Participation in Health Legislation: A Comparative Study of Participation Mechanisms in the Selected Countries and Iran


Ali Akhavan Behbahani ORCID 1 , Irvan Masoudiasl 2 , * , Somayeh Hessam 1 , Mohesn Najafikhah 3

1 Department of Health Services Administration, South Tehran Branch, Islamic Azad University, Tehran, Iran

2 Department of Health, Islamic Parliament Research Center of the I.R.I, Tehran, Iran

3 National Research Institute of Health Law, Ministry of Health and Medical Education, Tehran, Iran

How to Cite: Akhavan Behbahani A, Masoudiasl I, Hessam S, Najafikhah M. Participation in Health Legislation: A Comparative Study of Participation Mechanisms in the Selected Countries and Iran, Iran Red Crescent Med J. Online ahead of Print ; 22(5):e101924. doi: 10.5812/ircmj.101924.


Iranian Red Crescent Medical Journal: 22 (5); e101924
Published Online: May 11, 2020
Article Type: Research Article
Received: February 25, 2020
Revised: April 15, 2020
Accepted: April 19, 2020


Background: Health legislation provides a framework to implement various health policies. Participatory democracy in healthcare is inevitable. Citizens and health professionals should participate in participatory democracy, and health laws should be the result of a process in which participatory instruments and techniques have a prominent role. Health democracy can be achieved through the expansion of mechanisms for citizens’ participation in the legislative process. The health democracy enables citizens to participate in the decision-making process and to have equal access to services provided by the public health system.

Objectives: The current study aims to assess participatory mechanisms used by selected countries to participate their citizens in legislative processes.

Methods: The current study is a comparative study of the legislative processes of selected countries. To select countries, four issues were evaluated: (a) overall legal system; (b) how laws enforce; (c) legislative backgrounds; and (d) health system basic model.

Results: The number of legislative chambers, legislative initiatives, legislative authorities and institutions, legislative commissions, and citizens’ participation in the legislative process were analyzed in the selected countries. An analysis of the factors affecting public participation in healthcare legislation shows that participation in the legislative process is a complex phenomenon influenced by social, legal, cultural, political, and sovereignty factors. This phenomenon cannot be analyzed isolated from these factors. However, the way should be paved for citizens' participation. The selected countries use different methods for citizens’ participation, depending on their legal systems.

Conclusions: Research results show that there are various public participation mechanisms. In Iran, there is a huge potential for public participation, and members of the parliament can easily interact with the interest groups and relevant individuals. These conditions provide a golden opportunity for expert health legislation.

Copyright © 2020, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License ( which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited

1. Background

Health legislation provides a framework to implement various health policies. Although it is not the ultimate goal, but legislation paves the way for better administration of health systems or its sub-systems. Like other sectors, laws have many potential functions in the health sector. For example, providing legal rights or imposing obligations that affect providers’ behavior, administration of programs, resource allocation, and developing budgets. However, if legislatures do not make the best of the law to support health policies, the potential functions won’t be achieved.

When a law is legislated it should be appropriately placed in the hierarchy of laws. Before legislating a law, two issues should be evaluated: (a) applicability and (b) availability of resources. Moreover, any conflict of interests between different groups of the society can be resolved by embodying rights and responsibilities and reconciling human rights and the public interest as well as balancing the interests of different groups of the society (1). Though legislation by itself may not improve the functions of the healthcare system, but it can contribute to its improvement (2).

The relationship between the parliament and democracy can only be cemented with citizens’ participation. The way that different interest groups participate in the legislative process is of paramount importance. They can participate either in developing the draft(s) or enactment of legislation(s) in the parliament, or both. How can we provide a mechanism for optimal engagement of the interest groups in the legislative process?

In a democracy citizens’ participation in policymaking has two foundations: (a) people have both rights and duties and (b) democratic governance includes providing opportunities for active participation of citizens in shaping their world. Participation is a key concept in the traditional definition of democracy. Democracy leads to the participation of the masses in politics. Jacobsen defined democracy as “participation of the majority of people in the political life and decision-making” (3). The International Association for Public Participation defined the public participation as “involvement of those affected by a decision in the decision-making process” (4). Public participation enfolds a span of public involvements, ranged from simply informing the people about what the parliament is doing to delegating decisions to the people.

