The overall capture of the meaning of “health” by the medical industrial complex and its hospital systems and departments has helped to hide the absence of policy and structures to specifically address the health of the public. It’s time we named our health departments to describe what they actually do – provide illness care -and time to make health and equity explicit central goals of the whole system of government.
The Australian illness care system, which is primarily the hospital industry, is under great stress. Emergency department waiting times are blowing out. The media bemoan a lack of hospital beds. There are cries for ever more and bigger hospitals and more beds and clinicians. No politician can say no – if they don’t want to face industrial unrest from health professionals. The burden of funding public hospitals for state governments gets heavier and heavier.
In South Australia the Treasury states that 29% of the state’s budget 2023-2024 of $24B goes on public hospitals: ie $6.96B. The total spend for the Department of Health and Wellbeing is $8.28B (Budget Paper 4, Volume 3, Page 70). Hospitals account for over 84% of the Department’s spend. The situation is likely to be similar in other states. For the Commonwealth, AIHW reports that in 2020-21 $71B was spent on public hospitals, of which 53% was from state and territory governments, or approximately $37.6B. In addition $19B was spent on private hospitals, 32% of which was also publicly funded.
So, if you follow the money, state and territory health departments are almost entirely concerned with hospitals. They are actually hospital departments and should be so called. Indeed prior to the creation of the SA Health Commission in 1977, South Australia called it for what it was: the SA Hospitals Department.
But today they proclaim themselves to be health departments, or more usually, they drop the starchy bureaucratic vibe of the department, its SA Health or Queensland Health etc. Although in Victoria and NSW, community health services are still supported with a very small proportion of health department money. For the Commonwealth it’s a bit different as they actually do fund primary care via Medicare as well as public health and research. But for the states to call them health departments does not make sense. Some states have established bodies along side illness care departments that do have a focus on health, (most notably in Victoria) but overall what state health departments do is illness care, primarily through hospitals.
The WHO defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Having high quality illness care services is really important but that is not what the WHO positive definition of health is all about. The result of calling illness care, health care, is to hijack the meaning of health. This has serious implications for public policy and discourse about health, disease and illness.
Health is created by a complex interplay of factors – individual, genetic, environmental, social, economic, educational, historical, commercial and just plain chance as was shown by the WHO landmark Commission on the Social Determinants of Health. A mix of these factors does determine an individual’s chance of being healthy but most of those factors are not individually determined. Health determinants operate to influence the structures of society which in turn affect the health of individuals. Of course no one chooses to be poor or homeless or flood bound or without nutritious food, to suffer family violence, be socially isolated or work in an unsafe place. These factors are largely the result of policy choices by governments. All of these shape poor health outcomes, just as their opposites create good health. Sound public policy on the key determinants of health -such as housing, education, transport, food security, employment, environment and wealth distribution – is what builds equitable health in a population, as international comparisons clearly demonstrate.
When health is equated with what hospitals do, public policy is distorted. Health economics is not about ensuring an economy that promotes health. It’s about funding hospitals and the medical industrial system to deliver illness care services. Health policy is about managing the illness care system. Real health policy would be about the role of government in creating health, and ironically, if effective, would actually reduce and reshape the role of illness care services.
Sadly, misleading labelling is rife around health. “Public health” has been lost to the epidemiologists and sewer engineers. It is the health of the public that should be at the heart of health policy, but real health policy seems to have a faint and erratic heart rhythm. The Health in All Policies (HiAP) approach aims to address the problem by arguing that the health impacts of public policy in all areas must be assessed, and addressed, as an integral part of the policy development, implementation and evaluation process. HiAP is certainly a step in the right direction, but, like a software ‘patch’, it’s a ‘work around’ designed to compensate for a design failure in the wider system. Surely the creation and protection of the health of the public is important enough to justify a system of governance that gives it a central role.
How HiAP can be enacted begs the question: What is the purpose of government? Baum argues in her 2019 book Governing for Health that neoliberal policies aimed at the pursuit of wealth and growth have become the primary aim of Australian governments and that this “poses threats to our collective survival, let alone health and well-being.”
The overall capture of the meaning of “health” by the medical industrial complex and its hospital systems and departments has helped to hide the absence of policy and structures to specifically address the health of the public. That vacant space has been lost to neo liberalism. Imagine if an explicit and central role of the Department of Prime Minister and Cabinet was to ensure policies and practices to build and protect the health of the public. Imagine if the key performance indicators were about the quality and length of life and the equity of health outcomes, rather than growth and GDP. Given the ominous current trajectories of climate, pollution, land and species degradation, the choice is existential. It’s time we named our health departments to describe what they actually do – provide illness care -and time to make health and equity explicit central goals of the whole system of government.
Paul Laris is a semi-retired health and human services policy tragic, health care users advocate, medical regulator, community activist, gardener and sailor.
Fran Baum AO, FASSA, FAAHMS, FAHPA, LMPHAA is the Director|Stretton Health Equity, NHMRC Investigator Fellow School of Social Sciences, Stretton Institute at the University of Adelaide. Fran is Honorary Professor, School of Public Health, University of the Western Cape, South Africa; Honorary Professor, Regnet, ANU, Canberra and a Member of the Advisory Council, People’s Health Movement.