The Australian healthcare system is a complex amalgamation of social, economic, technological, constitutional, legal and political components determined by federal, state and local levels of government, funded by public and private providers (Palmer & Short 2014). According to the World Health Organisation (WHO), “health policy refers to decisions, plans, and actions that are undertaken to achieve specific health care goals within a society” (WHO 2018).
In Australia, public health policy is primarily the responsibility of government health policymakers who are responsible for creating health policy and must consider the services, organisations, institutions and funding arrangements within the healthcare system, including the proposed actions formed by public, private and independent organisations that influence health (Palmer & Short 2014). However, often policies of private and non-governmental organisations greatly intervene in the policymaking process and thus the proposed actions formed by public, private and independent organisations that influence health must also be considered (Palmer & Short 2014). As a result, the Australian health policy (process) is bombarded by an array of institutional, political and structural forces that have brought upon an unpredictable and uncertain policy environment that is perpetually being formed and reformed by a complicated interplay of opposing values and interests (Gardner & Barraclough 2002). Despite the efforts in policy agenda setting, formation and implementation, national policies are influenced by states and territories and the self-interests of stakeholders and/or partners, which may only intend to benefit certain populations or health priority areas. Despite the fact that health policy is heavily influenced by external forces, it theoretically intends to focus on public, not private health issues directed towards groups or populations rather than selected individuals.
Ethics is a crucial element in public health policy as public health is a moral and humane enterprise (Dunn 1983) that ultimately involves the health and wellbeing of people. The four principles of bioethics, best described by Beauchamp and Childress (1989) is based on autonomy, non-maleficence, beneficence and justice and primarily focuses on the rights of the individual, and should underscore both health policy and practitioners. On the other hand, in public health policy, some actions may be considered unethical to the perspectives of healthcare professionals, individuals and/or the general public but result in substantial improvements among the greater community. Hence there is a need to balance ethical foundations with governmental policies that intend to improve overall health. Though ethics is regarded as a theoretical requirement of good practice, it is a vital component to the ultimate success of a health policy. As without ethical consideration, health policies fail to achieve the goal of preventing disease, prolonging life and promoting health.
In support of this, health policies and strategies that have been modelled on achieving health outcomes or statistics such as the ‘Closing the Gap’ strategy, without much consideration on the ethical process of achieving outcomes result in greater problems. Thus, a health policy that is ethically sound is likely to be an effective and practical health policy (Churchill 2002). Unfortunately, public health policy has a tendency to become misaligned with the ethical foundations and perspectives of healthcare professionals, patients and/or the general public as the formal process of incorporating ethical deliberation in public health policymaking is considerably new (WHO 2008). When analysing health policy, it is important to understand that different health policies are understood and accepted in different ways amongst health professionals, consumers and the general public.
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The nature of health policy can divide the population based on opposing views and ethical justifications (Palmer & Short 2014). This essay will evaluate health policies that have become misaligned with the ethical foundations and perspectives of healthcare professionals, patients and the general public and their consequences using current examples within the Australian healthcare system. The health policies analysed in this essay include the National Medicines Policy, National Mental Health Policy and the National Women’s Health Policy. The manufacture and supply of medicines, including prescription, non-prescription and complementary healthcare products is the responsibility of the pharmaceutical industry in Australia, which is bound by government regulation and financial involvement by both public and private sectors (Palmer & Short 2014). The pharmaceutical industry involves all levels of government, manufacturers, importers and wholesalers, pharmacists, health educators, health practitioners and other healthcare providers, healthcare consumers and the media (Palmer & Short 2014; Department of Health and Ageing 1999). The National Medicines Policy (NMP) was launched in 1999, following the formation of the Australian Pharmaceutical Advisory Council (APAC) in 1991 (Department of Health 2014). The NMP is a collaborative approach by partners involved in the pharmaceutical industry to achieve better health outcomes for all Australians by focusing on timely access to and appropriate use of medicines (Department of Health 2014). The NMP focuses on four central objectives that incorporate elements of social and economic policy.
