Access to Fertility Treatment through Democracy Seoul

Tackling challenges together This case study is part of a series by CPI and Engage Britain examining innovations in citizen engagement that have used tech-enabled deliberative methods to enhance the policymaking process. There are seven assessed against the Public Impact Fundamentals and two briefings that describe processes for ideas gathering. The series demonstrates that though we are in the early days of using these methods, they offer much hope for more legitimate answers to the big public policy questions of our time. Such methods are also becoming more widespread but work best when used in combination with offline methods. Our paper pulls all the innovations together and offers a view on what we can learn so far.

South Korea has the lowest fertility rate in the world, an issue which is expected to create serious economic problems for the country in future,[1][2] and many South Koreans affected by infertility are experiencing mental health problems as a result.[3] Koreans seeking In Vitro Fertilisation (IVF) treatment encounter a range of barriers relating to the high cost and limited availability of services. The issue of the country’s low birth rate is recognised as a major problem, and the national government started providing support to infertile Koreans in 2006. However, the Seoul Metropolitan Government (SMG) had not developed any policy on infertility, considering it an issue for the national government. 

In 2018, a community of Koreans who were seeking fertility assistance, made a proposal calling for the SMG to expand the number of health centres offering IVF treatment. They did this through a new public engagement platform called Democracy Seoul. The platform allows citizens to propose and debate topics they would like to be considered by the SMG. These debates may ultimately lead to a vote, effectively petitioning the mayor and local government to respond. 

The proposal on infertility gained support from the public and officials alike. Following months of debate and consultation involving affected individuals, policy experts and the general public, the proposal was put to a vote on Democracy Seoul, and 97 percent voted in favour. In March 2019, Seoul’s mayor, Park Won-soon, committed to providing financial support for IVF treatment, expanding the number of health centres offering the treatment, providing information to the public about infertility treatment and government support, and taking measures to ensure those affected by infertility were able to receive support from mental health services. 

The challenge

South Korea’s fertility rate is the lowest in the world. In 2018, the average number of babies born per woman of reproductive age fell to 0.98, which is likely to create a number of problems for the country in future, including underfunded pensions and expanding debt. Experts warn that this may well produce a vicious cycle of economic uncertainty, causing the birth rate to drop even further.[1][2] At the same time, the number of infertile Koreans who would like to have a child is around 220,000, and infertility is increasing across the country.[3] Infertility can have a serious impact on the mental health and relationships of those affected. A study organised by the Korean Ministry of Health and Welfare showed that 86.7 percent of the 214,588 Korean women who were treated for infertility in 2015 said they had felt depressed, worthless and isolated, while 26.7 percent had considered taking their own lives due to depression caused by infertility.[3] 

Low birth rates have been recognised as a major social issue and, from 2006, the Korean government has been providing financial support to Koreans who seek fertility treatments, as part of its demographic policies to tackle the low birth rate.[3] To date, however, the SMG has not considered that improving access to infertility treatment was the way to address the issue. In fact, there are a number of barriers for those seeking IVF treatment in Seoul, including high cost and limited availability. Treatment involves daily injections for up to eight weeks, and the treatment is only available in a limited number of hospitals, meaning that it can be incredibly difficult, inconvenient and costly to receive treatment. While the SMG professed readiness to deal with the problem, there was no policy or department at the city level addressing this issue. In January 2018, the self-organised community for infertile couples sought to address the issue, using Democracy Seoul.[5]

The initiative

In January 2018, the community for infertile couples, which has approximately 50,000 members, posted the suggestion: “What if public health centres could provide IVF treatment?” through Democracy Seoul. [5] The platform was launched in 2017 to encourage citizens to take part in making suggestions to the SMG and thereby cocreating government policy. The SMG is responsible for the funding and administration of the project, but it works in partnership with the organisation Parti Coop in delivering Democracy Seoul. Parti is a social cooperative established by democracy activists, who aim to strengthen the public sphere and enable more democratic decision-making.[4] They use digital technology to provide innovative solutions to democratic problems, developing toolkits and platforms, as well as organising workshops and offline events. Parti is responsible for the planning and operational support of Democracy Seoul. 

