Introduction

This chapter builds on the definitions and history of public health in the previous two chapters, and provides an overview of contemporary health priorities. Why should you study health policy? It is important knowledge for you as a future health professional, whether a nurse, paramedic, nutritionist/dietitian, podiatrist, public health/health promotion officer, occupational therapist, doctor or other health worker, as your practice will be influenced by changing health policies and priorities. Public health policies address the health problems of many of your clients and populations, so this chapter will assist you in understanding current policies and programmes that the federal and State governments are implementing to address such health problems. For example, there are increasing roles for health professionals in preventing and managing chronic diseases/conditions, so understanding the policies and programmes in place to address chronic diseases will provide you with a solid foundation for your practice. We introduce you to definitions and types of policy, and the role of politics and values in public policy-making, and provide examples of these. We describe the role of the World Health Organization (WHO), in identifying global health trends, and how these impact on Australia’s health policy. Australia’s national public health priorities and the government’s most recent initiatives are introduced.

What is policy?

Policy has various definitions. For example, policy is ‘… the process by which governments translate their political vision into programmes and actions to deliver “outcomes” … desired changes in the “real world” ’ (Cabinet Office 1999). Policy can also be defined as a broad pattern or framework of collective action in a particular field (e.g. economic policy or health policy), based on specific decisions that aim to realise the visions and goals of that field. Policy is usually about problem solving, but it can also be about preventing or minimising problems.

Policy can refer to a number of intentions and actions:

The focus of policy is usually reform, establishing priority goals and accomplishing policy objectives. Policy can thus be seen as the exercise of argument through the use of evidence, and an ability to juggle competing interests to achieve a collective purpose. Lin and Gibson claim that ‘policymaking is based on discussion and persuasion and making a good argument’ (2003 p 256). Eva Cox (Cox n.d.) claims that ‘public policy’ also refers to the decisions taken at a government level to run, fund, support, regulate or ban certain services or activities. At its broadest, it is any intervention by the state in the community – encompassing the issues and ideas, the decision-making and the actions taken to implement those decisions (sometimes called the ‘policy instruments’).

Stages of the policy process

Ideally, the policy process consists of a number of stages – outlined in Box 3.1. In reality, there are often no discernible stages and no rational sequence because the policy process is changeable and influenced by many players. Determining policy goals is often not as easy as it sounds, as various stakeholders can analyse a problem differently, and may have diverse ideas about the preferred actions to take.

Policy can be seen as a framework for actions on specific public health issues. Policy development and implementation are also shaped by values and norms, which are often not explicit. For example, policies concerning Aboriginal and Torres Strait Islander Australians have reflected social and political values that have changed over time. Protectionism was the policy enacted in the first half of the twentieth century when Aboriginal and Torres Strait Islander peoples were segregated from other Australians, and there was no regard for their human rights. However, a period of social change began in the 1960s, with a growing ‘political and social consciousness among the general community and the plight of Aboriginal people constituted an urgent human rights issue’ (Couzos & Murray 2003 p 5). There were mobilisation actions by Aboriginal and Torres Strait Islander Australians, which led to the establishment of the first Aboriginal and Torres Strait Islander community-controlled health organisation in 1971 at Redfern (Sydney). Community self-determination was a key principle in establishing this health centre and all subsequent Aboriginal and Torres Strait Islander health organisations across Australia. See Chapter 13 for an introduction to Aboriginal and Torres Strait Islander health promotion, and Chapter 15 for a comprehensive analysis of the health status of Aboriginal and Torres Strait Islander peoples.

Policies, by their very nature, are not value free. They underpin how governments distribute and redistribute resources, and how judgements are made in implementing policies, as the following example by Gibson (2003) illustrates (Case Study 3.1).

