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Australian public health policy in 2003 – 2004

Australian public health policy in 2003 – 2004 In Australia, compared with other developed countries the many and varied programs which comprise public health have continued to be funded poorly and unsystematically, particularly given the amount of publicly voiced political support. In 2003, the major public health policy developments in communicable disease control were in the fields of SARS, and vaccine funding, whilst the TGA was focused on the Pan Pharmaceutical crisis. Programs directed to health maintenance and healthy ageing were approved. The tertiary education sector was involved in the development of programs for training the public health workforce and new professional qualifications and competencies. The Abelson Report received support from overseas experts, providing a potential platform for calls to improve national funding for future Australian preventive programs; however, inconsistencies continued across all jurisdictions in their approaches to tackling national health priorities. Despite 2004 being an election year, public health policy was not visible, with the bulk of the public health funding available in the 2004/05 federal budget allocated to managing such emerging risks as avian flu. We conclude by suggesting several implications for the future. aimed at primary prevention and the promotion and pro- Introduction Public health is a small component of the health system, tection of the public health ('rats and drains'). This has led both in terms of budgetary allocation at either state or to an increasing number of jurisdictions adopting the national level and in terms of the number of practitioners. label 'population health'. It incorporates a myriad of activities; legislation and regu- lation for health protection, preventive services directed at Renovation of the public health system has been on the specific diseases and populations, and health promotion international agenda for some years. In the US, the Insti- programs geared towards particular risk factors and vul- tute of Medicine released reports during 2003 about the st nerable groups in the community. As such, it looks like a public health workforce required for 21 century chal- disparate collection of programs and investments. lenges [1], as well as re-visited and updated its landmark [2]. report, The Future of Public Health in the 21st Century In Australia, there is also confusion about the very termi- In the UK, following the path-breaking review of the NHS nology of 'public health'. Despite its extensive history and by Derek Wanless[3] the Treasury commissioned him, in global understanding, in Australia the term is used vari- 2003, to undertake a review of whole-of-government ously; to refer to publicly funded health services, and effort in public health. Arising in part from the challenges interventions (regardless of the funding source) which are that confronted Canada during the outbreak of sudden Page 1 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:7 http://www.anzhealthpolicy.com/content/2/1/7 acute respiratory syndrome (SARS) in 2003, a new public The National Public Health Partnership (NPHP) and the health agency, at arms length from government, is being AHMC adopted the influenza pandemic plan in October created. 2003, and with the advent of the newly-identified disease SARS, as well as outbreaks of meningococcal disease, Public health in Australia, meanwhile, remained frag- management and prevention of communicable diseases mented – by programs, across jurisdictions (particularly was prominent. Following on from the significant fund- the states and territories) – and without a systematic ing boost for bioterrorism preparedness in 2002/03, pub- approach to funding, organisation, or conceptualisation. lic health preparedness became a more generic theme. In 2003/04, the gap between rhetoric and funding contin- ued to be noticeable, along with the tension between The arrival of SARS occupied the national popular and framing priorities for popular appeal versus the technical political imagination as well as tested the infrastructure language of the evidence base. capacity of public health. Australia fared well during the outbreak. Apart from escaping with only six Australian This article will examine some of the indicative develop- cases, it provided an opportunity to establish a coordi- ments of public health in Australia in 2003/04. The key nated approach between the Commonwealth and the developments are identified, and a number of them are states/territories and also contributed to the global epide- selected for in-depth analysis. In this article, we use the miological investigation and prevention effort. SARS also traditional meaning of the term 'public health' and focus prompted amendments to the Quarantine Act [4]. on activities which are usually designed to promote and protect the health of the population. The drivers for these While the recall following the Pan Pharmaceutical crisis developments, their short term implications and some put the Therapeutic Goods Administration (TGA) under signposts for the future are suggested. the spotlight, it also managed to conclude negotiations that had been in train for several years on a Trans-Tasman 2003/04 in Retrospect: A brief chronicle regulatory regime and authority. Also on the regulatory While early global anxiety over SARS occupied headlines front, the Australian New Zealand Food Regulation Min- between February and May, the more persistent popular isterial Council endorsed a nutrition, health and related headline in 2003 focused on obesity. Summits were held claims policy guidelines and established a review of genet- in NSW and Victoria, while the National Obesity Task- ically modified (GM) labeling of foods [5]. All these force was convened under the auspice of the Australian developments pointed to the global nature of public Health Ministers Council (AHMC). health, and the intersection between public health activi- ties and the economy. When Kay Patterson was the Federal Health Minister, she declared that prevention was the fourth pillar of Medicare Policy development in public health has never been con- and she wanted to be 'Minister for Prevention'. Indeed, fined to a set of health programs, and in 2003/04, the lead the 2003/04 federal budget, although limited, contained was often taken from outside the health sector. Most sig- a bundle of initiatives entitled "Prevention on the Health nificant was the adoption of the National Agenda for Early Agenda". In particular, a number of immunisation and Childhood [6], pushed by public health advocates for health promotion programs were included. child health since the mid 1990s. The National Public Health Partnership responded by coordinating a scoping Significant amongst the funding initiatives for public of child health strategies across Australia. Elsewhere in health announced in 2003/04 was government support Government, "Promoting and Maintaining Good Health" for the meningococcal vaccine. Although this was the cul- was adopted as one of the National Research Priorities [7]. mination of many months of careful planning, a percep- Healthy ageing also emerged as a policy theme in Ageing tion existed that this only occurred after considerable Research. public interest in and anxiety about deaths from out- breaks of this disease. Public health workforce development was pursued out- side the mainstream education and training arrangements Further changes to the recommended schedule in 2003 for public health in universities. The Community Services were made by the Australian Technical Advisory Group on and Health Training Board commissioned a consultative Immunisation (ATAGI), in particular the inclusion of process to develop population health competencies for pneumococcal and varicella vaccines; however, these did the Vocational Education and Training (VET) sector [8]. not result in similar prescribed vaccine programs or in New population health qualifications and competencies similar funding. These three developments are reviewed were proposed for incorporation into the Health Training in greater detail in the next section. Package – including certificates in population health and Page 2 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:7 http://www.anzhealthpolicy.com/content/2/1/7 in environmental health, and diplomas in population lower socio-economic groups, in rural populations, in health and in indigenous environmental health. some immigrant groups, and in Aboriginal and Torres Strait Islander (ATSI) peoples. The release in 2003 of the report "Returns on Investments in Public Health: an epidemiological and economic anal- Despite longstanding national cooperation on nutrition ysis" [9] (often referred to as the Abelson report), may (since the days of the National Better Health Program in have a significant impact in subsequent years. Commis- the late 1980s), and even more recent national coopera- sioned several years earlier by the Population Health Divi- tion on physical activity, public and political imagination sion of the Department of Health and Ageing (DoHA), the was not captured until the same issues were recast as report experienced a relatively low profile until Derek 'obesity', with a focus in particular on childhood obesity. Wanless visited from the UK. Having chaired a review that Following from the NSW Childhood Obesity Summit in contributed to a significant budgetary increase for the late 2002, the Australian Health Ministers agreed that a NHS, Wanless had been commissioned by the British national approach was required and established a Treasury to examine prevention across government. In National Obesity Taskforce [12]. September 2003, at a meeting in Canberra with senior officials across key agencies, Wanless marveled at the In 2003, NSW Health released it's response to the Summit value of the Abelson report, described in more detail recommendations and supported the vast majority of the below. 