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Health Policy in the Market State
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Health Policy in the Market State
edited by Linda Hancock
ALLEN & UNWIN
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For Nina and Ted, in thanks for their social justice dialogue and for Catherine and Lucy, the new generation
Copyright © this collection Linda Hancock 1999 Copyright © individual chapters remains with their authors All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without prior permission in writing from the publisher. First published in 1999 by Allen & Unwin 9 Atchison Street St Leonards NSW 1590 Australia Phone: (61 2) 8425 0100 Fax: (61 2) 9906 2218 E-mail:
[email protected] Web: http://www.allen-unwin.com.au National Library of Australia Cataloguing-in-Publication entry: Health policy in the market state. Bibliography. Includes index. ISBN 1 86448 724 0. 1. Public health—Australia. 2. Medical policy—Australia I. Hancock, Linda. II. Title. 362.10994 Set in 10/13pt Sabon by DOCUPRO, Sydney Printed by South Wind Production Ltd, Singapore 10 9 8 7 6 5 4 3 2 1
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Foreword ANNA COOTE FOREWORD
How can we best deliver health and health care in the 21st century? That is the central question addressed in these pages—a question that urgently confronts governments, academics, health professionals and ordinary citizens across the world. In Australia and New Zealand, as in the UK and most other European countries, these questions have assumed an urgency at the turn of the century. There are many complex and interrelated reasons why this is so, but two are overarching. The first is that health care costs are rising and populations are aging, giving rise to worries that national economies will be unable to take the strain of running health care systems as a public concern. The second is that governments have been busy marketising public service delivery—introducing new dynamics into health care and new soul-searching into the policymaking arena. Not all countries have travelled at the same pace, and to a certain extent we have been able to learn from each other. In the 1980s many looked to the USA for inspiration, wanting to find ways of turning rather sleepy and inflexible public services into more energetic, cost-effective systems. Trying to run health care as a business became intensely fashionable. It still is in some quarters. However, this fashion, like all others, is transient. The task now is to learn and act accordingly. What is valuable about the ‘market experience’? v
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What is worth keeping and what should be jettisoned? And what are the big issues for health policy in the coming decades? The arrival of a Labour government with a massive electoral majority in the UK in 1997, following a prolonged bout of freemarket Conservatism, has provided a useful perspective. Margaret Thatcher introduced an ‘internal market’ into the National Health Service and Tony Blair entered government with a pledge to abolish it. Policy analysts have been able to draw on practical experience of market rules in action, in a political and intellectual climate that is favourable to alternatives, as long as these are forward- rather than backward-looking. There is now broad agreement that it is useful to separate purchasing and providing functions; to specify goals, plan work to meet them and measure performance accordingly; to design services that respond to the needs of the user; and to weed out inefficiencies and unnecessary ‘red tape’. These can be seen as positive lessons from the quasi-market experience. On the negative side, market rules have been seen to generate heavy transactional costs which were not justified by results. Attempts to treat the patient as ‘customer’ laid bare the dangers of overlooking the wider interests of citizens, including those not currently needing or using health services. That is because resources that are finite must be deployed to the benefit of society as a whole, not just to meet the immediate demands of individuals. Competition between providers could not be relied on to drive up quality or efficiency, and was often counterproductive. Attempts to introduce private finance were also fraught with difficulties, as potential shortterm benefits were found to be outweighed by the longer-term costs, and private investors were reluctant to carry the necessary risks. The greatest casualty of the market experiment has been the damage done to the ethos of the service and the morale of staff. It is one thing to give your life and soul to an organisation devoted to the public good, and quite another to find yourself forced to work increasingly hard to satisfy the accountants. It is too early to tell how permanent the damage is. It was, undoubtedly, a grave mistake to push through sweeping changes based on untried and untested ideas. The Conservative government left the health service exhausted and demoralised by vi
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what seemed like an unrelenting revolution. It warned us to appreciate the value of stability. In what may now be called the post-market era, health policy is being shaped by a new configuration of ideas built on the positive and negative lessons of the past decade. There is a renewed commitment to the public health agenda, as policy-makers face the absurdity of spending more and more on curing illness while doing little to prevent it. In place of competition, collaborative partnerships between health authorities and a range of local agencies are now considered the key to planning and developing services that deliver better health as well as better health care. The balance of power between the primary and acute sectors has shifted, probably irreversibly towards the former, with family doctors acquiring a new role in planning as well as commissioning health services at a local level. There is an unprecedented level of interest in public involvement—drawing patients and citizens into decisions about how resources are allocated and how services are shaped. There is greater caution about introducing structural change and more enthusiasm for careful local piloting of new ideas. The drive towards ‘evidencebased medicine’ continues, with all its attendant difficulties, as incentives to avoid waste grow ever stronger. Ideas about management are being revised. Heavily recruited to run the new market, managers were obvious scapegoats when the weaknesses of the system were revealed. Before long, politicians on all sides were calling for resources to be switched from ‘grey suits to white coats’. As the dust settles, there is growing recognition that what the health service needs is not less but more appropriate management. Health care is being transformed by genetic science, information technology and pharmaceutical developments, as well as by the attitudes of an increasingly demanding and discriminating public. A major challenge for all health care systems in the future will be to develop and embed new managerial capacities. These must be geared to the objectives of the post-market era and able to cope with a future whose only certainty is that everything will go on changing very rapidly indeed. At the time of writing Anna Coote is specialist adviser to the Ministers for Women in the UK government, and deputy director of the Institute for Public Policy Research, London. vii
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Contents CONTENTS
Acknowledgments Contributors Tables Abbreviations 1
I 2 3
II 4 5
6
x xi xvi xvii
RIGHTS AND MARKETS: WHAT MAKES SUSTAINABLE HEALTH POLICY? Linda Hancock ANALYSING HEALTH POLICY POLICY, POWER AND INTERESTS Linda Hancock HEALTH, PUBLIC SECTOR RESTRUCTURING AND THE MARKET STATE Linda Hancock
1 17 19
48
FINANCING HEALTH 69 COMMONWEALTH/STATE RELATIONS IN HEALTH 71 Stephen Duckett HEALTH CARE FUNDING AND RATIONING HEALTH CARE 87 Linda Hancock and Paul Mackey CONSUMER PAYMENTS FOR HEALTH CARE 113 Sophie Hill viii
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CONTENTS
III MARKET STATE REFORM AGENDAS 7 CASEMIX: FINANCING HOSPITAL SERVICES Mary Draper 8 CONTRACTING OUT IN THE HEALTH SECTOR Michael Muetzelfeldt 9 SHIFTS IN COMMUNITY HEALTH CARE Janine Smith IV CATERING FOR THE DIVERSITY OF HEALTH CARE NEEDS AND INTERESTS 10 PERFORMANCE INDICATORS FOR ABORIGINAL HEALTH SERVICES Ian Anderson and Maggie Brady 11 WOMEN’S HEALTH IN A CHANGING STATE Philomena Horsley, Sonya Tremellen and Linda Hancock 12 HEALTH INDICATORS FOR DIVERSITY Liz Eckermann 13 SHIFTS IN MENTAL HEALTH POLICY Beth Wilson 14 CARING AND THE STATE Linda Hancock and Sharon Moore Notes References Index
129 131 149 169
185 187 210 229 247 265 288 297 335
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Acknowledgments ACKNOWLEDGMENTS
Thanks to all the contributors to this volume for their commitment to the book, over time, in an increasingly volatile economic and political climate and for their passion and concern about shifts in governance and the potential for better health outcomes. In so far as my own contributions are concerned, thanks to the colleagues and students upon whom I tested ideas and thanks to my colleague and former Minister for Health, Professorial Associate Brian Howe, for his insights and visions and to Deakin University and Melbourne University for their support of the project. Thanks to Elizabeth Weiss at Allen and Unwin for responding so positively to the idea that health is important in its own right and central to broader considerations of power and interests in social policy and for shepherding the book through the publishing process. Thanks also to Emma Cotter for her patience, thoroughness and forbearance as editor, in bringing the book to fruition. Linda Hancock
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Contributors CONTRIBUTORS
Ian Anderson trained as a doctor at the University of Melbourne, and published a book, Koorie Health in Koorie Hands (1988) while still a medical student. He has worked as the Chief Executive Officer of the Victorian Aboriginal Medical Service, and since October 1996 as a Medical Adviser to the Office of Aboriginal and Torres Strait Islander Health Services in the Commonwealth Department of Health and Family Services. He is also undertaking postgraduate studies in Sociology. Maggie Brady is a social anthropologist. Her work has included studies of lifestyle and risk assessment associated with the Maralinga region, petrol inhalation and health issues among remote Aboriginal youth, and alcohol misuse and recovery in a variety of Aboriginal populations. She has published several books including a study of petrol sniffing, Heavy Metal (Aboriginal Studies Press 1992) and a collection of personal accounts of indigenous peoples’ drinking careers, Giving Away the Frog (Drug Offensive, 1995). She is currently a Visiting Research Fellow at the Australian Institute of Aboriginal and Torres Strait Islander Studies. Mary Draper, formerly a Senior Lecturer in the Department of Social Science and Social Work at the Royal Melbourne Institute of Technology, now works for the Victorian Government Department of xi
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Human Services. Her publications include: Involving Consumers in Improving Hospital Care: Lessons From Australian Hospitals; with Tony Dalton, Wendy Weeks, and John Wiseman, Making Social Policy in Australia; with Sophie Hill, The Role of Patient Satisfaction Surveys in a National Approach to Hospital Quality Management; for the Health Issues Centre, Casemix, Quality and Consumers. She has been a member of the ACOSS Board and is currently on the Board of the Australian Institute of Health and Welfare. She has represented the Consumer Health Forum on a range of quality related committees, including the Taskforce on Quality in Australian Health Care. Stephen Duckett is Professor of Health Policy and Dean of the Faculty of Health Sciences at La Trobe University. From 1994 to March 1996 he was Secretary of the Commonwealth Department of Human Services and Health. From 1983 to 1993, Professor Duckett held various operational and policy positions in the Victorian Department of Health and Community Services and its predecessors, including Director of Acute Health Services, in which position he was responsible for designing and implementing Victoria’s casemix funding policy. His most recent monograph is Health Care in the U.S.: What Lessons for Australia? published in 1997 in the Australian Centre for American Studies’ Comparative Studies Series. He has also published numerous articles and book chapters on aspects of Australian health policy. Liz Eckermann is Co-director of the Centre for the Body and Society and Senior Lecturer in Sociology at Deakin University. She is also adviser and consultant on women, health and development for the Western Pacific Regional Office (WPRO) of WHO. Recent relevant publications include: Women’s Experiences of Aging in the Western Pacific Rggion: A Diversity of Challenges and Opportunities Volume 2, Women’s Health Series, WHO, WPRO, Manila, 1995; Lifestyle Changes and Their Impact on the Health of Women in the Western Pacific Region Volume 5, Women’s Health Series, WHO, WPRO, Manila, 1995; with R. Raj-Hashim, Women’s Health in a Social Context in the Western Pacific Region, Manila, WHO, WPRO, 1997. xii
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Linda Hancock, formerly Director of the Public Policy Postgraduate Program at Deakin University teaches at the Centre for Public Policy at the University of Melbourne. She was a Commissioner on the Law Reform Commission of Victoria from 1984–88 and was a Presiding Member on the Social Security Appeals Tribunal from 1988–90. She has undertaken policy consultancies for government, including Defensive Medicine and Informed Consent (1993), for the Commonwealth government’s Review of Professional Indemnity Arrangements for Health Care Professionals and has published numerous articles and chapters for books; most recently on the implications of the restructuring State for women’s health and justice policy. She is editor of the forthcoming book Women, Public Policy and the State, Macmillan, and, as President of the Contemporary European Studies Association has a keen interest in European policy issues. Sophie Hill, previously the Coordinator of Health Issues Centre, is a postgraduate student at La Trobe University. She has a MA (Health Studies) and a BA (Hons). In her PhD thesis, she is examining performance indicators for health services, in particular, consumers’ judgements on quality of care. She has worked for several years as a freelance researcher, in the areas of consumers’ judgements of care, research methods in public health, people’s knowledge of stroke prevention and telemedicine. Philomena Horsley has worked in the women’s health and sexual health area for twenty years. She was a co-founder of the Women’s Health Resource Collective in 1983 and subsequently worked as a state-wide education officer at both Family Planning Victoria and Healthsharing Women in the areas of intellectual disability and women’s health. She is a professional writer and editor and her publications include Feeling Good—A self-esteem model, Sexuality— rights and choices, ‘So you won’t get AIDS’ and numerous health articles for mainstream journals, magazines and the gay press. She is the Coordinator of Positive Women Victoria, the organisation representing women living with HIV/AIDS. Paul Mackey is the health specialist in the Information and Research Service of the Commonwealth Parliamentary Library where he provides analysis and advice on health policy and related issues to xiii
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Members, Senators and their staff. His interests include Commonwealth–State health issues, health financing and the rationing of health care services. Recent publications include papers on Medicare and private health insurance, the Medicare levy and women’s health. Sharon Moore lectures at RMIT in the School of Management in the Business Faculty and has a social science/social work background. Her research focuses on health and community care policies and programs; in particular, gender and contractualism, health and human services and the impact of change on managers, workers and users of services. She is the President of the Carers Association of Victoria and Australia; a member of the Australian Disability Council and a parent of four children, including two foster children with special needs. Two recently completed reports include: The Development of Hospital in the Home and The Impact of CCT [Compulsory Competitive Tendering] on Human Services in Local Government. Michael Muetzelfeldt is Director of the Centre for Citizenship and Human Rights, Deakin University. His research and publications are concerned with power, citizenship and organisational change, with an emphasis on the effects on citizenship of the introduction of managerialism and contractualism in Australian public management. His publications include Society State and Politics in Australia, Pluto Press, 1992. Janine Smith (PhD) is a lecturer in nursing at the University of Ballarat and has been a practitioner and lecturer in community health for a period spanning 24 years. Her Deakin University doctoral thesis analysed the effect of health policy trends on the role and practice of generalist community nurses in Victoria. She has published numerous papers and chapters in books. Sonya Tremellen worked for Women’s Health Victoria for four years in publishing and research. She has edited Healthsharing Women, the award-winning book Customer Satisfaction—Cultural Hurdles: marketing health services to women of non-English speaking backgrounds and Scarlet Woman magazine. Her research and policy interests include issues for family survivors of homicide, and lesbian health. She was an organiser of the Second National Lesbian, Gay, xiv
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Transgender and Bisexual Health Conference, 1998. She currently works with the Northern Division of General Practice, Melbourne. Beth Wilson is the Health Services Commissioner (health ombudsman) in Victoria. The Commissioner receives and resolves complaints from consumers of health services about health service providers with a view to improving the quality of health services for all. Prior to becoming the Commissioner, Beth was the President of the Mental Health Review Board. She is a lawyer by training, specialising in medico/legal issues and has an interest in law, medicine and ethics. Her publications include ‘Psychosurgery: ethical and legal issues’ Journal of Law and Medicine vol. 4, no. 1, pp. 21–59.
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Tables TABLES
2.1 4.1 6.1
Pluralist and structuralist approaches to power Total recurrent expenditure for health care in Australia, 1995/96 Major categories of private health expenditure, by area of expenditure, 1995/96
32 72 116
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Abbreviations ABBREVIATIONS
AHMAC AIHW ATSIC AHS CDHFS CAH CCT DAA DALYs DHSH DRGs FMII FMIP FOI HACC HMOs HREOC HRSCAA MII
Australian Health Ministers Advisory Committee Australian Institute for Health and Welfare Aboriginal and Torres Strait Islander Commission Aboriginal Health Services Commonwealth Department of Health and Family Services Council for Aboriginal Health Compulsory Competitive Tendering Department of Aboriginal Affairs Disability-adjusted life years Department of Human Services and Health diagnosis-related groups Financial Management Improvement Initiatives Financial Management Improvement Program Freedom of Information Home and Community Care Health Maintenance Organisations Human Rights and Equal Opportunity Commission House of Representatives Standing Committee on Aboriginal Affairs Management Improvement Initiative
xvii
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NACCHO NAHS NAIHO NCA NH&MRC NPH NWPH OATSIHS PPOs QALYs QOL STD WHO
National Aboriginal Community Controlled Health Organisation National Aboriginal Health Strategy National Aboriginal and Islander Health Organisation National Commission of Audit National Health and Medical Research Council New Public Health National Women’s Health Policy Office of Aboriginal and Torres Strait Islander Health Services Preferred Provider Organisations Quality-adjusted life years Quality of life Sexually Transmitted Disease World Health Organisation
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1
Rights and markets: What makes sustainable health policy? LINDA HANCOCK HEALTH POLICY IN THE MARKET STATE WHAT MAKES SUSTAINABLE HEALTH POLICY?
This book seeks to locate current health policy issues within the broader context of shifts in government policy and public sector restructuring. It thus places health policy analysis within the changing State and the issues of citizenship and rights this inevitably raises. Economic rationalism has become the dominant policy paradigm in the late 1990s—underlying continuing economic and managerialist reforms begun in the 1980s. There has bgen a shift from the postwar welfare state, which evolved into the wage-earners’ welfare state of the 1980s and into the market or neoliberal state of the late 1990s. In health, this is epitomised by the creation of quasi or false markets and the ‘marketisation’ of health services, under policies of competition, contractualism and privatisation. While governments struggle to balance political survival with a response to economic imperatives, profound changes are taking place in areas central to citizens’ welfare. The welfare state was criticised in the 1980s for its inefficiencies, mistargeted services, overspending, its capture by bloated public bureaucracies and poor response to specific needs (articulated b{ feminist, ethnic rights and consumer movements). In countries like Australia, New Zealand and Britain, it has been undergoing a transformation into what is referred to in this book as the ‘market state’. To a large extent, the analyses, debates and concerns raised in 1
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relation to health are applicable to other areas such as housing, education, community services and social security, conceived here as rights or entitlements rather than merit goods. These areas are commonly identified as integral to participatory democracy, in systems where taxation is used redistributively to ensure basic living standards, dignity and access to basic social services. However, as Easton (1997: 165) notes, health reaches further than the welfare safety-net: ‘Health is the part of the Welfare State which most touches everyone, including the articulate middle class and the swinging voter’. With growing demands on health budgets governments have instituted sweeping changes, as part of broader market-focused reform agendas associated with neoliberal or new right political agendas (King 1987; Marginson 1997; Williamson 1993). Across national boundaries, between governments of similar political persuasion, there has been much borrowing of ideas, specific reform models and programs, and consultants to implement them (Strange 1996). The internationalisation of neoliberal reform agendas is evident, although the major focus in this volume is on shift and change in health policy in Australia. A number of examples focus on the state of Victoria as the Australian epitome of the ‘market state’. Given the breadth and pace of changes since the election of the Kennett government in 1992, this is the direction in which other states following similar agendas are headed. Moreover, Victorian privatisation models are being promoted to developing countries by conservative think tanks—often without measured assessment or proper evaluation of longer-term impacts or cultural relevance. With such dramatic shifts in health policy, both at federal and state/territory levels in Australia, critics perceive profound shifts in governance and the relationship between the State and the individual, with the State as contractor and the citizen redefined as consumer or customer. These trends, however, are not confined to Australia, and various contributors draw on overseas examples and research. While this book focuses on selected areas of health policy, the chief aim has been to highlight the analysis of key shifts in policy and governance and to raise questions about the future direction and impact of health policy. 2
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A number of trends in health policy can be drawn from the book as a whole. Principal among these are trends towards:
• the individualisation of risk and responsibility—where increased
•
• •
•
•
•
service user cost-sharing or co-payments shift systems from a redistributive model based on taxation-funded universal access to a system based on the individual’s ability to pay; where individual responsibility replaces recognition of the structural effects of poverty, unemployment and disadvantage on health status; narrow budget accountability—with shifts in risk management and accountability under contractualism, and privatisation. The trend is away from broader ‘public interest accountability’ towards a narrowed form of quantitative ‘budget accountability’, thus blurring and transforming the accountability of government to its citizens; short-termism—whereby costs, risks and benefits are assessed in the immediate future, rather than the longer-term; bucket funding—where broad-banded funding, justified on the grounds of devolution and local flexibility, threaten to undermine centralised policy development of smaller national programs (such as women’s health), monitoring, accountability and services that cater equitably for disadvantage and diversity of need; the loss of program or service integrity, quality, and ‘time to care’—with the preoccupation with new managerialist techniques: cost savings, output measures, and usually quantitative performance measurement; capture by the acute sector—where programs such as community and women’s health, already marginal to the acute care sector, are being transformed and absorbed into acute care, relocated within the community, and environmental, occupational, social, preventive and public health agendas are marginalised; and the dominance of market values and economic efficiency—at the expense of other important values such as access, social equity (according to gender, race/ethnicity, age and disability), quality of care, catering for diversity of need, longer-term sustainability and democratic participation in an open and accountable system.
Such shifts raise questions about the nature of public responsibility, the role of public policy, the role of government and the State in 3
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relation to health, and the future wellbeing of citizens into the millennium. Australia has a valued and well-respected health care system, with access to free medical and public hospital care under income taxfunded Medicare. It is a complex system involving both public and private sectors, about two-thirds government-funded, involving all tiers of government, with powerful public and private interests. It could easily change form if, for example, physician bulk-billing of medical service rebates provided under Medicare were to bg discontinued, if health service-users’ co-payments for services were to be raised to the point of widespread inequity, or if private insurance were to be instituted as a replacement for universalistic health insurance under Medicare. A strong message from the contributors to this book is that present reforms based on managerialism and the marketisation of health have the potential to undermine valued aspects of the Australian health care delivery system. A number of policy initiatives have been introduced from the 1980s onwards in an attempt to address specific policy concerns and to provide broad frameworks for a more efficient and more equitable health system. Principal among these are the Better Health Commission (1986), Community Health Policy, National Health Goals and Targets (Health for All, 1988), and initiatives introduced under Labor’s National Health Strategy (including the Rural Health Strategy, National Mental Health Strategy and National Women’s Health Policy, 1989). Policy initiatives in single-issue areas include AIDS policy, men’s health, drugs, immunisation, domestic violence, child health, screening programs, health promotion, addiction, and Aboriginal health and nutrition. Initiatives under the National Health Strategy could be said to have approached health policy from the perspective of ‘health gain’ conceptualised as improvements in health status for groups and populations, as opposed to individual gain from specific treatment (drawing on the distinction made by Coote & Hunter 1996: 11). At the federal level, National Competition Policy and the application of the Trade Practices Act to the health industry underlie the shift to ‘managed competition’ in health, under policies such as ‘casemix’. Declining private health insurance coverage has pushed COAG (the Council of Australian Governments) to renegotiate 4
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Commonwealth/state relations on Medicare and health funding. These policies are to some extent the ‘big lever’ issues in health, which determine other policy tensions at the ‘business-as-usual’ level. Despite the main positive aspects of the health system in Australia, concern is raised in various chapters about policies of managed competition, outsourcing and privatisation of clinical and non-clinical services, broadbanding of Commonwealth funding to the states, more strictly targeted services, and increasing consumer co-payments. To see these reforms as part of the market state is to locate them in an ideological context. (The shift to the market state is discussed in more detail in chapter 3.) This book aims:
• to equip readers with an understanding of the broader government policy, public sector restructuring policy context, the ‘marketisation of health’ and the impact of shifts to a market state; • to equip students and health policy analysts with concepts, frameworks and analyses that will assist their understanding of key issues in health policy development and implementation in a climate of rapid and penetrating change; • to provide analysis of trends in key issues in health policy; and • to provide a checklist for assessing health policies and programs against such criteria as access and affordability, social equity, social democratic participation and efficiency, within a framework of citizenship rights. Structural changes to the public sector, the blurring of public and private sectors and the dominance of ‘the market’ transpose new issues onto ongoing ones of power and interests in relation to health policy, traditional relationships within hospitals and medical encounters and in relation to access, equity, rights and citizenship.
Citizenship, rights and health Framing such debates in terms of citizenship is a useful means of locating the State in relation to issues of rights, obligations and the citizen’s capacity to exercise the full dimensions of civil, political, social and economic citizenship. As O’Leary (1996) points out, 5
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citizenship incorporates an active legal and political participation in the shaping of the polity of the State and an identity shaped by belonging to that State. A number of factors have contributed to a rise in rights discourse in relation to health. Historically, this was consolidated in Australia with the introduction of a universal tax-funded health care system under Medicare, giving access to free or subsidised pharmaceutical and hospital services along with a range of other health services. With better-informed health consumers who demand access to and quality of care, the language of citizenship rights increasingly frames health debates. Health is central to wellbeing and is recognised as a fundamental and, indeed, a human right in international declarations. Article 25 of the Universal Declaration of Human Rights recognises rights to a standard of living that is adequate for health and wellbeing— including food, clothing, housing and medical care and necessary social services. Doyal and Gough (1993) recognise survival and physical health, and autonomy, as the two basic needs shared by all human beings. Health is often referred to as a fundamental right. Without health, an individual cannot access other rights and cannot enjoy quality of life. Health is thus an essential component of active citizenship and participation in society. As Lenaghan (1996: ii) notes: (C)itizenship implies entitlement, which in turn implies enforceability: citizens claiming and obtaining what is theirs by right. Health cannot be an enforceable ‘right’ but health services, as a means of achieving health, and the manner in which they are distributed, may be.
A continuing thread in this book is that citizenship is a core concept for analysing health policy and that citizenship differs in important respects from consumerism. As brought out in the chapters on health care funding (by Hancock and Mackey), contractualism (by Muetzelfeldt), casemix funding (by Draper) and co-payments (by Hill), rights within citizenship are increasingly differentiated from rights within consumerism. Citizenship rights are viewed as inalienable, enforceable and appealable. This implies clear lines of accountability in the public sphere, public participation in priority6
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setting, and clear means of redress when service provision is deficient. In the current climate, health systems in Australia are clearly falling short of these standards.
Criteria for evaluating the adequacy of health policy Central to this book is the belief that the health care system can be improved. One avenue to such improvement is the application of criteria against which the adequacy of health policies, programs and services might be evaluated. At the macrolevel, drawing on participatory democratic ideals, these criteria assume a strong role for government, the State and communities. Much has been written about the problematics of independent national sovereignty in the face of global challenges and global economic pressures. However, nation-states still make choices in the ways they approach structural adjustment in their manipulation of the ‘big levers’ of government-including inflation, interest rates, unemployment, labour market regulation, regulation of the business sector, the size and role of the public sector, decisions about public sector expenditure and policies on competition, public asset sales and privatisation. Chapter 3 critiques the privileging of free market ideology and the driving force of a narrow conception of economic efficiency. How these structural policies are handled determines outcomes in such areas as health, housing, education and social security. Reforms need to be evaluated against criteria that encapsulate the dimensions of ‘good’ health policy and practices that are sustainable in the longer term. These draw unashamedly on social justice goals and include economic efficiency. Political feasibility, although central to the political success of policy proposals, does not necessarily lead to good policy. These criteria include the following:
• Access and affordability. The central hallmark of a health system should be not the provision of programs and services per se, but affordability and equity of access. • Social equity and social justice. The provision of health services should be fair and appropriate and should not discriminate on the grounds of class, gender, age, ethnicity/race, Aboriginality, 7
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disability, rurality or geographical location. (The latter is an important consideration in Australia, given concentrations of populations and economies of scale in major cities and along the eastern seaboard.) Social equity entails equal access according to need, rather than individual resources or ascribed status. • Democratic participation and openness of decision-making. Health is historically an area where powerful medical interests have dominated. In the changed context of articulate and informed health care users and advocates, health systems need to make decisions in an open, responsive and participatory manner. The extent to which health care decisions are made openly will determine the extent of public acceptance and trust. The foundation of a strong and respected health system is built on openness of decision-making and involvement of stakeholders, with an emphasis on facilitating the involvement of historically weaker (consumer) interests. Such involvement makes for better decision-making with public services that reflect citizens’ or users’ needs and views, and inspires public trust and confidence. Current reforms can bg evaluated on the extent to which there are mechanisms in place for facilitating community involvement and how effectively such mechanisms work. As Coote and Hunter (1996: 5) point out, social solidarity can be enhanced through strategies that are ‘inclusive, and which build and maintain a shared sense of ownership and mutual benefit’. • Longer-term sustainability. Reforms and programs need to be assessed on gains in the longer term in relation to maintenance of the public interest. Short-term gains may prove unsustainable. The focus on public interest, underlaid by rights that come with citizenship, points to a focus on what happens to individuals in the present, also on the impact on the wider community and on specific structurally defined subgroups, both in the present and in the future. • Economic efficiency. With strains on the health care budget, the efficient use of public resources and value for money needs constant monitoring. Efficiency is complicated by the need to monitor both direct and indirect, short- and longer-term costs, the interplay between expenditure on preventive as opposed to acute health care, and the interactivity of health and other policy 8
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areas such as education, employment, income, housing, social security and the environment, which affect health and wellbeing. The relative merits of alternative approaches need to be monitored, including management reforms, privatisation and purchaser/provider splits under contractualism. • Quality of care. Services must be evaluated in terms of quality of care, from the perspective of service-users and -providers and drawing on both qualitative and quantitative, direct and indirect measures, including risk management. • Public interest accountability. Public interest accountability is broader than budget-driven economic effectiveness and needs to embrace procedural rights, including clear lines of responsibility for risk and redress and the social rights that come with citizenship. Public interest accountability examines not only the way funds are spent but asks whether publicly funded programs achieve their broader social objectives.1 Bynoe (1996: 82) lists as values that underpin social rights: the principles of fair treatment; clear entitlement to services, public and service-providers’ participation; openness and accessibility to service planning and operation; audit and inspection as vehicles of public accountability; and collaborative partnerships built on trust, cooperation, candour and responsibility. Unpacking the principle of fair treatment, he argues for procedural rights— the right to be heard, to consistency in decision-making, to relevance in decision-making, to unbiased decisions, to reasons as part of openness of decision-making, and to independent review. Such standards are central to the maintenance of social rights in modern democratic societies. Accountability is a two-way process, guaranteed not just at election time but by a continuous process of exchange and dialogue with the electorate, in which ‘the public can both obtain and provide information, while the authority is open to scrutiny, listens and responds . . . Effective accountability demands that responsibilities are clearly located and that those to whom account is given have power to elicit information and act upon it’ (Cooper et al. 1995: i). Limited financial accountability overlooks these important elements of public interest accountability. • Effective health care treatment and care. Health care interventions 9
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need to bg monitored for their effectiveness in treating presenting conditions, balanced against the cost and effectiveness of alternative treatments. Some progress on evidence-based clinical practice is being made through international data banks, such as the Cochrane Collaboration. However, dialogue in this area, which focuses on biomedical interventions, often omits more qualitative patient evaluations. In any event, data on relative clinical effectiveness are poorly developed.2 Effectiveness of medical and treatment interventions is nonetheless an important consideration. • Respect for patient autonomy. Policies and health services need to respect citizens’ autonomy to make informed choices on their health care. Patients’ rights to information about treatment risks is now well reinforced in judicial decisions in Australia, and is increasingly recognised by professional and patient advocate bodies. • A rights-based framework for decision-making. Placing health care priorities and decision-making within a rights-based framework reinforces access to adequate and affordable health care as an integral right of citizenship. As suggested by Lenaghan (1996), this involves creating the context within which fair and equitable health care is provided.3 As Plant (1989: 3) suggests, rights give special social, legal and political protection and insulate the individual from the vagaries of the market. Assessing current health policy and practice against these criteria can give direction to needed change.
About the book Writers draw on a range of disciplines—principally political science, sociology, economics, public health and epidemiology. With its focus on analysing shifts in health policy and assessing health policy against criteria such as those outlined above, this book is complementary to others in the field (Palmer & Short 1994; Gardner 1997). It is designed to assist advanced undergraduates and postgraduate students in the health sciences, including health policy, health administration, nursing, medicine, physiotherapy, occupational therapy, health planning and public health, along with students in a wide 10
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range of courses including social work, policy studies and psychology. It will also interest those employed in health care policy development and service delivery, citizens, and health consumer advocates struggling to understand health policy in a climate of rapid change. The book is divided into four sections. Section I deals with tools for Analysing Health Policy. Chapter 2 seeks to define the scope and nature of health policy. As an arena fraught with conflicts between powerful vested interests, power mediates policy. Different ways of conceptualising power are discussed. Pluralist interest group analysis, the study of policy systems and networks or coalitions of interest are useful to a point, but it is argued that structural theories of power extend analysis and ask more penetrating questions. Poststructural analyses are drawn on in two respects—to broaden and extend power from notions of topdown State sovereignty, and in relation to the notion of discourse as a critical analytical tool. In terms of structural interests, historically the medical profession has wielded enormous power over medical knowledge, health policy and practice. The chapter reviews medical dominance debates and concludes that controls under managerialism and market state reforms may bring about an erosion of traditional medical autonomy, as managers and corporate contractors increasingly dominate. Chapter 3 locates analysis within the changing structure of the public sector, with managerialist changes in the 1980s, contractualism and competition, and the emergence of entrepreneurial government and the market state of the 1990s. Section II deals with Financing Health. Chapters examine Commonwealth/state relations, the funding and rationing of health care, and growing consumer co-payments for health care. In chapter 4 Stephen Duckett, a former head of the Commonwealth Department of Health, discusses problems such as cost-shifting from the perspective of the Commonwealth and then from the states’ perspective, including vertical fiscal imbalance. Federalism poses problems, including lack of coordination, problems of political process and accountability, overlap and duplication. In terms of future directions, Duckett sees advantages in broadbanding with public health agreements, in multipurpose service programs, and the coordinated care trials. However, he sees radical change as unlikely, 11
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as Commonwealth/state relations ‘have been paralysed for the last decade’. In chapter 5 Linda Hancock and Paul Mackie examine the factors that are driving up health care costs. Resource allocation occurs at both micro- and macrolevels, and rationing occurs both implicitly and explicitly. When it comes to equitably and fairly distributing health care resources, the market is a poor allocative mechanism. Rationing involves a combination of clinical discretion, moral and political judgement. With a combination of supply and demand pressures driving up health care costs, the authors canvass different countries’ attempts to meet the challenge of cutting or containing costs while maintaining access, affordability and quality of care, and involving the community in decisions on health care funding priorities. In chapter 6 Sophie Hill presents a critique of great concern to health consumers. Data on total direct-payment spending show that individuals pay a substantial share of non-government contributions to health care costs. This has direct effects in terms of equity. Hill outlines strategies adopted by consumer advocates to establish the need for political recognition of consumer co-payments for health care, and, drawing on Fraser (1989), concludes with an examination of the ‘politics of needs interpretation’ and the ‘discursive resources’ available to groups to express their needs. Section III includes chapters specifically addressing Market State Reform Agendas, in chapters on casemix hospital funding, contracting out, and shifts in community health as it becomes increasingly ‘captured’ by the needs of acute care. In chapter 7 Mary Draper locates the issue of assessing casemix as a national hospital funding reform measure, against issues of what consumers want out of the health care system and the impact of technology and change. With shorter hospital stays, hospitals are having to confront issues of increased throughput of more acute care patients, a heightened responsibility for discharge planning and patient care in the community and the need for a mix of high-tech, state-of-the-art centralised hospitals and other hospitals capable of more routine day procedures. As Draper notes, assessing casemix is complicated, as it was implemented at the same time as hospital network reorganisation and massive budget cuts to hospitals in states 12
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like Victoria. Length of stay as a funding tool is problematic, and from the patient’s perspective there is concern about quality of care, discharge planning and a significant frequency of readmissions. Draper notes that casemix uses techniques reminiscent of the scientific management school. It is appealing to governments and to hospital administrators but problematic from the point of view of total patient care. In chapter 8 Muetzelfeldt examines radical shifts in public policy generally, and in relation to the use of market and contractual models in public sector organisations. He unpacks what the purchaser/ provider split means for the delivery of publicly funded products or services, compared with traditional bureaucratic public service organisational and service delivery models. Finally, he analyses the impact of contractualism on reconfiguring public accountability and citizenship. Rather than empowering us as citizens or as ‘public bgneficiaries’, the prevailing budget-driven, managerialist audit review model tends to position us as customers. As Muetzelfeltd and other contributors point out, we must critically analyse the impact of such shifts. With day surgery, faster throughput of patients in hospitals and early discharge, there is growing focus on providing services within the community. In chapter 9 Janine Smith looks at the impact of such reforms on community health generally and on generalist community nurses. In asking why the Community Health Program has failed to achieve its potential, Smith cites historical political opposition from organised medical interests, politicians and bureaucrats; lack of commitment to primary health care principles; and a prevailing perception that community health is a ‘conduit’ for postacute services in the community. She argues that medicalisation of community health and its capture by the acute sector is undermining the community health worker’s ability to pursue primary health agendas. This constitutes a form of cost-shifting from hospitals onto the already underfunded and over-committed community sector. Section IV deals with the challenges to health policy of Catering for the Diversity of Health Care Needs and Interests. Chapters address ways of developing performance measurements that cater for indigenous Aboriginal Australians; challenges to women’s health programs and services posed by the market agenda; the importance 13
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of developing health indicators that respond to diversity; the particular challenges of current changes in the area of mental health policy; and the impact of market state rgforms on carers. In chapter 10 Ian Anderson and Maggie Brady examine the background and context of government attempts to evaluate programs and policies aimed at improving Aboriginal health. Located in the context of a history of Aboriginal health services, Anderson and Brady review objections to various versions of performance indicators and program evaluation processes. They make the salient point that performance indicators have been instigated more for accounting purposes, and for evaluating the State, than for collaborative evaluation or usefulness to Aboriginal Health Services. Their critique points the way towards more useful and socially sensitive ways of approaching evaluation through criteria of consistency, feasibility and validity. Short-term election cycles are not geared towards programs that tackle intergenerational health status for Aboriginal Australians. In chapter 11 Philomena Horsley, Sonja Tremellen and Linda Hancock track the development of the women’s health movement and, following a court challenge, the confirmation of a National Women’s Health Policy to cater for the specific needs and diversity of women. But the integrity of stand-alone women’s health services is under challenge in the current climate of funding cuts, managerialism, broadbanded funding of Commonwealth payments to the states, contractualism and privatisation and the reshaping of community and women’s health services to cater for increased acute care within the community. In chapter 12 Liz Eckermann argues that health indicators need to bg gender-sensitive and socially differentiated. In contrast to approaches based on measuring levels of disease and infirmity, she argues health indicators need to reflect more accurately the diversity of health experiences and health outcomes. Much of Eckermann’s critique draws on studies of women’s economic and social status in both developing and developed countries within the broader WHO definition of health and wellbeing. In an era where contracts must specify performance outcome measures, Eckermann’s critique of three widely accepted applications in public health and social epidemiology 14
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points to the complexities of developing measures that are gendersensitive, qualitative, and that move beyond the biomedical model. In chapter 13 Beth Wilson examines mental health policy in Australia in the context of the critique of mental health services provided by the Human Rights and Equal Opportunity Commission (1993) and the evaluation of the National Mental Health Strategy (1995). Wilson’s examination of recent policy initiatives within mental health services—in particular deinstitutionalisation, community based care and mainstreaming—exposes the political nature of mental health policy and service provision and governments’ reluctance to provide adequate support for the mentally ill in the community. Mainstreaming brings problems of inadequate resourcing and inappropriate placement of chronic mental illness problems in hospital systems that are set up to provide acute care. Covert forms of privatisation such as the substitution of psychiatrists with community workers or general practitioners, are located within the market state climate of cost-cutting, cost-shifting, microeconomic reforms and withdrawal of the public sector. In chapter 14 Linda Hancock and Sharon Moore focus on the impact on carers (mainly women) of changing policies in the community and aged care services area. It is argued that the State’s dependence on women as carers grows with the impact of shifts from hospital-based to home-based care, with early discharge in the acute care sector, and with the shift in aged care policy from residential to community/home-based care. Although carers’ issues have gained greater recognition, this policy area raises real concern about the balance of the responsibilities of the State and of individuals.
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2
Policy, power and interests LINDA HANCOCK ANALYSING HEALTH POLICY POLICY, POWER AND INTERESTS
What is health policy? What is distinctive about health policy? How can we understand the interplay of powerful interests in the determination of health policy? What factors influence the implementation of health policy? How hegemonic is medical power/knowledge?
These questions are central to health policy analysis. The chief focus of this and the next chapter is on ways of analysing shifts in health policy, specifically those shifts of the late 1990s into the millennium, which draw on the free-market ideology developed within the neoliberal or market state.1 Power is central to analysing various facets of health policy and its implementation. The liberal–structural distinction has characterised much of the post-1960s debates about power. Discussion centres on the distinction between liberal pluralist and structural theories of power, and how these might be used analytically. In preference to pluralist approaches to power, a structuralist approach is drawn on by a number of contributors. This is followed by the selective use of poststructural notions of power, and the use of critical discourse analysis. 19
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What is health policy? Responding to the questions posed above depends on how we define both policy and health. Health may take on varying meanings, with consequences for the scope and focus of policy and policy analysis. As Baume (1995: 100) argues, most of what passes for ‘health policy’ is really about the treatment of illness and disease and coping with the consequences of ‘nutritional, alcoholic, driving and sexual excesses’—what Baume calls ‘salvage medicine’. Referring to Australia, he says neither political party has a health policy; instead, we have policies about the illness system and debates about financing hospital, medical and pharmaceutical care, medical insurance systems, consumer copayments, reimbursement for medical treatment costs, hospital administration and industrial disputes. These are important issues but they focus on ways of dealing with the ‘downstream’ consequences of disease and illness, rather than ‘upstream’ policies related to promoting health and wellbeing and preventing ill-health. From the early 1980s, with the World Health Organization’s Health for All by the Year 2000, an alternative agenda has been set, echoed by the Declaration of Alma Ata (WHO/UNICEF 1978), the Ottawa Charter (WHO 1986) and, in Australia, Health for All Australians (National Health Strategy 1988) and Goals and Targets for Australia’s Health in the Year 2000 and Beyond (Nutbeam 1993). WHO’s health agenda takes a broader view, focuses on lifestyle and environmental influences on health and wellbeing, and calls for all countries in the world to attain a level of health that permits people to live socially and economically productive lives. Accordingly, we need to develop approaches and measures of health that tap into broader notions of health, rather than illness. A consistent theme in this book is to stress that citizenship rights are only as good as access to them. That is, people must be structurally positioned (socially, economically, politically and in terms of health and wellbeing) to lead productive, healthy lives. This forces a broader notion of health onto the health policy agenda. The attainment of ‘health’ is thus dependent on certain social, economic and political conditions being met, along with adequate infrastructure and resourcing. To a large extent, debates on health policy reflect the dominant 20
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biomedical illness and disease treatment model. This is reflected in how the health funding dollar is spent, with almost four-fifths (78 per cent) of total public sector health expenditure going on hospitals, nursing homes, pharmaceuticals and medical services and only 5 per cent on community and public health (AIHW 1996: 259 quoting figures for 1993/94). A modest public health agenda has been adopted under Health for All Australians (Health Targets and Implementation Committee 1988) and the Better Health Commission (1986) report, Looking Forward to Bgtter Health. These have focused on prevention of avoidable violent death, avoidance of low nutrition, immunisation of children, prevention of dental caries and treatment of mild hypertension. However, as Baume (1995: 100) noted, all these goals (except perhaps child immunisation) have remained unmet, with only $39 million allocated over the three years to 1995. He explains that these preventive programs have not been incorporated into dominant hospital and medical management systems. Later cuts to the national dental treatment program under the Howard government indicate further marginalisation of the public health agenda. Several of the contributions to this book explore public and community health issues, and a number of authors engage with debates and critiques of the dominant biomedical system. Other contributions focus on trends within the mainstream health and illness system, on the understanding that, to a large extent, priorities in health spending define the parameters of health policy debates. Policy has a meaning in everyday language but is focused on here in the context of public policy—that is, policy made by the State or state agents in the public interest. This is not to deny the important role of private interests in forming and influencing health policy and being affected by it, but it directs our attention firmly to public or government activity in policy-making and implementation. Policy is an ambiguous and contested concept (See Bridgman & Davis, 1998; Gardner 1997). It may be used vaguely to refer to some or all of some general policy objectives (such as those expressed in Health for All by the Year 2000), general or specific programs that command resources for achieving specific objectives (such as a policy on aged and community care); it may refer to the actual text, the wording of a specific policy or formal statements of policy in 21
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legislation or statutory provisions; it may be focused on the policy process—how policy is framed, implemented or interpreted theoretically; or it may refer to the outputs, outcomes and impacts of policy. Both within political and social science and across disciplines, the way we frame our analysis and our responses to the above questions will differ. How we conceptualise policy will depend on our values, ideological and theoretical stance. Our understanding of health policy will relate to whether we conceptualise health as a general feeling of wellbeing that comes with avoiding illness and maintaining a healthy lifestyle or as treating disease and illness. We may imbue policy with an undeserved and unrealistic coherence and we may mistakenly seek closure from a written statement of policy as the ‘last word’. This is increasingly risky, given the focus of recent governments on packaging policy for public acceptability backed by large media management and policy promotion budgets. Policy may be distilled from an analysis of decisions and actions in a particular area—more in the form of a web or matrix, as Gardner (1992: 4) observes, than a neat set of principles. To advance our understanding of health policy, we need first to grasp the nature and dimensions of policy in the abstract. Davis et al. (1993) argue that policy is about disentangling the values, interests and resource issues involved in policy formation, to identify influential organisational or institutional arrangements and to analyse the way the political process affects policy outputs and outcomes. This is a useful framework, in that:
• Values are fundamental to the policy process, often possess a moral element, and may refer to an underlying philosophical commitment—such as ‘value for money’, or ‘community consultation’ and ‘social democracy’. • Interests become the basis for interest groups’ and lobbyists’ attempts to influence policy outcomes in their favour. These may include local, national, global or transnational interests such as a local hospital board, the professional interests of the medical profession or multinational pharmaceutical corporations, or they may refer to interests within the State (such as deficit reduction and a commitment to a minimal State in terms of infrastructure and service provision). Interests may be overt, or covert and 22
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•
•
•
•
indirect, and they are usually organised or grouped around shared values and interests. It is mainly through coalitions of interests that policy proposals gain sufficient approval to be developed and implemented. Resources are usually related to an organisational base and are used to influence public campaigns, research, and lobby government. Differentials in the resource base of powerful interest groups (e.g. the medical profession or the tobacco industry) compared with carers, community or health consumer groups have an effect on health policy outcomes. The context of the policy process sets the parameters for debates, so that the ideological underpinnings of a government’s stance (such as beliefs in the ‘free market’ and in small government, or a substantial interventionist role for government) will affect how it frames debates. Policy is located in the context of prevailing political, economic, cultural and social trends. Values, interests and resources operate within government and market institutions, which have their own values, interests and resources. Features of the Australian political party system, the Australian parliamentary system and the public service are an integral part of the policy process rather than a mere background feature. Constitutional, legal and administrative structures and procedures set some of the parameters of health policy formation, the health system and its players. Arrangements such as constitutionally defined Commonwealth/state division of powers, Commonwealth/state agreements and the role of the Executive in the Westminster system of government set the institutional parameters of policy. Politics is an important mediator of policy outcomes and processes. This refers not just to more obvious political election cycles and the policies and politics geared to win marginal seats, but to the inevitable politicisation of policy, in terms of ideological underpinnings, competing demands and interests. As Gardner observes (1992: 7), ‘(p)olicy making, implementation and evaluation are therefore essentially a political process’. In the Australian setting, policy proposals are fought out in Cabinet and in the Party room. It is thus political parties that set the strategic directions of policy. Politics is also important at the stakeholder/interests level, with the major political parties traditionally favouring different interests 23
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(professional/consumer; business/labour; elite/wider community) in terms of privileged access to decision-making, senior ministers and the policy-making process. In seeking to clarify what is encompassed by health policy, such attempts enter contested terrain. Under pluralist, institutional approaches such as Davis et al.’s (1993), the meaning of policy is non-problematic; identified as a concrete reality, an attempt at solving societal problems, often as a document or set of documents, where it is assumed that policy is self-explanatory and reflects the intentions of its authors; and one merely goes on to analyse it. Considine (1994: 4) contends that policy is more than the study of policy decisions or programs, and extends the definition to encompass processual aspects, ‘continuing work done by groups of policy actors who use available public institutions to articulate and express the things they value’. For Considine, public policy encompasses government’s stance on an issue, decisions to give or withdraw access to a valued good, commitment of public resources to programs or services, and the granting of rights or entitlements to particular individuals or groups. Drawing on postmodern ideas, critics question the idea of unproblematic explanations and meanings of policy, preferring notions of contested and diverse meanings and the embeddedness of truth claims in power relations. Illustrative of such an approach, Ball (1993) problematises policy as ‘text’ and as ‘discourse’. Viewing policy as ‘text’ focuses on policy as process—as constructed, evolving and open to diverse interpretations. Policy is rarely the work of one author or one process, and can change meaning within the political arena. Policy as ‘text’ inevitably produces a ‘plurality of readings’ for a ‘plurality of interests’, and is the product of compromise, politics and the ‘micro politics of interest group articulation’ (Ball 1993: 11). Actors can exercise their social agency and intentionality, in contesting, responding to and making meaning of ‘policy’. Discourses, on the other hand, frame the context within which truth claims and knowledges are constituted (a point taken up later in this chapter). Discourses constitute ‘what can bg said and thought’ and define ‘who can speak, when, where and with what authority’ (Ball 1993: 14). Thus, the discursive frame defines the parameters that give authority and meaning to particular voices and silence 24
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others. Ball argues that such analysis lays the ground for the interpretation of ‘dominant discourses’ in social policy, such as managerialism and economic rationalism (discussed later). As Yeatman (1990) observes, managerialism is dominant over social and political reform agendas, and has driven the emphasis on public financial management, financial accountability and the commercialisation of the public sector. Ball sets an ambitious agenda for the policy analyst, advocating cross-sectional rather than single-level analysis, from struggles over policy formulation to policy effects on various recipients of policy in the processes of implementation. Analytically, the study of policy struggles can focus on influence, policy text production and practice; on process, as well as outcomes (Ball 1993: 11). There is thus the potential for the policy analyst to critique the ideas, assumptions and language of policies, rather than just taking them at face value; and to focus on the processes of policy formulation/implementation, and not just outcomes. Some commentators express frustration at what they perceive as the localising, relativising, fragmenting and apolitical stance of postmodern analysis, with its tendency to de-centre the State. Henry (1993: 104) claims that Ball—in focusing on local contextualisation, with the role of the State ‘shrunk to being merely an aspect of a policy context’ and one of many policy actors—underplays the central and determining role of the State in relation to policy. Henry’s critique is a reminder of dissatisfactions regarding the perceived ‘policy blindness’ of postmodern and poststructural relativism, and the rglativism of key players such as the State, in ways that negate or underplay its dominance in policy processes and resource allocation. The postmodern focus on the potential infinite variety of claims to truth is open to the criticism that it then avoids any weighing in moral, structural or ethical terms. One such issue is the implications of policy for justice or equity or assessments in terms of class, ethnicity or gender. In contrast, a structuralist approach to analysing the social, economic and historical factors that have an impact on the public policy process reminds us of the central role of the State and of structural relations to policy analysis. These different approaches attune us to the problematic nature of policy analysis, in that policy can be conceptualised in different 25
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ways, at different levels and from different theoretical stances. However, commentators concur on the complexity of the policy process, the influence of intentional and unintentional processes, and the inseparability of policy from its context. Writers draw attention to the serendipitous nature of the policy process, referring to political skulduggery, ad-hockery, muddling and negotiation (Davis et al. 1993: 7; Ball 1993: 10), but at the same time to the importance of power (although each conceives of this differently). These debates serve to emphasise that policy studies is not a discipline per se, that there is choice and diversity in the way it is taught, theorised, analysed and discussed and that the notion of policy itself is problematic and, to some extent, situational. This broadly based approach may serve to deter policy researchers from seeking out and delineating single-source documents as indicators of ‘policy’ and to include, as part of policy, not only public or official documents but also memos, minutes, implementation guidelines, studies of the policy process and implementation, the conflicting interpretations held by key actors or mediators of policy and interests, quibbling, blurred meanings and public confusion, along with shifts and changes of meaning over place and time (with, for example, a change of government or minister). We return to Gardner’s (1992: 5) notions of approaching ‘policy’ with a healthy skepticism—examining it as a ‘web’, where the linkages between decisions and actions are not always clear.
Policy implementation Despite the recognition that process and context are central to our understanding of policy, commentators have tended to focus on policy decision-making, and policy implementation has received far less attention. The assessment of policy implementation has obvious relevance to health policy analysis, when it is clear that policy prescription often diverges from implementation and when the blurring of policy and implementation is recognised. Implementation of policy is often represented as part of a topdown, rational ‘policy cycle’ approach, which separates policymaking from implementation (Ham & Hill 1984). The rational 26
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comprehensive model of decision-making represents this process as one of problem definition, identification of a range of alternative solutions, selection and implementation of the one that best fits the problem, with a feedback loop based on reassessing policy in the light of implementation issues (Hogwood & Gunn 1984: 197). In reality, the process is far more muddied and complicated than this. Policy and policy implementation are often inextricably intertwined. A range of factors, political as well as resource and technical, are crucial to successful implementation (Graycar & Jamrozik 1993: 104). Most commentators agree that implementation is rarely straightforward and is fraught with difficulty. Implementation ‘success’ may be assessed in relation to various mechanisms or instruments of policy implementation. In this regard, Considine (1994: 41–4) proposes four instruments—rule-making, direct provision, grants and taxes, and charges—as ways in which government policy and programs may be implemented. However, gauging the success of implementation relies on other factors. Ham and Hill (1984) propose four idealistic criteria for minimising ‘implementation deficit’: unambiguous policy, a minimum number of links in the implementation chain, prevention of outside influence, and control over implementing actors. Other authors propose similar lists.2 Top-down approaches such as Hood’s (1976) raise three main issues of concern, especially in light of the earlier discussion on defining policy: the assumed unproblematic nature of policy, the false distinction between policy and implementation, and the normative or prescriptive approach inherent in such analysis. First, much of the discussion around implementation implies a degree of logic, rationality, clarity and accessibility to policy that is often lacking. (Sometimes, for example, coherence is lost when legislation is amended in the parliamentary process to such an extent that it becomes unworkable.) At other times, policy is evolving. Ham and Hill (1988: 101) describe policy as a ‘slippery concept’, which may emerge only through the implementation process. They describe this as a ‘bottom-up’ process, where policy evolves through the day-to-day decisions of officials. However, ‘implementation failure’ can relate to flawed policy or policy that is practically or politically 27
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non-viable, as well as to sloppy or problem-ridden implementation— say, where guidelines or resourcing are inadequate. Second, the distinction between policy-making and implementation is often blurred. Policy prescriptions at party or government level may lay down broad prescriptions which set strategic directions. Implementation in specific cases or translations into program implementation will often involve administration and interpretation (Wilenski 1988; Pusey 1991). Ham and Hill (1988: 107) give a number of reasons why important policy decisions may be left to the implementation phase: conflicts may not be resolved and tradeoffs between competing interests may have to bg bargained during implementation; more information may be available at the implementation stage to enable key decisions to be made; implementers (because of their special expertise and knowledge) may be better able to make decisions (which may change policy); the actual impact of decisions is often not known beforehand; and negotiation and compromise with powerful interest groups will often further shape and change policy as it is implemented. Implementation may also bg staged over time, as part of a strategy to secure first an agreement on policy principles from potentially competing interests, leaving practical implementation issues to be ironed out later. This was the strategy adopted in 1989 by the Labor government with the introduction of the Child Support Scheme, to secure agreement on broad aspects of policy from the three departments most crucial to its success. The practicalities of implementation were thus separated into two phases, leaving more controversial aspects until later. Although the pyramid model of top-down implementation (from the minister down) may overlook the role of advisers, the Senior Executive Service and senior managers in shaping policy, the distinction between setting strategic directions at high levels and managing the deployment of people and resources is a useful one. Reed (1989: 40) distinguishes between corporate, organisational and workplace levels. It may be that policy decisions are made at each level, but that at lower levels these are made within the strategic policy framework at the corporate level. Third, a top-down approach to policy implementation assumes a hierarchy of structural relations and control between policy-makers and the administrators and managers who implement policy, which 28
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may inaccurately represent the actual processes of bargaining, negotiation and power-play that percolate through both policy-framing and implementation. (This was realistically dramatised in the television series Yes, Minister.) In today’s public sector context of contractualism, competition and privatisation, implementers may be private corporations or organisations with international links and diverse political allegiances. The top-down approach tends to overlook the influence of powerful stakeholders outside government and public bureaucracy. In relation to medical indemnity insurance, for instance, powerful stakeholders include medical profession advocates (such as the Australian Medical Association), corporate malpractice insurers, private health/medical insurers, consumer organisations, private sector medical and allied health service providers as well as government, which has an interest specifically in reducing health services expenditure and ensuring quality of care. Policy implementation is an intensely political process. Assessing the politics of policy/program implementation includes:
• gauging government’s success at strategy, whether strategy is by incremental adjustment or by dramatic change, such as Kennett’s Victorian state hospital relocation package or the National Commission of Audit’s (1996) recasting of Commonwealth/state relations in health. In both cases, policy shifts coupled with budgetary cuts or adjustments have resulted in sweeping changes being implemented, but in ways that are fragmented (due, for example, to the corporatisation of individual services, resulting in a lack of overview of change). Changes may be difficult to assess, given that changes may be subtle and evident only over time; • evaluating ‘community’ and stakeholder receptivity and compliance by identifying stakeholder groups and analysing process and outcome in any confrontation between government and interest groups (such as the New South Wales surgeons’ strike—a successfully waged opposition by surgeons, securing changes to Medicare; see Daniel 1990); • assessing factors or interests outside and within organisations which affect decision-making and policy implementation. These include the influence of such professions as medicine, nursing, 29
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physiotherapy, occupational therapy and social work. Longestablished work practices, routines and power relationships, and protecting entrenched structural interests, reach outside institutions like hospitals. Degeling and Anderson (1992) make the point that the politics of service design, resource allocation and career progression are intertwined. Within organisations, shifting alliances along professional and departmental divisions often influence policy implementation and resource distribution; • studying organisational adaptations that subvert policy to either individual or organisational gain, which may lead to questioning the integrity or efficacy of policy itself; • assessing whether conditions prevail in the policy environment for successful implementation, including financial, management and technical resources (Walt 1994, 174), as well as political commitment, timing, political processes and people, and the continued strength of commitment to reform (Stanley 1993); and • assessing the extent of public/consumer participation in planning services, allocating resources, assessing outcomes and through various hotly debated means of assessing consumer or service-user response. As Ball (1993: 12) accurately observes, ‘(p)olicies do not normally tell you what to do, they create circumstances in which the range of options available in deciding what to do are narrowed or changed’. Implementation involves ‘creative social action’, influenced by factors such as ‘commitment, understanding, capability, resources, practical considerations, cooperation’ and compatibility with other policies (Ball: 13). Ball, however, tends to underplay the importance of power analysis in the politics of the implementation–policy nexus. Resource allocations and decisions on priorities are expressions of competing interests and demands (Gardner 1992: 7). Ultimately, policy-making, implementation and evaluation are political processes, to be understood through the analysis of power and interests.
Analysing power and interests Much of the debate on power has centred on debates between structuralism and varieties of liberalism such as pluralism, elitism 30
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and corporatism (examined below). While the individual is central to liberalist analysis of political action, structural perspectives emphasise the determining influence of external structures related to class (Marxism), gender (feminism) or race/ethnicity. In terms of power, liberalism identifies power as residing in interest groups (either clustered in an elite, or dispersed and shifting), whereas structuralism emphasises power as residing in collectivities, structured along lines such as class, race or gender. In seeking to analyse policy and its impacts, we are constantly confronted by questions of power and control. Does ‘real’ power rest with disaggregrated individuals, specific interest groups, the governing party, the bureaucracy, private sector corporate or transnational interests, or with other forces within or outside the nation’s boundaries? Any answer to such questions is prefaced by the conditional—‘It depends’. There is no one approach to analysing power, and different perspectives may be relevant to analysing different policy issues or events or different facets of an issue or event. An understanding of these approaches to power may also assist in unravelling claims to neutrality, fairness and the ‘level playing field’ made by politicians and government spokespersons in relation to policy decisions. As an aid to discussion, Table 2.1 summarises pluralist and structural approaches covered, in relation to their working definitions of power, conceptualisation of conflict, analysis of outcomes, main focus, resultant power structures, role of the State and main criticisms. Table 2.1 draws on Lukes’ (1974) distinction between the first, second and third dimensions of power.3 Many still regard Lukes’ work as predominantly pluralist, although his third dimension comes closest to a structural understanding of power. He described the first dimension of power in terms of direct and observable conflict and the dominance of one individual or group over another, measured in terms of outcomes. The second dimension was defined as the exercise of power in determining outcomes of observable or covert conflicts, including the determination of what constitutes an issue. This encompassed agenda-setting (such as the covert exclusion of the interests of particular groups or individuals from parliamentary sessions, local council or hospital board meetings) and non-decision-making, 31
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Table 2.1
Main proponent
Pluralist and structuralist approaches to power First-dimensional power (liberal)
Second-dimensional Third-dimensional power (reformist) power (radical)
Dahl (1976)
Bachrach & Baratz (1962)
Lukes (1974)
Elite pluralist, corporatist
Structuralist (with some liberal pluralism)
Theoretical Pluralist perspective Working definition of power
Power is equated with influence, in situations of direct and observable conflict
Power conceived as influence, coercion, authority, force or manipulation. Influential groups can manipulate agendas. Inclusion of non-decisionmaking in the analysis of power
Power is exercised to shape preferences in ways that may stifle people’s real interests. Power is a structural relationship that exists independently of individuals’ wills. Power is inseparable from structural relations (patterned in terms of class, patriarchy, race/ethnicity etc.)
