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In what ways does the mandatory nature of Victoria's municipal public health planning framework impact on the planning process and outcomes?

In what ways does the mandatory nature of Victoria's municipal public health planning framework... Background: Systems for planning are a critical component of the infrastructure for public health. Both in Australia and internationally there is growing interest in how planning processes might best be strengthened to improve health outcomes for communities. In Australia the delivery of public health varies across states, and mandated municipal public health planning is being introduced or considered in a number of jurisdictions. In 1988 the Victorian State government enacted legislation that made it mandatory for each local government to produce a Municipal Public Health Plan, offering us a 20-year experience to consider. Results: In-depth interviews were undertaken with those involved in public health planning at the local government level, as part of a larger study on local public health infrastructure and capacity. From these interviews four significant themes emerge. Firstly, there is general agreement that the Victorian framework of mandatory public health planning has led to improvements in systems for planning. However, there is some debate about the degree of that improvement. Secondly, there is considerable variation in the way in which councils approach planning and the priority they attach to the process. Thirdly, there is concern that the focus is on producing a plan rather than on implementing the plan. Finally, some tension over priorities is evident. Those responsible for developing Municipal Public Health Plans express frustration over the difficulty of having issues they believe are important addressed through the MPHP process. Conclusion: There are criticisms of Victoria's system for public health planning at the local government level. Some of these issues may be specific to the arrangement in Victoria, others are problems encountered in public health planning generally. In Victoria where the delivery structure for public health is diverse, a system of mandatory planning has created a minimum standard. The implementation of the framework was slow and factors in the broader political environment had a significant impact. Work done in recent years to support the process appears to have led to improvements. There are lessons for other states as they embark upon mandated public health plans. Page 1 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:4 http://www.anzhealthpolicy.com/content/4/1/4 MPHPs are not the only legislated plans at the local level Background Strengthening public health infrastructure and capacity is in Victoria. The Local Government Act 1989 and the Plan- an issue attracting increasing national and international ning and Environment Act 1987 both impose planning interest (see for example [1-4] and [5]). In the USA and requirements on councils. In addition to these plans there UK, attention has turned to strengthening public health are numerous other plans required and discussions are systems for emergency preparedness following September underway between State and local government about how 2001, the SARs outbreak and, more recently, avian influ- the administrative workload they impose might best be enza. One component of this work has been a focus on reduced [15]. how to improve planning processes at the community level (see for example [6,7] and [8]). In Australia, interest Another review of the Health Act was initiated in 2002, is also driven by the increasing complexity of the issues and some of the issues highlighted for comment relate faced by public health, shrinking resources and 'reforms' directly to MPHP activities. This review makes discussion in public administration. Although infrastructure and of the planning framework's impact to date particularly capacity have been variously defined, systems for plan- timely. However, it is not simply an issue for Victoria. The ning are generally considered to be a critical component Western Australian government is reviewing its Health Act (for definitions of infrastructure see [1,9-11] and [12]). and asking "should the public health powers, functions Australian activities in formal health planning date from and responsibilities of local government be spelt out in a the 1970s during which time there have been paradig- new Health Act in more detail than currently exists?" [16] matic shifts, from an interest in equity to a focus on effi- (see page 14). All jurisdictions have an interest in how ciency, that mirror changes in the broader policy best to plan for and deliver public health services. environment [13] (see pages 55–67). Currently, a central concern is how planning processes might be strengthened As a system for planning, the framework in Victoria is to improve outcomes in the public's health. unique in that it is mandatory. The aim of this article is to review the strengths and weaknesses of this framework, as In Australia the configuration of the delivery system for it was implemented in Victoria. Of particular interest are public health varies from state to state. In Victoria much the questions: has the Victorian framework improved of its public health services are delivered by local govern- planning processes and outcomes; what has been the ments (see [14] for an extensive review of the role played extent of any improvement; and what are the challenges by local government across Australia). The 79 Victorian that remain? Underpinning these questions is the broader local governments vary in a number of ways including issue regarding the degree to which problems, where iden- inter alia size, geography, population, and organisational tified, are specific to this Victorian framework for plan- income and capacity. They are an autonomous and sepa- ning or are general problems encountered in public health rate sphere of government, although a great deal of what planning, irrespective of the manner in which it is organ- they do is prescribed in legislation set by State govern- ised. ment. In addition, funding agreements with Federal and State agencies dictate a number of their activities. In 1988 Results the State government amended the 1958 Health Act and Analysis of the interview transcripts provided a great deal made it mandatory for each local government (council) to of information about the planning process from which develop a municipal public health plan (MPHP). The four significant, and interrelated, themes emerge: agree- Health (General Amendment) Act 1988 (29B) states that: ment that the legislation has improved systems for plan- ning but debate about the extent of that improvement; "A municipal public health plan must: (a) identify and significant variation in the way in which councils assess actual and potential public health dangers affecting approach planning, their level of sophistication and the the municipal district; and (b) outline programs and strat- priority they attach to the process; concern that the focus egies which the council intends to pursue to (i) prevent or is primarily on the process itself (producing a plan) rather minimise those dangers; and (ii) enable people living in than on outcomes (implementing the plan); and some the municipal district to achieve maximum well-being; tension over priorities, with frustration expressed by those and (c) provide for periodic evaluation of programs and responsible for developing MPHPs that areas they strategies." believed should have priority are either not included in plans or where they are included they may be relegated in Councils are required to prepare a new plan every three importance when State and Federal government prioritise years and review their existing plan annually. These provi- other activities. sions, within the legislation, constitute Victoria's munici- pal public health planning framework. Page 2 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:4 http://www.anzhealthpolicy.com/content/4/1/4 Legislation has improved planning or their idea in the plan but who were also really motivated to The majority of those interviewed believed that, on bal- do something about it" ance, the legislative mandate had improved the planning process. Local government representatives expressed a Comments from those external to local government also variety of reactions to the MPHP process. As the following corroborate the significant variations at play: quotes illustrate, some saw it as a useful activity that helped in 'making a case for public health' within the "we have a bit of a spectrum from those who have got a real broader council environment and increased the visibility community development, community participation focus and a of public health, whilst for others it was simply another real strong social model of health focus to those who have taken function imposed by State government: the National Health Priority Areas and modelled their health planning around health issues and diseases and risk factors" "they [council] have come around to understanding the impor- tance of a public health plan and have, quite rightly, given it "the ones that I've seen that have more of a focus in community, the resourcing it requires." that really have got their community strategies right, are really doing some good work" "the way we structured it [the MPHP] is to try and take the role of integrating public health thinking across the council's strate- The focus is primarily on the process itself rather than on gic planning process, and we are trying to lift awareness across outcomes council" Another central concern raised was the extent to which legislation emphasised the process of planning but not "it is not something that is high priority. Most councils don't the outcomes: prioritise it terribly highly ... it has to be reproduced every three years and it has to be reviewed every 12 months but in practice "because notoriously in the past many local governments ... most people just produce it every three years and forget about it" even though they have a statutory obligation to produce a plan ... they would produce it and it might just end up on the book- Those outside local government were generally, but not shelf" exclusively, more positive about the MPHP process and outcomes. They believed that publications by the Depart- "I was going to say outcomes but you know there are no out- ment of Human Services [17] and the Victorian Health comes to some of their municipal public health planning Promotion Foundation [18] had strengthened local gov- endeavours, you know apart from the obvious immunisation ernment planning functions. One respondent identified stuff that they have done forever anyway, I mean some of them what he believed to be a genuine shift in thinking about are lucky if they can throw together a document" planning away from what he classified as 'retrospective