Ahead of what’s been dubbed a “vote-bait” Federal Budget, Associate Professor Lesley Russell urges readers to delve beyond the headlines on budget announcements, argues that dental care should be an election issue, and spotlights the importance of prevention.
She also reports on the push to ditch low-value healthcare, the public health woes of Ukraine, and the power of community control in efforts to improve literacy among Aboriginal and Torres Strait Islander people.
Lesley Russell writes:
The federal election is expected to be held in mid-May, with an announcement likely soon after the 2022 Budget is released this evening. Make sure you follow the Croakey budget coverage with the hashtag #HealthBudget2022.
In preparation we have seen a fairly frantic and somewhat beleaguered Morrison Government engaging in a mad rush to clear the decks and the desks – provocative issues are suddenly resolved (for example 450 asylum seekers can now be resettled in New Zealand), delayed policies have been released (for example, the National Obesity Policy), and difficult reviews have been abandoned (for example, the National Medicines Policy review).
Pre-Budget announcement are flowing. But it pays to look at these carefully as they are not always as generous as they seem, and too often media reporting takes the Government spin at face value without further scrutiny. as they are carelessly reported.
My Croakey colleague Charles Maskell-Knight, in an article for Croakey Health Media, has highlighted how to read and critically analysed the Budget Papers and associated media releases.
I have added to his notes:
We both make the point that it is essential to look at the funding allocated in the light of how many years that is for, whether it is new or continuing, and how many services, staff or facilities that will provide.
Here are two examples of why Charles and I are so cynical and sceptical about so many of these announcements:
This funding, announced on National Close the Gap Day, is for a (much-needed) major capital works program for Aboriginal Community Controlled Health Services (ACCHS) to build, buy or renovate health clinics and staff housing.
However, it is a re-announcement of a commitment of $254.4 million for health infrastructure made in August 2021. In February $25.5 million of this was (re)announced – so, as far as I can determine, some $90 million remains unspent.
The National Ice Action Strategy (NIAS) was released in 2015 and implemented in 2016 with funding of $451.5 million over six years (from 2016-17 to 2021-22). It has now been extended for a further four years.
The media release from Health Minister Greg Hunt conflates the funding for ice/methamphetamine initiatives with that for drugs and alcohol; it says $315 million over four years is being invested in the ongoing fight to reduce the impact of ice, other drugs and alcohol.
That indicates that under the best circumstances (that all the funds go to NIAS) the new funding levels ($79 million/year) provide no meaningful increase over those from 2016 ($75 million/year).
There has been no attempt to update or improve the NIAS. A 2019 report from the Australian National Audit Office found that the Department of Health’s implementation of the Strategy was only “partially effective”. There was no monitoring to assess progress towards the Strategy’s goals of reducing the prevalence of ice use and resulting harms, and no evaluation approach in place.
An evaluation of the NIAS done by outside consultants and published in July 2021 (I’m not sure when it was publicly released) states: “Our evaluation was often limited by insufficient consideration paid to monitoring, documentation and outcome reporting during planning and delivery of activities. This deficit meant several activities could not be evaluated and resulted in a poor or moderate ‘evaluability’ score for most other activities.”
In other words, the Morrison Government is happy to continue to fund a Strategy whose effectiveness is unknown and currently unknowable.
It appears there has been no effort to address the ANAO criticisms and there has apparently been no analysis to ensure that the Strategy is responsive to current needs.
Make dental care an election issue
A perennial on the list of issues voters want to see addressed is dental care but, despite public pressure and the growing need, there is no indication from either the Coalition or Labor that making dental care more accessible and affordable will be an election issue.
I wrote about the adverse impact of the pandemic on dental care and services in 13 October 2021 edition of The Health Wrap.
In an article published recently on John Menadue’s Pearls and Irritations blog, Professor Heiko Spallek and I make the case for a change in culture that sees oral health as an essential part of overall health.
