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The Health Wrap: on rats, mice and the budget, primary care, pandemic lessons and “a beautiful gift”

As we await the formal launch of the federal election campaign, Associate Professor Lesley Russell covers a raft of important health issues that merit informed debate in the weeks ahead, including the Uluru Statement from the Heart.


Lesley Russell writes:

The Federal Budget, the upcoming election (now almost certain to be called for May 21) and some important reports have kept me busy these last two weeks.

I’m sure you have noticed and welcomed the fabulous job done by my colleagues at Croakey Health Media in reporting on the issues and responses to #HealthBudget2022. All of the Croakey articles on the Budget are collated here.

In particular, I would commend to you the analysis of the health budget by Macquarie University Centre for the Health Economy (MUCHE). In particular, we should measure the Morrison Government’s claims of increased spending in health against the MUCHE data.

For example, this paragraph should always be top-of-mind: “Health portfolio funding will be reduced by $5.7 billion in 2022-23 compared to 2021-22. This equates to a nominal reduction of 5.1 percent, but a real reduction of 7.5 percent once health inflation and population growth are considered. Funding will be tighter in 2023-24, with another $3.2 billion reduction. Most of the funding reduction in the next two years is from the cessation of COVID-19 emergency measures. However, real funding in 2025-26 is also estimated to be 6.0 percent lower than in 2021-22.”

Ross Gittins looks beyond health in his budget analysis and lists the winners and losers – essentially a list of Government mates and outsiders.

The almost unanimous decision is that this budget round was a missed opportunity by the Morrison Government to capitalise on the groundswell of support for primary prevention actions, ensuring the affordability and accessibility of healthcare services, supporting healthcare workers, boosting the resources of public hospitals, and significant reforms in service delivery across the board.

The pandemic and natural disasters have highlighted the huge socioeconomic, health and wellbeing divides in Australia, the value of investing in disaster preparedness, the consequences of not investing in tackling climate change, the pressures faced by healthcare workers and carers, and the need for governments to work co-operatively to address these issues.

Instead, what we got in this Budget was best described by Professor Stephen Duckett as “rats and mice” – dribs and drabs of funding spread thinly across a range of areas in the absence of any recognisable strategy (other than vote gathering) and with no long-term focus.

Senate Estimates for the Health Budget were held on April 1 and April 6. As is increasingly the case, these were pretty unedifying and uninformative, with a number of Senators hijacking the questioning around COVID-19 vaccines (sigh!). Transcripts are available here.

Now we are headed into what promises to be a bitter election campaign that is unlikely to see either of the major parties make a big effort to push health issues – even though these rank high on voters’ lists. (In saying this, I hope I’m wrong about Labor, which is claiming the high ground when it comes to aged care and Medicare and caring about what Australians care about.)

I’ve been pretty critical of #HealthBudget2022 (see my summary of the issues here and my analysis of the fate of the Quality Use of Medicines program here).

However, on reflection I think the biggest problem with the Budget, Labor’s Budget response, and the electioneering to date is that there is no indication that anyone is interested in a concerted effort to evaluate the national response to the pandemic  – what worked, what didn’t work, and why – and to ensure that the capabilities are in place to manage the next epidemic or major disaster.


Lessons from the pandemic

As early as December 2020 there were calls for a Royal Commission to investigate the Morrison Government’s response to the pandemic.

Others, like Professor Stephen Duckett and Victorian Chief Medical Officer, Professor Brett Sutton, were pushing for plans for recovery and living with the coronavirus.

Now a philanthropic group is pulling together an inquiry. The political independence of such an inquiry will be helpful in ensuring the focus is more on what can be learned that on apportioning blame, but it will be hindered by its lack of powers to gather information and compel people to testify.

This week the Senate Select Committee on COVID-19 brought down its final report which was  almost two years and multiple hearings in the making.

The report makes 19 recommendations. I’ve summarised the key recommendations (there are no surprises).

