All public health professionals may not be convinced of the value of nudging (bonell et al., 2011), and admittedly more research is needed into its effectiveness; however, it represents an impor-tant shift in governance, in which individuals are not treated only as perfect specimens of Homo economicus, always rational and calculating. Rather than using incentives directed at people’s pocketbooks, nudge policies interface with people “within the settings of their everyday life:
where they learn, work, play and love” (WHO Regional Office for Europe, 1986), subtly influenc-ing the norms by which they live and the psychosocial cues that can provoke healthier behaviour or discourage unhealthy habits.
When the governments of british columbia and Ontario announced that they would convene citizens’ assemblies to explore the issues of electoral reform and democratic renewal, they intro-duced a new mechanism for decision-making into the political process, a mechanism that could bring more women into canada’s decision-making and transform politics in the process. Tens of thousands of citizens in both provinces were told that they had been randomly selected from the electoral lists and could put their names forward for a draw to become members of the citizens’
assemblies. At selection meetings in both provinces, 250 eligible members were randomly picked to serve on the assemblies. Those selected spent months (18 in british columbia and 9 in Ontario) learning, deliberating and finally making collective recommendations about electoral reform,
Smart governance for health and well-being Governance for health in the 21st century
Box 2. Monitory mechanisms Citizen juries
Participatory budgeting Teach-ins
Archive and research facilities conflict-of-interest boards Railway courts
Consumer testing agencies Democracy clubs
Protestivals (a speciality of the Republic of Korea) Deliberative polls
Public consultations Social forums Blogs
Electronic civil disobedience Advisory boards
Talkaoke (local and global talk shows broadcast live on the Internet) Public memorials
Opportunities for professional networking Public meeting trigger clauses
Lok adalats (people’s courts in India) Consumer councils
Democracy cafes Summits
Boards of accountancy
Public scorecards (yellow cards and white lists)
Tendency for nongovernmental organizations to adopt written constitutions, with an elected component
International criminal courts Bioregional assemblies Think-tanks
Local community consultation schemes citizens’ assemblies
Global Association of Parliamentarians against Corruption
Smart governance for health and well-being
Box 2. (continued) Public interest litigation Online petitions
Public vigils
Global watchdog organizations
Expert councils (such as the German council of Economic Experts) Global social forums
unofficial ballots (such as text-messaged straw polls) Focus groups
Consensus conferences
Information, advisory and advocacy services Brainstorming conferences
Constitutional safaris (famously used by the drafters of the new South African Constitution to identify best practices)
Satyagraha methods of civil resistance Chat rooms
Peaceful sieges
Independent religious courts Public planning exercises
Web sites dedicated to monitoring the abuse of power (such as bully Online, a british initiative against workplace bullying and related issues)
Self-selected opinion polls
Source: adapted from Keane (2009).
which were proposed in referendums. Although the public rejected the recommendations of the citizens’ assemblies to reform the political system, remarkable things took place in the meeting rooms of the assemblies. For a range of public issues, from health care to climate change, poverty and childcare, an opportunity was given to ensure that all Canadians had a hand in shaping those decisions (nguyen, 2009).
Rise of the unelected
In this wide variety of new democratic mechanisms, one subcategory is of particular importance, referred to by vibert (2007) as the unelected. The focus on evidence-based policy led to the cre-ation of agencies such as the ncre-ational Institute for Health and clinical Excellence in the united Kingdom, an independent body for setting national guidelines, for example on treatment, use of
Smart governance for health and well-being Governance for health in the 21st century
medicines and quality of care, and to a similar organization in Germany, the Institute for Quality and Efficiency in Health care. further, the Eu has created a number of specialized agencies at the regional level, which bridge the interests of the Eu, the Eu countries and, ultimately, its citi-zens. Permanand & vos (2010) noted that, in practical terms, the Eu agencies have proliferated on numerous grounds but mainly “in response to an increased demand for information, expert advice and coordination at the community level, as well as the need to lessen the commission’s workload and its search for more efficient and effective decision-making.” The Eu countries sup-port these multilevel expert agencies because they facilitate collective action and improved gov-ernance without further strengthening the European commission and because “European union agencies are generally networks functioning to a ‘hub and spoke’ model, which directly involves national level counterparts.” (Permanand & vos, 2010). some of these unelected expert bodies have elaborate approaches for listening to public and patients’ opinions (such as the citizens’
Panel of the national Institute for Health and clinical Excellence) (Dolan et al., 2003).
When these new, highly capable, unelected actors meet the increasing involvement and grow-ing demands of informed citizens, the more traditional elected forms of government must react,
“propelled to change both the way they discharge their problem-solving role and the way in which they provide an arena for the expression of values in society” (vibert, 2007). In this regard, governments must facilitate and adapt to the new distribution of power. In Germany, public de-bates on the future of nuclear energy after the events at the fukushima reactors in Japan led to the establishment of the Ethics commission for a safe Energy supply chaired by the former head of the united nations Environment Programme (Grefe & schnabel, 2011), and the government based its decision to opt out of nuclear energy on the results of this commission’s deliberations.
similarly, in 2007, the High court of England and Wales found that the government’s consultation on the future energy mixture for the united Kingdom was misleading and required the govern-ment to revise its recommendations. Increasingly, established ways of taking controversial deci-sions are being called into question.
In the Eu, regulatory agencies such as the European medicines Agency and the European food safety Authority fill important gaps between regulation at the regional level and implementation of regulations by Eu countries (mossialos et al., 2010):
many of the [Eu] agencies represent the formalization into a single structure of what had previously been a series of loosely connected committees. This single committee structure can then work inde-pendently of both the [European] commission and the member states – though this is not to say that the main committees are not subject to pressures from both, nor that their decisions or recommenda-tions have never reflected these pressures – a fact that, in turn, generates its own credibility.
The agency approach therefore represents a new mode of Eu governance, which shifts from
“the long-standing, essentially top-down, rule-based ‘community method’” and aims to foster the credibility of Eu scientific decision-making and make processes such as risk assessment for health protection less political (mossialos et al., 2010).
The unelected are also reaching into governance for health in lower-income areas of the Euro-pean Region. for example, the Global fund to fight AIDs, Tuberculosis and malaria, a multilateral, multistakeholder donor agency, has established multistakeholder forums in Bulgaria, Romania