Chapter 13. Inclusive policies, equitable health care systems
Introduction
National health policies are usually informed by, and responsive to, global priorities and conditions. Ideally, state/territory or regional priorities would also be designed to follow or complement the directions of national policies. However, where political agendas differ, this may not always be the case. So, for example, it is possible that in one Australian state, policy-makers could place high priority on environmental issues in its health planning, whereas another might see aged care as its greatest priority. Both states would be governed by the goal of better health, but they may change the distribution of resources according to their respective priorities. In countries such as New Zealand, where there is a single health department (the Ministry of Health New Zealand [MOHNZ]), policy-making is more consistent across the country. Yet, even in this environment, there is a need for constant vigilance, to ensure that policy-making is inclusive, and results in all members of the community having equity of access to what they need to maintain good health.
Point to ponderPolicy development must be fair — that means advocating for those most in need while ensuring the needs of those born to privilege are also not overlooked.
Because of the complexity of health policy-making, it is important to understand how decisions are made. Optimally, decisions would be bi-directional, bottom-up and top-down. Local citizens’ groups, health professionals, town councils and city planners would convey the needs of local communities upward, to the regional, state/territory and national levels, where they would participate in informed debates about health and health care. Policy-makers would hear their voices and preferences, and attempt to accommodate multiple perspectives in the way they allocate resources for health. In this context, debates and decisions would be approached on the basis of equal partnerships, and expedient information systems, so that all policy decisions would also be evidence-based; or informed by the latest research and demographic data. Once considerations were aired and consensus was achieved, the policy-making group would communicate with the wider community, gathering further data and/or responses, which would instigate further cycles of input for decision-making. As a result, the policy would achieve three main outcomes. First, it would have a significant effect in improving the health of the population. Second, it would be fair. Third, it would be administered through efficient governance structures, with transparent goals, expectations, financial accountability and evaluation strategies. Yet, impediments to achieving this type of system remain for reasons that are political and financial. Too often, political positions dictate the terms or targets of health decisions, especially if there are vested interests involved. The discussion to follow outlines some of the most important issues in policy-making in the 21st century, with implications for the sustained involvement of all health professionals.
Point to ponderOptimal policy-making would ensure decisions are made in a bi-directional manner — from ensuring that consumer group input at the local level is heard at the national level, and that their input is accommodated in policy, and then fed back to the local level.
Politics, policy-making and health care
The main goal of health policy-making should be to improve and enhance health. This requires a strong health care system, and decisive leadership to guide the way policies are developed. The ideal health care system is ethical, fair, strategic in its endeavour to meet the needs of current and future communities; transparent in communicating its goals and capabilities; oriented towards community empowerment for informed choices, and resourced to the extent that it can support those choices. But the health care system alone cannot create or sustain health. This is why there has been an urgent call from global health policy-makers to incorporate health in all policies. If health was included in all policies our governments would ensure health and safety in education, transportation, media advertising, food services and the environment. Community planning would include health considerations in their plans for housing, infrastructure and public works. Health planners would participate in policies for safe neighbourhoods, community policing and disaster planning. There would be health considerations in decisions made by departments of immigration and multicultural affairs, and health plans for primary industry development and innovation, and workplace and industrial relations. Health issues are embedded in each of these aspects of daily life, and affect people at all stages of the life course from family planning, safe maternity care, illness management, injury prevention to healthy ageing and end-of-life care.
Point to ponderThe health care system alone cannot create or sustain health. Health must be considered in all policy development activities.
As mentioned previously, the defining purpose of a health care system lies in the provision of accessible, appropriate, equitable health care that is responsive to people’s expectations. When equity is achieved, the health care system,
Objectives
By the end of this chapter you will be able to:
1 identify the factors influencing the development of policies that affect the health of the population
2 explain the global issues that have an impact on national and regional policy development
3 explain the importance of community health literacy in all policy-making
4 discuss the issues that must be considered in planning health services to be responsive to the needs of different population groups
5 describe the features of a PHC system that contribute to better health and wellbeing
6 discuss the role of nurses and midwives in policy planning and implementation.