planning', where councils simply developed a plan that All the councils interviewed had an MPHP but about half reported what they had done in the past, towards more lacked a formal implementation strategy. strategic planning. Despite general agreement that the sys- tem had improved the planning process, there were con- Tension over priorities cerns about the quality of planning: Within council there can be resistance to including any- thing within a plan that senior management and/or coun- "it just depends on the council and how advanced they are. cillors do not see as the 'core business' of council. One Some, like [name of council] are very good and you don't have respondent noted that his community health unit had any problem with them but there are others who ... they just identified the need for low cost housing in the municipal- don't get it basically" ity but his council certainly did not see itself in the busi- ness of providing housing. Another noted that: Significant variation exists Significant variations exist in the way in which councils "even though you might identify something as an issue there is approach the MPHP process. This was evident from the no guarantee that it is going to be addressed in any proactive manner in which those within local government talked way" about the process, as the two following quotes illustrate: Even if health planners are successful in having an issue "State government sets a number of key performance indicators included in the plan, this does not guarantee that it will be that we pick up on and sort of blend our own stuff into" addressed. The process may then be overtaken by political demands, either from Federal or State government or "we ended up with a really energised, mobilised community [as from within council itself, usually as a response to com- a result of the planning process], who not only saw their name munity or political pressure. Immunisation and illicit Page 3 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:4 http://www.anzhealthpolicy.com/content/4/1/4 drugs are two examples of this. In the first instance, Fed- "should be acknowledged as one of the main institutional eral government recently decided to increase the age range foundations of public health practice" [19] (see page 3). Their initial, and in many cases continuing, role centred for children being immunised. This resulted in significant extra work in the states. In Victoria a great deal of this on traditional public health issues such as sanitation and th increase in work was borne by public health units within waste management. In the 20 century the role of many local government. As funding is contingent on this being local governments began to expand beyond an interest in undertaken, other activities within the MPHP are rele- the physical environment [20]. The pace of this expansion gated: increased from the mid-century. It occurred at a differen- tial rate from state to state and was most notable in Victo- "meningococcal immunisation was a case in point. The Federal ria [14] (see page 100). By the 1970s Victoria's local government decided it was something that they should fund for governments had a role in maternal and child health, all children from the age of birth to 20 years ... well who's going childhood immunisation programs, services for older to do it? There is a statutory requirement on local government people and more general welfare services [20,19]. As to do immunisation. So that meant that instead of doing our Smith notes, one of the significant features of this expan- normal workload for immunisation, the workload tripled simply sion was a growing interest in "people and their social cir- because the number of kids tripled" cumstances rather than on the physical environment" [20] (see page 6). In the case of illicit drugs, an apparent spike in the number of deaths, particularly in public spaces, resulted In the mid-1980s the Victorian state government under- in a great deal of media coverage and significant commu- took a series of reviews of health legislation, including the nity concern. Funding became available and programs Health Act 1958 that defines the roles and responsibilities were developed in response to the newly presented fund- of local government as they relate to public health. Smith ing opportunities. As one of the respondents noted: argues that there are two salient points to note about the intent underpinning the review of the Health Act: that it "the previous municipal public health plan did identify a need "regarded public health in terms of the New Public for a drug policy of some sort or some attention on drugs which Health" and that it "would involve the examination of the we did achieve, but not directly through the municipal public relationship between the then Health Department Victo- health plan. It was an adjunct of people dying on the streets" ria and local government" [20] (see page 7). However, as both Smith [20] and Wills [21] note, despite using the lan- A number of participants observed that everything 'comes guage of health promotion, the emphasis in the relevant down to money'. While most of those interviewed spoke sections of the legislation (29A and 29B) was on protec- about this phenomena in negative terms, as peripatetic tion and prevention – the so called 'old' public health. crisis funding, one person observed that a strong public Wills [21] argues that this disjunction led to confusion health unit could and should respond to these opportuni- about the scope of the MPHPs. ties: The Act was an attempt to introduce positive, rather than "we are looking to move ... towards a much more complex and punitive, legislation that would encourage councils to act much more flexible, much more flexible arrangement so that we in a certain way rather than punish them for failing to do can become, for want of a better word, 'nippy' you know so that so. In the discussion document preceding the legislation we can nip in and out where things happen and where we can the Health Department noted that: make an impact" "Health Department Victoria (HDV) must be careful not Discussion to impose rigid regulatory controls to be enforced by The four major themes that emerge from the interviews councils and which limit their ability to re-determine their (improvement in planning systems; variation in own priorities in response to changing public health approaches to planning; an emphasis on the process needs in the municipality" [22] (see page 11). rather than on outcomes; and tensions over priorities) indicate something of the strengths and weaknesses of the This notion of positive legislation is reinforced by the lan- Victorian planning framework. It is worthwhile to look at guage used in Department of Human Services (DHS) sup- the intent of the legislation, its implementation and the porting documents where the Act is represented as a value of the MPHP framework. 'planning framework' rather than a 'planning template'. The choice of language is deliberate, the distinction being The intent that frameworks allow for a bottom-up approach where Local government in Australia has played a role in public templates reflect a top-down approach to planning. This th health since the 19 century and, as Legge and Cox argue, distinction may not be apparent to people within local Page 4 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:4 http://www.anzhealthpolicy.com/content/4/1/4 government where, for some, the mandatory nature of the between local government as staff and operational units system is one of its most salient features. In Australia's became wary about sharing information with counter- three-tiered system of government, the state is not a single parts in other local governments in the newly competitive homogeneous entity. Tensions exist between spheres of tendering environment. In addition there was a significant government and between the centre and periphery. In Vic- impact on the public health workforce. Legge and Cox toria these tensions include feelings amongst some in report that in the two years to 1997 there was an estimated local government that State government fails to under- 40% reduction in the number of environmental health stand the local context and that it tends to treat local gov- officers within local government [19] (see page 11). ernment as its administrative arm rather than as a duly elected separate sphere of government. Wills [21] argues In 1999 a new State government was elected and this, per- that the State government's failure to consult with local haps, injected new enthusiasm into the implementation government when developing the legislative amend- process. In 2001 the DHS and the Municipal Association ments, and the concern that some in local government of Victoria (MAV) released an MPHP planning framework had that the changes were motivated by a desire to shift in the form of the document Environments for Health [17]. costs, created additional tensions. This was intended as a guide for those within municipal councils responsible for writing the MPHP. This may have In this environment the Act is open to at least two inter- partially addressed some of the concerns that had been pretations. The first is that it represents a genuine attempt raised [19][20] regarding the skill capacity of the work- to improve health planning at local government level. The force within local government, to undertake strategic second is that it is an attempt by State government to planning for public health. In 2004 a second document, assert control over the process of planning. In the discus- Leading the Way: Councils Creating Healthier Communities sion paper preceding the Act's amendment HDV noted [18], was released. Developed by VicHealth, DHS, and that local government were well placed to play an MAV, the document was designed to increase the under- expanded role in public health because they were closer to standing of elected councillors and local government sen- the local community and had the necessary staff. However ior management. It recognises, as the literature had they noted that in two instances State government had a highlighted, that senior level support is a critical factor in role to play: where there was insufficient local expertise – developing and implementing a strategic MPHP particularly in specialised functions; and where health [19][20][23]. These two documents were supplemented problems extended beyond municipal boundaries. Addi- by the Good Practice Program, through which from 2002 – tionally they recommended that "central government 2004 the DHS funded 26 projects involving 39 local gov- should retain oversight of local government in order to ernments in activities that used Environments for Health to negate the undesirable effect on all Victorians of variabil- improve public health planning [24]. ity of public health enforcement by local councils" [22] (see page 20). The value of the MPHP framework The significant variation in