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Healthy children, healthy country: the use of governing instruments in shifting the policy paradigm

Healthy children, healthy country: the use of governing instruments in shifting the policy paradigm The evidence on early childhood strongly suggests the need to shift child health policy from the current focus on social welfare to a socio-ecologically based approach. This paper reviews three governing instruments, exhortation, expenditure and regulation, that have been used by governments in Australia and discusses the relative effectiveness of these approaches in shifting the child health policy paradigm. lute or relative terms, has a negative effect on children's The evidence for healthy public policy for health [8,9]. In particular, poverty is associated with children There can be no keener revelation of a society's soul than developmental delay, poor school achievement and the way it treats its children [1]. employment futures, behaviour problems, increased inci- dence of chronic illness, visual and hearing defects and Research evidence has demonstrated that the experiences dental problems [10]. Parental poverty and exposure to of early childhood can have a profound lifelong impact unhealthy environments (eg smoking; low levels of liter- on a child's health, wellbeing and competence [2]. The acy; nutrition; emotional support) reduce a child's life importance of the early years of life in influencing future chances. Studies in neurobiology, neurodevelopment and outcomes, such as crime, obesity, heart disease, mental early intervention show that the time period from concep- health problems and poor school outcomes has been tion to school age is a critically important time for brain identified and highlighted [3]. While there are many fac- development, setting the scene for prevention of some of tors found to influence rising crime rates, various the identified adverse outcomes through early identifica- researchers have identified children with manifested tion and intervention [11]. behaviour disorders in early childhood [4], academic dif- ficulties and non-engagement in schooling [5], and the Consistent with the increasing evidence, many govern- quality of neighbourhood supervision and support as ments have identified support in early childhood as a life- contributing factors to criminal behaviour [6]. long determinant of health, wellbeing and competence, as a matter for policy development, initiating actions to Education, literacy and other social determinants of ensure comprehensive child development strategies for health can influence the coping skills of children, which their societies. This approach requires a whole of govern- provide the basis of learning, behaviour and health ment response, integrating health, welfare, education and throughout life [7]. Poverty, whether measured in abso- other relevant parts of government. The evidence suggests Page 1 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:4 http://www.anzhealthpolicy.com/content/1/1/4 that healthy public policy for infants, children and their  The National Health Policy for Children and Young People parents is dependent on understanding of the socio-eco- (1995) and associated Implementation Plan (1996) logical factors supported by integrated, multidisciplinary and intersectoral policy and programs.  The National Health Policy for Young Australians (1997). In Canada, Britain and the United States, targeted inter- These documents provided broad national goals for chil- ventions in the antenatal period, infancy and childhood, dren and young people: including parenting skills programs, are recognized for their potential to support healthier families. A socio-eco-  Reducing preventable premature mortality logical model of health is increasingly perceived to be the most appropriate approach for the early years of life  Reducing the impact of disability agenda. Consistent with this approach, the United King- dom program 'Sure Start', has been positively reviewed by  Reducing the incidence of vaccine preventable disease the UK Audit Office and is considered by many to be the standard for the whole of government approach [12]. In  Reducing the impact of conditions occurring in adult- addition, a recently released ten year plan is attempting to hood with their origins or early manifestation in child- significantly change the way in which children are treated hood or adolescence throughout UK systems [13].  Enhancing family and social functioning The Canadian experience is widely quoted as best practice [2], with both federal and provincial investment in early Although the evidence supporting a broader definition of childhood (See, for example [14-16]). In the US, during child health was strong, the focus of these National the Presidents' Summit for America's Future held in April Health Goals and Targets remained heavily focused 1997, Presidents Bill Clinton, George Bush, Jimmy Carter towards surveillance and the reduction of injury and ill- and Gerald Ford and First Lady Nancy Reagan stressed the ness, perhaps reflecting a comfort with current and past importance of early childhood, calling the nation to approaches. action. American policy in this area has built upon influ- ential reports that have led to investment in early child- To date there has been little evidence of an integrated, hood in most states [12]. multidisciplinary approach to child health at the national level. The 2003/04 federal budget did not provide the The adoption of healthy public policy for children based broad whole of government approach recommended for on this socio-ecological framework has been inconsistent child health, with only a few targeted interventions, such throughout Australia. In an attempt to explore these as the National Meningococcal C Campaign, and a much inconsistencies, this paper reviews the use of three govern- greater focus on the health needs of the aging population. ing instruments, that is exhortation, expenditure and reg- In 2003, the Australian of the year, Fiona Stanley sug- ulation, by national and state governments in Australia. gested that the social and economic policies of the Gov- Governing instruments are the major mechanisms gov- ernment were not effective in tackling the issues ernments use to seek compliance, support and implemen- associated with ensuring healthy children and young peo- tation of public policy. Governing instruments range from ple [18]. minimum coercion by exhortation, through expenditure, taxation, regulation, to maximum coercion through pub- The platform for a paradigm shift was established in 2001 lic ownership [17]. The following sections describe the with the appointment of the