A one-day citizen council initiative that used deliberation as a main method to explore what social values are considered important by lay citizens in health resource allocation priority setting.
Problems and Purpose
Prioritization of health resource allocation has become a major issue in South Korea due to the gap between the population’s demand for healthcare and the limited health resources. In order to address the issue, evidence-based decision-making system with a focus on cost effectiveness has been adopted in the form of a citizen council to deliberate health insurance priorities.
Although ‘cost effectiveness’ is one of the main criteria in health resource allocation, it has limitations in considering various social values and interests across the country. Participation of the lay public in the policy-making process ensures that the social value judgments regarding health priority setting represents the opinions of “average” citizens, as well as promotes transparency in the decision-making process.
Background History and Context
While public participation has not traditionally been accepted in Asian societies due to expert-driven decision making, the value of public input has recently gained growing acceptance in achieving efficient and equitable benefit coverage for national health insurance.
Organizing, Supporting, and Funding Entities
The Citizen Council for Health Insurance was organized and funded by South Korea’s National Health Insurance Service. Researchers at Seoul National University Graduate School of Public Health with expertise in public participation in health priority setting were partners in this project.
Participant Recruitment and Selection
Participants were recruited through advertisements in three different daily newspapers as well as online advertising. The targeted demographic was defined as those aged between 19 to 70 years old. Initially a total of 114 people volunteered, and 73 people were firstly selected based on their job-related interests in the national health insurance program. For instance, those working in private health insurance corporations and medical care providers institutions were excluded in the selection in order to avoid potential conflicts of interest. Eventually 30 citizen participants were selected via a stratified random sampling method using age groups, gender, income levels and residential areas as stratification factors.
Methods and Tools Used
The citizen council committee used deliberation as a main method during this one-day session. There were two sessions, one in the morning and the other in the afternoon. The first session was designed to provide relevant information to citizen participants regarding the current financing mechanism and the financial situation of the national health insurance system, insurance benefit coverage, and the current provider payment program. The second session was divided into one small group discussion and one large group discussion. Additionally, pre-deliberation and post-deliberation surveys were conducted to investigate how citizen participants’ response to health resource allocation changed after deliberation.
The survey's design benchmarked the Oregon experience of priority ordering of symptom treatment pairs. Considering the South Korean context, the research team devised two sets of questions regarding 12 disease group categories. Participants were fully informed by academic experts and then had a sufficient duration of time to deliberate in two consecutive discussions. Since the goal of this initiative was not to reach a single consensus on what healthcare benefit should be covered but to examine the public’s overall preferences and their preference change among different benefit options, the final discussion was held with a focus on differences among discussion groups so that participants could refer to the discussion in their final decision.
What Went On: Process, Interaction, and Participation
The objective of this citizen council initiative was to explore what social values are considered important by lay citizens in health resource allocation priority setting. Accordingly, pre-deliberation and post-deliberation survey questionnaires were designed to explore public perception regarding (1) the importance of national health insurance coverage expansion, (2) the need and priority of coverage expansion on non-covered medical treatments, and (3) the need and priority of coverage expansion on new health technology and new drug reimbursement. Each question items were paired in pre-deliberation and post-deliberation assessment.
Introductory materials, including the deliberation agenda, were mailed to the selected 30 participants. The one-day council meeting consisted of a morning session and an afternoon session. The morning session was designed to provide necessary information that helps citizen participants’ deliberation. In order to provide the information in an objective and precise manner, a team of academic-based professionals with expertise in the national health insurance system were invited. The main content delivered was regarding the current financing mechanism and condition of the national health insurance system, insurance benefit coverage, and the contract model in the provider payment program.