Public participation in the legislative processes is an important component of democracy. It has several important roles, such as (1) Providing the scene for citizens’ regular participation in the political life, not just during elections; (2) Providing a framework for citizens to defend their legal interests and, therefore, to contribute in developing a democratic society; (3) increasing the transparency of what government officials do and, hence, forcing them to comply with legislations; (4) Improving the quality of adopted public policies and facilitating their implementation; and, last but not the least, (5) Facilitating the role of Non-Governmental Organizations (NGOs) in monitoring implementation of policies (5).

Mansbridge noted that citizens’ direct involvement in legislative affairs can make “better citizens", because it both enhances parliamentary sovereignty and quality of decisions (better governance) (6).

Citizens’ participation in legislative processes related to the health sector can be categorized into two types: direct and indirect. Referendum is a method that contains citizens’ direct participation. Because of its operational difficulties and limitations, referendum often uses in exceptional cases (7).

Citizens’ participation also has a prominent role in the development of civil society, as documented by some countries. There are various forms of citizens’ indirect participation in the legislative process (7).

A great deal of evidence support the argument that public participation legitimizes decisions made by health authorities and improves the outcomes of health policies (8). Since most of the topics of health-related legislation are not controversial and are clear for most of the people, the people have little demand to participate in health legislation. However, organized civil players who are focused on legislations may consider their benefits, seek political support for their benefits, and, ultimately, take advantage of the legislative process (9).

Public participation in the phase of drafting legislation can increase the legitimacy and acceptability of the law. In this regard, the World Health Organization (WHO) believes that participatory democracy in healthcare is inevitable and should include all players, including citizens, health professionals, governmental organizations and NGOs, the private sector, and other interest groups. Accordingly, health laws should be developed and enacted through participatory democracy. Of course, such a process should be accompanied by accountability of participants and those who plan the health budgets (10).

The European Union is a rich example of participatory democracy in healthcare. As a prominent example, to obtain citizens’ opinions, the Department of Health of the United Kingdom used the “Have-Your-Say” mechanism when drafting a structural reform plan for its National Health Service (known as NHS) (11). Or in another example, the Republic of Macedonia used volunteer assistance of a steering committee to develop public health reforms (known as Green Book) (12).

Having an effective method in place to facilitate public participation is a sign of democratic governance. Health democracy can be achieved through the expansion of mechanisms for citizens’ participation in legislative processes. Health democracy enables citizens to participate in decision-making processes and to have equal access to services provided by the public health system (13).

2. Objectives

The current study aims to assess participatory mechanisms used by selected countries to participate their citizens in legislative processes.

3. Methods

The current study is a comparative study of the legislative processes of selected countries. To select countries, four issues were evaluated: (a) overall legal system; (b) how laws enforce; (c) legislative backgrounds; and (d) health system basic model.

To document various steps of the study, a quantitative method was employed. By taking a holistic view, qualitative research provides a comprehensive analysis of a phenomenon in which there is no prior information about it and due to the nature of the phenomenon, information cannot be collected through conventional quantitative methods (14). The following criteria were employed to select the countries:

(A) Comparing countries with different legal systems. In this regard, Romano-Germanic (France and Germany), common law (South Africa, UK, and USA), and Islamic legal systems (Egypt, Turkey, and Malaysia) were selected;

(B) Having a desirable degree of efficiency and success in the legislative process and policymaking. Also, nominated countries should be an example for other countries in terms of constitution and legislative processes. Most of the selected legislative systems have a well-established legal system with a long history, and their standards and parliamentary structures are adopted by other countries (e.g. legislative systems of United States (US), United Kingdom (UK), and France);

(C) Having different systems to enforce laws. Examples include the US, UK, France, Germany, and Malaysia that are selected from the presidential, parliamentary, semi-presidential or semi-parliamentary and mixed or Islamic systems, respectively;

(D) To select countries with different health system models, the Garden model was employed. Finally, it worth noting that the authors have done their best to select countries with prominent health systems, particularly in terms of resource allocation.

The selection criteria (which consider both legal and health system) are described in Table 1.

Table 1. Selection Criteria
Enforcement SystemLegal SystemHealth System
PresidentialParliamentarySemi-ParliamentaryRomano-GermanicCommon LawIslamic or MixedTraditional InsuranceNational Health InsuranceNational Health ServicesIntegrated Insurance
South Africa***

In the next step latest available documents related to legislative status, the legislature system, legislative commissions, and citizens’ participation in the legislative process of selected 10 countries were investigated. Then, required data were extracted and imported in an author developed table to compare countries.

4. Results

The number of legislative chambers, legislative initiatives, legislative authorities and institutions, legislative commissions, and citizens’ participation in the legislative processes that were analyzed are described in the following.

