Community case study: overcoming barriers to social participation for improved local health governance in Madagascar.

Government engagement with communities are critical for achieving health equity goals. The available literature is plentiful on community and civil society's barriers to meaningful participation. However, considerably less documentation abounds on how to address barriers to equal interaction within the participatory process, with concrete interventions tested and assessed. This paper aims to bridge that research gap by studying community engagement for health policymaking in Madagascar, focusing on how policy makers can design interaction with communities in a way which decreases power imbalances within a participatory space, thereby enabling constructive dialogue to address health systems issues. We conducted 37 key informant interviews across all levels of the health system (community, district, regional, and national) in one urban and one rural district of Madagascar's Atsimo-Andrefana region. Purposive sampling techniques combined with emergent, opportunistic sampling, were used based on participants' experience with the country's national health planning processes. Multiple rapid literature reviews - before, during, and after the interview phase - helped to guide, steer, and underpin the main conclusions presented in this article. This paper points to three simple strategies which can contribute to providing counter-vailing power to those with less voice: using the same language as those whose views and input are solicited; creating smaller, homogenous dialogue groups with participants whose voices are less heard; and bringing consultations to people's own environment. While these strategies are neither novel nor complicated, they are rarely leveraged by those seeking people's views on health policies. It is hoped that by providing qualitative evidence suggesting the effectiveness of these strategies, when properly implemented, they will become more widely used to promote meaningful community participation for health policymaking.