Deliberation on Long-term Care for Senior Citizens:

Deliberation on Long-term Care for Senior Citizens: A Study of How Citizens Jury Process Can Apply in the Policy Making Process of Thailand Wichuda Satidporn Stithorn Thananithichot 1 Abstract The Citizens Jury process is one of deliberative democratic tools that allow policy makers and the public to hear thoughtful citizen input. This paper examines the Citizen Jury process applied by the Thailand National Health Commission Office of Thailand (NHCO) as one of the participatory approaches used in the process of developing the Statute on the National Health System of 2014. Relying on a quasi-experimental method of examination, a case study of a Citizens Jury on long-term care for senior citizens was used to investigate what risks and benefits of applying a Citizens Jury process and how the framing of the process affected the attitude formation among the citizens. This article argues that the process of receiving public opinions used in this case study could be an evidence of true democracy, in which citizens are free and equal to engage in the public forums that provide them an opportunity to have a real influence on public policy decisions. However, the final decisions that used only some part of the public s opinions that emerged from the meetings are evidence of the limitations of deliberative democracy s practices. Thus, in order to realize the ultimate goal of deliberative advocates, to engages the public in discussion with decision makers in open and transparent ways before decisions are finalized, deliberative practitioners must avoid applying deliberative democracy as a mechanism aimed at getting some approvals on public policies that have already been set in the minds of policy makers. Keywords: Citizen Jury process; Public deliberation; Long-term care for senior citizens policy; Thailand 1 Contact information: King Prajadhipok's Institute, The Government Complex (Building B) 5th floor (Southern Zone), Chaengwattana Road, Thung Song Hong, Laksi District, Bangkok 10210 Tel: +66 2 1419594, Fax: +66 2 1438177, Email: stithorn@kpi.ac.th

1. Introduction The Citizens Jury process is one of deliberative democratic tools that allow policy makers and the public to hear thoughtful citizen input. This paper examines the Citizen Jury process applied by the National Health Commission Office of Thailand (NHCO) as one of the participatory approaches used in the process of developing the Statute on the National Health System of 2015. Relying on a quasi-experimental method of examination, a case study of a Citizens Jury on long-term care for senior citizens was used to investigate what risks and benefits of applying a Citizens Jury process and how the framing of the process affected the attitude formation among the citizens. This article argues that the process of receiving public opinions used in this case study could be an evidence of true democracy, in which citizens are free and equal to engage in the public forums that provide them an opportunity to have a real influence on public policy decisions. However, the final decisions that used only some part of the public s opinions that emerged from the meetings are evidence of the limitations of deliberative democracy s practices. Thus, in order to realize the ultimate goal of deliberative advocates, to engages the public in discussion with decision makers in open and transparent ways before decisions are finalized, deliberative practitioners must avoid applying deliberative democracy as a mechanism aimed at getting some approvals on public policies that have already been set in the minds of policy makers. 2. Debating Deliberative Democracy The concept of deliberative democracy has long been developed, yet it remains debatable. It may be conceptualized in a narrow sense as it was first devised as a discussion on the floor of the representative assembly (Bessette 1980; Elster 1998; Estlund 2008). It could also be defined in a very broad sense to include an everyday talk, which is not only formal forms of conversation but also informal ones such as storytelling, joking, and greeting, 2

as a crucial part of the full deliberative system (Mansbridge 1999). However, this paper focuses on the most familiar term of deliberative democracy that has widely been discussed and referred to as a theory of public administration that provides a bridge between democratic theory and concrete policy practices (Fischer 2003). More specifically, deliberative democracy or any other terms used in this paper such as democratic deliberation, public deliberation, and so on is understood as a political process that engages the public in discussion with decision makers in open and transparent ways before decisions are finalized. 2.1 What is Democratic Deliberation? According to Gutmann and Thompson (2004), there are at least four important characteristics of democratic deliberative process. First and most importantly, democratic deliberation is a reason-giving requirement process, in which the reasons that the deliberative democracy asks citizens and their representatives to give should appeal to principles that individuals who are trying to find fair terms of cooperation cannot reasonably reject. The reasons are neither merely procedural nor substantive, but they are reasons that should be accepted by free and equal persons seeking fair terms of cooperation. A second characteristic of democratic deliberation is that the reasons given in this process should be accessible to all the citizens to whom they are address. In other words, the reasons must be public, and they are public in two senses: (1) in the sense that the deliberation itself must take place in public, not merely in the privacy of one s mind; and (2) in the sense that the reasons must be public concerning their content a deliberative justification does not even begin if those to whom it is addressed cannot understand its essential content. The third characteristic of democratic deliberation is that its process aims at producing a decision that is binding for some period of time. In this respect the deliberative process is not like a talk show or an academic seminar. The participants do not argue for argument s 3