How conflict is conceptualised and studied
Concentrates on direct and observable conflict. Stated preferences are equated with interests
Conflict is evident from what is decided as well as what is left out
Conflict may not arise, as the structure of society may prevent certain groups from identifying or articulating their ‘real’ interests
where issues that are likely to be controversial are omitted from discussion. The third dimension recognised the exercise of power in shaping people’s preferences in the absence of overt or covert conflicts, and in such a way that results in the stifling of ‘real’ interests. Lukes described this as ‘A exercises power over B when A affects B in a manner contrary to B’s interests’ (1974: 24). Those affected see the prevailing order of things as natural or unchangeable, and can see or imagine no alternative (1977: 24). This last dimension invites us 32
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Table 2.1
Pluralist and structuralist approaches to power (cont’d ) First-dimensional power (liberal)
Second-dimensional Third-dimensional power (reformist) power (radical)
Analysis of outcomes
Clear decisions and outcomes occur that favour the group with the most power and resources
Elite groups ensure that their interests are met, possibly through non-decisions
Outcomes reflect the dominant, institutional structures (e.g. according to class and patriarchy)
Resultant power structures
Hierarchical, although society is seen as open and pluralistic, enabling community participation in political processes
Factional, corporatist
Social, institutional and structural power along lines of class, gender, race/ethnicity. People affected detrimentally may not realise there is a need to change the system
Role of the State
Neutral umpire
Neutral umpire
The State as allied to structural interests and/or with interests of its own
Main focus
Observed agency and decisionmaking, it is individual actors who affect the decision-making of the group or community
Actors, groups or interests that may not directly be observable; non-decision-making as an exercise of power
The socially structured and culturally patterned behaviours of groups and institutional practices. Use of comparative and structuralist analysis
to consider what ‘real’ interests would be in conditions of relative autonomy, free from constraints of class, gender, race/ ethnicity, place and time. It is this notion that is closest to a structuralist conceptualisation of power and to an analysis that sees structural positioning as crucial to the capacity or ability to exercise rights. Structural analysis was taken up by Marxist analysts such as Gramsci, making the point that bourgeois hegemony is maintained on a combination of coercion and consent; and consent of the 33
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popular classes to bourgeois rule is built on ignorance and misunderstanding (Hindess 1996: 6). Table 2.1 goes on to show how Lukes’ three dimensions of power have implications for the way conflict and the outcomes of policy may be conceptualised, with implications for policy analysis. Focusing on either decision-making (Lukes’ first dimension) or agenda-setting (the second dimension) would lead to a narrower and more limited analysis than tuning in to the structural implications of power. The focus of pluralist and elite or corporatist pluralist approaches on the State as a neutral umpire is criticised for its naiveté. Such views overlook structural bases of power and the State as aligned to its own and other power-brokers’ interests. Interest group pluralism thus overlooks broader analysis of systemic, structurally based factors that strategically locate some and not others for maximising self-interest.
Liberal/pluralist theories of power Elaborating Table 2.1, different varieties of liberal theory (pluralism, elitism and corporatism briefly described here) draw on liberalist assumptions of the centrality of the individual as the starting point in analyses of power. Drawing on Jeremy Bentham, John Stuart Mill and the utilitarians, liberal theory sought a democratic State that would ensure the conditions necessary for individuals to pursue their interests, participate freely in economic transactions, exchange goods and labour and amass private wealth. Pluralists argue that competing interests have equal access to government and to shaping government policy. Pluralists take the view that a variety of groups and organisations have power and influence over government but that no single group dominates or has a monopoly on power and decision-making. Coalitions between groups change, and no one group is dominant. Power is perceived not as centralised but dispersed among various groups, with each concerned to service its own interests. Under pluralism it is argued that the more pluralist a society, the more equal will be the distribution of power (Hogan 1993: 221). With no one group or set of interests dominating across a range of political decisions, pluralists 34
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see the system as both democratic and responsive (Head & Bell 1994). Classical liberal pluralists claim that the State adopts the role of a neutral arbiter, ‘umpire’ or ‘referee’, to arbitrate and decide between competing groups of interests. Thus, according to pluralists, the State has no sets of interests or agendas of its own. The pluralist view draws on the liberal idea of the individual as external to the State, operating within a self-regulating market, where through competition between self-interested groups, decisions in the public interest eventually emerge. It is claimed that across a range of issues no single group dominates political outcomes. Quoting Maguire (1978), Held and Kreiger (1984: 3) sum up succinctly the notion of the State under liberal pluralism: The state can be seen by everyone as a pure instrumentality which serves the ‘common good’, by settling questions which have to be settled at a general societal level, and by preserving the conditions for the market mechanism to reconcile individual and social benefit.
Thus, pluralists argue that no particular group monopolises power, power is dispersed, and decision-making institutions are open to the influence of a variety of interest groups. Under pluralist claims, policy decisions presented as a compromise between warring groups are not evaluated normatively. Drawing on C. Wright Mill’s work, The Power Elite, American elite theory of the 1950s saw the power elite as consisting of leaders of government bureaucracy, large corporations and the military, with much decision-making conducted informally and behind closed doors. In contrast to classical pluralism, elite pluralism recognises that certain groups, such as the medical profession in relation to health policy, stand to gain on a consistent and predictable basis. However, it maintains the view that decisions are made in the public interest and that the State takes a neutral role. Corporatism refers to the links between State policy and industry in deals between government and peak bodies, typically of business and labour. It has elements in common with both the pluralist and elitist models. It recognises competing interests but it also recognises that the interests of industry (and/or labour) are accommodated by 35
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those in power. In the area of economic policy, corporatism refers to the coming together of business and labour leaders with government. In terms of its theory of the State, corporatism acknowledges the directive capacity of the State in negotiating tripartite agreements with labour and business elites. In the health area, corporatism may refer to the way that governments (particularly conservative governments) have entered into direct negotiations with medical professional bodies (such as the Australian Medical Association) or with health business interests (such as the health insurance industry, the pharmaceutical industry or corporate nursing home operators). Multi-national corporate business interests such as the pharmaceutical industry and medical indemnity insurers represent influential business interests, often directly consulted by governments. (The pharmaceutical industry has an estimated 8000 lobbyists in Brussels, intent on establishing their interests in the consolidating European Union market.) As Bgll and Wanna (1992: 268) suggest, business interests exercise a form of ‘blunt’ power, influential in setting the parameters within which policy details are then fleshed out. However, under corporate pluralism, the State is still perceived as not being controlled by any particular class or group. Corporatism maintains that the State is independent and able to act in the interests of labour or capital, as appropriate (Ham & Hill 1988). Competition between groups is seen to result in policy equilibrium, with no threat to basic structural arrangements (Held & Keiger 1984: 13). Under corporate pluralism, certain insider groups have privileged access to government, but the assumption persists that relatively equal power prevails across the policy community, and little is said regarding power, conflict and hierarchy (Head & Bell 1994: 300). The assumptions on which pluralist analysis rests in its various forms expose it to a number of criticisms. It treats the State as relatively unified and unproblematic, disregarding the broader issue of the interests and values represented within the State itself and how these might become embedded in policy and legislation. Pluralist analysis fails to recognise that the State may act in the interests of structurally based categories such as the propertied class, or in a gender-specific way that may, for example, benefit men’s interests at the expense of women’s interests. In arguing that groups and individuals have equal access to the political process and that arguments 36
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are assessed on merit, it overlooks differences in resources, accessibility and the competence of interest groups to engage with the State. It should also be noted that claims to neutrality by politicians and the media often invoke pluralist justifications of interests as a means of gaining public acceptance of political decisions. On the matter of interests and outcomes, compared with consumers, medical lobby groups have traditionally been bgtter resourced, organised and connected to the State by class and privilege. Hence, as suggested by Head and Bell (1994: 28), the political system is in fact not open, accessible or responsive to poorly organised and underresourced groups or to ordinary citizens, as claimed by pluralists. Liberal pluralism overlooks the unequal starting position on the ‘level playing field’ that underlies liberal thought. It thus ignores the links between the groups that exercise political power and economic, political and social structures in society. Pluralist claims that the public interest will be protected as an outcome of conflicts between opposing groups are refuted by the American political scientist, Lowi (1979: 51), who argued that interest groups will inevitably act in order to enhance their own interests and this will not necessarily be in the public interest. De Angelis and Parkin (1990: 312) observe that pluralism ‘is indifferent, perhaps even hostile, to normative notions like justice and the public interest; it is concerned with procedures rather than ends’.
Structuralist approaches to power and the State Emerging from critiques of liberal pluralism, structuralists perceive the State as acting in the interests of dominant groups, thus maintaining the needs of capital domination (Marxist view) or masculine domination and control (feminist view) and/or acting to reinforce and reproduce its own interests (statist view).4 Structuralist approaches to power emphasise the collective interests and the costs and benefits that flow to members of collectives on the basis of ascribed factors such as race/ethnicity, class or sex/gender. The State may also act in ways that reinforce and reproduce its own dominant structural interests, not necessarily in the interests of particular groups or classes. Writing on international relations, Strange (1988: 27) differentiates bgtween relational power (akin to Lukes’ 1974 first 37
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dimension) and strwctural power: defined as the power to shape and determine structures within which states, institutions and professional elites have to operate. Strange acknowledges that agenda-setting (Lukes’ second dimension) may be regarded as one aspect of structural power, but describes structural power as conferring the power to decide how things shall be done and to shape frameworks within which people, corporate enterprises and states must relate to one another. Thus, a structural approach to power involves the analysis of societal power structures and the axioms along which they are patterned and organised. It is this context-determining power which distinguishes structuralist from pluralist approaches. Further elaborating structural power, Giddens (cited in Hindess 1996: 9) suggests a dual structure, including the capacity to act ‘to make a difference’ and structural aspects, seen as constraining actions and providing resources used in interactions with others (although Hindess criticises Giddens as still favouring power as ‘simple quantitative capacity’). Along similar lines, Wartenberg (1992) in his ‘situated model of power’ emphasises the importance of the broader social context in the way power relationships are created, constituted and maintained. Structural interests as an analytic framework. Drawing on Alford’s (1975) work, Duckett (1984) in Australia and the Canadian health economist Evans (1990a, b) have developed the notion of structural interests as a useful framework for conceptualising the power of different interest groups to influence health policy formulation and health care reform. Alford’s now classic work interpreted the continual representation of crisis and inadequate care in New York City hospitals as a political ploy (‘a public relations method’ masking the maintenance of reasonable quantity and quality of care compared with other areas of the USA) as a means of ‘powerful and strategically located interests’ in maintaining the status quo and resisting change (Alford 1975: xxii). Alford argued that these powerful structural interests do not have to exert power but do so by effectively resisting change. Alford classified structural interests into three categories: dominant, challenging, and repressed. Although these may need modification to fit contemporary analysis, they are a useful starting point. 38
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Dominant structural interests (‘those served by the structure of social, economic, and political institutions as they exist at any given time’) include health-providers—principally doctors—whose prestige, incomes and profits are vested in providing health services. Alford (1975: 14) refers to medicine as the archetypal professional monopoly (‘the private appropriation of powers and benefits by a structural interest’). Acknowledging conflicts between groups within medicine, this does not challenge the principle of professional monopoly. The second group, referred to by Alford as ‘corporate rationalists’, includes those such as governments and health insurers, with an interest in curbing health expenditures as well as concerns with equity of access and the provision of health services. Alford identifies the potential for change, from what he saw as the emerging structural interest of hospital administrators, medical schools, government regulatory or funding programs, in ‘breaking the professional monopoly of physicians over the production and distribution of health care’ (Alford 1975: 15). The third group of ‘repressed interests’ are health consumers, also referred to by Alford as ‘community interests’ and ‘equal health advocates’, as he limits this category to those just above the Medicaid income maximum, who miss out on funded medical care: ‘These are “repressed” or negative structural interests because no social institutions or political mechanisms in the society ensure that these interests are served’ (Alford, 1975: 15). Illustrative of the institutionalised power of dominant interests, Alford refers to the ‘quiet and continuous allocation of benefits’ to them. Despite the gains made by the consumer movement, it is still evident that repressed interests battle against disadvantage, and need to exert enormous energy to gain their desired outcomes. In her essay ‘The Five Faces of Opression’, Iris Marion Young (1992: 175) notes that oppression is structural or systemic. She defines oppression as the inhibition of the oppressed group’s ability to develop and exercise its needs, thoughts and feelings.
Poststructural views of power Poststructural notions of power conceptualise power more broadly than top-down or hierarchical State sovereignty. Two particular aspects of Foucault’s work are drawn on here: his reconceptualisation 39
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of the notion of power, and his contribution to our understanding of medical surveillance through power/knowledge. Drawing on Foucault’s ‘capillaries of power’ and his notions of disciplinary practices, surveillance and inner surveillance or ‘bio-power’ (Foucault 1976, 1977; Shumway 1989), and Clegg’s (1989) ‘circuits of power and resistance’, power is viewed as all-pervasive and multilevel. Clegg (1989: 82) describes Foucault’s conception of power as ‘a micropolitics of power’. Drawing on the concept of governmentality, Foucault (1980) sought to recast the analysis of power and to de-centre the State in relation to power. One important influence of poststructuralism has been to redirect attention from power over others (a top-down, State-over-individual conception of power as domination) to power as the capacity to influence others, along with a focus on the reproduction of State power at the individual level through self-control and discipline. (These notions are returned to later.) Discourse is central to understanding the dynamics of power/knowledge, and is used by some contributors to this book. It is seen as broader than ideology, as formed by and interrelated to broader social structures, and as constitutive of relations of power— drawing on Foucault’s notion of power as tactical and strategic, based around ‘techniques and tactics of domination’ (Foucault 1976: 237). Power is thus not limited to top-down hierarchical sovereign power, but is dispersed, mobilised selectively and strategically by some and not others, and operates at multiple levels—including self-discipline and surveillance at the individual level. This notion of power may help to explain the lack of dissent and current high levels of acceptance of dominant discourses around health policy, and shifts in public sector servicing in health and other arenas. Discourse refers to the representation or articulation of certain knowledge(s) as truths. These are not of course pregiven or coincidental, but are grounded in and interrelated to systems of knowledge, practices and institutions.
Critical discourse analysis Discourse analysis, as a critical analytical tool, is used in its broad sense to include analysis of the bundle of ideas, concepts and categories that constitute the way we think and act at a variety of 40
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conscious and taken-for-granted levels. As pointed out by Howarth (1995: 115), discourse theory draws on the traditions of interpretive sciences such as hermeneutics, phenomenology, structuralism and deconstructionism, and bears similarities to Weber’s Verstehen, or method of understanding through empathy with the actor. Its use here is broader than its application to microlevel sociolinguistic analysis or to studies in the medical field, focused on doctor–patient consultations (West 1990; Fisher 1991). However, Lupton’s (1992, 1994) analysis of media approaches to health issues from the point of view of underlying assumptions and sociopolitical and cultural context is closer to the approach adopted here. Drawing especially on Howarth (1995), the approach to critical discourse analysis emphasised here focuses on:
• the way ‘structures of meaning make possible certain forms of conduct’ (1995: 115);
• understanding the way discourses are produced, how they func• • •
•
•
tion and how they are open-ended and change; conceptions of power and agency as ways of understanding how discourses structure actors’ behaviour and thinking and the way power is exercised and expressed through discourse; the relational character of identity and meaning, wherein discourses gain meaning through their relation to a wider context; the historically contingent and political nature of discourses, with political processes ‘understood as conflicts and struggles between antagonistic forces over the structuring of social meanings’ (1995: 132); the concept of articulation, as the means by which discourses are constructed, by particular political interests, as a practice of incorporation—a ‘bringing together’ of ‘different elements and combining them in a new identity’ (1995: 119) (for example, in the way that competition policy welds together or articulates afresh, sets of existing ideas around privatisation and a changing role for government); the importance of hegemony, as a means of understanding the dominance of particular discourses and social formations, where hegemonic practices ‘determine the dominant rules that structure the identities of discourses and social formations’ (1995: 124). 41
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In light of these points, the political and hegemonising processes that underlie the formation of dominant discourses can be better understood. The notion of dominant discourse is useful for delineating the ways in which complex political ideas and traditions are drawn on selectively, sometimes in new ways, through the processes of articulation and hegemony. Contributors to this book use the concept of dominant discourse to include techno/medical dominance, rational medical knowledge, economic rationalism and free-market ideology. In further elucidating the way individuals bgcome a part of such discourses, and extending Lukes’ third dimension of power, critical discourse analysis can attune us to how individuals may direct their own attitudes, behaviour and thoughts in ways that are antithetical to their (real) interests.
Medical dominance debates: the erosion of medical autonomy? Integral to discussions about power in health policy are debates about the hegemony of medical power/knowledge. The medical profession has been and continues to be an influential force in health policy debates, although it may be argued that, at least for doctors working in the public hospital sector or in primary medical care, the power base is contested and shifting. The sociological literature is replete with analysis of medical claims to professional autonomy, self-regulation, control over other health professionals and medical practitioners as the interpreters of medical and social knowledge, derived from the dominant biomedical model (Freidson 1986, 1990; Willis 1989; Turner 1987; Daniel 1990). As distinct from other occupational categories, the medical profession has been described (Freidson 1970, 1986; Lupton & Najman 1995; Willis 1989) as having the particular attributes of:
• prolonged periods of specialised training in abstract, complex technical knowledge and shared ethical standards of behaviour; • commitment to service and community values rather than to material self-gain, reflected in the conceptualisation of medicine as a calling; 42
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• membership of professional bodies that set, control and selfregulate on quality and standards of practice;
• claims to autonomy, grounded in specialist training and knowledge and in its relationship to the State; and • State-supported monopoly of practice, controls on entry to the profession, practice regulations and monopoly over remuneration under (Australian) national health insurance. During the 1970s and 1980s, writers such as McKinlay (1973) and Navarro (1986) laid bare the self-interested motivations of medical practitioners through ‘backstage’ activities (such as fee-splitting, overservicing, unnecessary referrals), the perpetuation of class and privilege through admittance to the professions, the use of medical knowledge to legitimise hierarchical divisions of labour in medicine along class, sex and race lines, and the political economy analysis of the nexus between medical practice, the biomedical model and control over profits by medical transnational and pharmaceutical corporate interests. Navarro (1993: 10) refers to the latter as ‘the medical-industrial complex’, to describe the alliances between insurance companies and medical professions and, to some extent, government. Willis (1989), in Australia, draws attention to the dominance of the medical profession over other health care providers (nursing, chiropractic, midwifery, optometry)—if not directly, then through medical opposition and control over remuneration under nationalised health insurance. Willis (1989: 2) argues that medicine is dominant economically, politically, socially and intellectually in the division of labour in health, and this dominance is sustained in terms of its own work, others’ work and the wider health sphere. He conceptualises such dominance in terms of medicine’s autonomy to control its own work—its authority over health occupations and its sovereignty—as doctors are ‘institutionalised experts’ on all matters relating to health. Medicine is seen as the gatekeeper of the operating conditions and registration of other health occupational groups (Willis 1989: 3). Following a Marxist analysis, Willis also argues that, through its professional dominance, the medical profession exerts a controlling influence on behalf of the capitalist class (1989). 43
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However, this does not point to an unproblematic relationship between the State and medicine in relation to health policy issues. Relations between governments and medical interests have varied under Labor and conservative governments in the Australian context and writers have documented the negotiations, compromises and medical opposition regarding benefit levels and fees under Medibank and Medicare in the 1970s (Sax 1984; Daniel 1990). The AMA and specialist medical societies and colleges opposed the inclusion in Medibank of modalities (other than optometry) such as clinical psychology and midwifery (Willis 1994). The New South Wales surgeons’ strike in the mid-1980s undermined the mutual trust between the State and the medical profession (Daniel 1990). In these accounts, division and fragmentation within medical ranks are structured along lines of specialisation, diversity of practice modes and an increasingly diversified salaried medical workforce (with the growth of large, US-style medical corporations) (Daniel 1990: 8). The interface between the State and medical interests has bgen contested and problematic. Daniel (1990: 14) suggests that, as State intervention into the area of health services has grown, ‘(t)he character of the contest changes but always the struggle, over who decides and who controls, remains’. Analyses of past contestations have shown that the State has often accommodated itself to the interests of organised medicine (Sax 1990; Willis 1989; Daniel 1990). However, various writers have asserted that such professions as medicine are losing their privileged position. According to Freidson (1986: 110–11), commenting on the North American context, one argument is based on the public loss of trust and confidence in professionals in general, and a trend towards greater client questioning of professionals, with the narrowing of the knowledge gap and the erosion of professionals’ unquestioned authority—referred to as ‘deprofessionalisation’. The other argument is based around claims of ‘proletarianisation’ and loss of control and independence with the growing employment of doctors in bureaucracies. Refuting both these arguments, Freidson claims that US public opinion surveys establish sustained high levels of confidence in the professions, particularly medicine, and that self-employment among professionals has grown rather than fallen; although he acknowledges the effects of budgetary pressures, government regula44
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tory policies, and commercial enterprises that sell professional services (Freidson 1986: 121–9). Irrespective of whether professionals are employed or selfemployed, Freidson (1986: 129) draws attention to the role of ‘sheltering institutions’ that ‘support the position of the professions in the political economy’. Adopting an elite pluralist or, in some cases, a Marxist/structuralist argument, one could claim that medicine and medical interests have privileged access to policy decision-making and that the State is locked into perpetuating medical financial gains, even though it may seek to put limits on them. In the 1990s there are new shifts in relations between the State and medical interests, largely as a result of pressures on the State to cut expenditure on health, in the context of projected growth in demand for health services into the next century, and as a result of external challenges to medical knowledge posed by growing consumer preference for alternative therapies. Traditional notions of the medical profession’s ‘facilitative’ and ‘dispositional’ power (Clegg 1989) rest on public acceptance of the dominance of medical power/knowledge and autonomy in health care decision-making. These, it is argued, have shifted in the wake of interventionist government policies driven by budget reduction and finite resourcing concerns. Managerialist and microeconomic reforms around changes in senior hospital administration and funding rgstrictions (such as casemix-based hospital funding and quotas on annual patient psychiatric consultations in Australia) are changing the context within which Medicare functions under the neoliberal State. T. Osborne (1993: 346) argues that doctors and other health professionals are striving to preserve their autonomy against encroachments by administrators and economists. This is a different argument from that put by Turner (1987: 137), of the threat to professional freedom posed by working within hierarchical bureaucratic structures such as hospitals. It is an argument based around claims that market rationalities, budget cuts and managerialism undermine professional dominance/control and autonomy in new ways. This interpretation is born out in Victorian confrontations between surgeons and hospital administrators amid claims of manipulated hospital waiting lists (as a means of avoiding government penalties), unhygenic conditions and low morale (Toy & Davies 45
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1998). Victorian doctors’ outcry about the impact of managerialism and budget cuts in state hospitals highlights not just medical resistance to lack of control, but claims that public hospitals have become unworkable and that the preoccupation with efficiency and cost shifting to users and to the Commonwealth through charging Medicare for services such as outpatients, have undermined doctors’ ability to ‘care’ (Toy & Bkrnbaver 1998: 1). UK research suggests that National Health Service managers, via information systems and clinical budgeting, are imposing controls on doctors’ activities and resource usage; and that the creation of quasi-markets through the purchaser/provider split has implications for medical autonomy (Kelleher et al. 1994: xiv). On the other hand, it has bgen suggested that new management structures may enable some hospital doctors to bypass traditional power hierarchies. Fund-holding for general practitioners may create opportunities for greater autonomy, and doctors who bgcome managers may make decisions that pose no threat to medical power (Hunter 1994). Commonwealth funding to general practice regions in Australia for health-related training and research may also serve to reinforce biomedical models of research/knowledge compared with an alternative scenario (if such funding had been given to community health or health promotion programs). As further threats to the hegemony of medical power, Kelleher, Gabg and Williams also refer to independent clinical nurse practioners involved in screening, health promotion and counselling and reforms in nursing education; enhancing nurse autonomy in relation to doctors; growing consumer interest in alternative and self-help therapies; the involvement of lawyers in facilitating actions in medical negligence and in drawing up purchaser/provider contracts; heightened interest by journalists in putting lay as well as medical views in critiques of health services delivery, medical knowledge, technologies and practices; the role of self-help groups and groups engaged in ‘popular epidemiology’ (as the basis for legal claims of illness linked to industrial practices), which challenges orthodox expert opinion; and social movements, such as the health consumers’ and women’s (health) movements, putting increased pressure on professional accountability and responsiveness, and in some cases providing analysis that challenges the biomedical model. The 46
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authors conclude by arguing that although such challenges are unlikely to lead to an ‘emasculation of the power of medicine’ they should prompt a re-examination of debates on medical dominance (Kelleher et al. 1994: xxiii).
Conclusion This chapter has sought to introduce different ways of conceptualising policy and the interplay between policy, power and interests. Policy is underlaid by values and ideologies that may not be articulated. Policy is the product of power struggles. It is mediated by both private and public institutions and is underpinned by historical processes. Policy is often nebulous and crosses program, budgetary and government departmental boundaries, and has both short- and long-term impacts which need monitoring and evaluation. Health policy tends to be focused on ‘the illness system’. It should, however, include broad aspects of health that focus on broader notions of health and wellbeing, through health promotion policies and the creation of healthy living environments. Power is central to the formulation and implementation of policy and different theories of power have implications for the way interests, power structures and the role of the State are perceived. Given key stakeholders in the health policy process, structural interests analysis is particularly useful and is drawn on by a number of contributors to this book. Finally, given its dominant historical influence on health policy, the discussion of medical dominance debates argues that medical autonomy is being undermined by ‘new paradigms of power’ through budget control and managerialism, under economic rationalism and market state rgforms. Chapter 3 analyses shifts in the public sector that bear on health policy and the dominance of the market model.
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3
Health, public sector restructuring and the market state LINDA HANCOCK RESTRUCTURING AND THE MARKET STATE
Since the 1980s and into the 1990s, Australia has undergone policy changes and a restructuring of the public sector that has sparked debates about the role of government, the scope of public sector services and, indeed, changes in governance. These structural changes have affected all policy areas and will particularly affect health, given its centrality to public sector expenditure and the predicted growth in demand for health services. This chapter charts the rise of ‘entrepreneurial government’1 and the 1990s market reform agenda in Australia, culminating in structural shifts within the State, epitomised by Kennett’s Victorian ‘contract state’. It then discusses three fundamental assumptions underlying governance in the neoliberal or market state: beliefs in small government, in public choice theory as an explanatory framework, and beliefs in the efficacy of the free market.
The rise of ‘entrepreneurial government’ in the Australian public sector The public sector reforms of the 1980s were focused around managerialism and corporate planning, drawing on theories and models in the private sector. Public sector organisations were 48
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criticised for their inefficient and unwieldy bureaucracies, their preoccupation with process and lack of performance, and their protection of public servants who were criticised for their influence over ministers and at times, their perceived union-dominated intractability to change. Managerialist reforms retained hierarchical but flatter organisational structures, undertook some limited privatisation of government-owned enterprises (GOEs), and sought greater efficiencies through objective-setting, program management and budgeting, corporate planning performance-based appraisals, userpays and full-cost pricing of government services. Codd (1991: 5–14) saw the advantages of these changes as a ‘management revolution’, with a shift from the focus on inputs to that on results, performance measurement and evaluation, better resource allocation, substantial restructuring of job structures in the public service (notably the Senior Executive Service); improved accountability with the introduction of corporate planning and improved strategic management within departments (see also Weller & Lewis 1989: 4–7). Drawing to a large extent on systems theory, the driving force of 1980s public sector change was seen by critics as reducing policy and program effectiveness to inputs/outputs and measurable performance indicators. Corbett (1996: 247) notes that critics saw it as hypocritical, using efficiency as a disguise for reducing public expenditure and undermining the public sector’s influence; as advocating decentralisation of authority while practising top-down centralism. Critics saw government as becoming increasingly preoccupied with efficiency, measured in economic terms (Considine 1987: 21), and management for results, rather than improved processes and longer-term agendas (Sawyer 1989: 149); as overlooking differences between the private and public sector and the uniqueness of the public sector (McGuire 1989: 27); as focusing on measurable outputs and performance indicators and quantitative means of assessment; as undermining equal employment opportunity initiatives; as relying on acceptance of established hierarchies and centralised power structures, which are inevitably gendered (Yeatman 1986); as doing little to empower more effective participation in the policy process for those who are the targets of social justice strategies; and as emphasising the acceptance of existing authority structures (Sawyer 1989: 49
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148; Bryson 1986, 1987; Considine 1988; Painter 1988; Bgilharz et al. 1992). A widely published debate bridging academic/practitioner critiques was that between Considine (1988) and Paterson (1988). Paterson sought to defend the competence and objectivity of managers trained in management techniques—freed from the constraints of partisan practitioner views.2 Bryson (1987) was critical of the Senior Executive Service focus on managerialist skills rather than on policy expertise, and its focus on male managers. She questioned its impact on traditional public service goals of due process, democratic principles, equity and service delivery. Others defended managerialism, with Cullen (1986) in favour of an SES trained in management skills using a performance-based approach to senior public sector management; Keating (1989) extolled the virtues of new management approaches in public administration and Wilenski (1988) dismissed critics as university academics not directly involved in public administration. Managerialist reforms in the 1990s have further intensified, with the rise of the ‘New Public Management’, the shift to entrepreneurial management and the push for contractualism and privatisation. Drawing on Boston (1996 et al.: 26), the following are its key features: similar styles and models of management in the public and private sectors; a shift from process (bureaucratic) accountability to accountability through quantifiable results; an emphasis on generic management skills, devolution of management control under strict rules of reporting, monitoring and accountability; disaggregation of bureaucratic structures around separation of core from peripheral functions, policy advice from service delivery; the preference for privatisation, contracting and contestability; the use of specific, performance-based contracts; further emphasis on private sector management practices, including performance-based pay, corporateimage making and new management information systems; the preference for monetary incentives for performance, and ‘stress on cost-cutting, efficiency, and cutback management’. Within public sector organisations, the new public management brought a change in emphasis from corporate planning to ‘business plans’ in departments and sections within public sector departments. These are oriented towards quantifiable targets, performance indica50
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tors, outcome measures and results, reduced costs and improved efficiencies; the separation of core business to differentiate those service delivery tasks suitable for contracting out or privatisation; the introduction of competition where possible; the changed basis of public sector employment with individually negotiated performancebased contracts; and the disaggregation of large, monolithic organisations (such as airports, airlines, power utilities, banking institutions, hospitals and universities) into corporatised business units. Added to the concerns of the 1980s raised in relation to corporate managerialism, concern about the ‘new managerialism’ of the 1990s focuses more on the breadth and depth of fundamental shifts (see Yeatman 1993). As economic efficiency and budget accountability become the driving force of corporate management models, Colbatch contrasts the loss of technical specialists in fields like medicine and engineering, replaced by generic managers, in an environment of activist ministers, ‘attracted to a discourse which talks about government in terms of deciding rather than providing, and outcomes rather than process’ (1993: 31). Others raise questions about the preoccupation with economic efficiency, reflected in policies of privatisation, competition and contractualism, the preoccupation with the market and, more broadly, the role of the State, changes in governance, shifts in what might be regarded as ‘the public good’, the downsizing of the public sector, shifts from public interest to financial and budget-driven accountability and the ‘human costs of managerialism’ (Alford & O’Neill 1994; Cox 1995; Rees & Rodley 1995; Davis et al. 1997). The broader context within which health reforms are taking place reflects the market-dominated reform agenda at state, national and global levels. National policies include the Financial Management Improvement Initiatives (FMII) of 1983 and 1986, introduced under Keating’s 1990s Labor, National Competition Policy (NCP) (Independent Committee of Inquiry into Competition Policy in Australia 1993, implemented in 1995), establishment of COAG (the Council of Australian Governments) and the National Commission of Audit (NCA; 1996). At the national level, both National Competition Policy and the NCA (1996) have to some extent driven a changing role for government 51
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in the 1990s compared with the 1970s and 1980s. This is recognised in the report of the NCA (1996: vii) which emphasises the centrality of separating purchasers of services from providers under competiton policies: There is now greater appreciation that governments can produce better results if they operate more like referees and supervisors, specifying the rules and the results required. Delivery of desired outcomes is usually better if opened up to competition, so that suppliers within and outside the public sector can tender for the services required. Those setting the rules and desired outcomes where possible should be separate from those supplying the services. Referees shouldn’t be players as well, and vice versa.
The NCA argues for program beneficiaries to be given choice (patients being able to choose hospitals and doctors; parents and students being able to choose schools or universities), that governments should operate as program funders (with funding separated from service delivery) and that ‘service delivery should be as competitive as possible’. Service suppliers, whether public or private, should be required to tender or otherwise compete for the right to deliver government services, subject to safeguards to protect service quality; this helps to ensure service efficiency (1996: viii). The NCA draws on corporate management and managerialist frameworks pressing for ‘outcome focused input efficient’ processes, ‘more contestability (competition) in the provision of services and more focus on outcomes rather than inputs and processes’ and ‘best practice’ (through benchmarking, competitive tendering, new technology and cost recovery through ‘setting up accounting and performance monitoring frameworks against desired outcomes’ (NCA 1996: xiii–xiv)). Pushing for privatisation where possible, government business enterprises (GBEs) providing goods and services on a commercial basis ‘should only be retained in public ownership if there is a clear public interest case to do so’ (NCA 1996: ix). The influence of the NCA as a blueprint for change at the national level is reflected in other reforms. Of relevance to health are the COAG review of Commonwealth/state responsibilities and the devolution of much service delivery to the states, including the Aged and Community Care Program, ‘broadbanding’ of specific52
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purpose payments in public health and health services areas, greater contestability of Commonwealth Rehabilitation Services, downsizing of the Commonwealth Department of Health and Family Services, with added changes to child care, corporate services and information services, and retention of oversight of the Medical and Pharmaceutical Benefits Schemes; with possible ‘cashing out’ of benefits subject to the results of Coordinated Care Trials3 (Podger 1996). At the state level, reforms are evident across Australia. One state that has advanced apace with these reforms is Victoria, under the Kennett Liberal government—swept to power in 1992 and re-elected in 1995 against the dominating issue of Labor’s economic mismanagement. Rather than concentrating on the specific content of Victorian reforms, their broad direction and import is relevant to understanding general trends followed by other governments committed to similar reforms but not so far down the track. Kennett claimed a mandate to restructure the public sector radically and, indeed, to change forms of governance. The chief justification was to reduce the current account deficit and thereby reduce interest payments and to ‘put Victoria in the black’. Under Kennett, Victoria adopted a contract model based on market mechanisms and competition (Alford & O’Neill 1994). Both the Victorian Management Improvement Initiative (MII) (Government of Victoria 1993) and the Victorian Commission of Audit (1993a, b) gave direction for public sector restructuring, reforms to financial and asset management systems, and a new management approach to performance based on planning and accountability for outputs and outcomes. The MII stated five key principles for public sector reform (Government of Victoria 1993: 1):
• clear accountability for results; • empowering consumers of public services (through service commitments and choice, by funding consumers where possible); • minimising government bureaucracy for consumers (through defining government’s core functions and separating policy from service delivery); • preference for market mechanisms in the provision of public services; • professional and business-like management of public agencies 53
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(through devolution, risk management, performance incentives and improved financial management and reporting systems). With the goal of minimising government bureaucracy, the MII makes clear the principles on which reforms are to be based (Government of Victoria 1993: 6):
• refocusing government departments on the core functions of government—namely, policy development, resource allocation and specifications of public benefits and services, monitoring and regulation, in other words, ‘steering’ not ‘rowing’; • contracting out publicly funded service delivery to separate service delivery agencies—whether they be ‘public’ (owned by the State), ‘independent’ (non-government, not-for-profit) or ‘commercial’ (for-profit); • establishing new forms of control and accountability across publicly funded services to focus on outcomes and ‘value for money’ to government within ‘pre-defined policy, regulatory and financial parameters; and on empowerment of customers/consumers within a redefined ethos of ‘‘service to the public’’ ’. M
A long list of sweeping reforms4 reflect this government’s commitment to ‘steering not rowing’, to coin Osborne and Gaebler’s (1993) term. This separates government’s policy and directive role from that of service delivery. In the language of managerialism, government should focus on ‘core business’ and contract out the rest. This is seen to give flexibility, economy and efficiency. Key words are competition, contestability and transparency; slogans are ‘more for less’, ‘value for money’ and ‘keeping the public sector honest’. It is argued that contracting out formerly publicly run services—even those of the Auditor-General’s Office—brings a purer form of accountability. The upshot of these reforms is that they do not merely tinker at the edges but represent fundamental shifts in governance. The government has aimed to change and limit the influence of interest groups with preferential access to policy-makers and service managers (Alford & O’Neill 1994: 9; Sullivan 1997: 5); resulting, some claim, in side-lining public accountability. The separation of policy from service provision is seen as a means of achieving greater 54
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efficiencies through competition and of checking the distortion of policy advice that is assumed under public choice theory—where bureaucrats are assumed to be driven by the motivation to expand their empires and to ‘overcome the capture of government decisionmaking by producer and beneficiary interest groups’ (Alford & O’Neill 1994: 7). New legislation has resulted in shifts in the formal distribution of power to a greater concentration of formal power in the centre, principally the Executive, Cabinet and the Premier; more power but less security and independence for departmental heads; a reduction in power for the central public service personnel agency, with the rgplacement of the independent Public Service Board by a Commissioner with reduced powers; and a transfer of power from parliament to the Executive, with a loss of information-gathering, scrutinising, reviewing and decision-making powers to Cabinet (O’Neill & Alford 1994: 31–43). These reforms, interpreted by critics as assaults on traditional institutions of participatory democracy, include in Victoria a number of structural changes that impinge on the external review of government.5 Critics of the Victorian reform agenda have noted the stifling of dissent with the passage of special legislation used to prohibit demonstrations on the Albert Park Grand Prix site; clever manipulation of the media, including refusal to give interviews to some media outlets; and the stifling of public debate and dialogue to the point of democratic deficit (Zifcak 1997: 106). Commenting on these changes, Goldberg, for the Council for Civil Liberties, said ‘concern ought to be raised about any legislation, regulation or practice, which prevents people from criticising the decisions of any level of government, be it federal, state or local’ (1994: 4). Salvaris notes the threat to citizenship and democracy of the Kennett ‘management reforms’; and he argues that these have been accompanied by measures which ‘undermine democratic processes, civil rights, open government and the independence of public officials’ (Salvaris 1995: 1). In searching beyond the Kennett government’s managerialism, Salvaris notes: ‘down deeper, it is driven by a hand of bleak fundamentalism about government and society, a politics that is essentially loveless, authoritarian and punitive’ (Salvaris 1995: 10). 55
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In terms of impact on the health care system, critics of policy and public sector reforms at state and national levels have noted the following:
• hospital reforms, including amalgamations, closures and reloca-
•
• • • • • •
•
•
tions, representing a dispersal of expertise, a loss of community at the local level (with closures of smaller country and suburban hospitals); complete reorganisation of the network of Melbourne hospitals, downscaling larger inner metropolitan hospitals through funding reductions and establishing new hospitals with private sector involvement in outer suburban locations; early patient discharge, shifting the burden of care back onto families and carers; impact of shorter hospital stays on the traditional health promotion and community-focused concerns of community health; cost-shifting from the states to the Commonwealth through bulkbilling in casualty departments and off-loading hospital costs onto Commonwealth Medical and Pharmaceutical Schemes; concerns about managerialism and the loss of holistic patient focus, as patients become commodified ‘revenue-earning units’ under policies such as casemix; concerns such as access for health care consumers to affordable services, with the shift in service provision from government to private suppliers/providers under privatisation and contracting out; increased stress felt by health workers due for example to greater intensity of acute carg patients, with early hospital discharge for recovery, and work-related reforms, including (in Victoria) abolition of the changeover shift system for public hospital nurses; continuing dominance of acute care and fears of further marginalisation of health promotion, illness prevention and traditional community health programs as case management or managed care from hospitals is contracted out to community services, or to private service-providers; concern about issues of access, equity and declining quality of care, the marginalisation of rural health with hospital closures, loss of services, growing isolation and the disproportionate impact of user-pays on marginalised, poor and rural Australians;
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• the continuing dominance of beliefs in the ‘rationality’ of the biomedical model and of beliefs in the ‘rationality’ of the market, driving health reforms, policy development and service delivery. These changes, in both their abstract and specific forms, are identified with the transition to the market state of the 1990s. (Core assumptions are discussed below.)
Economic rationalism: public choice theory and the free market The shift to entrepreneurial government and the market state rgflects and draws on the dominant paradigm of economic rationalism, illustrating Australia’s interconnectedness with similar reforms and shifts internationally—especially in New Zealand, Canada, the USA and the UK. Pusey (1991) charted the commitment to economic rationalist ideology by senior bureaucrats in key federal government departments in Australia in the late 1980s and early 1990s. Others note the dominance of this paradigm to government at all levels (Carroll & Manne 1992; Bell & Head 1994b; Emy 1993) and its identification with neoliberal forms of governance. Neoliberalism draws on three core assumptions: first, the commitment to a limited role for government in creating the legal and institutional setting for the efficient functioning of the laissez-faire economy—what Campbell (1997: 93) refers to as the ‘build-down’ of government; second is the freedom of individuals from government coercion, except when individual rights are under threat and, relatedly, the assumption of individual rationality and the centrality of public (rational) choice theory to this rationality (Emy & Hughes 1991: 385); third is the assumed benefits of unregulated voluntary market transactions to optimal wealth creation, distribution and efficiency.
Public choice theory Underlying neoliberalism is a commitment to rational or social choice theory,6 drawing variously on agency or principal/agent theory 57
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(O’Neill & Alford 1994; Stretton & Orton 1994; Boston et al. 1996), the ‘new public management’ and transaction cost analysis7 (Boston et al. 1996). Rational choice theory assumes that humans are motivated in their political and economic behaviour to maximise self-gain. Perceived as a liberal economic unit, the individual is unitary, calculating, egoistic, motivated solely by the economic end of accumulating wealth by means of profit maximisation (Fay 1975: 45). Public choice and agency theories assume that managers and politicians seek to maximise benefits to themselves and/or their departments (in terms of budgets, votes or personal remuneration, or power) through self-seeking policy advice and decision-making— hence the drive to separate government policy decision-making from service-delivery functions in the public sector. Thus contractualism and purchaser/provider distinctions seek to separate personal gain from rational policy-making and service provision. Public choice and agency theories are criticised because of their assumption that human behaviour is driven by narrow self-interest, abstraction from reality and limited predictive power, inattentiveness to contextual factors, lack of grounding in empirical observations, failure to deliver on promised efficiency and accountability gains (Self 1993), and inability to explain inconsistencies in behaviour—such as when voters back parties or bureaucrats support decisions that put in place policies from which they will not personally gain (see Boston et al. 1996; Hindess 1988; Self 1993). Hindess (1988: 4) argues that rational choice theory treats complex structural features of social life as ‘reducible to the actions of individuals’ rather than acknowledging the importance of conditions external to individuals yet influential on their decisions and actions. It might be argued that bureaucrats are driven by more than budget maximisation and empire-building. There is also growing recognition that economic motivation is one of a complex range of motivations of human behaviour, and that politicians are driven by more than power enhancement and vote maximisation (Boston et al. 1996: 30). Hindess makes the point that while rational choice theory assumes actors are individuals, it overlooks other ‘actors’ that reach decisions and act on them, such as capitalist enterprises, state agencies and political parties (Hindess 1988: 5). On the enduring debate on the distinction between agency (indi58
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vidual action) and structure (social determinants and constraints), rational choice theory overlooks the social conditions within which individuals are located and the effect of such conditions on individual choice and action. Its analysis shies away from structural explanations (based on class, gender or race/ethnicity) which would point out how particular individuals or groups are better positioned to maximise outcomes for themselves. At its extreme end, structuralism perceives larger, supra-individual entities as closing off available options, ‘so there is nothing left to choose’ (Hindess 1988: 94). As ‘consumer choice’ and ‘consumer empowerment’ are two of the claimed advantages of current reforms aimed at increasing competition and thereby benefiting consumers, these criticisms of the theory of behaviour underlying such claims are important. Similarly, under agency theory, principal–agent relationships assume that the parties to a contract are equal and have tended to ignore differences in power within organisations and in society more generally (Boston, et al. 1996: 33; Davis et al. 1997).
The competitive ‘free’ market By emphasising the ‘free hand of the market mechanism’ and the catchcry ‘let the market decide’, economic rationalist economists perceive the market as being outside human influence, and advance the idea that market principles will ensure efficient management, resource allocation and consumer choice. As Pusey observes (1993: 14): Economic rationalism is a doctrine that says markets and prices are the only reliable means of setting value on anything . . . that markets and money can always, at least in principle, deliver better outcomes than states and bureaucracies.
Public choice theory advances ‘the market’ as superior to government bureaucracies as a principle of organisation. Stretton and Orton capture the critique commonly applied to government economists regarding public sector inefficiency (1994: 48). Public enterprises are thought to neglect their customers’ wants, to allocate resources inefficiently, to produce inefficiently at unnecessary cost, and often to be stuck in their ways, resisting
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necessary modernization or replacement. These inefficiencies arise because administrative planning is a poor substitute for the customer’s market demands; public investors and managers lack profit-seeking discipline and incentives; public employees can use industrial muscle to get more pay for less work than marketdisciplined employers could afford; and governments can and do finance inefficient and unnecessary activities to continue when market discipline would reform or close them down.
However, markets are not necessarily distinct from institutions and organisations, as the major players in markets are organised institutions or firms. Stretton and Orton (1994: 100) question the extent to which market relations are, as claimed by public choice theory, more ‘free, fair and efficient’ than government bureaucracy. If, as public choice theory argues, individual self-gain requires control, then surely individuals within the major market player organisations are required to suspend self-gain in favour of common corporate goals— in the same way that public choice theory argues is impossible for individuals in public sector organisations? Critics of the economic rationalist emphasis on the ‘invisible hand of the market’ (Heilbroner 1990; Pusey 1991; Emy 1993; Kelsey 1995; Saunders 1994; Cox 1995) cite as problems the narrow economic focus which invalidates social and moral concerns, the negation of the political role of market economics, and the inclination towards individualist rather than collectivist solutions to social issues and problems. Scott (1996) argues that ‘free markets’ are politically constituted social organisations. Moreover, there is some currency in the argument that differences in the essence of the private and the public sectors invalidate the unquestioning application of private sector principles and practices and free-market assumptions to ‘social’ goods, or to institutions or organisations that do not just produce goods or services but must look also to the public interest. Critics argue that the denial of a need for government intervention in the market in some areas characterised by market failure, such as health, overlooks important distinctions between the roles of the public and private sectors as currently played. The public sector is concerned about the public good based on beliefs in rights and a redistributive ethos, rather than being purely profit-driven. 60
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In relation to the presumed equivalence of public and private sector roles, comparisons between the two often exclude functions performed by the public sector (such as training, public service research and development, community development) which relate to longer-term benefits, uncoordinated with political electoral cycles, often unmeasurable in economic terms, often on a collective rather than an individual level. Stretton and Orton (1994) argue against the supremacy of markets over public sector provision, on the grounds that downsizing the public sector may overlook the multiplier effect of public sector stimulation of private sector performance. They cite examples where public provision of goods or services is preferable to an income transfer at the individual level, and argue that there is no definite superiority of either public or private enterprise for the provision of goods and services (Stretton & Orton 1994: 72–7). On the second point—of the specific characteristics of health in relation to the operation of free-market principles—the argument according to market theory is that consumer choice and competition result in efficiencies. In the health area, however, important differences prevail. Providers (doctors and health care professionals), rather than consumers, determine the supply (and demand) for health services; relationships are less direct, and the funder (government in the public sector or insurer in the private sector) is rarely the user or the provider (Easton 1994b: 43); consumers lack expert knowledge and are weak bargainers in the marketplace and are unable to judge for themselves the quality of hospital care prior to admission or the safety of a surgeon’s skills. Health needs are often not elective or subject to choice (in the same way that buying a new television might be). There may be no choice of facility or provider in rural or remote areas or, indeed, in metropolitan hospitals with no reserve casualty or ward capacity and where ambulance services and doctors may need to call on five hospitals to find a vacancy. Moreover, consumers’ willingness to pay is not so relevant as it is in other areas of consumption, given set fees (within ranges). Finally, health has traditionally been viewed as a system committed to access to services according to need, rather than ability to pay (Saunders 1994: 86); as a ‘social or public good’ and, indeed, a ‘right’ related to collective responsibility rather than as a commodity dependent on the individual’s ability to pay. It is these 61
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commitments to universal access to available health care resources that have helped to shape the NHS in Britain and Medicare in Australia. As Williamson (1993: 194) notes, health and ill-health, even compared with areas like education, are easier to define. Those in ill-health are often viewed as victims rather than the cause, and health ‘is also an area of provision where disaggregation or deferment of consumption is less feasible’. In stark contrast to these arguments is the ‘new right’ thinking of individual rgsponsibility for health care; in a system based on private sector competition rather than national publicly funded schemes, framed in terms of a mix of individual consumer choice and responsibility. Such arguments overlook structural barriers to the individual’s ability to exercise choice and consumer sovereignty. Emy (1993: 32–3) sounds a note of caution regarding a narrow economistic view of society, that downplays other social and moral values; the focus on individualistic rather than collectivist solutions; the narrow quantitative approach to organisational decision-making and the reification of ‘the market’: by stripping the market down to its bare essentials, by abstracting it from society, economic rationalists endow it with a misleading simplicity. By oversimplifying the social dynamics of market societies they run the risk of recommending policies which do not contribute to the long run viability of society as a whole.
Similarly, Self (1993), in his analysis and critique of public choice theory and the dominant market ideology in public policy, proposes a left-liberal agenda, where concerns of citizenship and democracy would replace the dominance of public choice theory.
Shifts in governmentality and new forms of governance: consolidating the market state One way of conceptualising these shifts is in terms of shifts in governance (alluded to throughout this chapter), rather than merely shifts in government (Jessop 1995). This highlights ‘a major paradigm shift in political (and economic) analysis’ and dissatisfaction with ‘a rigid public-private distinction in state-centred analyses of politics and its associated top-down account of the exercise of state 62
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power’ (Jessop 1995: 308, 310). This signals a shift in governmental rationality and, more generally, a shift from welfarist to neoliberal types of governance and to ‘more marketised, entrepreneurial consumerist forms of social organisation and a shift from social and legal to economic forms of rationality’ (Garland 1997: 183–5). Drawing on poststructuralist theory, and Foucauldian understandings of power, as diffused as well as centralised through State sovereignty and decision-making, the notion of governance seeks to encompass not just the sovereign power of the State but wide-ranging ‘political governance mechanisms’, ‘tangled hierarchies’, parallel power networks or ‘other forms of complex interdependence across different tiers of government and/or different functional domains’ (Jessop 1995: 310), as well as the ways these are translated at the individual level, into self-regulation. Use of Foucault’s (1980) ‘technologies of power’ and ‘technologies of the self’ emphasises the links bgtween self-regulation and broader systems of control and surveillance, or ‘governmental technologies’; referring to the means, strategies techniques and procedures, ‘through which authorities seek to embody and give effect to governmental ambitions’ (Rose & Miller 1992: 175). UK scholars, including Miller and Rose (1990), Rose (1996), Barry et al. (1996) and Garland (1997), writing on modern forms of power, have contributed to an understanding of the dynamics of community acceptance of neoliberal reform agendas. Miller and Rose (1992: 189) acknowledge the role of expertise (actors, powers, institutions and bodies of knowledge) which, while professing altruism and neutrality, play a crucial part in legitimising government and in aligning personal choices with the ends of government. Rose (1993: 293) and Rose and Miller (1992: 191–2), commenting on the shift from the welfarist to neoliberalist state of the 1980s and 1990s, describe the latter as a new form of governmentality. The transition from the welfare to the market or neoliberal state is marked by a shift from a system of governance based on an administrative and regulating State through the mechanisms of the bureaucracy, to one of the minimalist State, working through ‘the hidden hand of the market’. Yeatman (1996) conceptualises this as the shift from the welfare to ‘the competition state’. Emy (1993: 205) poses the key issue as a conflict between the values of democracy and of ‘the market’; between ‘the culture of 63
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production’ and shoring up the market economy, which threaten to undermine the values of equality, equity or fairness and respect for human dignity on which democratic institutions are based. Rein (1989: 3) sees it as a trade-off between social equity and economic efficiency. Concern about equity is based in a recognition that the market system does not result in even distributions of income and wealth, protect against monopolies, stabilise prices or necessarily bring about the best short- and longer-term benefits to citizens (Emy 1993; Emy & Hughes 1991). This concern raises questions about the role of government as regulator or arbitrator and adjudicator in relation to the market and the extent to which free-market principles are problematic in and of themselves, and in relation to areas of ‘market failure’ and externalities or spillover effects which impose social costs, such as industrial pollution or environmental degradation. Much has been written on the emergence of the postwar welfare state, its basis in communitarian ideals of social solidarity and community membership and its redistributive use of taxation to fund more equitable outcomes. The welfare model emphasised collective security and government intervention to provide social security, welfare payments to families, public health, housing and higher levels of employment, which resulted in governments in countries like Australia, New Zealand and the UK participating directly or indirectly in most aspects of the mixed economy. The postwar welfare state compensated for the needs and risks created by the market society, perceived as legal claims granted in citizenship (Offe 1984: 219). The social basis of the welfare state is thus located in the historical compromise between the interests of finance, capital and labour. Drawing on liberal and neoliberal theories, critiques of the welfare state highlight a challenge to postwar Keynsian welfare state consensus, services not meeting needs, lack of accountability of the public service and the ‘crisis’ of cost. Under conservative new right regimes in Thatcher’s Britain and Reagan in the USA during the 1980s, new right theories underlie the pursuit of public policies. Based on liberal free-market individualism, a conservative new right agenda followed policies of budget cuts to social welfare, shifts in public service functions to the private sector, the public float of 64
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government monopolies, selling off of government assets under privatisation, contracting out, and trade and industry restructuring aimed at restoring ‘the market’. Ironically, similar policies were instituted under successive Labor governments in Australia up to the Keating government’s defeat in 1995. Sharing a commitment to monetarism, the free market and limited government intervention, conservatives, unable to accept the notion of citizens’ rights to welfare, were united with liberals, seeking a minimal role for government and a market-based individual liberty (King 1987: 9). As King notes, conservative new right liberalism is ‘a restatement of the ideas central to the classical liberal tradition’—beliefs in competitive individualism, a reduced role for the State, and a commitment to the unfettered market (King 1987: 10). Similarly in New Zealand, critiquing the social costs of restructuring and the shrinking of the welfare safety-net, Kelsey (1996: 350) says: (W)hat were once basic priorities—collective responsibility, redistribution of resources and power, social stability, democratic participation and the belief that human beings were entitled to live and work in security and dignity—seemed to have been left far behind.
Rose and Miller (1993: 285) conceptualise neoliberalism as governing through regulating the individual citizen’s choices. This is accomplished through dismantling State provision of health, housing and education and replacing this with individuals providing for their own needs by purchasing goods in a competitive market. The role of the State is minimalist, regulating through contractualism and corporate management models and working through markets. Welfare is targeted as a safety-net to particular groups in acute need and self-provided (or based on self/community/government partnerships), encouraging individualism and independence (and thus minimising claims under group rights) involving an ‘individualisation of risk’ (compared to welfare models, where risk is carried by the State and supported by the collectivity). A further point is that the more centralised control by government bureaucracy brought by administrative (managerialist) changes under neoliberalism are undermining the autonomy of independent professional 65
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and local community interests (Beilharz et al. 1992: 153). This approach also serves to breach the walls between functionally independent areas (such as welfare, education and health) and to make them more accessible to the economic interests active at the centre. The argument is that in contrast to the 1970s, helping professions like nursing, teaching, social work and voluntary non-government organisations were a source of grassroots critique of bureaucratic practice and government policy and that centralised strategic control to ‘monitor, control and direct’ around management and funding accountability undermine this role (Beilharz et al. 1992: 153). As observed by Bryson (1987) and Beilharz et al. (1992), the demands of managerial accountability imposed through government and funding prescriptions often replace senior experts in particular policy areas with graduates in economics and management in government bureaucracy at the local and community organisational level, such as local councils, community health centres and hospital boards. Under market models, accountability is defined in terms of financial or budgetary transparency rather than measured against social justice goals and longer term sustainability. Policy decisions are depoliticised market decisions, thus transforming political issues into purely technical ones, such as budget cuts to the public sector, after the 1996 Commission of Audit in areas like education, health and Aboriginal affairs, which were justified on the grounds of taking a share in deficit reduction.8 An alternative is the idea of a ‘social market’ model (Emy 1993) or a justice-based model (Cox 1995). Such models seek to provide a more just, market-influenced system with safeguards, rather than a romantic return to the welfare state. Such models acknowledge the worth of efficiency measures successfully applied to the public sector, but apply a more qualified commitment to the market by acknowledging ‘market failure’ in some areas, the unique characteristics of the role of the public sector, and the inability of markets equitably to distribute resources such as health, education, housing and employment, which should be preserved as basic rights that are inherent in citizenship. Social and justice market models acknowledge the unequal structuring of need/access to ‘basic’ services along lines of class, gender and race/ethnicity, and thus bwild in the need for targeted programs which are not just part of a safety-net. Such 66
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programs would be informed by analysis of emerging (polarising) class structures, and would thus link into the observed effects of broader government policies in areas such as employment, taxation, job creation and the regulation of finance markets. Recognising the inadequacy of reliance on purely market mechanisms, there could be public watchdogs (such as Auditors-General) and public standardssetting (such as citizens’, patients and students’ charters), risk auditing, risk management and ‘community service obligations’ built into contracts and service agreements (discussed in more detail in chapter 8). The market is seen as one of a range of allocative mechanisms, supplemented by community service obligations, with broader accountability, assessed in social rather than purely economic terms. Along similar lines, Hood (1997) points to a range of forms of contract State: the ‘steering’ State, the ‘empowering’ State, the ‘consumerist’ State and the ‘amoral’ State, with the aim of broadening debates, recognising overlap and difference. Hood makes the point that contracts are in principle capable of serving differing moral and political agendas.
Conclusion Central to reforms introduced under the economic rationalist agenda are the following shifts:
• the transfer of corporate management principles, developed in the private sector, into the public sector (business plans, quantifiable performance indicators, total quality management, benchmarking); • the trend to ‘steering not rowing’, or separating funding and policy-setting from the service-delivery roles of government; the purchaser/provider split, where government becomes the purchaser and not necessarily the provider of services; • shifts from government to private sector provision of services, with privatisation, contracting out and reductions in the size of government bureaucracies; • shifts from government provision to user-pays and consumer cost-sharing under policies of cost recovery as opposed to government funding of services; 67
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• the shift in public bureaucracies from a focus on process or inputs to outcomes and outputs;
• changed relationships between the State as employer and public service employees, with individually negotiated contracts displacing unionised wage collective bargaining; • a shift from citizen to consumer; • a shift from the welfare to the neoliberal state. While oriented most explicitly towards increasing public sector efficiencies, it is argued that the changes discussed in this chapter signal shifts in governance, shifts in accountability, and shifts in the relationship between the State and the individual, principally in the transformation from citizen to customer. Such shifts have the potential profoundly to influence quality and scope of care along with access, equity and justice in relation to health care provision, and are thus of central importance to the analysis of health policy. It can be argued that the introduction of corporate planning and the focus on cost and efficiency has produced many positive outcomes. Management reforms in the public service have demonstrated the need for reforms, along with its ability to become more efficient and effective. However, from a critical/analytical viewpoint, reforms such as privatisation and contracting out raise questions about the impact on health care provision in relation to quality, access, equity and cost of reforms as well as the long-term sustainability of services. Contractualism and privatisation are central issues driving the restructuring of health policy and forging new relationships between the public and the private sectors, and between the State and the individual (Alford & Considine 1994; Davis, Sullivan & Yeatman 1997; McGuire 1994; Yeatman 1996).
