Questions ( 300 words approximately for each answer)
- Why is a policy cycle an appropriate tool for developing a new policy? (your response must include referenced materials and do not use dot points).
- How is a health policy different to a government policy document? (your response must include referenced materials and do not use dot points).
- How does the ‘new public health’ differ from the old public health approach? (your response must include referenced materials and do not use dot points).
- What are key sociological issues and how do they determine a person’s state of health? (your response must include referenced materials and do not use dot points).
- What policy considerations should be included in a national obesity health campaign? (your response must include referenced materials and do not use dot points).
1.2. What is Policy?
Policy, in the broadest sense, is something that has encompassed a set of specific issues, views, goals and ideas together and formed a plan of action based on this (Fleming & Parker, 2012). The aim of a policy is to solve potential problems through avoiding, preventing and even minimising these (Fleming & Parker, 2012). As Palmer and Short (2010) point out – policy can be a general set of intentions and directions or a specific statement. Time is represented by past, present and future directions and intentions (Palmer & Short, 2010). Public policy relates to government actions, laws and directives for a society or community including funding structures, regulatory control even cultural structure and societal morés.
Health policy specifically, is explained by Palmer and Short as a term that:
….embraces courses of action that affect the set of institutions, organisations, services and funding arrangements that we have called the healthcare system. It includes actions or intended actions by public, private and voluntary organisations that have an impact on health (2010, p.23).
1.3. The Policy Cycle
The definition of the term “policy” provides a broad statement that refers to a number of concepts that can vary from well defined objectives and processes to statements about organisational direction (Althaus, Bridgman & Davis, 2013). This unit involves an exploration of policy documents and courses of action that shape organisations, the provision of services and funding arrangements in the Australian Health Care system. Therefore, ‘health policy’ includes the actions that determine how health care is organised, how its services are delivered and the funding mechanisms that enable the process of delivery (Mason, Leavitt & Chaffee, 2012). It encompasses the role that private, public and non-government organisations play within the health care system.
Policy can be regarded as a set of ideals and activities aimed at decreasing inequalities or inequities by allocating and redistributing available resources. This process occurs at a local, state, national and international level.
Policy making has to contend with competing demands- allocation of resources, determination of priorities and competing values. It is a political process and takes account of:
- availability of funds and funding mechanism
- demography and epidemiology
- workforce availability
- electoral cycle and the government of day
- media and community expectations
Policy development is not a linear process that neatly and predictably follows a sequence of steps. It can be ambiguous and layered and not a single, uniform, transferable process. Policy development occurs as a series of processes that are continuous and vigorous and that always respond to an act or event. Policy development is however described within a policy cycle (Althaus et al. 2013).
As such, the policy cycle should not be read as a staged and ordered process but an active and iterative process. The policy cycle model does, however, outline the key components required to develop policy (Althaus et al. 2013).
The policy cycle forms a framework to consider presenting problems, the formulation of proposals for dealing with these problems and the endorsement and introduction of these as the government’s stated health policy.
Althaus et al (2013) offer an Australian policy cycle model (see figure 1) with the following stages:
- issue identification;
- policy analysis;
- policy instruments;
- implementation; and
1.4. Social Theory and Social Policy
Social policy is regarded as a set of ideals and activities aimed at decreasing social inequities and inequalities and by re-allocating and redistributing the available resources. This process occurs across all levels of government- local, state and national and also internationally through organisations such as The World Health Organisation http://www.who.int/en/)(.
The study of social theory draws on the body of knowledge contained in subjects such as, politics, economics, sociology, geography and philosophy. For example, political scientists argue over the privacy of the individual in health care provision, economists question the ability of Government to meet specific social needs, sociologists debate issues in regard to inequalities in health and other social needs on the basis of gender, age, class and race. Philosophers reflect on the under-pinning ideologies and the moral and political issues. Social policies in turn identify and promote issues in regard to human welfare including housing, employment, education, welfare benefits and health.
The last three decades have seen a global shift in the way governments determine social and health needs of their populations. Western Nation governments of all political persuasions have created a mood that stresses the need for individuals to take greater responsibility in the prevention of disease by practising healthy lifestyle choices. For example, “six of the 10 leading factors contributing to the global burden of disease are lifestyle related: unsafe sex, high blood pressure, tobacco use, alcohol use, high cholesterol and obesity (Resnik, 2007, p.444). This as well as the aging of the population, the proliferation of high technology, greater levels of consumer awareness and education on health issues, and greater fiscal consciousness have necessitated a rethinking of the provision of health care and social policy.
