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Employment conditions are important social and commercial determinants of health. Informal employment-also known as 'cash-in-hand' and 'undeclared' work-is a discrete employment condition that has salience around the world. Fuelled by neoliberal ideology, informal employment has become increasingly common in high-income countries. Public health research concerning the health of informal workers comes largely from low- and middle-income countries, where the phenomenon is more visible. There has been little research on the health effects of informal employment in high-income countries including Australia. Twenty-nine workers aged 18 years and older, who were undertaking informal work activities, were recruited using social media and an online marketplace in Tarndanya (Adelaide-Kaurna Country), Australia. Qualitative narrative data, demographic profiles, and physical and mental health scores were collected. Most informal workers reported unfair and indecent employment conditions including job insecurity, low income, coercion, and lack of respect and dignity at work, and were often exposed to unsafe and unhealthy work environments. Workplace injuries and exposure to occupational hazards were common; and Physical and Mental Component Scores were poorer among informal workers when compared to the population of South Australia as a whole. With informal employment in Australia described as part of a 'significant, pervasive, damaging and growing' problem, there is a need for a health promotion lens over industrial relations policies in the interest of creating equitable access to fair and decent work.
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Empleo , Humanos , Femenino , Adulto , Masculino , Australia , Persona de Mediana Edad , Lugar de Trabajo/psicología , Sector Informal , Estado de Salud , Adulto JovenRESUMEN
Carers were disproportionately harmed in the COVID-19 pandemic. Despite facing an increased risk of contracting the virus, they continued in frontline roles in care services and acted as "shock absorbers" for their families and communities. In this article, we apply an intersectional lens to examine care work and the structural factors disadvantaging carers during COVID-19 through a comparative case study analysis of 16 low-, middle-, and high-income countries. Data on each country was collected through a qualitative framework during 2021-2022. We found that while carers everywhere were predominantly women with low incomes and precarious employment, other factors were at play in shaping their experiences. Moreover, government responses to mitigate the direct impact of the pandemic have created local and global disparities affecting those working in this sector. Our findings reveal how oppressive social structures such as race, class, caste, and migration status converged in contextually specific ways to shape the gendered nature of care within and between different countries. We call for a better understanding of the multiple axes of inequalities experienced by carers to inform crisis mitigations, coupled with long-term strategies to address social inequities in the care economy and to promote gender equality.
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BACKGROUND: Concern is growing over the power, influence, and threats to health and equity from the operations of large global consultancy firms. Collectively, these firms support a neoliberal policy environment promoting business interests ahead of public health. Global consultancy firms act as commercial determinants of health, an evolving area of research over recent years. However, this research mainly focuses on specific corporations or industry sectors, especially those which produce harmful products, including ultra-processed food, alcohol, and fossil fuels. It is therefore important to expand the focus to include large global consultancy firms and place a public health and equity lens over their operations. MAIN BODY: Global consultancy firms have wide-ranging conflicts of interest. These arise from the 'revolving door' employment strategies between their own staff and those from government and regulatory bodies. These firms also advise governments on taxation and other matters while concurrently advising corporate clients on ways to minimise taxation. They advise fossil fuel corporations while also advising governments on climate and health policies. These firms undermine the capabilities of the public sector through the outsourcing of traditional public sector roles to these private interests. Consultancy firms foster private interests through their engagement with the higher education sector, and thereby weaken the tradition of transparent management of university affairs by accountable university councils. While private consultancies cannot be blamed for all the negative consequences for health and equity caused by the problems associated with globalisation and advanced capitalism, they have played a role in amplifying them. CONCLUSION: Addressing the negative impacts of global consultancy firms will require strengthening the public sector, enforcing greater transparency, accountability, and minimising conflicts of interest. It will also demand critical thought, counter discourses, and activism to reframe the narratives supporting neo-liberal ideas of governance that are promoted in both government and business arenas.