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II FINANCING HEALTH
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4
Commonwealth/state relations in health STEPHEN DUCKETT FINANCING HEALTH COMMONWEALTH/STATE RELATIONS IN HEALTH
Government responsibility for health and community services in Australia is shared between the Commonwealth and the states. Unfortunately, this sharing is not done in a consistent and coherent manner, and it is thus difficult to develop comprehensive national policies in this area. The state responsibility for hospital services, the Commonwealth responsibility for medical services, the joint responsibility for home and community care projects, and the divided responsibility for disability services, render coherent policy-making at the state level almost impossible. The Commonwealth government’s domination of health policy in Australia prevails despite the fact that its formal constitutional powers with respect to hospitals are limited. When states require extra money for their hospital systems their first port of call is the Commonwealth. Health insurance policy is set in Canberra, which in turn means that the Commonwealth exerts a major influence over issues relating to fees for private patients in public hospitals. Medical fees policy is also the preserve of the Commonwealth government. This chapter briefly reviews responsibility for health care spending in Australia to illustrate the different roles of the Commonwealth and the states/territories. Relationships between the Commonwealth 71
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Table 4.1
Total rgcurrent expenditure for health care in Australia, 1995–96 Commonwealth gov’t
State Health and local Insurance Out-offunds pocket gov’t
Public hospitals 4870 Private 240 Nursing 1860 Medica 6086 Dental 105 Other professionals 171 Pharmaceuticals 2086 Community and 507 public health Total health 17 321 expenditure Other 396 Total recurrent 16 321 expenditure
4150
433 2004
237 141
216 546 205 42
1312
434 641 712 1143 901 2091
Other 537 168 357 166
3
1822
9990 2846 2738 7371 1935 1443 4219
7152 933
4201 632
6594 95
1324 235
1822
6773
4078
6017
996
34 185
Source: Australian Institute of Health and Welfare (1998).
and states in health care policy are often fractious, and the chapter reviews some contemporary health policy issues highlighting the different perceptions of different players in the policy process, concluding by outlining two scenarios for reform of policy: one involving minor tinkering, the other a more fundamental realignment.
Shares of health expenditure The total recurrent expenditure for health care in Australia for 1995/96 (the latest year for which figures are available) was $41.3 billion, representing about 8.5 per cent of GDP (AIHW 1998b). Of that, about half was sourced from the Commonwealth and about one-fifth from the states; about one-eighth was funded through health insurance with a similar amount from outof-pocket contributions. However, the distribution of expenditure shares across the health sector is quite variable: most public hospital expenditure is by government, either Commonwealth or state (see Table 4.1). 72
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Expenditure on nursing homes and medical services comes mainly from the Commonwealth government, while private hospital, dental services and other health profession funding comes from individuals—either via health insurance or as out-of-pockets contributions. One can also look at expenditure from the perspective of the funder. For states and territories, public hospital and community and public health services are the main focus of their expenditure: these two items together account for almost two-thirds of their expenditure. Table 4.1 shows that the main foci of Commonwealth expenditure are medical benefits (35 per cent), public hospitals (28 per cent), pharmaceutical benefits (13 per cent) and nursing homes (11 per cent). These differential funding roles mean that the different players will place different emphasis on policies with respect to those different subsectors of the health sector. This is especially the case as each of these components has differential expenditure growth rates, with medical and pharmaceutical expenditure growing more rapidly than other areas.
The problems of Commonwealth/state relations in health: the view from the Commonwealth The different responsibilities of the different players mean that the players have different perceptions of the problems of Commonwealth/state relations. Reaching agreement on what the key problems are is thus difficult, making reaching agreement on solutions to those problems even more difficult. There are three key problems from the Commonwealth’s perspective: escalation of government health care expenditure; cost-shifting; and difficulty of policy implementation. Given the Commonwealth’s relative funding responsibilities, it is not surprising that one of the problems that Commonwealth agencies often perceive with the health area is the escalation of health expenditure. Although over one-quarter of Commonwealth health expenditure goes on public hospitals, Commonwealth expenditure on public hospitals is capped within the life of each Commonwealth/state Medicare Agreement. On the other hand, the key Commonwealth health care ‘entitlement’ programs (the Medical Benefits, MBS, and Pharmaceutical 73
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Benefits Schemes, PBS) have traditionally had high rates of growth. Expenditure for the PBS grew 65 per cent over the five-year period 1989/90–1994/95; medical benefits expenditure grew 50 per cent over the same period, but there are signs that cost escalation of medical benefits has moderated recently, with benefits expenditure in 1996/97 being just 2 per cent higher than 1995/96 (see Commonwealth Department of Health and Family Services, Medicare Statistics1). Those representing central agencies in the Commonwealth such as the Treasury and the Department of Finance often argue that the high rates of growth are ‘unsustainable’. However, on the basis of currently available data, there is no objective basis for making such a claim. In economic terms, the ‘sustainability’ or appropriateness of expenditure growth rate should be assessed on the basis of whether additional expenditure is warranted and, in particular, whether the marginal benefits that accrue from additional expenditure are greater than the marginal costs. Importantly, even though there is a high rate of expenditure growth on the PBS, new products listed for the scheme must demonstrate that they are cost-effective (Freund 1996; Mitchell 1996) and hence that expenditure is justifiable in economic terms. There is no such economic justification for the rate of growth in medical benefits expenditure; proposals for economic evaluation of new items in the government fee schedule were announced in the 1997/98 Budget, and are still being implemented. Demographic factors such as aging and population growth explain only a small proportion of the overall rate of growth in medical benefits expenditure (Barer et al. 1990), the principal reason being service-intensity growth—that is, the number of visits per head. Controlling this latter variable is complex, and successful prevention or substitution strategies often require cooperation between the Commonwealth and the states. Criticisms of the ‘sustainability’ of Medicare, particularly if maintained in the face of the more recent, lower growth rate in medical costs, need to be treated with a deal of scepticism. Such arguments often simply reflect an ideological predisposition to smaller government, or are used to create an appearance of a ‘crisis’ to allow the ‘reformers’ to purvey their latest nostrums. Similarly, conservative governments may wish to reduce the scope of current Common74
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wealth responsibilities for ideological reasons, as a way of reducing political pressure in future for new spending policies. The Commonwealth often seeks to pass some of the risk of expenditure growth to the states by proposing to transfer programs to the states with high actual or potential growth. (A recent example was a proposal to transfer responsibility for nursing homes and aged care to the states.) The Commonwealth also criticises the rigidities of Commonwealth/state relations as inhibiting innovative solutions to the cost escalation ‘problem’. A second problem of Commonwealth/state relations from the perspective of the Commonwealth (especially central agencies) is that the multiple and confused responsibility in health provides opportunities for cost-shifting. The most prominent example of cost-shifting is where a public hospital (funded at state level via a mixture of Commonwealth/state Medicare Agreement funds and state funding) closes an outpatient service which is replaced by a ‘privatised’ service, where specialists bill Medicare as consultants. In this way, costs that were previously met at the margin by a state government via the hospital would now be met by the Commonwealth. The Commonwealth perceives two main problems with costshifting. First is the direct effect of cost-shifting on Commonwealth outlays, and its contribution to the high rates of expenditure growth. In the example quoted above, Commonwealth officials argue that ‘double-dipping’ is occurring, in that the Commonwealth is paying directly through medical benefits expenditure for the newly ‘privatised’ services but is still contributing to the costs of now closed outpatients through its hospital Agreement payments. Commonwealth officials also would identify a second, indirect problem: cost-shifting potential may reduce the likelihood of microeconomic reform by states—that is, rather than addressing problems of efficiency in state health systems, states will reduce their own outlays by cost-shifting. Because there is no improvement in system efficiency, this implies a less efficient economy overall and contributes to higher costs. A third problem of Commonwealth/state relations from the point of view of the Commonwealth is that Commonwealth policies often can be implemented only through negotiation with states, using states to implement the new policy. This is partly because of political 75
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factors, such as the pre-eminence of the states in delivery of service in particular areas, such as hospitals, and partly because of Constitutional constraints on Commonwealth legislative power and the consequent use of the state grants power (Section 96) to give effect to new policies. Use of the states as the instrument of policy implementation may result in distortion of priorities (goal-shifting); so that programs as finally implemented may not clearly reflect the goals originally established as the basis for the Commonwealth funding.
The problems of Commonwealth/state relations in health: the view from the states States have a different litany of problems with Commonwealth/state relations. First is the problem of ‘vertical fiscal imbalance’ (VFI). Since the Uniform Tax Case of 1942, the Commonwealth has been the principal taxing power in Australia, in 1994/95 raising 76 per cent of all tax revenue; the state governments have had proportionately greater service-delivery responsibility. The disjunction between taxation and spending can be measured: the ratio of own-source revenue to own-purpose expenditure was 1.18 for the Commonwealth in 1994/95 but only 0.56 for the states; the 1994/95 ratio of taxable capacity to expenditure shows a greater divergence—0.8 (Commonwealth) and 0.26 (states) (Mathews & Grewal 1997). Assuming that Commonwealth, state and local government can be arrayed in a vertical hierarchy, there is thus a vertical imbalance in the assignment of taxing and spending powers in the Australian Constitution. States argue that this VFI hampers their ability to manage services for which they are responsible as, in the face of higher demand pressure, they are not able to increase revenue. They are put in a role of supplicants to the Commonwealth for funding to meet their service responsibilities. In this regard states also feel some of their financial pressures would be alleviated if Commonwealth expenditure currently directed to MBS and PBS services were directed to state programs (Paterson 1996). This is particularly the case where it is felt that substitution strategies could lead to a more efficient mix overall—that is, 76
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increased expenditure in some state or shared programs, such as Home and Community Care, may lead to offsetting savings in the Commonwealth’s rapidly growing MBS and PBS programs. This hypothesis is being tested in the Coordinated Care Trials discussed below. In 1994/95, Commonwealth payments to the states were a mix of tied grants (56 per cent) and untied general revenue assistance, this proportion having risen from 37 per cent in 1982/83 (Mathews & Grewal 1997: table 12.1). This leads to a second problem from a state perspective: that the conditions of the tied grants militate against their ability to manage their services appropriately; the states chafe at this restriction of autonomy. States often argue that there is substantial variation in local needs, and that the appropriate local response to meeting problems requires more autonomy and flexibility than the existing Commonwealth/state agreements provide. In reality, programs such as Home and Community Care are built on regional analyses of needs and incorporate substantial flexibility, as demonstrated by the variability of the program nationally (the guidelines allow home help to be contracted out by local government in Victoria and provided by the centralised Home Care Service of New South Wales). The arguments about lack of autonomy are probably most valid where there are multiple small specific programs. Although over half of the expenditure on Commonwealth/state programs for health is incorporated into the single Medicare Agreement, there is a large number of small specific programs which inevitably lead to boundary problems with administrative costs of implementation. Small programs have arisen in response to particular identified needs (e.g. AIDS or drug and alcohol programs) but have bgcome entrenched because of the support of the individual constituencies and the continuing nature of the problem addressed by the program. Unless there are careful coordination strategies, it is possible to end up with a number of separate programs addressing the same issue and thus a problem of programmatic overlap or duplication. (As one example, the needs of intravenous drug users could be addressed through an AIDS program, the drug and alcohol program, or both.) Finally, states often argue that the existing Commonwealth/state division of responsibilities leads to extensive duplication, waste and 77
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administrative burdens. The alleged duplication or waste has bgen quoted (by a state Premier) as being of the order of 20–30 per cent of expenditure. Such a claim is fanciful, given that the running costs of the Commonwealth Department of Health and Family Services (public servants, travel etc.) are about 1.25 per cent of its total expenditure ($275 million in 1997/98 out of $22 017 million). Even if all Commonwealth departmental costs duplicate state expenditure, it is still a relatively small proportion of total outlays.
Problems of Commonwealth/state relations in health: overview Dispassionate observers would not necessarily accept either the Commonwealth or the state formulations of the problems of Commonwealth/state relations. First, it is important to stress that lack of coordination per se is not a problem: it is the results of the lack of coordination (either sins of commission or omission in terms of costs, quality of care or access to treatment) that need to be considered. Second, there are real problems of Commonwealth/state relations in terms of the political process and accountability. The dissipation of responsibility in the health sector means that whenever state or Commonwealth politicians are under pressure they almost inevitably attempt to shift blame to politicians at the other level (the so-called ‘blame game’). This dissipation of responsibility undermines the functioning of political accountability for government actions. Third, overlap in multiple programs addressing the same need and current boundaries between the Commonwealth and states certainly lead to some irrationality. There are probably many examples where additional expenditure in tightly constrained state programs might lead to greater efficiency or better health outcomes for the whole system than additional expenditure on the Commonwealth entitlement programs such as the MBS. So, for example, higher state community health expenditure on podiatry for a person with diabetes may lead to substantial savings by the Commonwealth by reducing the demand for specialist physician services at a later stage. Clinicians and health workers feel real frustration when they 78
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are unable to provide needed services in a rational and efficient manner. Fourth, the existing Commonwealth/state division of responsibility and other aspects of program design almost inevitably lead to cost-shifting as managers seek to address budget problems by transferring programs to readily accessible Commonwealth entitlement programs such as MBS or PBS. However, health workers often perceive these strategies as irrational or cost-increasing in overall system terms. Health workers are also concerned when they are caught in conflict between the Commonwealth and the states—for example, when the Commonwealth threatens individual medical practitioners with prosecution for engaging in cost-shifting practices endorsed by states or hospitals. To the extent that multiple funding sources lead to increased (or conflicting) reporting requirements, there are also efficiency losses caused by Commonwealth/state relations. Finally, there are gaps in government provision, such as in the area of allied health, community health and health promotion, which may be able to be addressed by savings in the rapidly growing entitlement programs.
Directions for reform Two broad, contrasting approaches to reform of Commonwealth/state relations are minor tinkering to redress the most egregious problems and attempts for major restructure. Minor tinkering should occur in a number of areas. First, it is possible to consider some minor realignments of responsibilities, tidying up the obvious anomalies in the division of responsibilities. For example, Section 8.9(g) of the Medicare Agreement provides that states will: ensure that except in an emergency, a recognised hospital does not issue a prescription to an inpatient on discharge, an outpatient or an accident and emergency patient, that would attract (Commonwealth) pharmaceutical benefits.
Eliminating this clause of the Medicare Agreement and replacing it with some arrangement whereby there is a limited entitlement to 79
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prescribe on the PBS under some agreed pharmaceutical formulary would have a number of advantages, including:
• • • •
savings to the Commonwealth by reducing GP visits; a more convenient system for consumers; economies of scale in prescribing pharmaceuticals; and a possibly higher quality of care by ensuring that pharmaceuticals prescribed to patients are consistent with contemporary best medical practice.
There needs to bg a collapsing of some of the historic, highly specific programs into a smaller number of larger, more flexible programs. Such a trend is already beginning to occur in the public health area with the introduction of Public Health Outcomes Agreements. These broadbanded programs should also address the states’ problems of lack of autonomy by allowing considerable flexibility in terms of how the agreed objectives under the program are to be achieved. Increasing flexibility by replacing detailed input or process controls by broader, output or outcome controls is not necessarily an easy process: it will require governments—both Commonwealth and state—to specify what their policy goals are in output or outcome terms and for those outputs or outcomes to be measurable (Duckett & Swerissen 1996). However, much of the success of these broadbanded programs will lie in the extent to which outcome measures capture the equity concerns and longer-term goals of programs such as Women’s Health. Significant advances in measurement technologies have been made in some areas of health and community care, especially hospital inpatients (through casemix measures such as diagnosis-related groups) and immunisation coverage (through the use of the Australian Childhood Immunisation Register). However, there are many areas of expenditure, such as outpatient and community health activity, where output and outcome measures are still under development. Further, not all existing output or outcome measures directly reflect the performance of funded agencies or state governments. The performance of state governments with respect to prevention may not be measurable for some years if there is a long latency period for the condition (the most notable example being AIDS). A third set of reforms, still at the margin, would be to allow 80
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more flexibility to transfer funds from one program to another. The Commonwealth has designed and established a number of new programs to reduce demand on MBS activity, such as the Breast Cancer Screening Program. In addition to the health enhancement objective of promoting early detection of cancer and thus reducing breast cancer mortality, this program had the objective of moderating the previous rapid growth in MBS expenditure on mammography. More flexibility has also been introduced in provision of aged care services through the ‘multipurpose service’ program. This program provides flexibility in funding arrangements for aged care services to rural communities. Traditional nursing homes and hostels are often not independently viable as free-standing institutions in these locations and, in order to ensure access, the Commonwealth and states agreed to the development of a program that would provide care similar to that previously provided separately in nursing homes, hostels and acute hospitals. The Commonwealth has gone substantially further in this regard in recent years, with approval to ‘cash out’ Medicare expenditure in a number of pilot programs, the most important of which are the ‘Coordinated Carg Trials’. Coordinated care is defined for the purpose of these trials as being the explicit process of planning and organising the provision of services through pooling of funds, within current resource levels, and the development of agreed individual care plans for people who have difficulty accessing appropriate services and/or self-managing their care needs over a long period of time. Eleven trials have been established across Australia which involve the pooling of Commonwealth and state funds, including pooling of expected Medicare and pharmaceutical benefits in a single program. Such trials will result in improved individual client health and wellbeing within existing resources. The evaluation of Coordinated Care Trials will be finalised in 1999. The alternative broad approach to reform involves a more fundamental change to Commonwealth/state relations, to assign responsibility for all health and community services to one level of government. The logic of this approach is overwhelming: the Commonwealth already funds about half of all health care expenditure, with the state role being only about one-fifth of expenditure and a substantial proportion of ‘state’ expenditure being funded indirectly 81
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from the Commonwealth through general revenue-sharing arrangements. The Commonwealth assuming responsibility in health care would represent a major realignment in general government responsibilities, and would go a long way to redressing the problem of vertical fiscal imbalance: the Commonwealth as a tax-raising level of government would assume a much greater level of responsibility for service, producing a much clearer political accountability for services expenditure. Concomitantly, the states would lose responsibility for a substantial proportion of their budgets (about 30–40 per cent of their expenditure), and their existing tax-raising powers would thus meet a larger proportion of their expenditure. This is the rgverse of the typical proposals for addressing VFI, which commonly argue to transfer tax-raising powers to the states. Whereas a decade ago such a proposal would have been administratively unfeasible, advances in measurement technologies have now made it possible for such a change to be contemplated. The major area of overlap of expenditure relates to hospital services. A decade ago hospital budgets were essentially negotiated between state authorities and the hospital on a case-by-case basis. In 1997/98 all states except New South Wales set budgets for hospitals using a casemix formula: that is, hospital budgets are now determined less by local political argument and more on the basis of hospital activity, using casemix measures such as diagnosis-related groups (DRGs). Although the casemix funding arrangements differ between the states, all the formulae use the same classification system and the same underlying logic in terms of payments for normal cases and additional payments for very-long-stay patients. It would thus be a relatively straightforward process for the Commonwealth to move to fund all public hospitals on a case payment basis, harmonising the different state formulae. In terms of other areas of health expenditure not funded by the Commonwealth, health and community care programs are already jointly approved by Commonwealth and state officials and disability services were funded by the Commonwealth in the past. Community and public health services could easily be funded on a capitated population basis to community or regional organisations. The administrative costs of a unified national approach would not be prohibitive and are thus feasible. 82
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Case payments to the hospitals could either be managed through the Health Insurance Commission, in the same way MBS and PBS expenditure is managed, or caps on expenditures could be applied at either national or regional levels through budgetary strategies of reducing prices if volume increases were greater than target (a similar approach is used for medical payments in the USA). The Commonwealth could establish targets at national, state or regional levels. A unified arrangement would necessarily involve savings. Although administrative costs at the national level as a proportion of total expenditure are relatively small, there are significant administrative costs incurred in states and territories. It is difficult to argue that the state is the appropriate level of provision of health services given the very substantial variation in the size of states and territories: if New South Wales is the optimum size for management of a health system, with a population of 6 million people, then the Northern Territory cannot be the optimum size, given its population of around 200 000, or vice versa. A unified national approach would not necessarily mean that the states did not have any role in health care at all. Although the Commonwealth could assume responsibility for direct payment to hospitals and other health and community care providers, the organisational arrangements in terms of ownership and provision of services should not change. The Commonwealth should not re-enter direct provision of care, and public health and community services should remain provided by either state or local or non-government organisations. Although this radical reform approach has obvious logic and is administratively feasible, it is unlikely to be implemented. Commonwealth/state relations have been paralysed for the past decade—a paralysis caused by the attitudes of both Commonwealth and states. The Commonwealth has been averse to advocating strongly a unified approach because of internal divisions and the political risks involved. In terms of internal divisions, the central agencies, especially Treasury and Finance, have been strongly opposed to any expansion of Commonwealth responsibilities (for reasons outlined earlier in this chapter). The principal experience that Treasury and Finance have with health sector expenditure has been with the MBS and PBS, which until recently have bgen growing faster than most 83
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other areas of government expenditure. The health portfolio has not had sufficient power to overcome Treasury and Finance objections, and has not vigorously pursued a unified approach. At the ministerial level there are two kinds of political risks associated with a national system in health care. First, a unified approach would make the Commonwealth more clearly accountable for problems in the hospital system, and these are non-trivial. Most states have significant levels of waiting lists, and hospitals are better organised to exert pressure on politicians than the relatively diffuse medical profession and pharmacists. Second, a unified approach would not necessarily be politically popular in all parts of the country: that is, those opposed to a unified approach would be able to stimulate local political campaigns against ‘Canberra dominance’. This political opposition would be most easily generated in the smaller, outlying states, which legitimately feel that there would be a loss of control of local services. States have traditionally been opposed to a unified national system particularly because health and community care services represent a substantial proportion of state activity. In their arguments to support a continuing role in health and community care, states have emphasised the ‘subsidiarity principle’, which argues that decisions in any area should be made at the lowest possible jurisdictional level. This principle has a certain logic, although it is more relevant to management decisions than broad issues of social policy. The opposing principle, variously called the nationhood or solidarity principle, argues for equity across a whole jurisdiction. The issue then becomes which of these principles is most important—one that all Australians should have equal access to health care and that health care is a national responsibility, or one that argues for devolution to states and within states to regions. If its role were simply that of provider, the state government might not feel it had an adequate stake in an area of significant state expenditure, and so a move to a unified national approach would represent a significant weakening of an area of state responsibility. However, there is no intrinsic reason why states should continue to regard responsibility for funding health services as a necessary state responsibility. Much of the focus of the Departments of Premier and Cabinet in recent years has been on economic development 84
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(i.e. attracting industry and employment to the state), and privatisation through divesting substantial public sector assets (i.e. electricity, gas and water), and so in future states may not necessarily regard control of health funding as a core component of their responsibility. One of the major weaknesses of moving to a unified national approach is that state responsibility has allowed substantial experimentation in structures of health care provision. Over the past 20 years, for example, New South Wales has organised its services on an area basis, compared with Victorian and South Australian institutional base structures; and casemix funding was first introduced in Victoria before spreading to most other states. Unfortunately, the Commonwealth has rarely experimented in policy terms before introducing new policies (with the notable exception of some aspects of aged and disability policy), especially in experimenting with more flexible funding for accommodation and community support programs, and the current Coordinated Care Trials. Thus the unified approach would probably bring with it a more inflexible approach to system organisation, which would have long-term disadvantages. This might be overcome with improvements in management approaches at the Commonwealth level.
Conclusion These arguments about major restructure are periodically aired in national fora. For example, in 1995 the Council of Australian Governments proposed a major rationalisation of Commonwealth/state relations. The COAG process followed similar previous attempts (the special Premiers’ Conference process of the early 1990s) addressing a similar goal. As with previous attempts, the COAG process has been unsuccessful. Although agreement was reached on broad areas of principle, this was not able to bg translated into any practical reform strategies. The Commonwealth would not agree to giving up any responsibilities, nor would the states. Under the Howard Coalition government, conservative dominance of Australian politics could lead to an alternate strategy for major reform, involving a greater private sector role in health sector management, financing and delivery. Scotton (1995), for example, 85
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has argued forcefully that the health system needs to be restructured along the lines of managed competition. Under Scotton’s proposal, a national system would involve consumers electing to be covered by a number of competing health management organisations. Under Scotton’s proposals there would be a better alignment of incentives to manage both utilisation and efficiency. Although Scotton’s proposals do not necessarily involve the organisations being privately capitalised, managed competition could incorporate a significant role for the private sector. Conservative states may well be more prepared to divest their health sector financing role to private sector organisations than to the Commonwealth. Although Scotton’s proposals are well argued, they are not universally welcomed (Deeble 1990), and there are significant issues that need to be addressed prior to their possible implementation in Australia (Duckett 1996a, b). The Australian Medical Association has also vociferously opposed any scheme that involves any elements of ‘managed care’, as the Scotton proposals undoubtedly do. The likelihood of managed competition arrangements being implemented would thus, like the unified national arrangements, appear to be remote. The focus of this chapter has been Commonwealth/state relations in health, and the strategies for reform to the health system outlined above have been framed in that context. However, this is not necessarily the right frame: responsiveness to consumers, enhancing equity of access, or equitable financing could all be postulated as ongoing frames for health system reform. The major problem of Commonwealth/state relations in health might thus be that the present systems of financing health distorts how health system issues are considered and inappropriately defines the starting point for health policy discussions.
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5
Health care funding and rationing health care LINDA HANCOCK and PAUL MACKEY RATIONING HEALTH CARE
One of the most vexed issues experienced—not just in Australia, but internationally—is that of rising health care costs and the predicted blowout in health care spending for early next century. Unless careful planning and difficult decisions are made on the funding and rationing of health care, many predict that health systems will not be able to service the demands made on them. This chapter examines the factors that are driving up health care costs. It is complementary to chapter 6, on consumer co-payments, and chapter 4, on Commonwealth/state relations in health, which discusses funding from the point of view of shifts in intergovernmental relations and various intergovernmental mechanisms or instruments. With rising demand for health services and rising health care costs, the issue of rationing health care is inevitably raised. It has been raised in public discussion on the ‘crisis’ in health care as a threat to universal access based on need. How decisions are made about resource allocation and rationing of (or access to) particular procedures, treatment services or medications has the potential to be the most controversial health policy issue facing governments. That such decisions are made at macro- and microlevels through both implicit and explicit policy decisions is discussed. The chapter then turns to a discussion of how health rationing decisions have been 87
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made in other countries—in Britain (under the Conservatives and New Labour), the USA, New Zealand and Australia, and the various schemes devised to meet the challenge of capping expenditure while maintaining choice, accessibility, affordability, universality and quality of services. Reforms include GP budget-holding, consumer charters and citizen juries in Britain; managed care and the Oregon Health Plan in the USA; market-based reforms, including increased consumer co-payments and tighter eligibility criteria, in New Zealand; and the Australian Coordinated Care Trials. The conclusion raises questions as to who should shape the future of health care provision and how allocative and cost decisions should be made. As outlined in chapter 1, it should be borne in mind that evaluative criteria such as equity, access, social democratic participation and longer-term sustainability, as well as cost and choice, are important for evaluating the adequacy of health care provision.
What is driving up health care costs in Australia? It is now well recognised that health care costs are rising. Health expenditure as a proportion of GDP has risen from 7.4 per cent in 1975/76 to 8.6 per cent in 1994/95 (AIHW 1997b), and has settled at around 8.5 per cent of GDP (AIHW 1997b: 1) for 1995/96. This compares with lower expenditure on health in 1994 in New Zealand (7.5 per cent) and the UK (6.9 per cent) and higher expenditures in the USA (14.3 per cent) in 1994 (OECD 1996). While much of the debate on funding focuses on government expenditure, it should be acknowledged that a growing proportion of Australians seek out alternative therapies, estimated at over $1 billion spent on alternative medicines and therapists (Atkin & Kristoffersen 1997; Bisset 1996; MacLennan 1996). A growing number of doctors are practising alternative medicine, however, some are charging high up-front fees. More research is needed to factor private expenditures on alternative therapies into discussions of health care spending. Recurrent health expenditure is shared between the Commonwealth (around 45 per cent), state and local governments (around 22 per cent) and the private sector, including insurance and individuals (around 32 per cent) (AIHW 1997b: 1, for the year 1995/96). 88
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Growth in Commonwealth outlays on health reflects higher utilisation of medical and pharmaceutical services, with a ‘drift towards more costly drugs and medical services’ (Costello 1997: 4–41). Medical services (36.6 per cent) and pharmaceutical benefits (14.5 per cent) constitute over 50 per cent of Commonwealth outlays on health (Costello 1997: 4–42). They thus constitute an interrelated area where outlays are growing and are difficult to cap, although the rate of growth in these two areas is expected to slow as a result of measures to constrain growth, including supply-side measures such as pathology reforms, restrictions on the number of overseas-trained doctors entering the medical workforce and reducing ‘moonlighting’ by temporary resident doctors, and demand measures such as revoking eligibility for Medicare for some classes of temporary residents. Some evidence that the rate of growth may be slowing can be found in the annual report of the Commonwealth Department of Health and Family Services (1997: 79), which indicates that ‘the 1996–97 year saw the lowest annual growth rate for Medicare benefits expenditure since the commencement of Medicare’. In contrast, 67 per cent of states’ total recurrent expenditure on health is spent on hospitals, with large chunks of the remainder spent on community and public health, nursing homes, ambulance services and other institutional care (AIHW 1996: 259). Rising health care costs are the result of a combination of factors. These include:
• an aging population. As discussed in chapter 14, the population is greying. The rate of persons aged 65 and over is projected to grow at around 2 per cent between 1991 and 2006, and the percentage aged over 80 by 4 per cent, with growth expected to continue for the next 50 years. Although the majority of aged persons over 65 are in good health, service needs due to frailty and disability are growing, especially for those over 80 years. In numerical terms, a rise from 17 to 18 per cent (from 1991 to the year 2021) in the proportion of older Australians aged over 80 with a ‘profound or severe’ disability translates into a doubling in actual numbers from 352 800 to 709 600 (AIHW 1995a: 174, 178–9). Although the implications of these shifts for funding and services can be talked up or talked down, these projections have 89
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•
•
•
•
•
implications for both health and aged care services, as an aging population heralds a rise in chronic illness such as heart conditions, stroke and cancer; growth in consumer demand, with rising expectations on the medical ‘fix’ to individuals’ health problems along with betterinformed patients who demand quality of care. In terms of volume, services per year are growing at about 5 per cent, with about one-third due to population growth and aging and the remainder due to higher per-person service usage (Costello 1997: 4–43); growth in biotechnology is expanding the range of possible interventions. High-tech, high-cost treatments such as IVF and coronary bypass surgery, CT and MRI scanning have become more commonly expected by patients and have resulted in higher costs. The ‘sanctity of life’ ethic, some argue, contributes to unrealistic expectations by doctors and the public for ‘life at all costs’, resulting in wasteful allocation of resources (NH&MRC 1990: 1). The drift to more expensive services and medical procedures accounted for an estimated one-ninth of the 9.5 per cent increase in medical services and benefits in 1994–95 (Willis & Beazley 1995: 3–93); system inefficiencies, reflecting overlap and duplication of services, inefficient management, cost-shifting (from state to Commonwealth in areas such as hospital outpatient and emergency services and mental health). Any area of state responsibility where previously state-provided services are shifted onto doctorprovided medical services results in a rise in Commonwealth expenditure and a saving to the states. It can further be argued that doctor-provided services are more costly than those delivered by nursing or community health staff; a provider-driven medical services system. Unlike other areas of government expenditure, where costs are consumer-driven, blockfunded or capped (such as hospitals), medical service costs, structured around fee-for-service, constitute a potentially openended arrangement which is largely uncapped; growth in pharmaceutical expenditure. Closely interrelated to growth in medical services (but rising at a higher rate), pharmaceuticals are a major tool used by practitioners trained in the
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biomedical model of illness/treatment. Pharmaceutical benefits constitute the fastest-growing area of pressure on Commonwealth expenditure, with an estimated growth in pharmaceutical benefits of over 12 per cent (Willis & Beazley 1995: 3–92; Costello 1997: 4–42), although growth slowed slightly in 1996/97 to 9.1 per cent (Department of Health and Family Services 1997: 79).
Resource allocation and health care Given the above pressures on government expenditures in health, along with rising demand and finite resources, decisions are made in relation to resource allocation and health care rationing. Rationing here is defined broadly as the process whereby access to, or availability of, certain health care services, treatments, procedures or medications is regulated. There are several useful ways of conceptualising these decisions. Resource allocation occurs at both macro- and microlevels, and rationing occurs both implicitly and explicitly.
Macro- and microallocation of health care resources Drawing on the National Health and Medical Research Council’s (1990) distinction between macro- and microallocation, macroallocation refers to broad political/administrative decisions on health expenditure. Analysis of health expenditures over the past 10 years demonstrates the historical nature of health funding, with the acute care medical/pharmaceutical/hospital system dominating approximately 70 per cent of combined public and private expenditures (compared with 5 per cent of total recurrent expenditure allocated to community and public health) (AIHW 1996: 257). This has led critics such as Baume (1995) to claim that Australia has an ‘illness system’, rather than a health or wellness system. Government decisions on health as a percentage of total budget expenditure and on medical pharmaceutical and hospital services, set the broad macroallocative parameters influenced by history and tradition, ad-hockery and political expediency. Established services are often best equipped to mount excellent cases for extra funds, 91
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and it is often the case that ‘to those that have, more will be given’ (NH&MRC 1990: 3). Microallocation refers to decisions made by institutions and individual practitioners. At this level, specialties compete for resources and individual practitioners make decisions about treatment that affect costs.
Implicit and explicit rationing Allocative decisions are clearly made at political, managerial and clinical levels. Apart from funding and macroallocation decisions, broad issues concerned with service cost rebate level, regulations, guidelines and eligibility criteria constitute forms of implicit rationing. This refers to the way that funding, legislative and regulatory decisions set the parameters within which more open or explicit rationing occurs. These broad decisions are often influenced by those with a strong self-interest in maximising outcomes, such as providers, health managers, or other health professionals. Consumers are generally unaware of and uninvolved in implicit rationing decisions. Explicit rationing, which may or may not involve consumers in decision-making and priority-setting, refers to decisions where consumers essentially understand health system coverage and eligibility rules (Allen 1993: i). Explicit rationing involves decisions that more openly weigh considerations of cost containment/economic efficiency with those concerned with access, equity and justice—that is, those which try to tackle difficult decisions with a declared ethical basis. As McClelland (1991) notes, much government intervention in the provision of health and medical services involves balancing competing claims of efficiency and equity, with efficiency defined as the ‘maximisation of total benefits from the use of a given amount of resources’ and equity as the distribution of benefits (National Health Strategy 1991b: 5).
Market values, ethics and allocative decision-making As discussed in earlier chapters the market, left to its own devices, is a poor allocative mechanism in an area like health, which is prone 92
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to market failure. The market performs badly on criteria such as protecting equity, fairness and universal access to health services. Values are likely to become an increasingly important consideration as societies undergo change and as the State retreats further from the universalism of the welfare state. Writing about the USA, Lasch (1994) has identified what he labels the ‘revolt of the elites’. He builds his argument around the disappearance of the middle class and the growing tendency for the privileged classes (which he defines as the top 20 per cent by income) to make themselves ‘independent not only of crumbling industrial cities but of public services in general’. He places these developments within the context of the decline of the nation-state and the rise of globalism (Lasch 1994: 47, 49). Regardless of how rationing decisions are made, it is important to note that decisions are always made within ethical frameworks and are informed by particular values. Much decision-making and discussion about health financing draws on discourse of the economy and the market. Notions such as ‘cost containment’, ‘efficiency’ and ‘resource allocation’ can work to obscure the ethical frameworks and value systems that underpin every decision taken (regardless of who makes the decision) in relation to the provision and non-provision of health and medical services. This is the case whether the decisions are taken at the macrolevel (systemwide or at institutional level) or at the microlevel (affecting the individual patient) (Encyclopedia of Bioethics 1995: 1067). It is also the case, regardless of whether decisions are made explicitly or by default. These ethical frameworks and value systems can be examined in a number of different ways, several of which are canvassed below. Notions of ‘fairness’, ‘equity’, ‘rights’, ‘autonomy’ and ‘consent’ can be seen as fundamental to an ethical perspective on rationing. It is important to acknowledge that these are all contested concepts and to note that ‘ethical debates are extremely unlikely to result in unanimity’ (New 1996: 1596). Of these concepts, ‘autonomy’ is perhaps the most problematic. For example, critics of Oregon’s explicit rationing (discussed below) such as Ferrara (1994) highlight the limitations it imposes on personal choice without acknowledging the limitations in place in other States for low-income people. 93
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Bamford (1993: 34) argues that ‘choice’ is often little more than rhetoric because it ‘requires surplus capacity if it is to be real’. Three main ethical theories can be used to inform decisions on rationing of health and medical services: utilitarianism, deontology, and distributive justice. Utilitarianism can be characterised as ‘doing the greatest good for the greatest number’, while deontology is concerned more with respect for life at all costs and notions of autonomy, patient confidentiality and clinical paternalism. Girling (1993: 38) argues that utilitarianism is most familiar to managers, while clinicians have traditionally been more comfortable with deontology. Distributive justice is concerned with ‘giving to each person his or her due’, and is underpinned by the notion of ‘fairness’ (Scott 1991: 8); ‘A just allocation would offer equal treatment for those whose needs are similar’ (NH&MRC 1990: 5). Rationing of health and medical services creates a fundamental ethical dilemma for the medical profession. Doctors have traditionally been expected to act as the patient’s advocate even if this conflicted with the interests of the community. The dilemma of choice between what can be done for an individual patient and the capacity of society to pay is exacerbated when high cost but marginal treatments are involved. In order to assist the medical profession, the NH&MRC (1990: 6) argues that the community must decide ‘how far it is prepared to fund such treatments’ and where to draw the line. Duggan (1996) argues for the greater use of evidence-based medicine as a means of rationing health and medical services ‘intelligently’ (Duggan 1996: 10). Palmer and Short (1994) argue that society ‘has overestimated the effectiveness of curative medicine and underestimated its limitations’. They suggest there is a need to evaluate the effectiveness and efficiency of medicine (Palmer & Short 1994: 53). Evidence-based medicine is a necessary element of decisions about rationing, but it also has shortcomings. The importance of evidence-based medicine was pioneered by Cochrane, and the Cochrane Collaboration is a worldwide information bank on treatments and outcomes. Another means of addressing rationing is to weigh up the personal benefits (from a particular health care intervention) and the public benefits (from a particular health care system) (New 1996: 94
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1595). Writing about Britain, New (1996: 1596) identifies a range of ethical questions, which can be raised when rationing resources in this way: Which of the beneficiaries should be the focus of interest for the NHS? How should personal benefits bg distributed, or should they simply be as large as possible? If two or more kinds of benefit are judged relevant, in what order should they be placed? If they conflict, how much of one should be reduced in order that another may be satisfied more fully?
The values of different players in the health system are also of importance in any discussion of the ethical foundations of rationing health and medical services. Evans suggests that there are three categories of players in any health system—payers, providers, and users (1996: 101). The categories are not mutually exclusive because payers may also be users and providers may also be payers. Evans’ grouping is illuminating to the extent that it does highlight that decisions about rationing, even when the community is involved, may have implications for equity and fairness because different players have vastly different stakes in the health system. A disproportionate amount of funding in all health systems is spent on a small proportion of the population (users), often on people in their last two years of life (Paterson 1996: 10). Decisions taken about the rationing of services by payers and providers may disproportionately affect this group. The potential for conflict between the values of different categories of players in a health system needs to be addressed if notions of equity and fairness are adequately to be considered. New (1996: 1596) makes the suggestion that democratic systems of decision-making might be developed as a means of resolving conflicts. Girling (1993: 38) deals with this issue under his notion of ‘rights’ which, in terms of rationing, means ‘equal access to the decision-making mechanisms’. Leeder (1996) suggests that values may be safeguarded by using a random sample of the community to engage in debate on the general priorities to be covered by the public health system, but only patients should participate in the debate over which groups in society will be entitled to receive what care. (The 95
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use of citizens’ juries in Britain is explored below as one example of this approach.) While difficult, this process is not impossible and may even be enhanced by the introduction of market mechanisms. For example, the introduction of an internal market and fundholding by general practitioners in the UK’s National Health Service (NHS) has facilitated a more open discussion about rationing of health and medical services. In response, one GP fund-holding practice has developed a draft policy on rationing in consultation with medical ethicists, in order to ‘clarify the ethical basis for rationing decisions’. The draft policy has the aim of providing ‘a principled basis for the distribution of financial and medical resources within the practice’ (Crisp et al. 1996: 1528). As Lenaghan (1996: ii–iii) so aptly comments: (I)t is not the need to ration which causes difficulties, but how it is done and by whom, whether it is seen to be done in the public interest, and whether it can command the confidence of the public . . . Rationing involves not just clinical discretion, but moral and political judgements.
Making health funding decisions in Britain Under Thatcher and the Conservatives, the NHS was criticised for its inefficiencies, poor productivity, politicisation, subversion by employees, cost inflation and unequal access. Rationing of health care was mainly through the unequal historical means of waiting lists, which were politically controversial throughout the 1980s. Due to the political sensitivity of the NHS to the British voting public, health was left largely unscathed under Thatcher. Although there was controversial discussion of replacing the NHS with private insurance, this did not eventuate. From the early 1980s there were moves towards privatisation or the contracting out of ancillary hospital services (such as cleaning), which were identified with real savings. Lovey (1986: 116) notes that such efficiencies were achieved at the expense of wages and conditions for some of the poorest workers in Britain, and to the benefit of shareholders and directors of private sector contracting companies. It was not until the 1990s that the 96
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Conservatives adopted policies intended to curb costs by creating a greater role for the market. In 1992 the UK government launched the PFI (involving the private sector in public services) to encourage private investment in public services relying on user charges. Government also extended compulsory competitive tendering to other ancillary services, equipment leasing, clinical services such as pathology, radiology and operating theatres. Prime Minister Major introduced The Patient’s Charter, outlining patient’s rights, which Coote (1997: 70) criticised for raising expectations and being largely unenforceable. Reforms introduced in 1991 included the split of purchaser and provider functions, the establishment of hospitals and community health providers as semi-autonomous trusts, and a scheme inviting GPs to apply to become fund-holders. The purchaser/provider split is a central plank of British market reforms, aimed at increasing economic efficiency of the NHS by the creation of a quasi- or internal market within health. Purchasers of services include distinct health authorities and larger fund-holding general practices, and providers include private sector and selfgoverning NHS hospitals in competition with each other for purchasers’ contracts (Short 1996: 20). The establishment of hospitals and community health providers as semi-autonomous trusts was aimed at enhancing efficiency through competition. Fund-holding refers to the scheme under which some GPs were invited to apply to hold a budget for purchasing health and hospital care for their patients. It relies on patient enrolment and capitation payments. This involves patients registering with a particular practice and GPs being given a bucket of money to provide for their care within their own practice and for care purchased from hospitals. The underlying idea is that competition between hospitals and other health services for fundholders’ business would bring cost-reduction efficiencies in overall NHS spending and enhanced quality of care. As Coote (1997: 10) notes, whereas previous rationing had occurred behind closed doors, the creation of the internal market rendered the process of priority-setting and resource allocation more visible. Some purchasing authorities put out lists of treatments no longer provided, which led to criticisms from their constituencies. 97
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Importantly for consumers, health authorities had to defend their resourcing decisions more publicly than before (Ham 1993: 1–2). Fund-holding may have led to some improvements in practice and service, as it provides for continuity of care and more efficient patient record-keeping. It may have encouraged hospitals to be more accountable to GPs on issues of quality, timely service and cost, and it may have encouraged more responsive attitudes from doctors and other health service providers to the care of patients. The fixed fee per patient model of funding may also encourage GPs to practise preventive medicine and thus discourage unwarranted visits to the surgeon. However, it has attracted criticism. Devolution to the local level has resulted in inequities: access to treatment may be determined by factors such as age, marital status or geography, rather than clinical need; and health decision-making may suffer from a ‘democratic deficit’, as local health authorities making decisions are neither elected nor accountable to the public for their decisions, but to the Secretary of State for Health (Cooper et al. 1995; Lenaghan 1996: i–ii; New Labour 1997; Coote 1997; Hutton 1997).1 An additional problem is lack of choice—where consumers report difficulties with changing doctors or gaining access to a particular GP fund-holder practice and the confused accountability and potential conflict of interest for doctors that comes with potentially conflicting GP, clinical and fund-holder management roles. Prior to the 1997 election of the Blair government, New Labour (1997: 20) launched a scathing attack on the Conservatives. It criticised the internal market in health for costly red tape, the extra £1.5 billion per year spent on bureaucracy, top-heavy management in the NHS (20 000 more managers), 50 000 fewer nurses on wards, and in excess of one million patients on waiting lists. It stated: ‘under the Tories, the administrative costs of purchasing care have undermined provision and the market system has distorted clinical priorities’ (New Labour 1997: 20). Labour sought to retain a role for primary care, with access based on need, not on ability to pay individual GPs or on geographical location. While constrained by promises to maintain existing taxation and funding arrangements, Labour under Blair is seeking ways of reversing the ‘democratic deficit’ in the process of making difficult health funding decisions. Since Labour’s election, it has reinforced a commitment to citizens’ 98
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juries, as a mechanism for involving British citizens in openly making decisions about funding allocations (Cooper et al. 1995).
Funding and rationing health care in the USA The health system in the USA is a mix of public and private financing, with far from universal coverage. It is actually several distinct systems with only tenuous linkages. The US health care system is seen as one of the most costly, with inflation, vast inequalities in access to and usage of health services, and disproportionate incomes for elite medical specialists (Botsman, 1992; Oliver 1991; Honigsbaum et al. 1995). Health insurance funding is predominantly through private, mainly employer-based, insurance payments to insurers, HMOs (Health Maintenance Organisations) or to PPOs (Preferred Provider Organisations). An estimated 75 per cent of the population is covered in some way by health plans, with over 40 million Americans uninsured. The public safety-net systems, Medicare (federally funded) and Medicaid (federal/state-funded)—set up to provide some access to health care for the aged, disabled and poor, are under increasing strain.2 Reports abound of the impending bankruptcy of Medicaid and Medicare and of ordinary, uninsured Americans being denied treatment or being forced into bankruptcy or to sell the family home in order to pay medical bills. However, both hospital and medical cover under US Medicare can still require significant co-payments, and doctors can refuse services to those on low incomes. Largely a private sector system of medical services with only one-third of physicians’ fees covered by public payments (Botsman 1992: 48), central government regulation and control of doctors’ fees would require a major overhaul of the system. With an overconcentration of medical specialists and a shortage of general practitioners, Botsman (1992: 48) argues that rises in medical costs in the USA at three times the rate of inflation reflect a system where a deregulated market encourages ‘big ticket’ profit-making medical techniques, and ‘leads to over-concentrations of service in lucrative areas’; medical insurers pass on medical fee rises in higher premiums. He describes the USA as having ‘vast inequalities of care, a highly 99
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pluralistic and uncoordinated system of hospitals and . . . a proprietary for profit hospital sector’ (Botsman 1992: 97). These problems are by no means new, and concerns about spiralling medical costs and issues of inequity and cost, inefficiencies, excessive production and consumption of health services have been on the political agenda for the past 30 years. Rising costs in the public part of the US health system (with 17-plus per cent annual rises in Medicare payments for hospital and physician services since 1970), coupled with resistance to more comprehensive reforms, led to moves under Reagan in 1982–84 to regulate hospital costs by improving price regulation through a payment system based on DRGs (diagnosis-related groups), thus encouraging hospitals funded by the case to reduce costs though shorter stays and controls on unnecessary tests or treatments (Oliver 1991: 475). As discussed in chapter 7, the US system of prospective hospital funding based on a mix of DRGs forms the basis of casemix hospital funding adopted in Australia. In light of the failure of Clinton’s election promise to radically reform the health system, the national health insurance plan under ‘managed competition’ he proposed was designed to preserve the existing private health insurance industry. It met with opposition from the medical profession and insurers, due to perceptions that such proposals would reduce overall health care spending (Laham 1993: 156, 159). Such cost-containment measures threatened entrenched interests with financial losses. These and more radical reforms, some argue, are unlikely to be introduced until the system reaches the brink of bankruptcy, with crisis bringing opposed parties together in a coalition of interests. In the meantime, some present a more optimistic picture—that cost controls and the introduction of HMOs and managed care can work. The Economist (1997: 14) argues that this system has the ability to reward doctors for delivering value for money in a system that balances controls and incentives, encourages quality and quantity of care with ‘vigorous competition, informed consumers and vigilant monitoring’. However, attention to issues of affordability, inequalities in access to care and spiralling costs are absent from the analysis. 100
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The Oregon experiment Oregon was chosen because it provides a useful contrast to the rationing of health services both in other parts of the USA and in the other country case studies under examination. While the approach of the State and the market in the USA has generally been to ration services implicitly (so implicitly that many citizens are unaware that rationing does exist), Oregon has opted for explicit/community involvement in rationing its Medicaid program. In the USA, rationing of health and medical services is widespread, albeit largely implicit (Reinhardt, quoted in Feldbaum & Hughesman 1993: 122): Most other countries withhold some procedures from all of the people. We Americans withhold all procedures from some of the people . . . in this country we ration quite brutally by income and ability to pay.
Rationing is most obvious in the gaps in insurance coverage. Over 40 million Americans do not have health insurance coverage. Many small businesses provide no insurance coverage for their employees, while others provide limited coverage (Laham 1993). US Medicare, although not means-tested, limits the conditions covered. Although Medicare provides access to health and medical care for all elderly Americans, implicit rationing occurs in the care they receive. For example, regional variations exist in access to and quality of health services, while ‘covert age-based rationing places actual decisionmaking in the hands of physicians . . . subject to their individual tastes and values and guided by no systematic principles’ (Callahan 1996: 745). Very poor younger people living in some states are denied any coverage. Health care may be rationed by race. In an overview of research, Geiger (1996) argues that studies have found repeatedly that ‘blacks with ischemic heart disease, even those enrolled in Medicare or free-care systems, are less likely to undergo angiography, angioplasty or coronary-artery bypass grafting’. Other studies have found that ‘blacks are less likely to receive renal transplants, receive hip or total knee replacements . . . but are more likely to undergo hysterectomy and amputation of the lower knee’ (Geiger 1996: 815). 101
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Medicaid, which is means-tested, also limits the conditions that are covered; in addition, the income level that determines eligibility varies by state of residence. Private health insurance in the USA is risk-rated, which imposes rationing of another kind—rationing by illness or disease. Under risk-rating, people with pre-existing conditions may be denied coverage by the setting of high premiums, or simply by being denied coverage. All these types of implicit rationing have implications for equity, and there appears to be little discernible will for change within the American community. Graig (1993: 78) notes that ‘there is little indication that Americans would be willing to pay higher taxes to fund universal health insurance’. Aaron and Schwartz (1990: 34) point out that, while there is a view that increasing health care costs may require rationing of health care, price-based rationing is already a reality for about 15 per cent of Americans. They note, however, that a new question is entering the debate in the USA—whether to ration care for those people who can afford to pay for high-level care. The central difference between rationing in the USA generally and Oregon in particular is that the US health system rations health care by default, implicitly deciding through inaction by the State and user-pays who will receive care, whereas in Oregon rationing is more explicit. The impetus for reform in Oregon began in 1982 with the formation of Oregon Health Decisions, a citizen-based project which had the objective of increasing public awareness of the ‘dilemma in health care provision’ (Hall & Haas 1992: 436). Concerned at the rising costs of its Medicaid program, Oregon decided in 1987 to introduce explicit rationing by excluding organ transplants, with funds directed instead to prenatal care. Less than six months after Oregon legislated this change in coverage, a 7-year-old boy died of leukaemia after being denied a bone marrow transplant under Medicaid. Following public outcry, ‘the Oregon legislature moved to extend coverage either through private health insurance or Medicaid to all its citizens’ (Hall & Haas 1992: 436). Accordingly, as Klein (1991: 1) suggests, it is possible to see that the Oregon Health Plan (OHP) has been developed in response to crisis. Many people with incomes below the ‘federal poverty line’ were 102
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ineligible for Medicaid, while those who were eligible were unable to receive some high-cost procedures such as organ transplants. In developing its plan, Oregon had the objective of maintaining a balanced budget but had only a ‘limited tax base, relying exclusively on local income tax for its revenue’ (Klein 1991: 1). At the policy formulation stage, stakeholders, including community groups, individuals, providers and experts, were involved in a series of meetings and consultations to draw up a ‘prioritised list of services’. This was essentially a list in priority order of which services and treatments were to be subsidised by the state under the OHP. Consumer input was gained through a telephone survey of 1001 residents as well as through community meetings organised b{ Oregon Health Decisions, ‘a community service organisation dedicated to obtaining citizen input on ethical issues in health care’ (Conviser 1996: 3). In addition, the Health Services Commission, which was charged with developing and ranking health services, comprised consumers as well as providers of health and social care. In evaluating the OHP, it is possible to point to several shortcomings in the earlier stages of the policy process. While the community was certainly involved in the compilation of the ‘prioritised list of services’, this was effectively inequitable, because the rationing imposed by the list applied only to one section of the community—those people covered by Medicaid. Hall and Haas note that ‘less than 10 percent of the participants at the community meetings were living below the federal poverty line, people for whom the Plan is primarily intended’ (1992: 438). Drawing on the work of Crawshaw et al. (1990), Klein (1991: 2) points out that ‘only 600 citizens turned up at meetings to discuss priorities, and of those 56% worked in the health care system’. Hall and Haas (1992: 438) also caution that the community survey of 1001 residents, which was the basis for assessing the values placed by the community on particular health and medical services, was ‘neither large nor representative of the population’. Baume (1993: 858) echoes these points, arguing that ‘at the start at least, the lists were determined by middle class people to delineate (and therefore, to limit) the services to poor people’. In terms of equity, expansion of the coverage of Medicaid under the OHP has provided state-subsidised health services to a larger 103
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group of people, although choice for existing beneficiaries has been curtailed. Ferrara (1994) is critical that the OHP represents the state usurping ‘the essential freedom of the people to control one of the most fundamental and intimate aspects of their lives—their own health and its care’ (Ferrara 1994: 8). However, it can be argued that the expansion in the number of people covered by the Plan has provided those who were previously denied any choices by being uninsured with at least some degree of control over their health care needs. Under this explicit/community involvement model of rationing, all people covered by Medicaid are treated equally. The list makes it clear what services and treatments are covered. Decision-making in the OHP policy process has largely been observable, open and participatory, although some decisions and assumptions by elites have also occurred. This has principally involved decisions taken by the Health Services Commission concerning the costs and benefits of medical treatments. In the absence of empirical data, decisions on the clinical effectiveness of different treatments, crucial to the development of the ‘prioritised list of services’, were based on the judgements of medical practitioners (Hall & Haas 1992: 437). The arguments and language around the OHP tend to focus on ‘entitlement’, ‘universality’, ‘coverage’ and ‘effectiveness’, which worked to obscure or keep off the agenda one group of people—the existing Medicaid beneficiaries, who were clearly losers under the OHP. This group, comprising in the main single mothers and their children, who were arguably the poorest in the community (because existing Medicaid beneficiaries were well below the federal poverty line), had their access to health care services severely curtailed. They lost, for example, some 19 per cent of services which the community consultations rated as ‘very important’ (Hall & Haas 1992: 439). The ethical underpinning of the OHP appears to be utilitarianism, with an attempt to offer the greatest good for the greatest number. The OHP also attempts to reconcile three elements of ethical rationing—the individual’s claims to health care, the community’s responsibility for health care, and the importance of efficiency in health care (Encyclopedia of Bioethics 1995: 1068). It achieves this by providing coverage for all people with incomes bglow the federal poverty line and involving the whole community in a process of 104
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arriving at an agreed list of services to bg subsidised by the state. Finally, the OHP has attempted to incorporate the notion of efficiency by drawing on the available data on the costs and benefits of medical treatments. Hall and Haas (1992: 435) summarise the attractiveness of the OHP to policy-makers in other countries as lying in ‘its explicit approach to rationing within a framework of cost-effectiveness analysis and its involvement of the community in setting priorities’. In terms of its wider application, various commentators doubt whether the Plan can easily be transported into other health systems because it ‘is anchored in the state’s political system’ (Klein 1991: 2).
Market reforms and access to health care in New Zealand New Zealand is similar to Australia, with a mixed, two-tiered health care system, largely private medical practitioners, state financing, historically a welfare-based health system, with universal coverage and some consumer co-payments for services. Reforms to the health system are a central element in the ‘New Zealand Experiment’ (Kelsey 1995: 207) as part of its sweeping reforms, many of which have influenced the reform agenda in Australia. New Zealand has created an ‘internal market’ in health, and has sought to alter the role of the State in financing and delivering health care services. While mirroring some elements of the UK reforms of 1990, notably the creation of an internal market, the New Zealand reforms were more radical and drew more heavily on proposals to change the Dutch health system, contained in the Dekker Report of 1987 (Ashton 1992: 147). The reforms to the New Zealand health system, such as the creation of an internal market through the separation of purchaser and provider functions, were drawn from the recommendations of the 1988 Gibbs Report, and were released by the Health Minister in 1991 (Upton 1991). Greater efficiency in the health system was a core policy objective of the reforms. The chair of the Taskforce on Hospitals and Rebates Services, Alan Gibbs, was a key member of the New Zealand Business Round Table, a body which ‘has consistently argued for 105
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fiscal restraint . . . substantially privatised education and health systems’ (Roper 1993: 163) and which regarded health care as ‘simply another commodity to be bought and sold on the level playing-field of its particular marketplace’ (Kelsey 1995: 218). Following the transformation of public hospitals into Crown Health Enterprises (CHEs), the boards appointed to run them were ‘packed with businessmen (and the occasional woman) who have little experience of the health industry, replicating corporatisation of the state trading enterprises’ (Easton 1994a: 231). The restructuring of the New Zealand health system that occurred as a result of the reforms was overseen by a National Interim Provider Board, which was chaired by the head of a private company, Fletcher Challenge, and a Policy, Regulatory and Implementation Unit headed by a Treasury official (Kelsey 1995: 215). Critics argue that elected health boards in hospitals were replaced by business managers with little experience in the health industry (Easton 1997: 164). The New Zealand reforms were expected to save money—unlike the UK reforms, which were introduced with increased spending and a longer-term agenda. However, the expected revenue gains of $NZ95 million at February 1992 had been revised down to $NZ14.4 million by July 1992, and the predicted costs of implementing the reforms blew out from an initial budget estimate of $NZ15.7 million to $NZ82 million by December 1992 (Kelsey 1995: 216). Boston and Dalziel (1992) note that the reforms signalled the end of the universal welfare-based approach to health care in favour of a two-tiered system, which they regard as having profound implications for the social fabric in New Zealand. They ask: ‘do we want a society in which the poor must carry various health cards in order to secure access to health care, while the rich enjoy the advantages of private insurance, queue jumping and better quality services?’ (Boston & Dalziel 1992: xi). Evidence of this shift can be found in the marked rise in private health insurance coverage in New Zealand from around 40 per cent of New Zealanders in 1991 to 55 per cent in 1995 (Kelsey 1995: 215). Prior to 1991, access to services was generally rationed by waiting list, with co-payments for GP services bwt not for public hospital services. The New Zealand reforms provided for the introduction 106
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and extension of user charges for many health and medical services, which has changed the nature of rationing in the New Zealand health care system. Other reforms changed hospital governance and converted the use of country hospitals in order to concentrate acute care resources in cities. Reforms have moved the health system towards access according to ability to pay (rationing by price) (Ashton 1992: 162) and thus have shifted costs substantially from government to the individual. Examined from an ethical perspective, the focus of the New Zealand reforms has been clearly on greater economic efficiency in the health system. The claims of individuals to health care and the community’s responsibility for health care have been of secondary concern. Although universal coverage and State financing have been retained, stringent targeting, fiscal restraint and greater use of copayments have combined to compromise equity in the New Zealand health system. Stricter targeting of services has highlighted the exclusion of some New Zealanders from treatment. The case of Rau Williams, a Maori man in his sixties denied kidney dialysis treatment and effectively left to die, was the subject of an unsuccessful appeal by his family to the hospital managers at Northland Health. The family claimed his mild dementia and diabetes contributed to the decision not to resume treatment. Journalist Michael Field (1997) reported that rationing was now a fact of life according to the Associate Health Minister, Mr Tuariki Delamere. Field said that from July 1997 formal rationing would score patients awaiting surgery in the public system on clinical and social criteria to decide when they would be treated. Kelsey (1995: 207) argues that the New Zealand reforms have left it to the market ‘to reconcile competing efficiency and equity outcomes’, while the State has retreated to a minimal safety-net. There is reason to be cautious about the ability (or the will) of markets to operate in this way, because the very nature of competitive markets is to produce winners and losers. As Mooney (1996b: 22) argues, there is ‘little prospect that internal markets will create greater equity in health care’. It is too soon to identify clearly the winners and losers from the reforms in New Zealand in terms of rationing of health and medical services. The 1996 OECD report on New Zealand (cited in Easton 107
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1997: 162) states that ‘even though the system is in its third year of operation, it is not yet clear how the reforms will ultimately affect health care in New Zealand’. However, the severg targeting in New Zealand identified by Kelsey (1995) and the inequities becoming apparent in health care provision indicate that, for some consumers at least, the reforms have led to a less equitable, less accessible and less fair health system. In a brief evaluation of the New Zealand reforms, Ashton observes (1992: 163) that the use of price signals or user charges to ration health care is neither efficient nor equitable. Ashton (1997: 19) cautions that, while flexibility may have improved, the rationing of services has resulted in poorer access to services, a downgrading of public health, and has had a questionable impact on efficiency.