145 resolutions [13]. The Victorian Department of Human Services also held a summit [14], while Healthy Although 2004 was an election year, public health policy Weight 2008 – Australia's Future was released by the was neither visible during the campaign or in policy devel- Commonwealth [15]. The NHMRC joined in with release opment more generally. The Federal Government's initia- in late 2003 of clinical practice guidelines for general prac- tive to wind up the National Occupational Health and titioners and other health professionals [16]. Safety Commission received little publicity and comment, even though it indicated the Commonwealth's increasing While the specifics vary, the major themes and strategies tendency to pursue its own pathway, separate from states are captured in Healthy Weight 2008. These are summa- rised in the Table 1. and territories, and to bring the functions of statutory bodies into departments. The Commonwealth strategy is, however, relatively weak Jurisdictional and annual reports show that across the on intersectoral policy and regulatory measures. As an states and territories, there were multiple plans, draft illustrative example of the contrast at the state level, guidelines, meetings, episodic training and programs implementation in NSW now ranges from school physical across a broad range of areas. Some health issues are being activity and nutrition survey, to a school canteen strategy, taken up across jurisdictions – particularly tobacco con- to negotiating with Commercial Television Australia trol, sexually transmitted infections, Aboriginal health, about their code of practice on advertising in peak chil- and vaccination. Innovative activities were reported in dren's viewing hours. The Commonwealth apparently some jurisdictions, such as a new Health Impact Assess- chose not to consider how it might exercise its relevant ment Branch and a new public health training program in taxation or legislative powers, despite the history of health Western Australia. There was, however, no apparent con- promotion pointing to the importance of public policy sistency in health priorities across the nation, and an measures beyond the health system. apparent divergence in the interests of the states/territo- ries and the federal government. An examination of the manner in which the obesity issue was framed, and the details contained in the national Obesity: Old or new frontier for health promotion? strategy, raises a number of issues and questions: While the "prevention and management of overweight and obesity" agenda may have appeared to many observ- - Why was framing the issues as 'obesity' more successful ers as a new issue in 2003, its arrival was preceded by sev- than the focus on 'nutrition' and 'physical activity'? Why eral years of intensive work. The NHMRC had released did 'obesity' gain traction while the other terms did not? Acting on Australia's Weight: Strategic plan for the preven- tion of overweight and obesity in 1997 [10], the same year - Why did the Commonwealth opt for the softer program- the ABS published the findings from the 1995 National matic approach, rather than tackle obesity with stronger Nutrition Survey, revealing that 45% of men and 29% of public policy measures (such as taxation and regulation), women in Australia were overweight, with an additional and demonstrate its national leadership capacity? 18% of men and women classified as obese [11]. Further- more, overweight and obesity were more common in Page 3 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:7 http://www.anzhealthpolicy.com/content/2/1/7 Table 1: Major themes and strategies in public health weight programs A. SETTINGS KEY STRATEGIES Child care Good practice standards that incorporate physical activity guidelines and dietary guidelines for children Schools As above plus active transport to school and programs to reduce excessive TV watching and computer games Primary care services Support GPs to screen body mass index and implement lifestyle scripts Community-based support programs for management of overweight Family and community care services As per childcare settings Maternal and infant health Extend healthy eating and active living programs; breastfeeding support programs; disseminate information resources for parents; 'baby friendly' accreditation for hospitals and health services; Neighborhoods and community organisations Healthy eating and active living initiatives within existing programs; support improved physical and infrastructure planning; develop good practice 'tools' Workplaces Support active transport programs; healthy eating and active living support for parents with young children Food supply Accreditation for food service outlets; cold chain management initiatives; encourage reduction of energy content and size of servings in food industry Media and marketing Monitor effectiveness of Children's Television Standards B. NATIONAL ACTION KEY STRATEGIES Support for families and community-wide education Social marketing; promotion of fruits and vegetables; national awards for settings-based programs 'Whole of Community' demonstration areas Demonstration projects, with professional support unit and clearinghouse; dissemination and professional development strategy Evidence and performance monitoring Surveillance system and tracking indicators; policy research Coordination and capacity-building Leadership program for obesity prevention; support professional networks for dissemination of good practice - Was the absence of stronger public policy measures - Were children targeted because they are a "captive audi- because 'obesity' is regarded as largely a health issue, ence" and therefore easy targets or did the evidence sug- rather than a whole-of-government issue? Or was the Gov- gest the best return on investment (in terms of health gain ernment waiting to see if the US opposed the WHO Glo- and managing demand on the health care system) would bal Strategy on account of the strength of the industry come from a focus on children? lobby? - Was the move to appeal to a populist agenda, while - After a number of years of public concern about eating simultaneously progressing the longer-term agenda of disorders and whether they arise in part because of pro- tackling health inequalities through multi-sectoral part- motion of certain types of body image, was the 'obesity' nerships, a triumph for public health advocates? label a backward step for mental health and a return to traditional images of beauty? These complex threads are interwoven. For the moment, the publicly enunciated agenda represents a confluence of - Is there a risk that people, including children, who are a number of rationales. labeled as 'overweight and obese' will be stigmatised? To Vaccines: From evidence base to funding what extent have the voices of affected communities been incorporated into the development of national strategies, During 2003–4 three new vaccines were added to the if at all? schedule of recommended vaccines for Australians (an additional change to the schedule, recommending that - Given the correlation between obesity and socioeco- polio immunisation be changed from oral to injected nomic disadvantage, how would the proposed strategy (IPD) vaccine, will not be discussed here). These vaccines not exacerbate those inequalities? protect against serogroup C meningococcal disease, some strains of Pneumococcal disease, and chicken pox Page 4 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:7 http://www.anzhealthpolicy.com/content/2/1/7 (varicella) [17]. For the first time, not all of these recom- schedule. This vaccine became available in Australia in mended vaccines will be funded by Government. 2000, at a cost of about $75–$90 per dose, with two doses being required for full protection. Prior to the introduction of these vaccines, the quality of information about the epidemiology and burden of dis- In 2003 the Commonwealth provided its periodic update ease caused by these three infections was extremely varia- on the Australian Standard Vaccination Schedule, the list ble. Meningococcal disease has been notifiable for many of vaccines it provides as appropriate at no cost to all Aus- years, and in Australia almost all is caused by serogroups tralians [19]. For the first time it differed from the B and C. Whilst serogroup B predominantly occurs in National Immunisation Program recommendations in young children, a new strain of serogroup C [18] was caus- that besides meningococcal serogroup C conjugate vac- ing increasing anxiety amongst public health profession- cines, pneumococcal vaccine, varicella vaccine and also als, microbiologists, staff of accident and emergency inactivated polio (injected) vaccine were also recom- departments, intensive care units and of course the public mended: however, funding was only secured for menin- and media. gococcal conjugate vaccines, with a continuation of the provision of pneumococcal vaccines for indigenous chil- The cause of anxiety amongst health professionals was dren. As a result, although recommended, pneumococcal based on the fact that this new strain carried a high fatality and varicella vaccines were not funded and parents would rate with severe after-effects in a high proportion of survi- have to decide whether or not to pay for them. vors. The attack rate, although still small, was increasing exponentially each year and reaching an important trigger These funding decisions had important implications. Vac- point, and the majority of cases were now healthy teenag- cines protect most of their recipients from unpleasant and ers and young adults. Although an initial accelerated sometimes life-threatening disease. One view, subscribed catch-up programme was introduced for teenagers (the to in the UK, is that ethically, children should not be major risk group), the new conjugated vaccine was also denied access because of their parents' inability to pay. introduced to the childhood schedule at age one, as from These vaccines have been the subject of several cost-bene- that age, only one dose (at a cost of $30–$60) was consid- fit studies, with generally favourable to extremely favour- ered necessary for full protection from serogroup C able pro-vaccination results. Table 2 summarises the disease. various models for framing policy. Pneumococcal disease became notifiable in 2001, how- The policy of funding meningococcal serogroup C vaccine ever, with such a short surveillance history, not much is was built on a sustained program of epidemiological evi- certain locally, epidemiologically speaking, about risk dence, ethical decision-making and public support (and groups and effects (although there is no reason to suppose was arguably honed by public pressure). Pneumococcal that it has a different epidemiological pattern from other disease and varicella vaccination programs however, were developed countries). Pneumococcal disease is thought to neither supported by good local epidemiological evidence occur at least four times as often as meningococcal dis- nor respectable levels of public