4.1. Number of Legislative Chambers

In seven countries the parliament was bicameral (i.e. Germany, France, UK, Japan, South Africa, United States, and Malaysia) and in three countries was unicameral (i.e. Egypt, Turkey, and Iran) (15-17).

4.2. Legislative Initiatives

In seven countries (Germany, France, England, Japan, South Africa, Turkey, and Malaysia), the parliament and cabinet were the main legislative initiatives. In the United States the Congressmen are the holders of legislative initiatives. While in Iran this power is hold by Members of the Parliament (MPs), ministers' delegation and other institutions (15-17).

4.3. Legislative Authorities and Institutions

In two countries (Germany and Japan), the legislative process was exclusively the responsibility of the parliament. Meanwhile, in seven countries (France, England, Turkey, South Africa, USA, Egypt, and Malaysia) the parliament and the cabinet carry out the legislative process. In one country (Iran), the legislature and parliament, the Cabinet, and other institutions share the responsibility for legislative process (15, 16, 18).

4.4. Legislative Commissions

In all of the ten countries, there were various forms of active legislative committees. In six countries (i.e. Japan, Turkey, South Africa, US, Egypt, and Iran), there was an independent commission for healthcare affairs, such commission was not observed in the rest (15, 17, 19).

4.5. Citizen Participation in the Legislative Process

In the UK, before submission of the private bills to the parliament, local residents and/or other interest groups could be aware of bill’s intentions, therefore they were able to set forth their objections (if any) in the committee review process. In addition, lobbies and pressure groups could deal with MPs to pursue their goals. In addition, MPs whom were in close contact with people within their catchment area and knew their problems and demands were able to help them to fulfill their desires. It was also possible to identify the needs of civil institutions via media, questionnaires, research, and public hearings to take those needs and propose them to legislative processes (15).

In the case of South Africa, research institutions and NGOs can participate in the legislative process by contacting MPs, attending public debates of the parliament, participating in public hearings, and reflecting their opinions to the parliament through established mechanisms (20, 21).

In the legislative process of the German Federal Republic, interest groups (those other than political parties) play a crucial role in drafting legislatives and public hearings. Moreover, each of the specialized committees of the Bundestag (the constitutional and legislative body at the federal level) has Scientific Consultative Committees (SCC), which to somehow act as specialized consultative arms. The SCCs consist of about six thousand experts from various fields who are proposed to the Bundestag by the government. The German Parliament also uses research services of the German Bundestag (15, 22).

In Japan, the Research and Legislative Reference Bureau (RLRB) of the National Diet Library is a legislative support organization which serves the Diet of Japan. MPs can ask the RLRB to investigate legislative issues. To complete its investigations, the RLRB uses experts’ opinions (23).

In France, parliamentary delegations and committees can devolve research affairs to civil institutions or use their information. Civil institutions can also communicate with MPs (24).

In the US, public hearings are the most important method for citizens’ participation in legislative processes. Besides that, lobbying is common in the Senate, the House of Representatives, and other institutions at the state legislature level (16).

Turkey has thousands of NGOs that mostly are not well equipped to contact with parliament. Currently, except for those groups with enough power to directly contact with MPs, for others the only way to participate in legislative processes of the Turkey is to contact ministries. Only when the parliament invites specific groups to engage in relevant issues, they can participate in the legislative process (25).

In the case of Egypt, all parliamentary commissions can request the cooperation of expert(s) to address an issue. Additionally, parliament commissions can collect information related to an issue, both formally and informally (17).

In Malaysia, the parliament has adopted the “Electronic Participation (EP)” as a policy to improve the quality of its services. The EP policy intends to involve citizens in the decision-making processes through the use of information technology and tele-communication (26).

In Iran, the Supreme Council of Provinces can submit bills to the Parliament (18). Moreover, the Islamic Parliament Research Center of the Islamic Republic of Iran facilitates using the opinions of experts and civil institutions in the legislative process. In addition, experts and institutions can attend meetings of parliament committees and make remarks. The website of “Iranian Virtual Parliament” ( intends to involve various interest groups in the national legislative process of the Islamic Parliament of Iran. According to the Medical Council Law and the Sixth National Development Plan of the country, the Medical Council of Iran is obliged to submit its expert opinions about plans and bills (27, 28).

An overview of selected countries is provided in Table 2.