Allocating health care in Australia Medicare and Australian health and welfare programs were underwritten by primary objectives of social justice, equity and access for all (National Health Strategy 1991b; AIHW 1996). The universal nature of Australia’s Medicare and the split of roles and responsibilities bgtween the Commonwealth and the states and territories have worked to obscure the nature of rationing faced by many people in Australia’s health system. In relation to the medical (rather than hospital) services provided under Medicare, rationing is explicit because only certain types of services and treatments are subsidised, mainly those carried out by registered medical practitioners (Palmer & Short 1994: 48). Services provided by other health professionals (e.g. dentists, physiotherapists and chiropractors) or alternative health providers (e.g. naturopaths and herbalists) are rationed by price due to their exclusion from the Medicare Benefits Schedule (MBS). This situation can lead to patients consulting a GP (subsidised under Medicare) for a condition that might better be treated by another health practitioner. This arrangement can bg seen to reinforce the medical model of health care, rather than a holistic approach to the health and medical needs of consumers. Evidence that nonmedical services are important to Australian health consumers can be gauged from the $1 billion plus spent on a range of alternative 108
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medicines and consultations with alternative practitioners (Bisset 1996: 1). An indication of the inequitable outcome of this type of rationing, especially on lower socioeconomic groups, was highlighted in a National Health Strategy (1992) paper that found that ‘lower socioeconomic groups are less likely to use preventive services and services such as dentists’ and that ‘lack of economic resources may mean that those of low socioeconomic status cannot afford to give high priority to use of these services’ (National Health Strategy 1992: 84). Under the hospital component of Medicare, public hospital services are rationed through ‘top-down’ (Hicks 1991: 9) caps on Commonwealth and state/territory funding, with the result that funding is growing by about only 1 per cent per year (Leeder 1996). However, distributional problems exist, leading to rationing of services by geographical location that can also occur within cities. In Sydney, an attempt was made by NSW Health Minister Andrew Refshauge to redistribute resources from the relatively well-resourced hospitals of northern and eastern Sydney in favour of western and south-western Sydney. Steketee (1996) claims that it can be argued that consumers have little opportunity to influence the policy agenda in an environment where rationing is unacknowledged by the State. In her analysis of consumers’ attitudes to public hospital services, Moore (1996) notes that ‘many spoke of their feelings of powerlessness within the hospital system’ and that ‘procedures were performed upon them’ and they were ‘regarded as “objects” rather than “people” ’ (Moore 1996: 14). Implicit rationing is grounded in Lukes’ (1974) third dimension of power. This model features largely non-observable decisions and makes use of the existing social structure to lock consumers out of the decision-making process. A privileged role is accorded to clinicians who generally make rationing decisions, following limitations on funding by the apparatus of the State. The consumer whose care is limited, denied or delayed is unaware of any particular decisions that are taken, and is powerless to influence events. An example of this exercise of power is captured by Gow, in her personal account of a (Victorian) public hospital stay which, while beneficial from a 109
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health perspective, had, she felt, a ‘lack of focus on the reason for this system—the patient—me’ (1994: 24). Perhaps most importantly, ‘rationing in secret is less likely to find the best answer. It is also ethically indefensible’ (Hindle & Kerridge 1993: 13). It appears that rationing implicitly is less defensible on the grounds of equity and ethics than explicit rationing. There are also concerns that implicit rationing may not be efficient. As Cromwell and Halsall (1995: 5) point out: ‘unless rationing is undertaken explicitly, it is not known whether it is being administered in an equitable or efficient manner’. While attempts have been made during the 1990s to add rationing to the health agenda, the State has generally moved to limit the agenda by not encouraging the debate. Although various reports have highlighted the issue (Clare & Tulpule 1994; Committee for Economic Development of Australia 1993), little ongoing discussion has ensued. Although oriented towards better quality and better-coordinated care, it is hoped that efficiencies will come from the Coordinated Care Trials (a key component of COAG’s proposals for reforming federal/state arrangements). These trials work on networking of service providers, a pooling of funds from different sources including medical, HACC services and community health, and tap into a wider range of services than those provided under Medicare, with an emphasis on client self-management and participation in care planning and scheduling. Funds are capped with the aim of providing a better mix of services for patients with ongoing complex health conditions or those receiving multiple services. The program is described as ‘health outcome driven’ and based on best practice, rather than finance- or profit-driven as in the US system of managed care (McDonald 1996: 2).
Conclusion Australia is well behind other comparable countries in acknowledging the inevitability of rationing of health and medical services. While this may suit the agendas of many of the major players in the health system, it may not be helpful for the future direction of the system. The essential elements of the debate which need to occur in Australia 110
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can be identified as: how much to spend in total; what general services are to be publicly funded; and which groups are entitled to what care (Leeder 1996). Decisions on these matters must be informed by community consultation. This will not necessarily be easy or straightforward, nor will consensus be apparent on all issues. However, it can be argued that the State will need to move in this direction if it is to retain legitimacy in health care. Care will be required to ensure that the common good does not become ‘the good of the majority’ (Ford 1996: 2). Ultimately, it can be argued that ‘consumers are the best people to determine, with education, what they need’ (Cleave 1996: 55). Baume (1993: 858) argues that clinicians and administrators need to address some fundamental issues in order to facilitate a more open discussion of rationing in Australia: we do not have enough resources to do everything for everyone; we have to make choices about what we will provide and for whom; each such choice carries with it the denial of service for someone else, somewhere; personal values affect the choices we make; the public does not understand (or accept) the foregoing; choices include the desirable balance bgtween curative and preventive services, between institutional and community-based services, between services delivered by medical and other professionals, and so on.
Because rationing is largely unacknowledged in Australia, its adverse impacts on equity tend to be obscured. For example, despite Australia’s fundamental concern for equity in the health system, current expenditure fails to realise goals of access and equity for Aborigines (McDermott 1995: 72). Similarly, the structure of Australia’s health system can lead to some consumers having choices in the hospital system and others having none (Moon 1996: 45). Although access to services is supposed to be on an equitable basis, we do not as yet have any mechanisms to evaluate whether this in fact is occurring (Steering Committee for the Review of Commonwealth/State Service Provision 1995: 70). Finally, work already conducted by the London-based Institute of Public Policy Research (IPPF) provides some important groundwork for Australia to bwild on. It argues that health is integral to 111
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citizenship, that health is a right that rglies on equitable distribution of resources, and that access to health care on the basis of clinical need is a prima facie right (Lenaghan 1996). The IPPF proposed a Code of Practice to provide a rights-based framework; shared criteria and procedures for decisions; procedural rights for patients, including accountability for decisions and right of review; a National Health Commission to advise parliament and the use of citizens’ juries in decision-making. This would stimulate wider public debate and ensure that consumers’ voices are not overlooked. Chapter 6 explores further the ramifications of the State’s increasing reliance on health service users’ payments for health care.
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6
Consumer payments for health care SOPHIE HILL CONSUMER PAYMENTS FOR HEALTH CARE
Since the advent of Medicare in 1984 there has not been much attention paid in the public policy arena to the issue of what consumers pay directly for health care, with the exception of the furore around nursing home fees in late 1997. This may be partly due to the success of Medicare and the Pharmaceutical Benefits Scheme. Both keep an overall lid on the costs of care, and ensure access for no cost, or little direct cost, to the major categories of health care—medical services, hospital care and pharmaceuticals. This chapter examines the issues for consumer organisations in the area of direct out-of-pocket payments for health care. First, data on total spending on direct payments are presented, followed by an analysis of the success of Medicare in keeping costs low for consumers. Three main strategies have been used by two of Australia’s leading consumer organisations, to mount a critique of the direct payment system. These include a critique of existing arrangements, the definition of needs at the margin and an attempt to redefine core or central health needs. The concluding analysis draws principally on the framework developed by critical theorist, Nancy Fraser (1989), analysing the politics of needs interpretation. First the case of John Smith will be recounted. 113
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John Smith vs the medical specialist John Smith lives in the Whyalla area of South Australia. In 1993 he went to a private hospital for a thyroid operation. After he was discharged he started to pay all his bills, until he came to one from the anaesthetist. Although he had met the anaesthetist before the operation they had not discussed fees. The anaesthetist charged $76 over the Medicare scheduled fee for the service. This upset John Smith. In his story in Health Forum, the news journal of Australia’s national health consumer organisation, the Consumers’ Health Forum, he wrote: As for the anaesthetist, I objected to paying his ‘over the top’ fee as I had no control over who the anaesthetist was to be or what the fees might be . . . as a matter of principle I had decided not to pay any amount above the scheduled fee. (Smith 1994)
So Senior Sergeant Smith—a member of the South Australian Police Force as he was—paid the bill up to the scheduled fee but no more. The anaesthetist did not accept this, so the matter proceeded to the Small Claims Division of the Adelaide Magistrates’ Court. The Magistrate subsequently ruled in John Smith’s favour. There was an appeal but, when the Consumers’ Health Forum, the Commonwealth Attorney General and the Australian Medical Association all became involved in some way, the appeal was withdrawn. What does this real-life case tell us? It suggests a new militancy on the part of ordinary consumers of health care. Perhaps militancy is too strong a word, but the episode illustrates that some people have decided to eschew the passive, subservient or respectful position that people took towards the medical profession in decades past. John Smith paid his bill but did not feel he had to pay the discretionary amount that doctors are allowed to charge on top of the government recommended fee. No doubt his will was strengthened by the fact that he had already paid for private health insurance. I want next to paint the broader picture of consumer payments for health care. John Smith’s story is a sign of changing times in one respect, but there are still many Australians who have difficulty with the costs of care, whose social position may mean they are not able to take on a challenge as he did. 114
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Direct payments—the big picture First a note on terminology. Direct out-of-pocket payments is the term commonly used to refer to the amounts that individuals pay. Examples include the payment to the chemist for prescription drugs; the amount to the doctor for medical services after the Medicare subsidy has bgen deducted from the total bill; the fees to a nursing home or to a naturopath; or the premiums for private health insurance. The term is used to distinguish these payments from the other major payments people make via taxation, such as the Medicare levy and general tax, which the Commonwealth government uses to subsidise the high costs of health care. Consumer organisations also refer to co-payments, which are usually the amounts consumers pay after the insurance or Medicare subsidy amount has been removed. They do not include insurance premiums when using this term. The Australian Institute of Health and Welfare (AIHW) has estimated that the total amount spent by individuals on direct out-of-pocket payments—or non-government expenditure, as they term it—was $13 501 million in 1995/96 (AIHW 1997: 4); this represented a 32.3 per cent share of total health expenditure. The proportion borne by the Commonwealth government was 45.2 per cent; and that borne by state and local governments was 22.4 per cent. Direct payments by individuals were a greater share of health expenditure prior to the introduction of Medicare in 1984. Since that time, when they dropped to 28.1 per cent from 35.3 per cent (in 1983/84), the proportion has grown only slowly (AIHW 1995a). Set out below are data on private health expenditure extracted from data on total health expenditure, collated by the AIHW (1998). Table 6.1 shows the expenditure, by major category, paid by private health insurance funds (which is derived from premiums), and the amounts individuals paid. It does not include expenditure on workers’ compensation and compulsory motor vehicle third party insurance. A number of points can be made from these data. The cost of pharmaceuticals is the area of greatest contribution by consumers. Out-of-pocket payments totalled $2062 million in 1995/96. This compares with the contribution by the Commonwealth 115
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Table 6.1
Major categories of private health expenditure, by area of expenditure, 1995/96
Area of expenditure All hospitals Nursing homes Ambulance Medical services Dental services Other professional services Community and public health Pharmaceuticals items where benefits paid all other items Aids and appliances Administration Research Total
Health insurance funds ($ million)
Individuals ($ million)
2611 – 91 223 564 215 2
306 677 71 757 1149 758 –
– 44 172 504 – 4426
493 1569 438 – 125 6342
Source: Figures derived from AIHW 1998: Table S44: 288. Figures may not total due to rounding.
government—the other major body sharing the cost of pharmaceuticals—of $2504 million. The other major categories where consumers contribute substantially are dental services ($1149 million) and non-medical professional services ($758 million). The latter would include services such as physiotherapy, chiropractic and podiatry. The contribution by private health insurance funds to private dental expenditure is 33 per cent, with individuals bearing 67 per cent. In the category of ‘other professional’ health services, individuals bear 66 per cent of private expenditure. In other words, while private insurance assists in meeting the costs of care in those areas where there is no Medicare insurance coverage, it does not meet a major share. One other area where consumer out-of-pocket payments are substantial is for aids and appliances. In 1995/96, expenditure by individuals totalled $438 million. This compared with $172 million by private health insurers, $148 million by the Commonwealth, and nil by state and local governments. About a quarter of the population have a disability of some kind. These figures suggest that a significant proportion of the expenditure related to overcoming that disability in some functional way is met by consumers. 116
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Price signals for an efficient market It has been noted that approximately one-third of total health expenditure is met by private sources—that is, through private health insurance funds, or directly from individuals. Some may argue that this allocation of responsibility is a desirable health policy goal. Ian McAuley, an economist who is an analyst for the Consumers’ Health Forum, has summarised some of the key arguments in favour of out-of-pocket payments. He writes (1996: 11): To an economist’s way of thinking, co-payments are generally desirable in that they send price signals to consumers and producers to help ensure efficient resource allocation. Except in those cases in which demand is absolutely unresponsive to price, we would expect any good or service which is provided free to have some level of excess demand. This . . . will be reflected in either a queue . . . or some level of waste.
McAuley goes on to point out some of the problems with this way of thinking (1996: 11): . . . the economist’s view is limited. It ignores the unequal distribution of consumer resources (wealth and income), and, in the case of health care, the unequal distribution of health care needs. Only the most libertarian economist, oblivious to these inequalities, would propose prohibiting subsidised or free transactions, financed by third party payments, from operating in health care markets.
The main response to an economist’s argument in favour of direct payments is one which recognises the existing inequitable distribution of health, wealth and needs, and which recognises the power in the health market held by certain providers such as doctors. The concerns with direct payments centre on the impact of payments on equity considerations. Payments may deter people from seeking health care that they need. People on lower incomes or with many bills at one time may be in this situation. The second concern is that if health care bills are allowed to become too burdensome, people’s standard of basic living will be adversely affected (National Health Strategy 1991a). Many people in the USA have to go into debt to pay for health care, so this scenario is not a thing of the past. 117
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The third concern is the overall effect on the efficient working of the health care market due to a rise in the price of care. For instance, a fall in demand for medical care flowing from the imposition of higher direct payments to doctors may be offset by providers who can generate the demand for more service use in a response to falling incomes. A related point is that, while demand may fall, it does not mean that people are more discriminating in the type of health care they use (McAuley 1996: 11). An in-depth analysis of the likely impact of changes to copayments for medical services by consumers in the Australian health system was undertaken by Jeff Richardson (1991) for the National Health Strategy. The Strategy was a review of the health system initiated by Labor Health Minister Brian Howe in the early 1990s. The findings of the study should be examined in the light of often-heard claims that, if only consumers bore a greater share of the costs of care, through co-payments, then demand for health care would decrease and hence the overall cost of the health system. Richardson (1991) reported that, while consumer co-payments have a significant effect on the demand for medical services, the most likely result of increasing co-payments in the present system would be very small. This was not only because Australians already bore a share of medical costs but also because demand for services cannot be examined in isolation from the supply of services. Unless there was a reduction in the number of doctors, or unless doctors did not compensate for a reduced number of patients by changing their behaviour, it was not likely that there would be a reduction in the overall cost. Further, Richardson reported that he had found no evidence that co-payments encourage consumers to be more discriminatory in their use of medical services. They ‘reduce the use of medically ‘‘necessary’’ and ‘‘unnecessary’’ services by the same amount’ (1991: 5). In other words, policy-makers who increase co-payments run the risk that people who cannot afford it may forgo necessary care.
How much do health consumers pay? The effect of Medicare is that, since the mid-1980s, most people pay little or nothing on out-of-pocket expenses for basic medical, phar118
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maceutical or hospital costs. This was the central finding of a detailed review of direct out-of-pocket payments by the National Health Strategy (National Health Strategy 1991a). This compares with earlier historical periods, when there was no public universal health care provision and more limited access to bulk-billing arrangements. The evidence from research by community organisations indicated that people on low incomes were deterred from using services by cost. Those services most sensitive to cost barriers are general practitioner services and dental care (National Health Strategy 1991a: 45). Key features of Medicare that had ensured good protection from high out-of-pocket costs were that doctors could bulk-bill patients, free public hospital care was available, and the cost of pharmaceuticals was subsidised. This had proved important to two main groups of people: those on low incomes, particularly those not eligible for any concessions; and frequent service-users. However, there were some areas where people were still paying high amounts, and where access was compromised. These were dental services and specialist fees (National Health Strategy 1991a: 45–6). For example, when examining the direct payments by consumers for services covered by Medicare, the National Health Strategy found that the highest out-of-pocket fees were for specialist attendances and radiology services. This was due to the combination of the low incidence of bulk-billing, and the prevalence of specialists charging over the recommended scheduled fee. While this effect was ameliorated by the low or occasional use of these services, the impact of these charges on people on low incomes was an area of concern. The National Health Strategy also found that a small proportion of low-income households had retained private health insurance, despite its high cost burden relative to income. In terms of an equitable health financing policy, this was noted as a concern, as it might be an unnecessary expenditure based on the fear or the reality that access to hospital care would be denied without private insurance (National Health Strategy 1991a: 9). One of the difficulties for consumer organisations over the past ten years has been to define a need for greater government assistance for people so as to meet all the costs of health care, in a period 119
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where public policies have bgen so successful in meeting their objectives. In other words, while Medicare and the Pharmaceutical Benefits Scheme have provided an excellent degree of protection for high medical and hospital costs, and ensured access to care, their very success has created a context where it has been difficult for consumer groups to create a sense of problem on behalf of their constituents. Fraser (1989: 164), an American critical theorist, in providing a framework for analysing the discourses of the politics of need, defines this first stage as ‘the struggle to establish or deny the political status of a given need, the struggle to validate the need as a matter of political concern’. Australian consumer groups have tried to establish the need for political recognition of the cost-needs of some health care consumers by three strategies. The first strategy has been a critique of the existing arrangements, that is, the critique is played out within the present policy context. The second has been to define the needs at the margin. This strategy accepts that access is assured for most people, and concentrates on those people who may be experiencing difficulties that are not apparent. The third strategy has bgen to expand the understanding of what are central or core health care needs.
Critiques of the present system Being national and representing many specific consumer groups, the Consumers’ Health Forum has undertaken several detailed studies of consumer costs of care, and has focused on feeding its analysis into government policy-making. The research on pharmaceuticals (discussed above) illustrates this. The Forum’s overall policy position on out-of-pocket payments centres on the absence of any coordinated Commonwealth policy on the range of payments for all aspects of health and medical care. Its analyst, Ian McAuley, argues that Australia has a ‘messy’ system, with a wide range of ways in which consumers have to pay additional amounts for various types of care. He writes that the anomalies are ‘symptomatic of a lack of a coherent policy towards co-payments’ (1996: 12). McAuley (1996: 11) categorises the present system into two types 120
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of out-of-pocket payments: limited and open-ended. Limited copayment systems are those where the third party budget-holder pays all the costs above a certain level. For example, the Commonwealth government pays the cost of pharmaceuticals above the contribution of the consumer. Open-ended co-payments are those where the third party budget-holder limits its contribution to a fixed amount, and the consumer pays the remaining amount. This is the system most common for services covered by private health insurance, as John Smith’s story illustrated. The policy analysis by the Consumers’ Health Forum, therefore, has been directed to pointing out the unfairness of the present messy system. A Victorian consumer organisation with a focus on research and policy development has favoured a structural analytical approach. For example, its critique has highlighted the way consumers of care have bgen caught between the opposing forces of health funders and health care providers. Its main argument, presented in Who controls where the health dollar goes?, is as follows (Health Issues Centre 1991: 15): The attempts by health care providers to keep overall costs rising creates tension as the resources of the rest of society are stretched to provide a combination of larger incomes and wider professional opportunities . . . Against these forces are governments, which have an interest in compressing the growth dynamic of providers. Their concern may be that the expansion of the health care sector, or parts within it, may jeopardise the distribution of resources to other areas of priority . . . For most paying bodies (that is, governments, insurers) shifting costs to somewhere else can be as effective as limiting absolutely the growth of costs . . . The easiest group to transfer costs to directly are consumers, because they are dispersed and not organised into powerful lobbies.
The analysis of the structural forces at work in pushing health care costs onto consumers draws on the work by Canadian health economist Robert Evans (1990a). Evans likened the stresses generated in society by different structural interests to engineering concepts: of tension, compression and shear. The usefulness of this concept is the clear distinction between those organisations or institutions which ultimately pay for health care and the broad collection of different 121
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professional groups operating in the health system. This suggests that for consumer groups any organised lobbying may be effective, given the relatively silent position from which they start. The Health Issues Centre publication describes the ill-fated proposal by Labor Health Minister Brian Howe to raise the amount of direct payments people made for general practitioner services (HIC 1991: 30–2). Howe’s 1991 budget measure was defeated by an unusual (and temporary) alliance of consumer groups, medical practitioner organisations, academics and some state governments.
Needs at the margin Since the National Health Strategy (1991a) completed its research on direct payments the Commonwealth government has steadily raised the price of prescription drugs for consumers, including those on concessions. By the mid-1990s, the Consumers’ Health Forum (CHF) was reporting to the government on the effect of these policy changes (CHF 1995). The Forum undertook a series of consultations with members of consumer groups for a Commonwealth review of the impact of changes to the Pharmaceutical Benefits Scheme. Focus groups were held around the country with members of two types of consumer groups: those who were high users of pharmaceuticals due to the presence of chronic illness, and those who were at particular disadvantage economically or socially. People’s comments in the meetings illustrate the detail at the microlevel of the stresses and difficulties some groups of people have in affording their medications, and the interplay of different policies to subsidise the costs of care. One person commented: ‘medications make up only one part of a family’s health costs which also includes doctor’s bills, pathology charges and special nutritional items’. Another said: ‘You wonder if you should get your drugs and miss out on groceries’. And another: ‘If you can’t afford the medication, then you feel guilty and you torture yourself especially when it’s your kids’ (CHF 1995: 33–4). Anomalies in the system were the source of complaint (CHF 1995: 34–5). For example, diabetics pay for needles but for drugusers they are free. The government definition of what constitutes a 122
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family adversely affected the entitlements under the safety-net arrangements for people who did not fit this definition. Cost-shifting between hospitals and the Pharmaceutical Benefits Scheme meant that people paid where they had not paid before. The Consumers’ Health Forum identified one of the major problems as the way in which people had to spend a predetermined amount before the pharmaceutical safety-net came into play. While government policy was to alleviate the costs of drugs incurred annually, the difficulty for consumers with high needs or on low incomes was the impact on their weekly budget (1995: 63). People with restricted incomes and/or with high needs had to manage on a week-to-week basis. They therefore took decisions to balance the immediate cost of medications against other needed items in ways that may have had an impact on the quality use of medicines. For example, they took out-of-date medications, reduced the dosage, self-medicated with drugs bought over the counter, or stockpiled (CHF 1995: 34). The Consumers’ Health Forum concluded that government programs designed to ensure equitable access to services were undermined by both the ad-hoc nature of policy-making and the existence of consumers who did not ‘fit’ the administrative structures of that policy (1995: 63). The strategic message broadcast from time to time by the Health Issues Centre has been to highlight those doctors who charge fees above the rgcommended fees of the Medicare Benefits Schedule, at levels well above their colleagues’. Using data collected by the Health Insurance Commission, the Centre published tables that showed which doctors charged above the recommended fees, and by how much (Hill 1990, 1991). On GP fee levels, for example, the analysis pointed out the considerable growth in the number of consultations that were charged at more than 20–50 per cent above the recommended fee (Hill 1991: 15–16). In the same issue of the Health Issues Centrg journal, a companion piece was critical of proposed changes from Labor Health Minister Brian Howe to raise the amount consumers paid for GP services (a proposal subsequently defeated due to widespread criticism) (Hill & Peerson 1991). This critical piece drew ammunition from a phone-in in South Australia organised by a welfare group in 123
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response to the proposed fee changes. The callers itemised their present health costs: ‘We have lots of sickness, and we buy lots of medicine’ (country caller, mother of four asthmatic children); ‘each visit costs $5–$10, plus $10 in petrol and $15 in medication’ (Hill & Peerson 1991: 14). The article noted the trend to cash-on-the-day practices used by some general practitioners and the restrictive options for people in some country towns. The main political message of these reports was to show the Commonwealth government and the medical professional organisations that health costs were being monitored. While the Health Issues Centre was strongly supportive of Medicare, there were problems at the margin. Doctors, it was argued, derived most of their income from a tax-funded scheme and from people who were ill and needy. Hill concluded (1991: 16): Whilst the medical profession may have a good case to argue to Government that the rgcommended fees do not reflect the true cost of providing a service and need to be increased, they have proper channels in which to do that. At present, many individual doctors are making up their own minds as to what is a fair and reasonable income, and are translating this into their own schedule of fees.
Defining needs The third strategy by consumer organisations for seeking political recognition for unmet needs in relation to health care costs has been to try to identify the range of needs people have that are not met by current arrangements. For example, the Health Issues Centre conducted focus group research to explore people’s experiences in paying for health care. Their findings (Loftus-Hills 1993) were in accordance with the results of the analysis by the National Health Strategy reported above: namely, that dental care, pharmaceuticals and private health insurance were often prohibitive in cost. However, the analysis goes on to document other costs that were an issue for people: for example, the inadequacy of the pension levels for people who were caring for others; the expenses associated with attending 124
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health services, such as transport costs; and the cost of child care and interpreters. One of the drawbacks of such analysis by consumer groups is their inability to document the dimensions of the problem—largely due to the inadequate resources available to consumer groups to conduct large-scale projects to quantify the extent of the problems. However, the qualitative nature of such contained studies allows consumer groups to put the experiences of members of the public into the public realm, and in particular the experiences of people who may be less likely to complain, given their already disadvantaged position.
Discourses on needs Fraser writes that in examining the politics of needs interpretation we should examine the ‘discursive resources’ available to social groups in their actions to press claims (1989: 164–5). These resources include the idioms in which claims are made, the vocabularies for interpreting needs, the paradigms of argumentation, and the narrative conventions for constructing people’s identities and experiences. If we use this categorisation of discursive resources, we can tease out the political messages and actions of consumer groups. For instance, the idiom common to consumer groups when discussing the costs of care to consumers is that of needs, rather than rights, which is an idiom that characterises much other consumer work. Needs are contingent on timing: that is, the structures of protection do not accommodate the immediacy of people’s needs. The focus is on certain groups rather than whole population groups (e.g. those with ‘high’ needs, such as people with one or several chronic illnesses). Different vocabularies noted by Fraser for communicating needs are feminist, therapeutic and administrative vocabularies. Consumer groups use a vocabulary that would self-evidently be termed a consumer vocabulary. Users of health care services are always in one sense consumers. The term is used to mean all citizens or members of a social polity, participating in society’s benefits (here Medicare), or it is used in a focused way to refer to people undertaking particular transactions in the health market. 125
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The third discursive resource is the paradigm of argumentation: in other words, what is accepted as authoritative in adjudicating claims, and how conflicts over the interpretation of needs are resolved (Fraser 1989: 165). There has not been the space in this chapter to follow the analysis of consumer group claims with the responses by government or professional interests. However, the principal argument in the work of the Consumers’ Health Forum is that much government policy-making on direct payments is ad hoc. This claim attempts to undermine one of the planks of policy making—that policies and programs rest on evidence of meeting need, deliberate, rational decision-making, and evidence of likely effectiveness. The consumer argument therefore critiques the government programs on their own ground. The final resource drawn from Fraser’s work is that of the narrative conventions used to construct individual and collective stories (Fraser 1989: 165). The main narrative convention used by consumer groups is narrated experience. People’s actual words, drawn from research which facilitates this expression, are used to illustrate the lived experience, with its immediacy and complexity. The strategic importance of this is that the actual experience of disadvantage is foreign to many of those with political and bureaucratic responsibility. People’s words have a potency which makes a bridge between the microlevel of community life and decision-making on a national or state government scale. Tools such as discourse analysis are an important resource in policy research.
Conclusion Direct consumer out-of-pocket payments for health care have remained an important policy area for consumer organisations, despite the broad success of Medicare and the Pharmaceutical Benefits Scheme. However, consumer organisations have identified a number of areas where people do not have adequate protection against high health care costs, as well as groups of people who are not well protected. In the future, with concerns about increasing expenditure on both Medical and Pharmaceutical Benefits Schemes, governments may seek to raise consumer co-payments in response 126
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to pressures from other interested parties, namely the pharmaceutical industry and medical providers. The failed attempt in 1997 by the Howard Coalition government to raise nursing home fees illustrates that, in some service areas, a strong and vocal coalition of health consumer interest groups can block a cost rise, particularly in an emotional area of public policy such as older people’s homes. However, constant efforts by state governments over recent years to chisel away at the principle of free care for low-income earners (in community-based services) have largely gone unnoticed by the general population. One of the difficulties for consumer groups has been to identify the problem in such a way as to catch the political attention of the Commonwealth government, or to catch and maintain the attention of state governments. Fraser’s analytical framework has been used to tease out discursive resources—the resources used by social groups in pressing their political claims about needs. This has provided a tool for analysing the arguments and strategies of consumer groups in their struggles to establish the political need to address the issue of direct payments for consumers.
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III MARKET STATE REFORM AGENDAS
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7
Casemix: Financing hospital services MARY DRAPER MARKET STATE REFORM AGENDAS CASEMIX: FINANCING HOSPITAL SERVICES
This chapter continues the focus on health financing and looks at the way financing arrangements shape the delivery of health services and at the play of voices which call for reform of these arrangements. Looking at the current challenges affecting the financing of health care delivery from the different points of view of consumers, providers and payers, the chapter examines some specific policy responses, focusing in particular on casemix funding as an illustrative case study. Casemix funding is part of a broader reform of hospital management and funding, and is used in Australia at Commonwealth and state levels as a way of funding hospitals and negotiating budgets. The particular form casemix funding takes varies considerably across the states. Here, the Victorian model of casemix funding provides a starting point to begin to analyse casemix as a policy response to the formidable challenge of hospital financing. The Canadian health economist Evans uses engineering concepts to describe the scenario of cost containment in health. Like Alford (1975), Evans (1990a) draws on the concept of structured interests in health. The first group of interests, health providers, includes those whose incomes, profits, prestige and professional opportunities arise from providing health services. Essentially, Evans (1990a) argues that these groups have a basic interest in pushing up the amount of money available for health. 131
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Major payers for health services, on the other hand, such as governments and health insurers, have an interest in restricting the growth of expenditure on health. Alford (1975) includes the full range of those interested in the management of health care services, and terms this group of interests the ‘corporate rationalists’. This allows for a more complex set of interests, which can include the idea that accompanying basic preoccupations with the cost of the delivery of health may be other concerns, such as equity of access and the distribution of health services. Consumers, the third group in Evans’ argument (1990a), have the disadvantage, in relation to the previous groups, of not being an organised interest. This means that the interests of consumers are not always well represented in the struggle around health costs. In Alford’s analysis (1975), this third interest is termed the community interest. The crux of Evans’ argument is that in this basic contest over health finances, which essentially takes place between health providers and health payers, the pressure of compression from such conflict is often relieved by a process of slippage of force sideways. From the point of the view of the payers, a solution that has the effect of transferring costs elsewhere is as good as a solution that actually controls costs, and much less stressful (Evans 1990a). Essentially what this solution does is to step away from the difficult overall question of cost containment in health, to transfer onto consumers the cost of the compromises made (Health Issues Centre 1991). This is well illustrated by the co-payment issue discussed in chapter 6.
Starting with the consumer In the spirit of Evans’ concerns, we start by looking at consumer perspectives on health care services, and use these as a benchmark against which we can discuss the strengths and limitations of current health services financing arrangements. It is clear that, in Australia, consumers have reasonably equitable access to basic medical and hospital care, although not to health itself (National Health Strategy 1992; AIHW 1996). Low-income-earning Australians well recognise the importance of Medicare to their access to health services (ACOSS 1993). Numerous opinion polls testify the value Australians place 132
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on Medicare in guaranteeing access to medical services. Medicare provides access to medical services and hospital care, but not to a range of other health services such as allied health care and dentistry. While low-income Australians use more than average health care services, reflecting their health care status, they are underrepresented in the use of preventive health care services (National Health Strategy 1992). While the original Medibank envisaged a series of health care grants, which would have covered the broader range of health services, this aspect of Medibank was not implemented because of the demise of the Whitlam government. When Medicare was introduced in 1983, this part of the original project was not revived (Scotton 1993: 83–4). One major consumer criticism of the Australian health care system is its preoccupation with acute medicine at the expense of attention to those people with chronic illnesses and conditions. This is exacerbated by a long history of poor communication between different health professionals, and between hospitals and other parts of the health care system. This is one component of the poor record of discharge planning by Australian hospitals. Australian consumers comment on the degree of fragmentation of health care services, which is part of a profile of overspecialisation. The primary health care sector is itself highly fragmented, with a mix of private providers, medical and allied health professionals, and publicly funded community health centres. These different components of the primary health care sector are often in competitive and sometimes hostile relationships, in a terrain marked by professional and organisational tensions (e.g. South Australian Community Health Research Unit 1994b). Split financial responsibilities between different levels of government complicate the picture, with general practitioners being funded by the Commonwealth and community health centres by state governments, with no consistency in community health policy across states. Several common themes emerged from a review of Australian consumer research by Draper and Hill (1996: 53), which found that consumers raised issues about communication, being treated with respect, being involved in decision-making, getting adequate information, access to interpreters, seeing the same health professionals 133
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across an episode of care, wanting better hospital discharge planning, and being treated in a non-discriminatory manner. Consumers are positive about multidisciplinary teams and communication between professionals within and between services. The philosophy adopted by different specialty areas has a significant impact on the way care is structured and the approach taken towards consumers. Some specialties are more likely to treat the person on equal terms, promote self-management, involve a range of professions, and generally have a structured approach to treatment and care. Consumers are often advocates for these models, and would like to see services structured along these lines (Draper & Hill 1996: 53).
Technology and change Technology is a major player—and profit-taker—in shaping contemporary health care. The availability of more precise diagnostic technology rapidly becomes a routine part of diagnostic assessment. Other technology gains mean that surgery that was once complex and invasive can now be undertaken through the use of laparoscopy. Such procedures need lighter anaesthetic, and the overall result is rapid recovery. The availability of these less invasive procedures does not, as one might expect, reduce the costs of health care, as often more surgery is attempted. Technology and skill improvements result in the saving of lives that would once have been lost, such as low birthweight babies. Bypass heart surgery, in the 1960s front-page news, is now virtually routine. These shifts in technology have a number of consequences, such as shorter hospital stays with consequent greater throughput, and lives marked by varying levels of disability. The pattern or shift in health care services is away from institutional care and towards ambulatory care. This again reflects gains in the rgach of medical interventions. Conditions such as cancer are substantially treated, after an original hospitalisation, with forms of ambulatory care, chemotherapy being delivered during day visits to hospital or at home. This is linked to the growth of chronic illnesses and conditions, greater longevity, and the emergence of new illnesses 134
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which are long-term or chronic in their nature, such as HIV/AIDS. Many of these conditions are managed with periods of inpatient care and much longer periods of ambulatory care. There are also consumer preferences in these arrangements. Recent decades have witnessed a critique of the power and dominance of professional discourses (see Illich 1976). Many consumers have expressed a preference to de-medicalise critical experiences of life, such as birth and dying. Consumers have led a movement demanding the relocation of some of these critical life experiences, and argued for more active roles in decision-making about their health care. The hospital is central in health care and the major component of health expenditure. It is also the site of professional power and professional socialisation. There are, however, considerable shifts in the functions of hospitals. Victoria’s Health 2050 (Department of Community Services and Health 1995) is a perfect example of policy whose central argument rests on this point. The subsequent development of metropolitan hospital networks in Victoria rests on an argument about shifting the mix of services available. All states have variations on this theme (e.g. Area Health Boards in New South Wales). Writing in the USA, Zussman (1993) coins the phrase the ‘disappearing patient’ to note that studies of patient hospital experience have disappeared from the social sciences. This phenomenon, he argues, reflects a structural change and the decline of a collective patient culture, as most patients these days do not stay long enough to create one with the new forms of treatment and treatment architecture. The disappearing patient is part of a shift, which conceptualises a hospital patient as a more or less isolated individual reconstructed around a notion of individual rights. Other patients have become potential sources of infection. In many hospitals, intensive care beds have their own air supply. These changes, Zussman (1993) argues, make hospital a privatised, not a social, experience. The modern perception of a hospital is a technological one, focused on procedure as the rationale for patient stay, in a largely privatised conception of patienthood (Draper 1992a). Thus, in a contemporary hospital, patients who need caring rather than treatment become a management ‘problem’ for hospitals. 135
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Rationalising health care It is not surprising that cost containment preoccupies governments, even aside from the influence of ‘small government’ advocates. Modern medicine is expensive. Continuing innovation in health technology, population changes and new diseases put constant pressure on health expenditure. With technical innovation comes rising community expectations. Health professionals, in their separate areas of specialisation, also become strong advocates of increased finance in their area of medicine. However, there is no evidence that raising the amount of expenditure on health actually improves health status. This is well illustrated in the USA, where, in a system highly responsive to technological innovation, overall health expenditure far in excess of that of other countries does not result in improvements in the overall health status of the population. On the contrary, overall health status in the USA is lower than that of other countries which spend half the proportion of their GDP (see AIHW 1996: 9, 124). Nor is there any guarantee that higher expenditure on health goes to the right kinds of services. One of the problems of the way technological innovation drives the health dollar is that it draws increasing amounts of money after the event of illness. The same kind of pressure does not result in growing allocation of resources to measures that might reduce the level of illness in the first instance. Governments have a number of other considerations besides cost containment, such as equity of access to health care services and the appropriate shape and mix of services (in other words, the deployment of resources). Whatever the intentions of new ministers in the health portfolio, hospitals rapidly come to occupy a central space in concerns about health financing. This is not surprising, given that hospitals are the biggest item in the health budget. Essentially, payments to hospitals and physicians preoccupy health departments throughout the world. There is a worldwide wave of health care reform concerned with the containment and deployment of health costs. Interestingly, many of the reform ideas originate in the USA, a country famous for its failure to contain health costs adequately and guarantee equity of access by its own citizens to health care. This does not make such measures illegitimate, but it is worth bearing in mind the particular pressures in the health care system from which many of the measures originate. 136
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Health insurance organisations are another payer, and in many respects pressures on them for reform tend to come from outside these organisations themselves. In the USA, for example, pressures for reform arise from the costs that health insurance adds to production costs, because employers pay for health insurance. In Australia there has bgen little evidence of any real attempt by health insurance organisations to limit the cost to consumers by limiting the expenditure of hospitals and providers. Hospital management is the third component of the ‘corporate rationalists’. Their concern is to maximise their particular hospital share of government financing, but at the same time they have to accomplish the balancing of the hospital budget and are responsible for the ways in which finances are allocated within the hospital. For both government bureaucrats and health managers, controlling hospital costs is a challenge. Hospitals represent a particular kind of professional organisation (Mintzberg 1989). The difficulty with hospitals is that the group most influential in generating costs—doctors—are often in loose organisational arrangements with hospitals or, in some cases, own hospitals themselves. Particular hospitals represent only one site of practice for consultants, who spend only some of their time there but make decisions that have crucial resource implications. Even for doctors employed by hospitals, primary loyalties are to their profession and their patients. The doctor–patient relationship is a highly individualised one, and allocative decisions in health are decided by an aggregation of decisions about individual health care. At the same time, different clinical sections of hospitals are usually trying to get as many resources as possible into their own area. The medical profession puts autonomy at the centre of its conception of themselves as a profession. Evans (1990b) suggests that this preoccupation with clinical autonomy has come to take precedence over the demands of good science, another key professional attribute. Mintzberg (1989: 189) suggests that autonomy and multiple sources of decision-making lie at the heart of problems confronting professional organisations. The work of professionals can be controlled only through those strategies the professions themselves decide to adopt. Mintzberg (1989: 189–91) argues that professionals tend to overlook problems of coordination, discretion 137
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and innovation. Problems with coordination arise because, at the limit, professional organisations such as hospitals work as collections of independent individuals who come together to draw on common resources and support services (Mintzberg 1989: 189). The issue arising from discretion (autonomy) is that there is little rgdress for poor or misjudged performance. While peer review is regarded as the central professional control of doctors, the rgality is that doctors, like other professionals, are reluctant to act against their own (Hancock 1997; Rice 1988). The problem of innovation is well illustrated by the difficulty the Australian health care system has in responding to people with chronic illnesses or conditions. Submissions to the Professional Indemnity Review (Department of Health, Housing and Local Government 1995) from people with severe disabilities indicate that health care services have great difficulty coordinating packages of care that meet their needs. In particular, information on the availability of services is hard to find. People face multiple assessment procedures, which elicit much the same information. Services fail to focus on individuals’ needs and are often inappropriate. Frequent turnover of staff causes frustration, and the needs of carers are either ignored or catered for inadequately (Department of Health, Housing and Local Government 1995: 8). Technological innovation will not in itself create the innovations in organisational form or the communication needed to resolve problems of fragmentation. In Australia, these problems of coordination are exacerbated by split financing and management responsibilities between Commonwealth, state and local governments, as well as between dual streams of public and private health care. The boundaries created by these financing arrangements lend themselves to cost-shifting and shifting of responsibility to other levels of funding (COAG Taskforce 1995). This makes coordination of health care a central concern for health consumers—a difficult accomplishment.
Reforming health care The health policy sector is replete with ideas about reform. Globalisation has meant not only the spread of capital throughout the world 138
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but also common ideas about health financing reforms. The current crop comes with many names—managed care, coordinated care, case management, critical pathways, linkages, purchaser/provider split, and casemix. The terms come with different provenances, often reflecting the problems of the health care system in which they originated. Some are derived primarily from attempts to restrain funding, others reflect attempts to redesign service delivery and the systems that deliver care. It is no coincidence that many of them reflect ideas about the coordination of care. But as Finister and Hill (1993: 118) commented of community care reforms in the UK, ‘the flag of community care can be seen to flutter on the masts of ships sailing in very different directions’. The reforms reflect different ideas about the need for reform, the nature of the problems, and the shape of the solutions. Some appear to arrive as policy solutions in search of problems to which they can be attached. In this respect Evans’ phrase, ‘moving the target to hit the bullet’, is evocative (Draper 1995). Duckett and Swerissen (1996: 16) note that, in consultations over the past couple of years, whereas governments appear to be preoccupied with issues of cost-shifting between governments, consumers express little concern with these issues. Consumers are more concerned with gaps in service provision caused by both Commonwealth and state governments shirking responsibilities for emerging needs. It is against this background that some of the changes in the financing and delivery of health services in Australia, such as casemix funding and the various forms of managed or coordinated care, might be understood. The context is one of cost containment, appropriate deployment of resources, and the shape and details of provision of health services.
Casemix funding In July 1993, the Victorian government became the first in Australia to introduce casemix funding of hospitals. As a consequence, while a number of state governments have now introduced casemix funding of hospitals, each state has quite different casemix implementation. Much of the work at Commonwealth level has been preoccupied 139
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with technical issues rather than how casemix funding could address health policy objectives other than efficiency (Draper 1992a). Essentially casemix is a tool and in assessing it one needs to understand its strengths and limitations. But it is the use of the tool that determines its impact. This is why the policy context is essential in thinking about casemix. Casemix is a health information and funding system. It provides a means of describing hospital work and a means of comparing what hospitals do. Its strengths lie in providing a language about hospital activity, which offers an opportunity to look at the detail of hospital work. This makes it possible to track, with varying degrees of accuracy, the cost of providing care to groups of patients. This enables hospitals to understand characteristic patterns of resource use and to identify outlier (unusual) patterns, and through these to provide information to manage hospital resources better (see Scotton & Owen 1991; Health Issues Centre 1992; Fetter 1996). The unit of cost allocation for casemix is the patient stay. Hospital costs are allocated to categories of patients, who can be assumed to use roughly similar resources. Casemix classification systems potentially cover both hospital- and non-hospital-based care, as well as different forms of care from acute care to rehabilitation. The most developed forms of casemix in Australia are those relevant to acute hospital care—diagnosis-related groups (DRGs). DRGs describe episodes of patient care marked by admission and discharge. Like other casemix classifications, DRGs work on an averaging basis; they do not describe what should happen to a particular patient but the average cost of treating patients in that category. As a management tool, casemix encourages hospitals to work towards the average and, by comparing themselves with other appropriate hospitals, to judge their own resource use against those of like hospitals. Casemix is also used as a basis for funding hospitals. There is no single ‘casemix way’ of funding hospitals. The practice varies in different countries and across different states in Australia. Broadly speaking, the approaches fall into two camps—funding hospitals on the basis of their outputs, or using casemix as a way of pricing hospital care in the context of purchasing contracts (as in New South Wales and the UK). 140
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Assessing the impact of casemix A fair assessment of the impact of casemix as a funding tool is made difficult in Australia, as the two states with the most advanced implementation, Victoria and South Australia, accompanied the introduction of casemix funding with major budgetary cutbacks. Victoria removed $220 million from hospital budgets over two years. Additionally, in both states the introduction of casemix funding was soon followed by a range of other reform measures—in South Australia privatisation, and in Victoria hospital networks. As with any complex organisations, change and innovation represent a challenge for hospitals. It is likely that an evaluation of the current state of Victorian hospitals would show that they have suffered from a combination of budget cuts and an excess of reform strategies, not all of which push hospitals in the same direction. It is likely that there is neither the management expertise, nor the professional willingness, to manage the amount of change expected. It is also arguable that the degree of change expected in a relatively short period of time is unreasonable. It has bgen difficult for hospitals to manage the amount of adaptation required of them by casemix funding against a background of budget cuts and competing reform strategies. Using casemix funding as a way of distributing health financing among hospitals is a reasonable strategy from the point of view of corporate rationalists. Prior to casemix funding, the size of budget going to any hospital was largely determined by past allocations. These in turn were influenced by the history of the particular hospital, the status of the hospital, and the capacity of the hospital to lobby effectively in the private arena of negotiation with health departments and the public arena of the media. Some types of health care and some types of hospitals have more ‘purchase’ on the public imagination. As an allocative tool, casemix funding shifts the focus, so that hospitals undertaking a similar mix of activity are funded on the same basis. While this objective is quite a fair one, it is arguable whether casemix classification systems adequately account for differences in the mix of complexity and severity of what hospitals do. Some say that recent developments in casemix classification systems 141
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have gone some distance towards solving problems of complexity and severity (Fetter 1996). Casemix forces hospitals to look at their resource use and attempts to incorporate clinicians into a form of accountability for the resources used as a result of their clinical decision-making. The general policy context of casemix funding determines the extent to which hospitals have a discretionary space to utilise the analytical capacity casemix provides, and the extent to which the casemixfunded hospital becomes an institution focused on creative problem-solving, or one focused on classification manipulation to maximise resources. By focusing on resource use, casemix systems focus on areas that are critical to resource use and about which hospitals have information. One of the limitations of casemix in Australia derives from the fact that classification systems developed in the USA could rely on very high levels of detail about costing, because the health insurance environment ensures that hospitals bill on the basis of every unit of activity. On the other hand, Australian public hospitals have traditionally been funded on the basis of a global budget, and have not developed detailed information on each aspect of care costs. One consequence of the need to focus on those aspects of hospital care that are easier to manage has been to focus Australian hospitals on length of stay as an indicator of resource use and an area in which efficiencies can be gained. However, length of stay is not the only element of cost. A clinician could have quite short lengths of stay but high intensity of treatment involving, say, high-cost medical technology for the patient, making short stays at the same time expensive. The seduction of the length of stay option is that hospitals can track it with their current information systems. Political and public concern with waiting lists adds to the pressure on hospitals to focus on length of stay. From a consumer perspective, this preoccupation with shortening the length of stay has several consequences. The use of DRGs in the US Medicare program has been associated in the Rand review of quality of care with ‘quicker and sicker’ discharge (Koscoff et al. 1990). Coulim and Gaumer (1991), in an appraisal of US research, found that greater instability in health consumers at discharge has been accompanied b{ signs of poor discharge planning and manage142
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ment of post-hospital care. Culyer and Posnett (1990) argue that the full social costs of medical care need to be addressed when assessing the impact of cost containment. To bg clear, quicker discharge does not necessarily mean that the discharge is inappropriate: some is a consequence of less invasive surgical technique; but other quicker discharge is a consequence of shifts in thinking about the location of recovery. An earlier discharge can be considered inappropriate if the patient is not sufficiently recovered, not ready to cope, or if the services needed to support recovery post-hospital have not been organised or are not available (Draper 1992b). Discharge planning has not been a strong feature of Australian hospitals (National Health Strategy 1991b: 34). Research and consultations with consumers and consumer groups point to problems here (Health Issues Centre 1992; CHF 1994; Brotherhood of St Laurence 1997; Draper & Hill 1996). Hospitals are often insensitive to people’s social circumstances. Older people are discharged home, often with mobility problems, to accommodation which is difficult of access, to aged carers who may themselves be ill, or without adequate communication with services providing post-hospital care. In research by the Council on the Aging (1994: 15), one consumer commented: I have no problems with the care I got in hospital, but then they just threw me out, no planning, nothing. About two weeks later somebody from the council turned up to do an assessment. It was too late by then, I had recovered and was not a high concern for them. It was the worst time of my life, when I left the hospital.
Discharge from hospitals is often a by-product of the need to clear a bed rather than a planned process. These practices in hospitals predate casemix and are not, in themselves, a consequence of casemix funding. However, casemix funding puts the pressure on hospitals at a point in which traditionally they have found it difficult to perform well—that is, effective coordination of care. There is potential benefit from the focus on length of stay, insofar as it has generated within some hospitals greater preoccupation with more effective discharge processes, if for no other reason than effectively planned discharge assists hospital efficiencies. It is in hospitals’ interests in this environment to develop better relationships with post-hospital services, 143
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given that they are now reliant on them to bg able to achieve their own targets. The organisational leverage this makes potentially available to post-hospital services has not always bgen well understood. However, in some of those states (such as Victoria) where casemix funding has been introduced, and where deep budget cuts have been made to hospitals, cuts have also been made to, say, community health centres, which are likely to provide some of the post-hospital services. In addition, other sites of post-hospital service provision, such as local government, have been experiencing change and instability through council amalgamations, cuts to welfare services and the tendering of services. The lag in policy development to support these shifts in the location of recovery has resulted in higher demands on community-based services without increases in their budgets, and in ad-hoc and inconsistent service development across different parts of the state. On the positive side, a number of innovative projects and programs currently under way in Victoria and other states focus on better discharge arrangements, in particular for older people.
How good is the tool? There is nothing inherently offensive about the effort to cost the details of hospital care, and casemix is a robust attempt to do that. However, there are a number of problems that can bg considered limitations of the tool in use. The first is that, by having casemix funding of acute hospital care, the focus is on the episode of acute hospital care rather than the costs of the whole episode of care. This can result in decisions which, while efficient in the short term, are not efficient in the longer term. A patient who is discharged before all symptoms are resolved or before medication is stabilised may suffer one or more relapses, resulting in further hospitalisation and increased cost. The cost of this across a lifetime to the person and to the health care system may be considerable. It is quite conceivable that in many circumstances, the most efficient thing to do is to keep a person in hospital longer in order to ensure their recovery. Much of the containment of Medicare hospital costs in the USA has been accompanied by a rapid rise of costs in the ambulatory care sector. This transfers costs from one sector to another (Gabel 144
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et al. 1988: 62–4), essentially at cost to lower-income employees of hospitals, such as cleaners and attendants (Evans 1990b: 125). Containing the costs of health expenditure is not accomplished simply by controlling costs at hospital level, or by shifting costs to consumers in service costs or health insurance premiums, but by controlling costs across whole episodes of care, be these short- or long-term. Rgsponding to this, some of the current developments in casemix classification and funding have shifted towards classification and funding arrangements which work off more complete episodes of carg, and incorporate care across institutional boundaries and into community care. Evans (1990b: 124–5) argues that the preoccupation with cost containment often focuses on whether procedures should be done on an inpatient or an ambulatory care basis. The real question, he argues, is whether they should be done at all. A system that focuses solely on hospital efficiencies starts at the wrong point, and may simply shift costs to community-based services and to consumers and households. The real generator of costs in the health care system is the decision to treat and decisions made about the choice of treatments. Providers make these decisions. In the context of medical uncertainty there is often an absence of information about the efficacy of a range of medical interventions. Enormous differences occur from one place to another in the way that medical practice is conducted. This variation is not understood entirely, but one cause appears to bg an inadequate scientific basis for many common medical interventions, leading essentially to practice based on the priority of discretion and autonomy (Andersen & Mooney 1990). The current shift to basing clinical practice on the best available evidence about the effectiveness of treatments, through the development of practice guidelines and the Cochrane Collaboration (the international data bank on treatment effectiveness), is an interesting way of beginning to deal more effectively with these dilemmas. The National Health Service (NHS) in the UK has begun to develop guidance for purchasers, developed by clinicians, on using evidence to decide what services to purchase. The attraction of casemix to health bureaucrats lies in the transparency it offers them about hospitals. It is true that casemix provides a language that enables a more informed dialogue to take 145
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place between hospitals and health bureaucrats, and in this respect planning is enhanced. However, there is illusion as well: casemix is par excellence a system of rationality. It is a form of instrumental rationality, in the way the sociologist Weber uses this term. By giving a highly rational account of hospital activity, it attempts to deliver control of hospital expenditure. But this battle over health expenditure is a politically charged contest marked on one side by the considerable power that doctors wield, because of their control of knowledge and skill in a critical area of human uncertainty—illness— and on the other side by the power to allocate funding. The majority of health professionals are passionately committed to their craft and trade and to the perceived benefits of what they offer. For many, altruism is an important motivation. The staff members of hospitals show commitment beyond the call of duty. Hospitals are emotionally charged places, where people are confronted daily with the tragedies and limitations of human existence. Against this backdrop, health professionals tend to find it hard to see beyond their particular point of view, and have considerable resources to bring to bgar, including professional power and the capacity to generate both media interest and community sentiment. Many have written of the politics of health, and medicine is one of the world’s most powerful professions. Behind it, and often (but not always) separate, are the considerable financial interests of those who stand to profit from health care, such as the manufacturers of technologies and pharmaceuticals, and owners of health care facilities. On the other side, the health bureaucracy can be tempted to seek tidy solutions to what is clearly complex. In this contested terrain, casemix places its faith in rationality and transparency—a technical solution to a complex problem. However, this fails to take into account the non-rational elements of health care, as well as the very considerable politics of health policy. A related question is whether casemix has elements in common with scientific management. Scientific management was an attempt to describe and rationalise the way work was performed in organisations. One of the major criticisms of scientific management was that, whereas it was important in describing work tasks, it took the work process apart but failed to put the whole back together. 146
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Being task- and product-focused, it overlooked social processes. Casemix is focused in detail on particular elements of hospital activity but may overlook important elements. Many things contribute to making the hospital work as a whole and to accomplishing the various balances that need to be met and managed. In 1997 concern emerged about Victorian patients spending substantially more time on trolleys in accident and emergency units. One plausible explanation would suggest that, since the introduction of casemix funding, with its focus on greater throughput, many Victorian hospitals have become more efficient in handling elective surgery waiting lists, resulting in bgtter utilisation of theatre time and hospital beds. It is possible that insufficient slack remains to accommodate unpredictable emergency demands. The point of this hypothesis is that getting the balance of allocation of hospital resources right is a more complex task than simply managing the particular ‘product lines’ of the hospitals, and that casemix funding is focused on the product lines, not the whole. What has casemix funding meant for consumers? Insufficient research has taken place to allow the question to bg answered with any certainty. It is likely that such research would establish both gains and losses. The most problematic pressure point appears to remain the timing and planning of hospital discharge, which some hospitals manage better than others. There are also cost shifts to households. The test of casemix from a consumer perspective is whether it delivers organisational reform that results in better management of treatment and care within hospitals and across services.
Conclusion The need to struggle with the allocation of health financing will not go away, whatever the settlement about the overall levels of expenditure on health and its related services. Different forms of financing and managing health care have their strengths and limitations. New forms of financing are preoccupied with the concept of coordination. The goals of enhancing dignity and quality of life for people with serious health conditions, putting together care across different institutions and boundaries, plus containing expenditure, compete with 147
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the ascendancy over the past decade of neoclassical economic ideas about reducing the role of governments and relying on the mechanisms of markets to allocate health care resources. The health sector remains, more than ever, a strife of interests (Sax 1984) and a strife of voices. This chapter has posed the question: Whose interests are served by the processes of health care reform? Rglated to this is the matter of which voices are the most easily heard in debates about reform and which of these groups are most able to affect the outcomes of reform. There is not a settled answer to this in the current reform environment, although some interests clearly have more power. While an efficient health care system is a desirable goal, there are issues about how efficiency is to be judged. Commonly, the drive for efficiency results in a short-term focus, rather than a long-term view, and it is easily diverted to focus on cost alone, which is not the same thing. The matter of who stands to benefit most from the reforms that are sweeping all health care systems is one that requires careful and imaginative research. In the end, such research needs to include criteria about where the financial benefits fall, but also about whether consumers receive better care and services in an equitable way. Retaining public confidence is a challenge when confronting choices about managing fair and adequate health services financing.
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8
Contracting out in the health sector MICHAEL MUETZELFELDT CONTRACTING OUT IN THE HEALTH SECTOR
This chapter explores the radical changes in tenets, organisation, purposes and attitudes concerning public policy in general which have gathered pace since the early 1980s, and which have swept up health policy as part of that process. It does this by first describing the use of market and contractual models in the restructuring of organisations engaged in public management, then examining the impact of this restructuring on public interest, public accountability, and the understanding and reinterpretation of people’s capacities as citizens within the market state. It then points towards ways in which health policy might overcome the negative impacts of the prevailing contractual model through proactively engaging with it.
Markets, competition and contractual models for restructuring There is a strong move in Australia (as well as in Britain, Canada, New Zealand and the USA) to adopt market and contractual approaches to restructuring public management.1 This is based on a separation of government as purchaser of goods and services from the public or private agencies that provide them—often referred to as the purchaser/provider split. Under this model, small, core 149
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government agencies purchase services from non-public sector organisations which are contracted to be providers. In Reinventing Government, Osborne and Gaebler (1992) popularised this separation of purchaser from provider with the evocative but simplistic metaphor of ‘steering not rowing’. The model in effect involves setting up a market or pseudo-market in which potential providers compete for contracts from government, and where the contracts specify exactly what goods or services are to be provided and on what terms. Restructuring in Victoria provides a case study of this approach, and is described in some detail in Alford and O’Neill (1994: ch. 1). The archetypal example of the move to contractualism in public service management is Victoria. The Victorian Commission of Audit set out three principles for restructuring government. First, the department (and the minister) responsible for setting policy, regulating and ultimately contracting for the provision of goods and services should be clearly separate from the organisation responsible for providing these goods and services. Second, governments should aim to purchase designated outcomes (results) or outputs, rather than funding ‘inputs’ such as wages, salaries and operating expenses. The government, through its minister and the department, should be held responsible for outcomes, and as a general rule the department should contract ‘service providers’ for specific outputs to ensure that certain outcomes are achieved. Third, wherever possible, government should seek to foster competition between organisations supplying or providing the goods and services, or ‘outputs’, contracted by the departments (Victorian Commission of Audit 1993b: 2). Alford et al. (1994) identify four types of contracts that are being used in Victoria to implement these principles: contracts between employer and employee; between the government as purchaser and a public agency as provider; between the government as purchaser and private firms or voluntary agencies; and between the individual consumer and the private firm that comes about via privatisation (Alford et al. 1994: 5–6). Motivations for the use of the purchaser/provider split model are mixed. It is said to enhance ‘individual rights, and the accountability of government’ (Harden 1992: xi), and to improve responsiveness to client or customer needs, especially for customers’ service needs (e.g. 150
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Osborne & Gaebler 1992). New right analysts consider that the model avoids what they see as the hazard of government agencies being captured by their clients and collaborating with client groups to demand increased services at higher cost (Dunleavy & O’Leary 1987: ch. 3). But in terms of practical politics, a strong motivation is that establishing markets or quasi-markets2 is believed to lower costs by improving efficiency. Both the Victorian Commission of Audit (1993b: 81–133) and the National Commission of Audit (1996: 49ff., 307–21) argued that major savings in health expenditure would result from various combinations of contracting out, increasing contestability3 and improving price signals across a range of situations—from the contracting out of hospital cleaning services and hospital privatisation through to increased contestability in retail pharmacies and the provision of diagnostic services. New organisational and management, public interest and public accountability issues are raised by this new model of public management. Behind these lie the relationship between people and the state, and in particular whether that relationship should be based on the efficient delivery of services to clients, or on an expression of people’s citizenship.