awareness about these dis- ease, is known to carry major sequelae and has a high case eases. There had not been a similar program of sustained fatality rate. For some time it has been known to be even policy building to support or drive a decision to fund more common amongst the indigenous Australian popu- these vaccines. As a funding policy, this was noteworthy in lation with attack rates of up to 1 in 500 each year, knowl- that it marked a departure from previous policies where edge which underpinned the 1999 decision to target all recommended vaccines were fully funded by govern- Aboriginal people for free vaccination as soon as the new ments. National vaccination policy is designed to advise vaccines became available. Unfortunately at about $120 vaccination policy makers and practitioners of the most per dose, conjugate pneumococcal vaccine is very expen- up-to-date thinking about optimal vaccination schedules sive and, for the protection of the very young children for Australian children, and is not therefore proscriptive, who bear the brunt of this disease, it is licensed only to be unlike the United Kingdom (UK). Changing or adding given as a three dose course, making provision of this vac- vaccines to the recommended schedule is therefore an cine to all Australian children prohibitively expensive. advisory matter, and the question of funding the vaccina- tion program is decided separately. Varicella, predominantly a childhood disease, is caused by a Herpes virus known as herpes virus 3 or varicella-zoster Cost benefit studies indicate pneumococcal polysaccha- virus or VZV. It is not notifiable in Australia; therefore no ride and conjugate vaccines can be cost-effective although epidemiological population data are available. A reliable vaccine costs clearly affect ratios of cost to benefit greatly varicella vaccine has been available since the mid 1990s in [20,21]. Varicella vaccine is more contentious, because the USA and is part of American routine immunisation this disease is more severe in older cases, and it is possible Page 5 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:7 http://www.anzhealthpolicy.com/content/2/1/7 Table 2: New VPD awareness matrix Argument – do we What are the What are the risks What are the Ethics – what is in it have good political risks in not perceived by health perceived risks and for the epidemiological funding this professionals outrage by general stakeholders? evidence vaccine? public Meningococcal sg C Yes: notifiable disease High political risk; Low Public frightened- Much public support disease for many years – good recent high level of for gvt Vaccine detailed and awareness amongst provider contracts longitudinal evidence public, news coverage biased ++ to worst cases [26] Pneumococcal disease Some: notifiable since Med-low: public not High Public not anxious; Some public support 2000 so some local highly aware of news highlights for gvt Vaccine evidence, more from significance in children occasionally but less provider contracts published materials general awareness from overseas (See * below) Varicella Little – not notifiable Low – viewed by Med Very little; whilst Vaccine provider many people as an parents know this to contracts insignificant and mild be an unpleasant disease of childhood disease there is a general lack of awareness of complications, and vaccine not considered a high priority [27] (*Whilst there are several papers about the reasons older people, their families and health care providers use pneumococcal vaccines, there do not seem to be any published peer-reviewed studies of parental understanding of pneumococcal disease). Source [26] [27]. that one result of a vaccination program could be an (injected as well as oral) vaccination late in 2004, and it is increase in older cases (and therefore severe disease). possible that programs for these vaccines will also be Whilst the vaccine undoubtedly works, there is no consen- funded in the future. sus about precisely who should be vaccinated for maxi- mum population health as well as cost benefit, and again Federal budget: Prevention on the Health Agenda? potential financial savings are highly dependant upon The 2002/2003 Federal Budget papers stated that "the vaccine costs [22,23]. Government is committed to making disease prevention and health promotion a fundamental pillar of the health The costs of preventive vaccine programs and curative system": however, this was not evident in the subsequent medicine are funded from different sources. Vaccines are 2003/2004 budget. The Government's Focus on Preven- currently funded by the Commonwealth and subsidised tion Package in 2002/03 aimed to incorporate disease pre- through the states according to local vaccination policies, vention into the core business of the primary health care whilst the costs of curing cases of these diseases is broadly system and was reflective of how the public health agenda funded through the Medicare and private health insur- was evolving at the national level [24]. The package was ance systems. Savings to Medicare and health insurance comprised largely of a range of measures directed at spe- funds, as a result of successful vaccination programs, are cific diseases, plus a bundle of initiatives for general prac- not automatically transferred to the Commonwealth to titioners, also referred to as the "primary health care fund the vaccine programs. Savings – or costs – in one area system". are of little interest or importance to other program areas. Amongst health conditions affecting Australians, breast In 2004 the Government revised this funding policy, pro- cancer received the most attention, with the National viding funding for conjugate pneumococcal vaccines pop- Breast Cancer Centre being funded to develop a partner- ulation immunisation program for all children under ship approach to the review and dissemination of new seven years of age (as well as specific people in other risk information, along with information, support and man- groups) to commence in January 2005. The Australian agement initiatives for rural women diagnosed with Technical Advisory Group on Immunisation (ATAGI) breast cancer. Hepatitis C also received some attention, completed Ministerial reports on both varicella and polio with funding for national education and prevention Page 6 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:7 http://www.anzhealthpolicy.com/content/2/1/7 Table 3: Additional federal funds (in millions) for new public health activities between 2003–2007 INITIATIVES 2003/04 2004/05 2005/06 2006/07 Community awareness 2.1 1.5 0.7 - Primary care providers working together 2.7 4.6 4.6 4.5 Priority setting - - - - SARS 1.7 --- National Breast Cancer Centre - - - - Support for women with breast Cancer - - - - Hep C prevention and education - - - - Sharing healthcare - - - - Annual health assessment for older Australians - - - - Meningococcal C campaign 1.3 0.4 0.4 0.4 Preventing falls in older people - - - - Coordinated care planning - - - - Multidisciplinary case conferencing - - - - Enhanced divisional quality use of medicines 10.9 17.0 19.2 21.6 GP education, support and community linkages - 1.4 - 1.7 - 1.8 - 1.8 Source: [28] projects. Financial support was offered for the SARS efforts Judging by the actual quantum of funds made available in that had been undertaken by states and territories, in par- the 2003/2004 budget, it would seem that most elements ticular for providing medical personnel at international from the package did not actually receive additional fund- airports. A clear process for assessing priorities under the ing, as shown in Table 3. Indeed, many of the GP initia- broad banded National Public Health Program was also tives, previously cast as improving primary health care, flagged. were subsequently packaged as 'prevention'. For purposes of the budget, primary health care was The combination of these measures reflected a tight fiscal defined as general practitioners, and the measures funded climate, with little growth in the overall health budget, as included: well as that of other portfolios. It was also a package that demonstrated relatively limited imagination, with sup-  "Lifestyle prescriptions" to help GPs "raise community port for established issues (such as breast cancer) and re- awareness and understanding of benefits of preventive packaging general practice measures that were already in health"; train. With Medicare spending "uncapped" (and targeted public health programs "capped"), attaining more pre-  Collaborative approach to learning, training education vention dollars through the GP sector may appear to be and support systems; one of the few ways to 'grow' dollars for prevention. Although this could be considered to be consistent with  Coordinated care plans for people with chronic or termi- the Ottawa Charter of "reorienting health services", many nal conditions; and GPs are not trained in a population-based approach to practice, and simply providing new for payments to all  Involvement in multidisciplinary case conferencing. represents an undifferentiated, uncoordinated and untar- geted approach to prevention. If there is limited support The budget did not adopt a comprehensive approach to to GPs, and little monitoring, then these measures are the primary health care system, perhaps because many unlikely to translate into improved health outcomes. community health services, which represent the other important arm for delivery of public health services, are Meanwhile, the strategic framework for chronic disease the responsibility of states. The timetable for renewing prevention, adopted by the National Public Health Part- Public Health Outcome Funding Agreements (PHOFAs) nership in 2001, still lacked a policy and budgetary between the Commonwealth and states and territories in response in 2003/04 and in 2004/05, while states/territo- 2004 raised in the minds of some stakeholders, the possi- ries adopting varying measures singly. bility that the Commonwealth might adopt a more com- prehensive and strategic approach, linking public health Funding for the Tough on Drugs strategy was announced and primary health care funding streams. outside the Focus on Prevention package; perhaps due to Page 7 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:7 http://www.anzhealthpolicy.com/content/2/1/7 the fact that the Tough on Drugs was the responsibility of that were increasingly using economic evaluation in pub- the Parliamentary Secretary therefore requiring a separate lic health programs. It will be interesting to see