Deliberative democracy in the health sector

Deliberative democracy in the health sector

 The increasing demand for citizens to engage in daily policymaking processes have been on the rise in the recent past. The deliberative democracy allows citizens to engage in the legislative processes through a well-thought process and discussion that involves weighing reasonable decisions from citizens. As a result, policies and decisions are made through arguments and agreement on ideas that are supported with adequate reasoning.  In addition to the increasing use of deliberative democracy in politics, the approach has been widely utilized in the health sector to bring about quality and safe health services.  Deliberative democracy has been the previous utilized in the health sector in Canada in various ways such as the shared decision-making process,  provision of patient-centred health services, enhancing on the patients’ autonomy and also in promoting patients accountability health care.  Deliberative democracy, as practised in the health sector, has numerous advantages. However,  it is faced with numerous challenges that adversely impact on its effectiveness in promoting quality and safe health services.

History of deliberative democracy

Since the early 1990s, the deliberative democracy has been in the centre of democratic theories (David Held). David Held the application of the deliberative democracy for both governmental and governmental organization has been on the rise lately. Deliberative democracy focuses on the principles and procedures that govern the decision-making process under circumstances that involve deep moral disagreement (David Held). Specifically, deliberative democracy emphasizes on enhancing the process of reason-giving processes that citizens, as well as representative officials, should follow in the decision making process.  Many researchers and democratic theorists have defined the term deliberative democracy, and  Amy Gutmann and Dennis Thompson definition will be widely utilized for this essay. Gutmann and Thompson define deliberative democracy as the form of government whereby free and equal citizens, as well as their representatives, justify a decision by providing adequate support of their reasons which should be mutually acceptable as well as generally accessible by both the citizens and the representatives (David Held). The deliberative democracy primarily focuses on arriving at a conclusion that is binding for all the citizens and on the other hand, open for challenges in future (David Held).

Detailed experiments and analysis of public deliberation in the health industry started in the period around the 1990s in the UK”S National Health  Service (NHS) (..). A variety of approaches were utilized to involve the citizens in matters relating to health policies and decisions.  Deliberative polling, citizens panels and citizen juries are deliberative strategies used in the UK to inform the local health care providers on the priority setting decisions (…). The process of citizens involved in the health sector was replicated in different countries around the world through various techniques and mostly the utilization of the research studies.  Since the 1990s, the establishment of the numerous high profile citizens in the deliberation processes and structures over the last t decade demonstrate that public deliberation has gained attraction among policymakers as a means of incorporating the citizens’ values into the health policies as well as decisions involving health matters (…).  During the early years of the millennium, the principles of democratic deliberation influenced the development of twelve citizens dialogue which was held in different regions across Canada (…). The citizen dialogues influenced the recommendations provided by the government-appointed royal commission, to integrate the approach in future health care in Canada (…).

Since 1998, the health Canada focused on developing strategic frameworks and guidelines which emphasizes public involvement (…).  In this case, using the framework and the guidelines, the health Canada strive to a health system that is people focuses (..).  In this case, the corporate framework and guidelines aim at promoting public input in health processes that affect the establishment as well as influencing the programme delivery of the health services in Canada through enhanced accountability,  better decision making as well as increased public comprehension of health matters (…).

In 1994, during the throne 27 speech, the Canadian federal government committed itself to enhance extensive dialogue in matters relating to health and health care. The commitment brought about the development of the national forum on health whose primary goal was to promote citizens involvement in dialogue in health-related matters. The National Forum on health which was launched in October 1994 by the then  Prime Minister focused on involving and informing the Canadians as well as advising the different levels of government including the federal government on innovative ways of promoting the quality of health systems and the health of the citizens of Canada (..).  To date, the Canadian government is focused on promoting public participation in health and health services which in turn influences the process of health policy development.

Literature review

In the last two decades, the public demands to take part in policy development have significantly shaped the adaptation of the deliberative democracy. Deliberative democracy allows citizens to engage in meaningful decision-making processes based on reasoning. The primary goal of the deliberative democracy involves transforming private or individual preferences through the process of deliberation into standards subjectable to public scrutiny and test (David Held). Deliberative democracy achieves the transformation process through various processes. First is through a pooling of knowledge and increasing public awareness in regards to their interdependencies. Second is through exposure on how various viewpoints are connected to sectional interests. The process of transformation is through the replacement of the language of interest with what John Elster considers as a language of reasoning (David Held).

