Just what the Doctor Ordered: A Better Way to develop Health Policy
With low infant mortality, freely available vaccines, dwindling infectious disease rates and reliable health infrastructure, you would think Australia has generally good bill of health.
Especially compared to much of the developing world, our nation is fortunate in the sense that the problems preventing their populations from accessing healthier outcomes — think inadequate access to clean water, absence of birth control options and insufficient public health resources — are not prevalent in Australia.
Whilst it is clear that Australia represents the international gold-standard of health care, and Australians are truly living healthier, happier and longer lives, how would you — a diverse group of listeners — react if I put forward the proposition that the sustainability of our nation’s health system is at great threat in the near future?
And to stir the pot a little more, what if I suggested that Australia has lacked a real health policy for much of the last decade?
I assume you’re somewhat amused, slightly bewildered and hopefully curious at the aforementioned propositions. Let me assure you, however, that if you’ve got a young child with one of those notorious middle-of-the-night bouts of high temperature, the dedicated team at the local Emergency Department will provide the outstanding standard of care and support that you have come to expect.
However, the challenge that Australia’s health policy makers are yet to leap over are far more subtle and much more difficult to detect in the sort of top-line statistics and demographic trends that assert our status a healthy nation.
Take a moment to think and ask yourselves this: how certain are you of whether the funding government throws to health is keeping you, your family and friends healthier? Many — myself included — are curious as to whether the Australia’s health is commensurate with the record spending we’ve seen on healthcare.
Don’t take this as a call to cut health expenditure — it is not — but rather, a collection of thoughts on whether our health policy is still fit-for-purpose, and whether there is a better way in health moving forward.
On the surface, the fact that the significant number of triaged hospital patients are seen within an adequate period and that an ambulance is more likely than not to attend to an emergency in incredibly quick time highlights superior equity of access to healthcare. A further testament to that is that you can walk into an emergency department at two in the morning with your newborn.
Not to gloss over longstanding access issues in rural and remote areas — which government must urgently address and I’ll touch on later — the reality is that whilst significant health expenditure and investment have paid dividends, I contend that we are no more certain of whether outcomes have really improved across the nation.
In terms of health policy development, the securing of tomorrow’s health framework is dependant on how the policy makers of today promote the potency of outcomes arising from increased investment and improvement in equitable access to health care. To do this, policy makers must broaden their thinking and consider whether their decisions and commitments are promoting equity in health outcomes alongside the aim to promote equity in access to healthcare across the nation.
The securing of tomorrow’s health framework is dependant on how the policy makers of today promote the potency of outcomes arising from increased investment and improvement in equitable access to health care
Symptoms of a general health policy that lacks foresight are most apparent at election time, during the budget process or when the government of the day is struggling. Often showing in the form of vague promises to increase spending or commitments to build new hospitals in marginal electorates, good public policy that fosters equitable outcomes and promotes accountability from that very increased health expenditure comes second to managing political realities and getting re-elected.
Shameful tussles like those over Medicare highlight the huge deficit of intelligent debate in this complex policy area. Should policy makers adopt an alternative approach to health policy development that puts the impetus on delivering outcomes, then we should start to see tangible results that chip away at the more ingrained challenges threatening the integrity of our health system.
Let’s take Indigenous Health as an example. Given the remoteness of much of Australia’s vulnerable indigenous communities, this is an area where successive government have disbursed considerable time, money and resources to generate tangible improvements to less-than-ideal affect. The ever-extending disparity in outcomes between Australians of Aboriginal and Torres Strait Islander descent and non-ATSI Australians is also much reason for concern.
The problem is more pressing given the fact that those depressing figures come on the back of substantial expenditure on indigenous health. Whilst only constituting about 2.5% of the entire Australian population, ATSI Australians receive a higher concentration of funding relative to Non-Indigenous expenditure for a much larger population group. The Productivity Commission (whose figures were cited before) also noted that $6.3 Billion of the aggregated $30 Billion Commonwealth, state and territory spend in 2012–13 was directed towards indigenous health.
Herein lies the fundamental issue in Australia’s approach to health policy; funding, where it is not targeted and made accountable, quickly becomes a very blunt and ineffective tool if the aim is to actually improve outcomes. In many ways, the more money that is unaccountably spent, the lower the impact on the community and lesser quality feedback that is returned to governments, departments and the community.
Many of the macro-problems that such broad-based funding seeks to target emulate some of the more micro-issues you tend to find in challenging environments, and are therefore susceptible to public health measures- notably, preventative health programs and lifestyle promotion.
Funding, where it is not targeted and made accountable, quickly becomes a very blunt and ineffective tool if the aim is to actually improve outcomes
If the policy framework was set to allow bureaucrats, communities and health ‘consumers’ to accurately construct detailed and collaborative solutions to specific public health issues, then I suspect that we would see improvements in the closing the indigenous health gap and be less complacent about the potency of targeted expenditure.