sake; they do not argue even for truth s own sake. They intend their discussion to influence a decision the government will make, or a process that will affect how future decisions are made. The fourth characteristic of democratic deliberation is that its process is dynamic. Although deliberation aims at a justifiable decision, it does not presuppose that the decision at hand will in fact be justified, let alone that a justification today will suffice for the indefinite future. It keeps open the possibility of a continuing dialogue, one in which citizens can criticize previous decisions and move ahead on the basis of that criticism. Combining these four characteristics, Gutmann and Thompson (2004:7) define deliberative democracy as a form of government in which free and equal citizens (and their representatives), justify decisions in a process in which they give one another reasons that are mutually acceptable and generally accessible, with the aim of reaching conclusions that are blinding in the present on all citizens but open to challenge in the future. For this reason, deliberative democracy differs from some other attitudes and practices in democratic politics in that it exhorts participants to be concerned not only with their own interests but to listen to and take account of the interests of others insofar as these are compatible with justice. Practices of deliberative democracy also aim to bracket the influence of power differentials in political outcomes because agreement between deliberators should be reached on the basis of argument, rather than as a result of threats or force (Young 2001). 2.2 What are the Risks and Benefits of Establishing a Democratic Deliberation Process? What will democratic deliberation do for us? Gutmann and Thompson (1996) identify four principal benefits: it (1) helps promote the legitimacy of collective decisions; (2) encourages public-spirited perspectives on public issue; (3) promotes mutually respectful decision making; and (4) helps democracies correct the mistakes of the past. Deliberative 4

democracy promises legitimate that is, morally justifiable and rationally produced solutions to vexing political problems. Especially when these problems are difficult, affording no clear way to arrive at unequivocally satisfactory solution, deliberation recommends itself because it relies on a broad consideration of alternative solution, increasing the likelihood that the perspectives held by all members of a heterogeneous community will be given voice. Deliberation is also clarifying and enlightening, highlighting the moral issues at stake in political debates and allowing citizens to elucidate these issues for themselves. Finally, democratic deliberation enhances democracy. Democratic theorists now take deliberation to be the exemplary practice or activity for democrats, and they gear their arguments toward its realization. Hence, deliberation has become a standard for the accomplishment of democracy. And, when democratic theorists suggest remodeling our politics, it is in the direction of making them more deliberative. With these benefits, the deliberative democrat thinks that the best way to limit political domination and the naked imposition of partisan interest and to promote social justice through public policy is to foster the creation of sites and processes of deliberation among diverse and disagreeing elements of the polity (Young 2003). Most deliberative democrats, however, acknowledge one objection that critics have put to this contention: deliberative methods of decision making can fail to advance these political values under unfavorable conditions such as economic equality, cultural difference, or the absence of a reciprocal willingness to engage in the practice of deliberation (Fung 2005). Economic inequalities, for example, enable wealthier parties to improperly displace communicative power by mounting threats, purchasing compliance, drowning out other perspectives, mobilizing many forms of support, or simply privatizing some area of concern out of the domain of public deliberation. Another effect of such inequality is that individuals encounter 5