Table 2. Overview of Ten Selected Countries
CountryThe Number of Legislative ChambersLegislative InitiativesLegislative Authorities and InstitutionsLegislative CommissionsIndependent Health CommissionCitizen Participation in the Legislative Process
GermanyBicameral parliamentBundesrat, Members Bundestag Members and the federal governmentThe federal parliament has the authority to enact legislation. State laws are made by the states.Permanent commissions and special commissionsNoEstablishment of consultative bodies; active participation in drafting parts of the legislative process; public attendance at open meetings and commissions; preparation of drafts of proposed laws
FranceBicameral ParliamentThe government and MPsThe parliament plays a crucial role in the legislative process. The parliament can enact the authority vesting law and then allow the government to make laws in special cases by adopting bylaws as an alternative to laws6 Permanent Commission, Special Commissions and DelegationsNoInformal consultations, direct communications between citizens and representatives.
EnglandBicameral parliamentThe government, MPs and those engaged in developing bill The parliament has legislative authority. The legislative authority of the parliament can be vested only if the original law allows. The legislative authority of the parliament can be vested in ministries and deputy ministers or the Empress’s council or legislative bodies such as local authorities with the parliament's permission.Commission consisting of the whole Parliament, Permanent commissions and selected Commissions (research) and common CommissionsNoObtaining and promulgating the public opinion; establishment of consultative bodies; active participation in drafting part(s) of the legislative process; direct communication between citizens and representatives; public attendance at open meetings and commissions
Turkey Unicameral parliamentMinisters and RepresentativesThe parliament is the law-making body; however, the delegation of ministers also has the authority to make laws.Temporary commissions and 16 permanent commissionsYesInformal consultations in special cases; public attendance at open meetings and commissions
JapanBicameral parliamentMembers of bicameral parliament and members of the cabinetThe Diet has the exclusive legislative authority.Permanent committees and special committeesYesEstablishment of consultative bodies; direct communication between citizens and representatives
South AfricaBicameral ParliamentMPs, the president or ministers, vice president or deputy ministersParliament is the legislature (law-making) body; however, it can vest the authority in each of the governmental organizations established by the parliament.Major committees and minor committeesYesEstablishment of consultative bodies; direct communications between citizens and representatives; informal consultations; public attendance at open meetings and commissions; preparation of proposed law’s draft;
USBicameral parliamentCongressmenCongress has the sole authority to enact legislations; however, there can be independent commissions in which the president vests some of the authorities vested by congress.The Senate and the House of Representatives have 16 and 21 permanent committees, respectively. There are also five joint committees, consisting of both senators and representatives.YesDirect communications between citizens and representatives; establishment of consultative bodies.
EgyptUnicameral parliamentThe President, the cabinet, and MPsThe parliament is the legislator. In cases such as the dissolution of the parliament, the president can make decisions regarding laws. Special commissions (19 commissions), joint and special commissions, public commissions, ethics commissionsYesInformal consultations; direct communications between citizens and representatives.
MalaysiaBicameral parliamentThe government, representatives of the private sectorThe parliament has the legislative authority, and the legislature of a state may make laws for the whole or parts of that state.The house of representatives has five commissions, and the senate has 4 commissions.NoDirect communications between citizens and representatives.
IranUnicameral parliamentMPs, ministers' delegation, and the Supreme Council of ProvincesThe parliament has the legislative authority; however, various legislative bodies can make laws.Various specialized and particular commissionsYesEstablishment of consultative bodies; active participation in drafting parts of the legislative process; public attendance at open meetings and commissions; informal consultations; direct communications between citizens and representatives; preparation law’s draft.

5. Discussion

All around the world, citizens demand for opportunities to exercise their democratic rights beyond the election of MPs to participate in making decisions that affect their lives. Therefore, governments have developed mechanisms through which citizens can engage in legislative processes and to ensure transparency and accountability of governments (20). Citizens’ participation is an important prerequisite of good governance and is an instrument for enhancing legitimacy and effectiveness of laws and decisions. Investigating factors that affect citizens’ participation in healthcare legislation in the selected countries showed that participation in legislative processes is a complex phenomenon that influences by social, legal, cultural, political, and sovereignty factors and cannot be analyzed isolated from these factors. However, the way for citizens’ participation should be paved. Depending on the legal system, the ten selected countries use different methods for citizens’ participation.