Now, you might be feeling slightly despondent at the above analysis on the State of the Nation in health policy. Whilst it is true that Australia does not have as perfect of a health system as we complacently believe, a fundamental shift in the way we develop health policy is quite achievable if we position ourselves to aim for equitable outcomes and be accountable for achieving them.
The discussion would naturally be radically different; a meaningful start in implementing important reform and setting the foundations for a real and robust health policy. Instead of speaking in dollar amounts committed to the construction of a hospital, we would cite trends in the successful treatment, mitigation or prevention of cardiovascular disease as an example.
Step one would be to understand that while good health policy is the ultimate goal, active consultation with relevant stakeholders is the means to get there.
Stakeholders often criticise the Department of Health and its associated entities (like the Therapeutic Goods Administration) for shying away from collaboration, whilst others note that the Health Minister’s and their office elude from public view given ability for health policy decisions to make-or-break governments.
To those looking inwards, good health policy, in many ways, should resemble organised chaos. A labyrinth of pacts between government and stakeholders should be welcomed; allowing parties to have mutual involvement in the development of strategy and policy, as well as shared ownership and responsibility for the achievement of positive health outcomes. Minister for Health, Greg Hunt should be commended for being able to negotiate with four influential stakeholder groups in the health space.
It now must be said, however, that it is incumbent on policy makers to unwaveringly understand that the paramount pact they are party to is the one with the Australian public. This relationship should serve as the only point-of-reference for partnerships with other stakeholders; a solid understanding of the public’s fundamental needs and priorities — particularly in relation to accessibility to health care — will inform the scope and objectives of other pacts.
It is incumbent on policy makers to unwaveringly understand that the paramount pact they are party to is the one with the Australian public
Only then will the public, bureaucracy and government alike gain the capability to address intricate and subtle public health challenges, analyse the potency of health expenditure and — most importantly — track the equitable distribution of health outcomes.
Once this relationship network is developed, the trust on which they are built upon can generate value if leveraged appropriately. The value here being contextual insight. It may very well be hard to synthesise intimate understanding of every single niche public health challenge across every single community, however, approaches to health policy as they currently stand are unable to thoroughly detect trends and craft policy responses to them.
Given Australia’s health framework lacks the capacity to counter public health challenges, context is crucial. By tapping into the wealth of knowledge and experience within the community, policy makers gain an educated and credible partner through the entire development, implementation and analysis stages of policy. This, by extension, should translate into greater accountability for realising more equitable distribution of resources and ultimately, outcomes against health problems.
Finally, if health policy serves to do anything- it is to support opportunities that respond to the premise that the health sector is categorically different, but also stimulate competition in a manner that delivers more equitable and impactful benefits for the entire system, the patients and the general public. Thoughtful health policy should be equally conducive to curating initiatives that minimises health incidents, boost the population’s immunity or evolve public health know as they are to curing pre-existing conditions or treating preventative illnesses.
As we move towards a future where there is a far greater number of elderly Australians, yet-to-be-encountered health issues predominately arising out of the way we live our lives and innovation in treatment pathways; developers of health policy should approach the most unorthodox of health issues with a similarly unorthodox mindset. No longer can policy makers complacently handle vulnerabilities as they arise on an ad hoc basis, because that has been a key cause in the inequity of health outcomes across Australia.
Unorthodox thinking could look like, as an example, embracing competition in health care- particularly considering the private sector’s contribution in delivering health care and associated services to Australians. Not to get into detailed policy development proposals (thats an entirely different discussion for another time), but the provision of medical services — a sub-sector heavily subsidised by government — is perhaps an area where competition could be welcomed to remove a substantial burden off an already overloaded health system, and therefore transfer the onus of accountability for effectiveness to the provider. A combination of legislative and regulatory checks-and-balances would ensure that there is a marked improvement in the originally targeted challenge.
Australians are incredibly fortunate to have access to the best health system in the world. Ironically, it is secure access to health care and health infrastructure that has led to critical juncture we find ourselves in. How can government, stakeholders and — most importantly — the public credibly argue that we do have a broad health policy when we cannot confirm whether Australian’s are not only healthier today, but will be even healthier in the future?
I am the first to admit that top-line health and lifestyle indicators do show some improvements over time, but the reality is that if you were to break down these same indicators over geographical divides or certain sections of the Australian population- you would find stagnation or even regression. That’s the case even with all the rising expenditure we have seen over the years.
Vexatious as health policy may be, the challenge is for policy makers to cast focus away from promoting equitable access to healthcare — as important as that is — and start framing the discussion, debate and policy objectives as one about equitably improving outcomes across the board. Simply put- equitably improved outcomes are the objective, with equitable access the means to get there.
Opportunities to protect the sustainability of Australia’s health system are clear and tangible- so long as we accept that the Doctor has prescribed a drastic change in the approach we employ to developing health policy. Only then will we be able to honestly claim that we do have a functional, modern and working general health policy.
This is an amended for print speech I delivered on the state of Health Policy in Australia.