  • The establishment of an Australian Centre for Disease Control.
  • An urgent review of the Australian Government’s pandemic planning and immediate improvements.
  • The Australian Government to report to the Parliament at least once every two years on the state of Australian pandemic preparedness.
  • The Australian Government to commit to resourcing and delivering whole-of-government pandemic preparedness exercises every two years.
  • Consideration of appropriate arrangements to enhance the performance of the National Medical Stockpile and action to rebuild Australia’s diminished sovereign manufacturing capability to ensure pandemic preparedness and response.
  • An expert review of the National COVID-19 Aged Care Plan and the impact of COVID-19 and the pandemic response on residents and staff in residential aged care facilities.
  • Commonwealth and State and Territory Governments to work to identify ways to achieve better and more consistent outcomes around disaster mitigation and response. This to include a review to strengthen the Intergovernmental Agreement on data sharing between governments to address any gaps in access to timely and relevant data, particularly related to public health and aged care.
  • The Australian Government must adequately address the social determinants of health, which have been exacerbated by the pandemic, when delivering responses to COVID-19 with First Nations communities, including food security, fuel security, water security, quarantine facilities, transport, infrastructure, housing.
  • Australia to increase its contribution of COVID-19 vaccines and related support measures to Pacific region countries.
  • All previous and future minutes of the Australian Health Protection Principal Committee be publicly released to promote transparency and accountability.
  • A review of Senate mechanisms to compel compliance with a committee’s legitimate entitlement to receive the information it has requested, to ensure that there is greater accountability for unanswered questions on notice and claims of public interest immunity not accepted by the committee and the Senate.
  • A Royal Commission be established to examine Australia’s response to the COVID-19 pandemic.

There is of course a dissenting report from the Government Senators on the Committee. It is basically a polemic in support of the Morrison Government’s health and economic responses – all seen in a positive light. This was presumably written under the guidance of the Prime Minister’s office. The response offers no insights into what might have been done better.

This report will likely prove a useful weapon for Labor during the election campaign.  After the election, the newly elected Government must then face the challenge of addressing the report’s recommendations (or I suppose, try to bravely ignore them?).


Disappointments in primary care reform

Health Minister Greg Hunt dumped the final version of the 10-Year Primary Health Care Plan out on Budget night, presumably hoping he could argue that the grab bag of budget items listed under the rubric of ‘Guaranteeing Medicare – Strengthening Primary Care’ (who dreams up these headers?) would look like a response.

No-one in the sector was fooled. The increased funding for primary care touted by the Morrison Government is largely the consequence of population growth and ageing. And the current response – doing more of the same and hoping for different results because there is now a Plan – is not the pathway to success.

As the Consumers Health Forum stated:

While we welcome the release of the 10 Year Primary Health Care Plan, we are disappointed that after two years of extensive consultation and co-design with all stakeholders including consumers, there has been a failure to commit to a funded program of transformational implementation.

This is a lost opportunity for the government to lead and drive major structural and financing reform in primary care. Primary care is the backbone of a high performing health system and is the first place people turn to for healthcare. We cannot afford for it to experience under-investment and become overwhelmed.”

The push for action both in this area and more generally in the area of healthcare workforce has been reinforced by the release of the interim report on the “Provision of general practitioner and related primary health services to outer metropolitan, rural and regional Australians” from the Senate Community Affairs Reference Committee (the final report has been delayed until after the election).

My colleague Alison Barrett has written about this for Croakey so I won’t analyse the report’s recommendations. To my mind these are very prosaic, very focussed on keeping the current ship afloat rather than building a new and better boat.

The value of this report and its recommendations lies in the fact that they incorporate the needs of people working at the coalface and living in non-urban communities. Reforms in primary care will require simultaneously addressing these short-term, urgent needs while developing and investing in a shared long-term vision with new models of delivery and financing. And, of course, providing the necessary workforce.