Politics was once defined by Sax (1978) as the art of the possible in satisfying a ‘strife of interests’ (in Kamien 2009:65). In health policy-making there has always been a strife of interests, between rich and poor, urban and rural, young and old, sick and well, and those with competing biomedical or health promotion needs. Health care decisions revolve around distributive justice: who gets what. Ethically, the poor should receive the lion’s share of resources, as this would bring them up to the same level of opportunity as the rest of the population. However, no country in the world has achieved equity in resource allocation, leaving many people living impoverished lives. At the global level, the United Nation’s Report on the World Social Situation 2010 indicates a need to ‘Rethink Poverty’ (Online. Available: www.un.org/esa/socdec/rwss/2010_media.html [accessed 29 January 2010]). The report argues that poverty remains the central issue for global policy-makers, which should inspire governments to work towards equality and social justice throughout all countries in the world.
The global financial crisis, and the neoliberal policies that led up to the crisis, represented the global trend of over-reliance on market forces, where government efforts were focused on economic development, to the detriment of health and social services for the world’s poor. The United Nations (UN) suggests that the most important policy implication for the future is for governments to play a developmental role, integrating economic and social policies to support productivity and employment growth, while attacking inequality and promoting social justice. This is a more balanced approach to alleviating poverty, and it urges governments to work towards equitable, sustainable employment opportunities and public social expenditures on PHC, universal education and the provision of social security. The latter includes insurance, pensions, disability and child benefits (UN 2010).
Point to ponderAt the global level, poverty remains the central issue for policy-makers with an urgent need to integrate economic and social policies to achieve health.
The UN focus on employment policies is shared by others, including researchers who have developed a database of studies demonstrating how working conditions affect national competitiveness and unemployment throughout the world (Online. Available: www.RaisingtheGlobalFloor.org [accessed 5 December 2009]). This work, and that of other large research groups, is intended to draw global attention to the link between the SDOH and global inequalities (Bambra et al 2008). Bambra et al’s (2008) analysis of systematic reviews of health inequalities in relation to the SDOH, situates the workplace as one of the most significant settings for policy development. Where workplace policies are unfair or insufficient to support the labour force, there are implications across all of the SDOH. Parents are unable to care for their children. Maternal health suffers. Family relationships can be eroded. The lack of financial resources can prohibit children’s educational opportunities. Cultural and family connections can be disrupted. People may have to work into older age and consequently suffer illness and injury. These are only a few of the factors that cascade through family life from one type of policy. Together, these factors reinforce the primary role of employment policies in global and national policy-making.
Health services policies and the social determinants of health
No one would doubt that health service policies are also fundamental to improving the SDOH. However, there is a gap in our research knowledge of the policies that would be most responsive to the SDOH, and how these are linked to health services (Bambra et al 2008). Baum et al (2009) argue that this will only occur with a complete reorientation of health care systems. To date, health service policies continue to reflect the biomedical approach, and, because the political power rests with the medical, technological and pharmaceutical industries, this is where the greatest level of funding is allocated. Public demand for these services also plays a role in maintaining the dominance of biomedical, technological and pharmaceutical services. Politicians and decision-makers find it easier to provide expensive clinical care in urban environments, where it is most cost- effective. However, privileging hospital services, and concentrating health care in urban environments, deprives many rural areas of services such as obstetric care, care for older people and adequate distribution of health professionals (Farmer and Currie, 2009 and Kamien, 2009).
Point to ponderThere is a significant gap in our understanding of the type of policies that will be most responsive to addressing the SDOH.