“Social Policy is a mechanism for the allocation of a society’s resources for the purpose of achieving outcomes that bring to fruition the society’s dominant values and the corresponding objectives and goals. In practice, this means specifically the goals and objectives, and the underpinning values, of the government of the day…” (Jamrozik, 2001, p. 37).
Social policy-making has therefore to deal with competing demands including the allocation of resources, and the determination of priorities and competing values.
“everyday life issues…. are the substance of social policy: the way a society is organised, who gets what benefits, and who is left to fend for themselves” (Dalton, Draper, Weeks, & Wiseman, 1996, p.4).
This places social policy squarely in the lap of economic policy. In doing so, moral decisions are constrained and influenced by the amount of public funds, lobby groups, private corporations charities and trade unions (Gold, Pulman & Colman, 2013). The political process of making and implementing social policy involves three important determinants:
- availability of resources
- competing values
- determination of priorities
1.5. Social determinates of Health
Health arises from multiple actions within a person’s life such as work, home, school, the community and our leisure activities (Gunner, 2013). The World Health Organisation defines the social determinates of health as:
Access to and utilization of health care is vital to good and equitable health. The health-care system is itself a social determinant of health, influenced by and influencing the effect of other social determinants. Gender, education, occupation, income, ethnicity, and place of residence are all closely linked to people’s access to, experiences of, and benefits from health care. Leaders in health care have an important stewardship role across all branches of society to ensure that policies and actions in other sectors improve health equity. (Commonwealth on Social Determinants of Health 2008 p.8)
Key sociological issues which exert the greatest influence on health and health care such as poverty, gender, social class, ethnicity and race are explored in the reading by Baum (2008) and by Wilkinson and Marmot (2003) who were commissioned by the World Health Organization to compile a list of social determinants of health that were evidence-based and had a most significant impact on health.
1.6. Ethics and distributive justice in health resourcing
Ethical thinking requires an understanding that ethics is about ‘what should be done’ in the world rather than what is done (Staunton & Chiarella, 2013). It encompasses many schools of thought and amongst them are: deontological theories that propose that actions are of themselves (intrinsically) right or wrong; and teleological theories that hold that actions are either right or wrong based on their good or bad consequences (Staunton & Chiarella, 2013, pp. 32-33). Johnstone (2009, p. 57) explains that “deontology asserts that some acts are obligatory (duty-bound) irrespective of their consequences”. Examples that illustrate this ethical perspective include: people who feel duty-bound or obligated to always tell the truth irrespective of the outcome (good or bad); and people whose religious convictions lead to them to refuse life-giving medical interventions. Alternately in teleological (utilitarian), consequence-based theory actions or decisions are only considered to be good or bad in the context of the outcome. That is an action is good if it achieves the most favourable of outcomes, or “the greatest good for the greatest number of people” (Staunton & Chiarella, 2013, p. 33). Beauchamp & Childress (2013) discuss these and other ethical theories in the context of ethical dilemmas and challenges that impact on contemporary medical and nursing practice.
The need for ethical thinking when analysing policy is highlighted by Buse, Mays and Walt (2012) who draw attention to the fact that policy change and analysis is never-neutral but rather is politically driven and often serves political purposes. They argue that ethical issues arise from every aspect of policy change and analysis, even when intellectual and creative skills are sufficient to adequately understand and manage the complexity inherent in the policy process.
Whilst ethical theories can be applied in the broadest sense when making decisions about health policy there are four key ethical principles that are perhaps more readily used: respect for autonomy (the right to self-determination); beneficence (“above all, do good”); non-maleficence (“above all, do no harm”); and justice (fairness), (Beauchamp & Childress, 2013; Staunton & Chiarella, 2012). Rawls (as cited in Allingham, 2014) summarised the idea of justice as fairness, as follows:
“all social values – liberty and opportunity, income and wealth, and the social bases of self-respect – are to be distributed equally unless an unequal distribution of any, or all, of these values is to everyone’s advantage”: injustice “is simply inequalities that are not to the benefit of all” (Rawls, 1999, 24).
Clearly the key concept here is equality. Giving to all equally, however, does not a priori, lead to equal outcomes. Equality of outcomes is more likely to be a result of an equitable distribution of resources, that is, an unequal distribution based on need. Guy and McCandless (2012, p.55) refer to this equitable distribution as social justice and they explain, ”to be clear, “equity” and “equality” are terms that are often used interchangeably, and to a large extent, they have similar meanings. The difference is one of nuance: while equality can be converted into a mathematical measure in which equal parts are identical in size or number, equity is a more flexible measure allowing for equivalency while not demanding sameness”.
