The Covid-19 pandemic is complex and trade-offs are inevitable. As policymakers navigate these difficult trade-offs within a context of resource scarcity and broader uncertainties, there is a need for priority-setting processes that are evidence-based, as well as ethical and inclusive, to better inform these decisions. In addition, the Covid-19 crisis requires unprecedented social buy-in for interventions and measures to be effective. Much of this relies on meaningful public engagement.
The expectation on policymakers is to consider imperfect and evolving scientific data, take into account health and broader socioeconomic implications, and make appropriate and urgent decisions that will serve the best interests of the country. Even if the initial response to the crisis required an urgency that could not have aligned practically with meaningful public engagement, there are ongoing decisions that will prevail even likely into 2022. These decisions will be based on extremely difficult trade-offs between health needs (Covid-19 and non-Covid-related), financial impacts on individuals, national economic impacts, nutritional consequences and growing inequalities, among others, and public engagement will be key to the success of these decisions.
In South Africa, where participatory democratic principles prevail and are protected in the Constitution, there is commitment to the active engagement of the public in the decision-making processes of government, but in reality, this is challenging. Decisions are usually made by a handful of experts with minimal meaningful dialogue with those who are affected by these decisions. This can lead to a disconnect between government decisions and what is most important to the public.
While the country was initially lauded for responding so promptly following identification of the first SARS-Cov-2 case and taking a scientifically sound public health approach to addressing the pandemic, there is increasing criticism about how decisions are being made, how the trade-offs are weighed and which voices have been ignored.
When the legitimacy of the decision-making process is questioned, it results in low levels of public trust and acceptance of most measures to address the pandemic and mitigate its impact, even if many of these measures are evidence-based.
Public engagement in decision-making is important for transparency, at least to generate trust and buy-in. This in turn would increase the success rate of Covid-19 interventions. It would also manage expectations and improve public understanding of the various issues.
Beyond this, participatory community engagement approaches can assist in gathering insights into how the pandemic and related measures are impacting communities and what the social barriers and facilitators are of interventions, as well as gather ideas and garner active support for such interventions. This can assist decision-makers in developing solutions that are context-specific and more appropriate.
Public engagement, however, should go even further than this. In order for public priorities to influence policy-making in a more meaningful way, these priorities need to be positioned as trade-offs within a constrained budget. Through the use of deliberative approaches the public can be engaged in balancing trade-offs, and the justification behind these trade-offs can be understood.
There are different methods of public deliberation, but key components include providing participants with factual information that generates a shared knowledge base, ensuring that individuals with diverse perspectives are represented, and creating a setting where local knowledge, values and moral claims can be voiced and challenged.
One such method is the CHAT (Choosing All Together) tool. Originally developed in the USA, this has been modified for the South African context by PRICELESS SA in collaboration with the MRC/Wits Agincourt Unit.
CHAT is designed like a board game and allows people to make collective decisions about what interventions are most important to them as a group, within a limited budget. The justifications behind the trade-offs are made clear through the use of CHAT. Alongside the scientific evidence, the epidemiological data and cost-effectiveness analyses which continue to evolve in relation to Covid-19, deliberative engagement tools like CHAT could be useful in considering social values in the decision-making process, leading to more active buy-in of interventions at community level. Other deliberative methods like citizens’ juries and mini-publics could also play a role. The challenge of meaningful public deliberation in the context of physical distancing and soaring inequalities, where many do not have access to virtual platforms, would need to be addressed through innovative approaches that allow communities to congregate in meaningful ways so that health risks are mitigated.
Beyond responding to the immediate crisis, South Africa is committed to delivering quality universal health coverage over the next few years through a national health insurance funding scheme. Priorities will need to be set that reflect health needs, economic resources, professional and societal values, and political considerations, among others.
By bringing the voices of decision-makers and the public together through deliberative engagement tools like CHAT, the priority-setting agenda can be determined not just by experts but also by the public. This could ultimately ensure priority-setting approaches for both routine health coverage decisions and pandemic responses that are not only evidence-based but also ethical, legitimate, sustainable and inclusive. DM/MC
Aviva Tugendhaft and Karen Hofman are at the SAMRC/Wits Centre for Health Economics and Decision Science (PRICELESS SA), at the School of Public Health at the University of Witwatersrand. Rhian Twine is at the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) at the School of Public Health at the University of the Witwatersrand.
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