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Equidad en Salud , Humanos , Salud Global , Consultores , Conflicto de Intereses , Salud PúblicaRESUMEN
ISSUE ADDRESSED: The Australian government's 'Closing the Gap' (CTG) strategy has been implemented via multiple strategies. We examined CTG policy in early childhood within Southern Adelaide during the first decade of implementation (2008-2018) and critiqued the complexity and challenges of policy that is designed to promote health and well-being of Aboriginal and Torres Strait Islander children but lacked Aboriginal control. METHODS: A qualitative case study was conducted in Southern Adelaide, and we interviewed 16 policy actors from health and early childhood education sectors. Thematic analysis revealed key themes to show how policy had been implemented through mainstream structures. RESULTS: The rapid roll out of the CTG strategy, the limitations of short-term funding, cuts to Aboriginal health services, tokenistic consultation, and the mainstreaming of service provision were key features of policy implementation. The influence of Aboriginal leaders varied across implementation contexts. Participants advocated for services in health and education that are culturally safe to improve health of children, families, and communities. CONCLUSIONS: The implementation of the CTG strategy in Southern Adelaide was rushed, complex, and lacking Aboriginal control. This contributed to the marginalisation of Aboriginal leaders, and disengagement of families and communities. A more collaborative and Aboriginal led process for policy implementation is essential to reform policy implementation and address health inequity. SO WHAT?: Findings from this study suggest that policy has continued to be implemented I ways that reflect colonial power imbalances. Alternative processes that promote the recognition of Indigenous rights must be considered if we are to achieve the targets set within the CTG strategy.
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BACKGROUND: Including Aboriginal and Torres Strait Islander people and communities through consultation has been a key feature of policy implementation throughout the Australian Government's "Closing the Gap" (CTG) strategy. However, consultation often reinforces power imbalances between government and local community and can undervalue or marginalise Indigenous knowledge and leadership. Occupational therapy has a short history of examining colonial power structures within the profession, but there has been limited progress to decolonise consultation and practice. METHODS: Drawing on decolonising research methodology and positioned at the interface of knowledge, comparative case studies were used to understand policy implementation in two regions. In Shepparton, Victoria, CTG policy was implemented predominately through an Aboriginal Community Controlled Health Organisation, and in Southern Adelaide, South Australia, CTG policy was implemented through mainstream state government and non-government providers in the absence of a local Aboriginal-controlled organisation. Findings were examined critically to identify implications for occupational therapy. RESULTS: Our case studies showed that policy stakeholders perceived consultation to be tokenistic and partnerships were viewed differently by Aboriginal and non-Indigenous participants. Participants identified the need to move beyond a rhetoric of "working with" Aboriginal and Torres Strait Islander people, to promote Aboriginal leadership and really listen to community so that policy can respond to local need. The findings of this research show that Aboriginal-controlled services are best positioned to conduct and respond to community consultation. CONCLUSION: A decolonising approach to consultation would shift the status quo in policy implementation in ways that realign power away from colonial structures towards collaboration with Indigenous leadership and the promotion of Aboriginal-controlled services. There are lessons for occupational therapy from this research on policy implementation on authentic, decolonised consultation as a key feature of policy implementation. Shifting power imbalances through prioritising Indigenous leadership and honouring what is shared can drive change in CTG policy implementation processes and outcomes.
