Policymakers around the world are confronting the obsolescence of great portions of past health policy in similar ways. This appears to be consistent with trends in health policy in this country.
‘Hierarchical regionalism’ is a shorthand description of the global health policy that is becoming obsolete. The basic assumption of hierarchical regionalism — that the most important cause of better health would be biomedical science — has long been a matter of faith for most policymakers, health professionals, journalists and consumers of health care. Policymakers extrapolated promising evidence of interventions to prevent and cure infectious disease. They, and many in the public, came to believe that basic and clinical scientists would discover increasingly effective techniques of diagnosis, prevention and treatment and that these techniques would alleviate most of the burden of disease.
Policy based on this premise gave priority in health spending to creating and managing hierarchies of organisations topped by medical schools and teaching hospitals. These institutions would send new knowledge and professionals down hierarchies in geographic regions to less-sophisticated hospitals, clinics and doctors’ practices. Patients would move up these hierarchies as their conditions required interventions that were technologically more complicated.
This policy had a profound effect on the allocation of authority and resources for health. It allowed the medical profession most of the authority to organise services and to decide how to spend money from government, private insurers and individuals. For some years in each country it also justified relatively less attention to addressing determinants of health other than healthcare; for example, environmental toxins, nutrition, exercise and smoking.
Thanks to Sean Leahy.
Hierarchical regionalism is becoming obsolete in every industrial country as a result of converging forces. These include healthcare costs that for years have increased faster than general inflation; the growing burden of chronic disease and disability as a result of an aging population; scientific evidence that a great deal of effective and technologically sophisticated care can be delivered at the lower levels of hierarchies; and mounting evidence of the significance of behavioral and environmental risk factors for disease.
Policymakers are addressing these forces in every country in ways that are variations on an international theme. They are flattening hierarchies that had been sacred for almost a century by reallocating resources to primary care and to managing care in communities rather than institutions. They are changing established patterns of authority in the health sector by insisting that hospitals and doctors be accountable to the public for the safety, quality and efficiency of the care they provide. They are demanding that accountability be based on standards and measures that use the methods of a relatively new scientific discipline called evidence-based healthcare research. Policymakers are also according higher priority to preventing or delaying the onset of disease.
Australian policymakers can learn three lessons from international experience:. The first is that Australians should be proud that their country is an international leader in the development of the methods of evidence-based healthcare research and its application to policy and practice. The second is that providing more information to the public about Australia’s international reputation in repairing obsolete policy could help overcome resistance to evidence-based policymaking, especially by pharmaceutical companies. Third, Australian policymakers could explore whether more aggressive policy to address the multiple determinants of health reduces demand for health services.
These comments are based upon a paper delivered by Daniel Fox entitled Changing obsolete health policy: Can countries learn from each other? to a Menzies Centre for Health Policy Seminar, April 5-6, 2006, Sydney on Reforming the Australian Health System: Policy and Politics.