Next year marks four decades since promulgation of the seminal Declaration of Alma Ata, which declared health — complete physical, mental and social wellbeing — to be a fundamental human right requiring government action across a range of policy areas.
Alma Ata laid the foundations for what are now widely championed as the social determinants of health; the economic and social conditions underpinning the wellbeing of individuals, communities and nations.
Without action on the social determinants, the so-called 'causes of the causes', health policy — and indeed health expenditure — can be a little like that joke about the cyclopean orthopod who, when confronted with a patient suffering fatal internal bleeding, is interested only in fixing their broken leg.
So it is with the 2017-18 Federal Budget. Touted as a signal moment for health, and a principled exercise in fairness by Treasurer Scott Morrison, the budget promises much but delivers little.
Budgets are by necessity a political exercise, and this one was heavy on rhetoric venerating universal health care and a détente with doctors following Labor's damaging 'Mediscare' election campaign and unpopular missteps by the previous government on copayments, diagnostic tests and the Medicare rebate freeze.
The former never managed to limp its way through the Senate, but the latter two measures were prominently wound back last Tuesday night under the guise of a new era of cooperation with Australia's doctors and pharmacists.
These so-called 'landmark compacts' acknowledge that the government must rebuild trust with the health sector, but also demand the RACGP and AMA crackdown on after-hours services, promote the rollout of the controversial opt-out My Health Record and support government surveillance of and challenges to Medicare billing.
How these memoranda were agreed and under what terms are unclear, and the lack of transparency does little to dispel the notion that these negotiations were brokered by a self-interested elite.
"They have kicked the can down the road on prevention, primary care and Indigenous health, deferring them as priorities for a so-called 'third wave' of health reform. This is not only poor public health policy, it puts the cart before the horse in economic terms."
Olive branch or fig leaf?
There are two big-ticket olive branches being spruiked by the government in health — the thaw of the MBS indexation freeze and establishment of a Medicare Guarantee Fund to secure the long-term future of universal health and access to medicines through the Pharmaceutical Benefits Scheme.
The first was heavily lobbied for by doctors and has been welcomed by peak medical groups, but the glacial pace at which it has been scheduled to occur — with a full return to indexation of all services not due until July 2020 — make it a fairly hollow gesture. The Consumers Health Forum of Australia have warned that it will leave many families on average incomes facing co-payments for treatment that they can ill afford 'for at least another year'.
The Medicare Guarantee Fund, to be underwritten by the Medicare levy and topped up with personal income tax receipts, is being presented as the responsible solution to ballooning health costs as the population ages, but the devil is once again to be found in the detail.
The Grattan Institute's Stephen Duckett describes it as little more than a rebadging exercise or accounting trick designed to shore up the government's Medicare credentials. Worse still, it circumscribes Medicare in budgetary terms as the MBS and PBS, sidestepping considerable obligations to the public hospital system. This reinforces perceptions that the current budget is focused on medicine rather than health.
Examining the ledger in closer detail reveals the government is boosting spending, in real terms, by about 2.8 per cent of the overall health budget, according to the Australian Health Care Reform Alliance's Jennifer Doggett. Given the average annual GDP increase is currently running at about 2.7 per cent, it's more accurate to say that health expenditure is doing little more than keeping pace with economic growth.
Silence is golden
Most telling are the conspicuous absences in the government's calculus, with climate change, Indigenous health, prevention (particularly obesity, tobacco and alcohol) and aid for our vulnerable regional partners all failing to register.
Health Minister Greg Hunt and department secretary Martin Bowles have kicked the can down the road on prevention, primary care and Indigenous health, deferring them as priorities for a so-called 'third wave' of health reform. This is not only poor public health policy (and inexcusable given we are failing on six of seven Close the Gap targets), it puts the cart before the horse in economic terms.
For example, conservative estimates put the cost of obesity to the Australian economy at some $8.6 billion per annum, while a study examining the Indigenous health gap in the Northern Territory alone between 2009-13 suggested a $16.7 billion price tag in lost life years, productivity and direct health costs. Social determinants are estimated to account for more than 30 per cent of the burden of disease for Aboriginal and Torres Strait Islander Australians.
Morrison has trumpeted his budget as a triumph for fairness, and while there are certainly commendable initiatives in social housing, mental health and most importantly, full funding of the NDIS through a ringfenced 0.5 percentage-point bump to the Medicare Levy, his punitive crackdown on and demonisation of those accessing the social safety net have been rightly condemned. Drug testing and restricting access to benefits for substance users flies in the face of government rhetoric on mental health reform.
At the recent 15th World Congress on Public Health in Melbourne, delegates from 83 countries across the globe called for a renewed commitment to the principles of Alma Ata and a recognition that inequity is the primary driver of poor health. In Australia, this imperative remains unheeded.
Amy Coopes is a medical student, journalist and editor at Croakey.org. You can follow Amy on Twitter at @coopesdetat