System reform in the human services: what role can health promotion play?

In late 2016 the Productivity Commission released a report about introducing competition and informed user choice into the human services.¹ The main thrust of this report suggests that increased ‘competition’ and ‘contestability’ (i.e. more organisations – particularly in the private sector – attempting to deliver human services, including some health services) achieves greater economic efficiencies. In these circumstances low-cost service provision is favoured, in contrast to higher cost and potentially higher quality service provision. Within a health context, introducing an increased level of competition may reduce the quality of service provision and affect who is able to readily access services. History suggests that movement towards ‘competition’ favours neo-liberal ideals of economic rationalism, in contrast to positioning health and well being as a priority.² Unfortunately, there has been a persistent erosion of funding and resources within the human services sector under the leadership of the current Australian Government over the past few years. This means there is no room for ‘competition’ without seriously jeopardising population health outcomes in Australia. In short, a shift towards ‘competition’ is about as anti-health promotion as it gets.

History also indicates that ‘user-choice’ within a human services context does not necessarily equate to a trajectory of improved health outcomes.² As the Productivity Commission suggests, ‘the users of human services include the most disadvantaged in the community with vulnerabilities arising from very low incomes, mental or physical illness, frailties due to older age, low numeracy and literacy skills, or a lack of access to the resources and support needed to exercise informed choice’.^1(p.45) User-choice is greatly affected by health literacy and unless the growing evidence about the importance of health literacy at both individual and systemic levels is adequately addressed, then the concept of ‘choice’ remains fictitious at best. Infuriatingly, the Productivity Commission understands this. It states: ‘if public patients were given greater opportunity and information to make choices, low levels of health literacy may mean that many of them would be unwilling or unable to make choices independently’.^3(p.85) This comment is made in relation to decision-making within hospitals but the same issue applies within community settings, where informed choice may be equally difficult. The health promotion profession understands the important role of health literacy for better health outcomes and is well positioned to build health literacy within Australia. Fundamental principles of health promotion, such as citizen engagement, community empowerment, promoting health equity and intersectoral partnership development, can further assist in this quest.

The Productivity Commission^1(p.2) contends that ‘introducing greater competition, contestability and informed user choice can improve the effectiveness of human services’ (our emphasis); however, the growing evidence base on social determinants of health clearly demonstrates that such approaches disproportionately and negatively affect the health and well being of the most vulnerable people in our community.^4,5 In this context, the term ‘effectiveness’ needs to be questioned. It is appropriate, therefore, to pause and reflect on the impact that the introduction of ‘competition’ and ‘user-choice’ within the human services sector could have on population health outcomes. Given that health promotion and prevention have not been mentioned in the Productivity Commission report (with perhaps the exception of a flippant use of the term ‘health literacy’), it is timely to reinforce the role that the health promotion profession has in ensuring that positive health, social and economic outcomes can be gained if system reforms of this nature progress.

It is important that the health promotion community, and the broader human services sector, critique the way in which the Productivity Commission report attempts to frame concepts of ‘competition’ and contestability’¹. For example, the report states:

Increasing competition and contestability is not an end in itself. Rather, competition and contestability can be part of a system that encourages providers (and governments) to be more effective at achieving outcomes for service users by improving service quality, using innovative delivery models, expanding access so more people get the support they need, and reducing the costs to governments and users who pay for those services. (p. 9)

It could be equally said that competition and contestability can be part of a system that encourages a privatised market (rather than governments) to try to achieve the same level of service delivery with fewer resources, resulting in poorer quality services that are less accessible to the most vulnerable. Scholars suggest that this may affect the extent of citizen participation and intersectoral partnership development.² In addition, we already know that privatisation supported by competition and contestability enables powerful industry groups – such as tobacco, alcohol, fast food and global pharmaceutical companies – to continue on their journey of supporting unhealthy environments that contribute to a high burden of chronic disease in Australia. This drives health service delivery towards more costly clinical and tertiary healthcare provision, in contrast to investment in health promotion and prevention where economic efficiencies are most profound.^6,7 Realistically, introducing competition and contestability raises questions about the principles and values of the type of human services system we want to see in Australia. Is it one that is health-damaging or is it one that is health-promoting?

This is important, because the six reform priority areas identified in the Productivity Commission’s report focus on social housing, public hospitals, end-of-life care services, public dental services, services in remote Indigenous communities, and government-commissioned family and community services. There is little doubt that health promotion has played, and continues to play, a pivotal role in improving outcomes in all of these priority areas, despite its omission from the report. There are ample examples of research and program evaluations published in the Health Promotion Journal of Australia from which to draw on in this regard, some of which are described below. As health promotion professionals, we know that investments in these areas are critical for improving the health and well being of the Australian population. However, we also know it is important to have the right type of investment, in the right place, at the right time, being delivered by the right people.⁶

We acknowledge that the Productivity Commission concedes that the introduction of greater competition, contestability and user choice may not always be the best approach to reform.² As described above, this approach has significant potential to undermine the promotion and achievement of health equity. For example, what does increasing competition in human services mean for an Aboriginal community-controlled organisation that is trusted by its local community; is underpinned by a local community governance structure; and has a deep contextual understanding of the health and well being needs of the population it serves? In such instances, competition is counterintuitive to the potential community benefit. It could best be described as being anti-health promotion.

Ideally, investments that foster intersectoral collaboration, increase community ownership and engagement, and value diversity are important elements of contemporary health promotion. Similarly, enhancing the uptake of health promotion research and evaluation evidence to influence positive system change may provide alternative approaches for improving the effectiveness of a range of human services in Australia. We contend that there are many ways that the health promotion profession can strengthen outcomes experienced in the human services sector. But we need to ask: What does an improved human services system look like? How could a reformed human services system best support improved population health gains? And what role can the health promotion community play?