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Servicios de Salud del Indígena , Terapia Ocupacional , Humanos , Colonialismo , Competencia Cultural , Política de Salud , Servicios de Salud del Indígena/organización & administración , Liderazgo , Terapia Ocupacional/organización & administración , Derivación y Consulta/organización & administración , Australia del Sur , Victoria , Aborigenas Australianos e Isleños del Estrecho de TorresRESUMEN
BACKGROUND: Historically in Australia, all levels of government created collective wealth by owning and operating infrastructure, and managing natural assets, key public goods and essential services while being answerable to the public. This strong state tradition was challenged in the 1980s when privatisation became a widespread government approach globally. Privatisation involves displacing the public sector through modes of financing, ownership, management and product or service delivery. The Australian literature shows that negative effects from privatisation are not spread equitably, and the health and equity impacts appear to be under-researched. This narrative overview aims to address a gap in the literature by answering research questions on what evidence exists for positive and negative outcomes of privatisation; how well societal impacts are evaluated, and the implications for health and equity. METHODS: Database and grey literature were searched by keywords, with inclusion criteria of items limited to Australia, published between 1990 and 2022, relating to any industry or government sector, including an evaluative aspect, or identifying positive or negative aspects from privatisation, contracting out, or outsourcing. Thematic analysis was aided by NVivo qualitative data software and guided by an a-priori coding frame. RESULTS: No items explicitly reflected on the relationship between privatisation and health. Main themes identified were the public cost of privatisation, loss of government control and expertise, lack of accountability and transparency, constraints to accessing social determinants of health, and benefits accruing to the private sector. DISCUSSION: Our results supported the view that privatisation is more than asset-stripping the public sector. It is a comprehensive strategy for restructuring public services in the interests of capital, with privatisation therefore both a political and commercial determinant of health. There is growing discussion on the need for re-nationalisation of certain public assets, including by the Victorian government. CONCLUSION: Privatisation of public services is likely to have had an adverse impact on population health and contributed to the increase in inequities. This review suggests that there is little evidence for the benefits of privatisation, with a need for greater attention to political and commercial determinants of health in policy formation and in research.
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Propiedad , Privatización , Humanos , Australia , Sector Privado , GobiernoRESUMEN
Health services research is underpinned by partnerships between researchers and health services. Partnership-based research is increasingly needed to deal with the uncertainty of global pandemics, climate change induced severe weather events, and other disruptions. To date there is very little data on what has happened to health services research during the COVID-19 pandemic. This paper describes the establishment of an Australian multistate Decolonising Practice research project and charts its adaptation in the face of disruptions. The project used cooperative inquiry method, where partner health services contribute as coresearchers. When the COVID-19 pandemic hit, data collection needed to be immediately paused, and when restrictions started to lift, all research plans had to be renegotiated with services. Adapting the research surfaced health service, university, and staffing considerations. Our experience suggests that cooperative inquiry was invaluable in successfully navigating this uncertainty and negotiating the continuance of the research. Flexible, participatory methods such as cooperative inquiry will continue to be vital for successful health services research predicated on partnerships between researchers and health services into the future. They are also crucial for understanding local context and health services priorities and ways of working, and for decolonising Indigenous health research.
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Aborigenas Australianos e Isleños del Estrecho de Torres , COVID-19 , Humanos , Australia/epidemiología , Pandemias , Investigación sobre Servicios de Salud , COVID-19/epidemiologíaRESUMEN
BACKGROUND: Meso-level, regional primary health care organisations such as Australia's Primary Health Networks (PHNs) are well placed to address health inequities through comprehensive primary health care approaches. This study aimed to examine the equity actions of PHNs and identify factors that hinder or enable the equity-orientation of PHNs' activities. METHODS: Analysis of all 31 PHNs' public planning documents. Case studies with a sample of five PHNs, drawing on 29 original interviews with key stakeholders, secondary analysis of 38 prior interviews, and analysis of 30 internal planning guidance documents. This study employed an existing framework to examine equity actions. RESULTS: PHNs displayed clear intentions and goals for health equity and collected considerable evidence of health inequities. However, their planned activities were largely restricted to individualistic clinical and behavioural approaches, with little to facilitate access to other health and social services, or act on the broader social determinants of health. PHNs' equity-oriented planning was enabled by organisational values for equity, evidence of local health inequities, and engagement with local stakeholders. Equity-oriented planning was hindered by federal government constraints and lack of equity-oriented prompts in the planning process. CONCLUSIONS: PHNs' equity actions were limited. To optimise regional planning for health equity, primary health care organisations need autonomy and scope to act on the 'upstream' factors that contribute to local health issues. They also need sufficient time and resources for robust, systematic planning processes that incorporate mechanisms such as procedure guides and tools/templates, to capitalise on their local evidence to address health inequities. Organisations should engage meaningfully with local communities and service providers, to ensure approaches are equity sensitive and appropriately targeted.
