WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE
WPRfRC48/Technicai briefing/5 I August 1997 ENGLISH ONLY
Forty-eigbtb session Sydney 22-26 September 1997
PUBLIC HEALTH PARTNERSHIPS: GOVERNMENTS AND COMMUNITIES IN PUBLIC HEALTH
For some time now, there has been concern expressed in Australia over the need for a national approach to public health. Preliminary discussions in late 1995 and early 1996 between Australia's Chief Health Officers and other stakeholder groups saw the response take the shape of a National Public Health Partnership. This would be a coordination and collaboration mechanism with clearly articulated roles and responsibilities, which would add value to the work of each jurisdiction rather than inhibit decision-making or the setting and pursuit of local priorities. The Federal Minister for Health and Community Services placed the proposal to develop such a Partnership on the agenda of the Australian Health Ministers' Council in July 1996, for consideration and endorsement by his state colleagues. The October
Australian Health Ministers' Council endorsed the concept of a National Public Health Partnership for Australia. This briefing paper describes the intent of and arrangements for the National Public Health Partnership, and discusses its implication for jurisdictional and nongovernment interests.
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Public health development in Australia George Rosen, the eminent historian of public health, has summed up the concept of public health as the recognition, throughout human history, that the major health problems faced by society have been concerned with community life and therefore that community action is essential to the promotion of health and the prevention of disease. While the emphases of public health activities change, the objectives of protection, prevention and promotion have remained constant, underpinned by epidemiological analyses and informed by multidisciplinary research. The Australian colonies were legal appendages of the Imperial Government and their statutes were often copies of the British equivalents. In 1854, Victoria passed its first Health Act which closely resembled the English Public Health Act, 1848, which had been passed in response to high rates of death and illness In
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the rapidly expanding urban areas of Great Britain. The Victorian Act
and those passed by the other colonies imposed sanitary controls and they tended to be driven by miasmatic ideas, i.e. that bad smells (or the "effluvia" produced by insanitary conditions) caused disease. Specific controls to reduce the spread of diseases included provisions relating to They became important at certain times in
notification, compulsory examination and detention.
Australian history when epidemics and the panics associated with them highlighted both their usefulness and their potential for abuse. In 1901, the new Federal Government was vested with a series of named powers set out in the constitution. The newly formed States retained most of the controls they exercised formerly as colonies. Public health as such was not among the named powers given to the federal level.
However, a power to make laws with respect to quarantine enabled the Federal Government to pass the Quarantine Act, 1908. The Federal Government, through its Quarantine Service and Health Department and then through the National Health and Medical Research Council (NHMRC), became very influential in the development of public health policy across Australia. However, the States maintained the core responsibilities for public health law, policy and service delivery dealing with issues of sanitation and disease control, food, drugs, poisons and narcotics. In addition, industrial safety and the control of conditions that caused occupational
diseases were administered separately by state factory and mines inspectors. The success of early public health interventions (e.g. sewerage, waste management, water supply, housing, and nutrition) has contributed significantly to altering patterns of mortality and
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morbidity. New patterns of mortality and morbidity require new approaches to risk factors present in the physical, social and economic environment and to changing individual and community attitudes and behaviours. Individual actions to improve the health of Australians are constantly taking place throughout the health care system. Providers of personal care services, be they general practitioners (GPs), community health centres, maternal and child health services (MCH), or others, are critical avenues at the local level for identifying public health issues and meeting health improvement objectives. In the 1990s, in addition to chronic and degenerative diseases, Australia is experiencing new
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and emerging infections, sociobehavioural pathologies, and new environmental threats. In the context of globalization of the economy and developments in telecommunications, public health problems and solutions have transcended borders more than ever. In the face of the simultaneous presence of multiple factors which influence health and the wide range of contributors to health improvement across settings and sectors, a coordinated and collaborative approach - a partnership approach - across constitutional and territorial boundaries appeared to be the most efficient and effective way for governments to discharge their public health responsibilities. Coordination is required due to the need for complementary action to take place at different levels at the same time.