In recent years, the World Health Organization (WHO) has advocated for a stronger focus on systems thinking, particularly with regard to social determinants of health, and respective advocacy for well thought through whole-of-government approaches.^8,9 At a practical level, there has also been growing interest in, and learning from, investments in a Health in All Policies (HiAP) approach, which places health as a central consideration in all public policy development.^10,11 Australia, particularly South Australia, has been a global leader in this space.¹⁰ This has included the development of HiAP case studies to improve intersectoral action, many of which intersect with the human services sector.^10,11 The utility of HiAP was clearly documented in the Communities Affairs Reference Committee report¹² on Australia’s domestic response to the WHO Commission on Social Determinants of Health report. Indeed, this report recommended that the ‘government adopt administrative practices that ensure consideration of the social determinants of health in all relevant policy development activities, particularly in relation to education, employment, housing, family and social security policy’.^12(p.42) This could serve as a useful point of reflection for the Productivity Commission, given the focus of its recent report. In addition, a very recent international conference co-hosted by the South Australian Government and the WHO discussed explicitly the utility of HiAP in addressing the Sustainable Development Goals.¹³ We contend that HiAP could be used as an effective model in human services reforms in Australia. The health promotion profession has an important stewardship role to play in supporting this type of process.

The Productivity Commission report identified that ‘data are critical to system redesign’. We know that evidence takes different shapes and forms, and that contextual evidence is particularly important in the health promotion arena, such as prioritising community perspectives, acknowledging culture, understanding the local socio-political environment, and accounting for structural and environmental considerations.^14,15 We also know that there are challenges associated with developing, implementing and evaluating action on the social determinants of health,^9,15 particularly those relating to effective intersectoral collaboration and system change.^9,11,15,16 But we also have much to celebrate. We have a rich network of health promotion researchers in Australia with experience in traversing multiple disciplines. The generation of interdisciplinary research findings, and respective research translation efforts, supports the realisation of co-benefits between sectors. Recent scholarship relating to healthy places and spaces,¹⁷ partnerships in obesity prevention,¹⁸ and the intersection between food security and climate change¹⁹ provides three useful examples of such work. Interestingly, ‘increasing competition and contestability’ is seldom a feature of research that aims to promote improved population health outcomes. Rather, health promotion research is more likely to offer models for ‘sustainable partnership development’ and ‘effective intersectoral action’^11,15, consistent with current government trends towards co-design and co-production in the human services. Thus, the relevance of the evidence and its dissemination is increased.

Evidence derived from evaluation in health promotion can also play a vital role in guiding reform in the human services sector.²⁰ We already know there is a lack of comprehensive and robust evaluation in relation to human services policies, programs and services in Australia. Where reviews and evaluations have occurred, the implementation of recommendations has been marginal.²¹ Arguably, a failure of government to act on proposed changes and past recommendations that demonstrate promise and respond to community needs has stifled progress in this sector. This is particularly apparent in areas where health inequities are most prevalent. For example, Hudson recently revealed that less than 10% of Indigenous programs funded by government and non-government sources are evaluated for program effectiveness.²¹ Although there have been some marginal gains in some areas, gaps between Indigenous and non-Indigenous health outcomes have remained relatively unchanged over the past decades.²² Lack of progress has resulted in the Australian Government announcing recently its intention to invest $40 million over 4 years to strengthen evaluation and monitoring processes through the Indigenous Advancement Strategy.²³ This investment has potential to align with multiple priority areas outlined in the Productivity Commission’s report. It provides an opportunity to effectively use health promotion evidence generated through research and evaluation efforts to promote health equity in the human services, particularly to ameliorate the health disparities experienced by Indigenous Australians.

As health promoters we are well equipped with planning and evaluation skills, knowledge and expertise. These are considered core competencies of health promotion professionals in Australia.²⁴ Despite recent disinvestment in the health promotion workforce, these competencies are likely to become more formally acknowledged as the Australian health promotion community moves towards professionalisation over the coming years.^6,25 The Australian Health Promotion Association (AHPA) has recently been awarded National Accreditation Organisation status by the International Union for Health Promotion and Education. This will provide the Australian health promotion community with the opportunity to seek formal registration as a health promotion professional. The move towards health promotion professionalisation will mean that the human services sector will be able to identify suitably qualified and experienced people to actively contribute to positive transformations. This includes health promotion practitioners with expertise in community engagement and partnership development, an understanding of systems thinking, and an ability to generate and use evidence effectively.

This discussion demonstrates that there is currently no place for competition, contestability and user-choice in the human services sector in Australia, as this approach penalises the most vulnerable and does not lead to better health outcomes. There are alternative approaches that challenge current neo-liberal ideology and direct attention to human values of fairness and social justice, with the intent of promoting equity for all. One such approach requires the Productivity Commission to explicitly recognise and understand the role that health promotion and health promoters can play in human services reforms.^6,26 It relies on a commitment from health promotion professionals and the respective health services (and other social services, including state and local governments, and non-government agencies) to be much more vocal about what they have to offer. It also involves them advocating for the needs of the most vulnerable to ameliorate health and social inequities.^2,16 It involves acknowledging the strong evidence that demonstrates the cost-effectiveness of health promotion and prevention.^6,7 It involves celebrating the contribution that the health promotion profession plays, and can continue to play, in the human services landscape of this so-called ‘lucky country’.