Suggestion Stage

The community for infertile couples submitted a proposal calling for an expansion of designated health centres that provide infertility treatment. They did so via the first stage of the Democracy Seoul process, called “citizen suggestions”. At this stage, which lasts for 30 days, any citizen can leave a suggestion on a specific topic or proposal and share the idea with other citizens, who may support the proposal with a “like” as well as leaving any comments. If the proposal acquires 50 likes or more, it is reviewed to ensure it is acceptable for the process; if it acquires 500 likes or more, a citizen-led committee is required to consider including it as part of a public debate. The proposal submitted on infertility treatment received more than 2,500 comments and over 5,000 likes, thereby bringing it to the attention of officials and qualifying it for consideration for public debate.[5]

SMG staff and the Parti team performed a fact-check and audit of the proposal. The primary purpose of this was to ensure that different perspectives on the issue had been included for public debate. They also commissioned a private research institution to write a report documenting the country’s current infertility treatment policies and summarising existing research on these policies. In the summer of 2018, the proposal and accompanying reports were passed for the consideration of a citizen-led committee. The central role of this committee in the Democracy Seoul process was to check the report, determine whether the proposal should be put on the agenda for public debate, advise how the issue was to be framed, and ensure information and resources were balanced and easy for citizens to use. 

Public Sphere/Debate Stage

In October 2018, the issue of infertility treatment was chosen as an agenda point for discussion under the “public sphere” stage of Democracy Seoul. This stage consists of three types of debate: a workshop in which policymakers listen to people affected by the proposed policy; an online debate called “Seoul Asks”; and offline public debates. In November 2018, a citizens’ lab or workshop was held to allow policymakers to listen to people who have had difficulty conceiving and getting treatment, in order to understand their needs, their experiences with healthcare services, and how the SMG could support them. 

Between December 2018 and January 2019, the issue was also discussed through the online discussion forum “Seoul Asks”, where the general public were asked to debate the issue and vote on the ideas proposed. The SMG used both online and offline channels (e.g. print media and awareness-raising campaigns) to publicise the online discussion, and the debate was further promoted by the mayor. Parti advertised the discussion on Facebook and Instagram to draw in further participants, and they also ran offline workshops targeting those with limited access to the internet, including minority groups, the digitally excluded and marginalised groups. The stories, experiences and suggestions gathered through these offline workshops were analysed by Parti staff and fed back into the platform. The issue of infertility treatment received much attention from the SMG, the media and the general public [6]. There was broad support for the community’s proposal among the public and policymakers, and the debate enabled a broader consideration of the issue, highlighting cost and mental health issues. The proposal resulting from the public sphere stage called for financial support from the SMG for those seeking IVF treatment and an expansion of designated public health centres offering IVF.

An online vote on this final proposal was open from 14 December 2018 to 13 January 2019, and 97 percent of the 5,435 participants voted in favour.[5] The Democracy Seoul process states that if a proposal receives over 5,000 positive votes, the Mayor of Seoul is required to provide a direct response to the demands, and the proposal concerning infertility treatment was the first such case. The implications of implementing the proposal by making changes to the policy were considered in a series of expert meetings and conferences held between January and February 2019.

Implementation or “Results” Stage

On 26 March 2019, the mayor held a town hall meeting to address the proposal. Over 150 people attended the event, including many newly-married couples preparing for pregnancy, and couples and individuals struggling with fertility issues.[6] During the meeting, the mayor heard from citizens about their experiences, noting the economic burden of IVF and the effect of infertility on the mental health of those affected. The mayor recognised the need to expand IVF services and providing greater financial support for those seeking IVF, and the following action plans were made:

  1. Define a step-by-step implementation plan to enable more public health centres to provide fertility treatment
  2. Consult with stakeholders, the city municipal assembly, and the 400 Private Medical Institutions Network regarding delivery
  3. Establish the Seoul City Pregnancy and Childbirth Information Centre, to provide policy information related to the policy
  4. Cooperate with the national government to actively resolve the issue.[7]

In addition, the mayor also committed to providing better mental health support services, including counselling, for those receiving IVF treatment. The government has committed to executing the policy changes by the end of 2019 and aims to monitor its progress. [7]

The public impact

Before the initiative, there was no policy related to infertility treatment, and the SMG considered it to be an issue for the national government. The Democracy Seoul platform provided a space in which citizens were able to demand that action be taken on this issue at city level, and where they could collaborate with experts and policymakers to ensure policies effectively addressed the needs of those affected. The initiative resulted in the mayor committing to provide financial support to enable couples to receive fertility treatment, expand the number of public health centres that provide treatment, improve publicly available information about treatment and support, and provide mental health services to support individuals receiving IVF treatment and their partners. [7]

The Democracy Seoul platform has won international awards for its service design,[8] and has been recognised by the UN for promoting gender-sensitive public services to achieve its Sustainable Development Goals.[9] Its prominence has grown, and it currently has 147, 826 members, with 270,000 citizens participating in a number of debates (the population of Seoul is 10 million). The platform has hosted 3,141 suggestions, of which 28 led to action by the SMG. 

Written by Martin King

What did and didn't work

All cases in our Public Impact Observatory have been evaluated for performance against the elements of our Public Impact Fundamentals.

