If you’ve a concern for Indigenous affairs, there is some essential reading in the 470-page Strategic Review of Indigenous Expenditure (PDF alert) that was recently released under Freedom of Information legislation. 

The review, dated February, was not designed to produce savings, but to assess how well programs are meeting the objectives of COAG’s Closing the Gap targets, and to identify how funding could be redirected from low-value to high-value programs.

It found that the Commonwealth’s $3.5 billion annual investment in Indigenous-specific programs had “yielded dismally poor returns to date”, and that there was a need to use existing resources far more effectively.

Other general findings included the need for a sharper focus on the performance of mainstream services, that evaluation of programs has been “patchy at best”, and that there is considerable scope to rationalise programs, too many of which are based on “poorly articulated objectives” and flawed or unrealistic assumptions.

Meanwhile, The Drum and The Conversation have teamed up to provide a series of articles analysing Indigenous policies, with articles from Russell Ross, Associate Professor, School of Economics at the University of Sydney; Chris Sarra, Executive Director, the Stronger Smarter Institute at Queensland University of Technology; Jon Altman, Research Professor in Anthropology at Australian National University; Marilyn Wise, Associate Professor at the Centre for Health Equity Training, Research and Evaluation at the University of NSW; Peter O’Mara, President, Australian Indigenous Doctors’ Association; Ciaran O’Faircheallaigh, Professor, Griffith Business School at Griffith University; and Peter Billings, Senior Lecturer in Law at the University of Queensland.

There are also rich pickings in the article below from Professor John Wakerman, Director of the Centre for Remote Health, which analyses some of the forces driving policy, particularly around Indigenous and rural/remote health. It was the basis for his recent presentation to the National Rural Leadership Development Seminar, as previously mentioned at Croakey.


Understanding the messy policy process and how to influence it

John Wakerman writes:

In the lead up to the 2007 federal election, the Kevin 07 election, the Australian Government Intervention (AGI) was launched in the NT. This was a policy response from the Australian Government to the Little Children are Sacred Report into child abuse and neglect that had been commissioned by the NT Government.

The Australian Government had very rapidly developed a policy and legislative response leading to a raft of actions that included:

  • The $587 million package with the passage of the Northern Territory National Emergency Response Act 2007 in August 2007
  • Compulsory child health checks, specifically checking for signs of sexual abuse
  • Banning of alcohol and pornography in 73 prescribed communities in NT
  • Deployment of additional police to affected communities.
  • Compulsory acquisition of townships currently held under the title provisions of the Native Title Act 1993
  • Suspension of the permit system in remote communtiies
  • Quarantining of a proportion of welfare benefits to all recipients in the designated communities and of all benefits of those who neglect their children
  • The abolition of the Community Development Employment Projects (CDEP)
  • Suspension of anti-discrimination legislation to enable some of these measures.

When this policy bolt came out of the blue in 2007, I kept a folder of the considerable resulting email communication that I labeled ‘the tidal wave’, because it was a such a rapid and unexpected change in policy direction that hit many communities and individuals with tremendous force and changed the political and social landscape of the NT in very significant ways. So clearly, policy is important.  In some way, it affects us all on a day to day and year to year basis.

How can we understand this sort of policy response? Where did it come from? What was the evidence on which it was based? Why does an idea’s time come when it does? How can we influence these changes?

In this paper, I’ll use the Intervention and other examples of rural health and Indigenous health policy to illustrate a way of thinking about policy that addresses these questions.

The paper covers:

  1. Some of the current pressures on the health system;
  2. Current  major rural health policy issues;
  3. The definition of policy;
  4. A conceptual framework for thinking about the policy process with some illustrative examples relating to rural health; and
  5. What you can do to influence policy.

Current pressures on the health system

Firstly, let’s very briefly look at some contextual health system issues. Health service delivery is complex, challenging, costly and involves many different health professionals. All countries struggle to contain health care costs. Australia’s expenditure is at about the median of OECD countries.

