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Pandemic planning and responses must address equity concerns: national inquiry

Melissa Sweet and Alison Barrett write:

Aboriginal and Torres Strait Islander people, culturally and linguistically diverse (CALD) groups, people with disability, and children are among those who should be prioritised in planning and preparation for future pandemics.

This is a key message from the COVID-19 Response Inquiry, whose findings underscore longstanding concerns about the inequitable impacts of both the pandemic and responses.

In any future crisis, early engagement and responses for groups most at risk should be prioritised, says the report, urging that key advisory mechanisms be made permanent and embedded into planning and decision-making structures.

The inquiry notes that the Australian Health Protection Committee has now embedded the Aged Care Advisory Group and the National Aboriginal and Torres Strait Islander Health Protection subcommittees into its permanent structure.

Similar action is warranted, it says, for advisory groups such as the CALD COVID-19 Health Advisory Group and the Advisory Committee for the Health Emergency Response to COVID-19 for People with Disability.

“The COVID-19 pandemic showed the need for systemic changes to address underlying inequities before any future public health emergency,” says the report.

“Priority populations all have different experiences and needs. There is a clear need for government responses to be developed in advance, be informed by genuine consultation, and be tailored to reflect diverse and often complex needs.

“Once a crisis is upon us, it will be too late to establish these forums, programs and policies and access key data.”

The report also calls for pandemic policy measures to be analysed and developed through a gender lens to avoid adverse or disproportionate impacts on women, and to align with efforts to enhance gender equality.

To promote a greater focus on children in pandemic planning and responses, the report calls for a role of Chief Paediatrician to be established, and for this role and National Children’s Commissioner to be included on the Australian Health Protection Committee.

The report also urges increased mental health funding and investment in services for children and young people, to help manage the ongoing mental health impacts of the pandemic.

“We heard that the failure to explicitly consider the impact of policies on children and young people stemmed in part from inadequate engagement with, and representation of, their interests in decision-making at all levels of government,” the report says.

The inquiry was chaired by Robyn Kruk AO, with panel members Professor Catherine Bennett and Dr Angela Jackson. It received 2,201 submissions, held more than 250 consultations and 27 roundtables, convened focus groups and interviews with 176 participants, and commissioned a community survey with 2,126 individual responses.

A cross-government taskforce is to work through the 875-page report’s findings and recommendations.

Widespread inequities

Examples of inequities are highlighted throughout the report.

CALD communities had higher death rates from COVID, struggled to find comprehensive and timely information in relevant languages, and also experienced increased racism and discrimination.

They were less likely to be eligible for financial supports, faced challenges in accessing mental health support, and were more likely to live in areas with more restrictive government lockdowns, the panel reported.

Many inequities were also evident in the vaccine rollout.

Vaccine rollout plans for aged care, Aboriginal and Torres Strait Islander people and CALD communities were not finalised until February 2021 – more than a month after the general rollout started.

A plan for people with disability was never published, and the vaccine rollout to people with disability was slow, particularly in the initial phase.

The panel heard that people with disability felt ignored, deprioritised and abandoned, and that government underestimated the complexity of delivering vaccines to people with disability in a range of settings.

The panel also expressed concern about the lack of transparency around data related to people with disability during the pandemic, including mortality data.

The reopening of Australia coincided with the first and second Omicron waves of December 2021 to July 2022, leading to the highest number of COVID-19 cases and deaths during the pandemic.

Representatives of older Australians and people with disability in particular told the Inquiry of their fear at the sudden transition to opening up.

They said they felt public health measures, including isolation and mask wearing, which had helped to keep them safe, were dismantled too quickly.

Key stakeholders were clear that greater care should have been taken to protect vulnerable populations, especially older Australians, Aboriginal and Torres Strait Islander people and people with disability, once the economy reopened.

The report also underscores the wider health impacts of the pandemic in reducing healthcare access, and said Health Ministers should coordinate a ‘COVID Catch-up’ strategy to address elective surgery and cancer screening in particular.