Minister for Children and impact of the use of exhortation, expenditure and regula- Youth Affairs and the subsequent statement in 2002 of the tion on the implementation of healthy child policy. intent to develop a National Agenda for Early Childhood. The consultation paper Towards the Development of a Consensus building – exhortation as the national National Agenda for Early Childhood signaled a changing instrument of choice paradigm, with a whole of child and life course approach During the 1990s the Australian Government identified addressing promotion, prevention and early intervention the health of children and young people as a key policy for all children. area, with a series of policy documents: The last years have seen the creation of ever more advisory • The National Health Goals and Targets for Australian Chil- groups, partnerships and inquiries with a mandate to dren and Youth (1992) influence child health policy. The Child and Youth Health Intergovernmental Partnership (under the auspice of the Australian Health Ministers' Advisory Council) was con- Page 2 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:4 http://www.anzhealthpolicy.com/content/1/1/4 vened in December 2001 to develop a national child pub- from government, but also to it [21]. The strong use of lic health strategy and advise on the National Agenda for exhortation at the national level may be seen as the only Early Childhood. Their draft strategy framework Better way to encourage change, given the shared responsibility Child Public Health: A Strategic Approach to Building Capac- for child welfare among the various levels of government ity – A National Action Plan 2004–2007 has been devel- in Australia. Yet it is precisely this divided accountability oped and is being used in consultation and capacity and responsibility that has been identified 'as the greatest building initiatives. In October 2002 the Minister for barrier to the reform of children's services' [[22] pg. 980]. Children and Youth Affairs referred an inquiry into improving children's health and well being to the Stand- The use of exhortation may be successful at motivating ing Committee on Family and Community Affairs. The common approaches but will be much less effective at Australian Council for Children and Parenting (ACCAP), ensuring the sustaining structures are developed. This is an advisory body to the Minister for Children and Youth apparent in the existing committee structures, which still Affairs, was granted a two year term from July 2003, with operate from within the government structures and are a focus on strategic advice in the areas of early childhood thus unable to cross the 'silos' to promote the needed intervention and prevention, parenting and child protec- whole-of-government approach. To be effective in chang- tion, foster care and emerging early childhood initiatives, ing the paradigm in this area, the exhortation process will including advising about the continuing development of require back up by more coercive governing instruments. the National Agenda for Early Childhood. Conflicting expenditures – potential for As described above, the policy approach at the national uncertain outcomes in Victoria level has focused almost entirely on exhortation, the least In comparison with other Australian states, Victoria has coercive instrument, where support and compliance are been slow to provide visible translation of the socio-eco- sought voluntarily through persuasion and discussion. In logical model of health for children and young people in comparison with other countries, such as Britain and Can- a coordinated and systematic way to state policy. A recent ada, the lack of a common and shared understanding of review of Victorian paediatric services suggested that Vic- the socio-ecologic approach and its implications has toria needed to establish a child and young people focus made it difficult to show any significant advances in this ensuring appropriate mechanisms to plan, coordinate and area. In fact, the recent demise of the Child Health Unit monitor across government departments and service pro- within the Australian Government Department of Health viders [23]. It was suggested that a structure was required suggests less focus on child health. to coordinate child health among of the various portfolios in the Victorian Department of Human Services – Health, Nationally, child health has not been heavily addressed Housing, Welfare, and Disability – as well as among the through other policy instruments, such as expenditure, broader Government departments, contributing to the taxation, or regulation, although more recently the Com- whole of government approach required for early child- monwealth Government Department of Family and Com- hood intervention programs. munity Services (DFaCS) established the 'Communities for Children' initiative as part of the Stronger Families and The lack of coordinated focus on child health in Victoria Communities Strategy. Communities for Children will is perhaps the result of a lingering policy focus on health directly fund 35 Australian communities between $1 and surveillance. Despite the increasing evidence that surveil- 4 million over four years to support parents, neighbour- lance and screening programs have limited effectiveness hoods and the wider community to give children the in child health [24,25], it is only recently that Victoria has healthy start they need [19]. Importantly, there was little increased the focus on the social determinants of health evidence of a community development or even a consult- [26,27]. Most recently, Victoria has committed to the 'Best ative approach in the implementation of this program, Start' program and will pilot it as demonstration projects with the perception that Communities for Children has not in 10 communities across the State with an investment of been set up to respond to the greatest need. $7.6 million. Best Start is auspiced by the Departments of Human Services and Education and Training and is It has been suggested that system change can be accom- focused on reducing the impact of disadvantage (from any plished by motivating institutions, systems and actors to cause) and enhancing the life chances of all children by move in common directions and develop structures that strengthening the universal preventative system [28]. The sustain these efforts over time [20]. This requires a high aims of Best Start are multi-level including the social, emo- level of trust among the participants, such that they even- tional and physical well-being of children, capacity build- tually share common goals and voluntarily seek to ing of parents and carers and communities to assist them achieve common ends. Success