Today I attended a talk by Dr Piotr Ozieranski on the concept of deniability in drug reimbursement policy in Poland, and I really did find the discussions very insightful.
Piotr described various networks and structures in place that have established levels and degrees of power within the drug reimbursement processes in Polish public healthcare. The discussions began to focus on the presence of shadow elites (a concept discussed in a book of the same title by Janine.R.Wedel) who, through the ambiguious nature of their multiple roles in public and private sectors, are able to maximise their influence within drug reimbursement decision-making while minimising their accountability of making such decisions. These shadow elites, or ‘flexiants’ as they were coined, use their roles within private sector, public sector, media, legislation and non-profit organisations to influence decision making. By not having clearly defined job roles the boundaries for what is and is not acceptable , the blur at the borders between the difference sectors causes questionable informalities of negotiation and drug price setting to be standardised within the system. It was not uncommon to see one individual chairing a health NGO and at the same time working in a related position within the public sector. The two organisations would be working closely together and it would not be surprising if certain decisions were continually made to benefit the NGO, for example. Where their roles intersect across the different sectors, flexiants are able to affect many different stages of the drug reimbursement decision process depending on their desired outcome. This is all done without being held accountable for ‘one big decision’.
The failure to be held accountable despite having great influence represents the deniability aspect to Piotr’s current work. So far from Piotr’s findings, it seems like transparency is one of the key elements missing in the case of the drug reimbursement policy affairs. I was particularly intrigued that these individuals, through exerting their influence, could potentially be more powerful than the more apparent elite of those in political leadership or government (the imbalance of this power is felt more so in newer democracies across Eastern Europe and other parts of the world).
Flexiants, in many respects, can infiltrate traditional power hierarchies and this got me thinking about who the real actors were when considering public health policy implementation in the UK but more so in lower-income countries. So much time can be spent lobbying those in more apparent government positions to endorse or at least approve of a health initiative, but is enough attention paid to the less apparent influences? Is their present even recognised or acknowledged? And just how ethical is it to consider engaging in these substructures, even in the slightest, when pushing for change that can benefit the health of a local population?
The ability to implement successful public health schemes may, in some circumstances, depend more so on the hidden structures of flexiants than I had previously imagined. Unsurprisingly, such forms of decision-making are often deeply entrenched in practice and it becomes very difficult to first, accurately map the prevalence of shadow elite decision-making and secondly, to tackle the problem of such networks by possibly closing up loopholes in governance that have been allowing this to take place.