if public communications strategy, or because the Prime Minister health policy analysts and Treasury officials draw on this has a strong personal interest in the illicit drug strategy. report in future years. In the future it will be interesting to The range of measures funded (which included introduc- see if the focus on high-visibility programs can demon- tion of retractable needle and syringe technology, address- strate short-term economic returns. ing problems related to increased availability and use of psycho stimulants, establishing a research fund, support- Given 2004 was an election year, the "political economy" ing alcohol and drug workforce development needs, pro- of prevention programs could arguably have become a moting access to drug treatment in rural areas, and focus of future public health policy, with the 2003/4 tackling problems faced by drug users with concurrent agenda providing the Government with the opportunity mental health problems) certainly suggested more serious to gauge public reaction to this new positioning and government interest and commitment to illicit drugs. design their election campaign appropriately. This was, however, not the case. The American emphasis on 'prepar- The 2004/05 Budget indicated the Federal Government's edness' appears not to resonate with the Australian public agenda in public health had narrowed considerably. $33 in the same way. million new funding was announced for measures to address emerging risks (such as emergency medicines From the perspective of public health policy advocates, stockpile, disease surveillance and public health laborato- some lessons that can be drawn from 2003/04 are: ries, health security legislation and incidence response), but only $5.2 million new funding was made available for  Government's response to public health proposals are promotion of healthy lifestyles related to national health shaped by its understanding of the popular interest and priorities (for addressing such as tobacco, alcohol, drugs, desire to communicate directly with the general public; injury, and cancer). [25]  Longer term public health issues which have struggled to Drivers for Policy and Implications for Public Health gain support can be progressed if they are cleverly shaped During the course of the Howard Government, there has to fit the Government's "formula"; been a gradual process of re-casting the "landscape" of interest groups and policy constituencies. Strong support  Develop and nurture new advocates, particularly in for breast cancer and zero-tolerance on illicit drugs con- seeking to engage with the broader health system; and trasts sharply with the delays experienced in renewal of the National HIV/Hepatitis C Strategy. The new promi-  Work with the media as partners rather than adversaries nence given to meningococcal vaccine, child health and obesity creates space for other interest groups: even if the These lessons need to be learned well and quickly, to assist re-framing was shaped by nutrition and physical activity with moving the forum for public health policy debate lobbies, other clinical interests have been brought into the more into the public domain; beyond an essentially "in picture. These developments illustrate how 'political' con- house" discourse between politicians, researchers and siderations are important in determining 'public health public health advocates. If a more engaged and informed policy'. community takes up a public health issue, government will be more likely to respond. It was interesting however, to observe the interest in pre- vention from outside the health portfolio, particularly List of abbreviations from Treasury. This was motivated in part by the Intergen- ANTA – Australian National Training Authority erational Report and concerns about both the sustainabil- ity of Medicare as well as the social and economic cost AHMC – Australian Health Ministers Council burden arising from an ageing society. This helped to ensure interest in the Abelson Report[9]. ATAGI – Australian Technical Advisory Group on Immunisation Few countries have conducted research on return of investment from prevention efforts. Australia was praised ATSI – Aboriginal and Torres Strait Islander by Derek Wanless at a high-level consultation for com- pleting such an analysis, during his visit to Canberra while DoHA – Department of Health and Ageing conducting a review for the UK Treasury, "Securing Good Health for the Whole Population"[26]. His final report GM – genetically modified (foods) pointed to Australia and Netherlands as two countries Page 8 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:7 http://www.anzhealthpolicy.com/content/2/1/7 11. A.B.S.: National Nutrition Survey: Nutrient Intakes and Phys- GP – general practitioner ical Measurements Australia. [http://www.abs.gov.au/Ausstats/ abs%40.nsf/e8ae5488b598839cca25682000131612/ NHMRC – National Health and Medical Research Council 95e87fe64b144fa3ca2568a9001393c0!OpenDocument]. 12. N.S.W. Health Childhood Obesity Summit: Communique. [http:// www.health.nsw.gov.au/obesity/adult/summit/communique.pdf]. NPHP – National Public Health Partnership 13. N.S.W. Health: N.S.W. Childhood Obesity Summit Govern- ment Response. [http://www.health.nsw.gov.au/obesity/adult/gap/ ObesityResponse.pdf]. PHOFA – Public Health Outcome Funding Agreement 14. Department of Human Services V: A Healthy balance - Victorians respond to obesity. [http://www.health.vic.gov.au/nutrition/obes ity/index.htm]. SARS – Sudden Acute Respiratory Syndrome 15. Australian Government Department of Health and Ageing: Healthy Weight 2008 - Australia's Future. [http://www.healthyandac TGA – Therapeutic Goods Administration tive.health.gov.au/]. 16. National Health and Medical Research Council: Guidelines for the development and implementation of clinical practice guide- VET – Vocational Education and Training lines. [http://www.nhmrc.gov.au/publications/synopses/ cp30syn.htm]. 17. National Health and Medical Research Council: Australian Immu- WHO – World Health Organization nisation Handbook, 8th edition,. 2004. 18. Tribe D, Zaia A, Griffith J, Robinson P, Li H, Taylor K, Hogg G: Increase in meningococcal disease associated with the emer- UK – United Kingdom gence of a novel ST-11 variant of Serogroup C Neisseria meningitidis in Victoria, Australia, 1999-2000. Epidemiology & Infection, 2002, 128:7-14. Competing interests 19. National Health and Medical Research Council: The Australian The author(s) declare that they have no competing Standard Vaccination Schedule. [http://immunise.health.gov.au/ interests. schedule.pdf]. 20. Darkes M.J.M. PGL: Pneumococcal vaccine (Prevenat[TM]; PNCRM7): a review of its use in the prevention of Strepto- Authors' contributions coccus pneumoniae infection. Pediatric drugs 2002, 4(9):609-630. VL conceived the format of this article and contributed the 21. Ray GT, Butler JC, Black SB, Shinefield HR, Fireman BH, Lieu TA: Observed costs and health care use of children in a rand- sections on policy, governance and finance. PR contrib- omized controlled trial of pneumococcal conjugate vaccine. uted the sections on communicable disease control and Paediatric Infectious Diseases Journal 2000, 21(5):361-365. 22. Thiry MI, Beutels P, van Damme PI, van Doorslar E: Economic eval- vaccination strategies. uations of varicella vaccination programmes: a review of the literature. Pharmacoeconomics 2003, 21(1):13-38. Acknowledgements 23. Brisson M, Edmunds WJ: Varicella vaccination in England and Wales: cost-utility analysis. Archives of Disease in Childhood 2003, Staff of the Faculty of Health Sciences, La Trobe University for useful dis- 88(10):862-869. cussion and comments of previous drafts of this paper, and Sheryll Kay for 24. Australian Government Department of Health and Ageing: Annual research assistance. Report 2002-3. [http://www.health.gov.au/pubs/annrep/ar2003/1/ 1.htm]. 25. Wanless D: Securing Good Health for the Whole Population. References [http://www.hm-treasury.gov.uk/consultations_and_legislation/wan 1. Institute of Medicine: Who will keep the public healthy? [http:// less/consult_wanless03_index.cfm]. www.iom.edu/report.asp?id=4307]. 26. Irwin DJ, Miller JM, Milner PC, Patterson T, Richards RG, Williams 2. Institute of Medicine: The Future of Public Health in the 21st DA, Insley CA, Stuart JM: Community immunisation pro- Century. [http://www.iom.edu/report.asp?id=4304]. gramme in response to an outbreak of invasive Neisseria 3. Wanless D: Securing Our Future Health: Taking A Long-term meningitidis serogroup C infection in the Trent region of View. [http://www.hm-treasury.gov.uk/ England 1995-1996. Public Health Med 1997, 19(2):162-170. consultations_and_legislation/wanless/consult_wanless_final.cfm]. 27. Taylor JA, Newman RD: Parental attitudes towards varicella 4. Australian Government Department of Health and Ageing: . [http:// vaccination. Archives of Pediatric and Adolescent Medicine 2000, 154 www.health.gov.au/pubhlth/strateg/quaranti/]. (3)):302-306. 5. Australian Government Department of Health and Ageing: Newslet- 28. Australian Government Department of Health and Ageing: ter of Food Standards Australia New Zealand. Food Standards Focus on Prevention [http://www.health.gov.au/internet/wcms/ News [http://www.foodstandards.gov.au/_srcfiles/ publishing.nsf/content/health-budget2003-glance-glance1.htm] FSN45v2_June.pdf]. 6. Australian Government Commonwealth Department of Family and Ageing: Towards the Development of a National Agenda for Early Childhood. [http://www.facs.gov.au/internet/facsinternet.nsf/ family/early_childhood.htm]. 7. Australian Government Department of Science Education and Train- ing: Promoting and Maintaining Good Health. [http:// www.dest.gov.au/priorities/good_health.htm]. 8. Community Services and Health Training Board: Population health. [http://www.cshta.com.au/view_page.asp?ID=16]. 9. Abelson P: Returns on investment in public health. [http:// www.health.gov.au/pubhlth/publicat/document/metadata/ roi_eea.htm]. 10. National Health and Medical Research Council: Acting on Aus- tralia's Weight: Strategic plan for the prevention of over- weight and obesity. [http://www.nhmrc.gov.au/publications/ synopses/n22syn.htm]. Page 9 of 9 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australia and New Zealand Health Policy Springer Journals

Australian public health policy in 2003 – 2004

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Springer Journals
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Copyright © 2005 by Lin and Robinson; licensee BioMed Central Ltd.
