Getting the temperature of public health advocacy porridge ‘just right’

To put it bluntly, if you know you have powerful political adversaries, it’s probably not the best strategy to yell “come and get me” at the first available opportunity unless your ultimate motivation is martyrdom

Protecting New Zealand’s population from current and emerging threats to health is a core function of any government. Indeed, the role of public health and prevention constitutes one of the terms of reference of the Health and Disability Review chaired by Heather Simpson.

Yet the place of public health within government poses a highly complex policy puzzle. What sort of gov­ernment machinery is required in order to fulfil this function?

In New Zealand, the debate has been effectively outlined by emeritus professor Sir David Skegg in his highly informative and accessible book, The Health of The People, published in March.

Sir David asks whether the public health func­tion should be located within the Ministry of Health, or whether it should be housed in a separate, pur­pose-built government agency more at arm’s length from ministerial control.

In weighing up the arguments for each option in the final chapter of his book, he comes out firmly on the side of a stand-alone agency. Sir David once chaired such an agency, the Public Health Commission, in its brief existence from 1992 to 1995.

Currently, the public health function sits predomi­nantly under the Ministry of Health, and the profile of public health within the ministry has been beefed up since the new director-general of health, Ashley Bloom­field, (re)-established a directorate of population health.

The arguments against this status quo are that min­istries are too subject to political control by their minis­ters and governments, and that the public health voice will only be stymied in the risk-averse culture that char­acterises central government departments.

What is needed, according to many public health pro­fessionals, is a return to the Public Health Commission that can provide independent, frank and fearless advice to governments. Arguments for a stand-alone agency, including Sir David’s very nuanced and thorough analy­sis, typically characterise the demise of the commission in the 1990s as having many authors.

This account is analogous to the plot of Agatha Chris­tie’s Murder on the Orient Express in which every suspect was party to the assassination. In the commission’s case, this included a roll call of industry-vested interests (alcohol, tobacco, food, dairy), a range of National Par­ty ministers (Birch, Williamson, McCully and Shipley), and, driven by bureaucratic jealousy, the ministry itself.

I would argue that the demise of the commission should be seen as an act of suicide. Here’s why. Advo­cates for public health occupy an incredibly difficult and challenging political space. The benefits of the meas­ures they typically advocate (increased regulation of un­healthy products, taxation) accrue to many people, but these benefits are very dispersed. Those who benefit, on the whole, will not fight hard for those benefits.

Conversely, the losses incurred by such policies are concentrated and those who incur those losses can be expected to fight, and fight hard. In addition, New Zea­land’s dependence on food exports underpins signifi­cant power of the food industry.

So why was the commission’s death a suicide? In its series of draft policy papers produced in 1993/94 on alcohol, tobacco and food, the commission’s fear­less advice simultaneously upset all relevant industry stakeholders. To put it bluntly, if you know you have powerful political adversaries, it’s probably not the best strategy to yell “come and get me” at the first available opportunity unless your ultimate motivation is martyr­dom. True, your opponents might get you anyway, but there’s no need to make their job easier than it other­wise would be.

The bottom line is that public health advocates need to cultivate strong political allies within government, and within the broader body politic. It may be the case, a stand-alone public health agency is better placed to develop a more effective po­litical strategy than if public health is located within the ministry, but a recent piece of research comparing the experiences and successes of stand-alone public health agencies in government is sobering.

In the same month Sir David’s book was pub­lished, an article by John Boswell, Paul Cairney and Emily St Denny, which compared the effectiveness of public health agencies in New Zealand, Austral­ia and England, appeared in the high-profile journal Social Science & Medicine (2019;228[May]:202–10).

In Australia, the story of the Australian National Pre­ventive Health Agency’s demise was analogous to New Zealand’s Public Health Commision, in that once the political winds changed, the advice of this agency was considered “too hot”. Conversely, New Zealand’s Health Promotion Agency is an example of an organisation that lacks any cutting edge – the porridge it serves up is much too cold. The authors argue that England might have it “just right” with Public Health England, which effectively provides some insulation from opposing in­terests, and walks a fine line between advocacy and fa­cilitating bipartisan policy consensus.

More generally, the authors argue that “institutional­ising prevention via dedicated agencies seems destined to disappoint, but that some solutions are far less dis­appointing than others”. In each setting, public health agencies faced uncomfortable trade-offs between policy effectiveness and organisational survival.

Many of Boswell and colleagues’ informants, across all three countries, advocated for greater leadership with­in government ministries, where there is much more potential to link up with other parts of government, to understand the important informal alliances that shape policy.

The current political environment suggests it may be worth supporting a reinvigorated public health role with­in the Ministry of Health, but no one should underesti­mate the challenge, whichever approach is adopted.

Tim Tenbensel is associate professor, health policy, in the School of Population Health at the University of Auckland