The objectives include timely access to medicines of appropriate standards of quality, safety and efficacy (responsibility of the Therapeutic Goods Administration) at a cost that is affordable to individuals, the community and the government (mostly through the Pharmaceutical Benefits Scheme), quality use of medicines (through the National Prescribing Service) and sustaining a liable and feasible pharmaceutical industry (Department of Health and Ageing 1999; Palmer & Short 2014). The Pharmaceutical Benefits Scheme (PBS) facilitates access to certain prescribed medicines that are listed in the PBS formulary by subsidising costs. However, the subsidies are not entirely free of charge and the community overall is responsible to burden the cost, through taxpayer funds who often may not consume medicines. Additionally, not all medicines are listed on the PBS, meaning that health professionals are placed in an ethical dilemma about which medicines to prescribe to their patients, based on ensuring affordability and access to medications rather than following evidence-based practices and principles of beneficence. For example, if targeted therapies for rare diseases or a rare subset of diseases are threatening the cost-effectiveness of the population and subsequently not included on the PBS, then these patients are unfairly disadvantaged by the NMP (Lipworth et al. 2014).
Furthermore, the NMP fails to recognise the beliefs and needs of patients and the general public who consume non-prescription and complementary medicines. As a result, healthcare professionals and patients are not fully supported by the NMP in their decision to choose treatments based on their own needs. The cumulative co-payment expenses incurred by chronically-ill patients are accounted for by safety net arrangements despite whether or not the patient is entitled to concession. However, for the general Australian population without concession, co-payments are considerably higher and as a result, create a barrier for prescription affordability, particularly individuals with low income (Duckett & Willcox 2015; Doran et al. 2011; Kemp et al. 2011).
Policymakers need to be aware of these emerging ethical concerns in pursuit of achieving the objectives and ongoing evolution of the NMP. Historically, mental illness was associated with madness, religious punishment or demonic possession. Despite mental illness now medically recognised as a health problem, negative stereotypes and misconceptions still inflict discrimination and stigma upon people with mental illness (Department of Health and Ageing 2008). In Australia, mental illness is increasingly predominant and has a significant impact on the healthcare system and burden of disease (Duckett & Willcox 2015). Due to considerable economic and social burden and increasing prevalence of mental health problems, mental health policy is regarded as a crucial area of the healthcare system to promote and produce practical and efficient mental health services available to the community (WHO 2003). The National Mental Health Policy was endorsed by Australian Health Ministers in 1992 as a framework to guide mental health reform in Australia as a part of the National Mental Health Strategy (Palmer & Short 2014). The National Mental Health Policy was revised in 2008 and adopted a coordinated government approach to ensure that Australia has a mental health system that supports efforts to prevent mental illness through awareness, detection and early intervention, promote recovery by ensuring all Australians have access to treatment and support and reduce the impact and stigma associated with mental disorders (Barraclough & Gardner 2008; Palmer & Short 2014; Department of Health and Ageing 2009).
The Mental Health Policy quickly became misaligned with the ethical foundations and perspectives of healthcare professionals, patients and the general public as the policy was lacking an agreed understanding of mental health services and a target on service delivery and patient outcomes (Duckett & Willcox 2015). The lack of clarity surrounding the roles and responsibilities of various allied health and social care service providers lead to opposing agendas and differences in values, such as consumer-focused care by non-medical providers compared to disease-focused care by healthcare professionals (Banfield et al. 2012; Mitchell 2009).
The services within the Mental Health Policy remains scattered and unorganised despite policy reform and funding to develop services to improve coordination and integration of public and private mental health services (Barraclough & Gardner 2008). Coordination in mental healthcare involves ongoing interaction with a team of healthcare professionals and the patient that assists the delivery of services according to individual need (Haggerty et al. 2003). General Practitioners (GPs) are the mainstay of providing mental health care in the Australian healthcare system. However, only a small portion of services are claimed annually under the Medicare Benefits Scheme (MBS) that allows patients to access the services of psychologists and other allied mental health professionals for a capped number of services annually (Duckett & Willcox 2015). With only 35% of people with mental disorders receiving any care (Rosenberg & Hickie 2013), it raises concerns about ethics, equity and quality of mental health services within the National Mental Health Policy. The policy fails to recognise that people with mental illness have the right to be informed and involved in their own treatment and have different needs and preferences according to their stage of illness or social situation, making them vulnerable to human rights violations in the community and in a variety of services resulting to a misalignment in ethical practice.
