| Ensure widespread public awareness of user associations and their role | Strengthen the promotion of user associations by government agencies and define in detail what each EPS must do to ensure every insurance enrollee knows that user associations exist, what can they be useful for and how they can participate if they want. The clearly defined responsibilities should be non-delegable. Discuss and agree with the stakeholders the level of operation for the user associations, currently regulated at the department level in each EPS. Yet, interviewees indicated that an optimal operation of the user associations require proximity to the insurance beneficiaries and therefore, a more granular level of operation (eg, municipal level, or even lower as suggested by at least two interviewees) could help user associations to be more effective.
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| Provide adequate resource support for user associations | User associations require clearly defined sources and amounts of funding and in-kind resources to support their work (a room, email address, funds for transport and communications, training) User associations require routine training, which is currently provided by the SNS, but that interviewees report as insufficient.
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| Genuine decision-making power | Clearly define the user association’s role in terms of whether they have a voice and vote, and ensure their ability to participate in all types of meetings of the health insurance board. Also provide user associations with a seat on the board of directors of private EPSs. Mandate EPSs to involve user associations in lower-level decision-making bodies (eg, local committees in the EPS that make decisions about procurement or deal with local networks of providers). The decisions made at these lower-levels are probably closer and more relevant to the users, and in addition, there might be less resistance from the EPSs to allow participation in such instances than it would in the board of directors where more strategic macro-decisions are made.
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