in using exhortation as a to become more child friendly, while focusing on specific policy instrument requires that information not only flow interventions for socially disadvantaged families [29]. The Page 3 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:4 http://www.anzhealthpolicy.com/content/1/1/4 demonstration projects are required to follow a prescribed Young People focuses on increasing the participation of implementation and evaluation process attempting to children and young people in decision making that affects measure what works, under what circumstances and for their lives, promoting the safety and welfare of children whom, to ultimately improve services elsewhere in the and young people, and strengthening the important rela- State. Five approved demonstration sites with a total of tionships in the lives of children and young people and $7.6 million are ensuring a 'brighter future' for the chil- improving their well-being [32]. dren of Frankston, Hume, Shepparton, Whittlesea and Yarra Ranges, while the rest of the State's children wait in The implementation of Families First has been guided by a the dark. series of policy and practice guidelines. Recently, an inde- pendent review of Families First implementation within Despite the intentions of Best Start, existing government three regions, (Orana Far West, Illawarra and South West funding and reporting in the area of maternal and child Sydney) found that the system changes required to build health is still largely focused on surveillance [26]. The Vic- and strengthen service networks for families needed more torian approach to policy implementation in the area of than agreement and goodwill, with considerable effort to early childhood support is focused predominantly on develop structures and processes that sustain interagency expenditure. Public expenditure is moderately coercive, collaboration [33]. This resulted in a further guide to with distribution of government funds to achieve particu- implementing sustainable and effective child and family lar policy objectives. But the small expenditure allocated service networks. to 'healthy' child policy that is limited to identified dem- onstration sites with expectations that the program will be Regulation involves the imposition of requirements to shown to be effective before statewide mainstream imple- meet specific obligations. Often regulation is seen to exist mentation is overshadowed by a much larger expenditure within legislation outlining strict rules of behaviour. pool that is not focused on the socio-ecological model. However, in health policy guidelines are considered effec- While Best Start signals intent to change the child health tive means of imposing regulation, recognising the inher- policy paradigm, the incentives established through the ent uncertainty in safe practice in health care [17]. The broader expenditure pool suggest, for the moment, main- implementation of 'healthy' child policy in NSW suggests tenance of the status quo in Victoria. a strong focus on the socio-ecological approach supported by the research evidence. This is apparent in the whole of government approach with leadership from the Premier's Guidelines – will enforcement back the regulatory approach in NSW? Office, backed by regulation to effect the necessary In New South Wales the 'Families First' initiative targets changes in the delivery system. families with children 0 to 8 years, with the aim of helping parents give their children a good start in life. Demon- However, it is yet to be seen whether the policy will be strating the commitment to a whole of government supported with the necessary resources for compliance. approach, the Office of Children and Young People While regulation involves shifting costs of compliance (OCYP), located within The Cabinet Office, reporting from government to other participants, enforcement and directly to the Premier, has played a lead role in the devel- monitoring can be expensive and difficult [21]. Without opment and implementation of the Families First strategy. adequate enforcement the potential for inequality and This evidence-based approach is delivered jointly by five inequity in access to the proposed service model is high. NSW government agencies – Area Health Services, Com- munity Services, Education and Training, Housing and Conclusions Disability, Ageing and Home Care in partnership with A variety of instruments have been used by government to parents, community organisations and local government. change the child health policy paradigm from that NSW Health supports 'the ongoing development of part- focused on social welfare to 'healthy' public policy predi- nerships at policy, planning and service delivery levels to cated on a socio-ecological foundation. NSW has chosen enable improved co-ordination and intersectoral collabo- regulation to implement a child health policy framework ration in the delivery of child health services' [[30] pg. 44]. that is built upon the international evidence of the effec- tiveness of integrated, multidisciplinary and intersectoral NSW has also successfully translated much of the evidence policy and programs. A little slower to change paradigms, into coordinated service planning and delivery at the Victoria has established demonstration programs through regional level. Paediatric networks, associated with the targeted expenditure, without an overarching whole-of- Area Health Services, were established in 1997 and today government child health policy framework. Nationally, provide designated primary, secondary and tertiary level there is a move to change the paradigm to a broader defi- services for families with children aged 0 to 5 years [31]. nition of child health almost exclusively through exhorta- In addition, the NSW Commission for Children and tion. Page 4 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:4 http://www.anzhealthpolicy.com/content/1/1/4 2. Hertzman C: An Early Child Development Strategy for Aus- Instrument choice is influenced by a variety of factors. The tralia? Lessons from Canada. Brisbane, Commission for Children use of exhortation by the Commonwealth Government is & Young People, Queensland Government; 2002. a relatively risk-free easy approach, which can counteract 3. Tremblay RE: When Children's Social Development Fails. Toronto, The Canadian Institute for Advanced Research; 1998. the divided accountabilities among federal and state gov- 4. Tremblay RE: The development of aggressive behaviour dur- ernments in the area of health and social services. Exhor- ing childhood: what have we learned in the past century? International Journal of Behavioural Development 2000, 24:129-141. tation is easy to implement; it is the least coercive and 5. Vimpani G: Refashioning child and family health services in relies on voluntary goodwill. While it may be successful in response to family, social and political change. Australian Health building a common understanding, and even this is Review 2004, 27:13-16. 