Organisational and management issues In terms of organisational restructuring, the purchaser/provider split approach is similar to private sector franchise arrangements in, for example, the hire-car and fast-food industries. The franchisor exercises strategic control over the whole organisation (or cluster of organisations) by defining the products or services, establishing and enforcing uniform management and quality assurance procedures, and marketing the uniform products or services. The franchisor contracts out the delivery of the product or service to local franchisees, who are nominally independent operators. Typically, the franchisor controls quality through controlling and organising the inputs that the franchisee uses; providing and enforcing standardised training, management and accountability policies; and using strong management information systems (MIS). As well as conventional MIS reporting, using computerised inventory, sales 151
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and budget systems, these information systems may include deliberate monitoring of the franchisee through ‘shadow’ or ‘mystery’ buyers, who act like customers but who are employed to report back to the franchisor on the quality of the product (the temperature of the food, the cleanliness of the vehicle) and of the service (the speed of service, the warmth of the greeting). Franchisees have some discretion (in areas such as local advertising and the selection and morale of local staff), and are responsible to the franchisor for delivering a standardised product or service within a centrally determined tight structure. The new public management model is similar to this franchising model. A contracted-out service delivery agency (the provider) typically is required to deliver a standardised service to predetermined categories of clients within strong constraints concerning policy, financial accountability and resource use. The contracts are specified, funded and controlled by a small government agency (the purchaser), who sets these constraints and enforces them through its monopoly market power. Where service delivery is already being carried out by organisations such as hospitals, that are separated from but linked to government along fairly clear budgetary and organisational lines, it is relatively easy to turn those organisations into contracting agencies. Competitive casemix funding of hospitals using diagnosticrelated groups (DRGs) to specify the services to be provided is a mechanism through which hospitals are turned into contracted service delivery agencies. Once that has been done, it is organisationally simple (although perhaps politically difficult) to privatise hospitals or some of their functions. These private and public sector ‘purchaser/provider split’ models of organisation are often advocated because they are based on the management principles of letting the managers manage, and devolving responsibility to local agencies that are said to bg more responsive to local clients’ needs. However, they have major problems. First, they focus the attention of both government and the provider agencies on the specific and tangible outputs for direct and identifiable clients that can be specified in contracts. They thus downplay or disregard broader and less tangible outcomes for indirectly affected and less identifiable groups (such as the families and communities that provide key support to those clients). (This is discussed 152
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below, in the section on clients and citizens.) Second, they depend on the strong central control of strategic decision-making. This has been described as centralising strategic control while devolving tactical responsibility (Muetzelfeldt 1992). As a result, managers—or, more recently, provider agencies which work under contract from government—may find themselves responsible for achieving service delivery requirements within management frameworks and resource constraints that they cannot influence, and which they may perceive as inhibiting their ability to achieve the output requirements. This can operate at many levels. It applies to the private practice psychiatrist, who under Medicare arrangements introduced on 1 November 1996 is required to manage patients, irrespective of need, within the constraint of only the first 50 psychiatric consultations per year attracting the full Medicarg rebate. It also applies to the hospital board of management that is required to deliver services to a specified quantity and quality within tight funding agreements. In each case, the service provider has little or no control over the terms that specify the service and resources, but is responsible for delivering the service specified by those terms. These contractual models involve a strong separation between, first, the government as contracting purchaser and the contractor provider agencies and, second, between those provider agencies and clients. The three parties—government, provider agencies, and clients—are primarily connected through narrow and specific links based on the contractual exchange of behaviour or resources. For example, government may purchase from agencies such as hospitals or community health centres specified health benefits according to an agreed casemix, based on specified DRGs. And in turn the agencies may provide services to clients in return for clients’ conforming to case management contracts (such as abstaining from alcohol), or on a user-pays basis. This contrasts with the bureaucratic models of conventional, large organisations through which government traditionally acted. Under that model funds were provided to hospitals or health centrgs on the basis of historical funding patterns and in response to the services actually provided, which in turn depended on the professional decisions of health practitioners dealing with presenting patients. 153
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This new contractual separation is said to have the advantage of avoiding government agencies being ‘captured by their clients’ and hiding their possibly poor or inefficient service bghind a screen of complicit or dependent client representatives. However, it has corresponding disadvantages. It requires health workers to constrain their professional decisions about how to treat or manage individual patients within budgetary and performance profile requirements. And it limits the extent to which information can be shared, and joint learning and innovation can take place, within fuller and broader— although possibly less clearly defined—partnership arrangements bgtween government, its agencies, and clients (Considine 1988). Contracted-out service delivery systems raise a number of new questions about the nature and delivery of public services:
• What are the core or strategic government and public good requirements of a service delivery system?
• Do these requirements include broad population-based results
•
•
•
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(such as achieving particular infant mortality rates) and relatively intangible outcomes for communities as a whole (such as overall levels of wellbeing or confidence in the health system)? How, if at all, can these broad requirements be written into service delivery contracts, when contracts generally set short-term tangible outputs for direct and identifiable client groups, such as those satisfying DRG specifications? Which policy development or service delivery tasks and responsibilities have to be centrally controlled if they are to serve the public interest, and which can be done better by being devolved or contracted out? What management and performance information is needed so that government knows it is getting from providers the service delivery it requires, and is it possible to get that information reliably? Can contracting systems be designed so that service delivery provider agencies are encouraged to develop their skills base, learn to innovate, and pass back to the purchasing agency information about client needs and expectations so that future service agreements may better reflect the needs and capacities of all parties as a partnership?
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• Can communication between provider agencies, clients and other stakeholders be developed so that there is joint problem identification, problem-solving and learning?
Public interest and public accountability issues Critics of the contractual approach argue that public interests, public values and public accountability are seriously compromised when public services are delivered by organisations that have a purely contractual relationship with government. They emphasise the requirements of public management that make it different from private sector management, arguing that those distinctive requirements cannot be met using pure private sector models (e.g. Alford & O’Neill 1994; Pollitt 1993; Stretton & Orchard 1994). For example, Pollitt (1993: 149–55) gives a list of key requirements of public management, and compares the values underlying public and private management. He emphasises that in public sector organisations managerial techniques such as strategy, budgeting and the rationing of services should be based on the assessment of needs through political processes of bargaining and of balancing and reconciling different interests, rather than on maximising profit through market processes. For Pollitt (1993: 151): Public accountability goes beyond the idea of just holding to account. It requires the public manager to find ways of giving account, in many different forms and at different levels. Caution and propriety must not be allowed to stifle experiment and responsiveness to the public.
Advocates of contracting out (e.g. Victorian Commission of Audit 1993a) reject these criticisms, and argue that the public interest—and especially that part of the public interest that is served through smaller and more efficient government, and stronger financial and performance accountability—is strengthened through competitive, performance-based contract arrangements. This view in effect ignores or denies any public interest that is more than the sum of the individual interests of people directly involved in a transaction. As the then British Prime Minister John Major said, ‘Public services are there for only one thing—to serve the user’ (quoted in Lawson & 155
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Walker 1994: 85). The view that public interest is no more than the sum of individual interests mirrors the assumption of microeconomics that society is no more than the sum of the individuals within it (or, as Major’s predecessor Margaret Thatcher is reported to have said, ‘There is no such thing as society’), and that the total utility in a society is no more than the sum of individuals’ utilities resulting from their transactions. In short, by downplaying any intrinsically public interest, advocates of contracting out position themselves firmly within the market paradigm, using the market not just as a mechanism for implementing policy efficiently but also as the criterion by which policy objectives should be set. For all of their supposed efficiency, markets have well-known problems. They are prone to ‘market failure’ when the ideal circumstances which the market model assumes are not realised. In the health sector, markets or pseudo-markets may be set up at a variety of levels. For example, patients may buy health services from health professionals, health professionals may buy services (such as diagnostic or support services) from hospitals and pathology clinics, health professionals may sell their professional labour to hospitals, and governments may buy bulk services from hospitals. In all of these there are usually large differences between the information available to prospective buyers and prospective sellers. Often buyers have an urgency about receiving a service that sellers do not, and in some crucial situations there are high externalities (for example, sufficient levels of individual immunisation to provide protection for whole populations). So, in the health sector, markets or pseudomarkets do not satisfy the ideal circumstances of the market model, and fail to deliver the efficiency that is their main purpose and potential strength. For all of its apparent value neutrality, the market model has important values embedded within it. Ideal markets are said to produce the most efficient distribution of resources, regardless of the equity of that distribution. Also, as mentioned above, they recognise and measure only the bgnefits that individuals themselves directly recognise and bring to their market transactions, and they do not recognise and measure group or indirect benefits, such as long-term statistical changes in life-expectancy. In short, markets value efficiency above equity, and value individual direct and short-term 156
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outputs above group indirect and deferred outputs. No wonder, then, that a deputy secretary of the Department of Prime Minister and Cabinet wrote (Edwards 1996: 34): There are dangers in mistaking the means for the ends, that is, setting up processes to obtain competition (for example, in health) without also clearly specifying outcomes wanted. Evidence from the United Kingdom and the United States is that senior officials are playing with markets and adjusting as they go to see what works without having much of the information needed to understand the nature of the market. This is particularly evident in health where there is a real tension between the need to establish an internal market, and a reluctance to add to the administrative burden of government, but also a need to regulate to obtain desired outcomes.
Advocates of contracting out argue that public interests—such as subsidies and protection for needy or disadvantaged client groups— can bg explicitly rgcognised, costed, and built into contracts through community service obligations (CSOs), which are seen as an efficient way of achieving the ‘need to regulate to obtain desired outcomes’. CSOs are requirements for services or products that government has decided should be provided, even though that would not happen in a purely market-driven situation, which government as purchaser has specified in its contracts and for which it has provided funding (Steering Committee on National Performance Monitoring of Government Trading Enterprises 1994). Examples could be: uniform standard medical consultation fees throughout Australia, regardless of the isolation or unattractiveness of the location from the point of view of medical practitioners; uniform prescription charges for all scheduled medications, regardless of their market cost; and subsidies for nursing homes in rural areas. Government may decide on such CSOs for a variety of social and economic public interest reasons, such as: to reduce disadvantages that result from geographical remoteness; to ensure that disabled or disadvantaged people have full access to public goods (mass transport, electricity) even when these are provided by private agencies; or to support regional economic growth. CSOs aim to provide transparent government policy intervention through clear and direct costing for clear and specific benefits. They are intended: 157
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• to give government explicit control of its policy decisions; • to avoid historical, accidental or hidden subsidies through concealed transfers of benefits or costs; • to make the costs of policy decisions and their intended benefits explicit; and • in effect to subject government itself—as well as the agencies that provide services on its behalf—to greater scrutiny and accountability. CSOs assume that market decisions about the allocation of goods and services are the norm, and that any deviation from these market decisions needs to be explicitly declared, costed, and justified. In effect, they attempt to ensure that certain public interests are protected in a policy environment that is not based on the traditional view that society is or should be held together by complex, implicit, multilayered and essentially political connections between citizens that cannot be reduced to market or market-like exchange relations. But at the same time they make sure that the costs of protecting those public interests are made very clear, and so are made dependent on ongoing and explicit political justification. Contracts and service agency arrangements specifically address and pay attention to direct and explicit financial and performance accountability, and to the public interest involved in the efficient delivery of specified services. However there may be broader, less obvious, but important features of public and political accountability and public interest that remain unspecified in contracts and agreements. One aspect of this that is beginning to be recognised is the question of risk management and risk allocation. Contracts that fail to specify which party carries which risks may end up displacing onto service users risks that previously had been carried by departments and other public agencies as part of their broad and implicit commitment to public service. For example, the Commonwealth Ombudsman reports the case of a householder who had no redress apart from legal action when a contractor delivering mail for Australia Post damaged their letterbox, because the contract between Australia Post and the contractor did not specify which party was responsible for such damage (Commonwealth Ombudsman 1994: 7). 158
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The Ombudsman also reports the case of a nursing home proprietor who inadvertently inherited a debt when bwying the nursing home because of an overpayment to the previous proprietor by the Department of Human Services and Health (Commonwealth Ombudsman 1995: 30). On another occasion, the Department of Veterans’ Affairs terminated without notice the service contract of a company providing community nursing services to DVA clients, because of suspected fraud by that company (Commonwealth Ombudsman 1996: 13). In these cases, recipients of health services—here positioned as clients of private businesses with a contractual relationship to government agencies—faced potential disruption to their services because of the risks inherent in or built into the contracts. These risks can be managed through more explicit contracts or through insurance, but only at the cost of raising the contract price and so cutting the cost reductions that supposedly flow from contracting out. Because contracts are based on specific performance criteria between specified parties, they fail to provide for public interests that relate not just to clients, but to clients’ families and the broader community. They also fail to provide for public interests that are spread through time: government ministers express concern about intergenerational equity when justifying reducing public services in the name of reducing public debt; they do not show the same concern with regard to the long-term health consequences of environmental degradation and the growing stress resulting from worsening working conditions. They evade questions of broad (and usually political) public accountability for these wider public interests.
Customers, public beneficiaries and citizens Customer focus started in the private sector as a response to the growing pressure of competition for market share bgtween companies. The notion that dissatisfied customers could always go elsewhere was a powerful incentive for a customer focus. In the 1980s, public sector business enterprises such as British Telecom and (in more or less limited ways) Australia Post and Telecom Australia were exposed to competition. At the same time, the public sector in Australia and elsewhere moved to emphasise results over bureaucratic 159
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process, and so began to see itself as a service industry. As a result, the private sector emphasis on customer service began to take root in public sector organisations. In Australia the process has accelerated, particularly under the impact of the National Competition Policy introduced by agreement between the Commonwealth and the states in 1995. In Britain the Conservative Major government introduced a Citizens’ Charter (1992), with the proclaimed aim of empowering citizens in their dealings with public sector agencies. This might also be seen as a way of increasing external pressures on the public sector to improve its performance. There is a strong assumption in the Citizens’ Charter that the citizen is the individual who is directly receiving the service—that is, that the public sector is there to serve individual members of the public, rather than to serve stakeholders as a group or to serve the public good. Similar charters have been introduced in Australia, such as the Taxpayers Charter, and the NSW government’s ‘Guarantee of Service’, which declares as its purpose ‘To make sure, first and foremost, the government of New South Wales is serving the people as its customers’ (New South Wales 1992: 1). The Australian charters avoid calling the customer groups ‘citizens’, as was done in Britain, but they still tend to minimise the difference between these two very different ways in which governments and public service providers conceptualise and interact with the people. It is useful to consider the various connotations and assumptions that go with the words ‘client’, ‘customer’, ‘patient’ etc. because this helps us to understand what is characteristic about the public sector, and the impact of bringing private sector terminology and practices into the public sector. There is no agreed standard terminology, and different authors have strong preferences for different words. I will use ‘customer’ to cover those who have a direct relationship with a service provider, and ‘public beneficiary’ to cover the wider group of all those (including customers) who directly or indirectly benefit from the availability of the service. With the transfer of private sector imagery to the public sector, customers are conceptualised as individual receivers of a specific service, who can go elsewhere if they do not like or want the service that is being offered. They are seen as bging concerned with direct 160
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outputs, and have nothing to gain or lose in the service transaction apart from what is directly exchanged (what economists call a situation of no externalities). The service provider is seen as having no responsibility to them, apart from aiming to maximise sales to the customer. This image may not always bg appropriate even in the private sector, but it does inform much of the customer service approach and rhetoric that has been introduced into public management in recent years. On the other hand, public beneficiaries are not just individuals bwt include groups of individuals or stakeholders who benefit from services being provided, even though they are not directly receiving those services (such as the general public, which benefits from the provision of immunisation, because successful immunisation programs reduce the chance of an epidemic and so protect the few who remain unimmunised). Public beneficiaries cannot always go elsewhere (e.g. taxpayers in their relationship with the Australian Taxation Office). As well as being concerned with direct outputs they are concerned with general and at times nebulous outcomes, such as equity and justice in Australian society. Public beneficiaries are more likely to gain or lose from transactions in which they are not directly involved (such as those who lose out if a local clinic closes bgcause others decide to move away from the area), because public sector agencies often produce outputs and outcomes that have high externalities. While the private sector sees itself as having only customers, public sector agencies may have both customers and beneficiaries, although the mix will vary between agencies. The Department of Administrative Services’ customers (such as politicians and public officials who use the Department’s fleet of motor vehicles) are more likely to be similar to private sector customers, while an environmental protection agency will have important public beneficiaries that it serves through its dealings with the individuals and firms it sees as its customers. Health agencies nearly always have both customers and public beneficiaries, and most of us are both. Successful public sector management has to take into account the needs of and responsibilities towards both customers and public beneficiaries. By contrast, private sector management has only to focus on the twin bottom lines of profits and market share. So 161
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public sector management is generally more complex and difficult than private sector management, because it involves responding to a more complex customer and stakeholder base. When public sector management is pushed towards bging more like private sector management there is a tendency to pay more attention to direct customers and disregard public beneficiaries. Contracts are a major mechanism through which this deformation of public purposes occurs in the day-to-day practices of agencies caught up in purchaser/provider relationships. How active and empowered are or can be customers and public beneficiaries? The word ‘client’ when used with regard to professionals often suggests a relatively passive recipient of expert service, with the client not having the knowledge to evaluate the service. ‘Customer’ carries a more active connotation: customers can make choices, and in a true market can leave a service provider they are not happy with. Neither of these quite captures the complexity of the customer or client of a public sector agency. The public client can have power to assess and evaluate the service, but that power is more likely to be expressed through political processes (‘voice’) than through changing service provider (‘exit’).4 There are two aspects to this: one concerns the dual role and dual capacity of people who are both customers and public beneficiaries; the other concerns the involvement of customers in evaluation processes. In policy areas such as health, where essential public goods are provided to customers and public beneficiaries through service providers (such as hospitals) that are increasingly being made to compete with one another for funding and for customers, people have some, but limited, power of both exit and voice. They can exit by changing hospitals if they are dissatisfied with the service they are receiving (although there may be a high price to pay for exiting, especially if alternative hospitals are geographically distant). And they can use their voice through political processes to influence the overall system of health delivery and funding. Interestingly, shopping around between hospitals may maximise individuals’ direct service outcomes, but possibly at the cost of reducing overall public benefits. For example, hospitals may respond to people using their exit power as customers by improving patient services in those medical fields where patients are vocal and are willing to shop around between hospitals 162
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(such as obstetrics), and they may do this by diverting funds from fields where patients have less capacity or inclination to shop around and change hospitals if they are dissatisfied (such as emergency or intensive care). As a result, the overall distribution of funds between medical fields may not serve the best interests of all people across all their medical needs. Evaluation processes used b{ service providers tend to give customers some voice but in particular, highly structured ways. Wadsworth (1991) distinguishes two basic approaches to who should be involved in evaluations, and how they should be involved. She calls these approaches audit review and open inquiry evaluation. The audit review approach starts from assumptions that the required objectives are already given and can bg clearly defined and measured, and that customers or stakeholders should be involved in the evaluation in a fairly circumscribed way as sources of specific data. The open inquiry approach starts from assumptions that the objectives required by the customers or stakeholders may be changing and are still to be fully discovered, and that they should be involved in the evaluation through an open-ended and shared exploration with the service providers. From a management perspective, each approach has strengths and weaknesses, and managers may use both to gauge the efficiency and effectiveness of their programs. From a political perspective, audit reviews tend to frame and limit people’s responses, positioning them as customers, while open inquiry evaluations are more likely to empower people to contribute to program objectives, and so position them as citizens. A managerial view of public sector service provision, with its focus on efficiency and predicability, tends to push service providers towards using audit reviews, reinforcing their view of the people they serve as being just customers. Behind the purchaser/provider split model there is an assumption that much of what government agencies have traditionally done is not core government business—that governments have been delivering services or products that should be done, or could be done better or more efficiently, by non-government bodies. What should or should not be core government business is now being debated. With the contracting out of some of the work of the Australian National Audit Office (Coleman 1993), and of some legislation writing, it would seem that not all regulatory, control and legislative services 163
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are core government business. With privatised prisons and security services, many now argue that the administration of (at least parts of) the justice system is not core government business. If these functions, which have conventionally been seen as basic to the State’s defining characteristic of having a monopoly over the legitimate use of violence (Weber 1946), are no longer core government business, then a questionmark must hang over the public beneficiary functions of the State, perhaps including even life-preserving and life-enhancing health services. The polar opposite positions in this debate are defined by competing sociopolitical and economic liberal perspectives. From the sociopolitical position, government is said to bg about building the good society and governing and enhancing the economy, social development and civil justice; so anything that contributes to this should be considered as core government business. In contrast, for economic liberals, government is said to be only about providing the minimum necessary requirements for individuals and groups to pursue their own economic and social objectives. So the only core business of government is to see that someone provides the systems and processes that will lead to those requirements bging met. The first of these positions fits with and supports a view of the people as public beneficiaries and citizens, while the second fits with and supports a view of the people as customers. These are basically debatable and contested positions. What is or is not considered to be core government business is in the end a political decision, even if it is presented as a rational decision based on the pursuit of efficiency or of social justice. The image of government as a service industry tends to pre-empt this debate—or at least to mobilise bias in favour of a minimalist version of core government business, and a corresponding minimal sense of public benefit, of the essentially political character of governing and of citizenship.
The politics of health policy In the health field, political and constitutional factors tend to work against attempts by governments to reduce their role to that of a 164
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purchaser of health services provided by others. There is a complex web of Commonwealth and state interests covering electoral politics, interest group politics (medical professions, health insurance funds etc.), funding agreements and constitutional arrangements. Provider agencies, in the form of hospitals and health centres, already exist and have established substantial political constituencies of their own: they are being brought into stronger contractual arrangements through casemix funding, with some uncertain and politically uncomfortable consequences. Health insurance funds partly fit the purchaser/provider model (they provide insurance), but are not good examples of competitive agencies (Sullivan 1996) and partly undermine the capacity of governments to deal directly with dependent hospitals and other provider agencies. ‘Price signals’ such as copayments by patients for the health services they receive may be attractive cost-controlling mechanisms for economists (National Commission of Audit 1996: 52–3), but they can be unattractive to politicians who see those same patients as voters; and, as suggested below, they may be ineffective. As well, there is evidence that people value equity and caring as well as narrow health gains (Mooney 1995: 334). Patients and the community want not just health gains but also ‘information, reassurance, respect for their autonomy, dignity, caring and being cared about’ (1995: 331). Consequently, community and clinical values and objectives must be central to health policy planning, even if these cannot be readily quantified. As a result, the main political advantages of the purchaser/ provider model—the capacity to take issues and potential issues off the political agenda, and to deliver narrowly defined and quantitatively measured heath gains for controlled financial costs without paying too high a political price—are reduced. Contemporary governments may strive to tame this political octopus, but they are caught between their attachment to the simplicity of the purchaser/ provider model, and the need to take an explicitly political approach to what is an essentially sociopolitical problem. Some approaches to the sociopolitical problems of health policy emphasise the possibilities that lie within the purchaser/provider model. For example, it has been argued that Aboriginal health care would benefit from having a single funder (the Commonwealth 165
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government)—rather than multiple funders (Commonwealth, state and territory governments)—providing a coherent policy direction which could be implemented with sensitivity to local needs through devolved purchaser/provider arrangements (Mooney 1996). A similar approach might be taken to focused policy development and implementation for other constituencies, such as women, ethnic groups and HIV-positive people. As well, recognising that the rgal world does not satisfy the idealised assumptions of a perfect market provides opportunities for proactive policy development, as well as for critique. Evans (1984) argues that, despite the assumptions of the market, doctors and patients have interdependent rather than competing interests, which include a shared interest in care as well as in health outcomes. Also, there is lack of clarity about risk allocation in the provider–patient relationship, and imperfect information including doctors’ incomplete or misperceived understanding of patients. As a result, doctors as well as patients are concerned ‘not just with the outcome of treatment, but with the process’ (Mooney & Ryan 1993: 131), and this in turn leads to difficulties for policy-makers in developing effective ‘price signals’ (i.e. doctors’ remuneration and patients’ payments) as they strive to establish a de-politicised health care market. Other approaches take a broader view. In this spirit there are some indications that, even within the apparently de-politicising model of purchaser/provider service provision, it is possible for organisational structures to be developed that re-establish the complex political communications through which customers and public beneficiaries can bg given more voice, and so have their citizenship enhanced. In Britain, some non-government community sector organisations (NGOs), such as the National Autistic Society, are successfully winning human service delivery contracts over private sector providers on the basis of quality and public interest, rather than price. The private sector providers typically tender with a highly managerialist system, complete with arm’s-length relationships with customers, and quality assurance based on the ISO 9000 accreditation standard that focuses on the detailed routine documentation of decision-making and process control. In contrast, some NGOs tender with proposals that keep close connections between the service delivery agency, its 166
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staff, and its customers and public bgneficiaries; and which include wide- ranging quality assurance processes that are more participatory and value-based than the ISO 9000 model. They have client representatives on their boards of management, and ensure that their service delivery work does not overwhelm their commitment to advocacy work. Their quality assurance processes cover a range of matters, from equity and merit protection in staff selection and training, through to surveys of staff and client satisfaction (National Autistic Society 1993). In effect, they tender with proposals that are designed to ensure that broad public interests are met together with the provision of customer-focused service delivery. The purchaser/provider split model has been seen by both its advocates and critics as involving technically efficient managerialist service delivery systems that de-politicise government and policymaking. In contrast to this, the approach of the NGOs outlined above suggests that it may be possible to develop a complex sociopolitical approach to the provision of public services that can operate within the purchaser/provider split model, and defeat or at least minimise its negative effects. Organisations such as these NGOs can win competitive tenders only on the basis of providing the service and other bgnefits that the customers and public bgneficiaries want and are prepared to pay for. This requires that those customers and public beneficiaries, in their capacity as citizens, convince purchasing governments that this is indeed what they want, and that they are prepared to pay for it with their taxes. The promise and potential of this sociopolitical approach is that the very NGOs that, in their advocacy role, encourage citizens to voice their wishes to government, stand to gain service delivery contracts through that citizen action. Their service delivery functions and their advocacy capacity could be mutually supporting. Here is a possible dynamic to turn around the impersonal managerial apolitical tide that the purchaser/provider split has loosed on policy-making.
Conclusion The purchaser/provider split is said by its proponents to reduce costs, which in turn is assumed to bg a primary aim of government in the 167
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late 1990s. Whether this model will indeed do this is increasingly open to doubt. Hodge (1996) found in an extensive review of the literature that health was one of the services where competitive tendering and contracting out produced no significant improvement in economic performance. It may well turn out that, as more of the implicit services (including risk management) previously provided by public service agencies are written into contracts, contracted private sector agencies will be even less efficient than well-structured public sector agencies. A shift in emphasis from costs and efficiency to quality and effectiveness may dissolve many of the current perceived differences between public and private service delivery agencies. As people become more aware of the human, social and political losses that come with the claimed dollar-cost savings of reducing government to a service function that can be contracted out, they may well decide that the price of that cost saving is far too high. But that awareness will not arise easily in the face of the concerted media campaigns of major political parties and the private interests that stand to gain from shifting health services into an expanded private health industry. We do not yet know how well the sociopolitical models such as those being explored in Britain will work in the long run, or how readily they could be transferred to Australia. But in any case their importance is that they hold out the possibility of there bging mechanisms for increasing that awareness and developing citizenship capacity that can transcend the limitations of the contractual model. Health policy has no greater task than proactively seeking such mechanisms.
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9
Shifts in community health care JANINE SMITH SHIFTS IN COMMUNITY HEALTH CARE
Shifts in political ideology and health policy affect not only citizens but those who are responsible for the delivery of health care. This chapter centres on reforms to community health and the impact of growing medicalisation on the preventive focus of primary health care. It reviews shifts in community health generally and draws on a case study of experienced generalist community nurses, who provide a wide range of services throughout metropolitan, regional and rural Victoria. The chapter then examines the effect of economic rationalist ideology and managerialist strategies on the ability of the community health sector and nurses in particular, to deliver services that are appropriate to the needs of the community and that incorporate the principles of primary health care health promotion and illness prevention.
Refocusing health care: a primary health care approach Health care in Western society has changed dramatically over the past 50 years (Scotten 1972; Sax 1972, 1984, 1990; Navarro 1986; Palmer & Short 1994; Gardner 1995). Escalating health care costs worldwide, due in part to a domination of the health industry by large institutions and powerful medical and pharmaceutical interests, have forced a 169
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reappraisal of health care delivery methods. In addition, research on the social determinants of health status and an awareness of iatrogenic disease, caused by the often unnecessary medicalisation of social problems, has led to a growing number of health care consumers who—disaffected with the superficiality of Western lifestyles and the technological bias of modern medicine—advocate the adoption of preventive health alternatives. Changes in the focus of health care for women, for instance, reflect a growing awareness of the importance of social and emotional influences on health status and an expectation that refocusing health care priorities could highlight the value of prevention and education, and reduce the domination of a medical model of illness and disease. Much of community health and the work of generalist community nurses draws on a primary health care approach, adopting a broad notion of health and the importance of health promotion and illness prevention. A World Health Organization (WHO) report into community health nursing reviewed global changes that had seen the introduction of community health programs aimed at providing accessible services, ‘free of economic barriers, unlimited by social or cultural distinctions and within reasonably easy reach’ of the whole population (WHO 1974: 5). The report found that it would be feasible for all countries and all communities, even the most rural and impoverished, to develop effective health care based on a system that reflected the inherent characteristics of the community. WHO further maintained (1974: 6) that such a community health system must: . . . evolve from the community it serves; it should involve the community in all aspects of its organisation, such as in the planning, delivery and evaluation of care; it must be inter-related with other operating social systems within the community; and it must support as well as bg supported by the community for which it exists. Moreover the health system must be flexible in its approaches to health care; [and] those responsible for operating it should be aware that the primary avenue to health may be through education, economic progress, legislation, or other aspects of society rather than through organised health structures.
These concepts have always underpinned the primary care focus of generalist community nurses and have been reinforced b{ the sub170
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sequent declaration of Alma Ata (WHO 1978). This stressed the principles of equitable distribution, community participation, prevention, appropriate technology, and a multisectoral approach to health care. The Ottawa Charter (WHO 1986) offered a framework for restructuring and orienting health systems to give people more control over their own decision-making on health issues. Within this context, primary health care must be integrated into all levels of the health system as well as into the educational, social, environmental, industrial, commercial and legislative functions of community life. Primary health care is a philosophical approach to health care that requires a reorientation of thinking about health and illness, also commitment to an ideology of social justice, community participation and responsibility for healthy practices across all levels of society (WHO 1986; Wass 1994). A commitment to implement the principles of primary health care therefore requires some courageous policy decisions from government and considerable resolve from all sections of the health industry—a formidable undertaking!
Community health in an Australian context The Whitlam federal Labor government was elected in 1972 with a commitment to shift the emphasis of health care from the issues of finance and insurance that had preoccupied the previous Liberal government to a focus on improved service delivery. This included the rationalisation, integration and upgrading of existing services and the introduction of a community-based health program (Sax 1984). The Labor government promised to improve the efficiency and quality of health care, and to ensure equitable access to health services (Sax 1984: 101). Programs were to focus on prevention, support and rehabilitation, in response to a need expressed by the community and provided by skilled health professionals, supported by local, regional and state facilities and resources. Therefore, when the Community Health Program was introduced in Australia in 1973 there was an optimistic belief—at least on the part of its practitioners—that a primary health care focus was being introduced that would lead to bgtter health outcomes for the community and an eventual reduction in health care costs. The program 171
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was founded on an ideological framework of social justice, but in retrospect its policy objectives of prevention, rehabilitation and affordable, accessible treatments, as well as its evaluation criteria, were vague and ambitious. The Commonwealth’s funding to the program in its first year was $15.8 million (Duckett & Ellen 1982: 29), and although it was not possible to divert funding from mainstream health care, no incentives for preventive care were introduced and hospitals continued to be funded on the basis of the number of patients they treated. It was, therefore, not in the institutions’ interest to support programs aimed at preventing the incidence of illness or reducing levels of hospitalisation; so community health remained on the periphery of the dominant acute care system. Whether the program could have achieved its initial vision in the face of bureaucratic power-broking, political faction fighting and disparate competing forces in the political and medical fields is uncertain (Sax 1984; Duckett 1984). Distinctive about the evolving community health movement, however, has bgen its focus on a primary health care model that emphasises illness prevention, health promotion and community participation. While the concept of preventive health care as it is practised in Australia has its critics (Milio 1988; Goltz & Bruni 1995) and WHO has been accused of spending more on promoting itself than on health promotion activities (Farrell & Le Fanu 1993; Seedhouse 1994), the health policies of federal and state governments contain elements of preventive health care. These draw on Australia’s National Health Strategy (1993) and the Goals and Targets for Australia’s Health in the Year 2000 and Beyond (1993) within the guidelines of the new public health concepts of primary care (Palmer & Short 1994). These concepts are intended to underpin the health policies of federal and state governments. However, in practice, ill-health and acute care dominate the health care agenda and the allocation of resources. Community health and health promotion account for only 4.7 per cent of total health expenditure and consistently constitute only 6–7 per cent of combined Commonwealth/state government expenditure (AIHW 1997b: 11–14, 1996: 259). Many health and social commentators have critically reviewed the organisation and delivery of community health care and have 172
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commented constructively on ways to strengthen Australia’s primary health care focus (e.g. Australian Community Health Association 1989; Milio 1988; Bryson 1992a; Fry 1994; Swerissen 1997). Few of the innovative programs that have been developed in the community health sector have received recognition in the media or in policy decision-making circles, and the contribution of generalist community nurses, as major contributors to community-based primary health care, is seldom acknowledged. Unfortunately, primary health care is not a discrete program which can demonstrate short-term measurable outcomes that meet political imperatives. Its achievements are invariably qualitative and occur over time—often as disease and illness prevention and community development rather than as cure. That the Community Health Program has not been able to demonstrate a reduction in institutionalisation or a saving in health care costs may be partly due, as Milio (1988) contends, to a lack of strategic vision by community health workers. Even more important has been the marginalisation of the program by politicians, bureaucrats and the medical profession. Reforms to the health system inevitably threaten the entrenched position of powerful groups, who ‘close ranks’ to resist change and marginalise those who are perceived as a challenge to the status quo. The concept of community health, with its early focus on salaried doctors working in community health centres, was therefore actively opposed by the Australian Medical Association (AMA), which correctly interpreted it as a threat to their autonomy and power and an attempt to introduce public accountability into the ‘thuggish industrial practices’ of some medical practitioners (Mathews 1989: 44). However, even more damaging to the Community Health Program has been the lack of understanding of and commitment to the concepts of primary health care exhibited by political leaders of all parties and their policy advisers. Their unwillingness to support and strengthen community health on its own terms is reflected in the fact that health policies specifically targeted at community health were only developed in response to problems in the acute care sector. The current focus on community health as a conduit for delivery of post-acute care services has occurred in response to early discharge from hospitals, faster hospital throughput and increased day surgery 173
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with improved medical technology. This is leading to a medicalisation of community health that is not only cost-shifting hospital budget problems to the community health sector but is changing the modus operandi of community health. Other features of the acute care sector, such as long waiting lists and (as chapter 6 argues) growing user costs, have bgen reproduced in the community health sector. In Australia, governments contribute approximately 67 per cent of total recurrent health expenditure, while individuals contribute about 18 per cent and health insurance funds (hence, indirectly individuals) contribute about 12 per cent (AIHW 1996: 250). Current reforms could change the public/private mix of health care funding with little public debate or discussion (implicit rationing and the reasons for rises in health care costs is discussed in chapter 5).
Community health: the current Victorian context When the Kennett government came to power in Victoria in 1992, the health system was perceived to be in crisis, with a historical record of inefficiency and neglect reflected in substandard services and infrastructure (Tehan 1993). Since that time, a fundamental change in political ideology has seen shifts occur in health care delivery that call for careful evaluation of their effects on both consumers and providers of health services. As discussed in other chapters, economic rationalist ideology has been a driving force behind a range of managerialist strategies introduced to rationalise health service delivery, reduce the government’s share of health care costs and to increase the financial accountability of health service providers. Perceived inefficiencies and a reputation for inflexible, provider-dominated services (Paterson 1993) were a trigger for the then Minister for Health and Community Services Marie Tehan (1993) to signal her intention to change the focus of health delivery from systems and institutions to individuals. The stated aim of her strategies, which included the concepts of purchaser/provider splitting, casemix hospital funding, managed care, competitive contracting and post-acute community care, was to encourage competition and choice. Competition among health service providers, it 174
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was claimed, would ensure that taxpayers received ‘value for money’ and that high-quality services would result from a competitive market. The subsequent introduction of output-based funding mechanisms, co-payment and fee-for-service schemes and integrated networks by Minister for Health Rob Knowles were additional strategies aimed at changing the relationship between the government, health service providers and the community. These strategies have gradually been extended from the acute care sector into the community health sector, with, for example, the PHACS (Primary Health and Community Support) integrated service delivery platform proposed in 1998. Current health care policy is dominated by an ideology of economic rationalism that has transformed the health care industry from one of public ‘ownership’ to an increasingly privatised, marketplace enterprise. There are undoubtedly many commercial enterprises that benefit from competition and encourage consumer discrimination. But health care is not a supermarket commodity, and patients are not always in a position to ‘shop around’ or evaluate the outcome of their treatment (Coote 1996; Palmer & Short 1994). Coote (1996) in her role as Deputy Director of the UK Institute of Public Policy Research, warns that the corporatisation of health services in the United Kingdom, on which the Victorian reforms were modelled (Tehan 1993), led to a loss of consumer confidence in the UK health system under the Conservatives that is reflected in declining services, reduced revenue and, inevitably, reduced funding. Further, she contends that changed priorities in health care management and inappropriate planning have led to a reduction in the primary health focus advocated by contemporary community health professionals. At a general health system level, the internal market reforms that were intended to improve efficiency and effectiveness through competition, encourage innovation and flexibility through active consumer choice and provide value for money through managerialist strategies focusing on outputs, are not seen to be delivering betterquality health services, especially for health care consumers (Alford & O’Neill 1994; People Together Project 1997). Analysis of the shifts in community health agendas is complex, as it relates to subtle shifts in functions and ethos. In Victoria, this is illustrated by moves to 175
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integrate community health into a new service provision framework (PHACS), combining community and women’s health with psychiatric disability, aged care, post-acute care, Hospital in the Home, drug treatment and dental services, funded by Aged Community and Mental Health and Acute Health Divisions. This would combine services provided by GPs and pharmacists with non-institutional health and community services. A discussion paper proposed that PHACS providers would be established through ‘the bundling of existing services into a single contested selection process for each defined service catchment’ (Department of Human Services 1997: i). Thus, in metropolitan Melbourne for example, hundreds of primary sector contracts would be replaced by 13 PHACS contracts. The model is aimed at providing more efficient, responsive and bettercoordinated services with clear targeting of services to six client groups, with a single point of entry for clients into the system and an integrated electronic client record-keeping system. It is seen as introducing a new outcomes-based framework for primary health and community support services. Critics fear that the new ‘bundling’ of services within the revised structure will further marginalise original public health and the health promotion, illness and injury prevention focus of community health, and that the needs of the acute sector (and a biomedical model of treatment) will dominate. The following insight into the market state reform agenda within community health draws on findings of a Victorian study of generalist community nurses’ perceptions of current changes.
Primary health care as a focus of generalist community nursing The community health sector encompasses an extraordinarily diversified array of general and specialised services and organisations and a broad range of health professional occupations. Community health centres have been established across all rural, regional and metropolitan areas of Australia, and range from single-nurse, remote area centres to large, multidisciplinary centres supplying services appropriate to the needs of individual communities. Generalist community nursing describes a specialised branch of the nursing profession that 176
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attracts practitioners who want to move beyond a medically modelled focus of illness to one that values shared individual and community participation in health care. In this context, community nursing is much more than nursing practised in a community setting: in essence, it encompasses all the principles of primary health care. According to McMurray (1990: 9), a community nurse must be ‘. . . skilful at problem-solving, decision-making, researching, consulting, planning, organising, managing, co-ordinating, advocating, educating, counselling, providing care, referring and evaluating’. In addition, generalist community nursing practice requires a broad knowledge base that includes ‘. . . the study of bio-sciences, humanities, nursing process, practice and philosophy of nursing, research and statistics, law and ethics, principles of education, economics, policy development and politics of the health system’ (Australian Nursing Federation, ANF 1993: 1). Generalist community nurses are highly skilled professionals in a discipline that has a unique body of knowledge, is autonomous in its decision-making and practice, and has its own code of ethical practice (Kelly 1995; Kelly & Woodruff 1995). These skills, combined with ‘. . . empathetic, supportive, compassionate, protective, succorant qualities’ (ANF 1993: 21), delivered within an ethical and transformative framework, enable generalist community nurses to evaluate alternative approaches and offer informed, appropriate choices in health care. The interviews on which this chapter draws focused on the role of those community nurses across Victoria whose practice developed from the original concept of a nurse working in a generalist capacity across the broad spectrum of a community, according to the principles of primary health care (WHO 1975; Sax 1984; McMurray 1990; Rordan & McLennan 1992; Lamont & Lees 1994). It was envisaged by WHO that nurses in this context would be able to identify actual and potential problems specific to their local communities, initiate primary health interventions, and provide support and rehabilitation services where appropriate. They would also have skills in assessment and coordination in order to maximise existing services and provide safe, relevant care to a local community that was equitable and accessible to all, as well as socially and culturally acceptable. 177
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Views from the field The diversified role of generalist community health nurses in Victoria allows them to take a global view of the needs of a community and the variety of services that provide care across the state. Their observations and experiences, therefore, provide a valuable contribution to the analysis of current health policy as it relates to community health services. It is of concern, then, that they have identified a number of issues that they believe are compromising the quality of health care in the community and changing the ‘core function’ of community health from universally available primary health care to fee-for-service, medically driven illness care. It should be stressed that the nurses are not critical of change per se. On the contrary, they welcome changes that contain objectives for better health outcomes, such as programs aimed at drug and suicide problems. They are concerned, however, that the Community Health Program can no longer claim to bg responsive to community needs or to be able to reach those most in need. The main concerns of these nurses are summarised below.
Output-based funding This tool, for calculating funding levels based on recorded evidence of an agreed ‘mix’ of services provided by the staff of a centre, is seen to be an inappropriate mechanism for community health service management on several grounds. The nurses identify output-based funding as a management tool, which enables Health and Community Services to develop comparative statistics and monitor administrative efficiency, rather than as a useful tool for planning and evaluation purposes. Its limited reporting categories do not reflect the complexity or effectiveness of generalist community nursing practice, with the result that other clinically based treatment services are seen to be more productive and therefore more valuable than primary nursing care. The work of generalist community nurses is ‘hidden’ by inadequate reporting methods that do not reflect the true needs of the community or recognise the skills, experience and primary health care work of these nurses. Non-treatment services such as community development are not valued, and there is less 178
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opportunity for community participation in health care decisionmaking under output-based funding.
Purchaser/provider splitting This was introduced to distance the government from day-to-day management and to encourage a competitive contest to maximise the efficient delivery of health care services. It is also perceived to be a mechanism to allow the government to reduce its responsibility for and involvement in problems while maintaining tight control over what it will support and fund. Times of decreasing resources and increasing needs escalate the strain on many agencies, charged on the one hand with implementing health policy and on the other, with providing services that the community requires. Dilemmas are experienced when funding reductions force the closure of services that the community uses and values, such as those in more remote areas. Agencies are locked into health service agreements that prescribe services the government is willing to fund, although the demographics and need for the service may have changed. In theory, agreements can bg renegotiated if it can be demonstrated that needs have changed. In practice, this option is not generally favoured by either government or community health centre administrators (Lewis & Walker 1997). As a consequence, generalist community nurses often have to monitor and support whole sections of the community who have pressing needs bwt who cannot be helped under current funding categories. This, then, ‘camouflages’ the actual problems encountered in day-to-day practice, which compounds the problems caused by output-based funding. Contractual agreements have thus led to a lack of flexibility—locking providers into services for which needs have changed. Moreover, service contracts often overlook important services which, once omitted from contracts, are no longer provided.
Compulsory competitive tendering This requires that positions and programs in community health be open to competition and awarded on the basis of cost-effectiveness. This is perceived to bg potentially the most problematic issue in community health, both in terms of quality control and because it 179
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is a divisive process that threatens to destroy established professional and community cooperative relationships. There is a real danger that an unregulated ‘competitive’ market will lead to poor-quality care (Bennett 1997), especially when case managers do not have the professional background or expertise adequately to assess a client’s needs. The nurses also provide examples of instances where tenders were awarded inappropriately, due to the inability of the funding body to assess the tenderer’s competence accurately; awarded on cost alone, regardless of the quality of the program; removed from established professionals and awarded to inexperienced groups from ‘out of town’; and fought over by professionals who had previously enjoyed a collaborative relationship. The whole issue of contracting out services in community health is complicated by an accompanying reduction in the numbers of health professionals available to do ‘routine’ health care related to prevention, education and support, while time and energy is expended in administrative tasks related to contracting out and tendering for funding. The strength of a community-based health service lies in the relationship that is developed with the community, and it is considered essential that a generalist community nurse should be (WHO 1988: 2): . . . a clearly identifiable, skilful and dedicated health professional . . . whose work will involve the main themes of the health for all movement. This person should live in the community and maintain regular contact with individuals, families and groups, in their homes, schools and other institutions, workplaces and at leisure facilities. The generalist nurse must have the right education and practical experience and be able to grow into the job.
Clearly a competitive tendering market devalues both the role and the principle, as contracts may be given to providers with little understanding of the community.
Fee-for-service This requires consumers of health care to contribute a predetermined fee as a method of cost recovery for services provided. While not so subtly shifting the focus of community health to acute care, this 180
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strategy is seen to disadvantage the most needy in the community, while marginalising the preventive aspect of community health. An additional impact of fee-for-service has resulted from shifts in federal health policy that have reduced a number of health benefits—including those for dental, pharmaceutical and aged care services, which now require a consumer co-payment. A ‘set’ fees policy at community health centres is also seen to be counterproductive in terms of reducing overall health costs and improving the health of the community. The many individuals and families in the community who are now the ‘working poor’ with low-paid, part-time employment are disadvantaged by this system and are more likely to access medical services that bulk-bill after illnesses are established than to pay for preventive education. In addition, the nurses anticipate that, while charges might be considered ‘nominal’, individuals and families have to balance the relative opportunity costs of health education, groceries and leisure pursuits.
Integration This is increasingly used to describe the rationalisation and organisation of health care networks throughout Victoria in order to achieve ‘value for money’. Horizontal integration would involve the linking of community health services across the state in a flat organisational structure (similar to that created for health care networks in the acute and extended care sector). Vertical integration describes a hierarchical regional structure headed by the more powerful, large public institutions. The trend towards vertical integration has raised concern that community health budgets will be controlled by hospital-dominated administration and be absorbed into hospital running costs, used to finance post-acute care programs, or used to offset hospital shortfalls. Many nurses whose centrgs are administered by hospitals have already experienced difficulties in accessing information about their bwdgets. They are aware that the government has given early discharge and post-acute care services priority and are concerned that a medically dominated community health program will eventuate. As Swerissen observes (1997: 10): 181
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The challenge is to develop a policy which addresses the problems of co-ordination and organisation without destroying social capital built up through the informal relations between community health agencies and their communities of interest over long periods of time.
Governance This describes the system of management in community health centres that has traditionally encouraged community participation and a consumer voice in local policy and programs issues. Moves in Victoria to replace elected boards of management with appointed boards are perceived to have the potential to destroy social capital and ‘silence’ the community voice on policy implementation issues. While it was not yet in effect at the time of the study, the nurses express concern that changes in governance could reduce the community focus and local content of their programs. Baum and Butler (1997) reported a global recognition among health workers that the key strategy for primary health care was improved community participation and empowerment. They argued (1997: 11) that: . . . communities have considerable strengths and resources on which effective health programs can be built and that it was important to build capacity to participate in decision-making, policy formulation and monitoring policy development and implementation.
It is therefore a strategic imperative to re-establish and nourish community links with the Community Health Program, although this will be increasingly difficult under the current round of amalgamations and budget cuts. The above trends threaten to devalue, marginalise and undervalue generalist community nursing work. An emphasis on outputs rather than outcomes, the valuing of administrative efficiency over professional effectiveness and the increasing medicalisation of community health are significant factors that coalesce to ‘silence’ the work of the nurses. The dominant discourse of reforms marginalises the work of generalist community nurses and serves to deny the interests of the 182
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needy in the community. This issue encapsulates a trend that is seeing acute care imperatives displace primary health care, and the interests of the poor and needy taking second place to the economic power of dominant groups in health. The current restructuring of community health services assumes and relies on the commitment of generalist community nurses to their nursing and to primary health care principles. Much of their contribution goes unrecognised and undervalued, due to the managerialist, output-focused objectives of current health policy, and is therefore not achieving its full potential. These findings point to a conclusion that economic policies aimed at reducing health costs, such as output-based funding, consumer co-payments for community health services, integration and compulsory competitive tendering are adding to the administrative workload of generalist community nurses and are diverting community health away from important aspects of public health care. As a consequence, such trends are counterproductive in terms of raising the health status of the community or improving health service delivery.
Conclusion Generalist community nurses express a commitment to primary health care that is shared by many other practitioners who appreciate the potential of a reoriented health system. If this potential is to be realised it will require a renegotiation of health care objectives and concerted action on a number of levels. At a local level, it would appear that primary health care suffers from an image problem when competing for financial recognition with its more glamorous acutecare, high-technology contender. It is vital, therefore, that local resources are mobilised to ensure that the public, bureaucrats and politicians are aware of all the positive outcomes of local programs. Practitioners must also bg prepared to take a high-profile stance in promoting the work they do. The combined benefits of multidisciplinary teamwork are evident in many programs, which win awards both nationally and internationally. At a state level, it is important to coordinate action to network for more effective lobbying and coordination of programs. It is still 183
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necessary to educate the community, including politicians and policy advisers, about community health and primary health care, which can no longer afford to be seen as an amateur occupation, on the margins of ‘real’ health care. Finally, at both a local and global level, the individuals and organisations that rgpresent primary health care in Australia must be supported in their efforts to strengthen ties with international groups and agencies, to facilitate the sharing of information, the pooling of influence and action, and resistance to agendas that will undermine long-term gains. However, reforms such as those in Victoria discussed in this chapter illustrate the challenge presented by including GPs and post-acute home care services in a network with community and women’s health, which are founded on different traditions, thus raising fears that health promotion and illness prevention will be sidelined by the demands of post-acute care. Contributors to chapters 10–14 look to ways of catering for the diversity of health care needs and interests within the health system.
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10
Performance indicators for Aboriginal health services1 IAN ANDERSON and MAGGIE BRADY CATERING FOR THE DIVERSITY OF HEALTH CARE ABORIGINAL HEALTH SERVICES
It must be remembered that Aboriginal people suffer the poorest level of health of any identifiable group of Australians. This situation demands far-sighted and negotiated policies, objectives and strategies and demands that evaluation of Aboriginal health care services be professionally researched and performed, and carried out in a spirit of trust and cooperation. This quote from Moodie (1987: 13) launches this chapter which examines the background and present context of government attempts to evaluate progress towards improving Aboriginal health and the use of performance indicators in monitoring health processes. Performance indicators, introduced at many levels of government at a time when ‘management by objectives’ was adopted in Australia in the late 1980s, have remained an area of confusion within Aboriginal health. Why they are needed, how they are established and the uses to which indicators are put have all been subject to a high level of debate and dissension. This chapter aims to examine the reasons for this, as well as discussing what a ‘performance indicator’ is. 1
The Editor is grateful to the Centre for Aboriginal Economic Policy Research at the Australian National University for its kind permission to publish, in a revised and updated form, material from the discussion paper Performance Indicators for Aboriginal Health Services (no. 81/1995) by Anderson and Brady.
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The issue of program evaluation can evoke profoundly polarised views. In the highly politicised environment of Aboriginal health, performance indicators have at times been highly contentious. This in itself is not surprising: performance indicators tend to focus on contested claims for resources. Implicit in the construction and use of these indicators are ideological assumptions about the objectives that underlie resource allocation processes in Aboriginal health. Consequently, tying this form of performance evaluation to funding cycles often exacerbates an already inflamed situation.
International influences There are two broad trajectories that have had an underlying, and at times contradictory, effect on the process of evaluating and indicating progress in Aboriginal health in Australia. These have influenced the management of government funds at a federal level, and have affected the direction of health policies in this country. The first of these was the pledge in the early 1980s by member states of WHO to participate in the global strategy (Health For All by the Year 2000), sufficient to ‘permit people to lead a socially and economically productive life’. Integral to this process was the need for indicators of progress and change in health status which would contribute in a positive way to governments’ own selfassessment. Performance evaluation in this context is broadly oriented to measuring the distribution of health and health care resources between nations, and within nation-states. The goal of performance indicators is to measure the extent to which such changes in distribution have occurred. The second key trajectory has bgen the introduction of ‘management by objectives’ in Western industrialised countries, which has come to incorporate program budgeting (Barrett 1992). WHO itself, in conjunction with the global strategy, developed guidelines for what it termed a ‘managerial process’ for health development. This involves a continuous process of programming by objectives and budgeting by programs. The Department of Finance (1985: 1), in promoting the introduction of program budgeting in the Australian public service, stated that: 188
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the development of indicators should focus on questions of: (1) efficiency, which is the relationship between the inputs and outputs, (2) effectiveness, which is the extent to which the impacts of a program’s output (that is its outcome) meet its objectives.
In the deployment of performance evaluation for Commonwealthtargeted Aboriginal health programs, redistributive and managerialist approaches share an interest in efficiency and outcomes. However, measures of performance oriented towards evaluating efficiency and effectiveness tend to presume that resource inputs are a given, while redistributive measures presume that the level of resources in the Aboriginal health sector is inadequate. This leads to a lack of clarity as to which process has policy priority. To what extent will outcomes be enhanced by driving the dollar further, or to what extent is it necessary to increase current resource outlays in Aboriginal health? In the end, this tension is insoluble without a clear statement of policy principles. It is the parallel and sometimes converging course of these two influences—one an internationally agreed global target (Health for All by the Year 2000), the other a method for governments to link costs to objectives and evaluate progress towards those objectives— that constitutes the underlying theme of this chapter. We focus our comments on the implementation of performance indicators for the Commonwealth-funded community-controlled Aboriginal Health Services (AHS). In part this story needs to be contextualised with a brief history of relationships between AHS and the state. This chapter was first written in 1994 at a time when Aboriginal health funding and administration was lodged in ATSIC—a situation that was under intense debate. As of July 1995, the responsibility for Aboriginal health was transferred to the Commonwealth Department of Health and Family Services (CDHFS), which established a new Office of Aboriginal and Torres Strait Islander Health Services (OATSIHS).
Aboriginal Health Services (AHS) and the State In 1971 members of the Aboriginal community of Redfern, Sydney, took action to create a health service for their community. This 189
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service, like the Victorian Aboriginal Health Service that commenced operation shortly after, was initially run on a voluntary basis. After some months of operation both services were given a grant from the then very new Commonwealth Department of Aboriginal Affairs (DAA). The events of this period revolutionised the delivery of health care to Aboriginal people. There are now approximately 130 such organisations across Australia, funded by the CDHFS, ATSIC’s successor, or by a mix of Commonwealth and state-derived funds. A detailed history of the administration of AHS funding would need to take account of their development within the context of both Australian federalism and the ongoing transformation of Australia’s internal colonial relations. The history of Aboriginal health service provision is littered with many examples of state- and Commonwealth-funded programs, either competing directly for clients or at least operating parallel to each other (Saggers & Gray 1991; Nathan & Japanangka 1983; Robbins 1993; Kunitz 1994). At times, conflict between different systems of administration has crystallised into competing ideological positions, with the Commonwealth championing self-management strategies against recalcitrant states such as Queensland, which until the 1980s steadfastly maintained an assimilationist position and provided little in the way of funding (Kunitz 1994). In the Northern Territory and Western Australia, assimilationist health servicing policies were modified in the 1980s and 1990s to incorporate the rhetoric of community control. Nevertheless, while some departmental personnel are genuinely supportive of such policies, the assertion of community control has been used, in some cases, as an excuse for cost-cutting in which the state or territory hands over inadequate funds to a community (resulting in inadequate services) and leaves them to deal with the result. At times the existence of other agencies or levels of government has become a raison d’être for inaction and for underspending on Aboriginal citizens (Altman & Sanders 1995). With the transfer of Aboriginal health funding to the CDHFS in July 1995 it was hoped that these issues would be tackled. What is generally uncontested within the context of Commonwealth–Aboriginal community relations is the need for Aboriginal self-determination. What is contested are the meanings and practices that should cohere around this principle. As a principle of policy, ‘self-determination’ signified a shift in the form of regulation and 190
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surveillance of Aboriginal life. It opened a social space into which Aboriginal action could occur without the supervision of the Aboriginal welfare system. However, as a principle of political action, self-determination signifies a ‘more general principle of action of Aboriginal people and their communities, especially in relation to non-Aboriginal institutions and society’ (Anderson 1994). The differences are often subtle, but nevertheless important. The assertion of Aboriginal autonomy as a principle of political action is bound to lead to political conflict with any system of regulation. The DAA throughout its history was at the periphery of the Commonwealth bureaucratic apparatus. This position insulated the department from some of the earlier incursions of economic rationalism into the Commonwealth system of public administration (Pusey 1991). Even ATSIC, as a statutory authority, remains peripheral to the machinations of the Commonwealth apparatus. Since July 1995, however, it has been possible to engage with these agencies, examining primary care in terms of the rest of the health system. The low status of Aboriginal affairs has also meant that the DAA tended to inherit some remarkably ineffectual government ministers (Bennett 1989). Nevertheless, despite an early culture of ‘getting the job done’, the later development of the DAA was marked by growing centralisation of activities and growing adherence to bureaucratic regimes. The introduction of program budgeting in 1989 completed the transition to a new culture of managerial rationality. AHS emerged through the 1970s as the Aboriginal movement exploited the liberalisation of policy on Aboriginal affairs. As organisations, the AHS were community initiatives into which Aboriginal values and practices were incorporated. For example, the particular importance placed on kin relationships has resulted in the creation of organisational structures in which the boundaries between private and public social spheres are considerably blurred. There are two fundamental qualities inherent in the approach promoted by the community-controlled health services. The first is the two-way skills transfer process between (usually) non-Aboriginal professional staff and Aboriginal health workers, which is seen as integral to effective program delivery. Second, the principle of self-determination is embedded in the organisational operation of the services, as well as being a principle of health care practice (Anderson 1994). For 191
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this and other reasons, the impact of AHS in the communities they service is far more complex than that of a service provision agency and their clients. AHS, operating effectively, can become strategic sites for community development (Bartlett & Legge 1994). As initiatives founded on the idea of community control, the idea of community accountability is central to AHS operation. Nevertheless, the meanings and practices attached to the idea of community accountability are distinct, although not entirely unrelated, to corresponding bureaucratic notions. The best examples of conflicting ideas of accountability centre on the use of government grant funds to support community members in times of crisis. While an Aboriginal administrator may see that it is their responsibility to pay for the petrol so that an aunt or uncle can attend a distant funeral, such action places the community organisation in breach of grant conditions unless the conditions of grant allow for this type of expenditure. In this circumstance the administrator may be acting responsibly in a community context, but irresponsibly from the point of view of the funding agency. There is no national consensus among key stakeholders regarding the division of funding and administrative responsibilities for the core functions of AHS. In part this is a consequence of the submission-driven basis for AHS funding. Resource allocation is based on the strength and persuasiveness of the argument presented by the local agency, rather than by reaching consensus on the appropriate range of core functions which the Commonwealth funds. Many AHS receive a mix of funding from the state and the Commonwealth. However, the nature of the mix depends more on historical circumstance than any rational design. It would be nonsensical, however, to take the position that all AHS should deliver the same range of programs in the same manner. This would ignore the diversity of Aboriginal circumstances and undermine the ability of local organisations to respond flexibly and creatively to the contingencies of local variables. Rather than prescriptively choosing the necessary functions of the AHS, it should be possible, through consensus with key stakeholders, to determine the range of possible program initiatives that the Commonwealth will fund. Nevertheless, the health service delivery issue constitutes a 192
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prime example of the urgent need for working protocols to be established between Commonwealth, state and other agencies. Despite the lack of clarity in resource allocation policy, AHS have evolved across the nation to provide a broadly consistent range of services. These include primary clinical care, some secondary (or specialist) clinical services, child immunisation and developmental surveillance programs, dental services, education and skills development programs, health promotion/public health programs and research activities. Local factors or needs have shaped the range of programs at the local level. Equally potent has been the circumstance of history: the efficacy of local politicians and AHS staff; the responsiveness of that particular state government; and the quality of the relationship between that organisation and the Commonwealth Aboriginal Affairs bureaucracy.