In the context of this unit social policy has a range of goals including social justice goals that concern themselves with what it means to have a socially just allocation or distribution of resources for health. This is distributive or allocative justice (Althus et al., 2013) is likely to address the health disparities that exist between groups of people because of the extent of their social advantage or disadvantage (Wilkinson & Marmot, 2003). In Australia there are other, competing policy agendas and goals, including; economic goals for economic growth and prosperity (Palmer & Short, 2010); education goals for excellent standards of education and adequate resourcing (Gonski, 2011). This creates conflict between a Government’s agenda to redistribute the country’s resources to achieve equity, versus the push for efficiency in services and their subservience to market forces. In this context a Government’s role is to make hard decisions that are ethical, politically relevant and economically sustainable (Althus et al., 2013). It is for us to decide whether these macro-decisions made by Governments are sustainable in an ethical sense.
There are many examples of how ethical theories and principles can impact on biomedical decision-making in the Australian health care system. Take for example the dilemmas presented by the decision to preserve and prolong life at all costs, sometimes well beyond the point at which it’s possible for a person to regain a reasonable state of health or the situation when there is an end-of life decision, opposed by family members, to cease life-sustaining artificial nutrition and hydration for a person who has ongoing post-coma unresponsiveness (Barraclough & Gardner, 2008, pp. 166-170). This presents an ethical dilemma where what is right, is neither black nor white. The associated debate uncovers issues that are problematic for clinicians given the ethical imperatives to respect autonomy, to do good, and above all to do no harm. The Australian legal system has provided direction that enables lawful decision-making about appropriate action in the situation whilst the policy process has been less instructive. Barraclough and Gardner (2008) argue the need for national ethical guidelines that support health professionals in their effort to be ethical in their decision-making in complex health care situations. Another example may include decisions related to discharging vulnerable people from hospital before they are medically, socially or psychologically ready to leave, restricting treatments because of cost and supply, withholding treatment because of the demographic profile of patients/clients and rationing staff levels, and mix, because of the need to contain budgets and/or make profits (Fiack, Knapp & Lee, 2012). The ethical concepts that are implicated in this example refer to all four ethical principles, as well as to distributive justice.
When considering distributive justice in the Australian and International health care contexts it is essential to not only refer to ethical theories and principles but to also take into account the equally relevant social determinants of health. Wilkinson and Marmot (2003, p.7) argue that:
“even in the most affluent countries people who are less well- off have substantially shorter life expectancies and more illnesses than the rich. Not only are these differences in health an important social injustice, they have also drawn attention to some of the most powerful determinants of health standards in modern societies. They have led to a growing understanding of the remarkable sensitivity of health to the social environment and to what have become known as the social determinants of health.
A country’s culture and social systems are not the only factors that need to be considered when formulating policy. The law is also an integral part of policy development as many policies require legislation to make them effective. All policies have a legal context because governments and their departments are themselves subject to the rule of law. An example of this is that in Australia no policy may prejudice against religion. Commonwealth law prevents this occurring (see http://www.comlaw.gov.au/ for the complete and current collection of Australian legislation, bills, Acts etc). The constitutions of the Commonwealth, States and the Territories also describe the limits of governmental process. Thus whilst the making of policy is often heavily political, the power of politics in making policy is constrained by the constitution of the Commonwealth (Barraclough & Gardner, 2008).
The relationship between the law and policy is interesting. Both are adaptable and are sometimes required to change to allow the formulation of the other. A good example of how policy has shaped legislation is provided by the implementation of harm minimisation policies for drug use, specifically intravenous drug use. The provision of safe injecting rooms across the world has required the amendment of legislation to allow for the injection of illicit drugs in designated facilities without the fear of prosecution. Thus whilst the cultivation, trafficking, sale and possession of these drugs is illegal, the injection of them in medically supervised injecting rooms is not (see http://www.sydneymsic.com/ for details on the Sydney Medically Supervised Injection Centre).
Another powerful example of the relationship between legislation and policy can be seen in their respective roles in the formulation of human cloning and stem research policy. The Coalition of Australian Governments (COAG) met recently to determine a uniform approach to human cloning and stem research across all states and territories. Once agreement was reached, legislation was developed and then passed through parliament. This legislation was then used to inform policy making in Australia.
There are many emerging issues for public health law (Reynolds, 2011), and consideration needs to be given to the possibility of changing public health regulations in areas such as: tobacco control; the obesity epidemic (http://www.obesityaustralia.org/); creating healthy environments; regulating alcohol; the limits of personal responsibility for health; and the role of law and policy in responding to new epidemics (for example SARS, and vCJD (mad cow disease) see http://apo.org.au/research/impending-influenza-pandemic-lessons-sars-hospital-practice) .
The required reading illustrates clearly that in some instances to enact health policy, legislation is required. It is clear that legislation has had a significant impact on healthy public policy and its implementation.