The afternoon session was split between a small group discussion and a whole group discussion. 28 citizen participants (two people were absent) were divided into two groups based on their gender. After a brief introduction of participants, each group designated a discussion leader. There was no involvement of researchers, staff or other professionals in the discussion. Citizen panels made a discussion on the pre-defined agenda with the lead of citizen discussion leaders within the designated time. Both groups applied a consensus-based decision-making process in reaching agreements. When the members could not reach a consensus, disagreements were resolved through re-discussion and majority voting. The citizen participants compared the costs and the benefits of different medical options under the assumption that the health coverage expansion would lead to an increase in the health insurance premium paid by lay citizens. After the small group discussion, each team presented and shared the group’s choice. The whole group discussion was held after citizen panels delegated a new discussion leader for the larger discussion. Since the goal of the deliberation was not to reach a single consensus, the entire group discussion was held with a focus on differences between the two groups so that individual participants could reflect the discussion in their final decision.
Influence, Outcomes, and Effects
The outcome of the citizen council was derived from the comparison between the pre-deliberation survey, that was conducted before the information provision and deliberation, and the post-deliberation survey done at the end of the day after information provision and deliberation.
The disease group category that received the most support for coverage expansion was chronic disease with high disease severity. The support rate of citizen participants increased after the participants received relevant information from professionals and had time for deliberation (from 92.9% to 96.4%). The least supported disease category for coverage expansion was a common disease with low severity. The support rate for this disease category showed a meaningful decrease after the information provision and deliberation (from 46.4% to 25.0%). The strong support for highly severe disease was also observed consistently in treatment options for rare diseases with limited target population.
In contrast, the willingness to cover new health technology items generally gained a low support rate. New health technology treatments (e.g. new technology for AIDS treatment) that can be applied only to a small number of populations showed a dramatic decrease in the support rate after information provision and deliberation (from 64.3% to 25.0%) despite the high level of social attention. Likewise, the support rate for new health technology with uncertain clinical effectiveness decreased dramatically (e.g., from 50% to 25% for stem cell treatments).
During the council meeting, citizen participants shifted their original opinions on what treatments should be prioritized in health coverage expansion from ‘more health coverage benefits with as-low-as-possible contribution to ‘moderate health benefits increase with more premium contribution).
Based on the meaningful results of the citizen council initiative followed by a further citizen council meeting in 2012, South Korea’s National Health Insurance Service (NHIS) established the official Citizen Participation Committee in September 2012, with an objective to provide recommendations on medical service items for potential benefit expansion with a perspective of lay public.
Analysis and Lessons Learned
The experience of the citizen council initiative gives several important lessons. Citizen participants showed that their collective reasoning to critically analyze the information provided through the deliberation. The participants often held different values and opinions based on their initial individual reasoning. Throughout the deliberation, council members freely shared their doubts and tried to persuade each other. As a result, the council expressed the willingness to increase their financial contribution to national health insurance to achieve some, but not all, health benefit coverage expansion. This is important to note that the general public does not necessarily demand ever-increasing benefits, but instead decides to keep benefits at a reasonable level once they understand the nature of public funding, financial sustainability, and cost effectiveness.
Additionally, the citizen council initiative also demonstrated the public’s willingness to be involved in important health decision making processes. Before the initiative, the majority of the participants answered that citizens’ opinions are not reflected in health policy. After the initiative, however, most of citizen participants showed increased confidence in participating in health policy decision-making. More than 90% of participants answered either citizens can play the most important role in health policymaking or citizens can give valuable advice to health policy-makers.
While the mid-term and long-term effectiveness of implementing deliberative democracy still needs to be evaluated, it deserves broad recognition for its meaningful results that show citizen participation can change the public perception as well as the attitudes towards making difficult health policy decisions.
See Also
Public Deliberation on School Day Regulations in Seoul, Korea
References
Kwon, S., You, M., Oh, J., Kim, S., & Jeon, B. (2012). Public participation in healthcare decision making: experience of citizen council for health insurance. Health Policy and Management, 22(4), 467-496.
Juhwan Oh, Young Ko, Allison Baer Alley & Soonman Kwon (2015) Participation of the Lay Public in Decision-Making for Benefit Coverage of National Health Insurance in South Korea, Health Systems & Reform, 1:1, 62-71, DOI: 10.4161/23288604.2014.991218