6. Weatherburn D, Lind B: Delinquent-Prone Communities. Cam- debatable, an independent review of the Families First bridge, Cambridge University Press; 2001. implementation found that the system changes required 7. Power C, Hertzman C: Health, Well-Being and Coping Skills. to build and strengthen service networks for families Toronto, The Canadian Institute for Advanced Research; 1998. 8. Duncan GJ, Yeung WJ, Brooks-Gunn J, Smith J: How Much Does needed more than agreement and goodwill to develop the Childhood Poverty Affect the Life Chances of Children? necessary structures and processes – a suggestion that Toronto, The Canadian Institute for Advanced Research; 1997. 9. Caspi A, Taylor A, Moffitt TE, Plomin R: Neighborhood depriva- without other approaches to structural reform, exhorta- tion affects children's mental health: environmental risks tion is unlikely to be successful. identified in a genetic design. Psychological Science 2000, 11:338-342. 10. McClelland A: No Child: Child Poverty in Australia. , Brother- The expenditure policy of Victoria illustrates an approach hood of St. Laurence; 2000. that is compromised by the lack of an underlying agreed 11. Cynader M, Frost B: Mechanisms of Brain Development: Neu- ronal Sculpting by the Physical and Social Environment. evidence-based policy framework. This lack of coordi- Toronto, The Canadian Institute for Advanced Research; 1998. nated government approach is reflected in conflicting 12. Oberklaid F: Notes from Australia. The early childhood expenditure policy in this area, with the potential to con- agenda in Australia. Archives of Disease in Childhood 2004, 89:830. 13. Godfrey K: Framework for children aims to produce "cultural found outcomes. change". British Medical Journal 2004, 329:699. 14. Young B, Malley B: Making children a priority: Saskatchewan While the regulatory approach of NSW suggests bold steps listens. Early learning and care discussion forums 2004. Regina, Saskatchewan. Department of Community Resources and to change the paradigm, in fact, because regulation is not Employment; 2004. subjected to the same level of scrutiny of other instru- 15. Liberal Party of Canada: Foundations: A National Early Learn- ing and Child Care Program. Ottawa, Liberal Party of Canada; ments, such as expenditure, and even exhortation [17], it is a deceptively simple mechanism to implement policy 16. Panel on the Role of Government in Ontario: Investing in people. [21]. The strength of the government intent to change the Creating a human capital society for Ontario. Toronto, Gov- ernment of Ontario; 2004. paradigm will only become apparent with visible enforc- 17. Doern GB, Phidd RW: Canadian Public Policy. Ideas, Structure, ing of the service delivery directions. Process. Toronto, Methuen Publications; 1983. 18. Stanley F: Before the Bough Breaks. Doing More for our Chil- dren in the 21st Century.: ; Canberra. Academy of Social Sci- The evidence for a new policy paradigm is strong. But the ences in Australia; 2003. use of these different policy instruments underscores the 19. Department of Family and Community Services (Australia): Stronger Families and Communities Strategy. 2004. lack of shared understanding and policy agenda. Oberk- 20. Mechanic D: Improving the quality of health care in the United laid suggests that while there are similarities in the rheto- States of America: the need for a multi-level approach. J ric throughout Australia, there has been relatively little Health Serv Res Policy 2002, 7:Suppl1:S5-9. 21. Deber R, Topp A, Zakas D: Private Delivery and Public Goals: investment in child health [12]. The change in the child Mechanisms for Ensuring that Hospitals Meet Public Objec- health public policy paradigm will only be successful tives. , Background Paper prepared for the World Bank; 2004. when the governing instrument or combination of instru- 22. Oberklaid F: Child advocacy and the Queen's representative: an unlikely link. Archives of Disease in Childhood 2003, 88:980. ments induces the appropriate public and private behav- 23. La Trobe University Health Management Group: Review of Victo- iour. Perhaps we should be thankful that child health rian Paediatric Services. Melbourne, La Trobe University; 2002. 24. National Health and Medical Research Council: Child Health Sur- policy is on the agenda, and even without a strong, coor- veillance and Screening: A Critical Review of the Evidence. dinated approach built on the evidence, one would agree Canberra, ; 2002. that 'these developments in early childhood services dem- 25. Centre for Community Child Health: A Review of the Early Child- hood Literature. In Prepared for the department of Family and Com- onstrate the translation of research evidence into policy munity Services as a background paper for the National Families Strategy and practice, even if the implementation may be flawed, Melbourne, ; 2000. 26. Keleher KJ, Reiger K: Tensions in maternal and child health pol- belated or under-resourced' [[5] pg.15]. icy in Victoria: looking back, looking forward. Australian Health Review 2004, 27:17-26. Competing interests 27. Community Services Victoria: Child Health Surveillance Paper. Melbourne, Victorian Department of Community Services; 1992. The authors declare that they have no competing interests. 28. Ochiltree G, Moore T, McLoughlin J: Best Start Evidence Base Summary. Melbourne, Victorian Government; 2001. 29. Department of Human Services: Best Start website. [http:// References www.beststart.vic.gov.au]. 1. Mandela N: Speech by President Mandela: ; Pretoria. ; 1995. 30. NSW Health: The Start of Good Health. Improving the Health of Children in NSW. Sydney, ; 1999. Page 5 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:4 http://www.anzhealthpolicy.com/content/1/1/4 31. NSW Health Department: Building a New Network of Paediat- ric Services for NSW. Sydney, NSW Government; 1995:1-16. 32. NSW Commission for Children and Young People: What we're doing. [http://www.kids.nsw.gov.au/ourwork/]. 33. NSW Health: Families First. [http://www.familiesfirst.nsw.gov.au/ public/s26_homepage/]. Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." 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Healthy children, healthy country: the use of governing instruments in shifting the policy paradigm

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Springer Journals
