Dear Philister,

Thanks for highlighting the importance of power imbalances that may be present among the stakeholders, as a factor to be considered in determining the nature of relationship with stakeholder. Allow me to share from a slightly different context where this was felt and addressed. The accountability for reasonableness (A4R) framework that was intended to improve fairness and legitimacy in healthcare related decision-making, inclusive of stakeholder engagement originally had four conditions. Later, a fifth condition on “empowerment” was proposed to address concerns similar to what you have raised here. I am quoting from a paper that describes this [Strengthening fairness, transparency and accountability in health care priority setting at district level in Tanzania, available at:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3211296/%5D

“… the findings underline the need to recognise and deal with power asymmetries among various actors in the priority-setting process. More attention needs to be paid to issues of difference and the challenges of inclusion. It was evident that while priority setting was meant to be participatory, this was not the case. In practice, most of the district health plans were products of a few members of the CHMT, with private partners and community bodies at best operating as a rubber stamp for decisions taken without their input. The findings suggest that simply establishing institutional arrangements of participatory planning, priority setting and governance–in the absence of prior awareness and without the strong capacity for exercising countervailing power against persisting ‘rules of the game’–will not result in greater responsiveness to community needs and priorities. Rather, the best-intentioned mechanisms for participatory planning and priority setting might simply be dominated by the local elite.

This study reinforces the findings of an earlier study in high-income countries that advocated the need to add the empowerment condition in the Accountability for Reasonableness framework (22). The empowerment condition requires that steps should be taken to optimise effective stakeholder participation and minimise the impact of power differences in decision making (22). In this case, empowerment of user committees and boards enables them to be pro-active, to suggest solutions to local authorities and to insist on decisions being made and implemented. One of the tools in empowering boards and committees is the provision of good information, more so if they are involved in its collection. Well-informed members of boards and committees will be in a better position to make sound and informed decisions, and to participate effectively in the implementation of priorities. Another way to empowerment could be to engage the committees and boards in identifying not only community needs but also the available local resources, and in working out acceptable solutions (23).”