Competing Commitments? Independence versus “gold Standard” for Policy Choice in the Reimbursement of Pharmaceutical Drugs

Across the industrial democracies, public agencies operating in similar policy areas and performing similar functions often vary in their levels of independence. While this variation has long interested political scientists, little attention has been devoted to the fact that in complex policy areas, the sheer quantity, diversity and complexity of evidence has facilitated the emergence of a “gold standard”, i.e., a world-wide shared scientific standard applied when assembling, evaluating, and interpreting evidence in a particular policy area. Notwithstanding the important differences between independence from direct government control, and embedding a “gold standard” in the decision-making framework, we can regard both as alternative forms of policy delegation. This assumption raises an interesting question regarding the joint determination of these devices: are independence and “gold standard” for policy choice institutional substitutes or complements? An analysis of drug reimbursement mechanisms in New Zealand, Australia and British Columbia (Canada) reveals that in complex policy domains where a “gold standard” exists, independence and “gold standard” for policy choice are neither institutional substitutes nor complements: the true political choice variable, so to speak, is the application of a “gold standard”. Drug reimbursement mechanisms that abide by the “gold standard” for policy choice allow government ministers to make a credible commitment to prevent granting full-subsidy for treatments which lack comparative advantage, while concomitantly allowing room for policy flexibility by undermining the independence of these mechanisms.