We urge first-step efforts to implement a national program to address access to and affordability of dental care. It is essential to improve the status quo – to address quality of life, health equity and the barriers imposed by out-of-pocket costs – even if the inclusion of dental care into Medicare is currently seen as a step too far.
The Grattan Institute, in the Orange Book of policy priorities for the Federal Government 2022, makes the case that nearly two million Australians miss out on dental care each year because of cost. While those who miss out are mostly the most disadvantaged, about 10 percent of the least disadvantaged are unable to afford needed dental care.
The Grattan Institute has also published a paper on developing a universal healthcare scheme for Australia. It calls for the Commonwealth to develop a clear roadmap to a universal scheme, including the cost, timing, and workforce development.
It seems I’ve been writing about this issue forever. It would be nice if I could retire all these references to the dental divide after this next election!
- 2014 article in MJA Closing the dental divide.
- 2018 article for ABC News The dental divide and the decay of pubic dental services.
- 2018 article for Pearls and Irritations Ending the medical / dental divide (redux).
The value of prevention
Another of the neglected health policy issues is prevention.
The National Preventive Health Strategy 2021- 2030 was released in December 2021, but is currently unfunded and is not at the centre of federal policies on health. A Blueprint for Action to guide implementation of the Strategy is apparently under development.
The National Obesity Strategy 2022- 2032 was released without fanfare – and again, without funding – in March. Organisations like VicHealth have welcomed the Strategy, but expressed concern that it puts too much responsibility on individuals when big business spends more than $550 million annually advertising and peddling their unhealthy food and drink products.
It’s interesting to scan the DoH website page on preventive health. The focus is much more on secondary prevention for individuals (vaccinations, cancer screenings) than primary prevention (community-based efforts to improve population health) and it reads much more impressively than the reality of actions in this area.
There is no mention of the important social determinants of health like poverty, housing, public transport, education and health literacy and (no surprise!) climate change.
A recent rapid review from the Australian Prevention Partnership Centre builds the case for continued and expanded investment in prevention within and across state and territory jurisdictions and at the national level.
The review focuses on only four key risk factors:
- Overweight and obesity
- Unhealthy diet
- Physical inactivity
- Tobacco use and smoking.
It summarises the evidence about the health, social, economic and other benefits of population-level strategies of primary prevention that protect the health of the community through reducing exposure to these risk factors.
The evidence shows prevention is most effective when multiple strategies are used to target risk factors.
The review makes the following recommendations for prevention strategies are particularly effective and/or cost-effective:
- Regulation and policies – such as plain packaging of tobacco products, improved food labelling, limiting unhealthy food advertising to children, smoke free policies.
- Fiscal interventions – such as taxing harmful products including tobacco, sugar-sweetened beverages and alcohol.
- Healthy lifestyle programs.
- Health promotion in different settings to create health supporting environments – particularly in schools, early childhood services, workplaces and maternity services.
- Built environment and transport – such as supporting active travel, more walkable communities, and access to green spaces.
- Social marketing and mass media campaigns to support regulatory, fiscal and environmental initiatives – particularly campaigns to promote physical activity and prevent smoking uptake.
While it’s valuable to be reminded of the value of prevention, the fact is that this work was done twelve years ago in the seminal Assessing Cost Effectiveness (ACE) in Prevention study.
The ACE Prevention report was and remains the most comprehensive evaluation of health prevention measures ever conducted world-wide, involving input from 130 top health experts. The research team assessed 123 illness prevention measures to identify those which will prevent the most illness and premature deaths and those that are best value for money.
The most recent organisational chart for the Department of Health shows that there is an office for Preventive Health Policy within the Population Health unit and under the division of Primary and Community Care – but it’s buried so far down in the network that there is no chance this could influence efforts across the health portfolio, let alone be an advocate for a whole-of-government approach to issues of population health and wellbeing.
In the DoH Portfolio Budget Statements for 2021-22, prevention sits under Program 1.5 (Preventive Health and Chronic Disease Support) but preventive health targets are focussed solely on smoking, alcohol, illicit drug use and cancer screening.
