Dear Troppodillians, please welcome Luke Slawomirski to Troppo. I first met Luke at the OECD where I gave a paper on public-private digital partnerships with a particular focus on health policy. Luke was an Australian health economist working there and he’s recently returned to COVID free Perth. Anyway, I said I’d welcome a guest post from him and here it is. Nicholas
A few years ago, I had the opportunity to observe several groups of citizens deliberate on how their local health services should be managed in terms of provision and access. This approach could help policymakers navigate some upcoming challenges of COVID-19 crisis.
At the time, I was sceptical that a citizens’ jury could produce more than a wish-list of costly services and interventions. I was wrong. The 20-or-so jurors, randomly selected from the electoral roll and led by a strong, well-versed facilitator, quickly grasped the economic concepts at play: resource scarcity, opportunity cost, diminishing returns and even vertical equity – the unequal but equitable treatment of unequals.
In this way, the jury helped local policymakers define concepts such as health ‘need’, provided guidance for setting priorities that require value judgements and inevitable trade-offs when trying to do the most with limited resources.
Citizens’ juries date back to the ancient Athenian practice of sortition, a practice that involved citizens in the executive functions of government. More recently, they have gained traction in health and other areas of public policy.
The unique challenges of covid-19 illustrate its potential advantage and signals that perhaps their time may have truly arrived.
A SARS-Cov-2 vaccine is uncharted policy territory
While the COVID-19 curve has been flattened in most places for now, it is clear that the virus will be with us for some time.
A vaccine is expected in 2021. Beyond the first hurdle of negotiating prices and access internationally, its arrival on Australian shores will present major policy and political challenges. Demand for the vaccine will be unprecedented – and will vastly the outnumber supply for the foreseeable future.
How should Australia select those who are to be vaccinated as a priority … and those who should miss out? What will be considered fair? And who should pay for immunisation?
These are actually not unusual questions and can apply to any new or existing health technology. What’s unique in this case is (a) the urgent need for answers, and (b) that outcomes will play out quickly – in full view of the public.
Ask the people, as well as the experts
Most would agree that important decisions like these should be based, at least in part, on what the citizenry prefers. But who can know this given the current context? Abstractions like ‘need’ must be defined to be useful but can mean a range of things depending on one’s principles and priorities. Who is nest placed to do it? The government? Doctors? Policy makers, bureaucrats?
Fighting a pandemic was not an election issue and even the most diligent MP will be hard-pressed to know their constituents’ views on vaccine access. Doctors – we love and respect them – but they are trained to treat the patient in front of them. Policymakers may have the public interest at heart. But it would be presumptuous to assume they have meaningful knowledge of social preferences in this case.
In fact, the technocrat’s advice may well be informed by the concept of health utility – represented by the QALY, the expected longevity gain from an intervention adjusted for quality of life. Many medical therapies are rationed this way. But it is easy to see how this would disadvantage the frail and elderly, especially those in care homes.
Would such a cold, utilitarian calculus be palatable? Perhaps, but it’s difficult to say without asking.
But this isn’t a yes / no question. It’s also too complex for a survey. The questions need considered deliberation, with participants first gaining a basic understanding of the underlying issues (how the vaccine works) and the trade-offs involved (X amount of people in Y age bracket will likely die if we pursue option Z).
Citizens’ juries are the best available approach. A handful of juries of appropriate size, expertly facilitated, could easily be conducted across the country in the December quarter of this year. The financial outlay would be negligible considering what is at stake. Follow-up juries could be convened soon after to sort out any conflicting preferences from the first round.
The resulting information can complement expert advice to help the national cabinet decide what to do with limited number of vaccines. The decisions will be controversial regardless. But it will have more legitimacy if based on meaningful consultation with the most important stakeholders of all. It can also minimise unbecoming political squabbles, vacillation and the perception of influence by vested interests. There’s much potential gain for relatively little pain.
A healthier democracy
Most would agree that democracy demands more than simply voting. John Dewey said that elections are just the apex of a much larger structure that relies on inclusion, education and participation. Citizens’ juries represent a practical mechanism to promote a vibrant, deliberative democracy. Managing the public health aspect of the covid-19 crisis is a good opportunity to prove their worth. Let’s not waste it.
 This is not guaranteed. Safe, effective vaccines are difficult to develop (we’re still waiting for an HIV vaccine) but given the amount of resources thrown and a few early promising developments, we can expect something.
 A highly difficult task (worthy of its own post)… one that international institutions are hopefully up to.
 Manufacturing vaccines is more complex and time-consuming than manufacturing drugs, and global supply chains are not geared to produce the number of units required.
 Quality-Adjusted Life Year
 In my experience, juries tend to reach agreement once an issue is deliberated on. The force of the better argument prevails (to paraphrase Habermas), especially if the output is framed as guidance as opposed to a yes/no decision that requires ex ante agreement on unanimity or majority.