In many democracies, citizens’ participation in policymaking and service design has been debated or attempted, but rarely realized. Comparative studies revealed that there are various procedures that can be exercised to enhance citizens’ participation in decisions that are made by Parliaments. These procedures vary across countries, depending on their legislative protocols. These procedures can be divided into 11 general categories:

- Direct communications between citizens and representatives

- Informal consultations

- Citizen attendance at public commissions and open meetings

- Active participation in parts of the legislative process

- Formal lobbying

- Preparing texts of the proposed laws

- Obtaining and promulgating the public opinion

- Establishing consultative bodies

- Citizens participation in elections to select MPs

- Public legislative initiatives

- Prioritizing drafted proposals by citizens

Citizens’ participation is a common issue in many countries. In some countries, the law enshrines the right for citizens’ participation. The right to participate may be conceived of as a human right or as a manifestation of the right to freedom of association and freedom of assembly. In some countries, specific laws have been enacted for this purpose. In Russia, for instance, the federal law on the Prosecutor-General's Office (PGO) of the Russian Federation was adopted in 2005. Accordingly, the PGO was formed as a mediator between society and the government in order to evaluate various legislative proposals with regard to social benefits. Its task is to conduct expert analyses on federal constitutional bills, normative legal acts of federal executive authority bodies, the government of the Russian Federation, and local government agencies. Its specialty is also used for evaluation of national plans to support legitimate interests, freedom of citizens, and their associations. The PGO makes general recommendations and receives suggestions, nominations, and conclusion from the society. In Hungary, according to the main provisions of CXXXI Act (2010), which is about citizens’ participation in developing drafts of legislation, public consultations should be carried out through general or direct consultations (29). In Iran, a bill has been submitted to the parliament that intends to enhance citizens’ direct participation in the legislative process; however, the bill has not been approved yet (30).

Over the past decades, citizens have become much more involved in several aspects of policy-making and legislation (31). As an instance, in Costa Rica, there is an office that is named as “Popular Initiatives”. Citizens can offer their comments and proposals about laws to it. Ecuador gives citizens the power to propose legislation and to participate in discussions about various bills that are reviewing by the National Congress. Since 2003, Portugal has had a right of Citizens’ Legislative Initiative in force, whereby initiatives subscribed to by over 35,000 electors are required to participation in discussion and vote in the Assembly of the Republic (32). These procedures were consistent with the mechanisms used in the studied counties.

Parliament of the Brazil has set up the Portal E-Democracia (WikiLegis which is the abbreviation of Wiki Legislation) to facilitate citizens’ participation in legislative processes. This portal intends to collect public opinions (33). A similar mechanism has also been designed in Iran to consider public opinions about plans and bills.

In some investigated countries, "public hearing" is using as a mechanism to hear the public (e.g., the UK, Germany, and South Africa). Public hearing is employed in 13 countries of the Organization for Economic Co-operation and Development.

Similarly, in Germany, the legislature might announce, during the publishing period of a draft regulation, that audiences and the interest groups can request a public hearing instead of submitting written comments. This is also the case in Finland and New Zealand. In Canada, holding public hearings by Parliament committees is required for nearly all legislative cases. In the case of US, public hearings are usually part of the public opinion polling process (34). There is no public hearing procedure in Iran, and citizens can propose issues to Parliament committees only if they are invited to.

The ParlAmericas has analyzed various citizens’ participation mechanisms in 35 countries located in the Americas and the Caribbean. It reported four major mechanisms for citizens participation in legislative processes: consultation with citizens and experts, or attendance at committee meetings (23 countries); public legislative initiatives (17 countries); public meetings and consultations (11 countries); and appointments of citizens as members of the adjustment committee (4 countries).

Five other procedures were also observed: prioritization of legislative bills by citizens (1 country); public consultations on legislation’s draft (1 country); pre-legislative consultation (1 country); constituency opinion polling (2 countries); and citizens’ participation in the appointment of authorities by the parliament (2 countries) (32). Nearly all of the above mentioned procedures are consistent with the mechanisms used in the studied counties.

5.1. Conclusions

In all investigated countries, citizens’ participation in the legislative processes depends on the rules, regulations, and procedures of the country. The findings show that there are various mechanisms for citizens’ participation. Parliaments have also been sorted on this subject, depending on their conditions.

Although still no special law is enacted about citizens’ participation in Iran, but according to the by-laws enacted by the parliament, there is a huge potential for citizens’ participation. Furthermore, MPs can easily interact with the interest groups and relevant people. There are also good laws for the involvement of medical associations. These conditions provide a golden opportunity for experts’ opinions in health legislation. Information technology can facilitate and accelerate these procedures as well as the communications between researchers and experts about increasing citizens’ participation in legislative process.




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