Rural health policies
Rural health is therefore an important area for policy development. Policies to address the needs of those disadvantaged by distance would include a national e-health strategy, patient-assisted travel, community support systems for oral and mental health, and an adequate workforce (National Rural Health Alliance [NRHA] 2009). To advance the rural health agenda, there is a need for policy-makers to collect evaluative data on current issues and needs, and then to support evidence-informed practice and services that are framed in conjunction with other health policies (Farmer & Currie 2009; Wakerman 2009). However, after nearly a decade of development, Australia’s rural health policy discussions remain focused on health services and workforce issues, rather than the SDOH or proximal risk factors (Wakerman 2008). A similar situation exists in New Zealand. A recent health workforce policy has seen the introduction of bonding for health professionals who choose to work in areas difficult to staff, including some rural locations. As an incentive to work there, medical doctors and midwives who stay in a rural location for three to five years, can have up to $10 000 per year written off their student loans (Online. Available: www.moh.govt.nz/moh.nsf/indexmh/bonding [accessed 8 February 2010]). Interestingly nurses who are in an ideal position to provide essential PHC to rural communities, are not eligible for bonding.
Health promotion policies
Health policies oriented towards hospital care are only part of the problem creating inequities. For many years, health promotion policies have been developed on the basis of exhorting individuals to change their behaviour, rather than focus on the upstream causes of ill health, or the needs of the poor or those with disabling conditions. As a result, those with the worst health status, many of whom cannot afford health care, receive the fewest health services, and the cycle of inequities continues (Baum et al 2009). This does not mean that policies focusing on behaviours have been entirely ineffective, because there have been some remarkable successes. These include policies that have guided programs aimed at reducing injuries from road traffic accidents, preventing deaths from tobacco smoking and sudden infant death syndrome (SIDS) (now often referred to in New Zealand as sudden unexpected death in infancy, or SUDI), those focusing on screening for breast and cervical cancer, and early detection of cardiovascular disease, public awareness programs cautioning against behaviours that would spread HIV/AIDS or other communicable diseases, and initiatives to prevent suicide by creating public awareness of the warning signs (Wise 2008). But there remains a need for policies recognising the
Point to ponderHealth policies in Australia and New Zealand continue to focus on hospital care and behaviour change rather than on the causes of ill health or needs of the poor.
Community development policies
The absence of community development and community self-determinism in policies adds an additional layer to inequitable health systems. The lack of such policies runs counter to the need for community empowerment as a principle of PHC, which would foster full participation by community members in determining the direction and priorities for their health services (DeVos et al 2009). Community participation would help identify the need for services for the disadvantaged and vulnerable; those with the best understanding of the most urgent needs. Community input could also provide a basis for developing realistic policies for children’s health, adolescent health, men’s health, women’s health, migrant health, disabilities services, aged care, Indigenous health, rural health, mental health and other areas of policy development. If these groups participated in policy-making there would not only be greater inclusiveness, but better guidance on appropriate implementation strategies.
Policy-making and primary health care
An inclusive approach to policy development resonates with a careful balance of comprehensive and selective PHC, as we discussed in Chapter 2.Equitable services can be provided from comprehensive PHC systems that also accommodate selective care based on prioritised needs (Birn, 2009 and DeVos et al., 2009). Yet the logic of this type of policy environment has yet to be acknowledged by those competing for limited resources. Marginalised communities remain unable to control key processes that control their lives and their health or to select what they need. They are subjected to inadequate services, and difficult living conditions that prevent them from being able to challenge power brokers, or work towards building local capacity (DeVos et al 2009; WHO 2008).
When people live in disadvantaged situations, their predominant focus is on day-to-day survival, which not only causes substandard health, but erodes social capital. Without political leadership that is committed to addressing the inequities of disadvantage, this situation will remain unchanged. The policy ‘problem’ is that, rather than try to mitigate the consequences of powerless groups, policy-makers tend to shy away from redefining labour relations or unemployment arrangements, or imposing regulations on environmental pollution, or taxes on alcohol that affect the poor disproportionately (WHO 2008). Instead, spurred on by economic goals, social and health policies have continued to concentrate wealth in the hands of the powerful, which has left the poor and voiceless with a disproportionate amount of health-damaging experiences (Commission on the Social Determinants of Health [CSDH] 2008).