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Copyright © 2004 by Leggat; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Public Health; Social Policy
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1743-8462
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1743-8462
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10.1186/1743-8462-1-4
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Abstract

The evidence on early childhood strongly suggests the need to shift child health policy from the current focus on social welfare to a socio-ecologically based approach. This paper reviews three governing instruments, exhortation, expenditure and regulation, that have been used by governments in Australia and discusses the relative effectiveness of these approaches in shifting the child health policy paradigm. lute or relative terms, has a negative effect on children's The evidence for healthy public policy for health [8,9]. In particular, poverty is associated with children There can be no keener revelation of a society's soul than developmental delay, poor school achievement and the way it treats its children [1]. employment futures, behaviour problems, increased inci- dence of chronic illness, visual and hearing defects and Research evidence has demonstrated that the experiences dental problems [10]. Parental poverty and exposure to of early childhood can have a profound lifelong impact unhealthy environments (eg smoking; low levels of liter- on a child's health, wellbeing and competence [2]. The acy; nutrition; emotional support) reduce a child's life importance of the early years of life in influencing future chances. Studies in neurobiology, neurodevelopment and outcomes, such as crime, obesity, heart disease, mental early intervention show that the time period from concep- health problems and poor school outcomes has been tion to school age is a critically important time for brain identified and highlighted [3]. While there are many fac- development, setting the scene for prevention of some of tors found to influence rising crime rates, various the identified adverse outcomes through early identifica- researchers have identified children with manifested tion and intervention [11]. behaviour disorders in early childhood [4], academic dif- ficulties and non-engagement in schooling [5], and the Consistent with the increasing evidence, many govern- quality of neighbourhood supervision and support as ments have identified support in early childhood as a life- contributing factors to criminal behaviour [6]. long determinant of health, wellbeing and competence, as a matter for policy development, initiating actions to Education, literacy and other social determinants of ensure comprehensive child development strategies for health can influence the coping skills of children, which their societies. This approach requires a whole of govern- provide the basis of learning, behaviour and health ment response, integrating health, welfare, education and throughout life [7]. Poverty, whether measured in abso- other relevant parts of government. The evidence suggests Page 1 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:4 http://www.anzhealthpolicy.com/content/1/1/4 that healthy public policy for infants, children and their  The National Health Policy for Children and Young People parents is dependent on understanding of the socio-eco- (1995) and associated Implementation Plan (1996) logical factors supported by integrated, multidisciplinary and intersectoral policy and programs.  The National Health Policy for Young Australians (1997). In Canada, Britain and the United States, targeted inter- These documents provided broad national goals for chil- ventions in the antenatal period, infancy and childhood, dren and young people: including parenting skills programs, are recognized for their potential to support healthier families. A socio-eco-  Reducing preventable premature mortality logical model of health is increasingly perceived to be the most appropriate approach for the early years of life  Reducing the impact of disability agenda. Consistent with this approach, the United King- dom program 'Sure Start', has been positively reviewed by  Reducing the incidence of vaccine preventable disease the UK Audit Office and is considered by many to be the standard for the whole of government approach [12]. In  Reducing the impact of conditions occurring in adult- addition, a recently released ten year plan is attempting to hood with their origins or early manifestation in child- significantly change the way in which children are treated hood or adolescence throughout UK systems [13].  Enhancing family and social functioning The Canadian experience is widely quoted as best practice [2], with both federal and provincial investment in early Although the evidence supporting a broader definition of childhood (See, for example [14-16]). In the US, during child health was strong, the focus of these National the Presidents' Summit for America's Future held in April Health Goals and Targets remained heavily focused 1997, Presidents Bill Clinton, George Bush, Jimmy Carter towards surveillance and the reduction of injury and ill- and Gerald Ford and First Lady Nancy Reagan stressed the ness, perhaps reflecting a comfort with current and past importance of early childhood, calling the nation to approaches. action. American policy in this area has built upon influ- ential reports that have led to investment in early child- To date there has been little evidence of an integrated, hood in most states [12]. multidisciplinary approach to child health at the national level. The 2003/04 federal budget did not provide the The adoption of healthy public policy for children based broad whole of government approach recommended for on this socio-ecological framework has been inconsistent child health, with only a few targeted interventions, such throughout Australia. In an attempt to explore these as the National Meningococcal C Campaign, and a much inconsistencies, this paper reviews the use of three govern- greater focus on the health needs of the aging population. ing instruments, that is exhortation, expenditure and reg- In 2003, the Australian of the year, Fiona Stanley sug- ulation, by national and state governments in Australia. gested that the social and economic policies of the Gov- Governing instruments are the major mechanisms gov- ernment were not effective in tackling the issues ernments use to seek compliance, support and implemen- associated with ensuring healthy children and young peo- tation of public policy. Governing instruments range from ple [18]. minimum coercion by exhortation, through expenditure, taxation, regulation, to maximum coercion through pub- The platform for a paradigm shift was established