Current roles and responsibilities in public health
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Government involvement in public health has generally arisen from two perspectives. One is the importance of a healthy population as a contributor to sustained social development and creation of social capital. The second is the investment in human capital which is critical for economic development. Indeed, public health is often identified as a public good where government
involvement is justified on grounds of public interest and market failure. While the organization of public health activities differs across States, in the main, State health authorities have responsibilities for: carrying out statewide epidemiological surveillance to identify public health issues, ensure timely interventions, and monitor health outcomes;
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developing policy and implementing statutory responsibilities related to communicable diseases, environmental health, immunization, food, radiation safety, workplace risk, water quality, drugs and poisons, and emergency management; organizing preventive and early detection programmes, such as cancer screening, maternal and child health, school health and dental screening, immunization, etc.; supporting enhancement of health literacy and health-promoting behaviour in population groups, including developing strategic responses to enhance the effectiveness of health services for population groups; supporting health care providers at the local level in the provision of information and education and in the control of diseases; developing strategies to meet challenges of newIe merging health problems; examining the effectiveness of health services and programmes in achieving health gain; collaborating with local government public health services; working with other relevant authorities, nongovernmental organizations, and the public on shared public health concerns, such as environmental pollution, occupational health and safety, injury, alcohol and drug abuse, noncommunicable disease prevention (e.g. cancer, heart disease, diabetes, etc.); and coordinating with relevant authorities and providers to ensure the availability of an appropriately skilled public health workforce. State responsibilities may be delivered through a range of organizations. For instance, in several States, health promotion foundations playa vital role and complement the activities of the State department. Local government is the main vehicle in most States for food inspections and environmental health services related to habitat. Immunization services may be delivered through GPs, community health centres, local government, or maternal and child health services. States may also use university-based expertise, nongovernmental organizations and private sector services for public health functions. Furthermore, the cooperation of other government agencies, such as those responsible for environmental protection, road safety, consumer affairs, food and agriculture, education, etc. may be vital to the achievement of public health objectives.
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At the federal level, several entities play important roles. The responsibilities (Or quarantine and immigration are examples of long-standing federal contributions to public health. Additional contributions in specific areas are made by the Australian New Zealand Food Authority, Australian Radiation Laboratory, Nuclear Safety Bureau, and agencies in other portfolios, such as the Federal Department of Primary Industry and Energy, Department of Veterans' Affairs, Worksafe Australia and National Environmental Protection Authority. Within the Federal Department of Health and Family Services: There has been a series of large and small vertical programmes through the 1980s and early 1990s as well as national strategies targeted at particular diseases, risk factors, population groups and settings. Notable among these are programmes and strategies for HIV/AIDS, illicit drugs, and women's cancer screening programmes. Financial support of postgraduate public health education through the Public Health Education and Research Program (PHERP) has significantly expanded the available workforce. The coordinated development, implementation and review of strategies in national health priority areas (cancer, cardiovascular disease, mental health, injury, and diabetes) is currently being consolidated by the Department with a focus on the development of priority indicators for reporting/assessing progress. The national medicinal policy, implemented through the Therapeutic Goods
Administration (TGA) and the Pharmaceutical Benefits Branch, are critical in ensuring timely availability of therapeutic products while maintaining adequate assurances of product safety and efficacy and appropriate use. The creation and funding of GP Divisions established the foundation for a more coordinated primary care system, in concert with the States and Territories, strengthening the local vehicles for public health activities. The signing of the Framework Agreement between the Federal Government and States on Aboriginal and Torres Strait Islander (ATSI) health also provides a strategic opportunity for the public health dimensions to be addressed alongside the improvement of health services for ATSI communities.
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Other key federal agencies contributing to the broad spectrum of public health objectives are the NHMRC (National Health and Medical Research Council) and AIHW (Australian Institute of Health and Welfare), the former through its role in jJublic health research and development and the provision of expert advice and the latter through the development of national and consistent systems for public health information and its role in supporting the National Health Information Agreement. Examples of recent NHMRC reports shaping the public health agenda include: screening, re-use of single use therapeutic devices, infection control guidelines. relevant activities of the AIHW include: perinatal statistics, and death index. Nongovernmental organizations also playa vital part in setting and supporting the public health agenda, as well as in contributing to health improvement. These include professional, prostate cancer Some directly
injury surveillance, health outcomes clearinghouse,
community, and consumer organizations and research and educational institutions.
