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Health: missed opportunities in narrow budget focus

The health sector is reporting only on a very limited portion of the budget, rather than approaching all policies through the lens of health. Is this the right approach?

What will the federal budget mean for our health? For all the thousands of words written on this (and Crikey’s Croakey blog has contributed its share), the question cannot be properly answered. Many of the budget’s health impacts will result from measures outside the health portfolio, yet we in the media seem strangely happy to follow the government’s lead in reporting on health as if we were a product of the Health Department.

If we are to develop some real understanding of the budget’s implications for health, it would help enormously if someone (the government, researchers, media, the informed citizenry?) could do a health impact assessment. This is a tool for evaluating the positive and negative consequences for health of policies across sectors, as well as identifying unintended consequences. HIAs also consider whether policies impact differently on the health of different groups, and whether they will exacerbate or reduce health inequalities.

Instead of focusing narrowly on changes to Medicare rebates (which is what the Australian Medical Association and others would like us to do), we might look at the health impacts of broader economic policy (see, for example, a recent article in The Lancet investigating the toll of austerity policies in Europe).

We would also talk more about the health impacts of the Gonski school reforms, DisabilityCare (formerly the National Disability Insurance Scheme) and the National Broadband Network — all initiatives highlighted in the National Rural Health Alliance’s budget statement as important for addressing health and health inequalities. The NRHA said:

If rural schools can be funded according to educational need it should be possible to equalise educational outcomes in rural areas, making a contribution to greater city-country equity in employment, income and health. The NBN is a long-term and high cost project which, when fully delivered, will improve health and wellbeing (including through enhanced business opportunities) for people everywhere and give the same chances in a digital world for people in remote, rural and city areas.”

It is telling that when I asked Croakey contributors recently for the most important thing the government could do in the budget to improve population health, there was strong support for a “health in all policies” approach (which can be promoted by the use of HIAs). Other suggestions included:

  • For the long term, address climate change by removing the subsidies on the use of fossil fuels.” (A/Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW)
  • Sort out the shambolic alcohol tax system — especially abolishing the wine equalisation tax that enables wine to be sold cheaper than bottled water. Again reduces harms, protects the vulnerable, raises money for other health and social priorities.” (Professor Mike Daube, Public Health Advocacy Institute WA)
  • Increase taxation.” (Dr Greg Stewart, president-elect, Australasian Faculty of Public Health Medicine)
  • Increasing social benefits for unemployed people and single parents.” (Gail O’Donnell and Lyn Morgain, Healthwest Partnership).

I particularly liked a suggestion from Luke van der Beeke, managing director of Marketing for Change, for health-based key performance indicators to be introduced for all portfolios. He says this would help stop departments working in silos and promote health in all policies.

Perhaps it may even encourage the Department of Health and Ageing to focus on the critical public health issue of climate change. It is striking the issue doesn’t rate a mention in budget papers for the department’s outcomes of “population health” and “biosecurity and emergency response”.

Some of the interesting health budget news that is unlikely to generate large headlines include safety and quality initiatives to reduce unnecessary clinical variation in the use of blood products, and to reduce unnecessary radiation exposure from diagnostic imaging. And a national antimicrobial resistance prevention and containment strategy will co-ordinate efforts across human and animal health. It will include expanded surveillance of AMR and antibiotic usage, and antimicrobial stewardship programs for primary healthcare, residential aged-care facilities and hospitals.

We are also going to get an Annual Atlas identifying unwarranted variation in clinical practice — perhaps something like the Atlas of HealthCare Variation in NZ, which highlights variations by geographic area in the provision and use of specific health services and health outcomes.

Another one to watch are reviews of Medicare benefits schedule items to “ensure that items listed on the MBS remain clinically relevant and consistent with best practice”. Sixteen reviews are now underway, and a further two reviews of specialty items are planned. The aim is to identify areas for disinvestment from low value or ineffective or dated care. The question is whether the government and department will have the spine to take on the powerful medical interests.

Which is another pointer for why health in all policies is a helpful approach: it can help focus us on what is best for the community’s health rather than for the powerful lobby groups.

For those who think it idealistic pie-in-the-sky to ask for an HIA-informed approach to government budget reporting, take a look to Tasmania. Last August, the Social Determinants of Health Advocacy Network in Tasmania did its own HIA to consider the broader health impacts of the state budget (it’s not available online, but let me know if you’d like a copy). It said the analysis should be seen as a “preliminary demonstration project” and urged the state government to adopt the approach in preparing and announcing its budget in future.

Sounds like good advice for the Feds as well.

2
  • 1
    Margo
    Posted Wednesday, 15 May 2013 at 1:41 pm | Permalink

    Hopefully, in terms of HIAs, we will learn more from the South Australian experience (http://www.flinders.edu.au/medicine/sites/sachru/research-evaluation/hiap/) — but, as with all of these things, the challenge will be in disentangling the extent to which its various benefits and disappointments relate directly to the idea or to its implementation.

  • 2
    Fran Baum
    Posted Wednesday, 15 May 2013 at 2:00 pm | Permalink

    Excellent comments Melissa. Next month the WHO is hosting the 8th Global Conference on Health Promotion http://www.who.int/healthpromotion/conferences/8gchp/en/ which is on the theme of “Health in All Polices” (HiAP). I will be attended and addressing the conference about the evaluation of the The South Australian government HiAP approach. It would be great if the Federal government could follow suit with a HiAP initiative. The Senate Community Affairs Reference Committee recommended in its March report on “Australia’s domestic response to the WHO’s Commission on the Social Determinants of Health” that social determinants should be considered in all relevant policy development activities particularly in relation to education, employment, housing, family and social security policy. I would add that trade policy is equally important.
    HiAP is important in stressing that government is not just about surpluses and busgets but about ensuring a better quality of life for all of us.

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