Deliberative democracy utilizes five major approaches in healthcare application. First, if the development of policies, guidance and recommendations in regards to health issues. The citizens are involved in developing policies and recommendations regarding the citizens’ health and health systems. Globally, the utilization of the deliberation project to enhance health services have been widely adopted by many states. The deliberative projects for example in the US incorporate the government efforts in exploring as well as developing guidance on health-related topics such as childhood obesity,  issues relating to healthcare reforms,  involving public opinion on health insurance for the uninsured population as well as coverage priorities for medical plans such as the Medicare and Medicaid plans. Further,  public deliberative projects have been widely utilized to develop strategic plans for state-level pandemic planning processes.  The citizens’ involvement also leads to the adaptation of the policy ‘our budget our economy’ in the US, which focused on enhancing the budgetary allocation for health services.

Second, the setting of priorities whereby the citizens determine health factors that should be given a priority at a given period. In Canada, for example, citizens participation in the day to day health systems have taken place in all the provinces and also at the national levels. In New Brunswick, for example, the province initiated engagement with the public to determine the priorities in the health sector such as the primary care, acute care as well as other wide health system concerns.

In Ontario further, the public involvement was utilized in prioritization of services in community-based health facilities. The facilities were suffering from budget deficits. Hence, the citizens were involved in determining the core services necessary to be maintained in the health facilities as well as identification of noncore services that would be closed. The public involvement in Ontario aided in establishing the priority of the health services provided in the region and hence, allowing the health facilities to provide health services that were identified as essential among the people living in this region. The citizen’s actions further lead to the removal of some health services that were considered irrelevant for the specific community as a means of allowing the health facilities to continue providing crucial services under the limiting budget.

The third approach that citizens participate in the health care services focuses on the role of citizens in guiding various ethical as well as value-based dilemmas. Different communities have a different way of life that influence their belives, values, practices, and attitude towards health services. Quality and safe health services focus on providing healthcare products and services that match the specific community’s cultural expectation. In this regard, safe and quality healthcare incorporates the people’s culture in the day to day operations. A culturally relevant and acceptable health system promotes a healthy population(..).

In addition to influencing the health systems to meet the cultural expectation of a specific region that the health facilities operate from, the citizens also participate in solving value-based dilemmas experienced in the health sector.  The citizens play a vital role in shaping how conflicts are resolved in an institution operating in the community as well as influencing the healthcare providers code of conduct to match the community’s cultural and social expectation—multicultural health approach aid in providing individualized health services for people from diverse cultural groups in society.   The public also aid influences ethical and morality of the healthcare providers operating in different regions in the country.

Citizens involvement in solving value-based dilemmas in the health sector is influenced by Amy Gutman and Dennis Thompson, who argue that moral conflict in a political set up is unavoidable (David Held).  The citizens have an obligatory role of seeking the justice that is acceptable to all and at the same ensuring that the strategy utilized in seeking justice minimizes unnecessary conflict where applicable, Gutmann and Thompson referred the moral obligation of citizens as the economy of moral disagreement (David Held).

The public is further involved in the health sector through the process of risk assessment. In this case, the participants are involved in evaluating the risk-benefits of some actions, intervention procedures,  healthcare programs as well as health care exposures, for example, patient’s privacy and confidentiality. The processes aids in establishing and adopting health services and approaches that have minimal risk and at the same time leads to higher benefits to the patients in terms of the safety and quality of health services provided in health facilities. Some of the major risks assessment that involved deliberative democracy include the relative risk of surrogate consent for involvement in a  research process. An additional challenge includes evaluation of relative risks regarding the public body that utilize medical information of identifiable people without consent approval by the individuals in researches such as drug surveillance.  Further, deliberative democracy plays an important role in determining the benefits as well as the adverse effects involved in cloning (…).   The citizens are also involved in democratic democracy in health matters through the determination of the authority concerned with the decision making of health challenges and priorities.

Benefits of deliberative democracy in health policies

Public involvement in the health policy plays a vital role in solving dilemmas grounded on ethical and cultural factors,  equity, economic as well as other deep-seated concerns in the health sector.  The utilization of deliberative democracy began in the 1990s  with the United Kingdom National Health Services. Deliberative democracy was influenced by the increased demand among the health policymakers and the public policy scholars to develop a more informed, effective and also the legitimate approach that would aid the public and the patients in taking part in decisions that directly and indirectly affect them. In relation to health and health policies, the deliberative democracy has been widely utilized to understand various aspects of the public concerning the provision of quality and safe health services which in turn brings about the benefits of deliberative democracy in the health sector.