It’s impossible to know how much funding is dedicated to preventive health measures, but funding for Program 1.5 is shown as declining by eight percent over the forward estimates.
Equity in sport and physical activity
Too often policy initiatives in health prevention are poorly targeted and do not reach the most disadvantaged and those with the most need.
This is exemplified in a recent paper from my colleagues in the School of Public Health at the University of Sydney, who looked at socioeconomic disparities in physical activity and sport participation.
They found that children and adolescents living in higher socioeconomic status households were 1.2 times more likely to meet physical activity guidelines and 1.87 times more likely to participate in sport.
A similar analysis done in the United States reported similar findings. Children from low-affluence families reported fewer days of physical activity, fewer sports sampled, and lower rates of ever playing sports. These children reported that barriers to sports included: they don’t want to get hurt, they don’t feel welcome on teams, it’s too expensive, and transportation issues.
I can’t help thinking there’s a link here between the increasing level in government funding for private schools, with lots of sports facilities, and the failure to adequately fund public schools based on need.
Back in 2015, VicHealth produced an evidence summary, as part of the Fair Foundation Health Equity series, on promoting equity in physical activity. It’s definitely time to dig this out and dust it off.
De-implementing inappropriate healthcare interventions
The use of evidence-based clinical practice has significant consequences for both patients and healthcare costs. But optimising this is a major challenge within healthcare services.
Research from a number of developed countries including Australia, shows that 60 percent of care on average is in line with evidence- or consensus-based guidelines, 30 percent is some form of waste or of low value, and 10 percent is harmful. Professor Jeffrey Braithwaite and his colleagues refer to this as the “60-30-10 Challenge” .
The evidence-based movement is based on the approach that research findings and empirically supported (“evidence-based”) practices should be more broadly and/or efficiently implemented in various settings to achieve improved health and welfare of populations.
However, there is increasing recognition that an evidence-based practice also requires de-implementing (abandoning) practices that are not evidence-based (these are usually referred to as low-value care).
Maybe the hardest task in healthcare reform is de-implementing inappropriate or low-value health interventions – despite general agreement that this is essential for minimising patient harm, maximising efficient use of resources, and improving population health.
In Australia professionally-led campaigns such as Choosing Wisely and the Royal Australasian College of Physicians’ EVOLVE program aim to reduce the prevalence of low value care by alerting doctors to commonly overused interventions.
There has been some success – for example, with reducing the inappropriate use of antibiotics and medical imaging for back pain – but there is still a long way to go. A 2012 report identified 150 low-value practices to be addressed and a 2019 study showed the proportion of low-value care varied widely between New South Wales hospitals.
Implementation research is more mature than research on de-implementation, and there seems to be some disagreement as to whether implementation science knowledge, theories, and frameworks can provide support and guidance for de-implementation efforts.
A recent review aimed at identifying and characterising what influences efforts to reduce low-value care looked particularly at the role of habit in changing clinical behaviour. The authors note that much of a doctor’s daily work and interactions occur in unvaried, routine situations and in many cases their behaviour is guided more by habit than intention.
Other research has highlighted that patient expectations and professionals’ fear of malpractice are the most prominent determinants for the use and de-implementation of low-value care.
Doctors rarely see cost as a consideration unless they are aware of patients’ out-of-pocket costs.
The increasingly important role for empowering patients to be involved in these efforts to reduce low-value care is highlighted in a paper published in the Medical Journal of Australia in July 2021. It states that “evidence appears stronger and impact seems greater for strategies directed to, or mediated by, patients”.
The authors recommended that patients be encouraged to ask the following questions of their doctors:
- Is there a decision we need to make?
- What are my options?
- What are potential benefits and harms of each option?
- How will each option affect me in terms of what I consider important?
They conclude: “Efforts to increase patient empowerment in decision making should be seen as foundational for reducing low-value care, and should underpin all other strategies targeting clinicians, payers and policymakers.”
A recent OECD report found that, despite broad support for patient-centred care, the patient voice is weakly embedded in health systems. Surveys like the Australian Health Consumer Sentiment Survey, released this week, will serve as a baseline for improving people / patient empowerment.