Clearly, change is necessary, but it does not occur spontaneously. What is needed is an overt process of inviting community input, then an ongoing level of support. This would produce a combination of perspectives from the public, health professionals, health planners, and intersectoral policy-makers to encourage multilevel, multidimensional approaches for better health. The key to success in accommodating such a breadth of opinions is authentic communication between all participants (Hawe 2009). But first, those in charge of health care have to extend the invitations. Then practitioners need to advocate for communities, engaging with people to gain their support and input.
Point to ponderIn order to achieve health equity based on the principles of primary health care, health policy-makers must initiate and maintain authentic communication with community members.
Globally, changing policies, and changing health care systems to be more equitable, is based on the notion that redistributive justice is not only humanitarian, but an investment in the health of each country’s population (Smith & MacKellar 2007). This situates health as a public good, not a commodity (Baum, 2009 and Labonte, 2008). In each country, inclusive policies for better health must be aimed at improving daily living conditions. They should tackle the inequitable distribution of power, money and other resources, and then they should measure and understand local problems in the context of global issues (CSDH 2008; WHO 2008). From this foundation, policy-makers can then assess the impact of action and inaction on community health in terms of the principles of PHC: accessible health care, appropriate technology, health promotion and health education, cultural sensitivity and cultural safety, intersectoral collaboration, and community participation.
Policy action at the national level: think global, act local
As health professionals, we can be conscious and concerned about global issues and the failure of the global community to create equity. But this can also add to the ‘change fatigue’ that plagues many of us who are concerned about communities throughout the world. What we can do, is act on a local level to encourage community participation in the policy arena, and ensure that our knowledge and skills are used to the community’s advantage. As nurses and midwives, our participation in all policy areas is invaluable. In Australia, the National Review of Maternity Services mentioned in Chapter 6 (Commonwealth of Australia 2009a) is a good example of a national policy development that has relied heavily on input from nurses and midwives. The Australian Research Alliance for Children & Youth Declaration and Call to Action (see Appendix F) has had significant input from many nurses and midwives throughout the country (Australian Research Alliance for Children and Youth [ARACY] 2009). The Te Rito Family Violence Intervention Strategy in New Zealand relied heavily on input from nurses and other health professionals prior to, and during development. Wide consultation was also undertaken with Maori and Pacific Island people to ensure development of the policy was culturally safe.
Policies governing adult health such as the anti-tobacco strategies, national chronic disease strategies, falls prevention, healthy ageing, rural health, social inclusion and mental health have also been developed with input from nurses in Australia and New Zealand (Australian Nursing Federation [ANF] 2009; Francis et al 2008). Although each of these policy initiatives has invited comment from members of the public, in some cases, a lack of health literacy has prevented people from responding. Some people may be reluctant to participate in technical policy discussions, or they may have felt that their views have not been considered in the past, or that an invitation is simply tokenism (Bruni et al 2008). This suggests an important role for nurses and midwives in helping community members become aware of the issues involved, and assisting them in putting forward their views.
A number of national policy areas currently under review would be incomplete without the perspectives of the nursing and midwifery professions. These include: the proposed Australian Women’s Health Policy and the Male Health Policy; Indigenous Health Policy; the Intergenerational Strategy to address workplace and investment strategies for younger and older workers; Education policies; Healthy Ageing Policy; the National Drug Strategy; Quality Use of Medicines; and the National Mental Health Strategy. Each of these offers important opportunities to participate in policy development, which is integral to the role of nurses and midwives as part of our social contract with society to promote health and social justice (Fawcett & Russell 2001). Equally as important is the need for nurses and midwives to ensure that policies are framed within a caring discourse, especially those that have been developed with an emphasis on economics and the market.
ACTION POINT
Nurses and midwives must actively participate in all policy areas from consultation and development to evaluation.
The need for policy integration: lessons from mental health
Mental health is among the most significant policy areas for all countries of the world. In most countries, the incidence of mental illness has steadily increased over the past 30 years, while government funding has continued to decline (World Health Organization, 2009 and World Health Organization, 2010). In 2008, the WHO launched a global action program, the ‘Mental Health Gap Action Program’ (mhGAP) to forge strategic partnerships that would enhance countries’ efforts to combat stigma, reduce the burden of mental disorders, and promote mental health (WHO 2010). The mhGAP program and other WHO initiatives are based on the notion that ‘there is no health without mental health’ (WHO 2010).
