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The Health Wrap: COVID concerns, turmoil in Aotearoa/New Zealand, and a deep dive into health reform

Melissa Sweet
Lesley Russell
Tuesday, December 5, 2023

Aged care, Long COVID, COVID-19, The Health Wrap, Tobacco, Indigenous health, The Voice, Oral health, Disabilities, Pregnancy and childbirth, Global health, WHO, Health reform, Workforce matters, Primary healthcare, Primary Health Networks, Safety and quality of healthcare, Out of pocket costs, Media-related issues, Misinformation and disinformation, Prevention, Health inequalities, Vaccination

As COVID-19 cases spike, greater efforts are needed to get more Australians vaccinated and to understand why booster vaccination rates are so low, according to Adjunct Associate Professor Lesley Russell.

In her latest column, Russell also investigates the latest on health reform (a timely backgrounder for the National Cabinet meeting tomorrow), threats to public health in Aotearoa/New Zealand, and brings some salient lessons from the United States on tackling misinformation and disinformation.

The quotable?

The conclusion is unequivocal – that during the historic [Voice] referendum, the Murdoch Press ran an aggressive political campaign that weaponised misinformation and disinformation.”

Lesley Russell writes:

The news on COVID-19 never goes away – and neither does the virus!

The Albanese Government has finally approved the distribution and use of the newest COVID-19 monovalent vaccines against the XBB.1.5 strain, but it is very disappointing to see – at a time when infections are on the uptick and national immunity levels are sub-optimal – how limited early availability will be.

Perhaps that explains the equally disappointing absence of a national campaign effort to encourage vaccination?

When asked at a recent doorstop about this, Health Minister Mark Butler said: “[The public information campaigns that have been running over the course of 2023] have been well informed by research and we’ve been making sure that the community is up to date with all of the information they need to know about the COVID booster program.”

Hmmm!

The Pfizer vaccine is available for use in people aged five years and older and the Moderna can be used for those aged 12 years and older.

The ATAGI recommendations for these boosters are here; it is more clearly explained in the schema below. Basically only those who are aged over 65 years (and those younger who are immunocompromised) who have not had a previous booster (or a COVID-19 infection) in 2023 can get a new booster jab.

There are 4.2 million Australians aged 65 and older, and as of 1 September 2023 only 53 percent of this population had received a booster dose in the past six months (data from ATAGI September report).

That means some two million older Australians are eligible for the new vaccines although it’s likely that some of this cohort have recently had COVID-19.

It has been reported that the Australian Government currently has three million doses of the XBB.1.5 vaccines but I have not been able to verify that figure (and the figures given in Dr Monique Ryan’s tweet below do not actually support the contention that there are three million doses of this newest vaccine).There is a good summary of the issues on the ABC News website, here.

It is clear that, as COVID-19 cases spike, greater efforts are needed to get more Australians vaccinated and to understand why booster vaccination rates are so low.

See All eyes on our future vaccination strategy as COVID-19 spikes from MJA Insight+.

Those least likely to be vaccinated are poorer, less likely to speak English, living in rural areas or First Nations people. It is also concerning that so many older Australians, including those in residential aged care, are not fully protected.

An ABC News analysis shows that in November the number of aged care home residents who had received a booster vaccination in the past six months or had been infected had dropped below 40 percent.

The Grattan Institute has just released a report that addresses how to close the vaccination gap. This report looks not just at COVID-19 but also at other adult vaccines where the uptake is also low. Less than half of Australians in their 70s are vaccinated for shingles. Only one in five are vaccinated for pneumococcal disease.

The report’s recommendations are summarised here:

Governments must get their house in order. Strategies are out-of-date and responsibilities are unclear. Adult vaccination policy lacks the goals and incentives that helped increase child vaccination in recent decades.
A new National Vaccination Agreement should set adult vaccination targets to mobilise effort and clarify the roles and responsibilities of federal and state governments.
Vaccinations should be easy to understand and easy to get. Simpler rules would allow more high-risk people to get vaccinated during “surges” of flu, RSV and COVID-19 ahead of winter. There should be clear guidance and communication, advertising to boost awareness, and SMS reminders for people at high risk of serious illness. These should be the responsibility of the Australian Centre for Disease Control.
Primary Health Networks should be responsible for increasing vaccinations in their individual areas. They should get data and funding to help pharmacies and GP clinics reach more people, including cultural groups that are missing out and people in aged care.
Aboriginal Community Controlled Health Organisations should get ongoing funding to increase vaccination rates among Indigenous people.
People with profound challenges, such as people in poverty, or those who deeply distrust the healthcare system, need more support, using tailored programs developed with local communities. There should be ongoing funding for state governments to deliver these programs, along with guardrails that make sure they use the best evidence and achieve the biggest impact.

This thread outlines the issues covered in the report:

Finally, as always, Dr Norman Swan does a great job explaining the current COVID-19 situation in Australia.

Why improving vaccination rates is so important

The data keep coming in about the health impacts of the ongoing pandemic.

