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Speaking up for health equity at the CroakeyLIVE

The 2021-22 Federal Budget is being hailed in many mainstream circles for its “big-spending glory” and focus on the COVID-19 recovery, aged care, mental health, and women.

But experts at last week’s #CroakeyLIVE webinar delivered a different verdict.

They say the Budget is in many ways a disaster for health equity, climate health, and the social determinants of health, failing to address structural inequity, prevention, climate change, poverty, Indigenous health and justice, and the crisis in housing.

One panellist said it was a Budget of “expediency not equity”, another that it begged the question: “what hope is there for the future?”.

For another, the “number one missing piece” is real action to fix poverty, with households and communities across Australia now back to relying on desperately low Job Seeker payments after the coronavirus supplement, which brought so many benefits, was once again removed.

#CroakeyLIVE participants from across the health, social and disability sectors, including Aboriginal and Torres Strait health leaders, were asked by moderator Dr Melissa Sweet to reflect upon three questions: What were you happy to see in the budget? What was missing? And what are your key takeaways for health equity?

With a federal election possible in just a few months, they called for the health sector to put equity on the political agenda, asking what lessons can be learnt from how aged care, mental health and women’s health finally won the Government’s attention.

Marie McInerney has summarised the discussions, in order of the panellists’ appearance. Also check out this Twitter thread of the live discussion.


Devil in the detail

Dr Janine Mohamed, CEO of Lowitja Institute, Australia’s community controlled institute of Aboriginal and Torres Strait Islander research

Dr Janine Mohamed welcomed a number of measures in the Budget, including funding for the Aboriginal Torres Strait Islander aged care workforce, community COVID-19 responses, suicide prevention and the First Nations Research Network that Lowitja Institute is leading with Curtin University, Menzies School of Health Research, and the South Australian Health and Medical Research Institute (SAHMRI).

But what mattered, she said, was whether it would lead to an expanded Aboriginal and Torres Strait Islander health research workforce — missing are dedicated research funds for Aboriginal and Torres Strait Islander health researchers who are “put in the pool with dominant culture, which frankly puts them at a disadvantage “because they may not have the research track record.

Equally, funding for Aboriginal and Torres Strait Islander health, including for the implementation of the Closing the Gap National Agreement, will not improve health equity or outcomes if it goes to non-Indigenous organisations. Past examples tell us they won’t be able to deliver and will then “place the burden on Aboriginal and Torres Strait Islander organisations to deliver on services that our people have missed out on, without being funded or trusted to do so”.

Mohamed said the Federal Government’s much touted women’s package was focused on gender equity but did not address race equity, with targeted funding for Indigenous women “who obviously have an inequity within our gender”.

While it sought to make up for the “horrible headlines” on how women in Parliament and politics have been treated, it made no effort to address the national crisis of Aboriginal and Torres Strait Islander deaths in custody, she said, calling for the Federal Government to match Labor’s commitment on the Uluru Statement from the Heart.


Look beyond the spin

Lesley Russell, Adjunct Associate Professor at the Menzies Centre for Health Policy at the University of Sydney, Croakey contributing editor

Associate Professor Lesley Russell provided a series of tips for analysing the Budget, saying it’s vital, given government spin and growing lack of specialist knowledge in the media, to understand what lies behind the figures.

  1. Read all of the Budget papers in the context of what has happened in previous years, turning to expert analysis such as the Parliamentary Library, The Conversation or Croakey, although understand all analysis comes with caveats too.
  2. Be skeptical of government information and media releases, which is “basically their spin on what they think are their gifts to us”, and of media reports, given journalists “often don’t have the ability to do analysis”.
  3. Beware slogans and program titles, like ‘Fairer Medicare’, and large bundles of funding labelled, for example, as “prevention” but which may in fact have little to do with it.
  4. Ask questions: Is this an old program that’s just simply been renamed? Is it a program that was previously announced? What else is there in the budget or elsewhere that’s addressing this issue? If it’s a new program, what is the problem that it purports to be solving? Is it properly targeted? What is the evidence that supports this program? Who, why and what is driving this — is it political ideology, loud voices from certain stakeholders? And where are the dollars coming from? Is this a ‘robbing Peter to pay Paul’ scenario?
  5. Do your division. Divide the funding allocation by how many years those dollars are for, how many services they will deliver/units they will buy, and what’s the cost per population served?
  6. ‘Broad-banding’ of funding is an increasing problem (hard to actually assess what is actually being spent on specific issues).
  7. Look for what’s missing. What’s the Government ignoring (climate change), not continuing (Health Care Homes), reducing its commitments (for example, Adult Public Dental renewed again for only one year with 2019 funding)?