The report’s recommendations, in particular those around the need for reform of Medicare items and increasing Medicare rebates, are echoed in the findings of the recently released Australian Health Consumers Sentiment Survey and a round table on access to health services in rural, regional and remote areas held jointly by Consumers Health Forum and the National Rural Health Alliance.

See also this article for Croakey Health Media by Cate Carrigan.

While you are pondering what primary care in Australia should look like in 2022 and beyond, here’s a link to what are seen as threats to primary care (already in a sad state) in the United States. You don’t have to agree with all of the points in this article (I certainly don’t) to be just a little concerned about which way primary care could go in Australia.


The Lancet Global Health Commission in financing primary health care

It’s a nimble segue from the previous topic to this.

The Lancet Global Health Commission on financing primary health care (PHC) – just released – presents new evidence on levels and patterns of global expenditure on PHC; analyses key technical and political economy challenges; identifies areas of proven or promising practice; and suggests actionable policies to support low-income and middle-income countries in raising, allocating, and channelling resources to support the delivery of effective, efficient, and equitable PHC.

I’ve picked out some key points that I see as relevant to Australia. There’s nothing new here, but these are issues that must become a constant mantra if we are to see needed changes from government policy makers.

  • Public financing for PHC is the key to universal health coverage and strengthening health security, as highlighted by the pandemic.
  • The concept of PHC is broader than simply delivering primary care services and a “financing for health” approach is needed to reflect this. This includes addressing cross-cutting public health functions and health determinants that emanate from outside the healthcare system.
  • Funds need to directly reach the PHC team on the ground without being waylaid by layers of managers and interests in between.
  • Adjustments in the amount paid to a provider to cover patient services (the preference is for a capitation -style payment mechanism to cover all services) can target equity by considering high-risk groups and the multimorbidity, rurality, or socioeconomic status of patients. This approach requires that patients are linked to / enrolled with a designated provider.
  • PHC has been described as the coordination mechanism that links primary care, community care, specialised care, wider public health interventions, and long-term care services. However, efforts to improve coordination and integration often face challenges at the interfaces of services and specialities and financing arrangements are frequently at the core of these challenges.
  • PHC needs to continue to embrace new technologies that support coordination, interoperability, and regulation; and financing arrangements should continue to adapt to accommodate these.
  • The way health-care providers are paid often works against the objectives of PHC. In systems that pay providers a fee for a service, they typically set higher payment rates for specialty services, giving providers a financial incentive to prioritise curative, rather than preventive, care.
  • Definitions matter (and in Australia there is a consistent disregard of the difference between primary care and primary health care). They signal what is prioritised and valued, and they shape norms regarding how services should be organised. They also influence how data are collected and presented and expenditure is measured.
  • Efficiency reforms should not be seen as a way to either balance budgets or identify spending cuts in health

There is a lot to read in this report which provides plenty of reasons why Australia should not sit back and blithely think Medicare has got them covered.

In summary – advice for politicians and policy makers:

Finally, collaboration is at the heart of the concept of a whole-of-government approach that transcends line ministries and other agencies’ typical portfolio boundaries to achieve shared multisectoral goals.

This is particularly crucial to PHC and its financing, in which engaging the whole government involves, in part, recognising the relative power of different ministries involved (particularly health, finance, and other social sectors such as education or water and sanitation), and ensuring that their interests align.”


Closing the Gap efforts continue to falter

Under the National Agreement in Closing the Gap, the Productivity Commission is tasked with providing independent oversight and accountability of progress by:

  • Developing and maintaining an information repository which includes a data dashboard and an annual data report.
  • undertaking an independent review progress every three years, which will be complementary to a three-yearly Aboriginal and Torres Strait Islander-led review.

At the end of last month the Productivity Commission updated their Dashboard with Closing the Gap data across eight of the 17 socioeconomic targets under the Agreement.

This is ahead of the second Annual Data Compilation Report from the Productivity Commission which is expected by the end of July 2022. The first report, from July 2021, is available here.