Indicators of the distribution of health and of health care WHO has provided its member states with a framework for monitoring progress towards the goal of ‘Health for All by the Year 2000’, which is intended to assist countries to develop indicators of progress. However, indicators are also needed to illustrate differences in health situations within countries, in order to reflect progress towards closing the gap between those who ‘have health’ and those who do not. This, WHO states, is a fundamental principle for the selection and use of indicators relating to primary health carg (WHO 1981: 12). WHO proposes four categories of indicators at a macrolevel:
• • • •
health policy indicators, social and economic indicators, indicators of the provision of health care, and indicators of health status and quality of life.
It is perhaps significant that the first set suggested by WHO (health policy indicators) are what it refers to as ‘indicators of political commitment’, and these should, WHO suggests, be demonstrated initially by a high-level commitment to a policy statement or health charter: ‘The seriousness of political commitment, can only be 193
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measured by the extent to which socially relevant development strategies such as primary health care are actually being implemented’ (WHO 1981: 18). The allocation of adequate financial resources is considered by WHO to be a prime indicator of political commitment to strategies such as Health For All. WHO considers that it is necessary to have indicators relating to the degree of equity of distribution of financial resources—for example, to know the proportion and geographical distribution of the populations without access to clean water or primary health care services. The formation of national goals and targets is an important element of a strategic approach to achieving equity in health (i.e. equal access to equal care appropriate to need) and health care. So how does Australia measure up against these internationally identified criteria of political commitment to improve health? While its health policy performance concerning the total population is good, in terms of Aboriginal health at the time (late 1980s), a consensus was never developed on a set of Aboriginal goals and targets (Department of Community Services and Health 1988; Department of Health, Housing and Community Services 1993). The document that comes closest is the National Aboriginal Health Strategy (NAHS) Working Party report. While this document, with $232 million funding to implement the strategy, was intended to produce measurable outcomes, it did not nominate goals or articulate a policy in its 1989 report (NAHS 1989). An additional committee had to be set up to advise on the structural arrangements recommended in the NAHS (Aboriginal Health Development Group 1989). Consequently, as part of the Commonwealth government’s Better Health Program, two consultants (a medical professional and an Aboriginal health professional) were engaged by the Commonwealth Department of Health in 1990 to compile a document on goals and targets in Aboriginal health. By June 1991 the draft Aboriginal and Torres Strait Islander Health Goals and Targets had been drawn up and around 700 copies were distributed across the country for comment and feedback (Wronski & Smallwood n.d.). Only 27 responses were received. The draft set of goals and targets subsequently became the subject of disagreement between the states and territories, tripartite forums, the Council for Aboriginal Health and Aboriginal community-controlled 194
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organisations, and as a result have never been fully endorsed (Gordon 1994). Nevertheless, some state governments are using the draft as it was intended by the authors, as ‘milestones’ against which health services could monitor their progress. The interim set of goals and targets has an ambivalent place in the process of evaluating the NAHS. In effect, there were no accepted, nationally agreed-on criteria against which to evaluate the NAHS—nor Aboriginal health as a whole. The evaluation report states baldly, ‘There were no effective accountability mechanisms implemented by either the Commonwealth or by the States and Territories to measure progress’ (Gordon 1994: 11).
The introduction of program budgeting and the DAA Despite its somewhat institutionally peripheral position within the Commonwealth public service, Aboriginal affairs administration was by no means completely insulated from the moves to transform the culture of Australian public administrative systems. The program management and budgeting initiative has bgen a major element of budget reforms introduced by the Commonwealth government since 1984 under the Financial Management Improvement Program (Barrett 1992: 3). Throughout this process, central agencies such as the Commonwealth Department of Finance have redefined their role to centralise the importance of evaluating program performance and assisting departments to improve their financial management (Williams 1993). These reforms had been influenced by overseas initiatives in the government and private sectors, and by organisations such as WHO, which stressed ‘management by objectives’ (Barrett 1992: 4). In the case of Aboriginal health, it is true that before this, evaluation was haphazard (HRSCAA 1979: 109). As a result of these policy changes throughout the Commonwealth, DAA circulated a draft document in December 1986 entitled ‘Performance Indicators— Aboriginal Health Services’ that produced heated discussion among AHS, several of which undertook detailed analyses of the DAA document, making suggestions for changes. The overall response of the Aboriginal health sector, expressed through their umbrella organisation at the time, the National Aboriginal and Islander Health 195
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Organisation (NAIHO), was hostile; NAIHO interpreted the performance indicators as an ‘intrusion by the DAA’ (NAIHO 1987: 9). More specifically, NAIHO objections to the 1986 performance indicators were as follows:
• the inappropriateness of DAA formulating priorities in health; • the absence of a national Aboriginal health policy, aims or objectives (thus measuring outcomes against a non-existent yardstick); • tieing funding to quantifiable health improvements; • emphasis on empirical overinterpretive data as indicators; • unprofessional and uninformed selection of indicators. In 1987 letters were sent to AHS requiring them to submit sixmonthly throughput indicators to DAA. NAIHO argued that DAA was not the appropriate body to be formulating priorities in Aboriginal health: ‘the imposition of a series of predetermined performance indicators shall in effect amount to the establishment of de facto priorities for a particular service’ (NAIHO 1987: 9). There were simply no detailed policies or objectives on which to base the indicators other than the global objective to ‘raise the standard of Aboriginal health to that of the Australian community generally’. Another major concern to emerge was the proposition to tie funding to quantifiable changes in health status. This was highlighted by the unfortunate experience of the Aboriginal Medical Service in Walgett, New South Wales, which was offered funding in November 1986 on condition that it accomplish certain improvements in health status by 1988. These improvements included reducing hospital admissions (by 20 per cent) and the incidence of diabetes and sexually transmitted diseases (by 10 per cent). While it appears that these unrealistic and impossible demands made on an Aboriginal health service was an atypical event involving an inexperienced DAA officer, Moodie used the example to effect as part of a critique of the handling of the performance indicators issue on the part of DAA (Moodie 1989). By 1989, the DAA Program Budgeting Manual reiterated that ongoing funding was tied to the provision of performance data by grant recipients. These were divided into national and project level information (DAA 1989). Grant recipients were required to report 196
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every six months and provide data on the following performance indicators:
• National level. Births; deaths; morbidity rates for different diseases; hospitalisation rates; immunisation rates; infant mortality rates. • Project level. Client population; number of consultations by doctor, nurse, Aboriginal health worker, others; prevalence rates for significant ill-health conditions; immunisation rates (dental if appropriate). The collection of these data was the beginning of a planned reporting process whereby regional, state and central offices were in turn to accumulate the data from the initial reports, and then transform them into a performance report to the Secretary of DAA, the Minister and parliament. The initial mishandling of the introduction of performance indicators in Aboriginal health by the DAA was unfortunate, as it antagonised the Aboriginal health sector, whose cooperation was crucial to their successful implementation. The hostility towards ‘measuring performance’ has lasted for many years, and explains subsequent difficulties in gaining national Aboriginal endorsement of other government initiatives, such as the establishment of national goals and targets for Aboriginal health. It is worth noting that, when the Commonwealth introduced its program evaluation strategy, many agencies expressed concern that the strategy would reimpose a form of central oversight that was ‘contrary to the spirit of devolution of control, a centrepiece of the government’s public management reforms’ (Barrett 1992: 18). One defender of this process has argued that this was not the intention and that it has not eventuated. Nevertheless, Australia does appear to have placed ‘a greater emphasis on institutionalising the link between evaluation and the budget than other nations’ (Barrett 1992: 17).
ATSIC and the National Aboriginal Health Strategy There has bgen a gap in the development of Aboriginal health policy-making mechanisms which has implications for performance 197
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evaluation. Effective policy development is a strategic means of establishing principles of action, and in this context must engage all the key stakeholders. The lack of a national Aboriginal health policy apparatus also jeopardised the implementation of the NAHS, including the establishment of national goals and targets and performance indicators. The failure of ATSIC to mobilise the Council for Aboriginal Health thus undermined the sustained development of Aboriginal health policy. ATSIC’s own consultative structure does not in any way compensate for this lack. The regional councils of ATSIC are essentially funding allocation bodies and have little scope for policy development. The National Aboriginal Community Controlled Health Organisation (NACCHO), the successor to NAIHO, had no resources to meet under its own volition until the 1996/97 financial year. Finally, until very recently, there have been no formal links between ATSIC and the other key Commonwealth agency—the Department of Human Services and Health (DHSH). The recently formed Joint Planning Committee for Aboriginal Health Services (which has NACCHO, ATSIC, DHSH and National Health and Medical Research Centre representation) is primarily a funding allocation apparatus (for additional Commonwealth monies available in 1994/95) and has no collaborative policy-oriented functions. Given that improved intersectoral collaboration was a key component of the NAHS, this has been a key deficiency in the implementation of the strategy.
ATSIC and health performance indicators ATSIC has a responsibility under section 7 of its Act to ‘monitor the effectiveness of programs, including those conducted by bodies other than ATSIC’. In the first two years of ATSIC’s operations, 1990–92, grant agreements continued to utilise the old DAA throughput measures. In 1992/93 ATSIC sent out the manual in which the ‘local’ program performance indicators were inadvertently omitted, leaving only the ‘national’ performance indicators being requested from health services. Once the mistake was discovered, letters were sent out asking people to ignore them; but several health services sent in these inappropriate data anyway. The data (including births and 198
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deaths, infant mortality rates) are usable epidemiologically when collected from much larger population groups. A population with between five and ten births a year cannot sensibly provide figures on an ‘infant mortality rate’. In 1992/93 some AHS sent in indicators according to the incorrect ‘national’ guidelines; others ignored them (as instructed by ATSIC); and others negotiated new performance indicators of their own with regional offices. The error highlights a key problem with the identification of performance indicators by ATSIC and by DAA before it: namely, neither ATSIC nor DAA have ever been the sole actors in the provision of health services (or programs) to Aborigines, as is the case with other key services such as housing, education and employment. They have always been supplementary to (or in some cases substitutes for) existing services provided through states. Even if ATSIC were the primary funder of an Aboriginal communitycontrolled health service, such a service would only provide primary health care. It has limited impact on secondary health care such as hospital treatment and access to other tiers of health care. This means that, like its predecessor, ATSIC could not be held responsible for Aboriginal health status in general, and any indicators of performance that it collected would always, of necessity, be only partial indicators. In current circumstances, AHS are not perceived to be solely responsible for the production of Aboriginal health outcomes, and this has now been factored into the discussions on AHS reporting requirements. In addition, the Australian Health Ministers’ Advisory Council in 1996 initiated negotiations to develop performance indicators for the government sector on Aboriginal health. This will shift the responsibility for health outcome performance onto the broader state and Commonwealth sectors. The ATSIC Operational Plan for 1993/94 proposed that indicators would focus on the following:
• the number of people accessing ATSIC funding programs; • community participation in and control over health programs; • the training undertaken to ensure the appropriate service provision;
• monitoring of key activities, such as health promotion and prevention, immunisation, screening and surveillance. 199
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These were very different from indicators linked to health status; indeed, the Operational Plan for 1993/94 noted for the first time that the ‘vital statistics’ on births and deaths, morbidity, hospitalisation, immunisation and infant mortality would be provided by the Australian Institute of Health and Welfare. A decision had finally been made that it would be inappropriate for ATSIC to ask small AHS to collect and submit such information. The ongoing lack of specification of performance indicators points to a lack of resolution on exactly what performance the indicators are assessing: funding efficiency, staff effectiveness, number of clients or prevalence of illness, which are all indicative of different types of activities and services. There has not yet been a selection and refinement of indicators to satisfy the differing requirements of financial accountability, provision and effectiveness of service, and progress towards specific goals. Neither has there been any support provided to AHS (either advice or funding) to assist them in formulating their own objectives and internal evaluations.
The view from the ground Early performance indicator requests resulted in health services compiling tables noting the monthly totals for presentations in categories such as cardiovascular, respiratory, diabetes, trauma or skin. But, as one AHS administrator noted: ‘(i)t is not possible from the available figures to assess in what areas improvement has occurred or whether this improvement will be sustained’ (Koteka 1988). However, the same health service was able to measure a drop in outpatient consultations as well as alcohol-related injuries at one stage, and to suggest reasons why this had occurred. Health service administrators often made additional notes when they sent in their performance indicators, commenting on the numbers of births as opposed to deaths, pointing out the fundamental constraints on health improvement due to STD and diabetes rates, or making pertinent observations on health status. These reveal a level of frustration with the expectation that a small health service can deliver on health outcomes that remain largely outside their jurisdiction (Koteka 1988: 4): 200
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from the morbidity figures the population of both communities are rather unhealthy. This is not surprising in view of the poor hygiene and living conditions, poor nutrition, abuse of alcohol and volatile substances, lack of understanding and acceptance of some of the causes of diseases and their methods of prevention and control. These contributing factors to ill health could be overcome provided there is community determination and a will to improve. No matter how good a health service is provided, we will have little impact on the health of the people if these basic issues are not resolved.
Unrealistic outcome measures have the less than useful effect of highlighting the enormity of the task to what are often small, underresourced health services. These apparently ‘poor’ outcomes can then be used by the bureaucracy to imply that some services are not doing a good enough job. Health services received no feedback on the performance indicators they submitted (either before or after the commencement of ATSIC), or on the more personal comments that may have been sent in by individual health administrators. This reinforces the widespread view that performance indicators were instigated for purely financial accounting purposes, rather than to encourage some collaborative evaluation exercise which would be helpful to the AHS. It has been noted by the researchers that some regional officers of ATSIC have urged health services to ‘just put anything down’ in order to satisfy the requirements. A new draft Aboriginal Health Strategy for South Australia presented, as an imaginary negative case study, what had been the real-life situation of AHS sending in their performance indicators. (Aboriginal Health Council of South Australia 1994: 66): The funding body doesn’t comment, except on late submission, and the statistics are virtually meaningless without comparison and analysis to identify and ascertain reasons for trends. They are unrelated to statewide goals or strategies. They are activity statistics suggesting staff work hard but do not indicate whether or not health is improving . . . It is onerous for services to collect meaningless statistics which disappear into a ‘bureaucratic void’. It is also a poor basis for evaluation.
The 1993/94 financial year saw the continuation of confusion regarding the performance information required from AHS. Ensuring that 201
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AHS provide performance indicator data was a regional office function. Regional offices are generally understaffed, have a high staff turnover and do not employ staff that necessarily have any experience of health service delivery. AHS continued to be required to provide information on what DAA officers initially construed as national performance data. In addition, some AHS provided data previously required by the DAA, related to the number of active files and the number of consultations performed by doctors, health workers and nurses. Some agencies were also asked to provide a narrative description of program activities. It was very difficult for AHS administrators to operate effectively in an environment in which their prime funding agency could not introduce some consistency to the most routine aspects of the funding/grant acquittal process. In its document on the development of indicators, WHO acknowledges that the question of selectivity of indicators is crucial, particularly for developing countries, where health services are rarely adequate to permit routine information collection. ‘It is still very difficult’, the document observes, ‘to get the information where it matters most—at the community level’ (WHO 1981: 7). WHO (1981: 16) identified some of the issues that arise from local community-level collections: In the field of health, routine health service data are an essential source of information on disease-specific morbidity and mortality, on certain measurements of children, and on the various activities carried out by the health services. This information, obtained from ongoing programmes, is relatively cheap and easy to collect and analyse. It is, however, incomplete and often inaccurate, especially when those responsible for collecting it at the periphery are not taught how to use it themselves; are overburdened with so much form-filling that this activity seriously interferes with their service functions; have no feedback or see no relevance in collecting the information; or are generally unsupervised. There is another drawback when the data collected are not oriented towards particular problems to be solved or tasks to be fulfilled. The record systems of health services are often kept for administrative purposes rather than for monitoring, which means that data on required denominators are not available—for example the population at risk or the population to be covered by a particular service.
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The ‘success’ of health services in meeting the needs of their clients, and fulfilling administrative requirements for their funding agencies, is determined by a wide range of factors including the skills of clinic staff; the rate of staff turnover; the relationship between the health service and other community staff (store, office etc.) or organisations; and the influence of fluctuating community problems. The quality and severity of these problems vary according to sociohistorical context and geographical location. However, it means that even simple administrative tasks can be at times extraordinarily difficult.
Conceptual problems: what performance indicators are appropriate? The performance indicators requested by ATSIC were a mixture of outcome and throughput or process measures. Before considering some of the conceptual difficulties in developing appropriate performance indicators, it is worthwhile rgturning to the Department of Finance documents which outline the conceptual basis for the use of performance indicators within program budgeting: It is important to emphasise, however, that the role of performance indicators is to inform judgements rather than to replace them. It is not required or expected that any one indicator, or even set of indicators, will provide a definitive measure of program accomplishment. Rather their role is in indicating, or focusing attention on, relevant areas to identify where corrective action (by individual program managers, the responsible Minister, or the Government, as appropriate) might be required or where more intensive evaluation is needed. (1985: 2, emphasis added)
Performance indicators are only one part of the evaluation of program activity. They do not replace the need for internal organisational review, nor intensive externally driven evaluation. However, it would appear that a number of evaluative processes were collapsed onto the development of performance indicators for ATSIC’s health program. There is a need for the conceptual separation of the evaluative activities that are concerns of the state, such as the indicators of the distribution of health care and health care services; indicators relating to the performance of the Commonwealth health program; 203
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and evaluative activities oriented at assessing the operation of individual AHS. Aboriginal community organisations are more than mere sites of the interface between service resources and Aboriginal people. In a complex way they have become integral to the production and sustenance of the social relations which are often glossed under the rubric of ‘communities’. This is especially true in urban communities, where the only public space that can be construed as ‘Aboriginal’ is indeed that of the Aboriginal organisation. This was recently highlighted at a public meeting in Melbourne, where one woman, addressing the problem of organisational instability, stated simply: ‘Take away our organisations and we have nothing’. It is around this form of relationship with community that the service functions of AHS are bwilt. As a result of this complex relationship between function and context, and because many of the necessary elements of successful operation of AHS remain opaque to quantification, it is inconceivable that AHS be thought of as a simple production process—which characterises the development of performance indicators under the program budgeting regimen set out by the Department of Finance (1985). Further, the social relations which underlie the development of AHS would not support an evaluative framework that gave the funding agency the ability to manipulate organisational function (in the absence of a particular crisis in operation). AHS operate within a policy framework of self-determination. They are unlikely ever to cede this to a higher level bureaucratic agency. This does not mean an absence of evaluative activity. Rather, the development of internal and peer review evaluation mechanisms should play a vital role in any health service. Having discussed the difficulties in data collection at the local level, we discuss here in broad terms the issues around developing valid measures of performance, which can be consistently applied in AHS across Australia. To develop successfully the performance criteria envisaged by the Department of Finance it would be necessary for the indicators to fulfil the following conditions:
• Consistency. Are the variables of equal validity in different contexts? Is it possible to identify common program activities? 204
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• Feasibility. Can the data be feasibly collected in even the most undeveloped context, lacking resources?
• Validity. Is the variable measure of performance which reflects solely on the activities being measured? A key difficulty in defining performance indicators for Aboriginal health is consistency. Rate measures, which involve defining population denominators, are the only true measures of performance as they define actual activity or outcome relative to a potential total. Nevertheless, while it may be possible to define rates in contexts where there is an unequivocal service population (as in some remote and discrete communities), in an urban context any rate measure, as a measure of performance, is highly problematic. There are both high population movements (particularly to and from regional rural centres), and multiple sites of service (both Aboriginal and mainstream). Further, even though there are similarities in the activities of AHS across Australia, there are also significant variations which reflect the mix of funding, the local context (which is particularly relevant to promotion of public health programs) and the stage of service development. What this suggests is that program evaluation will be more meaningful if adapted to the local or regional context, longitudinally, rather than attempting to evaluate on a national cross-sectional sample. There is a substantial medical literature that has attempted to define those health outcomes which are amenable to improvement by medical intervention alone. These include: tuberculosis mortality; malignant neoplasm of the cervix; Hodgkin’s disease; chronic rheumatic heart disease; hypertensive disease; cerebrovascular disease; appendicitis; gallstone disease; and maternal deaths (Rutstein et al. 1976; Charlton & Velez 1986; AIHW 1994). There is considerable dispute about what can bg included on this list, and the discussions refer only to amenable causes of mortality, not morbidity. The significance of these causes of amenable mortality is that they serve as warning signs, and can be used to measure the quality of medical care. As Westerling (1992: 489) notes: avoidable mortality such as perinatal and maternal mortality [are] negative indices of health . . . these causes of death [arg] a
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warning signal, a sentinel health event, indicating that the quality of care may need to be improved.
But it is not feasible to collect mortality data from AHS. Measures of morbidity generated at point of contact with health services do not provide a picture of actual community morbidity. They in fact provide data on the relation between people with illness and the health service. Apart from the collection of notifiable disease data, actual morbidity prevalence or incidence can be measured only through techniques that require random sampling. Finally, the time frame for producing health transitions in many of the key aspects of Aboriginal morbidity (e.g. the chronic degenerative diseases) is outside the scope of the funding cycles. For some of these conditions it is far more appropriate to take a generational view than use a medium-term cycle such as a decade. It may be possible to view risk reduction as an outcome that is measurable (pap smear rates, screening/treatments rates for hypertension, and percentage of people smoking). It might be argued that these measures would relate to effort and not outcomes, but the difference between a process (activity) indicator and an outcome indicator is moot: for example, measurement of blood pressure is, from a microperspective, a measure of work or process: from a macroperspective, an effective system of blood pressure screening is an integral component of the effective management of hypertensive disease and therefore an integral component of the prevention of cardiovascular disease. It should be noted that most of these measures require estimates of denominators, which are difficult to arrive at in most service contexts. Finally, some measures of risk reduction can only be read longitudinally. For example, cervical dysplasia may increase rather than decrease in the early stages of program implementation and represent a health improvement, rather than a decline. We do not wish to suggest that health services have no impact on morbidity and mortality. We know that they do, and that health services should not be dismissed as a bottomless pit into which money is dropped from which there is no measurable benefit. The point is, as Kunitz states, that such services can and do make a difference (1994: 182). Under certain circumstances, accessible and culturally sensitive care has had a noticeable impact on health— 206
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infant, child and maternal mortality, and the severity of infectious diseases—while having less impact on the severity of non-infectious chronic diseases. With the exception of a very few morbidity risk reduction measures, it is not possible to define health outcomes that are feasibly measured by AHS. Even those which may be suitably used are rendered problematic by the difficulties in defining population denominators, in assessing the possible impact of other health agencies, and the fact that most measures could only feasibly be generated through service usage and therefore provide a partial insight only into community morbidity or risk. Health outcome measures, on the whole, must be separated from funding processes. They are a measure of the overall performance of the state and need to be tied to macro resource allocation processes, such as the overall allocation of resources into Aboriginal health, not as measures of performance of the Aboriginal health dollar. Consequently, they are more appropriately tied to measures of political commitment and resource allocation, as suggested by WHO. Throughput or process measures as performance indicators are problematic. Measures such as number of consultations per year do indicate effort, and a funding agency may wish to establish that such effort is occurring. However, such indicators do not measure performance or quality of service. As crude figures, these data are actually meaningless. If a service sees a given number of people a year, does this mean that it is being effective? What happens if the number of consultations increases? This could mean that AHS has made their programs more accessible. Alternatively, it could mean that their public health program is failing and community morbidity has grown. In the original Department of Finance documentation the hegemonic role of numbers was apparent. Yet it may be the lowest-ranked indicators—the narrative or qualitative indicators—that are the most useful in the context of AHS. It is entirely appropriate that a health service demonstrate the range of program activities that have been developed, and include locally developed measures of performance, or evaluation comments. Further, it is appropriate that the service 207
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demonstrate that certain forms of activity, integral to sustaining viable operations, are occurring. These may include:
• evidence of planning and internal evaluation; • evidence of community participation, mechanisms used to guarantee community accountability;
• evidence of training and skills development. Given the small number of services (approximating 130), it is still possible to produce narrative assessments of program activity and have these reports assessed by central office staff. An effectively functioning Commonwealth regional office should be able to identify potential problems in program activities in particular sites, or even on a regional or national basis. It does not replace locally based evaluation, which can more appropriately be contextualised against local circumstances and developments. In-house evaluations can include, for example, assessments of the quality of care via an audit of patients’ medical records. These reflect the quality of patient examinations and the rglationship between health staff and patients. Especially in situations where there is high staff turnover, good records are crucial for continuity of care. There is now a considerable literature on health care evaluation, program effectiveness and health status indicators to draw on (Public Health Association of Australia 1989; McClelland et al. 1992; Nganampa Health Council 1993; South Australian Community Health Research Unit 1994). Given the pressures from central agencies in the Commonwealth public sector, it is unrealistic to expect that any department that may be responsible for monitoring AHS could dispense entirely with quantitative indicators, although their interpretation is problematic and their validity open to debate. That being the case, the most appropriate indicators would be process indicators, with possibly some outcome measures related to risk reduction. In the main, however, health outcome measures should be separated from funding cycles.
Conclusion The development of performance indicators for AHS requires reassessment and consensus. It is therefore necessary for the Commonwealth 208
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to commit itself to the formulation of a national Aboriginal health policy apparatus which involves all the key stakeholders. This situation was rectified in 1996 with the formation of the National Aboriginal and Torres Strait Health Council. A major part of this policy process, vital to the development of performance evaluation, is the development and endorsement of realistic national goals and targets. With some exceptions, health outcome measures are inappropriate performance indicators for AHS. They are, in effect, measures of the performance of the state. Appropriate national performance indicators should, as argued by WHO, include measures of national political commitment, using analyses of resource allocation and ease of access to health care. Information on state and national assessments and indicators needs to be fed back to AHS, as the provision of data has often been a one-way process (from the local organisation up to the central office). There are at present no avenues whereby this might happen, but suitable mechanisms of feedback need to be discussed. The development of appropriate performance indicators must take into account the feasibility of data collection. The capacity of AHS in terms of their physical infrastructure and human resources needs to be developed as a priority. If a funding body is genuinely supportive of self-determination, the performance indicators provided by AHS to the funding body should reflect the needs of the client population or community. AHS should be properly resourced to determine the priorities and needs of the particular community, and to develop appropriate indicators as to whether these are being met. AHS should also be properly resourced to negotiate with the funding body on equal terms, so that appropriate indicators can be included in the contract, service agreement or grant conditions. Performance indicators alone are no substitute for the development of local mechanisms of evaluation which measure performance against the context of a particular region and the stage of development of AHS. In order to maintain a policy of self-determination in the development of evaluation strategies, such mechanisms should include internal evaluation and peer evaluation mechanisms. Accountability spreads in two directions: up to the fund providers, and down to the clients. 209
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Women’s health in a changing state PHILOMENA HORSLEY, SONYA TREMELLEN and LINDA HANCOCK WOMEN’S HEALTH
One great gift of the women’s movement has been its insistence that there is no neutral genderless, objective position from which to view the world or speak about it. (Broom 1991: p vii) The emerging women’s movement of the late 1960s and early 1970s, both incorporating and sparking the women’s health movement, launched a fundamental challenge at the institution of patriarchy (the structured system of power that supports white men in Western society). It insisted that the so-called ‘reality’ espoused by its agents, made up of particular assumptions, knowledges and beliefs, was in fact inherently biased through the factor of gender (as well as factors such as race and class). Accordingly, women’s liberationists argued that there was a need to acknowledge both a ‘women’s reality’ (including the existence of different experiences) and, therefore, women’s distinctive requirements of the health system. Health itself is a crucial area in the life of any society: among other things it describes the wellbeing of its citizens, it measures some outcomes of its particular social structures, it reflects a society’s interactions with the physical environment, and it is a vital part of the economy of Western societies. The particular health needs of women are determined by biology and by the social, economic, 210
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political and psychological factors that mediate and shape the experience of health and illness. These factors mean that women have different patterns and experiences of health from men (Webster & Wilson 1993). For instance, some conditions, such as eating disorders, are particularly prevalent among women, while issues that affect both men and women, such as cigarette-smoking, may have different causal factors and require different responses. Recent research has suggested that smoking in women is intrinsically linked to the gendered meanings afforded to smoking (Greaves 1996). The debate about women’s morbidity (or illness and injury incidence) relative to that of men has stopped focusing on the question of more or less, and turned instead to actual differences (Dennerstein 1995). Penny Kane has found that ‘women have a very different health profile to men in the illnesses they suffer and those from which they die’ (1994: 94). Women’s usage of the health system is also patterned differently from that of men (Broom 1991; Health Sharing Women 1990; Stanton 1996). It often involves maintenance of wellness, as with routine screening for such health conditions as cervical and breast cancer and contraception. Women often seek assistance for problems such as family violence, sexual harassment, stress and unhappiness. Women interact more with the health system on behalf of others—as carers of children, the aged and those with disabilities (Webster & Wilson 1993; also see chapter 14). However, women less often receive health care from a provider of the same sex or, if from a non-Anglo-Saxon background, from a practitioner of similar cultural background. As noted by Webster and Wilson (1993: 3), this affects the ‘extent to which women can confidently act as equal partners in their own health care’. Overarching concerns that women have expressed regarding health care include: their exclusion from how health care is delivered and managed; trivialisation and negation of their self-defined health concerns; high levels of medical intervention; the focus on specific diseases/conditions at the expense of the ‘whole’ person; high levels of sex-role stereotyping by health care providers, especially doctors; the intersection of social factors such as income, housing and education in relation to health and wellbeing; the undue emphasis on reproductive health and on women in their reproductive years; lack of recognition of the needs of particular groups of women (e.g. 211
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those from non-English-speaking backgrounds, lesbians and rural women); lack of acknowledgment of the realities of women’s lives; the need for access to information and resources to support informed choice; and the need for provision of locally based, primary care health services. This is especially the case in rural and remote areas, but applies also to those from lower socioeconomic areas in larger Australian cities (Davis et al. 1996; People Together Project 1997). Taking up these concerns, the women’s health movement has challenged the fundamental tenets of the biomedically dominated health system and the economic, political and social structures that impinge on the health of women. Despite their dominance as workers in the health sector (AIHW 1996; 1998) and as health care service users, a dominant theme in the women’s health movement has been women’s relative lack of power within the health system (Broom 1991; Doyal 1983, 1994). In order fully to appreciate both the depth of achievement of the women’s health movement, and the challenges of the work still ahead, this chapter charts the development of the women’s health movement; the achievements of the National Women’s Health Policy; the dual emphasis on alternative women’s health practices; changing mainstream medical practices; the impact of broader consumer and feminist movements on women’s health; and the challenge of preserving women’s health services against ideological challenges based on antidiscrimination and, more recently, the agenda of current economically driven reforms. Reforms associated with the market state indicate the vulnerability of the broader women’s health agenda in the current climate of funding cuts and the reshaping of community and women’s health services to cater for increased acute care within the community, with early hospital discharge and ‘hospital in the home’ policies.
The development of the women’s health movement A range of sources chronicle the key outcomes, stages and events relating to the achievements of the women’s health movement and its derivatives, both in Australia (Broom 1991; Commonwealth 212
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Department of Community Services and Health 1989; Alcorso & Schofield 1991) and in other developed countries (Doyal 1983; Philips & Rakusen 1978; Ruzek 1978). Rather than summarise or repeat these events, we present an episodic analysis of past and current critiques offered by the women’s health movement. In doing so, we can illustrate the activist beginnings, the recognition afforded by the development of national policy on women’s health, the innovations produced in putting the policy into action; the debates around the effectiveness and continuity of specifically targeted health policies within changed federal/state funding agreements concerning women’s health; and the impact of funding cuts and downscaling of programs coordinated nationally—including the Office of the Status of Women, the broadbanding of women’s health funding and devolution of women’s health to state and local levels (thus diluting national oversight of adherence to national women’s health goals). The specific history and ideological underpinnings of women’s health are crucial to understanding its proponents’ defence of standalone women’s health funding and services. ‘Bucket’ or broadbanding funding (including a whole range of programs in one grant to states) and integrating a wide range of primary health and community support services, including women’s and community health (as in Victoria), are seen as threatening the maintenance of the unique nature of women’s health programs and services. First, however, the background and history of women’s health is essential to understanding why it is different from mainstream health. Until the late 1960s, the biomedically dominated health system existed on the premise that the male-defined reality of health that it espoused was true for, and relevant to, all people. Such a belief created and sustained a closed and rigid system of health service provision that disregarded complaints, maintained an illusory mindset of medical provider superiority and promoted a system where privilege begat health (Ehrenreich 1978; Doyle 1983). This system had a long-established set of beliefs and practices through which all information was filtered and all understanding and knowledge derived. As with all systems, it was sustained by the process of ensuring that it excluded, trivialised and marginalised 213
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those ideas and practices that it could not comfortably incorporate (Broom 1991; Graham & Oakley 1981). Erupting into the 1970s, the women’s health movement challenged the notion of a single, defining reality or perspective in relation to health. It proposed multiple realities in terms of experiences of health and illness, where health status was viewed as being inextricably linked to social and cultural determinants such as gender, class, race, ethnicity and disability. The health arena became a major area of feminist analysis and activism, as women’s bodies were understood as theoretical and political sites (Broom 1991; Doyal 1983; Ehrenreich 1978; Graham & Oakley 1981). In 1975 the first Women’s Health in a Changing Society conference was held in Adelaide as part of International Women’s Year—shortly after the United Nations Decade for Women commenced in 1976—with international calls to address the status of women and the broader parameters of women’s health. Feminist critiques throughout the 1970s and early 1980s developed a framework by drawing on the commonalities of women’s experiences (even at the expense of differences) to define medical practices that confined, endangered and maligned women. Such practices were seen to represent potent forms of medicalisation of previously socially defined natural conditions and life events, such as menstruation, pregnancy and childbirth. For instance, in the introduction to the Spare Rib Reader on women’s health, a collection of 15 years of published writings, O’Sullivan (1987) explained how women’s health had primarily been defined through biology and sex-role stereotyping, where natural biological events in women’s lives—such as menstruation, pregnancy and childbirth—were regarded as pathological conditions needing treatment. The dominant medical approach to such events thus represents potent forms of medicalisation of previously socially defined natural conditions and life events. The contradictions between societal expectations of women’s role in providing services to others, while remaining infirm by virtue of being female, are made clear (O’Sullivan 1987: 3): . . . women are usually expected to soldier on in these male defined roles, both because of and despite this female ‘infirmity’, and so we often find the situation where men think women are
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‘diseased’ when we are not, and will not believe us when we say we are ill. The case of premenstrual tension is a case in point: our biology does incommode us on occasion, but by the same stroke it does not completely incapacitate us. We are no more automatic or perpetual victims of our biology than men.
What was radical in feminist critiques of the health system was the primacy given to the authority of women’s expressed views of their health experiences. A scepticism developed towards new technologies such as IVF, with demands either that it be stopped or become women-friendly and controlled by women (Arditti et al. 1984; Corea 1985; Koval 1986; Franklin 1997; Meyer 1997; Rowland 1992; Stacey 1992). By challenging the hierarchical notion embedded in the dominant biomedical model of health, of the doctor as sole expert and proprietor of knowledge about health and illness, feminism sought to undermine the very premise of the prevailing system—medicine’s ownership and control of knowledge and wisdom (Broom 1991; Ehrenreich 1978; Harding 1986; Rose 1993). As Broom (1991: 58) comments: [W]omen are not only the objects of medicine: they are also active agents in the constitution of their bodies and themselves, participating in other (sometimes conflicting) discourses, at times accepting and at other times resisting medicine’s impositions.
Dominant themes in women’s health Drawing on feminists’ critiques of positivist methodology and quantitative research, and an emerging qualitative feminist methodology (Roberts 1981; Harding 1992), the women’s health movement focused on legitimising women’s voices. It thus drew on a broad range of feminisms and direct consultations with women, enabling articulation of their expressed complaints and needs. As early as 1973 women packed out the Assembly Hall in Collins Street in Melbourne to ‘speak out’ about the health system. As Bon Hull (1994) said at the opening of the Health Sharing Women’s Health Resource Service in Melbourne: . . . the dominant issue was poor health care and the lack of information to women. Many of the testimonies were unbelievably
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shocking, but doctors, nurses and health workers also came to the microphones to endorse the disclosures . . .
Thus, a dominant theme has been women’s relative lack of power in the health care system, despite their numerical dominance as workers within the health sector and as health care service users. Other public meetings occurred around Australia, particularly in New South Wales. Such consultations found that women understood ‘health’ and its causative factors much more broadly than did orthodox medicine, and that women easily and readily defined their health within much broader parameters than those traditionally recognised, such as reproductive and gynaecological issues. By the 1980s the power of this strategy gained official endorsement: the first government-funded consultation was held, resulting in the report of the Victorian Ministerial Women’s Health Working Party (1987). The outcomes of this extensive consultation with Victorian women indicated that health services were seen by most women as inaccessible, inappropriate, unresponsive to their needs, and devaluing of their experience and knowledge. Further, the specific effects of gender inequalities on women’s lives were seen to mediate and define the experience of health as expressed in the Victorian Ministerial Women’s Health Working Party (1987: 1): The overriding and fundamental principle of this report is that the health and well-being of women is directly related to the social context in which women live their lives.
When Australian women were, and are, asked about what they want from a health system, the responses are remarkably consistent across time and geography. The list includes a desire for the health system to provide women with opportunity to bg:
• • • •
treated with dignity and respect; allowed access to informed decision-making; offered improved access to services; offered greater choice of practitioner, particularly in relation to gender; and • provided with information based on relevant, women-focused research. 216
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The achievements of policy development: the National Women’s Health Policy The Australian government’s adoption of the National Women’s Health Policy (NWHP) (Commonwealth Department of Community Services and Health 1989) was preceded by consultations around Australia with over one million women. Its clear focus, reconfirmed in 1993, centred on the social context of women’s health (AHMAC 1993b; Commonwealth Department of Health, Housing, Local Government and Community Services 1993). The NWHP incorporates a number of commitments to principles of access and equity, which include: enhancing participation of women in both health service delivery and decision-making about their own health care; a focus on health promotion and illness prevention; understanding the social view of health; reducing sexism and sex-role stereotyping in health service delivery; and managing and strengthening the focus on primary care, as the most appropriate sector for meeting women’s health needs. The policy also outlines seven priority issues that recognise women’s social roles as well as the concerns of women throughout the life cycle. The priority issues are reproductive health and sexuality, occupational health and safety, health of aging women, the health needs of women as carers, violence against women, women’s emotional and mental health, and the health effects of sex-role stereotyping. As a Victorian evaluation stated (Success Works et al. 1997: 34): The philosophy of women’s health services can be summarised as bging based on feminist principles, within a social context that recognises access, equality and equal participation for all and allows control and closure for service users in all aspects of service provision.
Australia has been internationally recognised as the first country to develop such a policy (Doyal 1994), and was influential on other countries’, such as Canada’s, subsequent formal adoption of similar policies. Recognition of structural barriers to quality care, beyond the identification of specific health concerns, has enabled the identification of five key action areas within the policy to inform strategies for 217
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effecting change. These structural issues include the need for improvements in health services for women, the provision of health information, research and data collection on women’s health, participation in decision-making, and the training of health care professionals.
The dual strategy of women’s health Both the national and the Victorian approach to reform of the health system has been based on the concept of a ‘dual strategy’. This approach provides for the reform of the mainstream health system while resourcing the establishment of separate and specific health services for women in the community, run on feminist principles (Stanton 1996: 47).1 Women’s health services. The Women’s Health National Funding Strategy recognised that, while greater sensitivity and responsiveness to the needs of women was the principal goal of national policy, autonomous services for women could hasten such change by highlighting particular health concerns and developing innovative approaches to particular issues. The emergence of a funded network of women’s health services across Australia from the late 1980s was fundamentally about identifying and developing alternative models, practices and resource materials in relation to health. The rationale was based on the view that women’s health services could provide a number of services and direct links to women and, at the same time, promote improvements in services for women provided by existing mainstream services. The services could also provide a key vector for women’s voices, and hence maintain a clear advocacy role and watching brief within the health system. Draper notes (1991: 331): In short, the aim was not to build an infrastructure of women’s health services parallel to mainstream health, but to use women’s health services to catalyse and model changes in mainstream services.
The nature of services provided, and to some extent the model adopted in women’s health organisations, has varied from state to state. Consistently across states, however, all have offered informa218
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tion and education to women and training to health professionals. With the exception of Victoria, they have also provided clinical services of a reproductive and screening nature. The design of such services provided an opportunity fundamentally to challenge established clinical modes of practice that women had found so unsatisfying. For instance, the Melbourne Women’s Health Collective encouraged women to write their own medical histories, which remained the property of the women. Such practices were (and are) considered heretical by medical practitioners, who have viewed women as ignorant and unreliable informants on their own lives, and medical records as the private and inaccessible property of the medical profession or institution.2 Such notions are still firoly entrgnched among the medical elite today, despite 20 years of women’s protestations. For instance, the account by Stephanie Brown and colleagues of the response to their recent research on women’s experience of motherhood is eerily familiar (Brown et al. 1994: 2): Our assumption that women could be bglieved when they rgport on their lives—that their reports have indisputable authenticity— is still seen as extremely dubious. This is illustrated by the letters we received from professional journals rejecting a paper . . . about the links between post-natal depression and women’s obstetric experiences. A fundamental objection to the paper was that we relied on and believed what women told us.
Changing mainstream medical practices. At the centre of women’s health services have been attempts to redefine and recreate the role of the doctor in health consultations. While feminist discourse has generally been anti-doctor, the presence of women doctors in feminist services has highlighted tensions and forged changed relationships. Rosemary Pringle (1996) argues that such renegotiation has occurred in three ways. First, medicine has been practised differently within women’s health services, and women doctors have significantly contributed to this through the process of articulating and working through the tensions with other non-medical workers. Second, women doctors are expected to practise differently from men, and have often believed in and responded to this expectation. Third, women doctors have challenged the way medical work is organised and the barriers imposed on them and not their male colleagues. 219
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Women’s health services have also strongly argued for the promotion in status and role of nurses and midwives—predominantly female professions, and long-viewed as ‘handmaidens’ to the doctor. Recent successes in credentialling ‘nurse practitioners’ (nurses trained to provide pap smears and other preventive health care to women) has capped a long and arduous process (Buckenham & Parsons 1993; Lorentzon & Hooker 1996). The determination of nurses to be more autonomous of doctors and to have more control over their practice has met with fierce resistance by various professional bodies representing the medical fraternity. Commenting on the introduction of women’s health nurse practitioners in New South Wales, Cox notes that economic recession and the oversupply of doctors have exacerbated medical resistance to these independent practitioners, despite the finding of higher levels of skill in taking pap smears compared with other practitioners. Similarly, midwives’ efforts to expand their authority and provide pregnant women with a greater range of birthing options has sparked trenchant opposition from these bodies and indeed state governments (Bennett 1995). Despite the wishes of women that an extended role for midwives be supported (Health Department of Victoria 1990), and research indicating that midwifery care results in lower monetary cost and less frequent medical intervention in birth, the management of birth remains a largely specialist medical perogative in Australia (Bennett 1995; Robinson 1989). The philosophy and practice of women’s health services also reintroduced historical notions of self-care (self-diagnosis and selfmedication) and shared health knowledge based on women’s collective experiences, which again challenge the sole authority of traditional medical practice. For instance, information leaflets on herbal remedies for a range of ‘women’s problems’ were widely distributed. Services went further in either employing alternative practitioners—long before they were socially acceptable—or promoting the existence of alternative health modalities modelled on holistic or ‘whole-body’ constructs of health and illness. Women’s health activists have recognised women’s profound dissatisfaction with the limitations of the mechanistic, biologically deterministic disease model of conventional medicine, which disallowed a recognition of the interaction of emotional, physical and social factors in health (Broom 1991; Dennerstein 1995; Webster & Wilson 1993). 220
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Today, alternative modalities of health have gained greater legitimacy, used either singly or in tandem with mainstream medical treatments. It is apparent that women are the primary users of alternative remedies and therapies and that they continue to do so in the context of significant resistance and suspicion from conventional medicine practitioners, and significant financial disincentives (Crook 1995; Harrison 1996; Smith 1989). For instance, an Adelaide study found that Australians expended a total of $621 million on alternative medicines and $309 million on alternative therapists in 1993. The study also found that women were more likely to consult naturopaths, iridologists and reflexologists than men, and were the greater users of non-medically prescribed alternative medicine (MacLennan et al. 1996). The researchers asked what induces people to spend large amounts on alternatives to allopathic medicine. They suggest that lacking in the normal doctor–patient encounter are time, empathy, personalisation, expectation of a cure in chronic disease states, counselling, and a general emphasis on health rather than disease. These concerns echo those consistently raised by women in the past two decades of public consultations. In developing models of service provision, women’s health services have intervened in highly protected areas of the medical establishment, such as research and training for health professionals. Again, the focus has been on mining the wealth of knowledge held b{ consumers and a training framework based on a collaborative relationship between women and their practitioners, based on mutual respect and listening. For instance, the National Women’s Health Program-funded project, Being Our Age: Older Women’s Voices (Elliott 1994), embarked on an ambitious process of mutually consulting and training both older women and health practitioners to encourage more positive health outcomes.
Women’s health and broader consumer and feminist movements It is no accident that the rise of the consumer health and feminist movements have paralleled the rise of women’s health activism, resulting in recognition of the right of consumers to participate in 221
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the development of health policy and in decisions on the allocation of research funding, and the right to informed decision-making regarding illness treatments. Feminist interventions in research methodology have been central to the arguments mounted by the women’s health movement and the policy directions taken. It is possible to indicate some of the broad tenets of these interventions, but important not to overstate the level of agreement about them. Ongoing debates on the usefulness of scientifically approved methods, such as randomised controlled trials (Westbrook 1996; Shelley 1996), recreate and renegotiate the terms and ideas through which women’s health policy is evaluated and understood. The overriding concern in the women’s health movement has been the participation of women and women’s perspectives in the health system. The explicit inclusion of women’s voices—hence their values, concerns, priorities, needs, politics and so on—has bgen a central aim in the policy strategy of providing centres run for and by women and, at the same time, attempting to influence mainstream services to be more appropriate and responsive to women. Feminism’s challenge to the development of knowledge about health has involved demonstrating the ways in which women have been excluded from research and modelling new ways in which participation can occur. Systematic bias in the form of exclusion of women from major clinical research trials has been identified as a significant problem (see also chapter 12). Many drug trials are based on male population data, with doses prescribed for the ‘standard 70 kilogram male’. Johanna Westbrook (1996) reminds us that some of the largest and most important medical studies in recent years have not included any women. She cites a 1988 US health study which concluded, on the basis of research on 22 000 men and no women subjects, that taking an aspirin a day might reduce the risk of heart disease. The ‘Mr Fit’ study on the interrelationships between heart disease, lifestyle and cholesterol intake studied 15 000 men (Freedman & Maine 1993, cited in Doyal, 1994: 147). Further, a review of research published in the The New England Journal of Medicine in 1989 found that over 60 per cent of articles displayed gender bias. A similar review in the journal Hypertension found that 40 per cent of the studies included no women (Westbrook 1996). Doyal (1994: 222
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146) argues that because medical researchers tend to overlook female health problems unless they are related to reproduction, chronic and disabling illnesses often suffered by women, such as dysmenorrhoea, cystitis and incontinence, receive little attention. The preferred methodology favours medical orthodoxy. A researcher taking a qualitative and participatory approach to a study of women’s mental health reported difficulties in gaining ethics clearance from a mostly male and medically trained committee, critical of the non-representative sample, qualitiative research methods and the researcher’s lack of clinical experience (Stanton 1996: 29). Only 1.9 per cent of $42 million of funds expended by the NH&MRC between 1986/87 and 1988/89 was allocated to women and health projects and, given the biomedical research focus of the funding body, these focused on clinical research programs on reproductive health rather than on wider issues of concern to women’s health (Melbourne District Health Council 1990; Stanton 1996: 29). A review of expenditure on Australian research on women’s health found that there was a paucity of funding to women’s health generally, and that the research that was funded tended to be biomedically oriented (Melbourne District Health Council 1990). Research funding for consumer organisations was the most scarce, but also the most likely to fund projects conducted according to action research, participatory and community development principles. The smallest slice of the research funding pie went to projects explicitly designed to address the expressed health concerns of women. Less than 1 per cent of the annual federal health budget goes explicitly to women’s health programs.
The challenge of preserving women’s health services The existence of Australia’s National Women’s Health Policy is an open acknowledgment that the medical system is not and should not be the only site of knowledge about health. Notwithstanding its low levels of funding, the policy and funded program has been an expression and recognition of different realities based on gender. After the successful evaluation of the first four years of the program (Commonwealth Department of Health, Housing and Local 223
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Government 1993), the policy was endorsed and funding reconfirmed for a further four-year period (1993–97) and, later, for 1997/98 and 1998/99. The continuation of the Women’s Health Policy and program has met significant challenges. First, the ‘Proudfoot case’: in 1991–92 Dr Alex Proudfoot, a Commonwealth bureaucrat, joined by two other male complainants, challenged the legality of women-only health services before the Human Rights and Equal Opportunity Commission (HREOC) on the grounds of discrimination and lack of men’s access to services under the Sex Discrimination Act. The gendered nature of health and access to health services had to bg re-argued, and the president of the HREOC ultimately found that the complaints were unsubstantiated and women’s health services are exempted under s.32 or s.33 (the ‘affirmative action’ or special measures section) of the Sex Discrimination Act 1984 special measures (Broome 1992). Nonetheless, the case demonstrates the vulnerability to challenge of women’s health and, for that matter, other services targeted at disadvantaged or special needs groups. Second, funding and system changes represent a potential challenge to women’s health. The 1993 Medicare Agreement committed Commonwealth and states to the development of an outcomes-based health system. Further, funding for women’s health will be ‘broadened’ and devolved in a block grant to states/territories that brackets funding for a list of specific-purpose public health programs. Under this arrangement, the objectives of the Women’s Health Program will be maintained through a regulatory framework agreed to by state health ministers. Each of the key objectives of the national program will be monitored through the collection of health outcomes indicators and underpinned by research, including a threeyearly population survey on women’s health; the 20-year Longitudinal Study on Women’s Health (at the University of Newcastle); and information held by the Centre for Outcomes and Understanding of Gender (Differentials) in Health. However, the efficacy of such a framework for achieving the qualitative objectives of the women’s health agenda will need careful monitoring. As chapter 12 points out, the development of ‘women-sensitive’ health indicators is an evolving process. Other issues that cloud the horizon include: 224
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• questions over whether the national longitudinal study funding will be maintained;
• the risk that women’s health program objectives will be marginalised if other programs in a broadbanded funding pool under the Public Health Funding Agreement are given priority; • the possibility of state political agendas undercutting service funding to the point where workers are unable to deliver needed services; • the risk that outcomes-based funding might divert workers’ productivity into measuring outputs; and • the risk that quantitative output measures might end up driving the direction of women’s health service delivery. Already in Victoria, funding cuts and service changes are undermining workers’ capacity to deliver effective quality services (People Together Project 1997). Both the Women’s Health and Community Health Programs are to be ‘bundled’ into the Primary Health and Community Support (PHACS) integrated delivery platform (Department of Human Services 1997), along with community rehabilitation centres, aged care social support, psychiatric disability, drug treatment, dental health, aged care, post-acute care, hospital in the home, family planning, sexual assault and innovative health services for homeless youth. These shifts in the way the Women’s Health Program is funded and organised have bgen perceived as a threat to maintaining and supporting the integrity of targeted programs. As pointed out in earlier chapters, the health sector has undergone major turbulence and is experiencing massive review and restructuring at both state and federal levels. The role of policy covering specific, targeted populations is increasingly unclear, although linking funding to health outcomes in an outcomes-based health system is firmly on the national agenda (Rubenstein & Sansoni 1996: 5). The upshot is unclear of developments such as competition policy and market state reforms, broadbanded funding and proposals by the Council of Australian Governments (COAG) to adopt overriding notions of ‘population health’ (Duckett et al. 1995). The emphasis is less on access and more on outcome, less on service providers and more on ‘streams of care’. While the theoretical focus of COAG’s reform 225
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proposal is on the coordinated integration of the acute and primary health sectors, greater efficiency and quality, and acknowledgment of the perspective of the consumer—all reforms applauded by women health activists—it remains to be seen how such a ‘global’ perspective will address the systemic disadvantage experienced by many groups with specific needs, such as women. The demise of special-purpose grants may mean fewer innovative programs to fill the needs of those most at risk. Indeed, one of the plenary recommendations of the Third National Women’s Health Conference in November 1995 (Davis, Andrews & Broom, 1996: 14) noted with concern: the potential of reforms of the Australian health system, such as those currently proposed by the Council of Australian Governments (COAG), to dismantle Special Purpose Programs, including the National Women’s Health Program.
A significant criticism levelled at the women’s health services, policies and programs has been the relative lack of success in changing the mainstream health system. While the Women’s Health Program has developed products and services that are innovative and have even been recognised as examples of best practice in primary health care provision, there are questions as to how effectively the implicit models and philosophy of ‘women’s health’ have been adopted by the core of mainstream services, which are not particularly gendersensitive. One example is the ongoing focus of national health goals and targets on the traditional concerns of childbirth, gynaecological health and women’s cancers. While women’s health services have bggun to meet this challenge of tackling the gendered nature of all illness, there has perhaps been some reluctance on the part of both women’s health and the mainstream to take on so large an agenda. The dual strategy has been a potent and powerful concept, allowing the privacy and power of separatism and at the same time granting a legitimate position of influence in relation to the mainstream. The practice, however, has proven complex and, at times, questionable in its impact. In the British context, Doyal (1994: 140) doubts whether medical opinion has altered to acknowledge women’s changed perceptions of health and healing. She argues that feminist analysis has had little impact on British doctors’ practice. There is 226
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an ongoing need to build and maintain networks into core areas of resistance, such as the acute health sector, and find ways to collaborate. For instance, if women’s health services were recognised as unique sources of quality data about the needs of particular groupings of women, this could form a basis for collaboration within the increasingly market-driven, customer-focused health system. Interestingly, this policy framework is now being paralleled in the men’s health movement. The Draft National Men’s Health Policy acknowledges that (Commonwealth Department of Human Services and Health 1996: 45): an analysis of the interaction between gender and health has proved extremely useful in the area of women’s health. It afforded a new insight into the health of a significant segment of the population. By extending this analysis to . . . men it may be possible to achieve further improvements in health.
The Draft proposes the adoption of a policy based on the social model of health, the links between masculinity and men’s health, and strategies including the establishment of ‘targeted initiatives and services aimed at meeting men’s health needs and modelling best practice for promulgation in mainstream services’, both key platforms of the NWHP. There are concerns held by some women’s health activists as to whether the imitation is a form of ‘flattery’, or is in fact a key challenge to the complex notion of inequity on which the women’s health policy was framed, and a bid for the scarce resources allocated to women-specific health services (Moore 1994). However, many women’s health activists, while questioning the reliance of the men’s health movement on simple mortality data, see positive signs in the developing recognition of gender as a social determinant of health status (Moore 1994; Broom 1995), a trend that may trigger the better development of both women’s and men’s health policies.
Conclusion Whatever form it takes, policy in relation to women’s health in the future will need to continue its links with the expressed needs of women in the community if it is to have an ongoing impact on the 227
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delivery of better health outcomes for women. The past 20 years of activism by Australian women has inserted and consolidated the view that women have common (though diverse) needs that are not the same as those of men. The future challenges will encompass a maintenance of the social view of health, the integrity of women’s experience, as well as greater understanding of the complexity of difference and diversity within the gendered health arena. It also entails the inevitable necessity of taking on contradictions and ambivalences—of being in constant renegotiation of positions and meanings as previous blindspots and points of exclusion are brought into view. The women’s health movement has struggled to challenge and change entrgnched patriarchal medical practices, to instil the importance of listening and responding to women’s voices, to view women’s health holistically and not just in terms of biological and medically defined models, to provide services by and for women, and to cater for women’s cultural and ethnic diversity. The Proudfoot challenge to specific women’s health services has now been overtaken by market reforms, funding cuts and changes to women’s health funding mechanisms. Cuts to services—especially for rural women—and ‘capture’ by the acute care sector (with early hospital discharge) has the potential to undermine the gains made over 20-plus years. Although the rhetoric of market reforms preaches responsiveness to consumer demands, these may be limited to the minority who can pay for services.
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Health indicators for diversity LIZ ECKERMANN HEALTH INDICATORS FOR DIVERSITY
Following the emphasis in chapter 11 on output-based funding, along with the requirement that health systems respond to diversity of need and interest, this chapter examines health indicators that are often used as a means of allocating resources. These will become increasingly important, given government’s focus on program and service output measures in current Australian health system reforms. In the market state, performance indicators are in growing use with competing calls on the health dollar. It is crucial that such indicators accurately reflect the diversity of people’s health experiences and health outcomes, rather than merely measuring levels of disease and infirmity. This chapter exposes the problems of a conventional focus on mortality and morbidity as indicators of health status and health intervention outcomes, and argues that to cater for diversity indicators must be broader, to include social indicators and subjective measures of quality of life. Questions need to be asked to develop gender-sensitive indicators. In international as well as Australian attempts to address inequalities in health and wellbeing, there are unintended consequences of applying a public health policy based on universalistic assumptions. Gender is just one (albeit an important one) of the dimensions of differentiation of human health experience, within which further differences are articulated by age, class, ethnicity, race, geographical 229
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location, ability/disability status, lifestyle and consumption patterns among many other dimensions, thus making it difficult to talk of either sex as a unified group. Notwithstanding diversity, gender does emerge as a key dimension of difference in health experiences and thus in policy-making and resource allocation (Vlassoff & Bonilla 1994; Mathers 1995; Rahkonen et al. 1995). There are some recent attempts to apply the ‘gender lens’ to develop more inclusive and differentiated health indicators. Compared to conventional approaches to health indicators, quality of life scales (QOLs) tend to adopt a contextual approach to measuring health. They acknowledge the importance of individuals’ subjective experiences of health and include the dimensions of social and emotional wellbeing, which renders them more reflective of the World Health Organization’s official definition of health. However, it is questionable whether QOLs reflect the lived health and wellbeing experiences of particular groups of people such as women, as few of these measures are gender-sensitive. Traditional indicators have overlooked women’s special needs and characteristics. Similar arguments could be put for the need to develop indicators that reflect men’s particular experiences, but these would require separate study.
The sociopolitical context of health indicators There are many reasons for collecting information on health status. These range from scientific arguments about knowledge for knowledge’s sake, to equity arguments about differential access to health care, to political efforts to promote a country’s image, to economic arguments about the distribution of resources and evaluation of program and intervention outcomes. The setting of parameters to evaluate the extent to which health objectives are being met is the raison d’être of health indicators. However, this is not a neutral process. One needs to ask: Whose objectives? In the past such objectives have usually been set by health professionals, public health professionals and health bureaucrats; in other words, the script has been written by the health care providers with little or no consultation with health consumers. The choice of indicators was premised on the discourses of economic efficiency, professional paternalism, 230
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and calculable risk at a personal and population level (Oakley 1983; Lupton 1993). Where health is defined objectively b{ professional groups with shared or at least overlapping interests, the parameters for measurement are relatively straightforward. More recently other agendas have appeared on the scene, especially in light of the growing political potency of the health consumer lobby, along with a growing cynicism among social scientists about Western scientific thought (Gleick 1987) and the inability of medical science to deal with the chronic health problems of the late twentieth century. The subjective experience of health and illness emerges as a focus of interest (Bowling 1991). These are just some of the forces that have put health indicators on the agenda as a negotiable item. The context of health experiences is emphasised at the international level in various WHO documents: in the Alma Ata (WHO/UNICEF 1978) and Ottawa Charter (WHO 1986), Health For All (WHO 1985) and the New Public Health. Another influence on the evolution of health evaluation indicators has been legislative change towards protecting human rights in relation to health (Cook 1993), that has been translated into measures which use social justice and rights discourse, such as ‘burden of disease’ (World Bank 1993). However, as McTurk (1994: 22) argues, the growing emphasis on health outcomes as a way of establishing budgetary and clinical accountability sits uneasily beside other principles such as equity and social justice, access to care at the time of need and comprehensive coverage. There is thus an implied irrevocable tension between ethicomoral-philosophical arguments and economic arguments about indicators of health status. However, debates about allocation of resources and choice of health indicators occur in a sociopolitical context. McTurk argues that the ‘rational actor model’ for decisionmaking in resource allocation is purely an ideal type. He says decisions about resource allocation involve trade-offs between stakeholders. Both social justice/human rights and economic values inhere in the arguments of most parties to the debates. The need to reflect human rights, politics and economic pragmatism in the current health policy environment has resulted in an alliance between psychologists, sociologists and economists in the development of new indicators of health status, such as DALYs (disability-adjusted life years) and 231
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QALYs (quality-adjusted life years), and happy life-expectancy (Veenhoven 1996), reviewed later.