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Medicine & Public Health; Public Health; Social Policy
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1743-8462
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1743-8462
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10.1186/1743-8462-2-7
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Abstract

In Australia, compared with other developed countries the many and varied programs which comprise public health have continued to be funded poorly and unsystematically, particularly given the amount of publicly voiced political support. In 2003, the major public health policy developments in communicable disease control were in the fields of SARS, and vaccine funding, whilst the TGA was focused on the Pan Pharmaceutical crisis. Programs directed to health maintenance and healthy ageing were approved. The tertiary education sector was involved in the development of programs for training the public health workforce and new professional qualifications and competencies. The Abelson Report received support from overseas experts, providing a potential platform for calls to improve national funding for future Australian preventive programs; however, inconsistencies continued across all jurisdictions in their approaches to tackling national health priorities. Despite 2004 being an election year, public health policy was not visible, with the bulk of the public health funding available in the 2004/05 federal budget allocated to managing such emerging risks as avian flu. We conclude by suggesting several implications for the future. aimed at primary prevention and the promotion and pro- Introduction Public health is a small component of the health system, tection of the public health ('rats and drains'). This has led both in terms of budgetary allocation at either state or to an increasing number of jurisdictions adopting the national level and in terms of the number of practitioners. label 'population health'. It incorporates a myriad of activities; legislation and regu- lation for health protection, preventive services directed at Renovation of the public health system has been on the specific diseases and populations, and health promotion international agenda for some years. In the US, the Insti- programs geared towards particular risk factors and vul- tute of Medicine released reports during 2003 about the st nerable groups in the community. As such, it looks like a public health workforce required for 21 century chal- disparate collection of programs and investments. lenges [1], as well as re-visited and updated its landmark [2]. report, The Future of Public Health in the 21st Century In Australia, there is also confusion about the very termi- In the UK, following the path-breaking review of the NHS nology of 'public health'. Despite its extensive history and by Derek Wanless[3] the Treasury commissioned him, in global understanding, in Australia the term is used vari- 2003, to undertake a review of whole-of-government ously; to refer to publicly funded health services, and effort in public health. Arising in part from the challenges interventions (regardless of the funding source) which are that confronted Canada during the outbreak of sudden Page 1 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:7 http://www.anzhealthpolicy.com/content/2/1/7 acute respiratory syndrome (SARS) in 2003, a new public The National Public Health Partnership (NPHP) and the health agency, at arms length from government, is being AHMC adopted the influenza pandemic plan in October created. 2003, and with the advent of the newly-identified disease SARS, as well as outbreaks of meningococcal disease, Public health in Australia, meanwhile, remained frag- management and prevention of communicable diseases mented – by programs, across jurisdictions (particularly was prominent. Following on from the significant fund- the states and territories) – and without a systematic ing boost for bioterrorism preparedness in 2002/03, pub- approach to funding, organisation, or conceptualisation. lic health preparedness became a more generic theme. In 2003/04, the gap between rhetoric and funding contin- ued to be noticeable, along with the tension between The arrival of SARS occupied the national popular and framing priorities for popular appeal versus the technical political imagination as well as tested the infrastructure language of the evidence base. capacity of public health. Australia fared well during the outbreak. Apart from escaping with only six Australian This article will examine some of the indicative develop- cases, it provided an opportunity to establish a coordi- ments of public health in Australia in 2003/04. The key nated approach between the Commonwealth and the developments are identified, and a number of them are states/territories and also contributed to the global epide- selected for in-depth analysis. In this article, we use the miological investigation and prevention effort. SARS also traditional meaning of the term 'public health' and focus prompted amendments to the Quarantine Act [4]. on activities which are usually designed to promote and protect the health of the population. The drivers for these While the recall following the Pan Pharmaceutical crisis developments, their short term implications and some put the Therapeutic Goods Administration (TGA) under signposts for the future are suggested. the spotlight, it also managed to conclude negotiations that had been in train for several years on a Trans-Tasman 2003/04 in Retrospect: A brief chronicle regulatory regime and authority. Also on the regulatory While early global anxiety over SARS occupied headlines front, the Australian New Zealand Food Regulation Min- between February and May, the more persistent popular isterial Council endorsed a nutrition, health and related headline in 2003 focused on obesity. Summits were held claims policy guidelines and established a review of genet- in NSW and Victoria, while the National Obesity Task- ically modified (GM) labeling of foods [5]. All these force was convened under the auspice of the Australian developments pointed to the global nature of public Health Ministers Council (AHMC). health, and the intersection between public health activi- ties and the economy. When Kay Patterson was the Federal Health Minister, she declared that prevention was the fourth pillar of Medicare Policy development in public health has never been con- and she wanted to be 'Minister for Prevention'. Indeed, fined to a set of health programs, and in 2003/04, the lead the 2003/04 federal budget, although limited, contained was often taken from outside the health sector. Most sig- a bundle of initiatives entitled "Prevention on the Health nificant was the adoption of the National Agenda for Early Agenda". In particular, a number of immunisation and Childhood [6], pushed by public health advocates for health promotion programs were included. child health since the mid 1990s. The National Public Health Partnership responded by coordinating a scoping Significant amongst the funding initiatives for public of child health strategies across Australia. Elsewhere in health announced in 2003/04 was government support Government, "Promoting and Maintaining Good Health" for the meningococcal vaccine. Although this was the cul- was adopted as one of the National Research Priorities [7]. mination of many months of careful planning, a percep- Healthy ageing also emerged as a policy theme in Ageing tion existed that this only occurred after considerable Research. public interest in and anxiety about deaths from out- breaks of this disease. Public health workforce development was pursued out- side the mainstream education and training arrangements Further changes to the recommended schedule in 2003 for public health in universities. The Community Services were made by the Australian Technical Advisory Group on and Health Training Board commissioned a consultative Immunisation (ATAGI), in particular the inclusion of process to develop population health competencies for pneumococcal and varicella vaccines; however, these did the Vocational Education and Training (VET) sector [8]. not result in similar prescribed vaccine programs or in New population health qualifications and competencies similar funding. These three developments are reviewed were proposed for incorporation into the Health Training in greater detail in the next section. Package – including certificates in population health and Page 2 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:7 http://www.anzhealthpolicy.com/content/2/1/7 in environmental health, and diplomas in population lower socio-economic groups, in rural populations, in health and in indigenous environmental health. some immigrant groups, and in Aboriginal and Torres Strait Islander (ATSI) peoples. The release in 2003 of the report "Returns on Investments in Public Health: an epidemiological and economic anal- Despite longstanding national cooperation on nutrition ysis" [9] (often referred to as the Abelson report), may (since the days of the National Better Health Program in have a significant impact in subsequent years. Commis- the late 1980s), and even more recent national coopera- sioned several years earlier by the Population Health Divi- tion on physical activity, public and political imagination sion of the Department of Health and Ageing (DoHA), the was not captured until the same issues were recast as report experienced a relatively low profile until Derek 'obesity', with a focus in particular on childhood obesity. Wanless visited from the UK. Having chaired a review that Following from the NSW Childhood Obesity Summit in contributed to a significant budgetary increase for the late 2002, the Australian Health Ministers agreed that a NHS, Wanless had been commissioned by the British national approach was required and established a Treasury to examine prevention across government. In National Obesity Taskforce [12]. September 2003, at a meeting in Canberra with senior officials across key agencies, Wanless marveled at the In 2003, NSW Health released it's response to the Summit value of the Abelson report, described in more detail recommendations and supported the vast majority of the below. 