Engaging the public in pandemic policy response: Missed and future opportunities for Canada
By Roma Dhamanaskar & Julia Abelson
We have learned over the last two years that public health crises are also policy crises. Governments need to act quickly and decisively, often under conditions of extreme uncertainty about the evidence for policy decisions. In these circumstances, governments can face significant challenges in making decisions that are viewed favourably by the public, which can erode public trust and policy acceptance.
An extensive literature supports a central role for public engagement in addressing these challenges and related concerns with top-down policymaking. Having the public “puzzle alongside policy elites” (Davidson, 2020) and contribute to policy design can promote policies that are more reflective of shared social values and attentive to public needs, fostering greater public trust and approval of policy decisions (Boothe, 2021; Norheim et al., 2021; Richards & Scowcroft, 2020). Importantly, these forms of public engagement typically go beyond one-way efforts to keep the public informed of government policy or to gather feedback through surveys.
Not only can we benefit from public engagement in pandemic policymaking, but we have a lot to lose by not involving those for whom policies are designed in the policy process. As McGrail et al. (2022) powerfully argue, policies made with the best intentions can still harm communities if they are designed or implemented without inviting communities to challenge the values that underlie these policies or discuss how policies will impact those on the ground.
Despite these well-established arguments, concerns about limited engagement efforts during the pandemic have prompted calls to action, which have included recommendations for particular styles of engagement and a strong emphasis on inclusive, equity-driven approaches (Norheim et al., 2021; Richards & Scowcroft, 2020; Sayani et al., 2021; Scheinerman & McCoy, 2021).
Canada presents an interesting case study in its approach to public engagement during COVID-19. Drawing on a rich history of experimentation (Abelson & Eyles, 2002; Government of Canada, 2002; Government of Canada, 2005), public engagement has become more institutionalized over the last decade through supporting legislation and major strategic investments (CADTH, 2019; CIHR, 2019; Legislative Assembly of Ontario, 2019; Ministère de la Santé et des Services Sociaux, 2018; Patient Voices Network, n.d.). Yet despite this rich history and current structures, the public seems to have played a passive role in informing Canada’s COVID-19 policy responses (McGrail et al., 2022; Sayani et al., 2021; Tripp et al., 2021). In fact, many (but not all) of the engagement activities embedded within governments and health system organizations across Canada were suspended or partially reduced during the early stages of the pandemic (Cramer, n.d.; Tripp et al., 2022).
Public engagement in Canada during COVID-19
As existing public engagement fell away in the early pandemic phases, few new public-facing engagement activities were initiated to inform policy responses. A recent case survey of government-initiated public engagement activities in Canada yielded four engagement efforts focused on COVID-19 policy response (Dhamanaskar et al., 2022). All four were surveys designed to gather broad-based public feedback (govTogetherBC, 2020 Apr; govTogetherBC, 2020 Aug; Engage4Health, 2020 Jun 5; Engage4Health, 2020 Jun 16). The federal government also established the COVID-19 Disability Advisory Committee, which ran from April through August of 2020, with the goal of bringing a disability lens to the federal government’s pandemic response (Government of Canada, 2021).
Several researcher- and NGO-led engagement activities were also identified such as the ‘Shifting to Recovery’ initiative which gathered public opinion on British Columbia’s COVID-19 Restart Plan (Public Health Association of BC, 2020), a public deliberation on the use of contact tracing apps for pandemic management (Bentley et al., 2020), and an online survey of COVID-19 vaccine acceptability among teachers (Racey et al., 2021). While offering valuable external inputs to policy, government-initiated engagement is also essential during a pandemic, where fundamental values such as individual liberty, protection from harm, duty to care, and equity underlie so many pandemic response policies, and are of public concern. With these considerations in mind and the extensive supporting infrastructure for public engagement in place across Canadian government institutions, one might have expected more direct and robust efforts to engage the public in various COVID-19 policy initiatives.
How does Canada compare with other countries?
While Canada was not alone in suspending many of its engagement activities (Cassasus 2020; Dimopoulos-Bick, Walsh & Sutherland, 2021; Kleefsta & Leistikow, 2021; Richards & Snowcroft, 2020), a number of countries initiated new, high-profile public engagement activities to inform their governments’ COVID-19 response. Notable features of these activities were the use of more interactive forms of deliberative public engagement either on their own or in conjunction with feedback and consultation activities.
For example, the Scottish government hosted an online public discussion soliciting citizens’ feedback on the government’s published framework for transitioning out of lockdown (Webster, 2021; Scottish Government 2020). The public was also able to suggest new ideas and respond to others’ ideas through comment submissions and star ratings. The online platform, moderated by the government and visible to the public, received over 18,000 comments and 4,000 ideas despite being open for only six days in May 2020. The results from the engagement activity were used to inform Scotland’s “route map through and out of the [COVID-19] crisis” (Webster, 2021).
As a follow-up to the online discussion platform, the Scottish Parliament convened a citizens’ panel of 19 citizens from January to February of 2021 to reflect on the priorities that should shape the Scottish Government’s approach to COVID-19 restrictions and strategy (Scottish Parliament, 2021). The panel met virtually four times and interacted through an online portal between meetings. The panel developed recommendations for Parliament which were discussed with the Parliamentary COVID-19 Committee.