Gender and health indicators Women’s health and the health needs of women have been recognised nationally, with the Australian National Women’s Health Policy (Commonwealth Department of Community Services and Health 1989) incorporating the call for a policy ‘based on accurate data and research concerning women’s health, women’s views about health, and strategies which most effectively address women’s health needs’ (Subcommittee on Women and Health 1993: 73). This was elaborated in the development of health goals and targets for Australian women—one of the seven ‘goals for key action areas’ being to ‘expand the knowledge base about the health and health needs of women’ (1993: v). Internationally, concerns about women’s health over the past 20 years are marked by the UN Decade for Women, the Fourth UN World Conference on Women held in Beijing in September 1995, the Global Commission on Women’s Health with activities at regional, national and local levels, activities of the Women’s Health and Development sections of WHO’s regional offices, and undertakings in Australia and other parts of the world to study women’s health. First, however, the question arises: Why, after nearly two decades of special attention to women’s health (including the UN Decade for Women), do we need to launch yet another crusade to promote the health and wellbeing of a group of people defined by their gender? After all, if we use the least ambiguous measure of health status— mortality rates—in most countries men’s life-expectancy at all ages is lower than women’s (WHO 1994). Thus it would seem appropriate to ask the questions that Broom (1991: 32) does: ‘Why women’s health rather than men’s health or people’s health?’.1 The response to some extent depends on the health indicator adopted—whether, as shown below, we use mortality, morbidity, social indicators or quality of life. Mortality. In most countries of the world, women outlive men. Life-expectancy at birth is higher for men in very few countries. 232
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WHO’s (1994) summary of progress towards ‘Health for All’ identifies Pakistan, Afghanistan, Bangladesh, Bhutan, Djibouti, Iraq and Nepal as the only countries where official reports claim that men outlive women. Djibouti has the greatest discrepancy, with the reported life-expectancy at birth of males being 56 years and of females 44 years in the 1983–85 statistical period (WHO 1994), although the reliability of these figures is questionable. In most other countries the situation is reversed, with the highest discrepancies being for the former Soviet Socialist Republics of Byelorussia and the Ukraine, where men’s reported life-expectancy at birth is 10 years lower than for women (1983–85); France comes a close third, with women outliving men by 9.3 years (1986–88). Czechoslovakia, Hungary, the Bahamas, El Salvador and Finland follow, each with a reported eight-year mortality disadvantage for men at birth. Some possible reasons for such sex differences have been well documented for a variety of ‘developed’ and ‘developing’ countries (Lopez & Rwzicka 1983; Ohadike 1983; Lopez 1983; Pool 1983). The proposed causes range from hormonal, genetic and biological factors to cultural practices (Bhatia 1983), to economic, occupational and social roles (Verbrugge 1983; Sandelowski 1981)—although the issue of reversal of the trend for the countries mentioned has not been adequately rgsearched. Morbidity. Without exception, epidemiological data suggest that in terms of ‘reported’ morbidity (i.e. illness and injury) women are worse off than men. In provider-reported and self-reported health care seeking, women also outscore men significantly (Nathason 1977; WHO 1994; AIHW 1990, 1992, 1994a; Broom 1991). Women seem to measure higher on all measures of non-fatal morbidity and disability (Saltman 1991; Sandelowski 1981). This may be partly an artefact of the diagnostic and accounting processes used to ascertain morbidity levels. Saltman (1991: 66–8) suggests that using hospital admissions and separations as an indicator of morbidity skews morbidity rates by gender because of a cultural bias towards hospital-based childbirth and the compression of chronic illness in the ‘old old’ women who outlive men. Similarly, Saltman argues that the use of visits to the doctor and sickness certification as indicators of level of illness masks the cultural tendencies to medicalise transitions or 233
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major ‘events in the life cycle of women’ and to view sickness as the only legitimate excuse for absence from work. Verbrugge (1983: 226) suggests that ‘women are more sensitive to physical discomforts; more likely to interpret them as signs of illness; more willing to restrict activities, seek professional health care, and take more drugs’, and are more inclined to seek out and use health services. Thus, it is little wonder that ‘national health surveys commonly find that women have higher rates of acute and chronic morbidity than men, and also higher rates of short-term disability’ (Verbrugge 1983: 226). Gender differences in morbidity have thus often been put down to women’s propensity to seek health care (Mechanic 1978).2 However, just because cultural and psychosocial factors may be ‘important in people’s perceived experience of illness and injury and their curative actions’ (Verbrugge 1983: 226) does not mean that the experienced illness or injury is ‘not real’. The differentials between men and women remain significant and worthy of investigation, whether the source of the difference is biological, cultural or psychosocial. Social indicators. In relation to existing indicators of economic status, political power, leadership and social standing, women consistently score worse than men. If we compare the situation for women on these indicators a decade ago (Sandelowski 1981; Johnson 1983) with current figures (Asian Development Bank 1993; UNDP 1997), we observe little change. For example, indicators of women’s share of GNP, women’s wages compared to men’s, women’s level of unemployment, and women’s participation in public life and governance still show that the inequities between the sexes consistently favour men (Asian Development Bank 1993; UNDP 1997). Kickbusch’s (1994) research in Eastern Europe reveals that in not one country in that region are women treated as well as men in social, political or economic terms. One cannot separate health from such issues as education, employment and domestic arrangements (South Australian Health Commission 1992). Social aspects of life are critical contributors to a person’s sense of life quality and wellbeing. This fact is reflected in the WHO definition of health as a ‘state of complete physical, mental and social well-being’ and the articulation of that broad concept of health in the Australian ‘Health for All’ strategy. For 234
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example, levels of education for women have been used as a key summary indicator of health status (Asian Development Bank 1993). However, in the case of educational attainment and maternal mortality, the relationship between social indicators and traditional health indicators (mortality and morbidity) is often convoluted rather that straightforward. This is particularly the case where global, regional or national indicators disguise massive intragroup differentials that require teasing out.
Quality of life The three sets of indicators mentioned above give us information about objective conditions that reflect or give rise to health or ill-health. In a sense, social indicators tell us something about possible quality of life experiences, they refer to some of the preconditions for achieving quality of life, but they do not tell us whether such quality is actually experienced or not. Quality of life indicators allow us to examine the relationship between subjective and objective health states. Here, the gender dimension is highly relevant. Historically, for example, physically experienced symptoms for which there is no clear diagnosis have been psychosomatised and women in particular have been subjected to the stereotype of the ‘nervous woman’ (Foucault 1980), as evidenced in the diagnoses of chlorosis (Figlio 1978), repetitive strain injury (Willis 1986) and anorexia nervosa (Robertson 1993). In each of these conditions, which are labelled ‘mental or psychological illness’, the individuals ‘afflicted’ are observed and diagnosed according to criteria that take no account of subjective experience. For example, recent feminist analysis of self-starvation (Celermajer 1987; Robertson 1993; Eckermann 1994) suggests that many people who are diagnosed as ‘suffering from anorexia nervosa’ see their self-starving activities as a solution rather than as a psychiatric problem. How one responds to such a discrepancy between objective and subjective perceptions in the case of life-threatening activities becomes an issue for ethical consideration rather than merely a scientific, technical or clinical deliberation. Davis and Fine-Davis (1991) argue that there is ‘no consistent relationship between objective social conditions . . . and perceived well-being’. Thus, to understand the higher occurrence of clinically 235
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diagnosed mental illness in women (AIHW 1990, 1992, 1994a; Broom 1991; Subcommittee on Women and Health 1993), illness definition and quality of life need to be addressed. As Bowling (1991: 1) observes, symptom response and survival rates are ‘no longer enough’ to evaluate therapeutic treatment.
Research implications To carry out research examining the inequities referred to above, we need to use all four of the indicator types—morbidity, mortality, social indicators, and subjective measures of quality of life. We need indicators that: 1. are general for all people but are gender-disaggregated;3 2. are gender-sensitive; 3. acknowledge the heterogeneity among both women and men (i.e. articulated by age, race, ethnicity, ability/disability status, geographical location, and social class); 4. deal with specific reproductive health issues of women; and 5. are gender-specific in other (non-reproductive) areas of health. Categories 1–4 are the sorts of indicators currently being used (World Bank 1993; Asian Development Bank 1993; WHO 1994). The last is the most contentious, given an implied essentialism. Broom (1991: vii) encapsulates the argument for gender-specificity, beyond reproductive issues, in her claim that: ‘One great gift of the women’s movement has been its insistence that there is no neutral, genderless, objective position from which to view the world or speak about it’. This claim does not support an essentialist argument that ‘the female body is a preexisting, timeless essence’—rather that the body ‘as studied or lived is always in the process of being produced socially, culturally and psychically’ (Broom 1991: 149). Given current social, political and economic arrangements bgtween the sexes in all parts of the world (Asian Development Bank 1993; World Bank 1993), it is inevitable that women will experience their bodies, as well as their health and illness, differently from men. This is not to say that biology does not play a part, but the experience of that biology is tempered by social, economic, political and cultural forces. 236
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‘Malestream’ methodologies and ‘malestream’ data do not necessarily reflect either women’s objective or their subjective experiences of health, illness and disability. Androgenising, ‘total-population’ tendencies in health promotion research and in traditional epidemiology have bgen particularly inappropriate for women. For example, the use of the body mass index and total weight (rather than relative distribution of weight) to establish risk of heart disease is, for women, not only inappropriate but may have serious unintended consequences. This was acknowledged by a key report on eating disorders in Australia (Ben-Tovim & Morton 1989), which argued that health promotion campaigns need monitoring and may have detrimental effects.4 In the health field, just any body or group of bodies will not do to standardise measures and develop health campaigns to be used with heterogeneous populations articulated by gender, age, social class, race, ethnicity, geographical location and other dimensions of difference. We cannot have single generic health promotion messages such as ‘Eat less fat, less sugar, less salt’. For a young woman on starvation rations of a lettuce leaf and a wafer biscuit a day, such a message means ‘cut out the wafer biscuit’. Similarly, for Third World populations whose calorific intake is inadequate, such global messages make no sense. Yet some populations in ‘developed countries’ contain groups of people living under Third World conditions (e.g. in some Australian Aboriginal communities). These examples illustrate the need for gender-disaggregated, gender-sensitive and gender-specific indicators in non-reproductive areas of health, and the need for a differentiated approach to human existence in public health research and in the development of public health policy. As McBride and McBride (1981) argue, to gain a clear picture of people’s health status we need to find out about their lived experiences of their bodies, and lived bodies are differentiated and gendered bodies.
Assessing recent social epidemiology We now focus on three applications in social epidemiology—the New Public Health, DALYs and QALYs—with a specific focus on the 237
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extent to which such approaches are gender-sensitive. The latter are two kinds of indicators that have bgen developed from combined efforts by epidemiologists, economists and psychologists to produce ‘a single composite measure of the effect of health programmes that includes both additional life years and quality of those years’ (Maynard 1991: 38).5 Within this process psychologists have tended to emphasise the concept of ‘wellbeing’, whereas economists have emphasised the quantification of life quality.
Application 1: ‘New Public Health’ as social epidemiology The ‘New Public Health’ (NPH) (Kickbusch 1986; Ashton & Seymour 1988), which represents the application of Alma Ata and the 1986 Ottawa Charter to the public health field, promises a social view of health that acknowledges health as an intersectoral and a social justice issue. Thus, provision of adequate housing, transport, education, income and town planning, alongside community action and participation, are seen as key factors in producing good health, promoting quality of life and wellbeing, as well as enhancing social justice and human rights. In measuring health outcomes, social indicators have been used as de facto health status indicators. For example, the Social Health Atlas of Australia (South Australian Health Commission 1992) notes high correlations between total household income, type of housing, employment status, geographic location and health status (defined in terms of mortality and morbidity). That report suggests that one needs only to measure these social and economic circumstances to get an idea about the health status (survival rates and level of sickness) of those living under such circumstances. The ‘Healthy Cities’ projects, which involve experimental cities throughout the world, were based on the NPH principle that an intersectoral approach to illness prevention and health promotion is the only way to produce equitable health outcomes. These projects, even in their short history, have had notable positive effects on social, environmental and health outcomes (Baum & Cooke 1992). However, most of the indicators that have been used to measure such outcomes have been ‘absence of disease’, focused on objective conditions for health (such as availability of 238
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adequate and accessible public transport and level of community participation). This is partly a consequence of the level of health action at the community level, at which the Healthy Cities initiative is pitched. The Ottawa Charter is used as the basic document for setting indicators for evaluation of the projects. The data that emerge from such evaluation tend not to be gender-disaggregated or gender-specific, and the concepts of subjective well-being and quality of life are not systematically explored. However, subjective responses to the initiatives in the South Australian Noarlunga Healthy Cities project brought out contradictions between objective and subjective criteria. Two of the collector districts of the Noarlunga area were identified as having particularly bad social conditions. Yet when this information was made public, a number of women who lived in the districts defended the quality of their life as positive, despite objectively defined ‘social deprivation’ (Baum 1994). Baum (1995) provides a review of cases of community research in South Australia where objective social indicators are not privileged over ‘community’ and ‘individual’ perspectives. For example, one researcher claims that ‘the epidemiologically-based standard setting approach to dealing with environmental pollution is at odds with the logic of community concerns about these issues’, the appropriate response being to ‘give more credence’ to the ‘form of reasoning used by community groups’ and to use research methods that are ‘capable of documenting their stories and perspectives’ (Abbott, referred to in Baum 1995). Another researcher points to the need for researchers to ‘engage in “experiential encounters”, which will enable them to grasp people’s perceptions and understand their interpretation of social phenomena’ (Wadsworth, referred to in Baum 1995). Baum adds the observation that we need not only a methodological reorientation but also changes to the ways in which researchers go about planning, conducting, interpreting and using their research. This participatory, democratising process means that a variety of approaches to health can bg adopted and brought together to form a richer picture of community health. Baum sums this up cogently (1995: 7) when she argues that, for a creative use of methods to gain a ‘patchwork of data’: 239
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The process of evaluation is about telling the story of the people, interactions and achievements. Often there will be more than one story, depending on whose perspective is being considered.
Although social indicators of health status move beyond the biomedical model of causes of disease and illness, those commonly applied (such as housing status) have been derivative of, or equated with, traditional mortality and morbidity indicators, and provide information about the preconditions for quality of life (as determined by public health professionals) but not about whether such quality of life is being achieved. The relationship between providing the conditions for a good quality of life and whether such quality is actually experienced could be explored within the Healthy Cities framework, as exemplified in the Noarlunga project in South Australia and community health initiatives in other parts of the world. In time, more subjective social indicators could be derived from more sensitive measures of individual, national and international status and of health intervention outcomes, and these could be used systematically in evaluation of Healthy Cities projects. In the process it is important that such information be disaggregated by age, gender, social class, race, ethnicity and geographical region. The concept of community is often used as a metaphor for ‘wholeness’ and shared values and as a rallying point for political purposes. But groups within communities do not necessarily share needs and interests. When the heterogeneity of communities is recognised, specific indicators could be developed for groups such as women, various ethnic groups, the aged, and the geographically or socially isolated. There is concern that, by privileging ‘expert’ knowledge of professionals and the objective power of science over consumers’ experiences, NPH will be no more facilitating for consumers than the medically dominated public health (Baum 1990). This would occur if professional aspirations of the NPH professionals and their investment in certain kinds of knowledge result in professional self-interest being promoted at the expense of health ‘consumers’. Noack (1988: 6), too, warns against the ‘real possibility that certain professional groups will dominate health promotion to the exclusion 240
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of other professional groups and lay people’. Petersen and Lupton (1996) further critique the modernist underpinnings of NPH and its continued reliance on the knowledge of experts and the ‘objective’ power of science. There appears to be much interest in expanding the indicators measuring the impact of NPH to subjective perspectives, but this is rarely acted on, partly because of the practical difficulties in applying macropopulation methods to microprocesses and to population subgroups. Emphasis on a population perspective may in fact hinder the opportunities for accurately reflecting the needs and desires of specific groups (Noack 1988: 10). New initiatives may also develop ‘positive’ indicators of health status for a specific group, such as women. These have emerged from the ‘Investing in Women’s Health’ project in Central and Eastern Europe referred to above (Kickbusch 1994). Kickbusch proposes ‘levels of choice’, ‘levels of political participation’ and ‘levels of security’ as additional indicators for women’s health, which tap aspects of women’s lived experience not covered by the traditional mortality, morbidity and social indicators.
Application 2: DALYs (disabklity-adjusted life years) The World Bank’s publication (1993; produced in consultation with WHO, World Development Report: Investing in Health) attempts to move beyond the crude analysis of mortality data by using the DALY method to measure differential burdens of disease by age, by region, by risk factor, by sex and by disease grouping. The methodology, which is constantly being updated (Murray & Lopez 1996), involves summarising large amounts of data to a single comprehensive measure. The DALY method combines death and disability losses from 109 diseases and injuries (the ICD9 classification) to produce a quantifiable account of the ‘full loss of healthy life’ (World Bank 1993). The unit of measurement is time lost along a continuum of time. It thus involves a far more sophisticated epidemiological technique than case-counting. The use of this method represents a major step beyond the calculation of aggregated and disaggregated mortality and morbidity rates as the only indicators of a country’s health status. The ‘global burden of disease’ concept recognises that much 241
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of the bwrden of disease of countries is the result of non-fatal illness, and this recognition is of particular significance to women, who as a group suffer a much higher burden of morbidity and its disabling outcomes than men (WHO 1994). The DALY method could be adapted for use as a framework to follow the trajectory of women diagnosed with a particular disease or injury in terms of their physical, mental and social wellbeing outcomes, over years or even decades (Lopez 1994). The major shortcomings of the DALY method are generic to all epidemiological research or population science. The outcome is only as good as the data available. If the data are ‘flaky’ or inappropriate, the methodology cannot produce the desired result. Similarly, the framework within which the method is used—in this case the ‘global burden of disease’ framework—circumscribes the methodological opportunities for innovation. As used in the ‘global burden of disease’ project, the DALY method was applied to clinically defined disease and outcome states. Thus, feelings of ill-health that ‘had no name’ and lay outside the ICD9 classification were discounted. Similarly, the population level emphasis meant that the method was unable to represent the health experiences of individual members of the communities of each country. The use of data based on the premise that health is absence of disease or disability, and the reliance on health experts, rather than health consumers, to quantify disease burden and the costs of disability, produced content problems which hindered the potential for an innovative methodology. Methodologically, the approach relies on experts and overlooks subjective aspects, as disability weightings and degree of loss estimates are conducted by ‘international health experts’ rather than by those who have experienced disability. Although the authors of the World Bank report acknowledge that ‘calculation of the disease burden is based on several assumptions, some of which involve decisions about ethical values and social preferences’ (World Bank 1993: 213), the lack of consultation with those who experience disability in calculating the disability weightings renders such measures invalid as a reflection of the lived experience of the disabled. Rather, the DALY scale is a measure of how health 242
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professionals or ‘experts’ perceive the disruptions and inconvenience that disabilities cause to their ‘patients’. The DALY measure was developed within an economic rationalist framework, but it does move in the direction of acknowledging the social as well as the economic costs of disability, and does acknowledge reproductive health as a separate issue (Murray & Lopez 1996), although less tangible personal costs and more general gendered experiences are given scant regard. However, the DALY holds much potential in terms of assessing women’s burden of disease compared with men’s on a total population level, and this could be complemented by more individually based and subjective QALY measures.
Application 3: QALYs (quality-adjusted life years) Numerous studies (e.g. Schneider 1976; Wasserman & Chua 1980; Kuz 1978) have revealed ‘no consistent relationship between objective social conditions . . . and perceived well-being of . . . inhabitants’ (Davis & Fine-Davis 1991). The concept of ‘quality of life’, as applied to health, generally refers to aspects of daily living beyond physical and social conditions and beyond physiological functioning to include ‘perceptions of well-being, a basic level of satisfaction and a general sense of self-worth’ or empowerment (Bowling 1991: 9). The nebulous nature of the concept makes it difficult to operationalise, and accounts for the resistance on the part of researchers to expanding their range of indicators of health status and intervention outcome. Bowling (1991: 11) argues that many of the measures that have been developed incorporating quality of life dimensions ‘have serious limitations in terms of reliability, validity and techniques of analysis’, especially those ‘derived from professional conceptions of well-being’. However, some of the reliability and validity problems are being addressed with modifications, such as an increase in the use of lay populations to establish the dimensions to be measured. Quality of life scales attempt to tap people’s positive experiences of health, and thus move beyond a disease and illness assessment of health status. QALYs can, however, be used to support both economic rationalist and human rights agendas (McTurk 1994). Bowling (1991) reviewed over 50 quality of life (QOL) scales. The field has expanded exponentially since the publication of Bowling’s 243
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book. Cummins (1993) suggests that there have been over 100 scales developed using the QOL construct. Although the various scales developed to measure quality of life do not share the same definition or dimensions of wellbeing and quality of existence, they share an emphasis on examining people’s subjective assessment of their own health (alongside objective measures) and on measuring the health context of individuals. For example, Cummins’ (1993) ComQol, which attempts to meld the best elements of a variety of QOL scales, is ‘multidimensional’, covering seven domains: ‘Material well-being, health, productivity, intimacy, safety, place in community, and emotional well-being’ (Cummins 1993: 3). ComQol is also ‘multiaxial’ in that it separately measures objective and subjective dimensions while acknowledging that the two rarely correlate. Within the subjective dimensions each domain is further articulated by ‘importance to the individual’ and ‘perceived satisfaction’. Although QOL scales have potential, very few of these measures are gender-sensitive, as most are based on gender-neutral assumptions about health experience. The ComQol measure has separate versions for adolescents and people with cognitive impairment, but not for women. Age and disability are seen as the key variables of differentiation in health experience. A review of currently used QOL scales revealed that few were gender-specific.6 This is especially surprising given that the impetus towards more subjective and qualitative measures of health has come in large part from feminist research. Most scales addressing quality of life are based on captive, structurally compliant populations, such as school students, university students and the aged (usually the institutionalised aged). They thus tend to be specific to those populations, with the aged getting most coverage. However, many scales have bgen used as global measures even though the populations they were based on were age-specific. Those based on data from younger women overemphasise women’s reproductive years. As Danguilan (1994) concludes in her report of women’s health issues in the Philippines, such an assumption means that the specific needs of older women and young girls are silenced. Danguilan argues that there is a serious gap in information about the health of certain groups of women which can be filled only by expanding the range of existing indicators of health status. 244
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The paucity of gender-specific indicators in the area of social networks and family life is most surprising, given the plethora of empirical data showing gender-specific responses to marriage (Gove & Tudor 1973; Glenn & Weaver 1975, 1988).
Conclusion At a general level, the literature reveals a hiatus between theory and practice in relation to qualitative aspects of health status. Much feminist research in the area of health and illness points to the need for a broader qualitative approach to understanding women’s health, yet the measures needed to establish such a profile are still being developed. This review has revealed few attempts to develop measures reflecting women’s experiences of health, wellbeing, illness and disability. Research suggests that, despite more than a decade of attention to women’s health, women are still worse off than men as measured by objective measures of morbidity and objective assessment of socioeconomic and political standing. However, we still know little about women’s subjective sense of health and wellbeing. It may be that knowledge of subjective experiences of health inform the lack of major improvements in objective measures of health. Some developments in QOL measurement look promising in providing guidelines for devising gender-sensitive measures. However, women’s health projects should study women’s health, not simply the health of women compared to the health of men. This points to the need to move beyond gender-sensitive measures to gender-specific measures, which explore the intricacies of women’s unique health experiences. This information could be used as the basis for evaluating existing services and interventions and for devising appropriate health promotion strategies and public health policy generally. The challenge is to combine culturally sensitive national or regional measures with global measures, and to triangulate methodologies in producing a picture that accurately reflects both the subjective experience of health for women and the objective realities. The task is a difficult but not impossible one. Practicality, manageability and ‘collectability’ of the data are key issues, but they should not override scientific arguments about accurately reflecting the 245
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world or human rights and social justice arguments about respect for the individual. The task requires imagination and perseverance. In the context of contracting out of health care services and contractual specification of performance indicators for service providers, this chapter points to the pitfalls of blind acceptance of limited, biomedical indicators and the need to include subjective and processual indicators. No single indicator can summarise health status and health experiences. What is needed is a combination of indicators, their composition being determined by the level of analysis at global, regional, national, special group or individual levels, and the reasons for collecting the data, whether that role be resource allocation, international comparisons, regional planning, national policy, needs assessment, intervention evaluation, clinical diagnosis or self-evaluation. To further address issues of diversity, chapter 13 analyses the particular policy challenges that confront mental health policy.
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13
Shifts in mental health policy BETH WILSON MENTAL HEALTH POLICY
In 1993 the findings of the National Inquiry into the Human Rights of People with Mental Illness (the Burdekin Commissioners’ Report 1993) were released in Australia. This detailed exposé of the denial of human rights to mentally ill people recommended sweeping changes. This chapter examines recent reforms to mental health services, concentrating on Australia but with reference to international trends. Particular attention is directed to deinstitutionalisation (and community-based care) and mainstreaming (the treatment of psychiatric patients within the general hospital system) as key trends in mental health policy. The political context of these reforms in a strained and underresourced public sector raises issues of justice and access to treatment for the mentally ill and adequate work conditions for mental health workers. The ‘Rights Analysis Instrument’ (Watchirs & Heesom 1996) represents one attempt to monitor states’ compliance with legislative protections in the problematic area of attempts to advance the rights of people with mental illness. The provision of treatment and care to people experiencing mental disorders poses complex policy problems (Rochefort 1996; White 1996). The services required to support them are necessarily different from those for people with other kinds of illnesses, because of the complexity of the range of conditions classified as mental 247
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disorders, the impact they have on the ways in which an individual is able to function (and this may vary enormously between individuals given the same diagnosis), and the high incidence of chronicity, competing professional and other interests, and differing ethical positions (Rochefort 1996). The debates about mental illness have never been concerned solely with medical issues. They have always been—and they remain— intensely political. They must compete with other health services for resources; and, while the claim is often made that mental health services have traditionally been the poor cousin to general health services, this has fluctuated at different times.1 Mental health services involve stakeholders including psychiatrists, psychologists, psychiatric nurses, administrators and policy-makers, striving to preserve their positions in the hierarchy, along with consumers, their families and carers, attempting to have their views taken into account. Within psychiatric services, different specialties compete for patients, and the very classification of what is, and what is not, mental illness involves political decision-making (Pathe & Mullen 1993; Spitzer 1991). The Burdekin Commissioners’ Report (1993) concluded that people with mental illness are among the most vulnerable and disadvantaged in our community: that they suffer from widespread, systematic discrimination; they are denied the rights and services to which they are entitled under international agreements; that mentallyill people with special needs (and those with dual- or multipledisabilities) suffer double disadvantage; and that levels of ignorance and discrimination are completely unacceptable. The Commissioners recommended more resources for communitybased care (arguing that these should be redirected from high-cost institutions to integrated services); better cooperation between the various agencies and departments involved; and health insurance funds that do not discriminate against people with mental illness. They recommended the development of national standards for mental health care and better links between the private and public sectors. At the community level, they called for an appropriate range of services, adequate facilities and resourcing, arguing that the levels of funding for people with mental illness should be at least equivalent to that for other categories of disability and that staff should be trained specifically for community-based work. Many of their recommendations reflected 248
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trends in existing policies, but the publicity given to the Report hastened the pace of change. In common with all health services, the mental health sector is undergoing radical change involving the distribution and redistribution of resources. Intense pressures on governments to ‘reform’ the general health system by cutting costs have affected mental health services, because a range of resource-intensive services is required to meet consumer needs. People who have long-term or chronic conditions require different types of services from those who have milder forms of mental illness—yet the acute care sector dominates health care expenditure in Australia. The episodic nature of many mental illnesses means that an individual’s requirements vary over time, ranging from emergency and intensive support to minimal intervention. Resource issues also dominate the debate about which services should be supplied by the public and the private sectors.
What is mental illness? There is widespread ignorance about what mental illness is, with many people believing it causes sufferers to be dangerous, or that people who are affected by mental illness never recover. These misconceptions, often aided by media stereotyping, enhance the stigma that mentally ill people encounter. Stereotypes overlook the diversity of mental illnesses. They may be mild and episodic, or be chronic and devastating. Mental illness may result from trauma, or there may be no obvious cause. At times, people may become so ill and disorganised that even their close relatives and friends barely recognise them as the same person. At other times, with some support, they function as well as other members of the community as workers, parents and autonomous human beings. Mental illness is complex, controversial and misunderstood. There is no consensus that would lead to a single acceptable definition. Instead, definiton depends on such factors as the background and training of those defining mental illness and the various explanatory models they adopt (Valenstein 1986). In analysing mental health policy it is important to understand that there are many explanatory models of mental illness. The 249
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explanation a person accepts will influence her or his acceptance of treatment options, and is relevant to an understanding of the cultural, political and economic issues contributing to professional power and influence within the mental health services (Miller & Rose 1994). It is not possible here to give a detailed analysis of all the models, but those which have dominated are the biomedical and social models. The biomedical or ‘disease’ model of mental illness claims to be objective and scientific by identifying clusters of undesirable characteristics, or symptoms, which indicate an underlying biological disturbance. This model views mental illness as caused by abnormalities in the brain. However, there is not just one biomedical model. Psychiatry is no different from other branches of medicine in having a number of schools of thought and competing specialties. The social model is often identified with the ‘antipsychiatry’ movement, which gained considerable popularity in the 1960s and 1970s. This questioned medical dominance and viewed psychiatry in its social, political and cultural contexts. The theories of Michel Foucault, R.D. Laing, Thomas Szasz and others held that psychiatry was not a science at all; it was, at best, a social science. Parts of Laing’s work have been interpreted in ways that blame families, especially mothers, for mental illness (Ussher 1992). Szasz characterised mental illness as a ‘myth’ perpetuated by the mental health ‘industry’ to further its own interests (Szasz 1974, 1994). To the theorists of the antipsychiatry school, neuroses and psychoses are not illnesses but merely deviant behaviour. According to Szasz, institutions actually cause or exacerbate mental illness. However, the closure of the large asylums has not made mental illness go away. The major contribution of the antipsychiatrists has been to ensure that the ethical issues in psychiatry are not ignored, and to urge the location of individuals’ problems within their social milieux rather than as signs of individual pathology (Mulvany 1994). Whereas the bkomedical model concentrates on the illness, the social model emphasises the social environment. The social model has drawn attention to the importance of difference—such as gender and culture—to understanding mental illness. Rgsearch conducted by Jayshri Kulkarni and others has revealed that women with schizophrenia are often given inappropriate doses of medication, based on male standards (Kulkarni et al. 250
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1996). Cox (1994: 3) argues that women-sensitive practices in women’s mental health, which recognise sex-role stereotyping, are needed to change services so they may respond more appropriately to women’s needs and address structural barriers. The Burdekin Commissioners reported that in traditional Australian Aboriginal culture there is no separate medical concept of mental illness. The collective wellbeing of an individual is associated with harmonious social relationships, spirituality, and a relationship with the land and the physical environment. Treatments prescribed for a traditional Aboriginal person that fail to take into account cultural issues are unlikely to be successful (Burdekin Commissioners’ Report 1993; O’Shane 1995), and few, if any, services have been available, on their own terms—especially in the Northern Territory and in remote communities. The key Commonwealth policy document for indigenous mental health is the National Aboriginal and Torres Strait Islander Emotional and Social Well Being Action Plan. This recognises the importance of community ‘ownership’ of services, and the need for indigenous communities to have services that meet the regionally identified needs of the individual communities. The plan involves indigenous people working to establish a network of regional support for the delivery of training and education, clinical support and supervision, data collection and research, effective liaisons and networking, and mental health illness prevention. Much more work needs to be done to assist our understanding of cultural and political aspects of mental health and to supply appropriate services (Minas et al. 1993). However, as Hof and Nicholson (1996) warn, there are dangers inherent in identifying disorders as being ‘culture-bound’. There is also growing awareness among some professionals and service-providers of the need to include the voices of consumers and carers in mental health policy decision-making processes (Consumers’ Health Forum 1990; Dubrow 1995). In Victoria and New South Wales, government departments acknowledge that services will be unsuccessful unless they are valued and supported by consumers (Health and Community Services 1996: 27–33; O’Brien & Murray 1997). The implementation of case management, better service and housing options, and consumer involvement in the evaluation of services is being taken more seriously, although some consumer 251
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representatives fear that these initiatives may be used as a smokescreen to justify further funding cuts (personal communications with community-based consumer advocates in 1997).
Deinstitutionalisation and mainstreaming The policy initiatives of deinstitutionalisation and mainstreaming have the best of intentions—to provide better services and to reduce the stigma and isolation that the mentally ill have endured (Benson 1994). However, they have also affected the interests of health service providers and the general public, as well as patients, and have been the subject of intense controversy (Barham 1992). Scull (1996) has argued that the concept of community-based care is no more than a masquerade for community-based neglect. The effects of illnesses on individuals are not well understood by the community at large, and governments have been slow to provide sufficient resources to support community-based services. This has begun to change, with federal government expenditure in 1996 of $8 million on a community awareness campaign and the production of relevant information by self-help groups and the bureaucracies.
Deinstitutionalisation In most Western countries the custodial model of treatment for mental illness was dominant until the 1940s. However, attempts to deinstitutionalise the mentally ill are far from new, and can be traced back to the 1500s in Belgium and the 1800s in England (Barham 1992). The dream of community-based care has taken a romanticised view of an accepting and tolerant community. Experience has shown, however, that, when it comes to paying the costs associated with the services required to support people with mental illness in the community, most societies have had other priorities. The asylums were designed to care for large numbers of people for whom there was little else available (Barham 1992; Tomlinson & Carrier 1996). One writer has described the mental hospitals in the USA during the 1940s as, ‘warehouses for human beings who had been discarded by society’ (Stein 1991: 99). Some have tended to 252
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romanticise asylums as places of quiet refuge by comparison with the rigours of living in the community (Scull 1996). While the asylums were intended to meet all the needs of patients by providing comprehensive care in a centralised institution which would also be economical to run, they fostered a lack of independence, choice and privacy (Great Britain Health Committee 1994). Others have characterised the asylums in terms of the ways in which they contributed to the power and prestige of the professional groups that controlled them, especially the psychiatrists (Scull 1996). Extreme and desperate treatments have been used to fulfil the dream of community-based care. During the 1940s and 1950s thousands of patients in Europe, North America and Australia were discharged from psychiatric institutions after having been given psychosurgery. Most were manageable but they were also dramatically changed, and were described as having lost their souls (Wilson 1996). The introduction of new pharmaceuticals during the 1950s made it possible for many more people to be treated in community-based settings rather than enduring long-term confinement in asylums, where the only treatments on offer were straitjackets, electroconvulsive therapy and psychosurgery (Valenstein 1986; Wilson 1996). Deinstitutionalisation is essentially a policy designed to reorganise mental health resources away from the institutions and into the community. It has resulted in shorter hospital stays, but some argue that coercion has merely shifted its form, and that it continues with the use of legal devices such as community treatment orders, which extend involuntary treatment (or civil detention) to a community setting (Mulvey et al. 1987; Mulvany 1992). Responses to community treatment orders vary from those who see them as a sensible approach to a need to those who consider them to be unnecessary coercion, an extension of medical paternalism and an overreach of state control (Bromley 1993; Exworthy 1995; Fulop 1995). Some of the arguments commonly put in favour of deinstitutionalisation are:
• Mentally ill people should be allowed to lead as near to normal lives as possible. 253
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• Because of improvements in pharmaceutical treatments, • • • • • •
mentally ill people can now successfully be treated in the community. Institutionalisation for long periods instills dependency and fails adequately to recognise the episodic nature of much mental illness. The isolation of mentally ill people from the rest of society is a breach of their human rights. Institutionalisation exacerbates mental illnesses. Isolation increases the prejudices and stigma associated with mental illness. Institutions, by their nature, create an environment that brutalises both patients and service-providers. Institutions support medical dominance and coercive practices.
While most commentators are now in favour of deinstitutionalisation, many misgivings have been expressed. These include:
• Australia has not learned from the mistakes made in the USA,
• • • •
• • •
Italy and the UK, where the failure to provide adequate funding for community-based services led to homelessness and poverty for former patients. The changing nature of the family has removed an important source of support. Most carers are women who suffer double discrimination. It is they who are prevailed on to provide care, often at the cost of participation in the paid workforce. There are doubts about the savings and sell-offs associated with deinstitutionalisation being redirected into community-based programs or, for that matter, mental health services. Community-based care, if it is to work properly, may not represent a saving and requires a large amount of money. This will not be available in a climate dominated by economic rationalism and cost-cutting in the public sector. Resources have been taken away from acute care services, which are no longer available. Mentally ill people pose a risk to the security of the community. Some people will always require full-time care.
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Given that we have now entered the ‘post-deinstitutionalisation’ stage of service delivery, it is important to understand that the majority of mentally ill people were never institutionalised and that community-based care is not an ‘all-or-nothing’ alternative. Governments have generally understood that, while some need only minimal services, others will continue to require intensive care (Health and Community Services 1994; National Health Strategy 1993). The issue is how much of the cake goes to which parts of the service, and who pays (Halasz 1997). While the criticisms of the ways in which deinstitutionalisation has bgen implemented are many and varied, thousands of people who would once have bgen institutionalised for life, or for long periods of time, are now successfully receiving treatment and care within the community (Great Britain Health Committee 1994). However, as the Burdekin Commissioners’ Report indicates, deinstitutionalisation has been perceived by many as a policy which has dumped mentally ill people into the community without adequate support programs, and this has contributed to neglect and intolerance.
Mainstreaming The policy of mainstreaming aims to provide services for mentally ill people in general hospitals and as part of general health services. It, too, has a long history and has bgen one of psychiatry’s elusive ideals. An ideologically driven process, it has involved cost-shifting and presumed savings derived from integrating psychiatric services into the mainstream health system. Supporters of mainstreaming argue that it brings psychiatric services out of isolation and into the mainstream, thereby reducing the stigmatisation of the mentally ill person (Australian Health Ministers 1992). Rochfort (1996) argues that an understanding of mental health services as part of mainstream health services is dependent on an acceptance that mental disorders are medical conditions. Mainstreaming is favoured by those who argue that there is an interdependence between physical and mental health which requires an integrated approach to services (Rochefort 1996; Health and Community Services 1994). Reservations about mainstreaming have been expressed by many commentators—from those of the antipsychiatry movement to those 255
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who want to strengthen and expand mental health services. The antipsychiatrists do not favour integration of mental health services into general health services, as they reject the research that indicates a biological basis for mental illness and argue that psychiatric diagnoses are unreliable (Rochefort 1996). Others who reject mainstreaming see it as a wrong service model because there is a high level of chronicity rglated to mental illnesses, which require long-term support, while other health services are more oriented to acute carg. Kiesler (1995), for example, advocates the improvement and expansion of separate mental health services to cater for special needs. Others question whether the available services are adequate given the malaise in all health services, as evidenced by long hospital waiting lists inappropriate for people with disorders that may affect their perception, mood or behaviour (Davies 1995). They also ask whether the policy is of more benefit to governments rationalising services and to health service providers than it is to consumers.
Effects on health workers and communities Deinstitutionalisation and mainstreaming affect the interests not only of patients but also of mental health workers (Thomson 1994). At some of the larger institutions, allied health services such as occupational therapy units flourished, but these too have been disbanded as the institutions have closed. This raises the issue of a service deficit—a loss of ancillary services to those placed in community settings and in the limited number of institutions, representing a substantial decline in the quality and variety of services available to the mentally ill. While official rhetoric states that health workers prefer the new arrangements, many say they are being deskilled in the smaller community-based units, where promotional opportunities are fewer and the chance to build up skills from, for example, ward experience has vanished (personal communication 1997 with psychiatric nurses). The fragmentation into localised services, especially under conditions of long hours and budget cuts, undermines communication and politicisation among mental health workers. Under market state reforms, community psychiatrists have been expected to take on larger regions with sparser resources specifically designated to mental health services. 256
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The closure of large institutions has had a dramatic impact on some small country towns, like Ararat and Beechworth in Victoria and Morriset and Orange in New South Wales, where institutions for the disabled were the major employers and large numbers of health workers lost their employment. Small towns formerly host to large psychiatric institutions often take what is perceived to be an unfair share of the burden of the shift to community treatment, because so many people with disabilities now live there. People from many other localities were transported to and institutionalised in regional centres and were subsequently discharged into the local community. When the institutions were scaled down or closed, the employees were no longer required, and their former patients became their co-residents. There have been some significant examples of resentment. In one instance a local councillor, who was also a nurse, organised a strike at the hospital and a demonstration in the town to denounce plans to deinstitutionalise some mental health services. Allegations were made that the water tank in a community-based residential project was poisoned with sheepdip by opponents of deinstitutionalisation. The problems associated with planning issues and the siting of community care facilities include objections from neighbours, environmental and zoning issues, disputes with local councils or authorities, and other sociocultural factors. Issues such as the number of residents allowed in any one unit will be influenced by economic and locational planning factors. As privatisation of health care facilities grows, it is likely that many government-owned facilities will be sold to the private sector, and the need for profit will become the predominant factor (Gleeson & Memon 1996).
Economic rationalism and mental health policy The political nature of mental health services is also apparent from the ideological rhetoric driving the ‘reforms’. In a climate dominated by notions of ‘the new managerialism’ and ‘economic rationalism’, policy-makers are faced with demands for more and better community-based services for people with mental illness, their families and carers, while at the same time they must be seen to bg 257
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doing more with less, or better with what they have (Davies 1995; Glanville et al. 1996).2 These ideologies encapsulate notions of achieving efficiencies by reducing centralised control and government involvement in service provision. This is to bg accomplished by replacing bureaucratic forms of government service provision with contracted-out services where possible, or none at all. The use of economic arguments to justify the abandonment of caring as a state responsibility is not new. Crude economic arguments were used in Germany in the first half of the twentieth century to excuse the starvation of patients in asylums (Burleigh 1994). The ‘economic burden’ of keeping alive mentally ill and disabled patients stigmatised as ‘life unworthy of life’ was considered to be denying resources to more worthy citizens. Those described as having existences of negative value were murdered ‘in the public interest’ (Burleigh 1994). The current economic rationalist urge to save money has coincided with a period of extraordinary change in mental health services. The ‘success’ of health policies is measured in terms of how cheaply they can be supplied and by the withdrawal of the public sector from this area of service delivery (Davies 1995). Service-providers, however, find themselves unable to cope with the new demands of community-based care without the necessary financial resources. Whereas consumer advocates once concentrated their energies on keeping people out of institutions, they are now acting for people who report that their illnesses have been allowed to progress because of the lack of beds for acute care patients (Anon. 1993). Consumers have complained that they can obtain admittance to hospital only when they become acutely ill, making it more likely that they will be unable to consent to treatment and will be classified as involuntary patients under the mental health legislation. Once admitted to inpatient services, the ethos of ‘pressure on beds’ encourages treatment regimens which bring about the fastest change in a patient’s mental state. This process is documented in Barrett’s (1996) Australian study of patients with schizophrenia. While in many cases a rapid response may also be clinically indicated, patients who do not respond quickly to medication or electroconvulsive therapy are susceptible to being labelled ‘management problems’ (Barrett 1996). In Australia the most radical current change in health services 258
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has been the introduction of the funding formula known as casemix, which provides finances to hospitals based on the numbers and types of treatments carried out (Australian Casemix Clinical Committee 1992; Health Issues 1994). The National Health Policy Medicare Agreements between the states and the federal government have been based on the implementation of casemix, and the effects are now beginning to be felt. Duckett has criticised the Victorian government for ‘cutting too deeply, too quickly’ (Anon. 1996). Concern has been expressed that the mix of services and the range of diagnostic-related groups identified by policy-makers as eligible to attract funding might not accord with the needs of people with mental illness, particularly those with chronic illnesses requiring long-term care (Fanker 1996). The battle for resources has been fought on many fronts, with the debate including claims that community-based care involves a devolution of responsibility from the federal government to the states, and from government to families (Benson 1994; Means & Smith 1994). Given that the majority of carers are women, who are likely already to be socially disadvantaged, the stresses on them are acute (Thomson 1994; Ussher 1992). Ideologically driven conflicts bgtween the public and private sectors reflect concern that, under the new managerialism, the team approach to the delivery of mental health services has led to a deskilling of the professional psychiatrist. Some writers have seen the work of doctors as becoming ‘proletarianised’ (Elston 1991). While these issues are important to doctors bgcause they affect their conditions of work, clinical autonomy and remuneration, objections to mental health management are usually expressed in terms of concern about patient care. The team approach has been seen by some critics as an attempt to reduce health costs by substituting psychiatrists with community workers or general practitioners, who lack the necessary training. The response has been that many skilled professionals have abandoned their involvement with public mental health services in favour of private practice. This is a covert form of privatisation that saps the public sector services of expertise and has serious implications for all aspects of service provision, including recruitment, teaching and research. It is also a form of cost-shifting from state-funded mental health services to Medicare. In Australia there has bgen concern that the US-based system of 259
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‘managed care’ is being imposed (Halasz 1997). It is said that Australia is being steered towards the US system by insurers, and that managed care has been a failure in the USA (Prytula 1997). The federal government’s attempt, in 1996, to cut rebates for psychotherapy after 50 consultations caused a flurry of criticism—mainly from psychiatrists—for being discriminatory and based on ‘a now outmoded view that mental illnesses are not biological conditions but behavioural problems’ (The Age 1996). On the other hand, psychiatrists in private practice have been suspected of overservicing, by providing prolonged psychotherapy that is not available to patients in the public system. The new policy attempts to control the number and types of services that psychiatrists can provide. These are generally considered to be clinical issues to be decided between doctor and patient, and the changes are seen by many clinicians as undermining medical autonomy. Following an intensive campaign by psychiatrists but also involving some consumer groups, the federal government eased its policy in late 1996 by allowing concessions for some patients with eating disorders and those who have suffered serious abuse. Closure of the large institutions was intended to free up dollars so that patients could be supported in the community. However, as the Burdekin Commissioners among others have revealed, these dollars have been slow in finding their way to the community. The Burdekin Commissioners’ Rgport (1993) also found that the private sector and the non-government organisations were unable, or had failed, to provide viable housing options for people with mental illness. Many mentally ill people are homeless or are living in appalling conditions (Mental Health Consumer Outcomes Task Force 1991). The asylums, for all their shortcomings, at least provided basic shelter and protection, even though this was often delivered in a paternalistic way and there were many abuses (Barham 1992; Great Britain Health Committee 1994; Tomlinson & Carrier 1996). While many of the homeless population are mentally ill, their homelessness may not be the result of deinstitutionalisation. British research indicates that provision of community-based housing has been adequate for those people with mental illness who were previously in long-term institutional care. Fewer than 2 per cent of homeless people in central London who are seriously mentally ill have ever been in institutional care for mental illness, and fewer than 260
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0.5 per cent became homeless after deinstitutionalisation (Great Britain Health Committee 1994). However, the Health Committee found that the number of homeless mentally ill people is growing, mainly because they have lost contact with mental health services and/or have been evicted by authorities or landlords with little knowledge of or sympathy for them. The failure to provide adequate housing options for people with mental illness means that they are visible on the streets. Some may be unusual-looking or have odd behaviours, and are prone to being seen as threatening. The popular media has shown little interest in informing the public that the incidence of violence perpetrated by people with mental illness is only slightly higher than that by the so-called ‘normal’ population, and this could be reduced if early intervention and appropriate treatment were more readily accessible (Guite 1994; Kennedy & Jones 1995; Monahan 1994). The rate of violent offending increases alarmingly when mental illness sufferers are also substance abusers.
Monitoring standards in mental health Although Australia is signatory to a number of relevant international covenants and treaties, the Burdekin Commissioners identified many areas in which our laws and policies fail to accord with our human rights obligations (United Nations 1948, 1958, 1966, 1975). The Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care, adopted by the UN General Assembly in 1991, make it clear that every person with a mental illness has the same basic rights as every other person.3 The Principles were endorsed in Australia’s National Mental Health Strategy in April 1992, with 1998 as the target date for ensuring full compliance by Australian mental health legislation with these standards. Since then some states, notably Victoria, have incorporated many of the Burdekin recommendations into mental health legislation but others have failed to achieve their international human rights obligations to the mentally ill. The monitoring of the progress of the National Mental Health Strategy is contained in reports. The 1995 Report (Department of Human Services and Health, 1995) indicated that the total spending 261
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by states and territories had grown by 3.1 per cent since the National Mental Health Strategy began. The expenditure was unevenly spread, with most occurring in 1994/95. All states and territories had increased recurrent expenditure in real terms, but Victoria’s per capita investment in mental health services was well above that for the others (although differences in method render such comparisons problematic). A key aim of the Strategy is to expand communitybased services. The National Mental Health Report concludes that the current level of community mental health services across Australia remains inadequate. Australia’s National Mental Health Strategy is designed to advance the rights of people with mental illness. A key element is to bring about consistency in mental health legislation to ensure that people with mental illness have similar citizenship rights and expectations of treatment. This is particularly important for people who receive services for mental illness on an involuntary basis. In June 1996 the Australian Health Ministers’ Advisory Council (AHMAC) commissioned the Human Rights Branch of the federal Attorney-General’s department to develop a ‘Rights Analysis Instrument’ (Watchirs & Heesom 1996) to measure legislative compliance by states and territories with the UN Principles and the National Mental Health Statement of Rights and Responsibilities, which are incorporated in the National Mental Health Strategy. The major features of the Policy are mainstreaming, community-based care, and consumer participation in all aspects of policy decision-making. The Rkghts Analysis Instrument (see Watchirs & Heesom 1996) measures whether the legislation complies by taking into account such matters as:
• having the objective of ensuring that human rights are met; • providing independent review by an appeal body; • including a definition of mental illness that is in accordance with • • • •
internationally accepted standards; strict criteria for involuntary admission to mental health services; provision of adequate and culturally appropriate information; providing clear guidelines pertinent to informed consent; access to services and rights of special groups, such as forensic patients;
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• for treatment purposes, the relevance of a person’s age, cultural background and gender;
• the right of minors to appoint a personal representative other than a family member; • inspection by competent authorities of adequacy of standards; • appropriate complaints procedures; and • mechanisms for appropriate disciplinary actions or judicial procedures for professional misconduct or violation of patient’s rights. The instrument is designed to assess whether the law in each jurisdiction gives patients the right to be treated in the least restrictive environment appropriate to their needs, while also taking account of the need to protect the safety of others. Treatment and medication issues are also to be assessed to ensure that legislation takes account of the best health needs of an individual rather than the convenience of others. While the instrument is a measure of the adequacy of legislative protections, the ‘National Standards for Mental Health Services’ are designed to improve services and outcomes. Based on the Mental Health Statement of Rights and Responsibilities adopted by the Australian Health Ministers in March 1991, they are being piloted and results will be available from 1998.
Conclusion The electorate has allowed governments to give people with mental illness a very low priority (Burdekin Commissioners’ Report 1993). Despite the large number either directly or indirectly affected by mental illness, the general community remains largely indifferent (Great Britain Health Committee 1994; Wilson 1995). People with mental illness have found themselves stigmatised by a popular media with an insatiable appetite for misleading ‘stories’ of violence— unfairly attributed to people who are assumed once to have been institutionalised and then released into the community (The Sun Herald 1994). Community-based care is the model of mental health provision of the present and the future. It is preferable to confinement in 263
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institutions but requires adequate resources, well-trained workers and an understanding community. Without these, community-based care can quickly become community-based neglect. In an age dominated by economic rationalism, a fair deal for the mentally ill and their carers has been difficult to achieve. Adequate care for people with mental illness, whether they are inpatients, voluntary or involuntary, must be available. The introduction of the team approach to community-based care using case management, crisis intervention teams, early intervention and mobile support teams has assisted in this. In Australia, however, as in Britain, efforts to implement these new programs have been inhibited by attempts to work with existing resource constraints, which means an increase in workloads. Mainstreaming and the use of general practitioners and mainstream hospitals has not been accompanied by adequate training for those providing services. Many general practitioners have complained that they are expected to take on additional responsibilities for people with mental illness without having enough knowledge of or training in psychiatry (personal communications with GPs 1997). When adequate resources are not provided, some mentally ill people have been doomed to homelessness, or to lonely lives in substandard accommodation. For some, the only viable option they have seen was suicide. In Australia the rate of involuntary treatment is very high compared with other countries, and this needs further investigation. It is not enough simply to have good legislation or to provide medication; the social and material needs of patients must also be met (Zifcak 1994). If a society is judged on the way it cares for its most vulnerable members, how will Australia rate? Will we attain the long-awaited ideal of genuine community-based care, or will other priorities continue to take resources away from people with mental illness and frustrate this ideal?
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14
Caring and the State LINDA HANCOCK and SHARON MOORE CARING AND THE STATE
A consistent theme in many of the foregoing chapters is the impact of health reforms on community services and families, and particularly on women’s paid and unpaid caring roles. This chapter argues that contemporary approaches to aged and community care policy disadvantage carers. There are four interconnected themes to the argument. Care-giving work is predominantly gendered, as it is done by women in the private sphere, yet dominant discourses have ignored this fact. The structure of the Australian welfare state increasingly depends on women as carers in the private sphere, as for example in health care provision and programs such as Home and Community Care. There is systemic denial of carers’ interests while the interests of dominant groups (doctors, private nursing home owners and the voluntary sector) predominate. Finally, it is argued, structural dependence of the welfare state on women as carers is increased with the transformation of the welfare state into a neoliberal market state, characterised by growing privatisation and contractualism of what were previously perceived as public sector responsibilities, tighter targeting of services and rising user copayments. The State’s dependence on women as carers is increased with the impact of new changes to State provision of health care, such as hospital early-discharge policies and ‘hospital in the home’ in the 265
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acute care sector, and the shift from residential to contracted and privatised aged and community care services. Such concerns are central to health policy and to home and community care in particular. At a general level, privatisation and contracting out have significantly shifted the nature of government community care programs and practices from public provision to market management under contractualism (Alford & O’Neill 1994; Hodge 1996). The shifts identified are often presented as unproblematic, reflecting a gender-blind reading of significant redirections in social policy. Given the high proportion of women involved in community care, the critique of changes within the State put forward in this chapter focuses on the gendered impact of these changes on services, carers, service-users and the community (Ernst & Glanville 1995). The argument is not against welfare/market state developments per se. At issue is the nature, weightings and gendered impact of ‘the mixed economy of care’ (that is, the mixture of State or public, private and voluntary or community provision of health care). Critics argue for a more nuanced analysis, which places women at the centre rather than the periphery, thereby recognising the gendered impact of government policies and reforms and pointing to the need for gender-sensitive and even gender specific policies and services. Before addressing the four areas outlined above, we look at the policy context of reforms in aged and community care. Along with the shifts in the welfare state from a postwar to the neoliberal market/welfare state of the 1990s is the ‘managerial transformation of State agencies’ and the voluntary or ‘not-for-profit sector’, discussed by writers such as Langan & Clarke 1995: 82).
Policy context of reforms in aged and community care: shifts within the State The Aged Care Reform Strategy has shaped changes in the aged care system over the last 10 years. One of the most important policy developments in aged and community care has been the planned reduction in nursing home bgds and a shift in emphasis to hostel- and community-based home care services. Other changes include a national system of regulation for residential care; community care packages 266
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delivering home-based care; the merging of nursing homes and hostels; a stronger user rights focus; expansion of brokered forms of community care; and an accommodation bonds scheme for residential care. (In terms of aged care financing, growing emphasis on service user contributions is discussed in chapter 6.) As background to these shifts, concern has mounted, both in Australia and the UK, over the burgeoning costs in aged care related to growing numbers admitted to nursing and retirement homes. Similar to other deinstitutionalisation movements of the mentally ill and the disabled, government policy has been driven by the twin objectives of the social benefits of maintaining people in the community and of cost savings from transferring care of the frail and dependent aged from residential care to care in the community. With aged care, this concern is magnified in light of population projections of absolute and relative growth of those aged over 65, from 10.5 per cent of the population in 1991 to 22 per cent in 2041; with the proportion aged 80 or over more than tripling, from 2 to 7 per cent (AIHW 1995: 179). However, inferences that those over 65 represent a drain on the public purse require closer scrutiny. The more crucial variable is the proportion aged 80 or over, who are at greater risk of illness and infirmity. Contrary to prevailing arguments of the projected drain of aged care on welfare and health systems, various surveys over time put the age-standardised prevalence rate of ‘profound or severe’ disability (used to establish dependency among the elderly) at 17–18 per cent averaged over the 65-plus age groups. This ranges from 6.2 per cent of men and 8.4 per cent of women aged 65–69 to 51 per cent of men and 59 per cent of women aged 85 and over (AIHW 1995: 181). The important factor is that the number of Australians aged over 80 will more than double in the decade from 1986 to 2006, with their proportion of the population growing from 2 to 4 per cent (AIHW 1997a: 241). The other salient point is that gender combined with age is an important determinant of the likely need and use of formal and informal care. Older women are more likely to enter residential care than older men—a probability of 0.76 for women and 0.48 for men aged over 80 (AIHW 1997a: 251). This reflects the fact that older men are more likely than women to have a spouse who will care for them at home. 267
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It is perhaps not surprising that aged and community care is the test case for implementation of more efficient and privatised solutions in welfare state arrangements. This is due to political concerns—evident in most countries but most clearly articulated in Europe, the UK and North America—that the population is greying and that costs to the State will escalate. In Australia, the care lobby is dominated by the private for-profit health/care sector, which largely supports private solutions to the costs of care. Behind national schemes for aged care policy reform and local innovation, basic shifts in welfare policies are evident. Evers (1991: 1–11) summarises these patterns of change as follows: Shift from standard to flexible services. Most personal services developed over the past decade have followed consistent patterns of development and production. Care services for older people have been highly standardised, as for example in nursing homes, seeking not only to guarantee rights and equality but also efficiency through uniformity and a growing division of tasks between different health care professions. However, social developments have bgen characterised by individualisation, diversification of needs and demands and a rising complexity of tasks, along with growing demand for longterm care. Home care is becoming increasingly emphasised, requiring flexible arrangements. The challenge of strengthening home-based care is part of a larger, post-welfarist agenda. The patterns and characteristics of the ‘standardised product model’ will be replaced with flexible home-based services. Shift from implicit to explicit interaction with informal care systems. Traditional systems of health services take existing informal (women’s) support networks as an implicit presupposition. Formal services are meant to form a substitute when informal networks break down. This involves a greater acknowledgment of the informal sector’s central role in care work, and redirects policy and practice toward strengthening home-based care for older people. Attention is therefore given to the problems, opportunities and resources for informal care, such as, in the Australian context, carers’ policies and initiatives and the Commonwealth government policy of Home and Community Care (HACC), discussed later. 268
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Shift from bureaucratic centralism to regulated pluralism. Monitoring changes in the division of tasks and responsibilities between public and private sectors is central to understanding the growing ‘mixed economy of welfare’. This new ‘welfare pluralism’ is characterised by an interaction and balance of responsibility between four strategic areas: the public system; commercial for-profit agencies; voluntary agencies; and the community, including families and households. Evers (1993) argues that what is innovative in this mixed economy is not the forms and qualities of the care provided so much as the ways these agencies try to strengthen or combine services. Shift to integrated social and economic criteria. Traditional service systems have usually been constructed in terms of a one-dimensional need/demand orientation. State-funded systems are financed through political decisions about the global amounts of resources to be spent. There are well-known, considerable political constraints and inbuilt injustices when one tries to use global financial ceilings or cuts. When financial austerity and the search for more varied service outcomes coincide, then traditional universalist assumptions about access, equity and so on may be threatened or undermined. Langan and Clarke (1995: 83) refer to the ‘care gap’ bgtween levels of need and available services, and to the game of ‘pass the parcel’ where the gap between needs and resources is devolved from government to care managers. These welfare state shifts to a market model represent major changes in the provision of health and care services, which are linked to broader public policy shifts at national/international levels and to similar reforms in education, housing, health and social security. In essence, there is a shift in the balance of care from the State to increased private, voluntary and informal participation—what amounts to a growing expectation that families and individuals will take responsibility for the full range of needs. Evers, as representative of mainstream ‘malestream’ policy debate, focuses on the State’s need to supplement and support women’s responsibility to care. Commenting on the UK context, where reforms in aged and community care in the 1980s and 1990s closely parallel those in Australia, Dalley (1996: 18) argues that government policy 269
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is based on the presupposition that ‘women are naturally carers’. While competition may bring ‘value for money’, flexibility and ‘choice’, this may be at the expense of quality service outcomes and respect for rights and entitlements (such as access and equity considerations), service reliability, standardised quality and geographical availability, of home and community care. The State’s reliance on women’s unpaid caring overlooks changes in the structural context of care, such as women’s increased participation in paid work, the fragmentation of the nuclear and extended family with higher divorce rates and mobility, and what some writers refer to as the caring ‘crisis’ or ‘the community care crunch’ (Langan & Clarke 1995: 83), where care services are increasingly under attack and there is a shortage of women willing and/or able to provide them.