each other with very different capacities to deliberate. Political and administrative inequalities allow officials to restrict and eliminate domains of deliberative governance and to substitute canonical expertise for argument when they do engage with citizens. Finally, cultural inequalities may favor hegemonic discourses or styles of communication in deliberative decision making. 2.3 Citizens Jury The Citizens Jury process is designed to allow decision-makers to hear the people s voice. A Citizens Jury provides an unparalleled opportunity for citizens to learn about an issue and deliberate together to find a common ground solution. Decision-makers who watch a Citizens Jury project in action or listen to a jury s recommendations are able to learn what an informed public wants, and why. This information can be an invaluable resource for elected officials and other decision-makers at the local, state, and national levels. The great advantage of a Citizens Jury is that it yields citizen input from a group that is both informed and representative of the public. Involving citizens in a high quality dialogue about a key issue ultimately leads to increased public support for the resulting policy. The Citizens Jury process is an effective way to involve citizens in developing a thoughtful, well-informed solution to a public problem or issue. In a Citizens Jury project, a randomly selected and demographically representative panel of citizens meets for four or five days to carefully examine an issue of public significance. The jury of citizens, usually consisting of 18 to 24 individuals, serves as a microcosm of the public. Jurors are paid a stipend for their time. They hear from a variety of expert witnesses and are able to deliberate together on the issue. On the final day of their moderated hearings, the members of the Citizens Jury present their recommendations to the public. 6

Key elements of a citizens jury project include: advisory committee recruitment, jury and witness selections, charge setting and assignment, and hearings arrangement. 1) Advisory Committee The Advisory Committee is composed of approximately 4-10 individuals who are knowledgeable about the issue. Members of the Advisory Committee represent a variety of perspectives and opinions. The role of the Advisory Committee is to assist the organizer in identifying key aspects surrounding the issue. The Advisory Committee advises the project in such areas as the charge, agenda development, and witness selection. The interest of the Advisory Committee is in the integrity and fairness of the process as a whole, not in a specific outcome. They are also on alert for any bias throughout the entire project. The members of the Advisory Committee are important advisors to the project, but the project staff makes all final project decisions. By including individuals from a variety of perspectives in the planning stages of a Citizens Jury project, the final agenda and witness list cover a wide range of relevant opinions and perspectives. 2) Jury Selection Creating a jury that is truly representative of the given community (city, state, nation or whatever) is yet another element unique to the Citizens Jury process. In creating a jury that accurately reflects the public, a number of key steps are taken. These steps are essential to maintain the integrity of every Citizens Jury project. Five demographic variables and one attitudinal variable are usually used to create a representative jury. The traditional demographic categories used are age, gender, educational attainment, race, and geographic location within the community. In some projects, certain variables may not be relevant. In such cases, other applicable variables such as political party affiliation or number of children are employed. In addition, one variable that reflects the general attitude towards the issue is employed. 7

The project staff, with advice from the advisory committee, takes great care to determine the relevant variables to use in selecting jurors. Targets for each variable are established based on recent census data or other recent reputable surveys. All of the randomly selected survey respondents who receive information are placed into the jury pool. The members of the jury pool are categorized based on the identified variables. A grid containing the pre-determined variables is used to track the jury pool. Final jury selection consists of selecting identification numbers off the grid until all the targets are met in the best possible configuration. Great care is taken to ensure balance within categories in addition to meeting the established targets. 3) Witness Selection Expert witnesses include neutral resource people, stakeholders, and advocates from various sides. Witnesses are carefully selected to present a balanced yet complete picture of the issue. Neutral resource witnesses provide an overview of the issue on the opening day of the hearings. These witnesses help jurors learn new terms and can provide a brief history of the issue. They are essential in making jurors feel comfortable with the subject matter. Stakeholders and advocates present a specific perspective or opinion on either a certain aspect of the issue or on the issue as a whole. They often present informational material as well, but their main role is to explain their position. The project staff ensures that the jury hears from a diverse set of witnesses who represent the many different perspectives of the issue. 4) Charge The charge is the task facing the jury. It usually takes the form of a question or series of questions that the jurors will address and answer. The charge defines the scope of the project and will guide the work of the jurors and the testimony of the witnesses. The charge is one of the most critical pieces to a smooth Citizens Jury project. Great care is taken to ensure 8

