Focus on community is heartening

Dr Anna Matheson, Senior Lecturer in Health Policy, School of Health, Victoria University of Wellington, comments:

"The focus on community and better responsiveness within the Health and Disability System Review is heartening. In 2008 the World Health Organisation’s Commission on the Social Determinants of Health reviewed the global evidence of what causes health and illness. It concluded that most of health and equity is created in the places we are born, live, work and play – our communities. It is pleasing that there is recognition of this evidence.

"The Review acknowledges the current health system is fragmented and still struggling with how to effectively deliver services, programmes and interventions locally, to diverse communities. We have still not addressed institutional racism, and we have not done well in tackling the social determinants of health, such as liveable incomes and healthy housing.

"It is however good to see culture change featuring prominently. Health organisations such as DHBs and hospitals are substantial assets to their communities which hold enormous potential to provide leadership and support for local collaboration and collective initiatives as well as role-model through their own behaviour, effective action on inequities and the environment.

"Whilst the recommendations in the Review are welcome reading, there remains a big risk that it is in their implementation where efforts will fall over. Our policy system has been dogged with systemic implementation failure in our past attempts to reorient the health system. Top-down initiatives and structures have so far failed to create or support real change within communities – despite intention.

"Action on the social determinants of health requires approaches that join up sectors, as well as join up communities. Whole-of-government and intersectoral action have been with us for a long time. But not only have they failed to achieve their aims across government, they have failed in achieving long-term integration of services and programmes within communities. Likewise, devolution of service provision and decision-making to communities has so far most often led to its devaluing, rather than a strengthening of control and voice.

"Long-term concerted attention needs to continue to ensure that the top down changes called for in this Review have real benefits for the wellbeing of local communities. The real challenge in the implementation of the recommendations is that real power is going to need to change hands.

"Leaders at all levels (not just the top) need to empowered and joined up, barriers to both individual and organisational collaboration need to be identified and removed, and more value needs to be placed on workforces who work locally with people within the context of their lives."