Honest Brokers, Technology, and Health Justice: What Are We Learning? – Non Profit News

In healthcare and social services, amid an aging population and an increased demand for care, there is a growing need for neutral—or at least quasi-neutral—honest brokers who can build trust and balance the conflicts of competing parties. For the nonprofit sector in particular, this can be key to resolving issues and creating more inclusive, fair, and effective systems through transparent decision-making.

In the past, brokerages have emanated from other organizations that often have interests in the contested area or are related to the agencies, such as a funding source or the state. But the sector needs a more compelling, ethical model for a brokerage that uses decentralized governance, transparency, and inclusivity.

An emerging promising approach is what is sometimes called the DAO—or decentralized autonomous organization—a geographically dispersed, peer-based virtual model that allows service recipients to oversee the services that they receive. By decentralizing decision-making, this structure empowers participants, families, and frontline workers to impact policies prioritizing dignity, justice, and positive change.

The Need for Honest Brokers in Healthcare and Social Services

The Cambridge Dictionary defines an honest broker as “someone who speaks with both sides involved in an argument or disagreement and tries to help the two sides to agree.”

Such a neutral entity is critical in healthcare and social service systems, where power imbalances and conflicting interests abound. Their sheer size and numbers create complexity and conflicting interests among them. In some cases, conflicts exist between organizations and their funding in state agencies. In others, the state office is the broker for struggles among agencies regarding who provides the service.

While many organizations strive to act as honest brokers, true impartiality is rare.

In healthcare, tensions among providers, patients, public and private entities, policymakers, and other practitioners create divergent interests that honest brokers mediate to ensure that a balanced, equitable, and just solution occurs. Vulnerable populations frequently lack influence in decision-making. Honest brokers can make evidence accessible to stakeholders, enabling informed decision-making, promoting transparency, building trust, and catalyzing reform, such as in the case of integrated care.

As another example, some use the term “honest broker” to refer to the protector of patient identity in tissue databanks. The honest broker collects and provides aggregate health data to investigators while protecting individual identities and privacy. They’re usually not part of the organizational team.

In other situations, the honest brokerage approach relates more to managing social relationships and divergent interests in evolving discussions. Trustful relationships increase the perceived credibility of the brokers and encourage more honest two-way communication. On the other hand, the brokers have faced ethical dilemmas and difficulties staying impartial while finding confidential information related to political strategies.

While many organizations strive to act as honest brokers, true impartiality is rare. The perception of what is fair depends upon transparency, primarily about the interests and motivations of the supposedly impartial organization.

Using an organizational structure similar to that of the parties involved is part of the problem of building real trust. By developing an alternative structure and approach, healthcare and social service agencies can create a process by which a disinterested organization can become an honest broker and move disagreements and disputes toward collective resolution more effectively.

The DAO Approach

DAOs are one potential way to disseminate the ethos and work of honest brokers throughout a system. DAOs are commonly associated with blockchain and cryptocurrency communities, but the decentralized governance approach of a DAO can be applied in other contexts.

A DAO, simply put, is a virtual organization where “decisions are made collectively by its members or stakeholders.” As the authors of a recent article in the Journal of Business Research elaborate, a DAO governance structure involves a shift from “traditional intermediary-reliant organizational structures towards more transparent, immutable, and distributed consensus mechanisms.”

For example, a community health center’s decision to allocate a grant traditionally involves the board and management. However, a DAO structure would empower all stakeholders—including patients, families, and other providers—to actively participate in decision-making. This inclusive approach would allow all parties to propose ideas on the DAO platform, such as expanding crisis intervention services.

Subsequently, these proposals would be openly discussed, with supporting data shared transparently, and finally, all participants would have the opportunity to vote on the proposals, with the DAO recording the decision permanently. This process, visible to all members, would foster trust and accountability, ensuring that every voice is heard and valued in the decision-making process.

Such a decentralized structure prevents dominance by any one entity and promotes equitable deliberation among the participants. The system ensures that voting power is distributed equally among participants or weighted to balance representation, thereby promoting fairness and equity in the decision-making process.

This balanced distribution of power reassures all parties—including healthcare professionals, policymakers, and community health stakeholders—of the system’s integrity and their equal standing within it. Groups that are usually marginalized, including elderly people and people with disabilities, can participate in shaping processes that directly affect them, knowing that they are not only present but have a voice and a vote.

This agility also allows DAOs to collectively mediate conflicts, propose solutions, and respond in real time to stakeholder concerns, such as prioritizing community investment and distributing grants and funds, particularly from public sources.

Making a Difference in Health Outcomes

The DAO structure can improve, even revolutionize, healthcare in several ways. The first is resource allocation. The structure could be used to oversee the distribution of emergency response funds during a crisis, ensuring that all communities receive their necessary resources. And for patient advocacy, a group organized as a DAO could gather various parties seeking to increase Medicaid funds.

It could also manage grants to support home caregivers and personal care assistants, tracking funds transparently to ensure equitable distribution. In some instances, personal care attendance could be part of this, with clients and providers both serving in the organization’s governance. Using smart contracts could assist in compliance by automating the approval of funds—for example, when Medicaid is paying an add-on for services provided above the basic benefit.

Smart contracts should be considered tools, not a complete replacement for human decision-making.

DAOs present an interesting concept for implementing agreements. For example, a DAO could ensure that a grant is used for its intended purpose or that a community health investment is carried out as agreed.

This works because preconditions and actions become part of a “smart contract”—effectively, a computer program that automates enforcement and compliance once the group has reached consensus on the scope of work and agreement. Operating standards and terms and conditions are visible on the blockchain (common server). These can’t be altered, ensuring the agreement’s integrity.

To be clear, while smart contracts can directly address qualitative or subjective criteria, program effectiveness requires measurable and clear metrics. Oversight is needed for these assessments, so smart contracts should be considered tools, not a complete replacement for human decision-making.

In some cases involving money, the DAO can manage the funds in escrow, releasing them automatically when contract conditions are met. For example, the structure could be used to authorize the release of funds to a clinic once a minimum number of patients has received care.

Since this process is automated, the DAO structure can also provide a tracking mechanism for compliance and issue that information to all parties. This process can also inform setting milestones for achievement and laying out penalties for noncompliance, thereby reducing human error and bias and increasing efficiency.

Challenges of Implementing DAOs

The DAO process offers a promising tool for more decentralized impartial decision-making, but it does have its challenges.

Some stakeholders may need more internet access or digital literacy. Part of establishing a DAO is assessing participants’ needs and training them in the tools and process.

Diverse interests may also lead to gridlock and conflict among stakeholders. Reaching consensus can be difficult, and technology alone does not solve this difficulty. Another challenge is that implementing decisions may require additional mechanisms and intervention since not every decision can be enforced simply through a well-written computer program.

Despite these challenges, DAOs—because they allow for a community of actors, many of whom are often excluded from participation, to come together, reach joint decisions, and then develop mechanisms to enforce them—hold significant promise to serve as honest brokers in complex healthcare and social services systems.

Healthcare and social services often face conflicts arising from competing interests and systemic inequalities. By leveraging the decentralized and inclusive nature of DAO structures, stakeholders can reimagine decision-making processes to prioritize justice, dignity, and meaningful participation.