Why a partnership? While there have been significant achievements by all jurisdictions in the various areas of public health, there are also some significant weaknesses in the current arrangements, from the viewpoint of a national public health effort. The vertical programmes have introduced rigidities and boundaries between the Federal and State Governments and between programmes, while the highly successful national strategies to date (such as HIV/AIDS, which was characterized by planning, adequate resourcing, cooperation and continuity) could be applied more broadly across public health activities. There are areas of activity (such as health promotion) where the potential exists for unnecessary duplication and inefficiencies due to lack of clear roles and responsibilities. The complexity and national significance of many public health issues (e.g. HIV/AIDS, foodborne diseases, ATSI health, etc.) require the strengthening of the capacity to identify and respond in a collaborative and complementary manner. As the focus of the health system moves to health outcomes and allocative efficiency issues, there is need for better articulation of the contribution of public health knowledge and skills to health system development.
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The NHMRC's Health Australia Review, conducted in 1996, identified the key ingredients of successful public health interventions as: (I) technical capacity - knowledge, skills, and information necessary to identify and implement change; (2) policy and strategic direction - commitment and mechanisms to bring about agreement on goals, priorities, plans and delivery of interventions; (3) support structures - the organizational, financial and other resources necessary to encourage all relevant parties to cooperate to bring about health improvement. A National Public Health Partnership provides the broad multilateral, intergovernmental framework to build a cooperative approach to ensure the.se preconditions for success can be met and the health of Australians is protected and improved. It is a move away from Federal or State
arrangements for management of selected programmes towards a more systematic and strategic approach for addressing public health priorities. It will also provide a vehicle through which major initiatives, new directions, and best practice can be assessed and implemented.
Broad aims of the Partnership
The main aim of a national effort in public health is to improve the health status of Australians, in particular in population groups most at risk. The Partnership is a mechanism and a process to ensure that government responsibilities in public health are consistent (where needed), coordinated (where complementary activities are required) and collaborative (where pooling of
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expertise and resources is beneficial). The broad objectives of the Partnership are: improved collaboration in the national public health effort; better coordination and sustainability of public health strategies; and strengthening of public health infrastructure and capacity. As such, the Partnership should lead to a better capacity to manage existing issues (such as immunization and food safety) as well as more efficient and strategic responses to emerging issues (such as hepatitis C). Additionally, improved consistency in public health information and the
regulatory framework and more strategic investment in research and workforce development should result in more effective use of resources.
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The Partnership arrangement should enhance the capacity of States to respond to public health issues of particular relevance and add value to the work of each jurisdiction, rather than inhibit decision-making or the setting and pursuit of local priorities. It is not concerned with a uniform approach except where appropriate, nor with dictating the way each jurisdiction arranges and carries out its public health responsibilities. It recognizes that different approaches will be adopted in different localities even for the same priority issue. At the same time, it enhances the capacity to account for outcomes and benchmark activiiies across the nation.
How does the National Public Health Partnership work? The National Public Health Partnership is framed by: a multilateral memorandum of understanding (MOU), initially for a five-year period, setting out key principles and processes, roles and responsibilities; a coordination mechanism consisting of senior representatives, known as the National Public Health Partnership Group, operating as a subcommittee of Australian Health Ministerial Advisory Council; a rolling three-year work programme, approved by Health Ministers, setting out key result areas, including joint priorities and how they would be progressed and monitored. The Partnership Group consists of senior representation (of decision-makers) from each of the jurisdictions participating in the MOU. In addition, because of their critical involvement in key aspects of public health, senior representatives from NHMRC and AIHW join the Partnership Group as full members. The Partnership Group is the focal point for planning and coordination, and
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provides leadership for matters of national significance. It ensures that communication channels exist for specific areas of public health programme delivery and that implementation of agreed priorities can be monitored. While the National Public Health Partnership is an intergovernmental arrangement, the partners are fully aware of the critical contribution to public health made outside health authorities. Other providers of public health, such as local government, public health research and education programmes, and relevant agencies from the State and Federal Governments, would be involved in specific activities on the "rolling" work programme related to their public health functions. Additional consultative mechanisms would be instituted by the Partnership Group to ensure two-way
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exchange with key professional, community, consumer, educational, and industry interests occurs on the development of national public health priorities and strategies. The work programme, approved by Health Ministers and initiated and maintained by the Partnership Group, ensures integration of the various elements of the national effort.
