Chapter 7 Engaging with Policy Makers
7.3 Policy Context
Policy makers are often frustrated if researchers do not present results which provide definitive policy implications. They find that research results are often ambiguous and do not directly suggest policy directions (Lomas, 2000). Public health researchers are increasingly aware of this frustration but also believe that research results have more to offer than direct policy directions. In this research we have documented clear inequalities between areas and people with different socio- economic status, and provided a detailed picture of each of the four study suburbs.
However, and as expected, the findings are less definitive about what factors are causing the difference between the suburbs and the people who live there. Our research demonstrates that the rich mixture of complex factors that contribute to the inequalities we have described are not, at this stage of our knowledge, accompanied by definitive and specific recommendations.
Too often, when policies aiming to improve population health are developed, the results are incremental changes in the margin at the expense of larger and more fundamental changes. This observation was supported in both the local and the
People and Places |chapter 7: Engaging with Policy Makers
state workshops in this study when participants spoke of plans that were not implemented, frustrations with short-term projects and the inability of the “whole- of-government” rhetoric to be implemented on the ground.
Hope for more fundamental change was pinned on the South Australian Strategic Plan. Time after time, in the policy consultations, it was argued that the South Australian Strategic Plan (http://www.stateplan.sa.gov.au/index.php accessed 25th January 2007) outlines the broad vision framework for addressing inequity and bringing about a significant change in the types of policies being designed to achieve equity. The plan outlines six interrelated objectives:
1. growing prosperity 2. improving well-being 3. attaining sustainability 4. fostering creativity 5. building communities 6. expanding opportunity
The state workshop argued that the Plan could only be successful if there were whole-of-government solutions, if it was ‘owned’ by the whole community, and if targets were measured not just by individual departments but assessed in terms of their effectiveness in increasing integration. There was a strong feeling that the crucial question is ‘how do we shift priorities towards creating health and well- being’ rather than repeatedly stating the problems. Some felt that the data produced in this study are not new and that we have known for many years that areas like Playford are severely disadvantaged in most respects. The important question is ‘what can we do’? This feeling has strong resonance at the international level with the work of the Commission on the Social Determinants of Health which has expressed the determination to base its work on evidence but to focus on recommending and encouraging practical action to improve the social determinants of health (CSDH, 2007).
People and Places|chapter 7: Engaging with Policy Makers
In South Australia the value of an integrated action approach to health has been demonstrated through the Noarlunga Healthy Cities initiative which has been a sustainable project over nearly twenty years. During this time it has led to much effective cross-sector action (for example, on injury prevention and environmental issues) and has been seen as an effective model of health promotion (Baum et al, 2006). But it is also clear that the approach was restricted by the fact that it was one project in isolation that owed much to strong and effective local leadership and community involvement but was not always supported by action and structures from central agencies. The innovative social planning work in Onkaparinga in the 1980s that was credited by many in the policy workshops with accounting for the higher social capital measures in the Onkaparinga postcode area, did receive strong support at the time from a cross-portfolio committee of government, suggesting the power of state level support for local level initiatives.
The policy changes suggested or required by the South Australian Strategic Plan qualify as fundamental because they are very challenging and are designed to be implemented over many years. The Plan has the potential to provide the context in which a succession of policy decisions are made to create more equity in health by encouraging higher levels of social capital, and changing policies, programs and actions that lead to economic and social exclusion. It is well known, however, that the mere existence of a plan does not guarantee implementation. Concerns were expressed in all workshops that any plan can be disconnected from policies and programs on the ground or in particular geographical areas.
Even the most heroic, theoretically sound and well implemented local actions cannot in themselves produce those fundamental changes envisaged in a written plan unless there are effective ways to connect the local and the central policy domains. Actions in South Australia are inevitably shaped by Federal Government actions, and health equity, with the important exception of Indigenous health, is not a stated objective of the Federal Government in policy or action plans (Newman, Baum and Harris, 2006). Thus, the South Australian Strategic Plan implementation process may be constrained by lack of action to address the more structural determinants of health inequities that are primarily determined nationally.
It is acknowledged that there are many powerful barriers that stand in the way of fundamental change. As a result, it is important to support those pragmatic, incremental and opportunistic changes that combine to comprise important steps towards the goal of more fundamental change. Incremental changes happen in individual agencies and sectors and by local, area-based agencies such as local government, educational facilities and primary health care services. However, our policy consultation supports what we know from the national and international literature about the ineffectiveness of short-term projects, involving either no collaboration or antagonism between sectors, as means to achieve the fundamental changes required for equity. There will normally be tension between central offices and central agencies and more local or area-based services. The essential links between the fundamental and the incremental lie in the ability of federal and state governments to create a context which promotes, at both state and local levels, collaboration, whole-of-government and long-term policies explicitly focused on the social determinants of health and health equity. Fundamental change is achieved when networks and whole-of-government strategies make effective, durable and well managed connections between the local and the central policy domains. In this way, there are many opportunities for creative and community-led local actions, enhanced by the resources for, and commitment to, change at a level which can only be achieved by the commitment of central agencies.
People and Places |chapter 7: Engaging with Policy Makers
Many of the concepts associated with social capital are not easily measured and their causal links with health outcomes are indirect and complex. Yet our study has made it evident that social capital components including trust, social and civic participation, and reciprocity are a significant part of the pathway explaining why health outcomes are unequally distributed. This means that while actions to reduce inequities must be firmly based on a re-distribution of material resources (including education and employment opportunities) there also has to be government attention to changing the systemic processes that our research suggests give rise to social exclusion and lower levels of social capital in our resource-poor communities.
We are aware that many of these ideas have been expressed before, and that this perspective on policy is one about which many people agree. The problem is translating these ideas into practice. From this research, it appears that in order to explore further how to operationalise policy for equity, it would be helpful to explore, in more detail than we have been able to here, the reasons why Onkaparinga has performed well on a number of indicators. It would also be useful to explore international examples of well-planned policy to produce whole-of- government strategies explicitly focused on equity.
Our research shows that policy makers, service providers and community representatives alike find that an understanding of the building blocks of social capital, as outlined in this study, provides a common language that makes whole- of-government and intersectoral collaboration easier. This common language will help resolve the creative tension between whole-of-government networks at the higher levels of government and more local networks of community members, agencies and programs.
People and Places|chapter 7: Engaging with Policy Makers