The panel suggests the National Health Reform Agreement, due for renewal in 2025, could address the inequities in regional, rural and remote communities that were amplified as a result of the pandemic.

Caught unprepared

The panel found that Australia was not prepared for a pandemic of the severity, complexity or duration of the COVID-19 pandemic.

One of the most common phrases heard during the Inquiry was ‘building the plane while it was flying’.

As an example of the lack of preparation, some of the most pivotal decisions in the pandemic were not considered in pre-existing plans, including the closure of international borders and the JobKeeper scheme.

Nonetheless, international comparisons today show Australia suffered fewer excess deaths per capita than most other countries, including Sweden, France and the United States, because of quick action in the early phase.

“The national effort to prevent most Australians from being infected at a rate that would have compromised critical care if needed, and the health of all Australians if the health system became overwhelmed, paid off in ways few Australians can fully understand,” says the report.

“By holding back widespread community transmission until the vast majority of the adult population had some immunity through vaccination, far fewer Australians experienced severe COVID-19 than would have otherwise been the case.

“As a result, thousands fewer Australians died from COVID-19, or from other causes through suboptimal care, than would otherwise have been the case.

“However, there is also a view that restrictive measures were kept in place for too long, and the broader individual, social and economic impacts came to outweigh the COVID-19 public health benefit.”

The inquiry was told that many structures and relationships built during COVID-19 had now fallen away, and pandemic planning and associated resourcing of important capabilities are at risk of “continuing to follow the same historic pattern of neglect and short-termism”.

“We heard that, if there were a pandemic tomorrow, Australia would be back at square one.”

Health Minister Mark Butler said: “The striking conclusion from this report is that right now, we are arguably worse placed as a country to deal with a pandemic than we were in early 2020 for a range of reasons” including significant scarring on healthcare systems and workforce, lack of “real-time evidence-based policy” and lack of transparency which has “driven a large decline in trust”.

The panel members said that many of the measures taken during COVID-19 are unlikely to be accepted by the population again, Butler said.

This has been the most talked about point in mainstream media since the report released, despite many other findings and lessons learned, and recommendations discussed in the report.

Professor Stephen Duckett told the ABC that it is an extremely comprehensive report, well documented, well researched, and very fair.

He also reminded us that “it’s not really post pandemic…the pandemic is with us. It’s not as bad as it was originally, and we’re not having a public health response, but people are getting sick with COVID”.

The panel members acknowledge that the next pandemic may be very different to the COVID-19 pandemic – some of the issues and solutions that eventuated in this pandemic may not be the case next time.

Governance matters

The inquiry called for action and investment in emergency management capability across the public service and more broadly, not just through exercises but also through training, readiness reviews and stronger governance and relationships.

Rather than rely on relationships and dedication of key individuals as during the pandemic, more effective governance structures were needed.

The inquiry recommended a national Australian Government governance structure to support future health crisis responses, including an appropriate emergency Cabinet Committee and a ‘Secretaries Response Group’ chaired by the Department of the Prime Minister and Cabinet that brings together the lead Secretaries and heads of relevant operational agencies, to coordinate the Australian Government response.

It also recommended mechanisms for National Cabinet to receive additional integrated expert advice on social, human rights, economic and broader health impacts (including mental health considerations), as well as specific impacts on priority populations.

Any future pandemic responses should also include a more structured engagement and active consultation with local government to enhance the coordination and communication of a national response.

The panel heard there was widespread public confusion around the roles and responsibilities of the Australian Health Protection Principal Committee, the Australian Technical Advisory Group on Immunisation and the Therapeutic Goods Administration.

That the Australian Health Protection Principal Committee reported directly to National Cabinet was a challenge for state Chief Health Officers because it potentially placed them in conflict with their own state statutory responsibilities. It also put restrictions on their briefing to their ministers.