Challenging the framing

El Gibbs: disability advocate, writer, disabled person

El Gibbs said the Budget allocated $13.2 billion for the National Disability Insurance Scheme (NDIS) over four years, but the big concern was the way it is being framed as new spending and with the message that the needs of people with disability are becoming an “unaffordable, unsustainable” burden, when in fact spending is on track with original projections.

Still the Independent Assessments for the NDIS, feared as a harmful cost-cutting exercise  by many disabled people, families, communities and advocacy organisations, were still “very much there” in the Budget, but there was nothing to address the “huge cliff at the edge of the NDIS”, where those who are not eligible for the NDIS have nowhere else to turn for support.

Gibbs said there were small pockets of good news in the Budget: $9.3 million over three years for addressing violence against women and children with disability and $12.7 million for improving the health of people with intellectual disability, after huge gaps in equity were exposed in the Disability Royal Commission and following a major campaign from the intellectual disability community.

However, another big concern about health equity was the shift in the Budget to save $800 million through the New Employment Services Model (NESM), by pushing job seekers, including people with disability and chronic illnesses, onto so-called digital first services, assuming “that everyone has got digital devices that work, access to the internet, and finds it easy to communicate that way”.

Those assumptions have been a major problem for the disability community throughout the COVID-19 pandemic, continue to be so now during the vaccination rollout, and worryingly are “now spreading firmly into more and more social services”, she said.


Mental health matters

Tom Brideson, Chief Executive Officer of Gayaa Dhuwi (Proud Spirit) Australia

Tom Brideson welcomed a number of initiatives for Aboriginal and Torres Strait Islander mental health and suicide prevention, the establishment of regional suicide prevention networks and funding to Gayaa Dhuwi and Lifeline to establish and evaluate a culturally-appropriate 24/7 crisis line governed and delivered by Aboriginal and Torres Strait Islander people.

But he echoed Dr Janine Mohamed’s concerns about the need for proper data for communities and for Aboriginal and Torres Strait Islander organisations to lead community work.

Still missing from the Budget understanding, despite being raised by Aboriginal and Torres Strait Islander organisations and researchers for many years, is recognition that if Government applied the social and emotional wellbeing principles around the Closing the Gap National Agreement to all mental health funding and policy, “you would save lives,” he said.


Critical health concerns ignored

Dr Simon Judkins, emergency physician, the Immediate Past President of the Australasian College for Emergency Medicine (ACEM) and a Croakey columnist

Having led campaigns on how Australia’s health system is failing to meet the urgent needs of people presenting to emergency departments for mental healthcare, Dr Simon Judkins welcomed the significant contribution in the Budget for mental health.

But he remains concerned that it will still not address “the most in-need patients”, people with very complex mental health issues, including multiple diagnoses, “who often spend a lot of time in emergency departments because they’re unable to access care in community”.

Working between regional and metropolitan emergency departments, Judkins welcomed Budget incentives for regional and remote GPs to try to address workforce shortages. But again, he believed the numbers did not “stack up”, and said “a lot more that needs to be done to ensure health equity and regional remote Australia”.

But the major concerns for Judkins in the Budget were its failures to address affordable housing and homelessness, ongoing stripping of financial support to the university sector, and the “glaring gap” of action on climate change, “the biggest public health threat to us all” but completely ignored in the Budget.


Failures to address poverty and housing

Kate Colvin, policy and communications manager with the Council to Homeless Persons in Victoria, and spokesperson for the national Everybody’s Home campaign.

Kate Colvin said the Budget was very disappointing on social housing and homelessness, with one of the “big wins” actually successfully campaigning against cuts to funding for homelessness services.

She said: “that doesn’t really feel like a super exciting win, given the demand for services is really increasing”.

The Budget allocated $12.3 million over four years for crisis accommodation, “a pittance” given that one-third of the 54,000 women and children escaping family violence who came to homelessness services needing accommodation are turned away because no accommodation is available, she said.

The big-ticket items for aged care and mental health, including homecare packages and support for people exiting hospital after suicide attempts, are welcome but they assume that people have a home, which too many older people and those with mental health issues do not, she said.

Demonstrating the importance of digging behind the figures, Colvin said the Budget contains a $200 million commitment for repair and maintenance of remote Indigenous housing.

Three years ago, that funding was $577 million a year and “in two years, it will be down to zero”, she warned, saying this will be devastating, given the health consequences of the poor state of housing in those communities.

Overall, Colvin said the “number one missing piece” in the Budget is “real action to fix poverty” that is devastating households and communities across Australia, with a lack of investment in housing insecurity and homelessness and no real increase in income support after the Federal Government failed to maintain pandemic levels of JobSeeker support.