The main concerns of the Mental Health Policy include the disparity between accessing mental health services in metropolitan and rural areas combined with underutilisation of innovative approaches to incorporate workforce and technology (Dunbar et al. 2007), low rates of bulk-billing amongst healthcare professionals and significant out-of-pocket costs incurred by the individual (Rosenberg et al. 2009), imbalanced focus on emergency and acute services rather than prevention and early intervention, lack of planning and coordination and service delivery based on the needs and beliefs of providers rather than that of the patients. Limited access to inpatient services, workforce availability and insufficient rehabilitation opportunities present an ethical dilemma amongst healthcare professionals as to which patients can access services based on eligibility criteria as the policy focuses more on the ‘seriously mentally ill’ (Barraclough & Gardner 2008). As a result patients with ‘high prevalence’ disorders such as anxiety, mood disorders, personality disorders or a combination of mental and physical health issues previously treated in public mental health services have difficulty accessing care as they are considered beyond the responsibility of public mental health services (Barraclough & Gardner 2008). Population groups including individuals with intellectual disability, drug and alcohol problems, Aboriginal and Torres Strait Islander people, culturally diverse backgrounds, refugees, survivors of torture and trauma, behavioural problems and homeless people experience varying levels of service as there is limited evidence regarding assessment and treatment among these groups (Thornicroft & Betts 2001). Disparities in expertise and culture within governments and amongst healthcare professionals serve as barriers to patient care.
The policy has failed to adequately distribute specialised mental health services to outer metropolitan, rural and remote areas compared to major cities, despite a large portion of the population residing in these areas. Even with the Mental Health Policy, stigma, resilient attitudes and lower educational levels can influence help-seeking behaviour, readiness to engage with mental health services and adhere to preventative measures among individuals and the general public (Hoolahan 2002). Additionally, factors such as low income and limited public transport are barriers to affording and accessing mental health care services and increase the risk and sense of isolation (NRHA 2017). As a result, timely diagnosis, treatment and ongoing management of mental illness in rural and remote areas is often delayed or completely unmanaged resulting in an increased risk of hospitalisation and self-harm and suicide (NRHA 2017). The Government needs to consider the ethical considerations and perspectives of healthcare professionals and patients including evidence-based patient centred care, considering and planning for all populations and groups, ensuring continuum of care, optimising technology and strengthening collaboration and partnerships to ensure better health outcomes for people with mental illness. In order to understand women’s health, one must agree and acknowledge that the life of a woman greatly differs from that of a man. Health challenges associated with both men and women require awareness of their particular needs and issues in order for them to be addressed ethically. Even though women are the primary healthcare consumers, service providers and carers in the Australian population, they are still marginalised within the Australian healthcare system (Palmer & Short 2014).
The women’s health movement in Australia has been responsible for shifting the paradigm of the existing health care system to bring attention to the importance of women’s health. This has been established by ensuring policymakers accommodate the specific needs of women in health policy, creating exclusive women’s health clinics and services oriented towards their needs and distribute resources and funding allocated to predominantly acute services provided in the hospital to include community-based and patient-oriented services to ensure justice among all groups of women (Palmer & Short 2014). These efforts resulted in the development of the first National Women’s Health Policy in 1989 based on the determinants of health which acknowledge health as a cumulation of biological, social, economic, cultural and environmental factors (Palmer & Short 2014). The first National Women’s Health Policy aimed to improve the health of all Australian women by attaining additional funding for women’s health based on the priority health areas identified in society and the healthcare system (AWHN 2008). However the policy failed to consider the ethical foundation of justice and as a result, many groups of women were neglected as there was an unequal distribution of resources, programs and services specifically for women’s health across state and territory levels (Palmer & Short 2014).