Figure 1 Health care expenditure as a percentage of GDP in 12 OECD countries [source: OECD (2008), OECD Health Data 2008, Version: December 2008 in NHHRC 2009  A  Healthier Future For All Australians Final Report]

(Source: AIHW 2010. Health expenditure Australia 2008-09. Health and welfare expenditure series no. 42. Cat. no. HWE 51. Canberra: AIHW)

Over the decade to 2008/9, actual expenditure in Australia grew by 5.4% pa and as a proportion of GDP by 3.2% pa.

These growing amounts spent on health will affect all other sectors. Some states, like NSW, estimate that at the current rate, health will consume 100% of the state budget by 2033.

Increasing costs are driven by overall income growth, technological change, population size, ageing and associated increasing chronic disease prevalence.

Drivers of expenditure:

  • 50% overall income growth  – as pc GDP increases, greater amounts are expended on health
  • 25%  technology, drugs, procedures
  • 12.5% population increase
  • 12.5% population ageing

Rural & remote health issues

Ensuring access to health services for all citizens is an additional major challenge in geographically large countries with dispersed populations like Australia. Key remote and rural health issues include:

  • Poorer health status as you move from metropolitan centres to remote regions
  • A socio-economic gradient as we move to remote areas
  • Aboriginal & Torres Strait Islander health inequalities
  • Limited access to appropriate care, particularly appropriate models of care
  • Heath workforce maldistribution
  • Recruitment and retention problems
  • Unmet infrastructure needs

But we also need to have a balanced view of the bush. As the Productivity Commission acknowledged, the relative scarcity of resources leads to innovation in rural areas – a culture of doing more with less. As Judith Brett noted in the current Quarterly Essay about the shifting relationship between the city and the country, the country also produces 93% of our food, defines our identity and is the place to which we and others go on holidays.

Good policy is critical to addressing these issues. I started with the vivid example of the NT Intervention. But generally, health care policy underpins health care delivery and funding that ensures sustainability of services. Indeed, we are in the midst of a national reform process that is attempting to address some of these issues.

Definition of policy

What is a policy? A policy is typically described as a principle or rule to guide decisions and achieve rational outcome(s). A policy can be considered as a ‘Statement of Intent’ or a ‘Commitment’; Or a ‘set of principles guiding action towards predetermined ends.’

Importantly, policies prioritise issues and funding.

The policy process

How does the policy process work? A common depiction of the policy process is:

  1. Issue identification
  2. Policy analysis
  3. Policy instrument development
  4. Consultation
  5. Coordination
  6. Decision
  7. Implementation
  8. Evaluation

A problem is identified, the evidence informing how it is best addressed gathered & synthesized, a coherent, co-ordinated policy is developed, discussed, implemented and evaluated. A feedback loop ensures that implementation is appropriate to the changing nature of the problem originally addressed.

In fact, the policy process probably works something more like this: (the presentation included a cartoon depicting an untidy mess).

Policy formulation is seldom a linear or straightforward process.  It’s messy, complex and subject to multiple competing interests. And it’s about power.

John Kingdon is an American researcher who has analysed and written about policy development based on observations of the political process in the United States. His conceptual framework is both appealing and useful. The policy process may be complex, but it’s probably not quite as messy nor as distasteful as I have made out. And it is amenable to analysis. Kingdon describes three separate, independent but interacting streams of Problem, Policy and Politics.

When a recognized problem marries an effective policy solution and the politics is right, this alignment of the three streams opens the ‘policy window’.

So, to return to our example of the NT Intervention, the problem of child abuse and neglect was not a new one: there was a decade or two of previous documented evidence. The publication of the Little Children are Sacred Report was a focusing event that re-identified the problem.

One could argue that what had changed most significantly was the politics: we were in a pre-election period, with government popularity waning in the polls.  There was thus a fertile political context and there was a conducive national mood for action in this area.

The policies were loosely based on work and discussion over some period of time in Cape York where they had negotiated a consensus between communities and government on a means to address social problems there. The Coalition government of the day rapidly formulated a policy that, they thought, would effectively address this major problem, but was far short of any consensus between government, the communities affected and professionals to be involved in the Intervention.

Politics and problem came together, resulting in a rapid policy response, and these streams aligning resulted in the Intervention.

And it is often the case that problems are recognized and existing policies implemented when the politics lines up. As Kingdon observes, ‘When a [policy] window opens, problems & proposals flock to it.’