council approaches to plan- The implementation ning, evident in the interview data, is a manifestation of Although the Act was amended in 1988, implementation the differences in councils' organisational capacity and of Section 29(B) has been a lengthy process. A pilot study, culture. Many of those in local government would argue with 11 councils, was undertaken in 1990 with the sup- that financial resources are a critical component. There is, port of a project officer funded by HDV. During the fol- within local government, a measure of wariness about lowing decade an increasing number of councils what is perceived as cost shifting by State and Federal gov- developed plans. This was done in an environment of ernment. A number of those who were interviewed dis- uncertainty and tension. The election, in 1992, of the Ken- cussed this with reference to the MPHP process. They saw nett Coalition government introduced a period of tremen- the role and responsibilities of local government expand dous change for local government. Driven by the without any commensurate increase in funding. Clearly prevailing ideology of 'small government', efficiency and there is a relationship between levels of funding (whether market models the Coalition forced the amalgamation of directly from the State or made available internally) and a many local governments (from over 200 to 78) and intro- council's ability to develop and implement their MPHP. duced a system of compulsory competitive tendering. What is less obvious is the degree of correlation between Although amalgamations have long been a feature of the councils' financial resources and their ability to deliver local government environment Australia wide, in Victoria public health outcomes. Analysis of the interview data the nature and scope of the 'reforms' was dramatic [14] suggests that those councils who take a strategic approach (see page 99) and had long-term consequences. These to MPHP, who make reference to the social model of changes created tension in the relationship between State health, who have high levels of community involvement and local government. They also stifled cooperation and who have formal processes in place for implementing Page 5 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:4 http://www.anzhealthpolicy.com/content/4/1/4 and evaluating their plans are not, as a matter of course, platform for public health practitioners within local gov- the wealthier municipalities. Nor were those councils who ernment – where it legitimates their activities. These peo- demonstrated a narrow approach to public health plan- ple work within an environment of limited power, with ning or who lacked processes for implementation and multiple competing demands. Public health activities not evaluation necessarily the less well financially resourced. already specifically described in legislation (that is activi- Other relevant factors include managerial support for the ties other than immunisation, food sampling, premises MPHP process (and public health programs and activities inspection, and water inspection) are often not given a more generally), organisational culture, community very high priority. expectations, and the skill and experience of those respon- sible for driving the process. Health Department Victoria argued that it did not want to: The persistence of differences in councils' approaches to "restrict itself to receipt of an annual report consisting of planning also reflects that there is no shared or agreed a 'shopping list' of inspections made, food confiscated, understanding of the nature or level of the plans. Dever food sampled etc but should instead, in conjunction with identifies three levels of planning: policy planning – what local government, develop a comprehensive public health ought to be done, strategic planning – what can be done, plan against which local government output is measured" and operational planning – what will be done [25]. He [22] (see page 11). notes that "health planners must recognise the level of planning appropriate in a given situation" [25] (see page If this statement is used as a marker of State government's 43). It is not clear exactly what level of planning MPHPs intention in introducing the policy, then the results have involve, policy, strategic or operational, and, as evidenced been mixed. Evidence from the interviews suggests that by the interview data, local governments approach it in prior to the implementation of the framework, public different ways. Smith suggests that because the require- health planning within local government, where it ment to produce a MPHP is contained in health legisla- existed, generally did resemble the 'shopping list' model tion it is often seen, within local government, as the of inspections and samples. What the DHS is now pre- responsibility of the council's health unit or Environmen- sented with by local government is more sophisticated, tal Health Officers (EHO). As a result it is perceived not as more forward looking and more likely to make reference a strategic plan but as simply another function to be to the social model of health. The National Public Health undertaken by the EHOs or health unit [20] (see pages Partnership notes that, with respect to proactive public 26–27). The report by McBride and Hulme recommends health strategies, Victoria through MPHPs now has the that those responsible for the development of the MPHP most explicit provisions of any state [14] (see page 97). have "sufficient authority and legitimacy to effectively Although there is a continuum from very strong to weak drive the public health process across the organisation" MPHPs, there is a sense from the majority of those inter- [23] (see page 41). In policy documents the framework is viewed that even in local governments where the planning most often talked about as a strategic planning process function is not as strong as would be desired, there have [17,18]. However, it is not clear from these documents been improvements. exactly what strategic planning is. For example, the DHS talks about "strategic local area planning" and a "strategic Publications such as Environments for Health and Leading and integrated approach" without ever defining strategic the Way, and the Good Practice Program have made a posi- [17] (see page 6). This distinction is important for public tive difference to the planning process but these were not health where being able to anticipate and respond to introduced until a decade after the legislation came into emerging challenges is vital. It is strategic planning, rather force. It may be some time before a judgement can be than any other form, that constitutes that capacity. The made about how successful they have been in promoting fact that what is planned for is often overtaken by other improved planning. The recently announced external demands diminishes the currency of the plans – particu- evaluation of Environments for Health may answer some of larly in the eyes of those directly involved in the process. these questions [26]. Plans are often seen as best case scenarios not minimum goals to be achieved. The current review of the Health Act 1958 signals the Department's ambition to move away from a focus on the Regulation to encourage organisational behaviour change process of planning, as an end in itself, towards imple- is a blunt instrument and certainly the MPHP framework mentation, or planning as a means to an end. Concern is not enough in itself. However, where there are other fac- that there needs to be increased attention paid to the tors encouraging effective planning, for example support- implementation of MPHPs is not new. As a result of his ive management, the framework does act as a lever. research in 1994 Smith notes that "not a lot of planning Perhaps the most significant way in which it helps is as a for implementation has been performed and that the task Page 6 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:4 http://www.anzhealthpolicy.com/content/4/1/4 of developing the MPHP document was the immediate as one of the conference participants noted, this would priority" [20] (see page 21). The current review poses sev- need to involve real changes in the way State and local eral questions related specifically to the MPHP process: government work together so that 35 medium-sized plans did not simply become three very large plans with no "12. Should the new Act place a greater emphasis on reduction in the administrative burden involved [15] (see implementing the MPHP and achieving its outcomes, page 6). rather than just developing a document, and if so, how could this be achieved? Conclusion Despite argument about the extent to which the planning 13. Should the new Act require that municipal councils set process has improved, those interviewed generally agreed out how they intend to fulfil their statutory functions in that there has been some improvement. A mandatory sys- their MPHPs?" [27] (see page 20). tem of public health planning has not removed the signif- icant variation in councils' approaches to public health Submissions in response to the discussion document [27] planning. Such an expectation would be unrealistic. The are mixed. There is clear agreement with the proposal that planning process occurs within a wider context, and pub- MPHPs be aligned more closely with councils' other plan- lic health units with resources and focus have been best ning activities (for example the Municipal Strategic State- placed to employ the framework. Where units are weak ment). However there is not agreement regarding an their planning remains less than optimal. However, the increased focus on implementation. A number of submis- system has at least impelled local government to address sions argue for a shift of emphasis towards implementa- the question of planning for public health. tion, with the City of Ballarat arguing that "the lack of sanctions has caused many councils to either ignore them The criticism that the focus has been primarily on the or pay lip service" [28] (see page 2) (see also for example process itself, rather than on the outcomes, seems a just [29][30]). Other responses claim that an increased one. The outputs of planning processes can be measured emphasis on implementation is unnecessary, with the (the document itself) but planning outcomes in terms of City of Stonnington noting that "there is adequate achievements (that is improvements in population emphasis on implementation of a MPHP in the current health) are a lot harder to measure. This is not a problem legislation. That this has not resulted in measurable out- specific to local government, nor to this framework, but is comes highlights the reluctance of councils to be a com- a feature of public health planning generally. In the cur- peting service provider ... particularly when there is not a rent review of the legislation, State government has clearly funding component to a MPHP" [31] (see page 