The policy change that has had the most powerful effect on mental health is that of deinstitutionalisation, wherein from the 1970s, mentally ill patients were shifted from psychiatric hospitals to be treated in their communities. Since this change occurred, the onus has been placed on families and community support systems to care for those with mental illness. However, without the provision of sufficient support services, many families caring for their loved ones have experienced enormous difficulties in the burden of care. In Australia and New Zealand, mental health support services are provided by a range of agencies, with heavy reliance on community mental health nurses or psychiatric nurses working as part of a team (see Chapter 4). This system is intended to provide families with specialist services and emergency responses when there are mental health crises, but major shortages of mental health specialists have meant that these services are unreliable, especially in rural areas. Even those without the need for crisis care suffer from a lack of guidance and support services in the community.
Point to ponderMental health is one of the most significant health policy areas. There is a growing need for new emphasis on mental health prevention strategies to guide health professionals to work effectively with those experiencing mental health issues.
Another important aspect of mental health policy is the need for guidance on preventative strategies. The mental health policy environment has thus far been directed towards mental illness, but the need for health promotion policies that respond to the SDOH is acute. Raphael (2009) explains that, compared with other kinds of health promotion, there is less infiltration of mental health promotion into government and public health-related documents. Although his comments refer to the Canadian situation, it is similar to the policy environments of Australia and New Zealand. The omission of mental health in the SDOH discourse is important, as mental health is seen as a mediating force between the SDOH and physical health. This primarily involves mental states associated with exposure to adverse living conditions and psychosocial stress, which can cause maladaptive biological responses, weaken immune systems, and create a greater likelihood of metabolic disorders (Raphael 2009). Responses to inequalities, such as feelings of shame, worthlessness, and envy, also have psycho–biological effects on health, precipitating coping behaviours such as over-spending, over-eating, use of alcohol and tobacco, or a range of other social behaviours that threaten health (Raphael 2009).
Good mental health policies should guide appropriate service provision for those needing help, but they should also work toward decreasing vulnerability by helping people develop coping skills. In response to the SDOH, such policies attempt to reduce people’s exposure to negative conditions; for example, by providing educational and recreational opportunities as community entitlements. Mental health policies should also provide employment and job security, social assistance for those in need, and balance universal and identified needs, again, through comprehensive and selective PHC (Raphael 2009). This illustrates the integrated nature of mental health and other policies.
Social policies and family life
Many policies have a cascade effect that can permeate family and community life; for example, policies governing child care. For parents who are both in the workplace, child care is a major source of stress. Family leave policies that provide income replacement and incentives for parents to take leave can help alleviate the stress of parenting. Although New Zealand has provision for 14 weeks of paid parental leave, Australia, like the United States, does not have a paid leave policy for parents (Brennan 2007). Instead, current policies see the male partner spending longer hours at work to cover family expenses when a mother chooses to stay at home. This leaves the child deprived of the father’s time, and the mother having to be the constant parent. For some women, the lack of respite can undermine their mental health, adding to the vulnerability of new parenthood. For both parents, economic hardship also compromises their mental health, and sometimes has an effect on physical health. In combination, these factors can also be a
Point to ponderIt is vital to maintain a ‘big picture’, intergenerational, ecological perspective in policy-making.
The policy on paid leave for child care is only one example of how important it is to maintain a big picture, intergenerational, ecological perspective in policy-making. Another example lies in the inter-relatedness of government policies to encourage child bearing, fair employment, productivity, retirement and superannuation. In 2010, Australian policy-makers realised that, after a decade of policy-driven cash incentives for young Australian couples to boost the fertility rate, there is a virtual baby boom occurring throughout the country. It was expected that providing cash grants to young couples to have a child would result in a modest change to the fertility rate. The idea was that by increasing the fertility rate, the children would become active in the workplace just when their tax contributions were most needed; that is, when they could support the growing number of retirees, who would be withdrawing their superannuation investments.