in 2001 lic ownership [17]. The following sections describe the with the appointment of the Minister for Children and impact of the use of exhortation, expenditure and regula- Youth Affairs and the subsequent statement in 2002 of the tion on the implementation of healthy child policy. intent to develop a National Agenda for Early Childhood. The consultation paper Towards the Development of a Consensus building – exhortation as the national National Agenda for Early Childhood signaled a changing instrument of choice paradigm, with a whole of child and life course approach During the 1990s the Australian Government identified addressing promotion, prevention and early intervention the health of children and young people as a key policy for all children. area, with a series of policy documents: The last years have seen the creation of ever more advisory • The National Health Goals and Targets for Australian Chil- groups, partnerships and inquiries with a mandate to dren and Youth (1992) influence child health policy. The Child and Youth Health Intergovernmental Partnership (under the auspice of the Australian Health Ministers' Advisory Council) was con- Page 2 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:4 http://www.anzhealthpolicy.com/content/1/1/4 vened in December 2001 to develop a national child pub- from government, but also to it [21]. The strong use of lic health strategy and advise on the National Agenda for exhortation at the national level may be seen as the only Early Childhood. Their draft strategy framework Better way to encourage change, given the shared responsibility Child Public Health: A Strategic Approach to Building Capac- for child welfare among the various levels of government ity – A National Action Plan 2004–2007 has been devel- in Australia. Yet it is precisely this divided accountability oped and is being used in consultation and capacity and responsibility that has been identified 'as the greatest building initiatives. In October 2002 the Minister for barrier to the reform of children's services' [[22] pg. 980]. Children and Youth Affairs referred an inquiry into improving children's health and well being to the Stand- The use of exhortation may be successful at motivating ing Committee on Family and Community Affairs. The common approaches but will be much less effective at Australian Council for Children and Parenting (ACCAP), ensuring the sustaining structures are developed. This is an advisory body to the Minister for Children and Youth apparent in the existing committee structures, which still Affairs, was granted a two year term from July 2003, with operate from within the government structures and are a focus on strategic advice in the areas of early childhood thus unable to cross the 'silos' to promote the needed intervention and prevention, parenting and child protec- whole-of-government approach. To be effective in chang- tion, foster care and emerging early childhood initiatives, ing the paradigm in this area, the exhortation process will including advising about the continuing development of require back up by more coercive governing instruments. the National Agenda for Early Childhood. Conflicting expenditures – potential for As described above, the policy approach at the national uncertain outcomes in Victoria level has focused almost entirely on exhortation, the least In comparison with other Australian states, Victoria has coercive instrument, where support and compliance are been slow to provide visible translation of the socio-eco- sought voluntarily through persuasion and discussion. In logical model of health for children and young people in comparison with other countries, such as Britain and Can- a coordinated and systematic way to state policy. A recent ada, the lack of a common and shared understanding of review of Victorian paediatric services suggested that Vic- the socio-ecologic approach and its implications has toria needed to establish a child and young people focus made it difficult to show any significant advances in this ensuring appropriate mechanisms to plan, coordinate and area. In fact, the recent demise of the Child Health Unit monitor across government departments and service pro- within the Australian Government Department of Health viders [23]. It was suggested that a structure was required suggests less focus on child health. to coordinate child health among of the various portfolios in the Victorian Department of Human Services – Health, Nationally, child health has not been heavily addressed Housing, Welfare, and Disability – as well as among the through other policy instruments, such as expenditure, broader Government departments, contributing to the taxation, or regulation, although more recently the Com- whole of government approach required for early child- monwealth Government Department of Family and Com- hood intervention programs. munity Services (DFaCS) established the 'Communities for Children' initiative as part of the Stronger Families and The lack of coordinated focus on child health in Victoria Communities Strategy. Communities for Children will is perhaps the result of a lingering policy focus on health directly fund 35 Australian communities between $1 and surveillance. Despite the increasing evidence that surveil- 4 million over four years to support parents, neighbour- lance and screening programs have limited effectiveness hoods and the wider community to give children the in child health [24,25], it is only recently that Victoria has healthy start they need [19]. Importantly, there was little increased the focus on the social determinants of health evidence of a community development or even a consult- [26,27]. Most recently, Victoria has committed to the 'Best ative approach in the implementation of this program, Start' program and will pilot it as demonstration projects with the perception that Communities for Children has not in 10 communities across the State with an investment of been set up to respond to the greatest need. $7.6 million. Best Start is auspiced by the Departments of Human Services and Education and Training and is It has been suggested that system change can be accom- focused on reducing the impact of disadvantage (from any plished by motivating institutions, systems and actors to cause) and enhancing the life chances of all children by move in common directions and develop structures that strengthening the universal preventative system [28]. The sustain these efforts over time [20]. This requires a high aims of Best Start are multi-level including the social, emo- level of trust among the participants, such that they even- tional and physical well-being of children, capacity build- tually share common goals and