3). The signalled that it would like to see some improvement in sections dealing with MPHP (29A and 29B) form only a this although it is not clear how this might be achieved. small part of the Health Act and the review discussion Introducing a punitive element to the legislation, so that document is not explicit regarding whether changes to councils who failed to develop and implement a plan these sections have been prompted by perceived failures were in some way punished, would be counter produc- in the existing arrangement or by a shift in the broader tive. For any number of reasons, tensions exist in the rela- paradigm of public administration towards a greater tionship between State and local government. In such an emphasis on implementation and outcomes. It argues environment, apparent 'poor' planning may be more than that shifting the emphasis towards implementation and simply a matter of local government lacking the capacity outcomes would "make planning a more meaningful to do 'good' planning. In some cases it may represent exercise" [27] (see page 19). The most recent public state- attempts by local government to resist what they see as ments from the DHS suggest that they favour the integra- another example of State government asserting control tion of planning processes and increased support (such as over their territory. Introducing a punitive element into implementation and evaluation tools) over prescriptive the legislation would exacerbate the situation. legislation to encourage a greater focus on implementa- tion [33] (see page 30–31). Victoria has had a system of mandated public health plan- ning for over a decade. Despite criticisms of the system it In addition to the current Health Act review, there are is difficult to argue that mechanisms, other than legisla- other indications that the State government intends mak- tive compliance, would be any more successful. In Victo- ing changes to reduce the number of plans required of ria's case, where the local delivery system is very diverse, a local government in the near future. In a recent speech to legislative imperative has created, at the very least, a min- local government representatives a State government Min- imum standard for public health planning. The Victorian ister argued that "we need to cut the number of plans cov- experience provides lessons for other jurisdictions as they ering local government, integrate them better and ensure consider how best to strengthen public health planning that planning cycles coincide" [34] (see page 9). However, (see Table 1). Page 7 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:4 http://www.anzhealthpolicy.com/content/4/1/4 Table 1: Lessons from Victoria ▪ The process of legislative change needs to be truly consultative ▪ The type of plan and its scope should be explicit ▪ There needs to be shared understanding among stakeholders about the level of planning ▪ Winning the support of senior managers within local governments is vital ▪ Workforce capacity in planning is essential ▪ Integration with other planning activities, both within the organisation and at State level, is required ▪ There needs to be investment in implementation strategies policy developments. KR provided comments on draft, Methods Interviews were conducted with 10 people in nine local including current policy developments. governments within one Department of Human Services (DHS) metropolitan region in Victoria, plus four addi- All authors read and approved the final manuscript. tional interviews with other state based public health agencies. All of those interviewed were public servants. Acknowledgements This project was supported by an ARC Linkages grant. Within local government people were selected on the basis of their seniority and responsibility for public References health, that is, people with highest level seniority whilst 1. Centers for Disease Control and Prevention: Public Health's Infra- still retaining direct responsibility for public health serv- structure: a status report. Atlanta , CDC; 2001. ices. The titles and responsibilities and levels of the posi- 2. Institute of Medicine: The Future of the Public's Health in the 21st Century. Washington D.C. , National Academy Press; 2002. tions varied as councils are often structured in different 3. Pan American Health Organization: Public Health in the Ameri- ways. Most commonly these people were titled Commu- cas. Washington DC , Pan American Health Organization; 2002. 4. Bettcher DW, Sapirie S, Goon EH: Essential public health func- nity Health or Health Services managers. In general they tions: results of an international Delphi study. World Health represent the middle layer of management within the Statistics Quarterly 1998, 51:44-54. council, reporting to a health/community services director 5. World Health Organization (Regional Office for the Western Pacific): Essential Public Health Functions: A Three-Country Study in or to the council's CEO/general manager. the Western Pacific. Manila , WHO; 2003. 6. National Association of County and City Health Officials, Robert The interviews were semi-structured. The intention was to Wood Johnson Foundation: Local Health Department Infra- structure Survey. Princeton , National Association of County and repeat some core questions to allow for comparison City Health Officials and the Robert Wood Johnson Foundation; between organisations, whilst retaining some flexibility to 7. Corso LC, Wiesner PJ, Halverson PK, Brown CK: Using the essen- enable participants to raise issues that they regarded as tial services as a foundation for performance measurement important. The interview schedule was built around the and assessment of local public health systems. Journal of Public broadest definition of infrastructure for public health Health Management and Practice 2000, 6(5):1-18. 8. Brodeur P: The Turning Point Initiative. In To Improve Health and developed by the National Public Health Partnership Health Care Volume VIII. Washington D.C. , The Robert Wood John- [10]. All interviews were audio recorded and transcribed son Foundation; 2005. verbatim. Thematic analysis was then employed to iden- 9. National Health and Medical Research Council: Promoting the Health of Australians: a review of infrastructure support for tify major themes emerging from the interviews. national health advancement: Final Report. Canberra , NHMRC; 1996. 10. National Public Health Partnership: Public Health in Australia. The project had approval from La Trobe University's Melbourne , NPHP; 1998. Human Ethics Committee (reference number 02–70) 11. Lenihan P: MAPP and the Evolution of Planning in Public Health Practice. Journal of Public Health Management and Practice 2005, 11(5):381-386. Competing interests 12. Freund CG, Liu Z: Local health department capacity and per- The author(s) declare that they have no competing inter- formance in New Jersey. Journal of Public Health Management and ests. Practice 2000, 6(5):31-41. 13. Eagar K, Garrett P, Lin V: Health Planning: Australian Perspec- tives. Melbourne , Allen and Unwin; 2001. Authors' contributions 14. National Public Health Partnership: The Role of Local Govern- ment in Public Health Regulation. Melbourne , NPHP; 2002. PB conducted the literature review, undertook data collec- 15. Local Government Victoria: Conference Report and Next Steps: tion and analysis and drafted the paper. VL conceptual- 13 May; Flemington. ; 2005. ised the study, provided framing and structuring of the 16. Department of Health: A New Public Health Act for Western Australia: a discussion paper on a new legislative framework paper and commented on drafts. PS conceptualised the for public health in Western Australia. Perth , Department of study and provided substantial comments on drafts. MW Health; 2005. 17. Department of Human Services Victoria: Environments for conceptualised the study and commented on drafts. TK Health: Municipal Public Health Planning Framework. Mel- provided key input into the framing of paper and current bourne , DHS; 2001. Page 8 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:4 http://www.anzhealthpolicy.com/content/4/1/4 18. Victorian Health Promotion Foundation (VicHealth): Leading the Way: Councils Creating Healthier Communities. Melbourne , VicHealth; 2002. 19. Legge D, Cox H: Partners for Public Health: Developing the State-Local Government Partnership for Public Health in Victoria. Melbourne , La Trobe University; 1997. 20. Smith J: Planning for Health in Local Government: A Review of the Implementation of Municipal Public Health Plans and Discussion of the Future Health Role of Local Government in Victoria. Melbourne , Municipal Association of Victoria; 1995. 21. Wills J: Case Study: Municipal Public Health Planning. In Health Planning: Australian Perspectives Edited by: Eagar K, Garrett P, Lin V. Melbourne , Allen and Unwin; 2001. 22. Health Department Victoria: Public Health Legislation in Victo- ria: a discussion paper. In Review of Health Legislation: Discussion Paper Series Melbourne , HDV; 1986. 23. McBride T, Hulme A: Strengthening Integration of Municipal Public Health Plans into Local Government Strategic Plan- ning: a report to the North East Health Promotion Centre. Melbourne , School of Health Sciences, Deakin University, Centre for Development and Innovation in Health, La Trobe University; 1999. 24. University of Melbourne: Good Practice Program: final evalua- tion report. Melbourne , Program Evaluation Unit, Department of Public Health,; 2005. 25. Dever G: Community Health Analysis: A Holistic Approach. Maryland , Aspen; 1980. 26. Department of Human Services Victoria: Municipal Public Health Planning Special Bulletin. Melbourne , DHS; 2006. 27. Department of Human Services Victoria: Review of the Health Act 1958: a new legislative framework for public health in Victoria: a discussion paper. Melbourne , DHS; 2004. 28. City of Ballarat: Submission to the Review of the Health Act 1958. 2004. 29. City of Casey: Submission to the Review of the Health Act 1958. 2004. 30. Victorian Health Promotion Foundation (VicHealth): Submission to the Review of the Health Act 1958. 2004. 31. City of Stonnington: Submission to the Review of the Health Act 1958. 2004. 32. Dixon J, Kouzmin A, Korac-Kakabadse N: Managerialism - some- thing old, something borrowed, little new. International Journal of Public Sector Management 1998, 11:164-187. 33. Department of Human Services Victoria: Review of the Health Act 1958: a new legislative framework for public health in Victoria: a draft policy paper for consultation. Melbourne , DHS; 2005. 34. Broad C: Speech by Minister Broad. In State and Local Govern- ments Working Together to Build Stronger Communities Flemington ; Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp 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

In what ways does the mandatory nature of Victoria's municipal public health planning framework impact on the planning process and outcomes?

