Five key policy documents articulating SA Government priorities and actions were analysed for evidence of an equity focus. [1]
While the concept of equity was evident in the language used, it progressively slipped out of the documents that articulated government agenda and priorities. It is important to understand why this occurred.
1. Accessibility is a priority
South Australia is home to one of the world’s most extensive and fair health care systems. Those who live, work and visit the state can take advantage of the state’s top-class health facilities, first-class health professionals, and the public Medicare system that entitles all permanent residents to free or subsidised treatment in public hospitals and from doctors, specialist nurses, optometrists, dentists and pharmacies.
However, for some people accessing these services is more difficult because of geographic, economic and social barriers. This is especially true for people in rural and remote areas of the state, where services are less accessible than in metropolitan areas. This is why it’s important that all organisations and businesses, regardless of their size or industry, consider accessibility as a priority. This is why it’s important to know your local government’s approach to accessibility and to understand how this can impact on your own organisation or business.
In an effort to improve the accessibility of the state’s health services, the government has developed a ‘Health in All Policies’ initiative (HiAP). HiAP is an innovation to enable joined-up policy making by linking the goals of other sectors to the pursuit of health and wellbeing outcomes. HiAP is a significant departure from dominant neo-liberal policy agendas that have historically closed off “small policy spaces” and limited governments’ capacity to address equity considerations.
HiAP was launched in 2007 and initially included a focus on equity within its core targets. These targets were defined by a process of inter-agency consultations and included accountability for the achievement of these target outcomes as part of individual agency chief executives’ performance agreements.
As time went on, the goal of the HiAP initiative shifted from equity as a central objective to a greater focus on intersectoral policy development through a co-benefits approach. This shift was the result of a complex set of influences that include a perception among policy actors that equity is inherently challenging to address; a strong focus on achieving cross-sector outcomes; and an emphasis on joint policy development as a way to facilitate joined-up government.
2. We are a signatory to the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD)
The South Australian Government signed the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) in 2007. The UNCRPD is an international treaty that recognises the rights and responsibilities of persons with disabilities. It establishes a framework for national laws and policy making to advance the rights of people with disabilities and to promote a human rights approach to disability. It requires all States parties to take measures that ensure the full and equal enjoyment of all human rights by persons with disabilities, including the right to live in a community of their choice and the right to participate fully in society.
South Australia has been a signatory to the UNCRPD since 2007. The State’s commitment to the UNCRPD is manifested in various ways. The State has a disability strategy, a statewide plan to support the community to achieve its goals, and a range of other policies that aim to promote inclusion and equality for all citizens with disabilities.
Despite the clear benefits to health and wellbeing of tackling social determinants of health, improving health equity remains a challenging goal for many governments. As a result, there is growing recognition for the need to involve non-health sectors in policy development and implementation. One way of doing this is by using the ‘Health in All Policies’ (HiAP) approach to mobilise cross-sector policy activity and address social determinants of health and health inequities.
HiAP was implemented in South Australia from 2007 and initially had a strong focus on equitable outcomes. However, over time equity has shifted away from being a central focus of HiAP work in favour of the view that HiAP is primarily a process to facilitate joined-up policy for co-benefits.
There are many reasons why equity has moved away from being a key goal of HiAP. These include a perception amongst policy actors that it is complex and difficult to address; the focus of HiAP on achieving shared goals through co-benefits which excludes discussions around equity; and the strong interest in joined-up policy solutions that HiAP has stimulated.
This research uses institutional theory to examine the reasons why equity has shifted from being a central goal of HiAP to being viewed predominantly as a process to facilitate joined-up policy across government. Institutional theory explains how dominant institutions (which comprise structures such as standard operating procedures, rules and norms, ideas such as world views and ideologies and principled beliefs) shape and constrain policy change.
3. We are a signatory to the Australian Government’s National Disability Strategy (NDS)
A key feature of the NDS is that it recognises all levels of government, along with people with disability and other stakeholders, play a role in supporting people with disability to enjoy their human rights on an equal basis with others. This includes the delivery of mainstream and targeted services, support and infrastructure systems. It also includes the changing of community attitudes and improving awareness of disability.
The NDS sets a framework for improving data collection and analysis, which is critical to identifying the impact of policies on people with disability. The NDS requires governments to set performance benchmarks, publish reports and use evidence-based practices in the development of policy. It also calls for all levels of government to work collaboratively to develop inclusive policies and programs.
It requires the state to work with people with disability and their representative organisations, local communities, businesses, and non-government agencies to develop policies that are accessible and affordable. This will lead to a system that is more responsive to the needs of people with disability and their families, as well as improving quality of life.
The NDIS is a system that will help improve access to a range of services and supports for people with disability, including accommodation, transport, community participation, education and training, employment, health, communication, and advocacy. It will provide new funding for disability supports and will change how these services are funded and delivered. It will also improve access to information and advice, increase choice and control, and improve accessibility for people with disability.
South Australia’s implementation of the NDIS will involve developing a National Plan for Disability (NPD), setting benchmarks to guide its effectiveness, and providing funding for targeted initiatives that are designed to deliver the NPD’s outcomes and achieve better outcomes for people with disability. It will also include new funding for home and living supports and new services to support family members to assist with the care of people with disability.
The NDS will be supported by a new model of coordination and cooperation between the Australian, state and territory governments, as well as with local governments and non-government organisations. It will be guided by the principles of equity and inclusion, and will be reviewed every five years.
4. We are a signatory to the World Health Organization’s Disability Charter
In South Australia, disabled people are more likely than other people to need health care services and to experience barriers to accessing those services. This is because, in addition to living in disadvantaged circumstances, many of these people face challenges with the everyday activities that most of us take for granted. These include travelling, visiting and staying at home; finding information on the Internet; and using telehealth to communicate with their health practitioner. These are all challenges that can be made even more difficult for disabled people if the policy environment is not disability-inclusive.
One way to reshape the policy environment is to use a HiAP approach. A HiAP focus considers health as constituted by social, economic, political and cultural determinants, and promotes intersectoral policy development in order to produce co-benefits across sectors. In this context, a HiAP approach can contribute to improved outcomes for vulnerable groups.
The policy environment can also be reshaped by addressing health equity as a central goal of intersectoral policy development. This is because a HiAP approach emphasises the need to take into account differences in outcome for different groups within society, and to address the structural determinants of those differences [1].
In South Australia, the implementation of HiAP has been supported by a high level mandate from government, an overarching framework that supports a diverse program of work, a commitment to collaboration and partnership across agencies, and a strong evaluation process. However, a HiAP approach has not consistently been used to support an agenda of health equity.
A number of factors may explain this. For example, policy actors may be influenced by the beliefs and values that they hold. These beliefs and values are shaped by the environment in which they operate, as well as their own experiences. These can include world views, ideologies and principled beliefs; and ideas, such as those derived from institutional theory.
The aim of this research was to explore how policy actors understood and responded to a range of issues affecting the implementation of the SA HiAP approach. To do this, 144 face-to-face or telephone interviews were conducted with policy actors from the Health Department and partner agencies; and local, state and federal government actors. Interviews were analysed for key themes.