voluntarily seek to ing of parents and carers and communities to assist them achieve common ends. Success in using exhortation as a to become more child friendly, while focusing on specific policy instrument requires that information not only flow interventions for socially disadvantaged families [29]. The Page 3 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:4 http://www.anzhealthpolicy.com/content/1/1/4 demonstration projects are required to follow a prescribed Young People focuses on increasing the participation of implementation and evaluation process attempting to children and young people in decision making that affects measure what works, under what circumstances and for their lives, promoting the safety and welfare of children whom, to ultimately improve services elsewhere in the and young people, and strengthening the important rela- State. Five approved demonstration sites with a total of tionships in the lives of children and young people and $7.6 million are ensuring a 'brighter future' for the chil- improving their well-being [32]. dren of Frankston, Hume, Shepparton, Whittlesea and Yarra Ranges, while the rest of the State's children wait in The implementation of Families First has been guided by a the dark. series of policy and practice guidelines. Recently, an inde- pendent review of Families First implementation within Despite the intentions of Best Start, existing government three regions, (Orana Far West, Illawarra and South West funding and reporting in the area of maternal and child Sydney) found that the system changes required to build health is still largely focused on surveillance [26]. The Vic- and strengthen service networks for families needed more torian approach to policy implementation in the area of than agreement and goodwill, with considerable effort to early childhood support is focused predominantly on develop structures and processes that sustain interagency expenditure. Public expenditure is moderately coercive, collaboration [33]. This resulted in a further guide to with distribution of government funds to achieve particu- implementing sustainable and effective child and family lar policy objectives. But the small expenditure allocated service networks. to 'healthy' child policy that is limited to identified dem- onstration sites with expectations that the program will be Regulation involves the imposition of requirements to shown to be effective before statewide mainstream imple- meet specific obligations. Often regulation is seen to exist mentation is overshadowed by a much larger expenditure within legislation outlining strict rules of behaviour. pool that is not focused on the socio-ecological model. However, in health policy guidelines are considered effec- While Best Start signals intent to change the child health tive means of imposing regulation, recognising the inher- policy paradigm, the incentives established through the ent uncertainty in safe practice in health care [17]. The broader expenditure pool suggest, for the moment, main- implementation of 'healthy' child policy in NSW suggests tenance of the status quo in Victoria. a strong focus on the socio-ecological approach supported by the research evidence. This is apparent in the whole of government approach with leadership from the Premier's Guidelines – will enforcement back the regulatory approach in NSW? Office, backed by regulation to effect the necessary In New South Wales the 'Families First' initiative targets changes in the delivery system. families with children 0 to 8 years, with the aim of helping parents give their children a good start in life. Demon- However, it is yet to be seen whether the policy will be strating the commitment to a whole of government supported with the necessary resources for compliance. approach, the Office of Children and Young People While regulation involves shifting costs of compliance (OCYP), located within The Cabinet Office, reporting from government to other participants, enforcement and directly to the Premier, has played a lead role in the devel- monitoring can be expensive and difficult [21]. Without opment and implementation of the Families First strategy. adequate enforcement the potential for inequality and This evidence-based approach is delivered jointly by five inequity in access to the proposed service model is high. NSW government agencies – Area Health Services, Com- munity Services, Education and Training, Housing and Conclusions Disability, Ageing and Home Care in partnership with A variety of instruments have been used by government to parents, community organisations and local government. change the child health policy paradigm from that NSW Health supports 'the ongoing development of part- focused on social welfare to 'healthy' public policy predi- nerships at policy, planning and service delivery levels to cated on a socio-ecological foundation. NSW has chosen enable improved co-ordination and intersectoral collabo- regulation to implement a child health policy framework ration in the delivery of child health services' [[30] pg. 44]. that is built upon the international evidence of the effec- tiveness of integrated, multidisciplinary and intersectoral NSW has also successfully translated much of the evidence policy and programs. A little slower to change paradigms, into coordinated service planning and delivery at the Victoria has established demonstration programs through regional level. Paediatric networks, associated with the targeted expenditure, without an overarching whole-of- Area Health Services, were established in 1997 and today government child health policy framework. Nationally, provide designated primary, secondary and tertiary level there is a move to change the paradigm to a broader defi- services for families with children aged 0 to 5 years [31]. nition of child health almost exclusively through exhorta- In addition, the NSW Commission for Children and tion. Page 4 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:4 http://www.anzhealthpolicy.com/content/1/1/4 2. Hertzman C: An Early Child Development Strategy for Aus- Instrument choice is influenced by a variety of factors. The tralia? Lessons from Canada. Brisbane, Commission for Children use of exhortation by the Commonwealth Government is & Young People, Queensland Government; 2002. a relatively risk-free easy approach, which can counteract 3. Tremblay RE: When Children's Social Development Fails. Toronto, The Canadian Institute for Advanced Research; 1998. the divided accountabilities among federal and state gov- 4. Tremblay RE: The development of aggressive behaviour dur- ernments in the area of health and social services. Exhor- ing childhood: what have we learned in the past century? International Journal of Behavioural Development 2000, 24:129-141. tation is easy to implement; it is the least coercive and 5. Vimpani G: Refashioning child and family health services in relies on voluntary goodwill. While it may be successful in response to family, social and political change. Australian Health building a common understanding, and even this is Review 2004, 27:13-16. 