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Springer Journals
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Copyright © 2007 by Bagley et al; 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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10.1186/1743-8462-4-4
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17376248
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Abstract

Background: Systems for planning are a critical component of the infrastructure for public health. Both in Australia and internationally there is growing interest in how planning processes might best be strengthened to improve health outcomes for communities. In Australia the delivery of public health varies across states, and mandated municipal public health planning is being introduced or considered in a number of jurisdictions. In 1988 the Victorian State government enacted legislation that made it mandatory for each local government to produce a Municipal Public Health Plan, offering us a 20-year experience to consider. Results: In-depth interviews were undertaken with those involved in public health planning at the local government level, as part of a larger study on local public health infrastructure and capacity. From these interviews four significant themes emerge. Firstly, there is general agreement that the Victorian framework of mandatory public health planning has led to improvements in systems for planning. However, there is some debate about the degree of that improvement. Secondly, there is considerable variation in the way in which councils approach planning and the priority they attach to the process. Thirdly, there is concern that the focus is on producing a plan rather than on implementing the plan. Finally, some tension over priorities is evident. Those responsible for developing Municipal Public Health Plans express frustration over the difficulty of having issues they believe are important addressed through the MPHP process. Conclusion: There are criticisms of Victoria's system for public health planning at the local government level. Some of these issues may be specific to the arrangement in Victoria, others are problems encountered in public health planning generally. In Victoria where the delivery structure for public health is diverse, a system of mandatory planning has created a minimum standard. The implementation of the framework was slow and factors in the broader political environment had a significant impact. Work done in recent years to support the process appears to have led to improvements. There are lessons for other states as they embark upon mandated public health plans. Page 1 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:4 http://www.anzhealthpolicy.com/content/4/1/4 MPHPs are not the only legislated plans at the local level Background Strengthening public health infrastructure and capacity is in Victoria. The Local Government Act 1989 and the Plan- an issue attracting increasing national and international ning and Environment Act 1987 both impose planning interest (see for example [1-4] and [5]). In the USA and requirements on councils. In addition to these plans there UK, attention has turned to strengthening public health are numerous other plans required and discussions are systems for emergency preparedness following September underway between State and local government about how 2001, the SARs outbreak and, more recently, avian influ- the administrative workload they impose might best be enza. One component of this work has been a focus on reduced [15]. how to improve planning processes at the community level (see for example [6,7] and [8]). In Australia, interest Another review of the Health Act was initiated in 2002, is also driven by the increasing complexity of the issues and some of the issues highlighted for comment relate faced by public health, shrinking resources and 'reforms' directly to MPHP activities. This review makes discussion in public administration. Although infrastructure and of the planning framework's impact to date particularly capacity have been variously defined, systems for plan- timely. However, it is not simply an issue for Victoria. The ning are generally considered to be a critical component Western Australian government is reviewing its Health Act (for definitions of infrastructure see [1,9-11] and [12]). and asking "should the public health powers, functions Australian activities in formal health planning date from and responsibilities of local government be spelt out in a the 1970s during which time there have been paradig- new Health Act in more detail than currently exists?" [16] matic shifts, from an interest in equity to a focus on effi- (see page 14). All jurisdictions have an interest in how ciency, that mirror changes in the broader policy best to plan for and deliver public health services. environment [13] (see pages 55–67). Currently, a central concern is how planning processes might be strengthened As a system for planning, the framework in Victoria is to improve outcomes in the public's health. unique in that it is mandatory. The aim of this article is to review the strengths and weaknesses of this framework, as In Australia the configuration of the delivery system for it was implemented in Victoria. Of particular interest are public health varies from state to state. In Victoria much the questions: has the Victorian framework improved of its public health services are delivered by local govern- planning processes and outcomes; what has been the ments (see [14] for an extensive review of the role played extent of any improvement; and what are the challenges by local government across Australia). The 79 Victorian that remain? Underpinning these questions is the broader local governments vary in a number of ways including issue regarding the degree to which problems, where iden- inter alia size, geography, population, and organisational tified, are specific to this Victorian framework for plan- income and capacity. They are an autonomous and sepa- ning or are general problems encountered in public health rate sphere of government, although a great deal of what planning, irrespective of the manner in which it is organ- they do is prescribed in legislation set by State govern- ised. ment. In addition, funding agreements with Federal and State agencies dictate a number of their activities. In 1988 Results the State government amended the 1958 Health Act and Analysis of the interview transcripts provided a great deal made it mandatory for each local government (council) to of information about the planning process from which develop a municipal public health plan (MPHP). The four significant, and interrelated, themes emerge: agree- Health (General Amendment) Act 1988 (29B) states that: ment that the legislation has improved systems for plan- ning but debate about the extent of that improvement; "A municipal public health plan must: (a) identify and significant variation in the way in which councils assess actual and potential public health dangers affecting approach planning, their level of sophistication and the the municipal district; and (b) outline programs and strat- priority they attach to the process; concern that the focus egies which the council intends to pursue to (i) prevent or is primarily on the process itself (producing a plan) rather minimise those dangers; and (ii) enable people living in than on outcomes (implementing the plan); and some the municipal district to achieve maximum well-being; tension over priorities, with frustration expressed by those and (c) provide for periodic evaluation of programs and responsible for developing MPHPs that areas they strategies." believed should have priority are either not included in plans or where they are included they may be relegated in Councils are required to prepare a new plan every three importance when State and Federal government prioritise years and review their existing plan annually. These provi- other activities. sions, within the legislation, constitute Victoria's munici- pal public health planning framework. Page 2 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:4 http://www.anzhealthpolicy.com/content/4/1/4 Legislation has improved planning or their idea in the plan but who were also really motivated to The majority of those interviewed believed that, on bal- do something about it" ance, the legislative mandate had improved the planning process. Local government representatives expressed a Comments from those external to local government also variety of reactions to the MPHP process. As the following corroborate the significant variations at play: quotes illustrate, some saw it as a useful activity that helped in 'making a case for public health' within the "we have a bit of a spectrum from those who have got a real broader council environment and increased the visibility community development, community participation focus and a of public health, whilst for others it was simply another real strong social model of health focus to those who have taken function imposed by State government: the National Health Priority Areas and modelled their health planning around health issues and diseases and risk factors" "they [council] have come around to understanding the impor- tance of a public health plan and have, quite rightly, given it "the ones that I've seen that have more of a focus in community, the resourcing it requires." that really have got their community strategies right, are really doing some good work" "the way we structured it [the MPHP] is to try and take the role of integrating public health thinking across the council's strate- The focus is primarily on the process itself rather than on gic planning process, and we are trying to lift awareness across outcomes council" Another central concern raised was the extent to which legislation emphasised the process of planning but not "it is not something that is high priority. Most councils don't the outcomes: prioritise it terribly highly ... it has to be reproduced every three years and it has to be reviewed every 12 months but in practice "because notoriously in the past many local governments ... most people just produce it every three years and forget about it" even though they have a statutory obligation to produce a plan ... they would produce it and it might just end up on the book- Those outside local government were generally, but not shelf" exclusively, more positive about the MPHP process and outcomes. They believed that publications by the Depart- "I was going to say outcomes but you know there are no out- ment of Human Services [17] and the Victorian Health comes to some of their municipal public health planning Promotion Foundation [18] had strengthened local gov- endeavours, you know apart from the obvious immunisation ernment planning functions. One respondent identified stuff that they have done forever anyway, I mean some of them what he believed to be a genuine shift in thinking about are lucky if they can throw together a