Ukraine’s public health woes grow and spread outside its borders
The dreadful plight of the Ukrainian people in the face of relentless bombing and military tactics from Russia confront us every time we read the news, turn on the television or scroll through Twitter.
Now – not surprisingly given the complete breakdown of services – there are reports of growing problems with COVID-19 and other infectious diseases. These problems are spreading as millions of Ukrainians cross the borders seeking refuge in neighbouring countries and elsewhere in Europe, the United Kingdom, the United States and even Australia.
Even before the war, Ukraine struggled with epidemics of HIV/AIDS, tuberculosis and hepatitis. The conflict threatens to undo decades of progress and experts say a public health crisis looms.
A report last week in Nature outlined the problems.
- The spread of COVID-19 is an immediate threat as people huddle in basements, subway stations and temporary shelters.
- Without adequate water and sanitation, cases of diarrhoeal diseases are rising.
- The risk of polio and measles outbreaks is high.
- Access to diagnostic services and treatments for tuberculosis and HIV/AIDS is being interrupted.
- There is also an excellent discussion in The Atlantic on these issues here.
Ukraine’s COVID-19 vaccination rates are dangerously low – about 65 percent in Kyiv, but as low as 20 percent in some regions. Less than two percent of the population has received a booster shot.
A longstanding mistrust of vaccines among the population has hindered immunisation efforts for COVID-19 and other vaccine-preventable diseases, such as measles and polio, as well.
A vaccine-derived polio outbreak had already appeared in the country in late 2021 with more than 20 cases reported. In October the Ministry of Health declared a “biological emergency on a regional scale,” and rolled out a plan in coordination with the World Health Organization to begin inoculating children. This began in February but within weeks it was halted by the war.
Measles is also an issue in any humanitarian crisis because it is so contagious. And again, there are concerns that the national vaccination rate is insufficient to prevent outbreaks.
Ukraine has one of the world’s highest burdens of multidrug-resistant TB. An estimated 32,000 people there develop active TB each year, and about one-third of all new TB cases are drug resistant. Twenty-two per cent of people in Ukraine with TB are infected with HIV, and TB is the leading cause of death among those living with HIV.
Access to HIV/AIDS treatment is also in jeopardy in Ukraine, which has the second highest burden of HIV/AIDS in Eastern Europe. About one percent of the population is infected, but that number is much higher (21 percent) in people who inject drugs. Before the war started, just 57 percent of people with HIV/AIDS were receiving treatment to suppress their viral loads.
An editorial in The Lancet outlines the health challenges for other countries of the displaced populations from Ukraine. The public health and healthcare systems must prepare for pregnant women, people with chronic diseases and underlying conditions requiring continuity of care, and the health risks associated with infectious and communicable diseases of large groups who are either travelling or living in conditions that are not ideal.
Previously at Croakey
- Russia’s bombardment and Ukraine’s departure ban leave children and those with disabilities most vulnerable
- Weapons of mass destruction, what are the chances Russia will use a nuclear or chemical attack on Ukraine
- As millions flee Ukraine, the focus must be on abolishing nuclear weapons
- The assault on Ukraine has massive and wide-ranging health implications
- Health leaders express solidarity for Ukraine and urge protection of health workers and facilities
- As the world watches Ukraine, here are some of the global health stakes.
The best of Croakey
The Federal Budget and health: how to read between the lines – a must-read by Charles Maskell-Knight PSM, who worked as a senior public servant in the Department of Health for over 25 years before retiring in early 2021.
The good news story
I found Patricia Karvelas’ recent interview with Professor Jack Beetson, a Ngemba man and executive director of the Literacy for Life Foundation, to be a very powerful case for community control in efforts to improve literacy among Aboriginal and Torres Strait Islander people.
You can learn more about Professor Beetson’s life story and how he became a champion for Indigenous literacy here.
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.
Previous editions of The Health Wrap can be read here.