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Equidad en Salud , Planificación en Salud , Humanos , Atención Primaria de Salud , Inequidades en Salud , AustraliaRESUMEN
BACKGROUND: Public health scholarship has uncovered a wide range of strategies used by industry actors to promote their products and influence government regulation. Less is known about the strategies used by non-government organisations to attempt to influence commercial practices. This narrative review applies a political science typology to identify a suite of 'inside' and 'outside' strategies used by NGOs to attempt to influence the commercial determinants of health. METHODS: We conducted a systematic search in Web of Science, ProQuest and Scopus. Articles were eligible for inclusion if they comprised an empirical study, explicitly sought to examine 'NGOs', were in English, and identified at least one NGO strategy aimed at commercial and/or government policy and practice. RESULTS: One hundred forty-four studies met the inclusion criteria. Eight industry sectors were identified: extractive, tobacco, food, alcohol, pharmaceuticals, weapons, textiles and asbestos, and a small number of general studies. We identified 18 types of NGO strategies, categorised according to the target (i.e. commercial actor or government actor) and type of interaction with the target (i.e. inside or outside). Of these, five NGO 'inside' strategies targeted commercial actors directly: 1) participation in partnerships and multistakeholder initiatives; 2) private meetings and roundtables; 3) engaging with company AGMs and shareholders; 4) collaborations other than partnerships; and 5) litigation. 'Outside' strategies targeting commercial actors through the mobilisation of public opinion included 1) monitoring and reporting; 2) protests at industry sites; 3) boycotts; 4) directly engaging the public; and 5) creative use of alternative spaces. Four NGO 'inside' strategies directly targeting government actors included: 1) lobbying; 2) drafting legislation, policies and standards; 3) providing technical support and training; and 4) litigation. NGO 'outside' strategies targeting government included 1) protests and public campaigns; 2) monitoring and reporting; 3) forum shifting; and 4) proposing and initiating alternative solutions. We identified three types of NGO impact: substantive, procedural, and normative. CONCLUSION: The analysis presents a matrix of NGO strategies used to target commercial and government actors across a range of industry sectors. This framework can be used to guide examination of which NGO strategies are effective and appropriate, and which conditions enable NGO influence.
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Gobierno , Política , Humanos , Salud PúblicaRESUMEN
Logic modelling is used widely in health promotion planning for complex health and social problems. It is often undertaken collaboratively with stakeholders across sectors that hold and enact different institutional approaches. We use hermeneutic philosophy to explore how knowledge is 'lived' by - and unfolds differently for - cross-sectoral stakeholders during comprehensive primary healthcare service planning. An Organisational Action Research partnership was established with a non-government organisation designing comprehensive primary health care for individuals experiencing homelessness in Adelaide, Australia. Grey literature, stakeholder input, academic feedback, a targeted literature review and evidence synthesis were integrated in iterative cycles to inform and refine the logic model. Diverse knowledge systems are active when cross-sectoral stakeholders collaborate on logic models for comprehensive primary health care planning. Considering logic modelling as a hermeneutic praxis helps to foreground and explore these differences. In our case, divergent ideas emerged in how health/wellbeing and trust were conceptualised; language had different meanings across sectors; and the outcomes and data sought were nuanced for various collaborators. We explicate these methodological insights and also contribute our evidence-informed, collaboratively-derived model for design of a comprehensive primary health care service with populations experiencing homelessness. We outline the value of considering cross-sectoral logic modelling as hermeneutic praxis. Engaging with points of difference in cross-sectoral knowledge systems can strengthen logic modelling processes, partnerships and potential outcomes for complex and comprehensive primary health care services.