document" planning away from what he classified as 'retrospective planning', where councils simply developed a plan that All the councils interviewed had an MPHP but about half reported what they had done in the past, towards more lacked a formal implementation strategy. strategic planning. Despite general agreement that the sys- tem had improved the planning process, there were con- Tension over priorities cerns about the quality of planning: Within council there can be resistance to including any- thing within a plan that senior management and/or coun- "it just depends on the council and how advanced they are. cillors do not see as the 'core business' of council. One Some, like [name of council] are very good and you don't have respondent noted that his community health unit had any problem with them but there are others who ... they just identified the need for low cost housing in the municipal- don't get it basically" ity but his council certainly did not see itself in the busi- ness of providing housing. Another noted that: Significant variation exists Significant variations exist in the way in which councils "even though you might identify something as an issue there is approach the MPHP process. This was evident from the no guarantee that it is going to be addressed in any proactive manner in which those within local government talked way" about the process, as the two following quotes illustrate: Even if health planners are successful in having an issue "State government sets a number of key performance indicators included in the plan, this does not guarantee that it will be that we pick up on and sort of blend our own stuff into" addressed. The process may then be overtaken by political demands, either from Federal or State government or "we ended up with a really energised, mobilised community [as from within council itself, usually as a response to com- a result of the planning process], who not only saw their name munity or political pressure. Immunisation and illicit Page 3 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:4 http://www.anzhealthpolicy.com/content/4/1/4 drugs are two examples of this. In the first instance, Fed- "should be acknowledged as one of the main institutional eral government recently decided to increase the age range foundations of public health practice" [19] (see page 3). Their initial, and in many cases continuing, role centred for children being immunised. This resulted in significant extra work in the states. In Victoria a great deal of this on traditional public health issues such as sanitation and th increase in work was borne by public health units within waste management. In the 20 century the role of many local government. As funding is contingent on this being local governments began to expand beyond an interest in undertaken, other activities within the MPHP are rele- the physical environment [20]. The pace of this expansion gated: increased from the mid-century. It occurred at a differen- tial rate from state to state and was most notable in Victo- "meningococcal immunisation was a case in point. The Federal ria [14] (see page 100). By the 1970s Victoria's local government decided it was something that they should fund for governments had a role in maternal and child health, all children from the age of birth to 20 years ... well who's going childhood immunisation programs, services for older to do it? There is a statutory requirement on local government people and more general welfare services [20,19]. As to do immunisation. So that meant that instead of doing our Smith notes, one of the significant features of this expan- normal workload for immunisation, the workload tripled simply sion was a growing interest in "people and their social cir- because the number of kids tripled" cumstances rather than on the physical environment" [20] (see page 6). In the case of illicit drugs, an apparent spike in the number of deaths, particularly in public spaces, resulted In the mid-1980s the Victorian state government under- in a great deal of media coverage and significant commu- took a series of reviews of health legislation, including the nity concern. Funding became available and programs Health Act 1958 that defines the roles and responsibilities were developed in response to the newly presented fund- of local government as they relate to public health. Smith ing opportunities. As one of the respondents noted: argues that there are two salient points to note about the intent underpinning the review of the Health Act: that it "the previous municipal public health plan did identify a need "regarded public health in terms of the New Public for a drug policy of some sort or some attention on drugs which Health" and that it "would involve the examination of the we did achieve, but not directly through the municipal public relationship between the then Health Department Victo- health plan. It was an adjunct of people dying on the streets" ria and local government" [20] (see page 7). However, as both Smith [20] and Wills [21] note, despite using the lan- A number of participants observed that everything 'comes guage of health promotion, the emphasis in the relevant down to money'. While most of those interviewed spoke sections of the legislation (29A and 29B) was on protec- about this phenomena in negative terms, as peripatetic tion and prevention – the so called 'old' public health. crisis funding, one person observed that a strong public Wills [21] argues that this disjunction led to confusion health unit could and should respond to these opportuni- about the scope of the MPHPs. ties: The Act was an attempt to introduce positive, rather than "we are looking to move ... towards a much more complex and punitive, legislation that would encourage councils to act much more flexible, much more flexible arrangement so that we in a certain way rather than punish them for failing to do can become, for want of a better word, 'nippy' you know so that so. In the discussion document preceding the legislation we can nip in and out where things happen and where we can the Health Department noted that: make an impact" "Health Department Victoria (HDV) must be careful not Discussion to impose rigid regulatory controls to be enforced by The four major themes that emerge from the interviews councils and which limit their ability to re-determine their (improvement in planning systems; variation in own priorities in response to changing public health approaches to planning; an emphasis on the process needs in the municipality" [22] (see page 11). rather than on outcomes; and tensions over priorities) indicate something of the strengths and weaknesses of the This notion of positive legislation is reinforced by the lan- Victorian planning framework. It is worthwhile to look at guage used in Department of Human Services (DHS) sup- the intent of the legislation, its implementation and the porting documents where the Act is represented as a value of the MPHP framework. 'planning framework' rather than a 'planning template'. The choice of language is deliberate, the distinction being The intent that frameworks allow for a bottom-up approach where Local government in Australia has played a role in public templates reflect a top-down approach to planning. This th health since the 19 century and, as Legge and Cox argue, distinction may not be apparent to people within local Page 4 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:4 http://www.anzhealthpolicy.com/content/4/1/4 government where, for some, the mandatory nature of the between local government as staff and operational units system is one of its most salient features. In Australia's became wary about sharing information with counter- three-tiered system of government, the state is not a single parts in other local governments in the newly competitive homogeneous entity. Tensions exist between spheres of tendering environment. In addition there was a significant government and between the centre and periphery. In Vic- impact on the public health workforce. Legge and Cox toria these tensions include feelings amongst some in report that in the two years to 1997 there was an estimated local government that State government fails to under- 40% reduction in the number of environmental health stand the local context and that it tends to treat local gov- officers within local government [19] (see page 11). ernment as its administrative arm rather than as a duly elected separate sphere of government. Wills [21] argues In 1999 a new State government was elected and this, per- that the State government's failure to consult with local haps, injected new enthusiasm into the implementation government when developing the legislative amend- process. In 2001 the DHS and the Municipal Association ments, and the concern that some in local government of Victoria (MAV) released an MPHP planning framework had that the changes were motivated by a desire to shift in the form of the document Environments for Health [17]. costs, created additional tensions. This was intended as a guide for those within municipal councils responsible for writing the MPHP. This may have In this environment the Act is open to at least two inter- partially addressed some of the concerns that had been pretations. The first is that it represents a genuine attempt raised [19][20] regarding the skill capacity of the work- to improve health planning at local government level. The force within local government, to undertake strategic second is that it is an attempt by State government to planning for public health. In 2004 a second document, assert control over the process of planning. In the discus- Leading the Way: Councils Creating Healthier Communities sion paper preceding the Act's amendment HDV noted [18], was released. Developed by VicHealth, DHS, and that local government were well placed to play an MAV, the document was designed to increase the under- expanded role in public health because they were closer to standing of elected councillors and local government sen- the local community and had the necessary staff. However ior management. It recognises, as the literature had they noted that in two instances State government had a highlighted, that senior level support is a critical factor in role to play: where there was insufficient local expertise – developing and implementing a strategic MPHP particularly in specialised functions; and where health [19][20][23]. These two documents were supplemented problems extended beyond municipal boundaries. Addi- by the Good Practice Program, through which from 2002 – tionally they recommended that "central government 2004 the DHS funded 26 projects involving 39 local gov- should retain oversight of local government in order to ernments in activities that used Environments for Health to negate the undesirable effect on all Victorians of variabil- improve public health planning [24]. ity of public health enforcement by local councils" [22] (see page 20). The value of the MPHP framework The