Work programme priorities The key areas identified for the work programme are outlined below.
Public health practice improvement
There are a number of potential avenues to improve public health practice across jurisdictions. These include: benchmarking of public health services; developing best practice guidelines for public health interventions; formalizing arrangements for cross-border deployment of expertise and resources especially for highly specialized areas (e.g. toxicology, chemical safety); instituting an electronic bulletin board for rapid communication at early stages of investigations of outbreaks;
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assessing the uses of information and telecommunications technology for public health activities and health gain; assessing innovations in service delivery models to priority population groups; assessing governmental strategies for public health; and assessing systems of standards and quality assurance for their capacity to improve public health practice. Public health information development
Australia's health information system is well-developed to monitor mortality and hospital morbidity. Progress is being made under the National Health Information Agreement on non-
institutional services data, but much of the information required for designing and monitoring public
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health interventions is not collected and analysed in a systematic fashion. For example, effective efforts to improve health depend on having good information on community knowledge, attitudes and behaviours, but no consistent surveillance system exists nationally. working on links between data on health status and exposures. Similarly, there is a group
Thus, the development of a
Behavioural Risk Factor Surveillance System, and an appropriate surveillance system to monitor environmental hazards and exposures are areas for consideration.
Public health regulation and legislation There is fragmentation of responsibility between the Federal and State Governments in many regulatory domains. Regulatory standards need to be harmonized to support a consistent approach to public health and to contribute to microeconomic reform within a health framework. In doing so, new models of regulation may be developed as well. The first task is to "map" current and anticipated reviews of public-health-related legislation so that common issues can be jointly examined and consistent approaches developed where needed. While some of this work has already begun, issues which could be pursued by the Partnership Group include: food safety; uniform therapeutic goods regulation (including use of radio pharmaceuticals); drugs and poisons scheduling, licensing and inspection; handling of blood and blood products; standards and procedures for handling of radioactive materials; notifiable diseases; and tobacco and alcohol control. The Partnership Group will also consider Trans-Tasman Mutual Recognition and involve New Zealand in discussions of regulatory harmonization. __
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National public health strategies coordination The Partnership Group will facilitate and provide high-level coordination across current and new national strategies, including developing a systematic approach to identifying priorities. The proposed third National HIV/AIDS Strategy, a National Environmental Health Strategy, and the
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National Communicable Diseases Surveillance Strategy are some of the current efforts underway. The Partnership Group will also act as a high-level coordination point for major campaigns. The development of each strategy will require clarity about roles and coordination mechanisms. Specific policies and the structural reform agenda will have to be defined at the
national level and coordination mechanisms will have to be instituted for national campaigns if required. Specific intersectoral collaboration efforts will need to be articulated and supported, The involvement of key nongovernmental
building on experiences in various jurisdictions.
organizations may be vital for successful attitude change and public policy development.
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The Partnership Group would need to ensure appropriate input is provided to the Commonwealth in relation to the public health dimensions of the national health priority areas. Taking an integrated approach, the Partnership Group would also ensure that the needs of priority population groups, such as Aboriginal and Torres Strait Islanders and people of non-Englishspeaking backgrounds, are adequately addressed in all public health strategies.