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BACKGROUND: Evidence-informed primary health care (PHC) planning in decentralised, meso-level regional organisations has received little research attention. In this paper we examine the factors that influence planning within this environment, and present a conceptual framework. METHODS: We employed mixed methods: case studies of five Australian Primary Health Networks (PHNs), involving 29 primary interviews and secondary analysis of 38 prior interviews; and analysis of planning documents from all 31 PHNs. The analysis was informed by a WHO framework of evidence-informed policy-making, and institutional theory. RESULTS: Influential actors included federal and state/territory governments, Local Health Networks, Aboriginal Community Controlled Health Organisations, local councils, public hospitals, community health services, and providers of allied health, mental health and aged care services. The federal government was most influential, constraining PHNs' planning scope, time and funding. Other external factors included: the health service landscape; local socio-demographic and geographic characteristics; (neoliberal) ideology; interests and politics; national policy settings and reforms; and system reorganisation. Internal factors included: organisational structure; culture, values and ideology; various capacity factors; planning processes; transition history; and experience. The additional regional layer of context adds to the complexity of planning. CONCLUSIONS: Like national health policy-making, meso-level PHC planning occurs in a complex environment, but with additional regional factors and influences. We have developed a conceptual framework of the meso-level PHC planning environment, which can be employed by similar regional organisations to elucidate influential factors, and develop strategies and tools to promote transparent, evidence-informed PHC planning for better health outcomes.
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Administración de los Servicios de Salud , Atención Primaria de Salud , Humanos , Anciano , Australia , Planificación en Salud , Servicios de Salud ComunitariaAsunto(s)
Equidad en Salud , Humanos , Políticas , Cobertura Universal del Seguro de Salud , Política de SaludRESUMEN
BACKGROUND: This paper considers energy as a social and commercial determinant of health. Stable access to clean and sustainable energy is integral for human wellbeing yet public health rarely considers its importance. METHODS: Using NVivo qualitative analysis software we analysed all Australian federal, state and territory strategic energy policies covering varying periods between 2016-2030. We defined strategic policy as including the goals, objectives and strategies of the department regarding a specific area of policy responsibility. This criterion excluded documents such as operational guidelines. 36 energy-related policies were analyzed. RESULTS: While the nature of energy supply is crucial to determining the impact of human and environmental health, our analysis showed that health and wellbeing are only rarely considered in policy. We developed a conceptual framework to guide our work linking energy policy with health. Australia's continued reliance on fossil fuels evident in the policies poses health risks, especially as climate change threatens physical and mental health. Yet health considerations were mainly absent from the policies. However, some jurisdictions (South Australia and the Australian Capital Territory [ACT]) had policies encouraging a fast move to renewables. Energy pricing was a key focus in each jurisdiction and had become highly politicalized in the past decade. Little attention was paid to equity considerations in the policies. CONCLUSION: Energy policy would be more health promoting if public health perspectives were considered during its development. On the basis of our policy analysis and literature review we conclude with recommendations for healthy energy policy.
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Estado de Salud , Política Pública , Humanos , Australia , Política de Salud , Investigación Cualitativa , Australia del SurRESUMEN
Previous research on commercial determinants of health has primarily focused on their impact on non-communicable diseases. However, they also impact on infectious diseases and on the broader preconditions for health. We describe, through case studies in 16 countries, how commercial determinants of health were visible during the COVID-19 pandemic, and how they may have influenced national responses and health outcomes. We use a comparative qualitative case study design in selected low- middle- and high-income countries that performed differently in COVID-19 health outcomes, and for which we had country experts to lead local analysis. We created a data collection framework and developed detailed case studies, including extensive grey and peer-reviewed literature. Themes were identified and explored using iterative rapid literature reviews. We found evidence of the influence of commercial determinants of health in the spread of COVID-19. This occurred through working conditions that exacerbated spread, including precarious, low-paid employment, use of migrant workers, procurement practices that limited the availability of protective goods and services such as personal protective equipment, and commercial actors lobbying against public health measures. Commercial determinants also influenced health outcomes by influencing vaccine availability and the health system response to COVID-19. Our findings contribute to determining the appropriate role of governments in governing for health, wellbeing, and equity, and regulating and addressing negative commercial determinants of health.