significant variation in council approaches to plan- The implementation ning, evident in the interview data, is a manifestation of Although the Act was amended in 1988, implementation the differences in councils' organisational capacity and of Section 29(B) has been a lengthy process. A pilot study, culture. Many of those in local government would argue with 11 councils, was undertaken in 1990 with the sup- that financial resources are a critical component. There is, port of a project officer funded by HDV. During the fol- within local government, a measure of wariness about lowing decade an increasing number of councils what is perceived as cost shifting by State and Federal gov- developed plans. This was done in an environment of ernment. A number of those who were interviewed dis- uncertainty and tension. The election, in 1992, of the Ken- cussed this with reference to the MPHP process. They saw nett Coalition government introduced a period of tremen- the role and responsibilities of local government expand dous change for local government. Driven by the without any commensurate increase in funding. Clearly prevailing ideology of 'small government', efficiency and there is a relationship between levels of funding (whether market models the Coalition forced the amalgamation of directly from the State or made available internally) and a many local governments (from over 200 to 78) and intro- council's ability to develop and implement their MPHP. duced a system of compulsory competitive tendering. What is less obvious is the degree of correlation between Although amalgamations have long been a feature of the councils' financial resources and their ability to deliver local government environment Australia wide, in Victoria public health outcomes. Analysis of the interview data the nature and scope of the 'reforms' was dramatic [14] suggests that those councils who take a strategic approach (see page 99) and had long-term consequences. These to MPHP, who make reference to the social model of changes created tension in the relationship between State health, who have high levels of community involvement and local government. They also stifled cooperation and who have formal processes in place for implementing Page 5 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:4 http://www.anzhealthpolicy.com/content/4/1/4 and evaluating their plans are not, as a matter of course, platform for public health practitioners within local gov- the wealthier municipalities. Nor were those councils who ernment – where it legitimates their activities. These peo- demonstrated a narrow approach to public health plan- ple work within an environment of limited power, with ning or who lacked processes for implementation and multiple competing demands. Public health activities not evaluation necessarily the less well financially resourced. already specifically described in legislation (that is activi- Other relevant factors include managerial support for the ties other than immunisation, food sampling, premises MPHP process (and public health programs and activities inspection, and water inspection) are often not given a more generally), organisational culture, community very high priority. expectations, and the skill and experience of those respon- sible for driving the process. Health Department Victoria argued that it did not want to: The persistence of differences in councils' approaches to "restrict itself to receipt of an annual report consisting of planning also reflects that there is no shared or agreed a 'shopping list' of inspections made, food confiscated, understanding of the nature or level of the plans. Dever food sampled etc but should instead, in conjunction with identifies three levels of planning: policy planning – what local government, develop a comprehensive public health ought to be done, strategic planning – what can be done, plan against which local government output is measured" and operational planning – what will be done [25]. He [22] (see page 11). notes that "health planners must recognise the level of planning appropriate in a given situation" [25] (see page If this statement is used as a marker of State government's 43). It is not clear exactly what level of planning MPHPs intention in introducing the policy, then the results have involve, policy, strategic or operational, and, as evidenced been mixed. Evidence from the interviews suggests that by the interview data, local governments approach it in prior to the implementation of the framework, public different ways. Smith suggests that because the require- health planning within local government, where it ment to produce a MPHP is contained in health legisla- existed, generally did resemble the 'shopping list' model tion it is often seen, within local government, as the of inspections and samples. What the DHS is now pre- responsibility of the council's health unit or Environmen- sented with by local government is more sophisticated, tal Health Officers (EHO). As a result it is perceived not as more forward looking and more likely to make reference a strategic plan but as simply another function to be to the social model of health. The National Public Health undertaken by the EHOs or health unit [20] (see pages Partnership notes that, with respect to proactive public 26–27). The report by McBride and Hulme recommends health strategies, Victoria through MPHPs now has the that those responsible for the development of the MPHP most explicit provisions of any state [14] (see page 97). have "sufficient authority and legitimacy to effectively Although there is a continuum from very strong to weak drive the public health process across the organisation" MPHPs, there is a sense from the majority of those inter- [23] (see page 41). In policy documents the framework is viewed that even in local governments where the planning most often talked about as a strategic planning process function is not as strong as would be desired, there have [17,18]. However, it is not clear from these documents been improvements. exactly what strategic planning is. For example, the DHS talks about "strategic local area planning" and a "strategic Publications such as Environments for Health and Leading and integrated approach" without ever defining strategic the Way, and the Good Practice Program have made a posi- [17] (see page 6). This distinction is important for public tive difference to the planning process but these were not health where being able to anticipate and respond to introduced until a decade after the legislation came into emerging challenges is vital. It is strategic planning, rather force. It may be some time before a judgement can be than any other form, that constitutes that capacity. The made about how successful they have been in promoting fact that what is planned for is often overtaken by other improved planning. The recently announced external demands diminishes the currency of the plans – particu- evaluation of Environments for Health may answer some of larly in the eyes of those directly involved in the process. these questions [26]. Plans are often seen as best case scenarios not minimum goals to be achieved. The current review of the Health Act 1958 signals the Department's ambition to move away from a focus on the Regulation to encourage organisational behaviour change process of planning, as an end in itself, towards imple- is a blunt instrument and certainly the MPHP framework mentation, or planning as a means to an end. Concern is not enough in itself. However, where there are other fac- that there needs to be increased attention paid to the tors encouraging effective planning, for example support- implementation of MPHPs is not new. As a result of his ive management, the framework does act as a lever. research in 1994 Smith notes that "not a lot of planning Perhaps the most significant way in which it helps is as a for implementation has been performed and that the task Page 6 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:4 http://www.anzhealthpolicy.com/content/4/1/4 of developing the MPHP document was the immediate as one of the conference participants noted, this would priority" [20] (see page 21). The current review poses sev- need to involve real changes in the way State and local eral questions related specifically to the MPHP process: government work together so that 35 medium-sized plans did not simply become three very large plans with no "12. Should the new Act place a greater emphasis on reduction in the administrative burden involved [15] (see implementing the MPHP and achieving its outcomes, page 6). rather than just developing a document, and if so, how could this be achieved? Conclusion Despite argument about the extent to which the planning 13. Should the new Act require that municipal councils set process has improved, those interviewed generally agreed out how they intend to fulfil their statutory functions in that there has been some improvement. A mandatory sys- their MPHPs?" [27] (see page 20). tem of public health planning has not removed the signif- icant variation in councils' approaches to public health Submissions in response to the discussion document [27] planning. Such an expectation would be unrealistic. The are mixed. There is clear agreement with the proposal that planning process occurs within a wider context, and pub- MPHPs be aligned more closely with councils' other plan- lic health units with resources and focus have been best ning activities (for example the Municipal Strategic State- placed to employ the framework. Where units are weak ment). However there is not agreement regarding an their planning remains less than optimal. However, the increased focus on implementation. A number of submis- system has at least impelled local government to address sions argue for a shift of emphasis towards implementa- the question of planning for public health. tion, with the City of Ballarat arguing that "the lack of sanctions has caused many councils to either ignore them The criticism that the focus has been primarily on the or pay lip service" [28] (see page 2) (see also for example process itself, rather than on the outcomes, seems a just [29][30]). Other responses claim that an increased one. The outputs of planning processes can be measured emphasis on implementation is unnecessary, with the (the document itself) but planning outcomes in terms of City of Stonnington noting that "there is adequate achievements (that is improvements in population emphasis on implementation of a MPHP in the current health) are a lot harder to measure. This is not a problem legislation. That this has not resulted in measurable out- specific to local government, nor to this framework, but is comes highlights the reluctance of councils to be a com- a feature of public health planning generally. In the cur- peting service provider ... particularly when there is not a rent review of the legislation, State government has clearly funding component to a MPHP" [31] (see page 3). The signalled that it would