential evaluation approach for each segment.