145 resolutions [13]. The Victorian Department of Human Services also held a summit [14], while Healthy Although 2004 was an election year, public health policy Weight 2008 – Australia's Future was released by the was neither visible during the campaign or in policy devel- Commonwealth [15]. The NHMRC joined in with release opment more generally. The Federal Government's initia- in late 2003 of clinical practice guidelines for general prac- tive to wind up the National Occupational Health and titioners and other health professionals [16]. Safety Commission received little publicity and comment, even though it indicated the Commonwealth's increasing While the specifics vary, the major themes and strategies tendency to pursue its own pathway, separate from states are captured in Healthy Weight 2008. These are summa- rised in the Table 1. and territories, and to bring the functions of statutory bodies into departments. The Commonwealth strategy is, however, relatively weak Jurisdictional and annual reports show that across the on intersectoral policy and regulatory measures. As an states and territories, there were multiple plans, draft illustrative example of the contrast at the state level, guidelines, meetings, episodic training and programs implementation in NSW now ranges from school physical across a broad range of areas. Some health issues are being activity and nutrition survey, to a school canteen strategy, taken up across jurisdictions – particularly tobacco con- to negotiating with Commercial Television Australia trol, sexually transmitted infections, Aboriginal health, about their code of practice on advertising in peak chil- and vaccination. Innovative activities were reported in dren's viewing hours. The Commonwealth apparently some jurisdictions, such as a new Health Impact Assess- chose not to consider how it might exercise its relevant ment Branch and a new public health training program in taxation or legislative powers, despite the history of health Western Australia. There was, however, no apparent con- promotion pointing to the importance of public policy sistency in health priorities across the nation, and an measures beyond the health system. apparent divergence in the interests of the states/territo- ries and the federal government. An examination of the manner in which the obesity issue was framed, and the details contained in the national Obesity: Old or new frontier for health promotion? strategy, raises a number of issues and questions: While the "prevention and management of overweight and obesity" agenda may have appeared to many observ- - Why was framing the issues as 'obesity' more successful ers as a new issue in 2003, its arrival was preceded by sev- than the focus on 'nutrition' and 'physical activity'? Why eral years of intensive work. The NHMRC had released did 'obesity' gain traction while the other terms did not? Acting on Australia's Weight: Strategic plan for the preven- tion of overweight and obesity in 1997 [10], the same year - Why did the Commonwealth opt for the softer program- the ABS published the findings from the 1995 National matic approach, rather than tackle obesity with stronger Nutrition Survey, revealing that 45% of men and 29% of public policy measures (such as taxation and regulation), women in Australia were overweight, with an additional and demonstrate its national leadership capacity? 18% of men and women classified as obese [11]. Further- more, overweight and obesity were more common in Page 3 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:7 http://www.anzhealthpolicy.com/content/2/1/7 Table 1: Major themes and strategies in public health weight programs A. SETTINGS KEY STRATEGIES Child care Good practice standards that incorporate physical activity guidelines and dietary guidelines for children Schools As above plus active transport to school and programs to reduce excessive TV watching and computer games Primary care services Support GPs to screen body mass index and implement lifestyle scripts Community-based support programs for management of overweight Family and community care services As per childcare settings Maternal and infant health Extend healthy eating and active living programs; breastfeeding support programs; disseminate information resources for parents; 'baby friendly' accreditation for hospitals and health services; Neighborhoods and community organisations Healthy eating and active living initiatives within existing programs; support improved physical and infrastructure planning; develop good practice 'tools' Workplaces Support active transport programs; healthy eating and active living support for parents with young children Food supply Accreditation for food service outlets; cold chain management initiatives; encourage reduction of energy content and size of servings in food industry Media and marketing Monitor effectiveness of Children's Television Standards B. NATIONAL ACTION KEY STRATEGIES Support for families and community-wide education Social marketing; promotion of fruits and vegetables; national awards for settings-based programs 'Whole of Community' demonstration areas Demonstration projects, with professional support unit and clearinghouse; dissemination and professional development strategy Evidence and performance monitoring Surveillance system and tracking indicators; policy research Coordination and capacity-building Leadership program for obesity prevention; support professional networks for dissemination of good practice - Was the absence of stronger public policy measures - Were children targeted because they are a "captive audi- because 'obesity' is regarded as largely a health issue, ence" and therefore easy targets or did the evidence sug- rather than a whole-of-government issue? Or was the Gov- gest the best return on investment (in terms of health gain ernment waiting to see if the US opposed the WHO Glo- and managing demand on the health care system) would bal Strategy on account of the strength of the industry come from a focus on children? lobby? - Was the move to appeal to a populist agenda, while - After a number of years of public concern about eating simultaneously progressing the longer-term agenda of disorders and whether they arise in part because of pro- tackling health inequalities through multi-sectoral part- motion of certain types of body image, was the 'obesity' nerships, a triumph for public health advocates? label a backward step for mental health and a return to traditional images of beauty? These complex threads are interwoven. For the moment, the publicly enunciated agenda represents a confluence of - Is there a risk that people, including children, who are a number of rationales. labeled as 'overweight and obese' will be stigmatised? To Vaccines: From evidence base to funding what extent have the voices of affected communities been incorporated into the development of national strategies, During 2003–4 three new vaccines were added to the if at all? schedule of recommended vaccines for Australians (an additional change to the schedule, recommending that - Given the correlation between obesity and socioeco- polio immunisation be changed from oral to injected nomic disadvantage, how would the proposed strategy (IPD) vaccine, will not be discussed here). These vaccines not exacerbate those inequalities? protect against serogroup C meningococcal disease, some strains of Pneumococcal disease, and chicken pox Page 4 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:7 http://www.anzhealthpolicy.com/content/2/1/7 (varicella) [17]. For the first time, not all of these recom- schedule. This vaccine became available in Australia in mended vaccines will be funded by Government. 2000, at a cost of about $75–$90 per dose, with two doses being required for full protection. Prior to the introduction of these vaccines, the quality of information about the epidemiology and burden of dis- In 2003 the Commonwealth provided its periodic update ease caused by these three infections was extremely varia- on the Australian Standard Vaccination Schedule, the list ble. Meningococcal disease has been notifiable for many of vaccines it provides as appropriate at no cost to all Aus- years, and in Australia almost all is caused by serogroups tralians [19]. For the first time it differed from the B and C. Whilst serogroup B predominantly occurs in National Immunisation Program recommendations in young children, a new strain of serogroup C [18] was caus- that besides meningococcal serogroup C conjugate vac- ing increasing anxiety amongst public health profession- cines, pneumococcal vaccine, varicella vaccine and also als, microbiologists, staff of accident and emergency inactivated polio (injected) vaccine were also recom- departments, intensive care units and of course the public mended: however, funding was only secured for menin- and media. gococcal conjugate vaccines, with a continuation of the provision of pneumococcal vaccines for indigenous chil- The cause of anxiety amongst health professionals was dren. As a result, although recommended, pneumococcal based on the fact that this new strain carried a high fatality and varicella vaccines were not funded and parents would rate with severe after-effects in a high proportion of survi- have to decide whether or not to pay for them. vors. The attack rate, although still small, was increasing exponentially each year and reaching an important trigger These funding decisions had important implications. Vac- point, and the majority of cases were now healthy teenag- cines protect most of their recipients from unpleasant and ers and young adults. Although an initial accelerated sometimes life-threatening disease. One view, subscribed catch-up programme was introduced for teenagers (the to in the UK, is that ethically, children should not be major risk group), the new conjugated vaccine was also denied access because of their parents' inability to pay. introduced to the childhood schedule at age one, as from These vaccines have been the subject of several cost-bene- that age, only one dose (at a cost of $30–$60) was consid- fit studies, with generally favourable to extremely favour- ered necessary for full protection from serogroup C able pro-vaccination results. Table 2 summarises the disease. various models for framing policy. Pneumococcal disease became notifiable in 2001, how- The policy of funding meningococcal serogroup C vaccine ever, with such a short surveillance history, not much is was built on a sustained program of epidemiological evi- certain locally, epidemiologically speaking, about risk dence, ethical decision-making and public support (and groups and effects (although there is no reason to suppose was arguably honed by public pressure). Pneumococcal that it has a different epidemiological pattern from other disease and varicella vaccination programs