We have seen a very colorful example of this with the current minority national government. Rural health problems have been well documented over decades. When the balance of power fell to a small number of rural independents – the politics was right – problems and proposals flocked like galahs at dusk on a summer’s day.

As well as benefits for their individual electorates, the rural independents secured very significant gains for the bush; these included prioritization of the NBN implementation for rural areas, two dedicated rounds of infrastructure funding from the Health and Hospital Fund, a regional Education Infrastructure Fund round, the establishment of a Rural Health Agency within government to co-ordinate RH policy, and an expedition of the formulation of a national rural health policy – the policy stream had been meandering listlessly for some time, the national rural health policy having actually expired three years ago.

Other similar examples of the politics stream changing to open the rural health policy window relate to the mid to late 1990s, when a disaffected rural electorate facilitated the emergence of Pauline Hanson and the One Nation party as a real political threat.

This was brought home by the unexpected loss of the Kennett Government in Victoria in 1999, losing 13 seats mostly in regional centres such as Ballarat and Bendigo. The national government took stock of the national mood in the bush and this resulted in a budget centrepiece around health: the Regional Health Services program with a budget in excess of $500 million, particularly  to address some of the outstanding issues relating to rural health workforce supply

More recently, after the last WA state election, Brendon Grylls used the balance of power held by the National Party in WA to negotiate the Royalties for Regions policy formulated in 2008.  This entails the redirection of government spending from the major population centres, particularly Perth, into the rural areas of the state by setting aside 25% of the state’s mining and petroleum royalty revenue.

How the agenda is set by government – the prioritisation and definition of ‘problems’ – is highly sensitive to politics. Participants perceive swings in national mood or poll results or impending elections. These are very powerful agenda setters. Politics is probably the strongest driver, but not the only way in which agenda are set.

Let’s take a closer look at how problems are framed and the participants in the policy process.

1. Problems:  indicators may show a problem, like the rising costs of health care;  or there may be a focusing event – such as a highly publicised report which begs action (like the Little Children are Sacred report) or the recent suspension of live cattle exports to Indonesia. This affected many fellow Territorians in the cattle industry. The video of cruelty to animals in an Indonesian abattoir – the problem – dragged the politics and policy with it.

But how a problem is framed is also important in relation to the policy response.

For example, there is currently a debate about alcohol and related problems in Alice Springs. This can be viewed as a law and order issue, or a medical problem relating to a relatively small group of very heavy drinkers; or a broader social problem affecting the entire community.

  1. If viewed as a law & order problem, the response is more police, more street lights, more CCTV, harsher penalties.
  2. If a medical problem confined to a small group of problem drinkers: restrict access, an alcohol court, mandatory rehabilitation.
  3. Or you might see this as a complex social problem affecting the entire community. If the NT were a country, it would have the second highest per capita alcohol consumption in the world; evidence-based strategies to address this complex social problem could include decrease overall supply, using pricing to decrease consumption, or primary prevention with sport & recreation, enhancing educational and early life opportunities, employment etc.

Now, interestingly, the NT government has responded to excessive alcohol consumption as (a) a law and order problem, (b) as a problem affecting a small group of problems drinkers, but not (c) as a whole of community problem.

It has been resistant to setting a floor price on alcohol – regulating the price of a standard drink that eliminates cheap grog and decreases consumption, especially amongst young drinkers and heavier drinkers. The evidence for reduction in alcohol consumption is strongest for price regulation – the one option rejected by the NT Government.  More about this in a moment.

2. Participants – there are both visible and hidden participants; politicians & media commentators are very visible, and the academics advisors, bureaucrats, advocates and community groups involved in the policy process are often less visible. These participants interact in the various ways and cook up what Kingdon calls a policy ‘primeval soup’ of ideas floating around in speeches, research papers, briefing documents, lunchtime conversations, parliamentary committee meetings etc.