The news is not good.

The new data highlight that the rates of Indigenous Australians being jailed, dying by suicide, and having their children placed in out-of-home care are continuing to worsen, not improve.

  • The age-standardised rate of Indigenous prisoners was 2,222.7 per 100,000 people at June 2021, an increase from 2,142.9 in 2019. That figure is more than 10 times higher than the imprisonment rate for the general population.
  • The suicide rate for Aboriginal and Torres Strait Islander people rose from 25 per 100,000 people in 2018 to 27.9 per 100,000 people in 2020. We don’t actually know the true extent of the problem because data from some States and Territories are not available.
  • The rate of Indigenous children being placed in out-of-home care has gone up from 54.2 per 100,000 kids in 2019 to 57.6 in 2021. There is a high rate of disability among these children; 19.1 percent have a reported disability, but the rate could be higher because the disability status of 38 percent of the children is unknown.

The ability to accurately track what is happening with Closing the Gap initiatives continues to be beset by limited data. For example, the life expectancy figures have not been updated since 2015-2017, with information not available for some states and territories. And life expectancy is a poor proxy measure for the target of ensuring that people enjoy a long and healthy life.

As this tweet by the National Aboriginal Community Controlled Health Organisation (NACCHO) notes: these are sobering issues to consider on World Health Day – and every day.A media release from the Minister for Indigenous Affairs Ken Wyatt on 7 April outlines what we already know – that the Productivity Commission is to undertake its first three-yearly review of the National Agreement on Closing the Gap. Perhaps the timing of this release reflects the endorsement of the Terms of Reference for the review by the Joint Council on Closing the Gap.

The media release states that: “The Government has asked the Productivity Commission to release a draft report and then provide a final report by the end of 2023”.

That’s a long time to wait for information about the extent to which Closing the Gap initiatives are not targeted or working well.


In case you missed it

A quick summary of some recent publications that caught my eye.

Why Covax, the best hope for vaccinating the world, was doomed to fall short. As another wave gathers, global health experts wonder why the best plan to fight back against the coronavirus didn’t succeed.

Can Trump persuade Americans to get a COVID-19 vaccine shot? Researchers made an ad to find out – and the answer is yes!

Report from McKinsey Health Institute. Adding years to life and life to years. At least six years of higher-quality life for everyone is within reach

Commonwealth Fund report. Health and Health Care for Women of Reproductive Age: How the United States compares with other high-income countries. Sadly, perhaps not surprisingly, the United States ranks last. More information from the US perspective here. Australia ranks poorly on cost issues.

BMJ article. Action on patient safety can reduce health inequalities. Providers and health systems should use ethnic differences in risk of harm from healthcare to reimagine their role in reducing health inequalities.

White House rolls out national plan to address long-COVID.  More information here. When will we see such a plan in Australia?


The best of Croakey

I recommend this article on the new report from the Intergovernmental Panel on Climate Change (IPCC).


The good news story

Thanks to Twitter I just discovered this speech given by Adjunct Professor Janine Mohamed, CEO of the Lowitja Institute, at the National Foundation of Australian Women event held in November last year.

In her speech, title “The Great Australian Dreaming”, Mohamed speaks of her optimism for the future of her children and grandchildren and how First Nations peoples derive strength from individual acts of activism. But she also highlights that cultural safety for Aboriginal and Torres Strait Islander peoples must be at the heart of the pursuit of important changes like the Uluru Statement from the Heart and Closing the Gap initiatives.

I’m optimistic that a Government response to the Uluru Statement from the Heart will be a key issue in the election campaign, and this speech highlighted the hopes and fears of like-minded Australians (Indigenous and non-Indigenous) who want to see progress on this issue.

Indigenous elder Pat Anderson – who co-chaired the Referendum Council which designed the process that resulted in the Uluru Statement, which she describes as “a beautiful gift to the Australian people” – has recently called for “a people’s movement” to make it an election issue.


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.

 

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