however, were developed countries). Pneumococcal disease is thought to neither supported by good local epidemiological evidence occur at least four times as often as meningococcal dis- nor respectable levels of public awareness about these dis- ease, is known to carry major sequelae and has a high case eases. There had not been a similar program of sustained fatality rate. For some time it has been known to be even policy building to support or drive a decision to fund more common amongst the indigenous Australian popu- these vaccines. As a funding policy, this was noteworthy in lation with attack rates of up to 1 in 500 each year, knowl- that it marked a departure from previous policies where edge which underpinned the 1999 decision to target all recommended vaccines were fully funded by govern- Aboriginal people for free vaccination as soon as the new ments. National vaccination policy is designed to advise vaccines became available. Unfortunately at about $120 vaccination policy makers and practitioners of the most per dose, conjugate pneumococcal vaccine is very expen- up-to-date thinking about optimal vaccination schedules sive and, for the protection of the very young children for Australian children, and is not therefore proscriptive, who bear the brunt of this disease, it is licensed only to be unlike the United Kingdom (UK). Changing or adding given as a three dose course, making provision of this vac- vaccines to the recommended schedule is therefore an cine to all Australian children prohibitively expensive. advisory matter, and the question of funding the vaccina- tion program is decided separately. Varicella, predominantly a childhood disease, is caused by a Herpes virus known as herpes virus 3 or varicella-zoster Cost benefit studies indicate pneumococcal polysaccha- virus or VZV. It is not notifiable in Australia; therefore no ride and conjugate vaccines can be cost-effective although epidemiological population data are available. A reliable vaccine costs clearly affect ratios of cost to benefit greatly varicella vaccine has been available since the mid 1990s in [20,21]. Varicella vaccine is more contentious, because the USA and is part of American routine immunisation this disease is more severe in older cases, and it is possible Page 5 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:7 http://www.anzhealthpolicy.com/content/2/1/7 Table 2: New VPD awareness matrix Argument – do we What are the What are the risks What are the Ethics – what is in it have good political risks in not perceived by health perceived risks and for the epidemiological funding this professionals outrage by general stakeholders? evidence vaccine? public Meningococcal sg C Yes: notifiable disease High political risk; Low Public frightened- Much public support disease for many years – good recent high level of for gvt Vaccine detailed and awareness amongst provider contracts longitudinal evidence public, news coverage biased ++ to worst cases [26] Pneumococcal disease Some: notifiable since Med-low: public not High Public not anxious; Some public support 2000 so some local highly aware of news highlights for gvt Vaccine evidence, more from significance in children occasionally but less provider contracts published materials general awareness from overseas (See * below) Varicella Little – not notifiable Low – viewed by Med Very little; whilst Vaccine provider many people as an parents know this to contracts insignificant and mild be an unpleasant disease of childhood disease there is a general lack of awareness of complications, and vaccine not considered a high priority [27] (*Whilst there are several papers about the reasons older people, their families and health care providers use pneumococcal vaccines, there do not seem to be any published peer-reviewed studies of parental understanding of pneumococcal disease). Source [26] [27]. that one result of a vaccination program could be an (injected as well as oral) vaccination late in 2004, and it is increase in older cases (and therefore severe disease). possible that programs for these vaccines will also be Whilst the vaccine undoubtedly works, there is no consen- funded in the future. sus about precisely who should be vaccinated for maxi- mum population health as well as cost benefit, and again Federal budget: Prevention on the Health Agenda? potential financial savings are highly dependant upon The 2002/2003 Federal Budget papers stated that "the vaccine costs [22,23]. Government is committed to making disease prevention and health promotion a fundamental pillar of the health The costs of preventive vaccine programs and curative system": however, this was not evident in the subsequent medicine are funded from different sources. Vaccines are 2003/2004 budget. The Government's Focus on Preven- currently funded by the Commonwealth and subsidised tion Package in 2002/03 aimed to incorporate disease pre- through the states according to local vaccination policies, vention into the core business of the primary health care whilst the costs of curing cases of these diseases is broadly system and was reflective of how the public health agenda funded through the Medicare and private health insur- was evolving at the national level [24]. The package was ance systems. Savings to Medicare and health insurance comprised largely of a range of measures directed at spe- funds, as a result of successful vaccination programs, are cific diseases, plus a bundle of initiatives for general prac- not automatically transferred to the Commonwealth to titioners, also referred to as the "primary health care fund the vaccine programs. Savings – or costs – in one area system". are of little interest or importance to other program areas. Amongst health conditions affecting Australians, breast In 2004 the Government revised this funding policy, pro- cancer received the most attention, with the National viding funding for conjugate pneumococcal vaccines pop- Breast Cancer Centre being funded to develop a partner- ulation immunisation program for all children under ship approach to the review and dissemination of new seven years of age (as well as specific people in other risk information, along with information, support and man- groups) to commence in January 2005. The Australian agement initiatives for rural women diagnosed with Technical Advisory Group on Immunisation (ATAGI) breast cancer. Hepatitis C also received some attention, completed Ministerial reports on both varicella and polio with funding for national education and prevention Page 6 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:7 http://www.anzhealthpolicy.com/content/2/1/7 Table 3: Additional federal funds (in millions) for new public health activities between 2003–2007 INITIATIVES 2003/04 2004/05 2005/06 2006/07 Community awareness 2.1 1.5 0.7 - Primary care providers working together 2.7 4.6 4.6 4.5 Priority setting - - - - SARS 1.7 --- National Breast Cancer Centre - - - - Support for women with breast Cancer - - - - Hep C prevention and education - - - - Sharing healthcare - - - - Annual health assessment for older Australians - - - - Meningococcal C campaign 1.3 0.4 0.4 0.4 Preventing falls in older people - - - - Coordinated care planning - - - - Multidisciplinary case conferencing - - - - Enhanced divisional quality use of medicines 10.9 17.0 19.2 21.6 GP education, support and community linkages - 1.4 - 1.7 - 1.8 - 1.8 Source: [28] projects. Financial support was offered for the SARS efforts Judging by the actual quantum of funds made available in that had been undertaken by states and territories, in par- the 2003/2004 budget, it would seem that most elements ticular for providing medical personnel at international from the package did not actually receive additional fund- airports. A clear process for assessing priorities under the ing, as shown in Table 3. Indeed, many of the GP initia- broad banded National Public Health Program was also tives, previously cast as improving primary health care, flagged. were subsequently packaged as 'prevention'. For purposes of the budget, primary health care was The combination of these measures reflected a tight fiscal defined as general practitioners, and the measures funded climate, with little growth in the overall health budget, as included: well as that of other portfolios. It was also a package that demonstrated relatively limited imagination, with sup-  "Lifestyle prescriptions" to help GPs "raise community port for established issues (such as breast cancer) and re- awareness and understanding of benefits of preventive packaging general practice measures that were already in health"; train. With Medicare spending "uncapped" (and targeted public health programs "capped"), attaining more pre-  Collaborative approach to learning, training education vention dollars through the GP sector may appear to be and support systems; one of the few ways to 'grow' dollars for prevention. Although this could be considered to be consistent with  Coordinated care plans for people with chronic or termi- the Ottawa Charter of "reorienting health services", many nal conditions; and GPs are not trained in a population-based approach to practice, and simply providing new for payments to all  Involvement in multidisciplinary case conferencing. represents an undifferentiated, uncoordinated and untar- geted approach to prevention. If there is limited support The budget did not adopt a comprehensive approach to to GPs, and little monitoring, then these measures are the primary health care system, perhaps because many unlikely to translate into improved health outcomes. community health services, which represent the other important arm for delivery of public health services, are Meanwhile, the strategic framework for chronic disease the responsibility of states. The timetable for renewing prevention, adopted by the National Public Health Part- Public Health Outcome Funding Agreements (PHOFAs) nership in 2001, still lacked a policy and budgetary between the Commonwealth and states and territories in response in 2003/04 and in 2004/05, while states/territo- 2004 raised in the minds of some stakeholders, the possi- ries adopting varying measures singly. bility that the Commonwealth might adopt a more com- prehensive and strategic approach, linking public health Funding for the Tough on Drugs strategy was announced and primary health care funding streams. outside the Focus on Prevention package; perhaps due to Page 7 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:7 http://www.anzhealthpolicy.com/content/2/1/7 the fact that