For example, the training of Nurse Practitioners in New South Wales to provide and perform a variety of women’s health services including breast, vaginal and pelvic examination, pap smear collection, prescribing of oral contraception, diaphragm fitting, pregnancy testing and counselling and contraceptive advice (Meredith 1986) misaligned with the ethical considerations and perspectives of medical professionals in other states particularly surrounding providing evidence-based diagnostic and curative services to women and ensuring beneficence (Palmer & Short 2014). However by training other qualified healthcare professionals such as Nurse Practitioners and Aboriginal and Torres Strait Islander Health Workers, the NSW government was able to reduce the strain of workforce availability of specialists ensuring distribution of services that are targeted to specific populations and therefore improving their health. Due to differing perspectives of state and territory governments, other groups of women in Australia were disadvantaged due to unequal distribution and funding of women’s health services. Despite recent advancements in health, considerable disparity in health status still exist among Australian women with “32 percent higher rate of disease for the most disadvantaged population compared to the least disadvantaged” (Begg et al. 2007).
The new National Women’s Health Policy 2010 is based on five key principles encompassing gender equity, health equity between women, prevention through health promotion, evidence-based services and a lifespan approach to women’s health (Bennett 2009). Through prevention and promoting health equity in view of the social determinants of health, the policy aims to support women to be proactive ambassadors for their own health and that of other women in the community. Consultations with women reveal that the policy is misaligned with the autonomy of women, in that those with limited access to resources may be compelled to make health decisions according to their affordability as opposed to the treatment that best reflects their health needs (Department of Health and Ageing 2010). Even though the policy intends to accommodate the health needs of all Australian women including Aboriginal and Torres Strait Islander women, culturally and linguistically diverse women, women from rural and remote areas, women with disabilities and lesbian and bisexual women, they may avoid seeking help entirely due to discrimination and culturally insensitive services. For example, Aboriginal and Torres Strait Islander women may not benefit from the policy as the services available do not align with their traditional values and holistic approach to women’s health.
Studies indicate 34% of lesbian, gay, bisexual and transgender (LGBT) avoid disclosing their sexuality or gender when accessing services (Leonard et al. 2008) and lesbian and bisexual women may not access or delay access to women’s health services due to the fear of being susceptible to discrimination and stigma from heterosexist opinions in healthcare professionals and a reduced quality of care due to insensitive services (Department of Health and Ageing 2010; Heck et al. 2006; Mayer et al. 2008). Furthermore, health practitioners are placed in an ethical dilemma with regards to treating women whose principles do not align with western medicine practices such as abortion.
The overall advancements in sexual and reproductive health in the 21st century encountered by most women have not been of equal benefit to some groups of Australian women. For example, the sexual and reproductive rights of disabled women have not been addressed in healthcare services due to a lack of research and understanding (Department of Health and Ageing 2010). Therefore, further research is needed to understand the specific health needs of certain population groups to ensure services are culturally appropriate and accessible. Improving the health outcomes for all Australian women will involve more than targeting the key principles in the National Women’s Health Policy by individual women, policy makers, program leaders, service providers and governing bodies but also addressing ethical considerations and perspectives from all stakeholders to in turn improve the health of the wider Australian community.
In conclusion, moral dilemmas arise within health policies in the healthcare system due to multiple involvement from a variety of stakeholders such as government bodies, committees, managers and multidisciplinary teams that are often comprised of many health care professionals and service providers that have differing understanding of ethics. From the examples provided, it can be seen that policy makers must explore beyond the objectives of public health policy to recognise and incorporate ethical principles and social determinants that influence health of individuals rather than the overall population such as gender, culture and language, education, socio-economic factors and the environment to ensure health needs of the society are considered fairly. Such considerations impose practical ramifications in the development, implementation and evaluation of public health policies. Thus new models and means of ethical analysis are required to integrate ethical foundations within public health policy to ensure ethical perspectives of healthcare professionals, patients and the general public are addressed to achieve better health outcomes.
