Background: All health systems struggle with unlimited needs for health care, yet limited resources with which to address them. Under national health insurance systems, policymakers must make explicit and potentially contested decisions around resource allocation. Policymakers have recognized the need to include public values in decisions of how to distributing funding and other resources across competing health priorities. Given the complex nature of these decisions, however, research into how to effectively measure public preferences is underdeveloped. Measuring community values poses special challenges since they involve subjective judgments that can be interpreted differently across individuals and communities. A 2014 study proposed the integration of two methods currently used for soliciting and aggregating public preferences around health care services: i) an individual survey instrument, Discrete Choice Experiments (DCEs) and ii) a group-based model that incorporates informed opinions and deliberative dialogue, Citizen Juries (CJs). This study developed a framework for implementing that integration and empirically tested it in Taipei, Taiwan.
Objectives: This study’s first objective was to assess methodological issues in the integration of DCEs and CJs, including issues of generalizability and validity. The second objective was to evaluate differences in preferences when solicited through individual, quantitative surveys (DCEs) versus an informed, dialogue-based group setting (CJs) and whether ethically communitarian values from a CJ can be captured by an individualistic methodology.
Study Design: The study was structured as a two-part, mixed methods study. In Part I, participants completed a DCE, which served as a baseline pre-test. In Part II, participants took part in the integrated CJ-DCE method, which asked them to define an equity principle for the National Health Insurance (NHI) program and rank a set of attributes in terms of importance for future resource allocation under the NHI. During the CJ, experts on health policy presented background information and participants engaged in facilitated dialogue to choose a health equity principle and rank priorities through consensus. Immediately following, participants completed an extended version of the DCE from Part I, which was organized to allow for direct comparison with the pre-test during the analysis stage. Participants also completed an evaluation survey to comment on their experience of the integrated method. Results of the DCE were analyzed using a mixed logit model. The results of the pre-test and post-test DCEs were compared to determine whether participation in the CJ changed preferences. The ranked list from the CJ was compared to the statistical rankings of the post-test DCE to assess whether the CJ ranking was reflected in the DCE.
Population Studied: Participants were citizens of Taiwan at least 20 years of age who reside in Taipei City and New Taipei City. The study sample was broadly representative of the underlying population in demographic categories of gender, age, nationality/ethnicity, and income. The sample was overrepresented in college educated participants and underrepresented in those who had completed high school or below. The sample had no representation from rural residents or naturalized citizens.
Principle Findings: CJs and DCEs have conflicting epistemological and methodological foundations, which impact how researchers analyze results of the integrated method. Empirical results support the value of the CJ in developing an ethically communitarian consensus and the validity of the DCE in capturing that consensus, i.e. participating in a CJ influenced juror preferences and the near consensus decision arrived at through the CJ was captured by the subsequent DCE.
Conclusion: The results of this study demonstrate that an ethically communitarian set of values can be captured via an individualistic methodology. This provides preliminary evidence that the integrated method offers an innovative research framework capable of meaningfully capturing community preferences.
Implications for Policy or Practice: Several distinct recommendations emerge from this study. Researchers and policymakers interested in measuring social values should determine the philosophical orientation of their research question prior to study design, which will assist in choosing an appropriate research method. Health policymakers in Taiwan should consider increasing public participation in policymaking around values-based questions. Further research is needed to investigate the reliability of our findings and how it may be implemented to maximize public acceptance. Advancing these methods can provide an improved method for capturing public preferences to policymakers tasked with priority setting.