that the charge is neither too broad nor too narrow. The questions of the charge may address separate and distinct issues or may be a series of connected questions. The charge can consist of main questions with sub-questions, but the more questions the jury must answer, the less in-depth their responses to each question. The jury may choose to go beyond the charge, but the charge questions are top priority. The jury may also choose not to answer a charge question or to answer it in a different way, but the jury must provide detailed reasons for altering the charge. The Advisory Committee provides advice and direction to NHCO project staff regarding the charge. 5) Hearings The agenda for the hearings is carefully planned by project staff. Setting the agenda for the hearings includes planning the order of witnesses, deliberation sessions, meals, breaks, and more. A Citizens Jury typically meets for five consecutive days, from 8:30 AM to 4:30 PM. The first day of the hearings introduces the jury to the Citizens Jury process, provides a general overview of the issue, and allows the jurors to get to know each other. It is very important to create an atmosphere where all jurors feel comfortable participating. Establishing ground-rules and rules of procedure in the beginning are a critical part of the process. Over the next few days of the hearings, the jurors learn about the issue, the underlying topics, and the different perspectives. The agenda is set to allow time for juror discussion and deliberation throughout. Both small and large group discussions are included in deliberations. Witness presentations are structured to allow for questions from the jurors. In addition, witness panels are often used to illustrate both common ground and fundamental differences between witness perspectives. A team of two moderators professionally moderates the entire hearings. Presentations conclude by the afternoon of the second to last 9

day. The remaining time is dedicated to final deliberations and answering the charge questions. The morning of the final day is spent finalizing the jurors recommendations and reviewing the initial report that is issued on the afternoon of the final day. On the afternoon of the final day, the jury issues its findings and recommendations in a public forum. An initial report is issued at this time. The recommendations appear in language that the jurors themselves develop and approve. The jury appoints representatives from the jury to present their recommendations at the public forum. Depending on the issue and the scope of the project, those in attendance at the forum range from sponsors and interested citizens to press and public officials. A final report of the project is completed within three weeks of the hearings. The final report includes additional information about the project, as well as the jury s recommendations. The recommendations remain in the approved language. All final reports are made available to the public. 3. Citizens Jury on Long-Term Care for Senior Citizens: Case Summary As a process that was emerged from the idea that concerns about deliberation, transparency, and openness to public input, Citizens Jury on Long-Term Care for Senior Citizens is an appropriate case study that enable to provide us a clear picture of what the democratic deliberation in the practical world is as well as how it links to the problems of administrative ethnics. Before moving to the discussion of such topics, it would be great to learn briefly about this case. The NHCO Citizen Jury Process can be divided into three stages. 10

3.1 The Preparation Stage The preparation for the NHCO citizens jury started in April 2014. As the jury was going to discuss problems concerning the long-term health care for senior citizens nationwide, the 12 jury members were selected by a multi-stage random sampling method from all Thai citizens between the age of 35-70, which has approximately 45 million residents (the total number of Thai citizens currently is about 67 million). All jurors were invited in person by the NHCO staff. The working group appointed by the NHCO selected witnesses/experts for the jury from a wide range of backgrounds and experiences in dealing with the long-term health care for senior citizens. Pre-meetings were held several times in order to prepare the witnesses/experts for the process. 3.2 The Jury Days The Citizens Jury took place in Bangkok on January 7th-11th, 2015. As one of the aims of a citizen jury is to increase awareness about the problem under consideration, not only among the citizens who participate in the Jury, but also among society as a whole, representatives from several related organizations and medias were invited to observe the process through a closed-circuit television. A professional moderator facilitated the event. Day 1 There was welcoming session from the NHCO executives. Introductory session was then held in order to prepare the Jurors to get familiar with the process and each other. In order to provide jurors with some necessary information for the discussion, one expert was invited to present a brief review of Thailand s health care system and situation while other two ordinary people who are living with senior citizens were invited to share their experiences. The final session of the first day ended up with a summary session. The issues to be answered (charge) on the last day were also reviewed and given to the jurors. 11