For example, Chief Health Officers’ briefings to their state/territory Health Ministers were complicated by Cabinet confidentiality requirements and by differences in the roles, statutory responsibilities and communication pathways of Chief Health Officers across jurisdictions. This meant First Ministers had different levels of briefing before National Cabinet meetings.

The panel heard that National Cabinet confidentiality requirements created an unintended disconnect between leaders, bureaucrats and the public and impeded sharing and coordination of key information, advice and planning.

Build trust

Public trust had been undermined by a lack of transparency, fairness, compassion and proportionality around decision making, as well as inconsistency in responses, misinformation and disinformation, and perceptions of ‘politics’ being played, the inquiry found.

Vaccine mandates also contributed.

“Government cannot rely on people willingly adhering to similar public health restrictions in a future public health emergency,” the report says.

National planning for future pandemics must be based on proactively rebuilding trust and resilience with populations, communities and settings that were most negatively impacted by the pandemic and related measures.

This is particularly important as the recent increase of Australia’s national terrorism threat level from ‘possible’ to ‘probable’ has been linked to the growth of anti-authority beliefs and the erosion of trust in institutions.

The inquiry urges National Cabinet to develop transparency principles for the release of advice that informs decision-making in a public health emergency, and also called for a national strategy to rebuild community trust in vaccines and improve vaccination rates (other public health experts have commented more in The Conversation).

Human rights

The panel urges National Cabinet, the Australian Government and the Australian Health Protection Committee to embed human rights considerations into their decision-making processes.

The panel heard that human rights were not a primary consideration in decision-making at the National Cabinet or federal level.

Aboriginal and Torres Strait Islander people were disproportionately impacted; for example, by fines for noncompliance with restrictions.

Mental health

The panel heard that the response to the pandemic prioritised population-level physical health and did not adequately consider the mental health impacts of protracted wide-ranging and coercive measures.

The Deputy Chief Medical Officer for Mental Health attended almost every meeting of the Australian Health Protection Principal Committee, but we heard from some that mental health was peripheral to their discussions, as it was a struggle for the Australian Health Protection Principal Committee to deal with the entirety of the response.

The panel highlighted the importance of better integration of primary care into emergency planning and preparedness frameworks and said Primary Health Networks are well placed to play a key role in emergency planning.

“Primary Health Networks need to play a much larger role in a future pandemic. However, they must be flexibly funded to do so and support innovations in primary care delivery.”

The panel notes the significant reforms in primary care since the pandemic, including the establishment of Medicare Urgent Care Clinics, which will potentially be of benefit in a future public health emergency because they could reduce pressure on hospitals and emergency departments.

Workforce matters

The health and aged care workforces experienced wide-ranging traumas.

These ranged from the stress of working “to breaking point…in the most confronting and challenging of environments”, to suffering moral distress because they felt unable to contribute to the response to the level that their experience and capacity would allow.

Some nurses and allied health professionals felt left on the sidelines, especially during vaccine rollout.

Aged care workers were often so overworked they could provide only minimum care for aged care residents, and many aged care workers experienced a “profound mental health impact and moral distress” during the pandemic.

The report noted that during the COVID-19 pandemic, most aged care workers earned as little as $2 above the minimum wage, 93 percent of direct care workers were employed part-time, and many worked across multiple sites, providers and sectors.

Department of Health and Aged Care data indicate that more than 117,000 nurses left the workforce between 2020 and 2022, compared with 97,745 nurses leaving the workforce between 2018 and 2020.

Data provided to the Inquiry by the Australian Health Regulation Protection Agency show that the number of practitioners applying for non-practising registration has increased across all professions, and there has been an increase in the number of practitioners not renewing their registration at all across many professions from 2018 to 2023.

Some argue the scope of practice changes during the pandemic did not go far enough. The panel heard that Aboriginal Health Practitioners were invaluable for delivering COVID-19 vaccines and should have been used to administer other vaccines and prescribe antivirals.

