This article presents a case study of a project known as 'Designing Better Health Care in the South' that attempted to transform four separately incorporated health services in southern Adelaide into a single regional health service. The project's efforts are examined using Kotter's (1996) model of the preconditions for transformational change in organisations and the areas in which it met or failed to meet these preconditions are analysed, using results from an evaluation that was commenced during the course of the attempted reform. The article provides valuable insights into an attempted major change by four public sector health organisations and the facilitators and barriers to such change. It also examines the way in which forces beyond the control of individual public sector agencies can significantly impact on attempts to implement organisational change in response to an identified need. This case study offers a rare glimpse into the micro detail of health care reform processes that are so widespread in contemporary health services but which are rarely systematically evaluated.
This paper describes the experiences of the authors in conducting a three year evaluation of health system reform processes in the southern region of Adelaide and explores how the evaluation team utilised 'insider' and 'outsider' roles to establish and maintain trust and cooperation with stakeholders and informants in a turbulent policy environment. It uses the results of focus groups and interviews to analyse how the team was able to encourage the sharing of sensitive information and to examine the roles, responsibilities and risks to evaluators in carrying out a controversial evaluation. The importance and some means of finding a balance between insider knowledge and outsider objectivity in evaluation are discussed.
Evaluators in the health sector struggle to develop effective mechanisms with which to evaluate healthcare reform programmes. Evaluation of these programmes is difficult because they are entangled in complex, inherently political processes and often shift away from their original aims and objectives as a result of policy changes within the health system. This article describes the evaluation of a healthcare reform process occurring in South Australia and discusses some of the methodological challenges encountered in evaluating a case study of continuous change with shifting policy objectives. It describes how the evaluators have attempted to address these challenges through a flexible and dynamic action-research approach. The article concludes by discussing the role of the evaluator, as intelligent observer, in reflecting on and documenting change in the highly political and complex field of healthcare reform.
AbstractEarly childhood education (ECE) and development is internationally recognised as important to child health and wellbeing and to enabling children to become healthy productive adults. This paper analyses Australian ECE policy current in 2019. It uses the institutional framework of ideas, actors and institutions to determine the extent to which ECE policy recognises and acts on social determinants of health and health equity. We found that the policies supported integrated approaches, intersectoral collaboration and partnerships with parents and families. Evidence was important in formulating the ideas underpinning ECE policy. ECE was widely recognised as a social determinant of health, and the impacts of other social determinants of health and health equity were acknowledged. The ECE policies tended to be future-focused and not respond to social determinants that influence children and their families in the present time. The policies lacked strategies to address social determinants, or to engage with other sectors for this purpose. While some policies focused on breaking the cycle of disadvantage, they did not explore potential policy responses to pathways from intergenerational disadvantage to reduce poverty. Despite this, Australian ECE policy has achieved significant coherence, with shared understandings of the purpose and benefits of ECE.
Mobilising cross-sectoral action is helpful in addressing the range of social determinants that contribute to health inequities. The South Australian Health in All Policies (SA HiAP) approach was implemented from 2007 to stimulate cross-sector policy activity to address the social determinants of health to improve population wellbeing and reduce health inequities. This paper presents selected findings from a five year multi-methods research study of the SA HiAP approach and draws on data collected during interviews, observation, case studies, and document analysis. The analysis shows that SA HiAP had dual goals of facilitating joined-up government for co-benefits (process focus); and addressing social determinants of health and inequities through cross-sectoral policy activity (outcomes focus). Government agencies readily understood HiAP as providing tools for improving the process of intersectoral policy development, while the more distal outcome-focused intent of improving equity was not well understood and gained less traction. While some early rhetorical support existed for progressing an equity agenda through SA HiAP, subsequent economic pressures resulted in the government narrowing its priorities to economic goals. The paper concludes that SA HiAP's initial intentions to address equity were only partially enacted and little was done to reduce inequities. Emerging opportunities in SA, and internationally, including the UN Sustainable Development Goals, may revive interest in addressing equity.
AbstractTrust has been consistently identified as an important enabling factor for joined‐up government activity to generate strong, integrated and effective social policy. Despite this, there has been comparatively little detailed analysis of the complexities and dynamics involved. This paper provides a detailed examination of how trust is built, nurtured and, in some instances, lost during joined‐up policy activity. It draws on interview and survey data that reveal the dynamics of relationships formed under the South Australian Health in All Policies initiative. The research extends the parameters of organisational analyses of trust. Previous typologies are mostly descriptive, with limited explanatory power, typically focusing on individuals and institutions separately rather than integrating these foci to consider how trust operates within whole systems. By integrating Giddens' theoretical perspectives on trust with existing typologies, the paper generates understanding about how trust operates as a resource within non‐traditional joined‐up government working relationships, serving to bridge the gap between the known and unknown, and acting as a productive resource to stimulate action within government systems that are perceived to feature high levels of risk. A model is provided to explain the interrelated dynamics of trust building, maintenance, monitoring and repair.
Background This paper examines the extent to which actors from sectors other than health engaged with the South Australian Health in All Policies (HiAP) initiative, determines why they were prepared to do so and explains the mechanisms by which successful engagement happened. This examination applies theories of policy development and implementation. Methods The paper draws on a five year study of the implementation of HiAP comprising document analysis, a log of key events, detailed interviews with 64 policy actors and two surveys of public servants. Results The findings are analysed within an institutional policy analysis framework and examine the extent to which ideas, institutional factors and actor agency influenced the willingness of actors from other sectors to work with Health sector staff under the HiAP initiative. In terms of ideas, there was wide acceptance of the role of social determinants in shaping health and the importance of action to promote health in all government agencies. The institutional environment was initially supportive, but support waned over the course of the study when the economy in South Australia became less buoyant and a health minister less supportive of health promotion took office. The existence of a HiAP Unit was very helpful for gaining support from other sectors. A new Public Health Act offered some promise of institutionalising the HiAP approach and ideas. The analysis concludes that a key factor was the operation of a supportive network of public servants who promoted HiAP, including some who were senior and influential. Conclusions The South Australian case study demonstrates that despite institutional constraints and shifting political support within the health sector, HiAP gained traction in other sectors. The key factors that encouraged the commitment of others sectors to HiAP were the existence of a supportive, knowledgeable policy network, political support, institutionalisation of the ideas and approach, and balancing of the economic and social goals of government.
Background:Insufficient progress has been made towards reducing health inequities, due in part to a lack of action on the root causes of health inequities. At present, there is a limited evidence base to guide policy decision making in this space. Key points for discussion:This paper proposes new principles for researchers to conduct health equity policy evaluation. Four key principles are presented: (1) where to evaluate – shifting from familiar to unfamiliar terrain; (2) who to evaluate – shifting from structures of vulnerability to structures of privilege; (3) what to evaluate – shifting from simple figures to complex constructs; and (4) how to evaluate – shifting from 'gold standard' to more appropriate 'fit-for-purpose' designs. These four principles translate to modifying the policy domains investigated, the populations targeted, the indicators selected, and the methods employed during health equity policy evaluation. The development and implementation of these principles over a five-year programme of work is demonstrated through case studies which reflect the principles in practice. Conclusions and implications:The principles are shared to encourage other researchers to develop evaluation designs of sufficient complexity that they can advance the contribution of health equity policy evaluation to structural policy reforms. As a result, policies and actions on the social determinants of health might be better oriented to achieve the redistribution of power and resources needed to address the root causes of health inequities.