Abstract Objective In 2024, the 77th World Health Assembly adopted a resolution on social participation for health (SPH), underscoring the importance of inclusive health system decision-making to achieve universal health coverage. Inclusion-oriented SPH is key to achieving health equity, enabling the needs and perspectives of marginalized communities to reflect in decisions, yet many initiatives fall short. A realist review sought to determine the contextual factors influencing the inclusiveness and outcomes of SPH reform initiatives, alongside their mechanisms of influence. Methods Studies were sourced through a comprehensive search focused on social participation, health reform, and inclusion. Following title-abstract screening, quality and relevance were rated using adapted 0–5 scoring. The sub-analysis presented here mapped SPH reform processes, outcomes, geographic spread, and strategies and resources for inclusive SPH. Results 150 studies were retrieved. Strategies to enhance inclusiveness focused on ensuring access to platforms, tailoring recruitment, and employing culturally safe approaches, and were undergirded by diverse (e.g., financial and technical) resources. 50% of studies reported the nature of diversity in participatory processes, while others addressed qualitative aspects of inclusion/exclusion. Conclusions While efforts have enhanced inclusiveness of social participation in health systems decision-making, challenges of meaningful engagement and exclusion remain. There may be no single point or threshold at which complete inclusiveness of social participation for health may be achieved, but it is clear that for populations overall as much as for particular “left behind groups” there are key entry points that may help overcome limitations and barriers.
Mishra et al. (2026) studied this question.