Participatory Budgeting in Public Health: Promise, Evidence, Challenges, and Opportunities

Participatory budgeting (PB) is a deliberative decision-making process that invites community participation to direct spending for a defined portion of public budgets. Originating in Brazil in the 1980s, PB has since diffused across the globe, including several hundred cases in the United States and Canada alone. PB programs vary but are generally characterized by five core principles: voice, vote, social inclusion, social justice, and oversight. Research on PB shows promising though moderate associations with improved population health outcomes, including infant mortality reductions and health and sanitation spending increases. Despite PB's conceptual alignment with many public health values, adoption of PB by US public health agencies remains limited, constrained by categorical funding requirements, small discretionary budgets, and a polarized sociopolitical environment. This article reviews PB's conceptual foundations, evidence base, and real-world applications before examining structural and political challenges and opportunities for PB as a means to improve the public's health.