Health Promotion International, Vol. 16, No. 3, 299-300,
September 2001
© Oxford University Press 2001
RESOURCE REVIEW |
Health Reform in Australia and New Zealand
1 Oxford University Press, Melbourne, 2000 2 National Centre for Epidemiology and Population Health Australian National University Canberra ACT 0200 Australia This book has an insider's emphasis on the management, government and realpolitik of health care in Australia and New Zealand. The editor, Abby Bloom, has managed a specialist consulting firm in the health industry, while the contributors represent some of the more powerful figures in health care in these countries, such as the past and present secretaries of the Commonwealth Department of Health in Australia, and the current chief executive of the Ministry of Health, New Zealand. So the book deserves careful study—both for what it says and for what it leaves out.
When does reform begin? The choice here is somewhat arbitrary, considering that frequent change of financial, organizational and service arrangements for health care is the rule. Cost has always been a focus; the book contains much introductory material on health economics. Quality of care is a more recent concern, with the current demand for—if not supply of—measurement and transparency in medicine and evidence-based government policy in general. The gaps in our understanding remain large: Bloom acknowledges (p. 279) that the ultimate ‘products’ of health care are still often poor, with unexplained variation from place to place.
Bloom identifies financial and social crisis as the starting point for reform of the health sector, but later ‘waves’ are more relevant in the peaceful countries of the book's title, with the restructuring of ministries and relationships between central and local governments, and even more so, the concern to stabilize the finances, particularly in mixed public–private health care systems.
Australia and New Zealand have demonstrated that universal insurance schemes can sustain access to high levels of health care, but this book also makes some rather obvious points about the real functioning of bureaucracies. ‘The time-frame for health reform is longer than participants sometimes predict’ (p. 351). Of course this is the case, yet ‘tinkering’ may sometimes be a more accurate term than ‘reform’, which is often retarded by the difficulty of reversing many of the measures introduced previously, also in the name of reform.
How will the next phase of reform, with managed competition, using market-like mechanisms and budgetary incentives, sit with health promotion and public health? Should we expect change to the current proliferation of vertical programmes and strategies? This book cannot promise expanded activity in disease prevention or health promotion, even though Rhonda Galbally, the founding Chief Executive Officer of the Victorian Health Promotion Foundation, asserts that this should be integral to reform. Evaluation remains a key problem in public health: health promotion will have to demonstrate its worth at least as rigorously as the health care sector.
Galbally recognizes that any reform process must incorporate strategies that are structured around major social transitions, such as the changing nature of work and employment, the roles of men and women, and the potent role of new forms of information and communication. These transitions provide better points of entry for health promotion than programmes that simply address disease trends. The public–private sector interface will be important; the private sector could and should do more than provide health care services and infrastructure.
Like Galbally, Vivian Lin and Cathy King give a positive account, looking this time at intergovernmental reforms in public health in Australia. The rationale for the development of a National Public Health Partnership is explained, but it remains to be seen whether the changed relationships between the federal and state and territory governments that are assumed to have taken place will indeed promote the inclusion of community organizations in public health activity. The list of tasks remaining (p. 263) for the Partnership includes:
- instituting rigorous approaches to public health risk assessment and communication;
- developing local-level partnerships for public health that involve professional, community and other non-government sectors alongside government;
- developing indicators to measure progress;
- identifying mechanisms to fund public health priorities; and
- adopting public health methods to measure health outcomes as an integral part of health system management.
Very little of this can be achieved, of course, without the allocation of major resources. How great will the difference between rhetoric and reality be, in an era of shrinking budgets, deregulation and privatization?
Health Reform in Australia and New Zealand provides useful introductions to aspects of health care administration, rather than rigorous political or sociological analysis of the changing context [for which a better generic introduction would be Gill Walt's Health Policy (Walt, 1994
)]. There is a tendency to dwell on success rather than to analyse failure [compare the ‘dynamics without change’ in the health care institutions of New York, dissected by Robert Alford (Alford, 1975)]. The role of universities, local government or environmental concerns in changing the function of health care, for example, requires further examination. We need to consider not only what has happened to the health system, but also how the health system has changed society.
REFERENCES
Alford, R. R. (1975) Health Care Politics. University of Chicago Press, Chicago.
Walt, G. (1994) Health Policy. Zed Books, London.
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