We interviewed 20 former Australian Federal and State and Territory health ministers about the extent to which they were able to focus on promoting health, health equity and social determinants of health during their tenure. Social determinants of health are the conditions of everyday life (income, housing, food availability, employment, education) and the structural factors that shape those conditions (distribution of wealth, taxation levels, extent of political empowerment) that combine to determine health outcomes and their distribution. Evidence from the Commission on the Social Determinants of Health showed that action on the social determinants are vital to achieving equitable health outcomes.
One health minister told us of a public servant who advised: ‘Health has two components to it. There’s health services, which is like a swamp full of crocodiles, and public health which is like a very pleasant garden’. The public servant noted that most ministers try and spend as much time ‘in the garden’ as possible but warned the minster to “make sure there’s a fence around the swamp and the crocodiles can’t get out first”. From our interviews it was clear that nothing detracts more from a focus on social determinants than hospitals demanding ever more resources and ensuring they get on the front pages. The strategies our ministers reported included “divide and rule”, for instance make allies with GPs at the expense of other groups of doctor and having a very well-articulated, evidence-based policy framework to “divert money away from this monster of hospital based critical care”.
Part of the process of fencing in the crocodiles was trying to shift the system towards primary health care, which as one minister said is “the only way to ameliorate the galloping demands and costs of the acute health care system”. Health ministers who had achieved a shift in health care resources in the direction of equity frequently reported it as a politically difficult move, given the competing, often emotive, calls for funding for the acute care sector. The good news is that when they did make a shift in the direction of primary health care they reported it as a legacy of which they were proud.
Our interviews were with health ministers who held office between 1988 and 2010. In the current health policy context even fewer few health minsters appear able to fence in the crocodiles. In South Australia we have seen very significant reductions in spending on our community health services, all done under the guise of a health funding crisis. Yet last year the salaried doctors received 9% pay increases, which seems to be a case of the crocodiles running the show! It will be interesting to monitor what happens in Queensland where Minister Springborg appears to be trying to fence in his crocodiles by introducing more stringent contracts, despite threats from the doctors about mass resignations unless Springborg backs down.
Our study showed that only really brave health ministers are able to stare down vested interests sufficiently to make changes that are likely to increase health equity and bring about action on the social determinants of health. One of the most important things that might drive this action is a strong commitment to social justice and redistribution and a rejection of the current commitment to market fundamentalism as the bible which drives policy decisions. It is tempting to speculate that the influence of content- free managerialism has joined with careerism amongst politicians to reduce the likelihood of any effective ministerial commitment to equity. A number of the ministers we spoke to felt that a spirit of redistribution had been more event in the 1970s and 1980s before the religion of neo-liberalism occupied the state. The introduction of Medicare was possible because it was linked to the Accord between the government, unions and business.
If we are to see health ministers in the future who are driven to pursue health policy aimed at achieving health equity then they are going to have to stand up to some very powerful ideologies and players. These include the organised medical profession, those pushing market fundamentalism as a basis for organising society and a powerful medical-industrial complex that lobbies for privatisation of health services. With such pressures it becomes easier to see why the compelling evidence on the social determinants of health equity quite rarely translates into enacted policy.
Baum, F. Laris, P. Fisher,M. Newman, L. MacDougall C. (2014) Dear Health Minister: tend the garden but make sure you fence the crocodiles. Journal Epidemiology and Community Health Published 2 January 2014, doi:10.1136/jech-2013-203040 http://jech.bmj.com/content/early/2014/01/02/jech-2013-203040.abstract.html?papetoc
Fran Baum is the Matthew Flinders Distinguished Professor of Public Health and Director Southgate Institute for Health,Society and Equity, Flinders University. Paul Laris is Member Medical Board of Australia and adjunct researcher Southgate Institute for Health, Society & Equity, Flinders University.