Legitimacy

Public Confidence Strong

A member of Parti observed that the initiative attracted attention and support from the public, the SMG, and the media.[5][6] The community of infertile couples, who initiated the process, took an active role, and their demands were perceived by the wider public as being entirely justified, while their proposal was seen as meeting broader social needs on the vital issue of South Korea’s low birth rate.[6] Moreover, infertility is an issue that resonated with many people who engaged in the online discussion and who had experienced it, either directly or through friends and family. Parti, which archives the events and records feedback from participants regarding their opinions on the public debates they attended, also found strong support for the proposal and satisfaction with the Democracy Seoul process and the mayor’s response. [7]

The issue was widely reported by local and national news networks.[5][6] News reports of the town hall event attended by the mayor described strong public support for the way in which he listened to and engaged with those speaking and for the policy commitments emerging from the process.[6]

Stakeholder Engagement Strong

The process was initiated by the community of infertile couples, and one interviewee involved in delivering the initiative describes how this community group took an active role throughout the process. After the proposal was submitted, Parti took steps to ensure the policy was thoroughly researched, different stakeholders’ views were identified, and the framing of the agenda was balanced. Throughout the public debate, Parti and the SMG reached out to the citizens affected, policy experts, and other stakeholders, such as health centres, and mental health experts, to ensure that the process was informed by their experiences and knowledge.[6]

Political Commitment Strong

Media reports suggest that SMG officials have declared their strong commitment to the initiative and to address the problem of infertility by introducing new policies.[5] A member of Parti commented that the Mayor of Seoul has a “massive interest” in Democracy Seoul, highlighting the platform’s importance in his election campaign “Democracy City, Seoul” and his commitment to respond directly to popular proposals made on the platform. Another member of Parti further noted that they had received strong support for the project from the SMG’s New Media department through its resourcing and promotion of public debates on the platform. 

Policy

Clear Objectives Strong

The initiative developed a set of specific policy objectives based on a nuanced and in-depth consideration of the nature of the problem and the experiences of those affected. The overall objective of the initiative was to improve access to IVF treatment and support those affected. The main barriers to accessing fertility treatment were identified as the high cost and the shortage of hospitals providing IVF. The policy proposals directly addressed these challenges by calling for greater financial support from the SMG for those seeking IVF and an expansion of designated public health services offering treatment. The mayor committed to providing a step-by-step implementation plan to meet these objectives.[5] [7]

Evidence Strong

There were extensive efforts to ensure that the best available evidence informed the decision-making process and the resulting policy. Teams from Parti and the SMG fact-checked and audited the proposal and other suggestions made during the engagement process. A policy research institution was hired to provide a report of current policy, any potentially controversial issues, and additional considerations. These elements were included to ensure the debate was well informed and supported by rigorous and balanced evidence. The policy proposals went through several stages of scrutiny from experts, a citizen-led committee, and the wider public. 

Feasibility Strong

Parti has run Democracy Seoul since October 2017, and its team is made up of members with extensive experience in facilitation, democratic engagement, and the use of civic tech. Members of Parti observed that the process was run efficiently and they received sufficient financial resources from the SMG to deliver the project. The initiative met the original timeframe, and the policies’ feasibility was rigorously scrutinised through consultation with policy experts. The media have reported positively on Democracy Seoul’s capacity to address this and many other issues, including topics related to healthcare, gender equality, and the environment.[5] The platform won an international design award from iF in 2019, which commented positively on its use of digital technology to enable effective citizen engagement and participation.[8]

Action

Management Good

Media reports suggest the initiative followed a transparent procedure that clearly established who was responsible for the delivery of different elements of the process.[5] The initiative drew on appropriate support, applying the expertise of independent academic researchers, SMG staff, and other stakeholders. Public debate was supported by consultation with experts and policymakers to identify the risks and issues involved. Media reports describe how the mayor took clear responsibility for implementation.[6

Measurement Good

The project is in the early stages of implementation, and its measurement is therefore difficult to assess. However, the mayor has committed to providing a step-by-step plan for implementing the envisaged policy changes and monitoring the progress of their implementation.[6] The Democracy Seoul platform also has a dedicated space for monitoring and evaluating the execution of policies that have been implemented as a result of the debate on the platform.[10]

Alignment Strong

A member of Parti observed that Democracy Seoul’s focus is on fostering a public sphere for debating policy issues and encouraging departments to understand citizen opinion. This interviewee felt there was close alignment between the values of the policy and those of the political actors involved. Moreover, policymakers recognised the challenge of better supporting those experiencing infertility as an important one, and all the participants considered that the recommendations emerging from the initiative were valid and met a pressing social need.[7]