Stakeholders told of the need to maintain and strengthen the public health workforce in non-pandemic times to ensure there is a greater pool to draw from in a future public health emergency.

They noted a lack of regulation of public health workers made it difficult to identify and recruit appropriate expertise during the pandemic. As a result, public health roles in the pandemic were often filled by general health workers, government officers or Defence Force personnel.

“The capability of the public health workforce is not evenly spread across states and territories,” the panel reported. “We heard there is a need to ensure health departments at all levels of government are bolstered with public health expertise to better inform policy decisions.”

Participants at an Inquiry roundtable told us there has been no specific investment from any level of government directly in public health since the pandemic, even though leadership recognises the need to expand training for the public health workforce.

Aboriginal and Torres Strait Islander people

The inquiry found that early success in minimising harms to Aboriginal and Torres Strait Islander people was largely the result of a rapid community-led response aligned with the Closing the Gap Priority Reforms.

Aboriginal and Torres Strait Islander Community Controlled Health Services played a central role in developing and delivering local community responses, reflecting existing trusted relationships, effective planning, coordination and consultation, and flexible funding to the community-controlled sector.

However, the panel also heard about the difficulties of isolating in overcrowded housing, significant challenges in the vaccination rollout and with access to PPE, and lack of cultural safety in response measures.

Some stakeholders criticised government communications with Aboriginal and Torres Strait Islander communities, and the report recommended that in a future pandemic, the community-controlled health sector should have responsibility for and funding to tailor and deliver public health communications to Aboriginal and Torres Strait Islander people, with clear links into broader government communications activities.

Most quarantine facilities were not considered culturally safe, and the report called for the National Quarantine Strategy to establish culturally appropriate options for people in remote Aboriginal and Torres Strait Islander communities to quarantine on country in a national health emergency.

Older Australians

Older Australians, particularly those in residential or community-based living, experienced and continue to experience significant impacts from COVID-19, according to the report.

The report notes that vaccination coverage in residential aged care has declined and surges of COVID-19 cases have continued in 2023 and 2024.

As of 12 September 2024, the total number of COVID-19 associated deaths in residential aged care facilities had reached 7,003.

“Australia is lagging behind in aged care vaccination rates for COVID-19 compared to other countries”, the panel members wrote.

As with the health workforce and systems, existing issues in the aged care system were exacerbated in the pandemic and will continue to be in future public health emergencies unless adequately addressed.

The Australian Government released an aged care specific COVID-19 plan in November 2020, months after the pandemic started.

The aged care plan was intended to be ‘periodically reviewed (at least every quarter)’ with stakeholder feedback from across the sector. However, to date, no public review or amendment has been published, despite the changes in operating environments.

People without secure housing

The inquiry heard that the housing and homelessness sector was quick to respond to COVID-19 and protect those experiencing housing insecurity and homelessness, who were at a higher risk of exposure to the virus, as well as higher risk of poorer health outcomes.

However, many of the supports were withdrawn once the worst of COVID-19 was over, leaving many people in the same position, or worse, than they were in before the pandemic, according to the inquiry report.

The panel members recommend that supports provided during a pandemic need to be phased out in a planned manner.

The pandemic had a significant impact on housing policy and on the housing system, “with implications still being felt today”, the panel members wrote.

But the most effective protection for people experiencing homelessness or insecure housing will be addressing the underlying issues which lead to housing precarity before a future emergency – “this will ensure, as much as possible, that people can face such challenges from a more equal foundation”.

Given the significant impact of housing insecurity on Aboriginal and Torres Strait Islander people and communities, it is noteworthy that engagement with the Aboriginal Community-Controlled and housing sector was not highlighted explicitly in this section.

• Read our previous article on the inquiry report’s recommendations for an Australian Centre for Disease Control. Next week, we will examine some of the communications issues raised by the inquiry.

• Also see this article in The Mandarin by Andrew Podger, Health Department must listen to these lessons from our COVID-19 experience.


See Croakey’s archive of articles on health inequalities

 

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