like to see some improvement in sections dealing with MPHP (29A and 29B) form only a this although it is not clear how this might be achieved. small part of the Health Act and the review discussion Introducing a punitive element to the legislation, so that document is not explicit regarding whether changes to councils who failed to develop and implement a plan these sections have been prompted by perceived failures were in some way punished, would be counter produc- in the existing arrangement or by a shift in the broader tive. For any number of reasons, tensions exist in the rela- paradigm of public administration towards a greater tionship between State and local government. In such an emphasis on implementation and outcomes. It argues environment, apparent 'poor' planning may be more than that shifting the emphasis towards implementation and simply a matter of local government lacking the capacity outcomes would "make planning a more meaningful to do 'good' planning. In some cases it may represent exercise" [27] (see page 19). The most recent public state- attempts by local government to resist what they see as ments from the DHS suggest that they favour the integra- another example of State government asserting control tion of planning processes and increased support (such as over their territory. Introducing a punitive element into implementation and evaluation tools) over prescriptive the legislation would exacerbate the situation. legislation to encourage a greater focus on implementa- tion [33] (see page 30–31). Victoria has had a system of mandated public health plan- ning for over a decade. Despite criticisms of the system it In addition to the current Health Act review, there are is difficult to argue that mechanisms, other than legisla- other indications that the State government intends mak- tive compliance, would be any more successful. In Victo- ing changes to reduce the number of plans required of ria's case, where the local delivery system is very diverse, a local government in the near future. In a recent speech to legislative imperative has created, at the very least, a min- local government representatives a State government Min- imum standard for public health planning. The Victorian ister argued that "we need to cut the number of plans cov- experience provides lessons for other jurisdictions as they ering local government, integrate them better and ensure consider how best to strengthen public health planning that planning cycles coincide" [34] (see page 9). However, (see Table 1). Page 7 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:4 http://www.anzhealthpolicy.com/content/4/1/4 Table 1: Lessons from Victoria ▪ The process of legislative change needs to be truly consultative ▪ The type of plan and its scope should be explicit ▪ There needs to be shared understanding among stakeholders about the level of planning ▪ Winning the support of senior managers within local governments is vital ▪ Workforce capacity in planning is essential ▪ Integration with other planning activities, both within the organisation and at State level, is required ▪ There needs to be investment in implementation strategies policy developments. KR provided comments on draft, Methods Interviews were conducted with 10 people in nine local including current policy developments. governments within one Department of Human Services (DHS) metropolitan region in Victoria, plus four addi- All authors read and approved the final manuscript. tional interviews with other state based public health agencies. All of those interviewed were public servants. Acknowledgements This project was supported by an ARC Linkages grant. Within local government people were selected on the basis of their seniority and responsibility for public References health, that is, people with highest level seniority whilst 1. Centers for Disease Control and Prevention: Public Health's Infra- still retaining direct responsibility for public health serv- structure: a status report. Atlanta , CDC; 2001. ices. The titles and responsibilities and levels of the posi- 2. Institute of Medicine: The Future of the Public's Health in the 21st Century. Washington D.C. , National Academy Press; 2002. tions varied as councils are often structured in different 3. Pan American Health Organization: Public Health in the Ameri- ways. Most commonly these people were titled Commu- cas. Washington DC , Pan American Health Organization; 2002. 4. Bettcher DW, Sapirie S, Goon EH: Essential public health func- nity Health or Health Services managers. In general they tions: results of an international Delphi study. World Health represent the middle layer of management within the Statistics Quarterly 1998, 51:44-54. council, reporting to a health/community services director 5. World Health Organization (Regional Office for the Western Pacific): Essential Public Health Functions: A Three-Country Study in or to the council's CEO/general manager. the Western Pacific. Manila , WHO; 2003. 6. National Association of County and City Health Officials, Robert The interviews were semi-structured. The intention was to Wood Johnson Foundation: Local Health Department Infra- structure Survey. Princeton , National Association of County and repeat some core questions to allow for comparison City Health Officials and the Robert Wood Johnson Foundation; between organisations, whilst retaining some flexibility to 7. Corso LC, Wiesner PJ, Halverson PK, Brown CK: Using the essen- enable participants to raise issues that they regarded as tial services as a foundation for performance measurement important. The interview schedule was built around the and assessment of local public health systems. Journal of Public broadest definition of infrastructure for public health Health Management and Practice 2000, 6(5):1-18. 8. Brodeur P: The Turning Point Initiative. In To Improve Health and developed by the National Public Health Partnership Health Care Volume VIII. Washington D.C. , The Robert Wood John- [10]. All interviews were audio recorded and transcribed son Foundation; 2005. verbatim. Thematic analysis was then employed to iden- 9. National Health and Medical Research Council: Promoting the Health of Australians: a review of infrastructure support for tify major themes emerging from the interviews. national health advancement: Final Report. Canberra , NHMRC; 1996. 10. National Public Health Partnership: Public Health in Australia. The project had approval from La Trobe University's Melbourne , NPHP; 1998. Human Ethics Committee (reference number 02–70) 11. Lenihan P: MAPP and the Evolution of Planning in Public Health Practice. Journal of Public Health Management and Practice 2005, 11(5):381-386. Competing interests 12. Freund CG, Liu Z: Local health department capacity and per- The author(s) declare that they have no competing inter- formance in New Jersey. Journal of Public Health Management and ests. Practice 2000, 6(5):31-41. 13. Eagar K, Garrett P, Lin V: Health Planning: Australian Perspec- tives. Melbourne , Allen and Unwin; 2001. Authors' contributions 14. National Public Health Partnership: The Role of Local Govern- ment in Public Health Regulation. Melbourne , NPHP; 2002. PB conducted the literature review, undertook data collec- 15. Local Government Victoria: Conference Report and Next Steps: tion and analysis and drafted the paper. VL conceptual- 13 May; Flemington. ; 2005. ised the study, provided framing and structuring of the 16. Department of Health: A New Public Health Act for Western Australia: a discussion paper on a new legislative framework paper and commented on drafts. PS conceptualised the for public health in Western Australia. Perth , Department of study and provided substantial comments on drafts. MW Health; 2005. 17. Department of Human Services Victoria: Environments for conceptualised the study and commented on drafts. TK Health: Municipal Public Health Planning Framework. Mel- provided key input into the framing of paper and current bourne , DHS; 2001. Page 8 of 9 (page number not for citation purposes) Australia and New Zealand Health Policy 2007, 4:4 http://www.anzhealthpolicy.com/content/4/1/4 18. Victorian Health Promotion Foundation (VicHealth): Leading the Way: Councils Creating Healthier Communities. Melbourne , VicHealth; 2002. 19. Legge D, Cox H: Partners for Public Health: Developing the State-Local Government Partnership for Public Health in Victoria. Melbourne , La Trobe University; 1997. 20. Smith J: Planning for Health in Local Government: A Review of the Implementation of Municipal Public Health Plans and Discussion of the Future Health Role of Local Government in Victoria. Melbourne , Municipal Association of Victoria; 1995. 21. Wills J: Case Study: Municipal Public Health Planning. In Health Planning: Australian Perspectives Edited by: Eagar K, Garrett P, Lin V. Melbourne , Allen and Unwin; 2001. 22. Health Department Victoria: Public Health Legislation in Victo- ria: a discussion paper. In Review of Health Legislation: Discussion Paper Series Melbourne , HDV; 1986. 23. McBride T, Hulme A: Strengthening Integration of Municipal Public Health Plans into Local Government Strategic Plan- ning: a report to the North East Health Promotion Centre. Melbourne , School of Health Sciences, Deakin University, Centre for Development and Innovation in Health, La Trobe University; 1999. 24. University of Melbourne: Good Practice Program: final evalua- tion report. Melbourne , Program Evaluation Unit, Department of Public Health,; 2005. 25. Dever G: Community Health Analysis: A Holistic Approach. Maryland , Aspen; 1980. 26. Department of Human Services Victoria: Municipal Public Health Planning Special Bulletin. Melbourne , DHS; 2006. 27. Department of Human Services Victoria: Review of the Health Act 1958: a new legislative framework for public health in Victoria: a discussion paper. Melbourne , DHS; 2004. 28. City of Ballarat: Submission to the Review of the Health Act 1958. 2004. 29. City of Casey: Submission to the Review of the Health Act 1958. 2004. 30. Victorian Health Promotion Foundation (VicHealth): Submission to the Review of the Health Act 1958. 2004. 31. City of Stonnington: Submission to the Review of the Health Act 1958. 2004. 32. Dixon J, Kouzmin A, Korac-Kakabadse N: Managerialism - some- thing old, something borrowed, little new. International Journal of Public Sector Management 1998, 11:164-187. 33. Department of Human Services Victoria: Review of the Health Act 1958: a new legislative framework for public health in Victoria: a draft policy paper for consultation. Melbourne , DHS; 2005. 34. Broad C: Speech by Minister Broad. In State and Local Govern- ments Working Together to Build Stronger Communities Flemington ; Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 9 of 9 (page number not for citation purposes)

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Australia and New Zealand Health Policy – Springer Journals

Published: Mar 22, 2007

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