In the olden days, in the city best known as a democratic city-state, where, arguably, the concepts of citizenship and democracy emerged, there was something called Ecclesia. Here, eligible citizens would gather to have the final say on legislation and the right to call magistrates to account after their year of office. Unlike a parliament, the Ecclesia's members were not elected, but attended by right when they chose. Although these assemblies weren't always inclusive (i.e. of women, rural people or the poor), I suppose it is a reasonable assumption that at least in certain matters, such as public health, the participation on these platforms would be meaningful.

The healthcare system in Bangladesh is presently battling what Al Jazeera recently referred to as "a double blow", with a sharp spike in dengue cases coupled with the worsening coronavirus crisis in the country. In addition, it was recently reported that mental illness is taking a silent toll on healthcare workers. However, while we are all battling the same storm, we are not all in the same boat. In 2015, the Asia Pacific Observatory on Health Systems and Policies published a report that identified inequitable access to health services between urban and rural areas, including variable health financing mechanisms, as a key challenge. One wonders if the response, or at least part of the response, to this challenge might involve greater citizen participation in policymaking.

While ancient Athenians would probably readily agree, we could, maybe, start with asking three questions. Firstly, would a more participatory process help the healthcare system in Bangladesh, especially in the time of this global health crisis? And secondly, how doable is it? And thirdly, if it eases the burden and is feasible, how much of an active effort exists to ensure that the health policymaking in the country is participatory?

To attempt to answer the first question, we have to clarify what we mean by citizen participation. Citizen participation implies the concept of citizen responsibility, right and governance, making full use of intelligence, knowledge and information in formulating policy. It can ensure that the policy represents the views that are shared by the majority.

Now, to answer the question, does a participatory process help the healthcare system in Bangladesh? Theoretically, the answer would be yes. Experts agree that effective engagement and a comprehensive pledge from relevant key stakeholders from the very onset are crucial to ensure the development and implementation of effective national policies and strategies. Without the participation of citizens, facilitation and the execution of policy might prove difficult, and multi-sectoral stakeholder involvement is proven to accelerate the process of any political commitment. While ensuring greater citizen participation can be a costly process, the benefits of including citizens' perspective in public policy can outweigh the costs by helping reduce the gaps of power to decide over policies, which affect them and their communities. This will eventually result in a reduction of inequities in services and might, in turn, reduce the cost burden on the health system.

Now, to answer if it is doable, citizens' participation doesn't necessarily mean that people have to gather in assemblies to give their opinion on policies. Participation is not limited to decision-making. It can include monitoring, and evaluating results and the impact of social policies. So, even if citizen participation in policymaking is difficult, setting up monitoring and evaluation cells led by citizens can improve the quality of health services. And by that definition, it can be made more feasible than, say, gathering people in monthly assemblies to get their feedback on every policy that was proposed in the parliament.

Now, let's investigate whether there are active efforts to ensure that policymaking in the country is participatory. Policymaking in Bangladesh is virtually in the domain of the bureaucracy. In a report published by the Bangladesh Health Watch, Dr M Atiqul Haque, Associate Professor at the Department of Public Health and Informatics of Bangabandhu Sheikh Mujib Medical University (BSMMU), examined citizen participation to identify principal actors and factors based on views of representatives from states, health service providers and the citizens. The findings of the study were that although stakeholder engagement and communication are theoretically cited as important for ensuring transparency, accountability and effectiveness of public health policies and events, there is very little practical action being taken to ensure that there is active public consultation in the decision-making process. Government officials take it as their responsibility to develop policies and so they do it, but only half-heartedly, by making incremental improvements over something that already exists.

So, the participation of civil society or citizens in policymaking is controlled by bureaucrats and is often challenged by the unwillingness and ignorance of government stakeholders. The citizen stakeholders, therefore, are purely ceremonial, and not truly valued for their engaged, constructive participation. Without clarity, or even a definition of which citizens are engaged in stakeholder consultations, citizens are only engaged to tick off boxes.

Now that we have discovered that there is room for improvement in terms of engaging citizens more effectively in policymaking, let's ask a fourth question. How do we ensure a more participatory process in decision-making? Looking to others might help. In Thailand, for example, the National Health Assembly (NHA) was first convened in 2008 after which until 2019, 85 resolutions from 12 assemblies have been implemented, including resolutions on Thailand's Global Health Strategies antibacterial resistance, illegal advertisement of drugs and health products, daily cycling, waste management, health, and housing, to name a few. Despite learning and adopting from the World Health Assembly, the exemplary Thailand National Health Assembly is often cited for its inclusive participation from the government, academia, professions and people throughout the process.

But like any relationship, the relationship between the state and its citizens is a two-way process. What can we do as citizens? Maybe we can start with asking questions. Questions like, how effectively has civil society organised itself over the years? How familiar are those who have the privilege of literacy and knowledge, with the policies that currently exist in Bangladesh? And if there was such a thing as an Ecclesia in Dhaka, Khulna or Rajshahi, how many of us would be able to make meaningful contributions to policies that have direct bearings on our lives? And if we were making meaningful contributions, how prepared is the state to listen to us and take on board citizens' voices? And until the state and the citizens find an equilibrium where they are both ready to listen to each other, how will things improve?

Shagufe Hossain is a freelance consultant and the founder of Leaping Boundaries.