France established a 35-person citizens’ panel in January 2021 to steer government strategy on COVID-19 vaccinations with the goal of improving COVID-19 vaccine confidence and providing practical tips on how best to distribute vaccines to the public (Cassasus, 2021). The citizens’ panel was supplemented with a broader public consultation about concerns, questions, and expectations of a government-led vaccination campaign (Government of France, 2021).
Importantly, we are unable to assess the quality or impacts of these engagement efforts, including how representative and inclusive these activities were. However, they demonstrate varied approaches to formalized, government-initiated public input on various pandemic policy responses that were not seen in Canada.
Future opportunities for public engagement in Canada’s pandemic response
The COVID-19 pandemic has had profound health and social impacts on a Canadian public that has been largely responsible for curbing the spread of the virus. Despite bearing this significant burden, citizens and communities have had little direct involvement in shaping the substance or implementation of any of these government-directed policies (Dhamanaskar et al., 2022; McGrail et al., 2022). Notably, communities with the worst health outcomes were also the communities least likely to be meaningfully engaged in the health policies that affected them, suggesting the important relationships between policymaking for health equity and inclusive engagement (George & Abebe, 2022; Rotaru et al., 2021).
How can we address these deficiencies as Canada enters the next stages of the pandemic and its pandemic recovery period?
We suggest some initial steps to move us from principles to practice when it comes to more inclusive, legitimate, transformative public engagement:
Governments could rely less heavily on passive, feedback-style engagement activities, which often attract populations of convenience or those able to find their way into these forms of engagement. These surface-level approaches miss the opportunity for more layered engagement seen in other countries and the ability to prioritize specific communities. Both Scotland and France supplemented broad surveys with carefully constructed citizen panels, suggesting that a combination of engagement approaches may be a valuable strategy for gathering both breadth and depth of public opinion.
The growing interest in deliberative approaches to public engagement worldwide also warrants consideration (OECD, 2020). Deliberative processes involve reasoned and informed discussions between individuals with the aim of reaching common ground on solutions for challenging public policy problems. These types of discussions are particularly useful when conflicting public values are at stake (Solomon & Abelson, 2012) and can be structured through formal deliberative bodies (Gutmann & Thompson, 2004) or embedded in advisory processes or online forums (Scheinerman & McCoy, 2021).
A commitment to deliberative engagement approaches requires dedicated investment. Canada is well positioned to support this approach given its history of leadership in the field (Abelson et al., 2012; Bentley et al., 2019; Maxwell et al., 2003). Existing structures and processes could be repurposed to engage with new and emerging policy issues and that prioritize particular communities. Effort could also be given to harnessing the informal deliberation that is occurring across civil society, generating insights that can enrich formal policymaking processes. Governments can solicit and integrate these broader perspectives while specifically attending to those viewpoints that may be excluded from more formal deliberative processes, such as those reflecting the experiences of marginalized groups.
Additionally, more meaningful partnerships between governments, community organizations, and researchers would allow for more nimble and flexible public engagement. Community organizations are aware of their communities’ needs and have established relationships with their communities. Public engagement researchers can bring their knowledge of inclusive, equity-oriented engagement approaches to this effort (George & Abebe, 2022; Sayani et al., 2021). As we have seen, researcher and community-led engagement efforts have been highly visible during COVID-19. Governments would benefit from supporting this activity and treating community-driven engagement and advocacy as valuable inputs to the policy process.
Finally, COVID-19 has initiated a shift from in-person to online engagement, which presents new opportunities and challenges for public engagement (Kuang & Abelson, 2022; Tripp et al., 2022). Digital platforms may allow larger groups of people to be engaged more conveniently. However, the accessibility of online engagement may be limited to those who have and can use the required technology (e.g., computer, internet access). Confidentiality and privacy may also be threatened in online engagement, and the interpersonal merits of in-person activities may be sacrificed. Making online engagement equitable, safe, and satisfying is an important endeavour as we seek to modernize public engagement.
COVID-19 has shown us how public engagement is necessary for responsible COVID-19 policy response and how status quo engagement approaches have fallen short. In crisis situations, we need to be confident in the possibilities and promise for public engagement to enrich policy responses and focus on creative, flexible, equity-driven approaches that prioritize those most affected in their design.
Roma Dhamanaskar is a PhD student in the Health Policy program at McMaster University and a research fellow with the Public Engagement in Health Policy Project. Her research interests reside at the intersection of public engagement and health policy ethics. Roma holds a Master of Bioethics from the University of Pennsylvania and aims to apply theory from political philosophy to the field of public engagement in health policy. Roma is also a research assistant with the Public Engagement in Health Policy Project and Public & Patient Engagement Collaborative.
Julia Abelson is lead of the Public Engagement in Health Policy Project as well as the PPE Collaborative, a Professor in the Department of Health Research Methods, Evidence, and Impact at McMaster University, and member of the Centre for Health Economics and Policy Analysis (CHEPA). Throughout her career, Dr. Abelson's research program has been guided by a long-standing interest in how the public interacts with health systems as patients, community members, voters, and taxpayers. These interests have provided the foundation for numerous research studies focused on the design and evaluation of processes for engaging the public and patients in health system decision-making. Through her research, she has developed productive and long-standing partnerships with a wide range of policymakers and health system managers at the provincial and regional governance levels across the country and is regularly invited to advise policy decision makers an health system managers on the design, implementation, and evaluation of public engagement processes.
This essay was prepared by members of the Public Engagement in Health Policy team, which is supported by the Future of Canada Project at McMaster University. Please visit www.engagementinhealthpolicy.ca for further research outputs and resources.
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