Drug and alcohol policies are often fraught with different and sometimes conflicting viewpoints. For example, should alcohol availability be increased or restricted? Should the legal drinking age be raised? Should taxes on alcohol be increased? How should people who are users of illegal drugs be dealt with: through the criminal justice system or rehabilitation programmes? Do high-performing athletes who use illegal drugs receive different treatment compared with non-athletes, and why? The next case study, adapted from Lin and Gibson (2003) on harm minimisation¹ for injecting drug users, shows how empirical evidence together with values, and a focus on the care of individuals, were blended into a policy framework in establishing safe injecting facilities (Case Study 3.2).

In this discussion of policy, the claim of the great nineteenth-century German pathologist, Rudolph Virchow is relevant – ‘political action as well as rational science is necessary to initiate action to control public health problems’ (Gunn et al. 2005 p 11). The case studies on breast cancer screening and needle syringe programmes illustrate how Virchow’s statement is relevant to the dynamics and complexities of public health policy making in contemporary Australia.

We now turn to an introduction on various types of public policies.

Types of public policies

Various public policies affect the way communities live, their quality of life and their access to services. The following provides an example of how different types of public policies may be categorised.

What is policy for?

The focus of policy is on reform and, in public health, to promote and restore the health of populations. Health policies are tools that can be used to identify, plan responses to and act on prioritised health problems. A health problem can be considered significant if it:

Health policies and priorities must be periodically revised, according to changing patterns of morbidity and mortality, as the breast cancer and drug use examples demonstrated.

John Last, a well-known epidemiologist, identified five essential ingredients for solving public health problems:

These five ingredients led to the sanitary revolution and have led to ‘better control of tobacco smoking, impaired driving, child abuse, domestic violence, environmental lead poisoning, and various occupational diseases’ (Little 2010 pp 751–752).

The above processes were influential in the public health reforms of the nineteenth and twentieth centuries, and are still relevant to contemporary public health policy.

Politics and policy

Australia has what has been termed a liberal-democratic political system. The characteristics of such a system of governance and a society is that ideally there are numerous channels for participation in political parties, being involved in community organisations and special interest groups, and the media is ‘free’ – meaning that freedom of expression is encouraged (Baum 2002). Britain, Canada and the United States are other examples with this political tradition and, therefore, share some similar characteristics with regard to policy-making, although obviously dynamics and processes are unique to each. Kickbusch (2010 p 263) claims that ‘politics in democracies is all about bargaining and compromise’; this is played out daily in liberal democracies. Current issues in Australian politics exemplify this as, at the time of writing, Australia has a minority Labor government and the balance of power is held by four Independents and the Greens. Examples of such national debates are: the proposal about a carbon tax – this is about altering economic policy; the National Broadband policy; new directions in education in schools; and negotiations with the States about lifting teaching standards and the national curricula. (See Chapter 11 for an analysis of climate change, health and policy developments.) So while we may think that politics is only about politicians, ‘politics’ comes from the Greek polis, which referred to the city-state or its citizens, so politics can be seen in terms of governance of citizens and, in a liberal democracy, opportunities for participation in society.

As public health is about maximising the health of the population or ‘citizenry’, it seems inevitable that the means to reach this public health goal would be challenged in an open society. Politics and policy is a recurring theme in public health in Australia and internationally (Baum 2002; Navarro et al. 2006; Palmer & Short 2010).

Health is political, because there is variation in access between groups; social determinants of health are amenable to political action, and the right to a standard of living adequate for health is an aspect of citizenship and a human right (Bambra et al. 2005). Health problems are also complex. Kickbusch (2010 p 261) argues that the visibility of health issues ‘relate to larger agendas such as the freedom of markets, the responsibility of individuals, the protection of vulnerable groups and the extent of state intervention – this makes any health issue inherently political’. The process of policy development in public health, therefore, is an intensely political one that is aggravated by the different parties being in control of different governments or houses (House of Representatives and the Senate) and the vested interest of those playing the political game.