Lessons for health equity action

Jennifer Doggett, Croakey editor

Jennifer Doggett said her takeaway message from the Budget, with its big spending on mental health, aged care and women, was that even Coalition Governments will spend money where they perceive there is some electoral benefit for them.

That raises the question: how can health equity advocates pursue funding for what was missing, including climate, Indigenous health, prevention, housing, and the social determinants?

What also stood out for Doggett was that, despite significant funding in particular areas, the Federal Government had not looked at any of the structural barriers to critical reforms, such as prevention, particularly with obesity.

Doggett has written for Croakey that missing from the women’s package was any attempt to address some of the broader structural barriers to women accessing health care, such as out-of-pocket costs and the low availability of public outpatient specialist services.

Her analysis is that the Government is very reluctant to lead action that takes on vested interests, such as doctors and the food industry, works across jurisdictions and looks at the flow of money across the system.

The health sector needs to understand that windows of opportunity for spending and health do open, sometimes unexpectedly and sometimes not exactly where it might want, but the sector needs to jump through those windows to make the most of opportunities.

“I think we need to learn from what worked this time — why was it aged care? Why mental health? Why women? And work out how to use those learnings to drive change in some of those other areas like social determinants, like climate, like prevention,” she said.

Another challenge, she said, is to better sell to the community and government, as became apparent during the COVID-19 pandemic, why equity is not just good for what they perceive as sectional interests.

The case needs to be made about why equity is “good for everybody, why making a case for greater equity across the health system is not just the right thing to do but the smart thing for everyone”.


Expediency trumps

Charles Maskell-Knight, a former senior public servant in the Commonwealth Department of Health for over 25 years. He worked as a senior adviser to the Aged Care Royal Commission in 2019-20.

Charles Maskell-Knight also welcomed the $18 billion funding — which he sees as a down payment — for aged care in the Budget, and the renewal of the Dental National Partnership Agreement for another year — “the last vestige of a commitment by the Commonwealth to take the dental health of people that aren’t children seriously”.

What was missing?

About $20 billion more for aged care to address cuts over two decades, commitment to increase wages for an underpaid and predominantly female workforce, regulatory reform to make sure extra aged care funding is spent on care not Maseratis for CEOs, and a Seniors Dental Benefit Scheme.

The 2021-22 Budget was, he said, a “budget driven by expediency rather than equity”, noting that the allocation of $96 million on pre implantation genetic testing for the 40,000 women a year who access in vitro fertilisation is more than the additional funding that will be put into Aboriginal and Torres Strait Islander healthcare over the next three years.


Youthful focus

Associate Professor Megan Williams, Wiradjuri woman and Research Lead and Assistant Director of the National Centre for Cultural Competence at the University of Sydney

Mindful that around one-third of Aboriginal Torres Strait Islander communities are young, Associate Professor Megan Williams said she had taken a “youth perspective” to the Budget.

It led her to wonder “what hope is there for the future”, given the Government’s failure to shore up the TAFE system to support its apprenticeship initiatives, to plan climate action, or to respond in any way on the health and wellbeing of Aboriginal Torres Strait Islander people in the criminal justice system, with no mention of Justice Reinvestment or the need for action on deaths in custody.

And while we do need a Budget that acknowledges recovery from COVID-19, she said we also needed innovation and more focus on prevention.

Williams offered a quote from Change the Record Co-Chair Cheryl Axleby:

This is not a budget for the future, this is a Budget that entrenches the inequalities and injustice of the past.”

That was also to be seen where the Productivity Commission’s new Indigenous Evaluation Strategy, with its blueprint for evaluating the effectiveness of programs designed for Aboriginal and Torres Strait Islander people, is “not mentioned in this Budget”, nor any measures to build the research capacity of Aboriginal and Torres Strait Islander people to be able to do that evaluation themselves.

“So we’re really investing in old ways of doing business and missing opportunities,” she said, noting she had also hoped for more investment in Indigenous knowledges and caring for Country bushfire prevention.

Williams echoed Tom Brideson, saying:

You get it right for Aboriginal and Torres Strait Islander people, you get it right for everyone, because we are the authority and the knowledge holders for this country.”

Williams agreed with Doggett that the health sector needs to learn how aged care and mental health were put on the agenda for this Budget and to work out urgently how it can make renewable energy an issue at the next federal election, which may come as early as October.

“That’s not very long for us to get mobilised, but it’s possible,” she said.

Croakey acknowledges and thanks donors to our public interest journalism funding pool for supporting this article.


Twitter analytics

More than 300 Twitter accounts participated in the #Budget2021Health conversations on Twitter from 7-19 May, sending more than 1,000 tweets and creating more than 10 million Twitter impressions, according to Symplur’s analytics. Read the Twitter transcript here.


See Croakey’s articles on health inequalities.

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