the Tough on Drugs was the responsibility of that were increasingly using economic evaluation in pub- the Parliamentary Secretary therefore requiring a separate lic health programs. It will be interesting to see if public communications strategy, or because the Prime Minister health policy analysts and Treasury officials draw on this has a strong personal interest in the illicit drug strategy. report in future years. In the future it will be interesting to The range of measures funded (which included introduc- see if the focus on high-visibility programs can demon- tion of retractable needle and syringe technology, address- strate short-term economic returns. ing problems related to increased availability and use of psycho stimulants, establishing a research fund, support- Given 2004 was an election year, the "political economy" ing alcohol and drug workforce development needs, pro- of prevention programs could arguably have become a moting access to drug treatment in rural areas, and focus of future public health policy, with the 2003/4 tackling problems faced by drug users with concurrent agenda providing the Government with the opportunity mental health problems) certainly suggested more serious to gauge public reaction to this new positioning and government interest and commitment to illicit drugs. design their election campaign appropriately. This was, however, not the case. The American emphasis on 'prepar- The 2004/05 Budget indicated the Federal Government's edness' appears not to resonate with the Australian public agenda in public health had narrowed considerably. $33 in the same way. million new funding was announced for measures to address emerging risks (such as emergency medicines From the perspective of public health policy advocates, stockpile, disease surveillance and public health laborato- some lessons that can be drawn from 2003/04 are: ries, health security legislation and incidence response), but only $5.2 million new funding was made available for  Government's response to public health proposals are promotion of healthy lifestyles related to national health shaped by its understanding of the popular interest and priorities (for addressing such as tobacco, alcohol, drugs, desire to communicate directly with the general public; injury, and cancer). [25]  Longer term public health issues which have struggled to Drivers for Policy and Implications for Public Health gain support can be progressed if they are cleverly shaped During the course of the Howard Government, there has to fit the Government's "formula"; been a gradual process of re-casting the "landscape" of interest groups and policy constituencies. Strong support  Develop and nurture new advocates, particularly in for breast cancer and zero-tolerance on illicit drugs con- seeking to engage with the broader health system; and trasts sharply with the delays experienced in renewal of the National HIV/Hepatitis C Strategy. The new promi-  Work with the media as partners rather than adversaries nence given to meningococcal vaccine, child health and obesity creates space for other interest groups: even if the These lessons need to be learned well and quickly, to assist re-framing was shaped by nutrition and physical activity with moving the forum for public health policy debate lobbies, other clinical interests have been brought into the more into the public domain; beyond an essentially "in picture. These developments illustrate how 'political' con- house" discourse between politicians, researchers and siderations are important in determining 'public health public health advocates. If a more engaged and informed policy'. community takes up a public health issue, government will be more likely to respond. It was interesting however, to observe the interest in pre- vention from outside the health portfolio, particularly List of abbreviations from Treasury. This was motivated in part by the Intergen- ANTA – Australian National Training Authority erational Report and concerns about both the sustainabil- ity of Medicare as well as the social and economic cost AHMC – Australian Health Ministers Council burden arising from an ageing society. This helped to ensure interest in the Abelson Report[9]. ATAGI – Australian Technical Advisory Group on Immunisation Few countries have conducted research on return of investment from prevention efforts. Australia was praised ATSI – Aboriginal and Torres Strait Islander by Derek Wanless at a high-level consultation for com- pleting such an analysis, during his visit to Canberra while DoHA – Department of Health and Ageing conducting a review for the UK Treasury, "Securing Good Health for the Whole Population"[26]. His final report GM – genetically modified (foods) pointed to Australia and Netherlands as two countries Page 8 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:7 http://www.anzhealthpolicy.com/content/2/1/7 11. A.B.S.: National Nutrition Survey: Nutrient Intakes and Phys- GP – general practitioner ical Measurements Australia. [http://www.abs.gov.au/Ausstats/ abs%40.nsf/e8ae5488b598839cca25682000131612/ NHMRC – National Health and Medical Research Council 95e87fe64b144fa3ca2568a9001393c0!OpenDocument]. 12. N.S.W. Health Childhood Obesity Summit: Communique. [http:// www.health.nsw.gov.au/obesity/adult/summit/communique.pdf]. NPHP – National Public Health Partnership 13. N.S.W. Health: N.S.W. Childhood Obesity Summit Govern- ment Response. [http://www.health.nsw.gov.au/obesity/adult/gap/ ObesityResponse.pdf]. PHOFA – Public Health Outcome Funding Agreement 14. Department of Human Services V: A Healthy balance - Victorians respond to obesity. [http://www.health.vic.gov.au/nutrition/obes ity/index.htm]. SARS – Sudden Acute Respiratory Syndrome 15. Australian Government Department of Health and Ageing: Healthy Weight 2008 - Australia's Future. [http://www.healthyandac TGA – Therapeutic Goods Administration tive.health.gov.au/]. 16. National Health and Medical Research Council: Guidelines for the development and implementation of clinical practice guide- VET – Vocational Education and Training lines. [http://www.nhmrc.gov.au/publications/synopses/ cp30syn.htm]. 17. National Health and Medical Research Council: Australian Immu- WHO – World Health Organization nisation Handbook, 8th edition,. 2004. 18. Tribe D, Zaia A, Griffith J, Robinson P, Li H, Taylor K, Hogg G: Increase in meningococcal disease associated with the emer- UK – United Kingdom gence of a novel ST-11 variant of Serogroup C Neisseria meningitidis in Victoria, Australia, 1999-2000. Epidemiology & Infection, 2002, 128:7-14. Competing interests 19. National Health and Medical Research Council: The Australian The author(s) declare that they have no competing Standard Vaccination Schedule. [http://immunise.health.gov.au/ interests. schedule.pdf]. 20. Darkes M.J.M. PGL: Pneumococcal vaccine (Prevenat[TM]; PNCRM7): a review of its use in the prevention of Strepto- Authors' contributions coccus pneumoniae infection. Pediatric drugs 2002, 4(9):609-630. VL conceived the format of this article and contributed the 21. Ray GT, Butler JC, Black SB, Shinefield HR, Fireman BH, Lieu TA: Observed costs and health care use of children in a rand- sections on policy, governance and finance. PR contrib- omized controlled trial of pneumococcal conjugate vaccine. uted the sections on communicable disease control and Paediatric Infectious Diseases Journal 2000, 21(5):361-365. 22. Thiry MI, Beutels P, van Damme PI, van Doorslar E: Economic eval- vaccination strategies. uations of varicella vaccination programmes: a review of the literature. Pharmacoeconomics 2003, 21(1):13-38. Acknowledgements 23. Brisson M, Edmunds WJ: Varicella vaccination in England and Wales: cost-utility analysis. Archives of Disease in Childhood 2003, Staff of the Faculty of Health Sciences, La Trobe University for useful dis- 88(10):862-869. cussion and comments of previous drafts of this paper, and Sheryll Kay for 24. Australian Government Department of Health and Ageing: Annual research assistance. Report 2002-3. [http://www.health.gov.au/pubs/annrep/ar2003/1/ 1.htm]. 25. Wanless D: Securing Good Health for the Whole Population. References [http://www.hm-treasury.gov.uk/consultations_and_legislation/wan 1. Institute of Medicine: Who will keep the public healthy? [http:// less/consult_wanless03_index.cfm]. www.iom.edu/report.asp?id=4307]. 26. Irwin DJ, Miller JM, Milner PC, Patterson T, Richards RG, Williams 2. Institute of Medicine: The Future of Public Health in the 21st DA, Insley CA, Stuart JM: Community immunisation pro- Century. [http://www.iom.edu/report.asp?id=4304]. gramme in response to an outbreak of invasive Neisseria 3. Wanless D: Securing Our Future Health: Taking A Long-term meningitidis serogroup C infection in the Trent region of View. [http://www.hm-treasury.gov.uk/ England 1995-1996. Public Health Med 1997, 19(2):162-170. consultations_and_legislation/wanless/consult_wanless_final.cfm]. 27. Taylor JA, Newman RD: Parental attitudes towards varicella 4. Australian Government Department of Health and Ageing: . [http:// vaccination. Archives of Pediatric and Adolescent Medicine 2000, 154 www.health.gov.au/pubhlth/strateg/quaranti/]. (3)):302-306. 5. Australian Government Department of Health and Ageing: Newslet- 28. Australian Government Department of Health and Ageing: ter of Food Standards Australia New Zealand. Food Standards Focus on Prevention [http://www.health.gov.au/internet/wcms/ News [http://www.foodstandards.gov.au/_srcfiles/ publishing.nsf/content/health-budget2003-glance-glance1.htm] FSN45v2_June.pdf]. 6. Australian Government Commonwealth Department of Family and Ageing: Towards the Development of a National Agenda for Early Childhood. [http://www.facs.gov.au/internet/facsinternet.nsf/ family/early_childhood.htm]. 7. Australian Government Department of Science Education and Train- ing: Promoting and Maintaining Good Health. [http:// www.dest.gov.au/priorities/good_health.htm]. 8. Community Services and Health Training Board: Population health. [http://www.cshta.com.au/view_page.asp?ID=16]. 9. Abelson P: Returns on investment in public health. [http:// www.health.gov.au/pubhlth/publicat/document/metadata/ roi_eea.htm]. 10. National Health and Medical Research Council: Acting on Aus- tralia's Weight: Strategic plan for the prevention of over- weight and obesity. [http://www.nhmrc.gov.au/publications/ synopses/n22syn.htm]. Page 9 of 9 (page number not for citation purposes)

Journal

Australia and New Zealand Health PolicySpringer Journals

Published: Apr 6, 2005

References