So what is the role of political parties in developing health policy? Each political party in Australia designs policies on national issues based on their parties’ political ideology – what they stand for. It is worth visiting the websites of the various parties, to discover party health policies and how they differ on particular issues. These policies are the platforms that are often released near an election and have usually been debated at party conferences of assembled members. Anyone can join a political party in Australia, and therefore participate in party committees and activities. In reality, there are often obstacles to enshrining party policy through the House of Representatives and the Senate, as different sections even within the same party may disagree regarding the policy being proposed. For example, it may have an impact on a Member’s electorate, or interest groups, or advocacy groups may have lobbied the Member with concerns about the policy. Such groups can be community groups representing patients with a specific health problem, powerful health professional groups such as the Australian Medical Association and the registration boards of health professionals, and, of course, the influence of the ‘media’.

‘Social media – talkback radio and letters to the editor as well as blogs, social websites and microblogs, such as Twitter – provide constant qualitative and quantitative feedback on the issues of the day’ (Baume 2011 p 1). Thus the principles and foundations of health policy and directions for its implementation can be shaped by numerous influences and also by powerful media sources and interests.

Political priorities in health are enhanced or tempered, not only by political realities, but also by economic realities and political promises. The federal government wishes to return the national budget to surplus by 2013, and thus potentially some health programmes could be cut. As health is perceived to be a high priority in Australia, the level of the cutbacks has to be balanced against vested interests.

Health economics

Governments and other health care organisations need to balance their own health policy priorities against political and economic realities within societies that have increasing demands for health care, ‘and the costs of supplying healthcare services are rising’ (Graves et al. 2009 p 81). Health economics can be influential in assisting governments and departments within governments and other health care organisations to make decisions on the most effective economic investments to maximise health in a population or within health care organisations. Health economics can examine the cost effectiveness and costs benefits of different interventions and provide economic evaluations ‘aimed at examining alternative courses of action’ (Hale 2000 p 341) to assist in making choices. Traditionally, health economists have focused ‘on “medical care” important research on the delivery of medical care services’ (Halpin et al. 2009 p 276), but there is a need for ‘economic analysis in public health interventions’ (Ammerman et al. 2009 p 273) to decide how to allocate scarce public health resources.

Such economic analyses are being used increasingly in public health, as the following examples demonstrate. An economic analysis of the impact of the proposed National Tobacco Campaign, contained in the National Preventative Health Strategy, predicts that there would be ‘a sustained 1.4% drop in prevalence (of smoking) observed in the first phase of the campaign that will prevent an estimated 55 000 premature deaths (in an investment of $9 million over only seven months), and will lower health care spending by at least $740 million on the four major diseases caused by smoking’ (National Preventative Health Task Force 2009 p 44). Similarly, Graves et al. (2009) studied the economic rationale for infection control in Australian hospitals. There are a predicted 175 153 cases of health care-acquired infection among admissions to Australian hospitals annually. This means that patients are staying in hospital longer to have their infections treated. In an economic analysis that was informed by epidemiological and economic data, the authors estimated the gross costs of hospital-acquired infections, and concluded through their analysis that ‘the cost-effectiveness of hospital services might be improved by allocating more resources to infection control, releasing beds and allowing new admissions’ (Graves et al. 2009 p 81).

In your role as future health professionals, it is important that you understand the influence of politics on public health, what the government’s priorities are and how you can participate in shaping public health policy, and be aware of the increasing value of health economics as an invaluable tool to aid decision-makers in allocating scarce health resources. See Chapter 8 for the use of evidence in public health.

For an in depth analysis of politics and health, see the books by Baum (2002) and Palmer and Short (2010) in the reference list for this chapter.

International developments and their impact on contemporary health policies

In Chapter 1 you were introduced to the WHO’s six-point plan (WHO 2008). Over 60 years have passed since the WHO was constituted, yet its relevance to public health policies and practice is still substantial, as it identifies world trends for public health action.

The WHO was formed in 1946 in an international climate of hope for promoting a better, more peaceful future, after the chaos of the Second World War (1939–1945). Three physicians – from China, Norway and Brazil – proposed the formulation of a single health organisation that would address the health needs of the world’s people. There are currently 193 member countries, and its headquarters are in Geneva, Switzerland. The WHO constitution stated:

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