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Public Health and Commonwealth-State Relations
Greg Lewis
Social Policy Group
29 June 1998
The primary objective of public health is the reduction of disease and
the maintenance of the health of the population(1). The measles and pertussis
(whooping cough) epidemics of the last few years illustrate Australia's
capacity to respond to immediate public health problems. At the same time,
the low childhood immunisation rates associated with these epidemics has
demonstrated the lack of a national, strategic public health policy. Currently,
there are around twenty separate Commonwealth public health strategies,
most on specific issues(2).
The delivery of public health services has involved considerable Commonwealth-State
relations difficulties in financing, determination of objectives and program
implementation. Client stakeholder involvement in public health issues
has been considerable, as in women's health and HIV/AIDS issues, and this
has been influential in the allocative decisions on financing and program
development.
It can be argued that a national public health strategy is needed that
considers the social and economic causes of ill-health(3) and promotes
public health approaches that aid the development of Australia's social
capital. Canada and the UK are developing a health focus on the underlying
environmental, social and economic contingencies associated with ill-health(4).
Cohesive Commonwealth-State relations and balanced stakeholder involvement
are essential requirements for an Australian national public health agenda.
Two recent developments in public health financing and administration,
the National Public Health Partnership and the Public Health Outcome Funding
Agreements are indicative of the impact of tensions in Commonwealth-State
relations on the development of a coherent financing and policy framework.
The National Public Health Partnership
The National Public Health Partnership was established in December 1996
to facilitate public health collaboration and co-operation between the
Commonwealth and States and Territories. The National Health and Medical
Research Council and the Australian Institute of Health and Welfare are
involved in the Partnership, and New Zealand has observer status(5).
The Partnership, which emerged through the Council of Australian Governments
(COAG) reform process(6), is taking a considerable time to formalise.
Whilst all States and Territories have contributed at officer level, Western
Australia has not formalised its participation and New South Wales only
did so in May 1998, eighteen months after the Partnership's initial establishment.
Commonwealth-State financial relations, particularly in tying Medicare
and public health financing to efficiency outputs, and the hesitancy of
States in identifying public health roles and responsibilities, have been
influential in the delays.
Under the Partnership, the Commonwealth is responsible for national public
health policy and the States and Territories for public health services.
The work program is managed by an all jurisdictions representative group
with administrative support from the Victorian Government. Hopefully,
the Partnership will achieve the stated objectives of enabling national,
standardised public health approaches in the areas of legislative reform,
resourcing, research, strategic development and program delivery, workforce
development and in the provision of public health information(7). Reported
achievements have included multilateral input to the Food Regulation Review(8)
and draft reviews on public health planning and practice, research and
information development, and co-ordination of national strategies. The
value of the Partnership will depend on its success in establishing a
framework for common agreement on national public health policies. An
evaluation of the Partnership is to commence later this year.
Public health outcome funding agreements
The difficulties of Commonwealth-State financial relations have been
evident in the slow progress of the negotiations over the Public Health
Outcome Funding Agreements between the Commonwealth and States and Territories.
The replacement of Specific Purpose Payments (SPPs) with broadbanded contracts
for a number of public health programs was included in the 1997-98 and
1998-99 Budgets. Only four States and Territories have signed agreements;
the Northern Territory in July 1997, Queensland and Tasmania in December
1997 and South Australia in January 1998. The quantum of funding under
the Agreements and the associated performance targets have been major
negotiation issues. Despite vigorous efforts by the Commonwealth, the
other States and the ACT are still to sign(9). New South Wales only agreed
in-principle to broadbanding in April 1998.
Public Health Agreements Base Funding (a)
|
State/Territory
|
1996-97 SPPs
$ million
|
1997-98 Budget
$ million
|
1998-99 Estimate
$ million
|
|
Queensland
|
$19.655
|
$16.448
|
$16.980
|
|
Tasmania
|
$3.804
|
$ 4.010
|
$ 4.389
|
|
South Australia
|
$9.292
|
$ 9.208
|
$ 9.975
|
|
Northern Territory
|
$2.768
|
$ 2.289
|
$ 2.516
|
(a) 1996-97 SPPs include HIV/AIDs, Indigenous
health, bone marrow registers and other one-off funding not included
in the Agreements. Funding for 1997-98 and 1998-99 based on 1996-97
SPP program funds.
Public health financing under the Agreements
Five women's health programs, the HIV/AIDS Matched Funding Program, the
National Childhood Immunisation Program and the National Drug Strategy
have been broadbanded. The Agreements include a funding base for each
of the participating States and Territories and additional funding for
vaccines dependent on the numbers purchased. The option for re-negotiation
of funding in the event of target population changes is also included.
Focus on performance
States and Territories do not appear attracted by the stated primary
benefit of the Agreements of flexible administration and financing(10).
A major sticking point has been financing on the basis of agreed outputs
and outcomes-the poor childhood immunisation levels of the past, for example,
is indicative of the need for tighter accountability. The performance
targets are mainly related to public health activity levels and the development
of data, with some progress towards desired outcomes expected. The Queensland
Agreement has performance targets for childhood immunisation, breast and
cervical cancer screening and other women's health and birthing services,
and for HIV/AIDS and the National Drug Strategy. The targets for breast
cancer screening include progress towards national participation and quality
standards, measured by screening detection rates, over a specified period.
States and Territories are not tied to specific activities or matching
of funding but local priorities and high need populations are to be considered
within the context of national priorities(11). Incentive payments are
included for performance on agreed targets in relation to immunisation
and communicable diseases and for demonstration projects on quality improvement
in public health services delivery(12).
Conclusion
One academic commentator has identified Australia's public health agenda
as:
- understanding the determinants of health
- identifying outbreaks of diseases and disease surveillance
- developing and applying effective interventions for health and disease
treatment, and
- ensuring effective and efficient systems to deliver public health(13).
The effectiveness of the National Public Health Partnership in addressing
the future of public health in Australia remains to be demonstrated. It
would be fair to say that that the progress in the broadbanding of current
programs through the Public Health Outcome Funding Agreements has been
disappointing. Progress with the development of an effective national
public health policy to underpin Australia's social capital may be some
time coming.
Endnotes
- R. Beaglehole and R. Bonita, Public health at the crossroads,
Cambridge University Press, Cambridge, 1997, p. 145.
- Department of Health and Family Services, Commonwealth - State
arrangements for public health: The National Public Health Partnership
and the Public Health Outcome Funding Agreements, 3 June 1998. (Available
from www.health.gov.au/pubhlth/about/nphp.htm)
- R. Beaglehole and R. Bonita, op. cit., p. 76.
- 'Our healthy nation', British Medical Journal, 1998, Vol. 316,
No. 7130, pp. 487-488 and National Forum on Health, Canada health
action: building on the legacy, Ottawa, 1997.
- House of Representatives, Debates, 13 May 1998, p. 3320.
- J. W. Owen, 'Making gains in health', The Medical Journal of Australia,
1997, Vol. 166, No. 12, pp. 650-653.
- ibid.
- The draft report of the Blair review of State and Territory food regulations
was issued for comment on 27 May 1998.
- Senate Community Affairs Legislation Committee, Senate Official
Committee Hansard, Thursday 4 June 1998, pp. 270-271.
- Department of Health and Family Services, op. cit.
- ibid.
- ibid.
- J. Hall, 'An open letter to the Federal Minister for Health from Jane
Hall, immediate past president', inTouch, 1996, Vol. 13, No.
2, pp. 1-7.
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