6. Weatherburn D, Lind B: Delinquent-Prone Communities. Cam- debatable, an independent review of the Families First bridge, Cambridge University Press; 2001. implementation found that the system changes required 7. Power C, Hertzman C: Health, Well-Being and Coping Skills. to build and strengthen service networks for families Toronto, The Canadian Institute for Advanced Research; 1998. 8. Duncan GJ, Yeung WJ, Brooks-Gunn J, Smith J: How Much Does needed more than agreement and goodwill to develop the Childhood Poverty Affect the Life Chances of Children? necessary structures and processes – a suggestion that Toronto, The Canadian Institute for Advanced Research; 1997. 9. Caspi A, Taylor A, Moffitt TE, Plomin R: Neighborhood depriva- without other approaches to structural reform, exhorta- tion affects children's mental health: environmental risks tion is unlikely to be successful. identified in a genetic design. Psychological Science 2000, 11:338-342. 10. McClelland A: No Child: Child Poverty in Australia. , Brother- The expenditure policy of Victoria illustrates an approach hood of St. Laurence; 2000. that is compromised by the lack of an underlying agreed 11. Cynader M, Frost B: Mechanisms of Brain Development: Neu- ronal Sculpting by the Physical and Social Environment. evidence-based policy framework. This lack of coordi- Toronto, The Canadian Institute for Advanced Research; 1998. nated government approach is reflected in conflicting 12. Oberklaid F: Notes from Australia. The early childhood expenditure policy in this area, with the potential to con- agenda in Australia. Archives of Disease in Childhood 2004, 89:830. 13. Godfrey K: Framework for children aims to produce "cultural found outcomes. change". British Medical Journal 2004, 329:699. 14. Young B, Malley B: Making children a priority: Saskatchewan While the regulatory approach of NSW suggests bold steps listens. Early learning and care discussion forums 2004. Regina, Saskatchewan. Department of Community Resources and to change the paradigm, in fact, because regulation is not Employment; 2004. subjected to the same level of scrutiny of other instru- 15. Liberal Party of Canada: Foundations: A National Early Learn- ing and Child Care Program. Ottawa, Liberal Party of Canada; ments, such as expenditure, and even exhortation [17], it is a deceptively simple mechanism to implement policy 16. Panel on the Role of Government in Ontario: Investing in people. [21]. The strength of the government intent to change the Creating a human capital society for Ontario. Toronto, Gov- ernment of Ontario; 2004. paradigm will only become apparent with visible enforc- 17. Doern GB, Phidd RW: Canadian Public Policy. Ideas, Structure, ing of the service delivery directions. Process. Toronto, Methuen Publications; 1983. 18. Stanley F: Before the Bough Breaks. Doing More for our Chil- dren in the 21st Century.: ; Canberra. Academy of Social Sci- The evidence for a new policy paradigm is strong. But the ences in Australia; 2003. use of these different policy instruments underscores the 19. Department of Family and Community Services (Australia): Stronger Families and Communities Strategy. 2004. lack of shared understanding and policy agenda. Oberk- 20. Mechanic D: Improving the quality of health care in the United laid suggests that while there are similarities in the rheto- States of America: the need for a multi-level approach. J ric throughout Australia, there has been relatively little Health Serv Res Policy 2002, 7:Suppl1:S5-9. 21. Deber R, Topp A, Zakas D: Private Delivery and Public Goals: investment in child health [12]. The change in the child Mechanisms for Ensuring that Hospitals Meet Public Objec- health public policy paradigm will only be successful tives. , Background Paper prepared for the World Bank; 2004. when the governing instrument or combination of instru- 22. Oberklaid F: Child advocacy and the Queen's representative: an unlikely link. Archives of Disease in Childhood 2003, 88:980. ments induces the appropriate public and private behav- 23. La Trobe University Health Management Group: Review of Victo- iour. Perhaps we should be thankful that child health rian Paediatric Services. Melbourne, La Trobe University; 2002. 24. National Health and Medical Research Council: Child Health Sur- policy is on the agenda, and even without a strong, coor- veillance and Screening: A Critical Review of the Evidence. dinated approach built on the evidence, one would agree Canberra, ; 2002. that 'these developments in early childhood services dem- 25. Centre for Community Child Health: A Review of the Early Child- hood Literature. In Prepared for the department of Family and Com- onstrate the translation of research evidence into policy munity Services as a background paper for the National Families Strategy and practice, even if the implementation may be flawed, Melbourne, ; 2000. 26. Keleher KJ, Reiger K: Tensions in maternal and child health pol- belated or under-resourced' [[5] pg.15]. icy in Victoria: looking back, looking forward. Australian Health Review 2004, 27:17-26. Competing interests 27. Community Services Victoria: Child Health Surveillance Paper. Melbourne, Victorian Department of Community Services; 1992. The authors declare that they have no competing interests. 28. Ochiltree G, Moore T, McLoughlin J: Best Start Evidence Base Summary. Melbourne, Victorian Government; 2001. 29. Department of Human Services: Best Start website. [http:// References www.beststart.vic.gov.au]. 1. Mandela N: Speech by President Mandela: ; Pretoria. ; 1995. 30. NSW Health: The Start of Good Health. Improving the Health of Children in NSW. Sydney, ; 1999. Page 5 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2004, 1:4 http://www.anzhealthpolicy.com/content/1/1/4 31. NSW Health Department: Building a New Network of Paediat- ric Services for NSW. Sydney, NSW Government; 1995:1-16. 32. NSW Commission for Children and Young People: What we're doing. [http://www.kids.nsw.gov.au/ourwork/]. 33. NSW Health: Families First. [http://www.familiesfirst.nsw.gov.au/ public/s26_homepage/]. Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." 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Australia and New Zealand Health Policy – Springer Journals

Published: Nov 18, 2004

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