Ideas are sorted from this soup of ideas by a number of criteria:

  • Technical feasibility
  • Congruence with community values – the broader community, but importantly the policy community
  • Anticipation of constraints, especially budgetary constraints (think about ‘Denticare’)
  • Politicians’ receptivity

To return to the Alice Springs alcohol consumption problem, there is an advocacy group, the Peoples Alcohol Action Coalition (PAAC), that has been advocating strongly for restricting access and a floor price on alcohol for some years. Their spokespeople, particularly Dr John Boffa, a local GP, have been professionally and persistently presenting the evidence to the media, highlighting that, for example, the major supermarket chains in Alice Srpings were selling cleanskin wine at a price less than a drink of Coke. As a result, first Coles, then Woolworths and then smaller retailers have agreed to a floor price for the alcohol they sell.

So despite government intransigence, the persistent, professional evidence-based advocacy of the PAAC has brought results.

Importantly, whilst we focus many of our efforts on influencing government policy, in this instance it was a large retailer that responded in an effective fashion. The Commonwealth Government referred the pricing issue to the Preventative Health Agency; the NT Government rejected a floor price policy; and the local government wrote to Coles asking them to reverse their decision.

Thus advocacy led to voluntary policy change by the large supermarkets concerned about their image in the community. The change was affected despite government, rather than because of it.

Solutions are hawked by policy entrepreneurs. These are lobbyists, activists or  advocates like PAAC with solutions looking for problems with which to couple their solutions. They broker ideas and people, and are persistently engaged in a process of softening up: improving the receptivity of decision-makers; waiting for and facilitating the linking of all three elements – problem, policy and political receptivity – into one successful package.

A good example of this related to the NT Intervention is the Enhanced Health Service Delivery Initiative. In the first phase of the NT Intervention, the Aboriignal Medical Services Alliance of the NT (AMSANT) engaged with government and moved the policy discussion from child health checks – of doubtful usefulness on their own – to sustainable, better funded PHC service in regions of greatest need.

For the latter, AMSANT had previously developed a regional hubs & spokes model of care & appropriate funding. Here was an opportunity to have it implemented. They cannily attached their solution to the problem.

Health professionals’ role in the policy process

So, finally, what can you do in the policy process?

Firstly, it is important to understand the importance of policy in establishing principles of action to address pressing problems.

Secondly, it’s useful to understand the issue at hand using a conceptual framework that works for you. I have described one way of analysing the policy process  – problem, policy & politics – that I have found useful.

Critically, it’s important to appreciate that individuals have agency – the power to effect change. To identify problems, describe solutions and to be aware of political opportunities to enact change. Individual actions and broader social structures and processes are in a dynamic, linked up relationship. And if you have an understanding of the policy process, then you are well situated to affect that process.

Academics can respond to identified problems or help to identify problems. They can provide advice, create and synthesize evidence.

Health professionals can be effective advocates within their communities, especially in smaller rural and remote communities. They can also work very effectively through professional and advocacy groups, and relevant community organisations.

At the National Rural Health Conference earlier this year, Mike Daube, a public health physician and very experienced advocate, offered some handy hints for effective advocacy. I have pinched and adapted these as I think they are useful in the practicalities of the softening up process, and in linking problem, policy and politics.

1. Ensure you have the solid evidence – appropriate indicators of the problem and ensuring technical feasibility of the solutions eg a floor price for alcohol;

2. You must be in it for the long haul. Keep finding new & effective ways of presenting the evidence. Think about the impact of the film of an Indonesian abattoir; or comparing the cost of a standard drink of cheap wine with the cost of a glass of coke;

3. Describe the problem or wait for the problem come along, but make sure you have your solution ready. Focus on policy solutions, don’t just describe the problems. This just perpetuates a deficit view of rural health.

4. Personalise the message: as a colleague once remarked, statistics are stories with the tears wiped away. Tell the stories.

5. Ensure consensus on the solutions amongst different groups. This is an important part of the softening up process: the same message from many sources.

6. Utilise effective coalitions eg national groups like AMSA, NRHA, or local groups like PAAC & other organisations that can amplify the message.

7. Always be professional.

8. You are in it for the long haul. Be patient, persistent and available to the media and other audiences. The softening up process, waiting for the problem to come along can take a while. Most overnight successes have taken some time.

As current and future health care providers and leaders, you will be subject to health policies as well as being able to influence them. You and your organisations have the potential and power to be agents of change. I hope that this paper has helped you in some small way to be active leaders in the process of healthy public policy formulation.

• Note from Croakey: references available on request

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