Day 2-3 During the next two days, 10 witnesses/experts presented their view on long-term health care for senior citizens. Among these witnesses/experts: 5 of them support the community-based approach to the long-term health care for senior citizens (community should provide and manage health care for its senior citizens);while the other 5 preferred the institution-based approach (health-care problems of the elderly should be solved through institutional care). On each day, the process ended up with a group discussion session in order to summarize what the jurors learned from each witnesses/experts and share their opinions with the groups. Day 4 On the afternoon of the final day, the jury issues its findings and recommendations in a public forum. The jurors decision was that health-care problems of the elderly should be solved through both community and institutional cares depended on which one is fit to individual citizen. However, due to a limitation of budget and human resource, the community-based care should be priority [ex: 70% of the government budget should spend for a development of the community-based care]. An initial report is issued at this time. The recommendations appear in language that the jurors themselves develop and approve. 3.3 Jury s Recommendations At the end of the event, all the witnesses and the Jurors could have their say. Many witnesses mentioned that this was the first experience for them to listen to opinions of ordinary people in the issues of long-term health care for senior citizens, and they were surprised that people could discuss on the issues informatively and suggest many useful ideas to solve health-care problems of the elderly. The Jurors said they were very pleased to receive an invitation to such an event and that they had an opportunity to express their opinion. They also highly expected that their 12

recommendations will be considered meaningfully by the NHCO and other policy making organizations. 4. Discussion and Conclusion A deliberative democratic process can be simply understood as a political process that engages the public in discussion with decision makers in open and transparent ways before decisions are finalized. A commitment to deliberation is, after all, a commitment to finding a way to address concerns, resolve disagreements, and overcome conflicts by offering arguments to our fellow citizens that are supported by reasons. In theory, the main benefits of democratic deliberation are: to promote the legitimacy of collective decisions; to encourage public-spirited perspectives on public issue; to promote mutually respectful decision making; and to enhance democracy. However, in practice, especially in Thai politics and perhaps other developing countries, challenges such as how more of the people who routinely speak less might take part and be heard and how those who typically dominate might be made to attend to the views of others still occur. The process of receiving public opinions used in this case study could be an evidence of true democracy, in which citizens are free and equal to engage in the public forums that provide them an opportunity to have a real influence on public policy decisions. The key success learned from this case study is that: The Citizen Jury process that was supported by the policy makers themselves (i.e., the NHCO) made participants trust in the process and having a confidence that their opinions might be an important part of a policy making process. In addition, in order to convince policy makers to buy ideas proposed by ordinary citizens, the deliberative process that can bring true representatives of involved citizens into the equal, transparent, and informative discussion is required. Throughout the process of the NHCO Citizens Jury, all stakeholders 13

were informed and invited to engage in. The process of witnesses selection was transparency and acceptable while all involves citizens have an equal chance to be selected as a juror through a random sampling method. Information given to jurors during the jury process was neutral, sufficiency, and easy for ordinary people to understand. However and for this reason, organizer should avoid the final decisions made by the NHCO that totally ignore or use only a small part of the public s opinions that emerged from the Citizen Jury process as it used to happen when they applied other deliberative democracy s practices in the past. In order to realize the ultimate goal of deliberative advocates, deliberative practitioners must avoid applying Citizen Jury process (and other public deliberation mechanisms) only as a mechanism aimed at getting some approvals on public policies that have already been set in the minds of policy makers. References Bessette, J. M. (1980). Deliberative Democracy: The Majority Principle in Republican Government. In Robert Goldwin and William Schambra (Eds.), How Democratic is the Constitution? (pp.102-116). Washington, DC: American Enterprise Institute for Public Policy Research. Carcasson, M. & Sprain, L. (2010). Key Aspects of the Deliberative Democracy Movement. Public Sector Digest (July 2010), Center for Public Deliberation, Colorado State University. Chick, M. (2013). Deliberation and Civic Studies. Good Society Journal, 22(2), 187-200. Cohen, J. (1997). Deliberation and Democratic Legitimacy. In Deliberative Democracy: Essays on Reason and Politics, eds. James Bohman and William Rehg. Cambridge, MA: The MIT Press, 67-91. Crosby, N. & Nethercut, D. (2005). Citizens Juries: Creating a Trustworthy Voice of the People. In Gastil J. & Levine P., (eds). The Deliberative Democracy Handbook: Strategies for Effective Civic Engagement in Twenty-First Century, 111-119. San Francisco: Wiley J. & Sons, Inc. 14

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