Resource allocation

First, deliberative democracy aid in the effective allocation of resources and promoting accountability in public resource management in the health sector. One of the major challenges that continue to affect the quality of health services in the world is linked to health inequalities experienced by different regions of the world. For example, in the US, Canada and UK as well as other European nations, people living in the urban areas have access to quality social amenities which include health services. While people living in rural areas have limited access to well-equipped health facilities which in turn interferes with the quality of health services provided in the rural areas. The deliberative democracy allows the government at all levels, including the federal, state and local government to effectively allocate resources to ensure that all citizens have access to quality and safe health services.

Further, deliberative processes help in evoking empathy as well as civic-mindedness by influencing the citizens to assume societal perspective as opposed to an individual’s point of view. Incorporating public deliberative process in health policy matters primarily aids in addressing challenges that involve resource allocation, priority setting, health insurance coverage, as well as the accessibility of health services (…).  In Canada, for example, the deliberative processes have been put in place to systematically gather public input in regards to priority setting for health services (…).   In 1989 further,  in the US, the Oregon legislature developed a reimbursement priority list as the major sort-containment character of the Oregon health plan.  The Oregon health plan ensured the coverage of Oregonian citizens who were previously uninsured who were subjected to payment in part through the process of eliminating reimbursement for services considered as low-priority (..).  The legislature demanded Oregon Health Service Commission to actively utilize the public input through the various strategies of public participation precisely the legislature advocated for the use of community meetings. The community meetings primary objective was to build a consensus-based on the values intended to guide the health resource allocation decision-making process (….). The Oregon health plan serves as an excellent example of how deliberative democracy can be utilized to solve the tension between the formal and informal public input in matters relating to resource allocation in the health care industry.  The deliberative democracy is an effective technique that promotes equal allocation of resources in the health sector intending to improve the quality of health services in a region.

Helps in resolving value-based dilemmas

Public deliberation is one of the strategies utilized to address the ever-changing nature of medical technology,  health care, as well as bioethics. The health industry is currently suffering from controversies related to the adaptation of advanced technology that encroaches upon the peoples ethical as well as moral beliefs.  In the vent where ethical and moral beliefs oppose each other or set a conflict, and in a situation where technological information solely is inadequate to arrive at an informed decision, public deliberation serves as the major strategy to utilize to solve the existing challenge (…).  In this case, the competing values, beliefs, practices, ethics and opinions are voiced and explored following public education regarding the issue at hand in an attempt to allow the public to make an informed decision.   New technological opportunities in the UK,  for example, brought about uncertainty in the health sector on whether or not to use the equipment, who and when the technology should be utilized and to whom. In an attempt to address the problem, the UK’s National Institute for Health and Clinical Excellence (NICE) focused on public input.NICE focused on the utilization of innovation in pharmaceuticals, medical equipment, diagnostic techniques, surgical procedures as well as other practices in the health sector to promote a healthy and safety health institution as well as the provision of quality and safe health services to the patients. Public input was required to determine whether or not to incorporate innovation in the health sector. The approach further focused on who and when to use the technology, whom the technique should be utilized, and how to pay for the health services. In this case, the deliberative democracy is utilized in the health sector to resolve ethical and moral dilemmas which further serves as an advantage of enhancing the quality and safety of health services.

Source of evidence

Scientific information might present controversial, multiple or opposing information from different stakeholders which in turn calls for multiple forms of evidence in an attempt to arrive at an informed health care decision (..).  In this case, there is a need to reconcile the scientific information for effective decision making in matters relating to health care.  Scientific evidence might be perceived as majorly a scientific conflict. However, the contextual setting in clinical evidence is collected as well as interpreted based on the scientific evidence presented; therefore, influencing the nature of decisions made in relation to the evidence (..).  Public opinion through deliberative democracy can be utilized as additional evidence in regards to the involved values and contextual factors. In this case, the public opinion serves as additional evidence when scientific evidence is inadequate to arrive at a policy decision.

Further, in the event where scientific evidence is balanced but on the contrary offers conflicting ideas, in such a case, the public opinion is utilized as a source of evidence to arrive at an informed decision regarding health care.  The public opinion can also serve as a source of additional evidence for decision making in the case where the scientific evidence creates unjustifiable inequalities (..).   In the three instances, public deliberation supplies additional information that the policymakers use to guide the decision-making process.  Further, deliberative processes involving clinical evidence arguments aid in the provision of values that shape the health care sector. In this regard, the health care is based on both the evidence-based approach as well as the incorporation of the people’s culture, values and practices which further enhances the quality of health care provided in the health facilities.

