Table 3.

International learning on building social participation in health systems, process reflections, and future adaptions. Adapted from [40]

International learning	Process reflections	Adaptations
1. Participation is both a means for health improvement and an end in itself based on values and rights	Broader understanding of forms, processes and contexts requires explicit reference to, and ultimately transfer of power towards, disadvantaged groups, and a focus on change processes developing community voice as a continuous process, situated within social and political environments	Framing in terms of social justice and citizenship may help to communicate key features of the process and what it seeks to achieve
2. Community experience is a key entry point, and community activism and leadership are key drivers of participatory practice	Mobilisation activities related to participation and deliberation were possible to progress, and there was some evidence of individual acts of information sharing in the wider community	Enabling community experience and leadership, with less researcher control and more shared ownership should be incorporated into collective design decisions
3. Participatory processes and social power in health are more likely to thrive when services go into community settings	All activities were conducted in accessible community spaces in which there were generally supportive attitudes. Community settings appear supportive and enabling of PAR	While institutional and political support is important, claimed spaces in which issues can be autonomously raised and framed are important to cultivate and maintain
4. They are supported by and elicit more holistic models of health	Self-nominated priority topics, and facilitated participatory problematization clearly elicited holistic models of health	For acting on the evidence generated, a wider set of stakeholders should be engaged, beyond department of heath
5. Informal and formal spaces and processes both play key roles. The synergies and links between them enrich both	Formal (e.g. clinic committees) and informal (e.g. VAPAR) structures exist for community participation in this setting	Interaction between claimed and invited participatory spaces will be sought and progressed
6. Institutional and individual facilitators play a critical role	Sensitive facilitation was key to convey process, co-design, and power dimensions that enabled rich action-oriented interpretations of community nominated. Management of expectations important	Lift up and make explicit the key contribution of facilitation. Explore skills exchange for effective and respectful facilitation
7. Sharing Information and participatory processes to gather, analyse, discuss and use community evidence in planning are necessary (but not sufficient) for meaningful social participation	The wider VAPAR process is geared towards cooperative action cooperation with health authorities in the province, district, sub-district and locally	A wider set of stakeholders beyond department of health, should be engaged to share, interpret, act on, and learn from community evidence
8. Accessible processes for co-determination that link decisions to shared plans, actions and resources to act are central to meaningful participation		Careful consideration and appraisal of implications of proposed actions in cooperation with health systems stakeholders, and other government and non-governmental stakeholders, are necessary as process progresses
9. Deepening of participation takes a consistency of presence, time and capacities	The wider VAPAR programme supports this consistency	Attention to specifics of engagement over time, and beyond defined periods of engagement, is required with a focus on making implicit issues of presence, time and capacities explicit. Careful attention to issues of marginalisation and representation are required
10. Learning from action (and evaluation) needs to track diverse forms of progress to build strategic review	Wider VAPAR programme enables the tracking of progress	Diverse forms of progress (and failure) require careful monitoring as the action elements progress