Public health research and development
To date, public health research has tended to be investigator-driven. A relatively small amount of research has been commissioned by various health authorities to address specific policy requirements. While there will continue to be research tied directly to specific policy requirements
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or driven by investigator interests, a public health research and development strategy could be developed by the Partnership Group to indicate the research and advice work needed. This could then be undertaken by the NHMRC as a contribution to the national public health effort. Such a plan would balance, rather than replace, the research activities informed by intellectual curiosity. The public health research and development strategy would also underpin a more coordinated investment of funds from different programmes, thus systematically generating information required for an evidence-based approach to public health policy and practice. Some or all jurisdictions may identify common problems and commission joint research, involving relevant Cochrane-style systematic reviews of evidence, university consortia, and other approaches. States could further benefit from strengthening capacity for research and evaluation in public health programme delivery units, including primary health care services. Practice-based research
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opportunities could be created where research and action become mutually informing and reinforcing.
Public health worliforce development
PHERP has made a significant contribution to workforce development, although there remains a need both for more advanced researchers and for practitioners who have well-developed public health knowledge and skills. Recent reviews have pointed to the need to reorient public health workforce development from a focus on postgraduate education to broader, practice-based learning. The creation of a wider base of practitioners with public health expertise has been identified as an essential ingredient in strengthening public health infrastructure. Continuing education for primary health care providers and local government health officers is, however, unevenly developed across the country. At the same time, public health content and skills are lacking in the basic training for doctors, nurses, dentists, allied health professionals, etc. Both areas may benefit from joint consideration. The Partnership Group would establish mechanisms for working with relevant government agencies, educational institutions, and professional organizations to ascertain employer and workforce needs, assess quality of public health training and education, promote models for workforce development, and develop consistent frameworks for training particular categories of workers (such as Aboriginal health workers). At the same time, there is a need continually to improve public health knowledge through research. The question of how to strengthen postgraduate public health education to produce doctoral level researchers could be considered jointly by the health authorities, NHMRC, and tertiary education interests. In the longer term, research deficits may need to be addressed through
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appropriate workforce development. That research workforce will also need to have the capacity to make the findings of research meaningful for public health practice.
Public health planning and resource allocation
Output-based funding has been identified as an appropriate direction for the health and related community services system. Case mix and its variants are now accepted and used as the basis for funding or purchasing hospital-based personal health services. The most appropriate approaches
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for funding or purchasing population health programmes and some primary health care services, however, are not yet clear. As some jurisdictions are considering how to develop appropriate
incentives and accountability arrangements in funding or purchasing for public health, shared developmental work, including analysis of international experiences, is likely to be invaluable. Increasingly, state health authorities are interested in purchasing for health gain, which requires the strengthening of the evaluation capacity and the application of public health knowledge and skills to health system development. There is a range of developmental work being undertaken in this complex area. A collaborative approach will accelerate the pace of development in this area and make significant contributions to debates about allocative efficiency.
Implications for governments and communities The National Public Health Partnership will promote clarity of roles and responsibilities and a collaborative and complementary approach to work in public health for the Federal and State Governments. It will allow for a shift to an integrated "whole of system" approach to public health rather than a focus on vertical programmes. The Partnership should maximize coherence and
simplify complexity without losing the machinery needed to progress individual issues. It is anticipated that such a national collaborative approach will facilitate infrastructure development, harmonization of regulatory frameworks, and joint investment in developmental
projects. As such, the arrangement should result in a more effective national outcome from a governmental standpoint. However, public health, as defined by John Last, is the organized effort by society to promote and protect health. As such, it is not the responsibility of government alone. The recent history of national public health strategies in Australia, such as HlY/AIDS and women's health, has demonstrated the critical importance of active participation by affected communities. Thus, the success of the National Public Health Partnership will depend on mobilizing the support and contribution of nongovernment interests, including industry, professional and consumer groups and academia. It is the intention of the Partnership Group to include representatives of key stakeholder groups in its working parties, to hold annual consultative forums as part of its work programme development process, and to establish an advisory group of key organizations. In bringing together a
WPRl RC4Sf fechni cai briefing/S page 14 diverse group of interested parties, the NPHP seeks not only to receive input and feedback but also to help create a shared agenda amongst those involved in public health, thus developing a stronger voice for public health.