Women and caring work Mainstream discourses referring to care and the informal network of caring have, until recently, overlooked the gendering of care work. Caring refers to the mental, emotional and physical effort involved in looking after, responding to and supporting others (Waerness 1984). Dalley (1996: 13–14) observes that because the two aspects of care—‘caring for’ and ‘caring about’—closely coalesce in motherhood, caring comes to bg viewed as part of women’s nature; for men, it is accepted that ‘caring for’ and ‘caring about’ may be separated. This, she argues, leads to confusion between biological and social reproduction in the domestic sphere, which is then reproduced in the public sphere. In our society, most caring work is done both informally and formally, in private and in public, by women in varying forms throughout their lives. It is done as mothers, daughters and wives in the context of individual relationships, in the community as volunteers, through the female-dominated professions of nursing, social work and teaching, as low-wage workers in hospitals, child care centres and home carg services (Cox 1995). While it must be recognised that caring work is also undertaken by men, this generally involves less onerous, lighter tasks, and is concentrated in older men caring for their spouses (Dalley 1996). 270
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Women’s caring, Dalley argues, is more frequent, more onerous, more prolonged, and concentrated at the ‘heavy’ end of care (Arber & Ginn 1995). Caring, emotional and physical work done primarily by women and focused on meeting the needs of others has both emotional and material consequences (Pascall 1986: 71). Notably, the diverse forms of women’s caring work are largely invisible and thus are not considered part of our current definitions of labour, gross national product, leisure and parenting. Similarly, an understanding of the complexities involved in caring and its accompanying costs and benefits has not been incorporated in the design of our social policies and formal services, nor has it been reflected in our expectations about families (Bryson 1992b). Bryson distinguishes between ‘benefits’ and ‘disbenefits’ for members of society in relation to government outlays and the State’s actions or failure to act. Women, she argues, suffer intangible ‘disbenefits’ from their association with home, caring and the private sphere, because these activities are not valued as highly as those in the public sphere. Indeed, Pateman (1989) has argued that the very dichotomy of public and private serves to disadvantage women, because it implies that the spheres are separate and this allows a privileging of the public domain, where men are dominant, to bg seen as more important. Caring as human service work or ‘people work’ is not recognised as ‘work’ (Pascall 1986: 70). Finch and Groves (1983) suggest that caring involves both love and labour, and it is precisely this combination that underlines its conceptual complexity. The provision of comfort and nurturing to children, an elderly mother or a disabled child is arduous work (James 1992), but it is usually undertaken within a network of personal relationships in which affection can be mixed with resentment and intertwined with norms of family responsibility and obligation (Bowman & Moore 1994). Because caring is provided in the context of a supposedly freely entered relationship and regarded as ‘natural’ for women, the labour involved is not acknowledged and is rendered invisible. Rosenmann (1993, 1995) claims that women in families provide 80 per cent of unpaid care in the family and community, but that this often goes unrecognised. Thus, care-giving work continues to be women’s work, underpaid and devalued. Graham usefully rgminds us that ‘we must begin our analysis by recognising that caring defines both the identity and 271
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activity of women in Western society’ (1983: 30). Stehlik (1993) argues that an understanding of why the messages of caring are directed at women involves an appreciation of the inextricable links between socialisation, patriarchy, and the relations of family and labour in advanced industrialised societies. Pateman (1988) and Orloff (1991) have discussed the ways the State regulates gender relations in the family and the labour market. Gender relations are shaped by a range of structures and processes resulting from the sexual division of labour within the household and in the paid labour force. Feminist work on social provision is concerned with the extent to which the State can bg ‘women-friendly’, to use Hernes’ phrase (Hernes 1987: 120), or its opposite, the extent to which it functions to reproduce male dominance (Orloff 1992: 2). Even in countries with well-advanced welfare states, the bulk of caring is still performed in an unpaid capacity by women. The idea in Nordic countries that unpaid caring has been replaced by social care performed by different kinds of welfare professionals is a common misunderstanding (Johansson 1991). Even when the percentage of women working full-time is high, the infrastructure of caring consists of women’s unpaid care at home, in kinship relations and in informal settings. It is widely argued that when the concept of community is used in connection with welfare provision, it is actually a synonym for family. Furthermore, ‘family’ is usually a code word for women (Bryson & Mowbray 1984), as is ‘community’. The market economy’s emphasis on the ‘productive’ value of men’s (paid) work has helped to obscure the significance and visibility of ‘women’s (unpaid) work’ and has contributed to the emergence of a nuclear, autonomous family model dependent on the wage of a male ‘breadwinner’. Historically, women were not expected to bg primary breadwinners, although there were periods, such as World War II, when women were needed in the paid labour force. Many women have always been the family income-earner. However, the view of women as temporary workers, working for ‘pin money’, is still used to justify their relegation to the low-paid and insecure secondary labour market. Typical of OECD countries, the Australian labour market is sexually stratified: more than half the women who work outside the 272
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home in Australian industries are employed in three service industries; women’s work is different from men’s work; women tend to work alongside other women in ‘women’s industries’; women are neither promoted as much as men nor are they to be found in as great numbers in the professions or in management jobs, where they are grossly underrepresented (Probert 1995); and women’s waged work is often part-time—80 per cent of part-time workers are women workers, and most women work in the services sector (DEET 1995). Paid work is undertaken in addition to coping with care responsibilities at home; 60 per cent of married women in Australia are in the paid labour market (two-thirds have dependent children); and 30 per cent of women workers have children under five years of age. Approximately 60 per cent of women aged between 35 and 64 were likely to support and care for older relatives and family members with disabilities; 25 per cent of this group had an older person/person with disabilities living with them; and 10 per cent of all working women were responsible for the care of at least one older or disabled person (DEET 1995; Rosenmann 1993). From these and other studies, it is abundantly clear that women as dual-role workers carry a double burden.
The State’s dependence on women as carers in the private sphere As observed by the Australian Institute of Health and Welfare (1996: 190–3), community informal networks, friends, relatives and older people themselves play an important role in maintaining older people in the community. This is born out in the finding that only 35 per cent of 227 400 people over 65 living in the community (assessed as having a profound or severe ‘disability’) received some sort of government assistance. A later report has confirmed that about three-quarters of the over-65 groups classified as having a profound or severe disability needed help with five or more activities. However, the vast majority of assistance is provided by informal carers (with 80 per cent specifying informal carers as the providers of personal care, mobility, communication, meals, financial management and transportation), which probably reflects the fact that capacity to 273
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remain in the community is largely dependent on high levels of informal care (AIHW 1997a: 247, 252). Work in home and community care services is quintessentially women’s work in a woman’s world. A recent home care study (Moore 1995) reveals that care staff look on their work as similar to that of a housewife and often describe it as an extension of their own home care tasks. Service-users in the study talked of home care staff as ‘surrogate members’ of the family. Wages in home care are low and are being reduced, as services are contracted from the public to the private sector (an hourly wage rate reduction from $12 to $9.50 per hour occurred in Victorian services; Moore 1995). The work is viewed as unskilled, although it is actually multiskilled, and emotionally and physically taxing. Training is often minimal or non-existent and there is no scope for promotion. Most staff work part-time or as casuals. Most are middle-aged women workers, the majority have dependent children, and almost 20 per cent have care responsibilities for older or disabled relatives. Work in home and community care is firmly predicated on dual-role workers, and home care staff are mainly women in their middle years, with greater domestic responsibilities than the average working woman (Moore, 1990; Watson & Mears 1996). Land has examined the relationship between employment and income for these dual-role women workers (1991), describing them as women who ‘often have a fitful and often exploited experience of the labour market’. For many home care workers, paid employment raises their family income out of poverty or near-poverty. High unemployment, as well as the need for married women with children to work part-time and near to home, largely explains why disproportionate numbers are in stressful and tiring jobs with low weekly earnings. Their responsibilities are heavy, adding, to a full-time unpaid job as housewife, mother and carer at home, a poorly paid job at work. Both in institutions and in the home, caring for disabled people is in large part a matter of what James (1992) refers to as ‘bed-andbody work’. It involves routine and often heavy physical work such as lifting people, unpleasant jobs such as care of the incontinent, and ‘housework’ such as bed-making, laundering and room-cleaning. Care of the mentally disturbed or confused may pose the added 274
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burden of constant supervision. A guide to caring for Alzheimer’s sufferers at home, for example, is entitled ‘The 36-hour day’. In nursing homes and hospitals this work is performed by nurses and aides, almost all of whom are women. In the private sphere primary care-givers are women: wives, daughters and other female rglatives of the aged (Kendig et al. 1983: 151) and the mothers of disabled children. The amount of care provided by female relatives to the physically and mentally disabled elderly overwhelms that provided by the public sector. A British study by Russell (cited in Langan & Clarke 1995) found that six times the number of such people in nursing homes are cared for at home by relatives, mainly women. In Australia, the primary providers for older people with disabilities are spouses (mainly wives to husbands) and daughter carers (Bowman & Moore 1994). Women have provided and continue to provide at least 80 per cent of care and 90 per cent of aged care, in the form of unpaid domestic and caring labour for their chronically ill relatives (Kendig 1986, Kendig et al. 1992; Bowman & Moore 1994). Community services provide minimal support to family carers. Although the ‘average’ elderly home care patient living with her family may be more disabled than the ‘average’ frail older person living alone, two of the main forms of domiciliary care—home help and meals on wheels—are often not available to people living with relatives. British evidence suggests that local authorities manage care rather than provide it, that the bulk of service provision goes to those who live alone rather than those living with others, and that there is minimal service support for carers (Parker 1990, cited in Pascall 1997: 92). With regard to pay for such work, paid care schemes are focused on supporting women under the greatest stress with some small monetary benefits (Qureshi 1990). They are experiments into how women who care for their relatives or other dependent people are willing to continue caring if they are provided with a small amount of money. The Howard government renamed the Carer’s Pension the Carer’s Payment, in part as a reframing and revaluing of carers’ personal and social contribution (Carers Association of Australia 1996). However, Bowman and Moore’s (1994: 4) study noted that 275
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many Australian carers would rather have it increased and called a ‘Carer’s Wage’, to reflect the work involved and nature of the payment. Women, then, provide the bulk of care for the chronically ill and they do so unpaid or under the conditions of a working-class employee. Of central significance to this argument is the fact that both domestic labour and volunteer work is work, although it may be unpaid. These forms of work are of considerable economic benefit to the nation and to gross national product, as they provide social welfare services that would otherwise have to be provided by the State. Rosenmann (1994) has costed the ‘saved’ State contribution in Australia at $6 billion in 1994, a conservative economic costing. As the women who perform these tasks do not constitute an organised political force, they cannot make effective claims on the State for more resources. At the same time, their provision of unpaid care allows the State to minimise its expenditure on community services. The cost to carers is often considerable. Economic costs include lost earnings and additional expenses, among many others (Rosenmann 1994). Over one-third of Australian carers give up paid employment in order to look after an elderly relative (Office of Disability 1995). There are the costs of providing extra heating, transport, laundry, food, aids such as grip rails and bath chairs, and other house modifications. It is important to remember in this context that it is the very poorest elderly people who live with their adult children and, given income patterns in families, it is likely that their children will also be at the lower end of the income spectrum (Rosenmann 1994). The costs of caring may well involve pushing carers further into poverty (Bowman & Moore 1994: 7). Most chronically ill people living at home are not cared for by the ‘community’ but by their female relatives. They are not kept out of institutions by the provision of formal community services. Rather, they receive substantial amounts of women’s care—with or, more commonly, without formal support from community-based services. Although clearly of enormous benefit to many individuals, community services are inadequately resourced and unable to meet the full extent of need. Their operation does little to overcome the isolation, segregation and powerlessness of service-users and, for that matter, care-givers. 276
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Systemic denial of carers’ interests compared with dominant groups—Who gains? Drawing on Evans’ structural interests analysis (1990a), competing interests in aged and community care comprise doctors (traditionally gatekeepers of access to benefits and services); middle-level managers of aged care in State health and aged care bureaucracies; the top administrative staff of voluntary organisations; the private for-profit service-providers including nursing homes; and those with a ‘community interest’, including the fledgling carers’ movement and care clients. Administration and supervision of the aged and community care industry in all its facets rests with middle-level managers, especially doctors. In this capacity doctors have been described as ‘gatekeepers’—that is, the key interpreters of legal and administrative rules and guidelines—who control information, influence others’ decisions and determine access to services. The main official criterion for access to both institutional and community services (even meals services), as well as certain cash benefits paid to the disabled or their carers, is ‘medical need’. Many frail elderly, especially the mentally confused, do not qualify for a service in terms of strict ‘medical need’. In effect, this often amounts to a form of medical fraternity control of social problems. Similarly, payment of a minimal cash benefit for home carers of the frail aged requires a medical practitioner to certify that a patient has ‘a continuing need for nursing care’. In fact, only a minority of carers receive this allowance, in large part because it is only paid when the elderly person also receives continuing care from a home nursing service. Although motivated by humanitarian concerns, non-government aged care bureaucrats and administrators are constrained by their organisational structures and by their links to the State to seek funds for services which maximise bureaucratic control of the ‘problem’. It is these organised interests which command the largest share of public resources in home and community care. Most of the aged care budget (67 per cent in 1995/96) is still spent on residential services (the majority on nursing homes, which maintain a dominant hold on health and community care debates to ensure their overall dominance in aged care). Much of the aged care 277
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industry is operated as private, profit-making business, as is increasingly occurring with privatisation of the health and community care sector. More than half Australia’s nursing home beds are in the private sector. Home care, along with other community care services, is increasingly being contracted out to the for-profit sector, especially under local government reforms of contracting out services. The sustained profitability of the care industry is reflected in the high rate of investor involvement by doctors, accountants, lawyers and other professionals. The problem of incompatibility between profit maximisation and the maintenance of good-quality care has not been addressed by legislation, ‘since the current fee-setting mechanism and lack of competition guarantee continued profits regardless of the level of care provided, or its suitability for the recipient’ (Fine 1993: 26). The full extent of profit-making is difficult to establish because details of ownership changes, trust companies and shareholdings are often concealed (Senate Select Committee on Private Hospitals and Nursing Homes 1992). The State has responded to excessive demand on its funds from these sources by a move to ‘deinstitutionalise’ services for the aged, psychiatrically ill and disabled out into ‘the community’. It has attempted to limit growth in nursing home bed numbers and has promised higher funding for community services. This is readily perceived b{ most people as a ‘good thing’. After all, to question the value of ‘community care’ would imply that institutional care is preferable, and no-one likes the idea of institutions. In terms of shifts to a market state, the interests of the medical profession do not appear to be threatened by deinstitutionalisation, contractualism and privatisation, as doctors continue to perform a gatekeeping function on access to services and continue to provide medical services on a fee-for-service basis. Managers of aged care in government and voluntary sectors maintain power through contractual overview and competitive tendering, and the for-profit nursing home sector maintains its dominant pull on the aged care budget. Among those likely to bg adversely affected by these changes, however, are women whose unpaid or poorly paid labour continues to underwrite the whole system. What is involved in such moves is that the real cost of care is further transferred from the State to individuals, who are predominantly women.1 278
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Although women perform most of the day-to-day manual labour of caring, they are not ultimately in control of vital resources and decisions on which their own welfare and that of their charges depends. This is just as true of unpaid workers in the ‘community’ as it is of paid staff in institutions. In the 1990s, the fledgling Australian carers’ movement has bgen formalised by government and has subsequently mushroomed.2 Through links with service-user groups and adroit political lobbying and advocacy, the carers’ movement is developing into a key national and state level consumer group in community care policy and practice. A belief that the costs of providing care are far less in the home than in institutions underpins government policy. Yet there has been remarkably little effort to test this assumption and little interest in properly costing women’s unpaid care. Furthermore, what evidence we have casts serious doubt on this, especially with respect to good-quality care. The low costs of home and community care continues to be dependent on women’s caring in the home, and aged care policy is implicitly dependent on women in families.
Assessing the impact of restructuring the welfare state: HACC and privatisation Substantial overhaul of the aged care system—the Aged Care Reform Strategy—began to bg implemented in the 1980s, and changes have been considerable. The Report of the Nursing Homes and Hostels Review (Department of Community Services and Health 1986) unequivocally recommended substantial restructuring of aged care services, highlighting excessive concentration on institutional care, failure to develop adequate assessment procedures, lack of coordination between various levels of government, and inefficiency of the prevailing funding mechanisms. After the mid-1980s, a series of committees was set up: the McLeay Committee (House of Representatives Standing Committee on Health Expenditure 1982), the Senate Select Committee on Private Hospitals and Nursing Homes (the Giles Report 1981), the Joint Review of Hostel Care Subsidy Arrangements (1984), and the Joint 279
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Review of Nursing Homes and Hostels (1985). The Aged Care Reform Strategy, within the broader context of the Commonwealth government’s Social Justice Strategy, emphasised access, equity and participation. The HACC program, announced in the 1984/85 budget, aimed to substantially improve the quantity and range of services available to the frail and disabled aged living at home. The period from 1985 has seen the restructuring of residential care in Australia, with further projected longer-term shifts in emphasis— from the provision of 49.5 nursing home beds and 41.4 hostel places in 1996 per 1000 people aged 70 and over, to estimates for 2011 of 40 nursing home beds, 50 hostel places and 10 community aged care packages (AIHW 1997a: 261).
The Home and Community Care program Combined Commonwealth and state government expenditure on HACC services has more than quadrupled, and the range of services has expanded beyond traditional home nursing, home help and meals services to include centre- and home-based respite care, gardening, and home handyperson assistance. Most significantly, younger people with disabilities were included as a target group. Initially, HACC was conceived as the vehicle for the coherent planning, financing and delivery of a range of home and community-based support services, with its target group operationalised according to ABS definitions of persons with a ‘moderate, severe or profound’ disability (AIHW 1997a: 246). It was a key component of the Commonwealth’s Aged Care Reform Strategy—a 10-year plan for the restructure of services for older people—and relied substantially on a partnership model of government funding reliant on existing (women’s) informal support networks. Commenting on similar reforms in the UK, Dalley (1996: 5) refers to the consensus struck by policy-makers, planners, professionals and academics in relation to community care as ‘ideological corporatism’. In both Australia and the UK, aged and community care have emphasised the centrality of the family. As Dalley (1996: 11) comments, ‘the family, it is believed, has a moral duty to care’. HACC provides a pertinent case study of the impact of welfare state shifts, in the context of lack of significant transfer of resources 280
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with deinstitutionalisation and early discharge from hospitals (Kumrow 1994). Similar to the 1980s UK reforms in aged and community care, Australian reforms emphasised family-based care provided in the home. Dalley sees the shift in the 1970s and 1980s in the British context, as a shift in resources from the acute care sector and NHS-provided facilities and services to ‘expensive care within the private sector or no care at all’ (Dalley 1996: 25). In Australia, this shift is from governments to those doing the caring (Turner 1997: 31). The HACC program exists in a very different policy environment from when it was introduced. The program has not delivered the promised growth, due to lack of appropriate funding and to changes under contracting out. The states have not met the matching requirements and the Commonwealth has continued to reduce its allocation (Kumrow 1994: 38). The Commonwealth is committed to retaining a growth rate of 6 per cent per annum in HACC funding, but this is partially funded by higher user fees (AIHW 1997a: 259). HACC illustrates the way that shifts to integrated targeted access to programs may undermine universalist assumptions about access and equity. Prior to the introduction of HACC in Victoria, a range of community support services was provided through generic agencies, such as councils, non-government agencies and district nursing services. These services had evolved largely in response to local circumstances since the 1940s, and were ‘universally available’. HACC specified its target group as frail older people, disabled younger people and the carers of these people. It specifically excluded, or allocated to a ‘no-growth’ category, other groups which historically had had access to other community-based services. Under HACC, funds are targeted to those at risk of admission to residential care (Kumrow 1994: 38). The use of tighter targeting strategies is now a key feature of community care. The Australian Institute of Health and Welfare (1997a: 249–50) estimated that 128 000 people in the ‘mild need’ category, 12 700 in the ‘not determined category’ and 10 600 in the ‘no handicap [sic] category’, aged over 65, required assistance but did not get it for group 2 activities (moving around, home help, meal preparation, taking medicine or dressing wounds, financial management or shopping). Beilharz et al. (1992) showed that the experiences of HACC serve as a useful illustration of a number of policy concerns. HACC both 281
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illustrates the move towards greater strategic control at the centre, and the complications and potential hazards of service rationalisation in a climate of cost cutting. Much effort was spent on creating organisational linkages, rules, and new forms of accountability and coordination. Important players and sources of funds had to be related to one another; consequently, efficiency often ceased being a means to an end or became the end, consuming attention and resources. Clearly, tighter targeting is leading to greater gaps in the net, and to those clearly in need missing out on services. Transposed on these changes is the shift from local council or non-profit organisation towards private (for-profit) providers, under policies of contracting out. This has the consequence of distancing service users further from the source of funding and policy setting (government). One Victorian study cited problems of service costs and access; lack of information; lack of regional co-ordination; lack of consultation with service users; lack of mechanisms for complaints about services and inadequate mechanisms to cater for non-English-speaking carers and service users. Unlike New South Wales, Victoria lacks a Patient Support Office to assist with complaints and supports for service users (Turner, 1997).
Privatisation, contractualism and quality of care Unlike residential care, where the private for-profit sector has traditionally played a major role in service delivery, until recently community care services have been delivered by the public, not-forprofit sector, with a mix of government funding and heavy reliance on the contribution of informal care provided by family members (women) and the non-profit sector. With local government as a major traditional provider of home care services, there is concern about the impact of local government restructuring and the introduction of contractualism (especially in Victoria, where in excess of 50 per cent of services were contracted out by June 1997 under local government compulsory competitive tendering (CCT) reforms). Contracting out raises issues of variations in standards, commitment and quality of care, as state government funding flows to local government, which then outsources service provision. Contractualism 282
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may also shift the goalposts in relation to quality of care, with the erosion of the once essential building blocks of service quality (integration, cooperation, support and a philosophy of public service and communal benefit). As a Victorian evaluation (Ernst, Glanville & Murfitt, 1997: 16) found, those involved in local government level service delivery noted the adverse impact on quality of care, loss of service capacity, pulling people off line to participate in contract specification and the use of lower standard private sector staff rates, training and supervision benchmarks. Contractual agreements rely on pre- specified outcome measures and performance appraisal, which often favour easily measured quantitative dimensions. The Australian Institute of Health and Welfare (1997a: 276) recognises the difficulty of devising clearly specified outcome measures in the aged care area, given the varied client mix, the range of chronic and acute conditions, and varied formal and informal sector services. At other levels of government, it is evident that both the Commonwealth and state governments increasingly favour privatisation via private sector approaches, including contracting out, separating purchaser from provider, the encouragement of a multiplicity of providers and the development of a competitive culture in accordance with National Competition Policy. It is assumed that such privatisation will deliver a reduction in possible conflicts of interest bgtween purchasers and providers of services, cost efficiencies and better value for money alongside increased flexibility and consumer choice, as outlined in Everyone’s Future Victoria 1993 (Department of Health & Community Services 1993). In 1993 the National Health Strategy issues paper, Pathways to Better Health, canvassed a market-based range of options on this subject, arguing in favour of selective use of market mechanisms (sometimes referred to as internal markets or managed competition) and competition between service agencies to provide the specified services within the set pool of funds. Empirical evidence is not there to support claims that privatisation and contractualism will result in better outcomes for carers or for those being cargd for, and there is concern about its impact on such areas as aged and community care services (Moore 1997). Preliminary findings from the RMIT (1997) Compulsory Competitive Tendering (CCT) Research Project, on mainly women carers and service-users of local government aged and disability services in Victoria, found 283
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that contracts have bgen won at the expense of workers’ wages and conditions; there were minimal public consultations regarding the introduction of CCT; some councils are referring clients to private (fee-paying) services, which clients say they cannot afford; finally, some services have been reduced to the ‘lowest common denominator’, with a reduction in the ‘less tangible human care and concern’ and social support aspects of services. Questions raised more generally by contractualism in aged and community care include a number of fears and concerns, including whether:
• a plurality of providers operating in a competitive environment will create better outcomes for consumers/service-users;
• contracting out services will further limit, rather than expand, • • •
•
• •
consumer choice;3 such changes will affect equity, access to and affordability of services, with tighter targeting, commercial rate charges for services and exclusions from subsidised services; the notion of a competitive market in aged and community care is a flawed concept; the multiple interpretation of ‘purchaser’ in purchaser/provider relationships will cause confusion and be counterproductive to more efficient and equitable outcomes. Government departments as funders of services become purchasers to case management or brokerage agencies in the purchase of services from other providers (Municipal Association of Victoria 1993); competing to secure contracts and employment under casualised work agreements will undermine work conditions and pay for aged and community care workers (contractors have been able to offer the same services as before, for less, by reducing workers’ pay and conditions, such as eliminating overtime and penalty rates); commercial ‘for-profit’ corporations (perhaps overseas-owned) will dominate the market, resulting in a decline of service quality in the longer term, once their market share is secured; contracting out in the community care sector will lead to fundamental changes in the relationships between statutory and voluntary sectors, thus changing from a partnership model to a
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• • •
•
•
competitive, customer–contractor model (as in domiciliary care in the UK; Booth 1990); contractualism to the for-profit sector will undermine voluntarism; growing commercialisation of services will erode the ‘collective good’ and ‘public stewardship’ functions central to the meaning of government (Ernst 1993); the competitive environment will encourage a takeover by managerialism, to the detriment of ‘care’, with managementdominated facilities and services intruding an ‘alien ethos’ of business culture on the world of care (Langan & Clarke 1995: 73); ‘outsourcing’ of community care will result in a loss of ‘corporate memory’ of local needs, networks and services, when local providers lose tenders to outside corporate providers; especially, where local councils feel they already carry a substantial part of the burden of service delivery (Municipal Association of Victoria 1987: 8) and where local government is the main care service provider (Cochrane 1993). the current rush to privatise local, state and national health and community care services on communities, workers and serviceusers; will have a detrimental impact predominantly on women.
It is increasingly the case in Australia that those with lower needs in the context of tighter targeting and priority-setting are being excluded from subsidised care services, and will have to pay commercial rates, do without, or rely on the availability and willingness of unpaid help from families and friends (Bowman & Moore 1994; Moore et al. 1995). What, then, of all those who could be categorised as ‘disadvantaged’, due to disability, advanced age, poverty, inadequate housing, lack of family and social support and lack of ability to pay for privatised care?
Conclusion Today, with general interest in cost-cutting, we find a renewed interest in non-government and private services (Evers & Svetlik 1993). This is evident not only in countries such as Britain and 285
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Australia, where the welfare state is undergoing transformation, but also in Nordic countries, which have managed to maintain a strong public service provision orientation. Everywhere there is a general growing emphasis on ‘community care’—a reliance on networks of largely women carers, paid, underpaid and unpaid, alongside an associated system of State-regulated ‘voluntary’ and for-profit organisations. While over recent decades, under pressure from the women’s movement, some recognition has been afforded to women’s caring work, there is widespread evidence everywhere that as governments seek fiscal economies more responsibility falls back on women, both within the family and in the wider community. There are critical shifts in care service provision arising from competition policy and a preoccupation with efficiency, tighter targeting of services and value for money. These trends have significant implications for women as workers, carers and as care service users. It is critical to understand the restructuring of the welfare state not only as a neoliberal response to the crisis of the State, or as a shift away from universalist assumptions of access and equity in service provision to prepare the ground for a post-welfare state formation, but as a reflection of challenges and accommodations to balances of power around class, race and gender. In some areas of conservative social policy, such as the 1997/98 Coalition’s child care and child support scheme reforms, there are clear attempts to reassert traditional family values (Hancock 1998). The growing role of the private for-profit sector, as a result of the current and growing rush to privatise local, state and national health and community care services, is another major concern. The costs and perceived benefits for communities, workers and serviceusers, all predominantly women, are as yet largely unknown. Neglect of the issue of caring, and its gender component, must be understood as part of the general acceptance of the naturalness of the traditional sexual division of labour. This is compounded by the low status afforded much care work, which renders it invisible to those who frame the debate. Feminist critiques have, however, positioned caring labour as part of the debate about the nature of women’s subordination and, significantly, caring becomes a funda286
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mental concern in the determination of the sort of society that feminists strive to attain (Cox 1995; Dalley 1996). If we take aged and community care services as an example of major policy intervention in the 1990s, they appear to play out contested issues in the field of welfare more generally. Principally, these include: attempts to generate self-help and encourage traditional roles in the family while also introducing markets into welfare; the stimulation of the private for-profit care sector and the marginalisation of the State care sector; a shift in the power and responsibilities of governments at all levels from service provision to contracting out to private (for-profit) providers; an attempt to give service-users a say through ‘choice’ while at the same time limiting access to services through co-payments, tighter targeting and eligibility criteria; and a continued reliance on the unpaid and underpaid caring performed by women. A proper assessment of the full impact of these changes awaits careful evaluation.
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Chapter 1 1 Assessments by the Audit Commission (UK) and the AuditorGeneral (Victoria prior to late 1997 legislation) have taken this broader, public interest approach. 2 Lenaghan (1996: 33) cites the finding of US academic Eddy, Duke University Professor of Health Policy and Management, who estimated that only 15 per cent of clinical interventions are fully supported by good scientific evidence. 3 In relation to the NHS in Britain, Lenaghan (1996) suggests mechanisms such as national guidelines, a code of practice setting out a framework of rights and a guide to professional conduct, national monitoring, the pre-eminence of clinical need as a criterion of provision of appropriate health care, procedural rights in provider/patient interactions, appeals mechanisms, and public participation in decision-making.
Chapter 2 1 A description of the Australian health care system or the health care workforce is beyond the scope of this book. See Palmer & Short (1994) and AIHW (1996; 1998). 288
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2 Hood (1976: 6) argued, rather idealistically, that implementation could be studied by analysing the conditions for ‘perfect administration’. These are: (1) making sure the administration system is unitary, with a single line of authority, like an army; (2) there must be uniform norms or rules in the administrative system; (3) the objectives must be implemented and there must be perfect obedience or perfect control; (4) there must be perfect information and communication; and (5) there must be adequate time in which to act, and an absence of time and pressure. Similarly, Gunn (1978) noted 10 preconditions for perfect implementation: no crippling external constraints, adequate time and resources, a suitable combination of resources at each state, a valid theory of cause and effect, direct links between cause and effect, a single implementing agency (or at least a dominant one), understanding and agreement on objectives, a detailed specification of task to be completed, perfect communication and coordination, and perfect obedience. Although part of the oft-cited literature on implementation, these preconditions serve more as a wish list in the light of finite resources and growing knowledge about organisational behaviour and leadership styles. 3 Lukes’ analysis was a response to the 1960s and 1970s: the community power studies in North America were the site of debates by writers such as Dahl and Bachrach and Baratz about the nature of power and ways of analysing it. Briefly, Dahl (1957; 1976) sought to measure power precisely, along the lines that the power of A could be measured according to the response of B. Bachrach and Baratz (1962) criticised the limitations of Dahl’s analysis and added the concept of ‘non-decision’ to this focus on the analysis of power in terms of concrete acts of decisionmaking. As Clegg (1989: 11) observed, ‘(p)ower might be manifested not only in doing things but also in ensuring that things do not get done’. 4 On Marxist theories of the state, see Held & Kreiger (1984), Head & Bell (1994); on feminist theories of the state, see Pringle & Watson (1990), Watson (1990), Burton (1985), Franzway et al. (1989); on statism, see Bell & Head, (1994a) Proponents of statist theory see the state as an autonomous actor, not necessarily influenced by the interests of any dominant class—more by its 289
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own agendas and interests which may coalesce with those of dominant state elites and government officials (Pusey 1991).
Chapter 3 1 The term entrepreneurial government has gained general currency, and is used by McKenna (1996) and Moss (1997), the Ombudsman for New South Wales. 2 Others defended managerialism, with Cullen (1986) arguing in favour of a Senior Executive Service trained in management skills using a performance-based approach. Keating (1988) extolled the virtues of new management approaches in public administration, and Wilenski (1988) dismissed critics as university academics not directly involved in public administration. 3 These include at Commonwealth and State levels: • selling off corporatised government-owned enterprises (e.g. public utilities) to private consortia; • increased contracting out of previously government-provided services, resulting in growing private sector provision of public sector services; • downsizing the public sector (e.g. loss of hospital beds and staff); • lowering of government spending per person on education, hospitals, family and child welfare, to levels lower in Victoria than other states (Hayward 1996: 3); • introducing the purchaser/provider relationship between government and its departments and between and within departments, as well as between government and the private sector, based around contractual agreements; • consolidating federal portfolios down to 13 and then eight; • changing the basis of public sector employment with the Public Sector Management Act 1992 and the Employee Relations Act 1992 in Victoria; and the Workplace Relations Act 1996—which brought a weakening of collective bargaining and an ‘individualising’ of the employer/employee relationship. This was effectively a shift from compulsory conciliation to private contracts between employers and employees. 290
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•
complete reorganisation of the network of Melbourne hospitals, including closures of smaller community hospitals in the suburbs, downscaling larger inner metropolitan hospitals through funding reductions and establishing new hospitals in outer suburban locations. Coordinated care refers to a designated person or agency (GPs, etc.) working to identify and arrange the care and support most appropriate to needs in high need (and thus, expensive) groups (Barnes 1996). 4 These include: • the sacking of elected local councillors (replaced by appointed commissioners in newly amalgamated councils to implement local government reforms, based around compulsory competitive tendering of 50 per cent of council business by 1996); • the abolition of the Law Reform Commission of Victoria, an independent review mechanism; • amendments to FOI legislation that increased fees (introducing charges for members of parliament and expanding the definition of exempt documents); • the banning of compulsory unionism, introduction of individually negotiated employee/employer agreements and replacement of the Industrial Relations Commission with an Employee Relations Commission (see Alford & O’Neill 1994: 10, 24); • moves to reduce the powers of statutory authorities such as the Office of the Public Prosecutor, traditionally associated with independence and separation of powers; • new legislation to enable some of the auditing tasks of the Victorian Auditor-General to be contracted out to private enterprise, thus treating review as a normal function of government subject to ‘the competition test’, rather than as an independent watchdog on the integrity of government. • the replacement of the independent Public Service Board by a Commissioner, with extensive powers now vested in the Premier, including the power to dismiss senior executive staff and department heads on four weeks’ notice (Alford & O’Neill 1994: 34). 291
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5 Similar criticisms are made of New Zealand reforms (Boston 1996; Kelsey 1995; Easton 1997). 6 Stretton and Orchard (1994) outline the origins of public choice and social choice theory and the theory of public goods from postwar writers such as Buchanan, Arrow and Samuelson. 7 Boston (1996: 21) describes transaction cost analysis as ‘dealing largely with the optimal governance structures for various kinds of transactions, in particular the best way of organising the production and exchange of goods and services’. This is based on a similar assumption to agency theory—of rational choices in decision-making being made to minimise transaction costs.
Chapter 4 1 The e-mail address for the Commonwealth Department of Health and Family Services is: http://www.health.gov.au/pubs/medstats/ gencoms.htm.
Chapter 5 1 GP-style fund-holding has met with criticism from the Australian Medical Association on the grounds that it restricts patient freedom, emphasises cost rather than clinical reasons for treatment, and forces GPs into the role of rationing health care (Maxwell 1995: 319). 2 All citizens aged 65 years and over and some of the permanently disabled are covered by the federally funded Medicare. Eligibility is on a non-means-tested basis and covers some 37 million people. Some co-payments are required and Medicare does not generally cover pharmaceuticals (out-of-hospital), nor does it cover nursing home care. Medicaid is the federal/state health insurance scheme for the poor. However, under Medicaid ‘poor’ is a relative term, because eligibility is decided at State level. For example, in order to qualify for Medicaid in 1987, ‘family income had to be less than 38 per cent of the poverty level in West Virginia, 55 per cent in Maryland, but 82 per cent in New York. In Alabama, a family of four was ineligible if its income was over $1860 per 292
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year’ (Reagan 1992: 21). The states must provide a basic package of services under Medicaid, but additional services can be provided at the discretion of each state.
Chapter 8 1 A useful source of material on this topic is the Department of Administrative Services (1995) annotated bibliography on competitive tendering and contracting. For a review of recent trends in public management, see Stewart (1996). 2 For an account of quasi-markets in public management, see Le Grand and Bartlett (1993: 10). 3 Contestability refers to the maintenance of standards of ‘fair play’ in relation to the process of competition and contracting out in the public sector. 4 Exit refers to the capacity of people, groups or organisations to ‘vote with their feet’, to go elsewhere if they are not satisfied with what they are getting: it is a characteristic of market choice. Voice refers to the capacity of people, groups or organisations to express their dissatisfaction and press to get things improved: it is a characteristic of political action (see Hirschman 1970).
Chapter 11 1 Stanton (1996: 30) reports on a number of Victorian projects that have incorporated women’s health care experiences and needs into information and education to improve medical practice and procedural guidelines for best-practice and quality services for a culturally diverse society. Similarly, in New South Wales, the Women’s Health, Information, Resource and Crisis Centres Association has developed a manual of standards for Women’s Health Centres. 2 While copies of medical records from the public health system are now available to most women under Freedom of Information legislation, a recent High Court decision has affirmed that records 293
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held by private practitioners remain their personal property and are not available to consumers.
Chapter 12 1 This question was raised at a public level in Australia in 1990 with a legal challenge to designated women’s health services in that country (Broom 1994). The case hinged partly on the problem of the use of indicators of health status. 2 In a research project using the Nottingham Health Profile as an instrument to measure subjective health status, Hunt et al. (1981: 226–7) found that ‘women are more likely to report problems in the emotional and social domains [which] suggests that there is no general tendency for women to report problems more readily but rather that sex differences lie in differential ability to admit to certain kinds of problems’ (see also Mechanic 1978). 3 The need for gender-specificity, in areas outside reproductive functioning, is based on arguments about sex and gender. Sex is biologically defined, and if we assumed that biological functioning alone determines the differences bgtween men’s and women’s experiences of their bodies we would only need specific data for women in reproductive areas. Gender refers to the cultural, social, temporal and political construction of men and women. Adopting a gender perspective rather than a sex perspective has profound implications for health and the type of information we need to assess women’s health. Broom (1994: 46) argues that ‘a woman’s body has been constituted throughout her life through distinct psychic and cultural processes that do not cease to apply simply because the organ in question is also present in male bodies’. 4 The same case can bg made for population-based cholesterollowering campaigns, as the scientific data supporting the need for such campaigns is now seriously disputed (Hughes 1994). Similarly, the ‘untoward effects’ of such campaigns systematically affect women more than men (Eckermann 1994), given that women make up 90 per cent of the diagnosed cases of ‘anorexia nervosa’ and ‘bulimia’ (Ben-Tovim & Morton 1989). 294
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5 Use of indicator depends on the issue at hand. DALYs and QALYs address different aspects of health, largely because of divergent rationales for gathering the data. DALYs are assessed for comparative purposes on a population level to gain a global picture of differential burdens of disease across regions, age groups, gender and type of disease or injury. The DALY measure is derivative of conventional indicators of mortality and morbidity, and involves objective assessment of illness status and degree of severity of disability. Some QALYs combine objective and subjective assessment of health, wellbeing and quality of life, others concentrate on subjective evaluation. They are used to assess health status and for outcome evaluation on an individual basis as well as on a population level. 6 Bowling’s (1991) review of over 50 QOL scales mentions gender differences only five times.
Chapter 13 7 Rochefort (1996), for example, describes how during the nineteenth century mental hospitals in the USA and Britain were better developed than those in the general system, but in the late nineteenth century psychiatry found itself marginalised. 8 This is not confined to mental health but affects also the community health sector in general. For a defence of economic rationalism, see James et al. (1993). 9 Principle 1.5; this includes the rights set out in the International Covenant on Civil and Political Rights and the rights recognised in the Declaration on the Rights of Disabled Persons (United Nations 1966, 1975).
Chapter 14 10 Illustrative of the transfer of service from institutions to the community is the UK fall in hospital beds for elderly patients, from 56 000 in 1982 to 40 000 in 1992 (Dalley 1996: 7). 11 Carers adopted a ‘user rights’ strategy over the period 1989– 91, involving both residential and community care programs. 295
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These included a Charter of Residents’ Rights, a proprietor/resident agreement and a Community Visitors Scheme in the residential sector, a Statement of Rights and Responsibilities for HACC, and advocacy services or complaints units (or both programs). 12 One UK study found that consumer choice under contractualism translated into ‘take-it-or-leave-it’ (Common & Flynn 1993, cited in Langan & Clarke 1995: 84).
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Rgferences REFERENCES
Aaron, H. & Schwartz, W. 1990 ‘Rationing health care’, Across The Board, 27(7/8), Jul/Aug, pp. 34–9. Aboriginal and Torres Strait Islander Commission (ATSIC) 1994 ATSIC Operational Plan 1993–94, ATSIC, Canberra. Aboriginal Health Council of South Australia 1994 Aboriginal Health Dreaming Beyond 2000: Our Future Is in Our History, Aboriginal Health Council, Adelaide. Aboriginal Health Development Group 1989 Report to Commonwealth, State and Territory Ministers for Aboriginal Affairs and Health, AGPS, Canberra. Alcorso, C. & Schofield, T. 1991 The National Non-English Speaking Background Women’s Health Strategy, AGPS, Canberra. Alford, J. & Considine, M. 1994 ‘Public sector employment contracts’, The Contract State, eds J. Alford, D. O’Neill & J. O’Neill, Centre for Applied Research, Deakin University Press, Geelong. Alford, J. & O’Neill, D. (eds) 1994 ‘The contract state’, The Contract State: Public Management and the Kennett Government, eds J. Alford & D. O’Neill, Centre for Applied Social Research, Deakin University Press, Geelong. Alford, J.O., Neill, D., McGuire, L., Considine, M., Muetzelfeldt, M. & Ernst, J. 1994 ‘The Contract State’, eds J, Alford & D. O’Neill, The Contract State: Public Management and the Kennett Government, Centre for Applied Social Research, Deakin University Press, Geelong.
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is this at the expense of women?’, Towards the Third Triennium, Council of Social Service, Sydney, pp. 22–9. Wilson, R. 1992 ‘Reasons for decision of the President, Human Rights and Equal Opportunity Commission 1992’, Proudfoot vs ACT Board of Health, ACT, Canberra Women’s Health Centrg, Commonwealth of Australia and others. Wilson, R.M.L., Runciman, W.B., Gibberd, R.W., Harrison, B.J., Newby, L. & Hamilton, J.D. 1995 ‘The quality in Australian health care study’, Medical Journal of Australia, 163, pp. 458–71. Wolfe, S. 1996 ‘Doctor-patient relations suffer under managed carg’, Health Matters, 11, Apr/May. Women’s Health, Information, Resource and Crisis Centres Association, 1995 Manual of Standards for Health Centres, NSW Health Department, NSW. World Bank 1993 World Development Report: Investing in Health, World Development Indicators, Oxford University Press, Oxford. World Health Organization (WHO) 1974 Community Health Nursing, Report of a WHO expert committee, WHO, Geneva. ——1975 The Definition of Parameters of Efficiency in Primary Care and the Role of Nursing in Primary Health Care, 14–18 Jul, WHO, Copenhagen. ——1978 The Declaration of Alma Ata, WHO, Geneva. ——1981 Development of Indicators for Monitoring Progress towards Health for All by the Year 2000, World Health Organization Health for All Series no. 4, second corrigendum, WHO, Geneva. ——1982 Regional Strategy for Health for All, Regional Office for the Western Pacific, WHO, Manila. ——1985 Targets for Health for All, WHO Regional Office for Europe, WHO Publications Centre, New York. ——1986 The Ottawa Charter for Health Promotion, WHO, Copenhagen. ——1988 European Conference on Nursing, Summary report, WHO, Vienna. ——1994 Progress Towards Health for All: Statistics of Member States, WHO, Geneva. WHO/UNICEF 1978 Alma Ata 1978: Primary Health Care, WHO, Geneva. Wronski, I. & Smallwood, G. n.d. Aboriginal and Torres Strait Islander Health Goals and Targets (Interim), Department of Health, Housing and Community Services, Canberra. Yeatman, A. 1986 ‘Administrative reform and management improvement: a new ‘‘iron cage’’?’, Canberra Bulletin of Public Administration, 13(4), pp. 357–61.
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——1990 Bureaucrats, Technocrats, Femocrats: Essays on the Contemporary Australian State, Allen & Unwin, Sydney. ——1993 ‘Corporate managerialism and the shift from the welfare to the competition state’, Discourse, 13(2), Apr, pp. 3–9. ——1996 ‘Interpreting contemporary contractualism’, Australian Journal of Social Issues, 31(1), Feb, pp. 39–54. Young, Iris Marion 1992 ‘Five faces of oppression’, ed. T.E. Wartenberg Rethinking Power, State University of New York Press, NY. Zifcak, S. 1994 ‘The United Nations principles for the protection of people with mental illness and the Victorian mental health system’, Human Rights, the Law, and Psychiatry: Proceedings of the One Day Seminar, 25 Mar, National Centre for Socio-Legal Studies, LaTrobe University, Bundoora. ——1997 ‘Managerialism, accountability and democracy: A Victorian case study’, Australian Journal of Public Administration, Sep, 56(3), pp. 106–19. Zussman, R. 1993 ‘Life in the hospital: a review’, Milbank Quarterly, 71(1), pp. 167–86.
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Aboriginal Affairs, 190, 191; and program budgeting, 195–7 Aboriginal and Torres Strait Islander Commission, 189, 191, 197–200, 201 Aboriginal health: influences, 188–9; performance indicators, 187–209; policy, 4; WHO indicators, 194–5 Aboriginal health services, 14, 187–209 Aboriginal Health Services and the State, 189–93 Aboriginal Medical Service, 196 Aboriginal mental health, 251 Aboriginal self-determination, 190–1, 204 access, 7, 39, 56, 98, 157, 217 accountability, 3, 9, 46, 192, 288; in contracting out, 155–9; market model, 66;
private sector, 50, 159–64; public sector, 50, 78, 159–64 acute care, 3, 56, 133, 144, 172–4, 249, 281 addiction policy, 4 aged care: contractualism, 284–5; reform in, 266–70; services, 81, 89–90, 143, 277–80 Aged and Community Care Program, 52 Aged Care Reform Strategy, 266, 279, 280 agency theory, 59, 292 AIDS policy, 4 allocation of resources see resource allocation Alma Ata, 20, 171, 231, 238 alternative therapies, 46, 88, 108–9, 220–1 Australian Childhood Immunisation Register, 80 Australian Institute of Health and Welfare, 115 335
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Australian Medical Association, 29, 36, 44, 86, 114, 173 autonomy: Aboriginal, 190–1, 204; medical, 42–7, 137–8, 259, 260; patient, 10, 93–4 Better Health Commission, 4, 21 Breast Cancer Screening Program, 81 broadbanding; in funding, 3, 52–3; of programs, 80 bucket funding, 3 Burdekin Report, 247–63 passim care for aged see aged care carers, 15, 265–87; burden on, 56, 270–6; interests of, 277–9; of mentally ill, 259; movement, 279, 295 Carer’s Payment, 275–6 carers, women, 265–87 passim case payments, 82, 83 casemix classification systems, 141–2, 145 casemix funding, 82, 85, 139–47, 165; hospital services, 131–48, 152; impact of, 141–4: limitations of, 144–7; and mental health, 259 changes in health policy see health policy reforms Charter of Residents’ Rights, 295 child health, 4 Child Support Scheme, 28 Citizens Charter, 160
citizen juries, 88, 96 citizenship, rights and health, 5–7, 9, 20, 111–12, 288 COAG, 4, 51, 52, 85, 225 Cochrane Collaboration, 10, 94, 145 Commonwealth Dept of Health and Family Services, 53, 189, 190 Commonwealth Rehabilitation Services, 53 Commonwealth/state Medicare Agreement see Medicare Agreement Commonwealth/state relations, 23, 71–86, 108; problems of, 73–9, 90, 138; reform of, 29, 79–86 community health: Australia, 133, 171–4; Victoria, 174–6 community health care, 13, 82, 169–84; compulsory competitive tendering, 179–80; and contractualism, 179, 284–5; fee-for-service, 180–1; governance of, 182–3; integration of, 181–2; output-based funding, 178–9; purchaser/provider splitting, 179; reform in, 266–70 community health centres, 176 Community Health Policy, 4 Community Health Program, 13, 171, 173, 178, 182, 225 community nursing, 176–8, 182, 183 community service obligations, 157–9
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Community Visitors Scheme, 295 community-based care, 248–64 passim competition, 1, 4, 29, 51–2, 86, 97, 174–5 competitive free market, 59–62 competitive tendering, 179–80 consumer charters, 88 consumer payments, 95, 107, 113–27; case study, 114; see also fee-for-service consumers: contestability, 54, 151, 293; co-payments by, 3, 115–21, 126–7, 132, 175; drug costs of, 122–4; marginalised, 39, 122, 124–5; needs of, 56, 90, 122–6, 132–4, 159–64; participation by, 30, 103, 133–4, 163, 251, 262 Consumers Health Forum, 114, 117, 120, 121, 123, 126 contracting out see contractualism contracts, 67, 150–1, 152–9, 162, 176 contractualism, 13, 29, 50–7, 58, 68, 149–68; impact on delivery, 154–5, 179–80, 266; management of, 151–5; and public interest, 155–9, 296; and quality of care, 282–5; and restructuring, 149–51, 292–3 Coordinated Care Trials, 53, 81, 85, 88, 110, 290 co-payments see consumers
corporatism, 35–6 cost-containment, 131–2, 136, 139, 145 cost-shifting, 56, 75, 79, 90, 123, 138 costs of health care see health care costs Council for Aboriginal Health, 198 Council for Civil Liberties, 55 Council of Australian Governments, 4, 51, 52, 85, 225 Council on the Aging, 143 critical discourse analysis, 40–2 customers see consumers DALYs, 231, 241–3, 294–5 Declaration of Alma Ata, 20, 171, 231, 238 Declaration of the Rights of Disabled Persons, 295 deinstitutionalisation, 252–7, 260–1, 278, 281, 295 Dekker Report, 105 dental treatment, 21, 116, 119 deontology, 94 deprofessionalisation, 44 Dept of Aboriginal Affairs see Aboriginal Affairs Dept of Human Services and Health, 198 direct payments, 115–16 disability, costs of, 241–3 Disability-Adjusted Life Years see DALYs disaggregation, 50, 51 discharge planning see hospitals discourse analysis, 40–2 337
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distributive justice, 94 domestic violence policy, 4 double-dipping, 75 economic efficiency, 49–51, 64, 148 economic rationalism, 1, 57–62, 67–8, 175; and mental health policy, 257–61, 295, 264 entitlement programs, 73–4, 79; see also Medical/Pharmaceutical Benefits Schemes entrepreneurial government, 48–57, 290 epidemiology, social, 237–45 ethical rationing, 104, 107, 110 evidence-based medicine, 94 exit, 162, 293 expenditure see health care expenditure explicit rationing, 92, 101, 102, 108, 110 Federalism, 11 fee-for-service, 90, 123, 175, 180–1 Financial Management Improvement Initiatives, 51 free market, 57–62, 64–5 fund-holding, 97–8, 292 funding of health care see health funding gender, 294; bias, 216, 222–3; and health indicators, 232–6, 244–5, 294
generalist community nursing, 176–8, 182, 183 governance, 53, 54–5, 62–7, 182–3 government business enterprises, 52 health, right to, 5–7, 9, 20, 111–12, 288 health care: allocation in Australia, 108–10; rationalising, 136–8, 181–2 health care consumers see consumers health care costs, 12, 131–2, 137, 138, 145; escalation of, 88–91, 118, 126–7 health care expenditure, 72–5, 76–8, 80–91 passim, 115–16, 131–2, 136, 145, 174 health care funding see health funding health care rationing, 87–112; by race, 101; in USA, 99–105; see also resource allocation health care reform see health policy reforms health care system, 4, 83–5, 133; reform of, 56–7, 138–9, 175–6; in New Zealand, 105–8 health care treatment, effectiveness, 9–10, 288 Health for All 1988, 4, 20 Health for All by the Year 2000, 20, 188, 193, 231, 233 health funding, 21, 81, 87–112, 174, 223; in
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Britain, 96–9; in USA, 99–105; see also broadbanding Health in the Year 2000 and Beyond, 172 health indicators, 14, 193–4, 229–46; and ATSIC, 198–200; feedback from, 200–3; and gender, 232–6; problems of, 203–9, 246, 294; and quality of life, 235–6; research implications of, 236–7, 294; social epidemiology, 237–45; sociopolitical context of, 230–2 health insurance, 99, 101, 102, 106, 119; industry, 39, 43, 100, 116, 117, 137, 165 Health Insurance Commission, 83, 123 Health Issues Centre, 122, 123, 124 health performance indicators see health indicators health policy, 11, 19–47; adequacy of, 7–10; implementation of, 26–30, 289; politics of, 23, 146, 164–7; power in, 19, 47; sustainable, 1–15; values of, 22 health policy reforms, 2–3, 4, 7–10, 51–6, 88, 138–9; in New Zealand, 105–8; in Victoria, 2, 53–7, 135, 141, 291 health promotion, 4, 46, 47, 172, 238 health services: delivery,
52–3, 131; responsibility for, 71–86 passim Health Sharing Women’s Health Resource Service, 215 Health Targets and Implementation Committee, 21 Healthy Cities Project, 238, 239 Home and Community Care, 268, 295; and privatisation, 279–85; program, 77, 280–2 Home Care Service of NSW, 77 hospitals, 56, 135, 137; casemix funding, 139–47, 152; length of stay, 12–13, 56, 142–4, 281 Human Rights and Equal Opportunity Commission, 15 human rights, 6, 261, 295; see also health, right to immunisation, 4, 21, 80 implicit rationing, 92, 101, 102, 109, 110 Institute of Public Policy Research, 111 integration, 181–2 International Covenant on Civil and Political Rights, 295 Joint Planning Committee for Aboriginal Health Services, 198 legislation in public sector reform, 55 liberal theory of power, 34–7 339
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macroallocation of health care resources, 91–2 mainstreaming, 15, 255–6, 262 managed care, 88, 139, 260 managerialism, 4, 25, 49, 50, 56, 290; impact on medical autonomy, 46, 259 marginalisation: of consumers, 56, 122, 124–5; of rural health, 56 market state, 56–7, 62–7 marketisation of health, 1, 3, 4, 96–7, 269 measurement technologies, 80, 82 Medibank, 44, 133 Medicaid, 99, 102, 103, 292 Medical Benefits Scheme, 53, 56, 81, 83, 108, 113, 120; growth in, 73–4, 77, 89, 126 medical indemnity insurance, 29, 36 medical lobby groups, 37 medical negligence, 46 medical profession: autonomy of, 42–7, 137–8, 259, 260; government relations, 44, 45; power of, 29, 42–7, 146, 260; privatisation of, 259 Medicare Agreement, 73, 77, 79, 259 Medicare, Australia, 4, 6, 44, 89, 119, 133; changes to, 29; sustainability of, 74–5 Medicare Benefits Schedule, charging over, 123 Medicare, US, 99, 100, 292
Melbourne Women’s Health Collective, 219 men’s health, 4, 227 mental health policy, 15, 247–64; Aboriginal, 251; analysis, 249–51; and economic rationalism, 257–61, 264, 295; standards in, 261–3 Mental Health Statement of Rights and Responsibilities, 263 mental illness, definition, 249–52 microallocation of health care resources, 91–2 morbidity, 206, 233–4, 294 mortality, 205–6, 232–3 ‘multipurpose service’ program, 81 National Aboriginal and Islander Health Organisation, 195–6 National Aboriginal and Torres Strait Health Council, 209 National Aboriginal Community Controlled Health Organisation, 198 National Aboriginal Health Strategy, 194, 197–200 National Commission of Audit, 51–2, 151 National Competition Policy, 4, 51–2, 160, 283 National Health and Medical Research Centre, 198 National Health Goals and Targets, 4 National Health Policy
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Medicare Agreements, 259; see also Medicare Agreement National Health Strategy, 4, 20, 122, 124, 172, 283 National Mental Health Policy, 261, 262 National Mental Health Strategy, 4, 15, 261 National Standards for Mental Health Services, 263 National Women’s Health Policy, 4, 14, 212, 217–21, 223; see also Women’s Health Program New Public Health, 231, 238–41 New Public Management, 50 New Zealand restructuring, 65, 105–8 non-government organisations, 166–7 nurses’ widening role, 46 nursing homes, 36, 277–8 nutrition, 4, 21 Office of Aboriginal and Torres Strait Islander Health Services, 189 Office of the Status of Women, 213 Oregon experiment, 88, 93–4, 101–5 Ottawa Charter, 20, 171, 231, 238, 239 out-of-pocket payments see consumers output-based funding, 175, 178–9 patient autonomy, 10, 93–4 Patient’s Charter, 97 performance indicators, 49,
50; in Aboriginal health, 187–209 performance measurement and evaluation, 14, 49, 188, 189 performance-based contracts, 50, 51 Pharmaceutical Benefits Scheme, 53, 56, 83, 113, 120; changes to, 122–3; growth in, 73–4, 77, 89, 91, 126 pharmaceutical expenditure, 89, 90–1 pharmaceutical industry, 36, 43, 127 pluralist theory of power, 31, 34–7 policy see health policy politics: of health policy, 23, 146, 164–7; of policy implementation, 29–30 poststructural views of power, 39–40, 63 power: dimensions of, 31–4, 289; and health policy, 11, 19, 29, 47; and interests, 30–40, 55; liberal/pluralist theories, 31, 34–7; pluralist and structuralist theories, 31–4; poststructural views, 39–40; and the State, structuralist approaches, 37–9, 289–90 power of medical profession see medical profession prevention, 21, 80, 172, 238 Primary Health and Community Support, 175, 176, 225 primary health care, 133, 169–78 passim, 193; see also community health care 341
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private health expenditure, 115–21 private sector: accountability, 159–64; managerialist reforms in, 50 privatisation, 1, 2, 15, 29, 50, 52, 279–85; and quality of care, 282–5 Professional Indemnity Review, 138 program budgeting, 188–9, 195–7 proletarianisation, 44 Proudfoot, 224, 228 providers see purchaser/provider public choice theory, 57–9, 60, 62, 291 Public Health Outcomes Agreements, 80 public health policy, 21–6; see also health policy public sector: accountability, 159–64; reforms in, 48–51, 53–7, 59, 68, 195, 291 purchaser/provider: contracts, 46, 58; splitting, 97, 149–52, 163, 165–7, 179; see also health services QALYs, 232, 243–5, 294–5 QOL scales, 243–4, 245, 295 quality of care, 9, 56, 282–5 quality of life, 240, 243–5; as health indicator, 230, 235–6 Quality-Adjusted Life Years see QALYs rational choice theory, 58–9 rationing of health care see health care rationing
reform of health policy see health policy reforms resource allocation, 30, 91–6, 140–8, 192, 231; see also health care rationing responsibility for health services, 71–86 passim Right Analysis Instrument, 262–3 risk, 67, 158–9 Rural Health Strategy, 4 screening programs, 4, 46 self-care, 220 social choice theory, 57, 291 social epidemiology, 237–45 social equity, 7–8, 64, 238–41; see also health, right to social indicators, 234–5 social justice, 7–8, 66–7; see also human rights sociopolitical position, 164, 165–6 standards-setting, 67 structuralist theory of power, 31–4, 37–9, 59, 289–90 sustainable policy, 1–15 technology and change, 134–6 tied grants, 77 Trade Practices Act, 4 transaction cost analysis, 58, 291 trends in health policy see health policy reforms Universal Declaration of Human Rights, 6 untied general revenue assistance, 77 users see consumers utilitarianism, 94
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values, 22, 23; and resource allocation, 92–6 vertical fiscal imbalance, 76, 82 vertical integration, 181–2 Victoria, community health, 174–6; contractualism in, 150–1; reforms in, 2, 53–7, 135, 141, 291 Victorian Commission of Audit, 53, 150, 151 Victorian Management Improvement Initiative, 53 voice, 162, 293 watchdogs, 66, 67 welfare state, 64; and
restructuring, 1, 63, 65, 269, 279–85 women carers, 15, 265–87 women in medicine, 219–20 women’s health, 3, 210–28, 232–4; consultations, 219–21; dual strategy, 218–21, 226–7; funding, 224–5; services, 14, 218–19, 223–7, 293 women’s health movement, 46, 212–15 Women’s Health National Funding Strategy, 218 Women’s Health Program, 221, 224, 225, 226 World Health Organization, 20, 188, 193–4
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