In Australia, the intergenerational view of family leave policies was seen as appropriate to solve the dual problems of declining infertility and population ageing, while maintaining productivity. However, so many couples have taken advantage of the scheme, that there is a drain on government funds (to pay the child bonus). One option being considered by the government to rebalance the situation, is a policy to encourage older people not to retire, but to undertake part-time employment, so they can continue to contribute to the government superannuation scheme, rather than drain existing resources. Retirees are naturally concerned, and plan on watching the policy debate closely. Othersare concerned at moves towards increasing the popu‑lation, and therefore productivity, either through further incentives to lift the fertility rate, or by increasing the number of migrants. On the other side of these arguments, is the need for sustainability of the environment and its infrastructure. This is a classic policy debate illustrating the fact that everything is indeed, connected to everything else.
What’s your opinion?Will increasing the fertility rate now have the intended consequences? What are some of the advantages and disadvantages of this policy?
Australian mental health policy
Australia’s Mental Health Strategy has undergone numerous transformations from its inception in the 1970s. At that time, government authorities had assumed responsibility for those with mental illness, but with deinstitutionalisation, this responsibility was devolved to families (Henderson 2005). The expectation of deinstitutionalisation was, that by integrating those with mental illness into the community, they would receive more humane, individualised and culturally appropriate care. This was seen to be more empowering, and equated mental ill health with physical ill health in terms of treatment options. However, the lack of a national approach to mental health care and prevention inspired a second Mental Health Strategy in 1992 (Department of Health and Ageing [DoHA] 2010a). This was aimed at strengthening mental health reform, and developing a national approach that would include input by the states and territories to prioritise mental health issues. Importantly, a centrepiece of the strategy was to establish advisory committees throughout the country, to foster community input on mental health.
The goals of the Mental Health Strategy were admirable, but one of the problems was that it was written in the language of the market, and, typical of the 1980s thinking on health, polarised people as ‘consumers’ or ‘providers’ of health care. This type of language illustrated how commodified health had become, with policy-makers valuing the input of market forces and competition for services. Like many other commodities, services became fragmented, and dominated by medical specialists. The policy also created a moral imperative for families to care for the mentally ill in this context, which undermined their autonomy in planning care (Henderson 2005).
Despite its shortcomings, the emphasis of the 1992 strategy on cooperation between different government levels has been widely accepted. The newer policy has aimed to increase health literacy, including the development of programs to promote mental health in schools. It is also intended to address the stigma of mental health, by reversing negative media images and reports of those with mental illness, developing community advocacy for those with mental illness, supporting global initiatives such as World Mental Health Day, and enhancing relationships between mental health professionals, carers, and those with mental health needs (DoHA 2010a). It is an imperfect system, but working towards a slightly more preventative orientation than in the past.
Point to ponderAustralian mental health policy is slowly moving towards a preventative orientation.
New Zealand mental health policy
New Zealand’s history of mental health policy is not dissimilar to that of Australia. Deinstitutionalisation, responsibility for care placed on family members, and commodification of health care with business models and language, have all been similar features. In 1994, the first New Zealand Mental Health Strategy was released. This was followed in 1998, by publication of the Blueprint for Mental Health Services in New Zealand (Mental Health Commission 1998). The Blueprint described the mental health service developments required for implementation of the 1994 Mental Health Strategy, setting the scene for incorporation of mental health as a priority area in health policy. Mental health as a priority health area for the government was subsequently reflected in the New Zealand Health Strategy (Minister of Health 2000), New Zealand Disability Strategy (MOHNZ 2001b) and the New Zealand Primary Health Care Strategy (King 2001). Although a number of areas for development outlined in the Mental Health Strategy and subsequent blueprint are still to be implemented, progress has been made in many areas — in particular, a focus on models of recovery has been a defining feature of current New Zealand mental health services.
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