Increase transparency and trust

Health policies play a vital role in promoting the population’s health. Therefore, deliberation can be utilized as a tool to bring about transparency, enhancing understanding of policy arguments as well as promoting citizens trust in public institutions entrusted with the role of policymaking and administration of health services (…). In 1992-1994, the US government was faced with a major controversy in regards to the Clinton health care initiative in 45 United States. Despite the fact that the motion was defeated in  Congress,  the initiative attracted the public interest in the question of whether and how the US as a nation was going to achieve the universal healthcare insurance coverage (…).  In an attempt to solve the controversy, the US government through the public agenda and the National Issues Forum (NIF) established a nationwide campaign termed as the Condition Critical whose primary role was to inform and engage the public on the matter which would in turn influence the citizens approach on the national debate regarding the challenge. Throughout the history of  US and other nations, the deliberative democracy plays a vital role in allowing the public and the patients to contribute and shape the health care policies which in turn promotes quality and safe health services.

Challenges

Deliberative democracy in the health sector leads to improved and quality healthcare. However, the process of public involvement in healthcare policies through deliberation processes is faced with numerous challenges that limit the benefits of the approach in the health sector. First, the problems and challenges facing deliberative democracy in the health sector are rooted in the broad and ambiguous concept of deliberative democracy as viewed by different stakeholders such as the patient, health practitioners, administrators as well as political leaders (…).

Additional challenges further emanate from political, institutional as well as professional resistance against the shared decision making power and also reduced and lack of genuine interest among the stakeholders in matters relating to openness to diverse ideas and values represented by diverse citizens.  Further lack of clarity on the goals and objectives of public involvement and patients engagement in the process of policymaking in health policies poses a challenge in the utilization of deliberative approach in the health care and health policy development.  Further, the process of engaging the public and patients in the process of deliberative democracy is costly, therefore, conflicting with the objectives that focus on cost-saving approaches.

Different regions utilize different deliberative initiative which is isolated and fragmented to meet the specific region health needs, hence, limiting the integral technique of a systematic approach to deliberative democracy as well as public involvement.  In addition,  concerns with the productivity and time pressure of deliberative democracy,  lack of commitment among the policymakers to include and implement citizens panels and the question of imbalanced resources among the citizens continue to pose a challenge in effective utilization of deliberative democracy in health care and decision making in matters relating to health care policies.

Recommendations

In an attempt to maximize the productivity of deliberative democracy in promoting quality health care through well-thought health policies, numerous approaches can be implemented. First is the equal distribution of financial resources to meet the cost of public and patient involvement in the deliberative decision-making process.    Creating public awareness is also a technique that can be used to increase public and patients involved in deliberative democracy.  The public awareness programs also equip the public members with adequate information that, in turn, allows them to actively engage and make an informed decision regarding health policies.  Further, training the health professionals on shared decision-making techniques will also aid in promoting the utilization of deliberative democracy in the health industry.   Lastly, encouraging commitment and transparency among the stakeholders will significantly aid in influencing the public and patients to participate in deliberative democracy which will in turn aid in shaping the health policies to meet the patient’s health needs including the adaptation of a multicultural approach of health services.

Conclusion

Deliberative democracy in the health industry and health policies has to lead to significant benefits for the patients as well as for the healthcare providers. The patients are actively involved in deliberative democracy using various approaches.  Some of the widely applied techniques of public and patients involved in deliberative democracy include shared decision making (SDM), patient-centred care whereby the health care services are individualized to meet individual patient’s health needs and wants while focusing on the patient’s background.  Further, deliberative democracy in the health sector has also enhanced patients’ autonomy. In this case, the patients have the autonomy to either accept or reject a health intervention. Citizens involvement in the health policy assumes various strategies such as deliberative focus groups, Citizens’ jury, Citizens’ council, and Consensus Conference, among other numerous techniques.

Deliberative democracy has widely contributed to enhanced and quality health services throughout the global, despite this, the deliberative democracy is faced with numerous challenges that influence its effectiveness in health policy. Therefore, in an attempt to maximize on the benefits that arise from deliberative democracy in the health sector, adequate financial support should be provided and increased public awareness on the role of the public in shaping the health care policies. The recommendation strategies should, therefore, focus on reducing and eliminating risk factors that hinder the effectiveness of deliberative democracy in the health sector in an attempt to maximize on deliberation in promoting quality and safe health care through well-developed health policies.