“This virus has not gone anywhere. It’s circulating. It’s changing, it’s killing, and we have to keep up,” said Maria Van Kerkhove, the COVID-19 technical lead at the World Health Organization (WHO), recently.

New variants continue to emerge, although to date there hasn’t been one as successful as the Omicron variants which are dominating. But experts warn that could easily change.

Van Kerkhove encouraged people to continue to get tested if they think they have COVID-19 because that allows scientists to track the virus and later sequence it to study possible mutations.

“What we’ve lost recently is the ability to really get a sense of the whole diversity that’s present in these virus populations,” she said.

Research now suggests that we should be worried not just about the impact of the virus in the short term but the possible long-term impacts.

Professor Catherine Bennett recently outlined to news.com.au how the inflammatory response generated by an infection with SARS-CoV-2 can become chronic and lead to health problems beyond long COVID. There is increasing evidence that links this inflammation to an increased risk of Parkinson’s Disease, diabetes and dementias.

I have written previously (The Health Wrap, 5 October 2022) about the increased risk of developing diabetes after a COVID-19 infection and since 2022 the evidence for this has grown.
There’s a complex relationship between COVID-19 and Parkinson’s Disease that is not yet well understood, but it appears infection activates the same inflammatory response in the brain as Parkinson’s Disease.
There are fears that brain inflammation (perhaps the cause of “brain fog” that many people with long COVID experience) might also increase the risk of dementias or aggravate dementias in older people.
There is good evidence that COVID-19 has what has been described as a “monumental impact” on inflammatory bowel disease which leads to an increased risk of bowel cancers.

While vaccination does not mean you never contract COVID-19, it does attenuate the infection and thus the inflammatory response. Vaccinated people are about four times less likely to get long COVID than someone who is not vaccinated.

This finding comes from a Swedish study published in October which looked at the incidence of long COVID in 299,692 vaccinated individuals who had COVID-19 compared with 290,0030 unvaccinated individuals.

It also found that vaccine effectiveness against long COVID was dose dependent – for one, two and three or more vaccine doses, the reduced risk was 21 percent, 59 percent and 73 percent, respectively.

This study was conducted over the period December 2020 to February 2022, so it looked only at the original COVID-19 vaccines, not newer boosters. Also it did not assess long COVID after re-infection, which is known to increase the risk.

As such, the findings may not translate perfectly to the present day, when many people have received updated shots and had COVID-19 multiple times.

See the BMJ article.

See the BMJ editorial.

COVID-19 infection during pregnancy is associated with adverse health outcomes for both mothers and newborns due to disintegration of the placenta, preeclampsia, and ICU hospitalisations leading to premature births.

Now there is evidence that vaccination prevents these premature births.See the article in PNAS.

Healthcare funding reforms

These days there are lots of healthcare reform reviews underway. (In my cynical moments I think these are excuses to postpone the difficult decisions, the tough turf fights, and the hard work of actioning what we already know.)

Key among these is the mid-term review of the National Health Reform Agreements 2020-2025, under which the Australian Government provides the States and Territories with funding for public hospitals.

This review was announced by the Health Minister on 24 February and is due for completion this month.

The Minister’s media release states that, under the Terms of Reference, the review will consider whether the objectives of the NHRAs are being met, including:

The impact of external factors (such as the COVID-19 pandemic) on the demand for hospital services and the flow-on effects.
The performance of small rural and small regional hospitals.
The implementation of the long term reforms and other governance and funding arrangements.
Any unintended consequences such as cost-shifting, perverse incentives or other inefficiencies that impact on patient outcomes.

It will also consider whether the NHRAs remain fit-for-purpose, given the priorities for better integrated care and more seamless interfaces between the health, disability, and aged care sectors.

Interestingly, these Terms of Reference are somewhat different than those outlined on the website of the National Health Funding Body (charged with improving the transparency of public hospital funding) which says the review will examine:

Whether the stated objectives of the NHRAs – improving health outcomes, access and innovation – are being met.
Whether the health funding, planning and government architecture is fit-for-purpose, given emerging priorities for better integrated care and more seamless interfaces between health and primary care, mental health, aged care and disability systems.
Potential options for future reforms and agreements.

The reviewers were to provide an interim report to all Health Ministers in August 2023, and a final report in December 2023. I have not been able to find a publicly available copy of the interim report, or any indication that it was presented and / or discussed at a meeting of the Health Ministers.

Many of the submissions made to the review in the period May – July 2023 can be found online, but these have been released by the health and healthcare organisations that made them. There does not appear to be a consultation website.

Read more about the lack of transparency around this review in this article by my colleague Charles Maskell-Knight.

NSW inquiry

New South Wales has just begun a Special Commission of Inquiry into Healthcare Funding and this is almost guaranteed to lay bare the issues the states like NSW are presenting to the Australian Government as part of the NHRA Review.

Submissions can be accessed here. There’s some interesting reading!

The NSW Health submission argues that healthcare funding is in need of reform. It focuses on the fact that the current NHRAs reward activity rather than outcomes in hospitals, and that the failures of the Commonwealth to adequately invest in primary and community-based care leaves the States and Territories to shoulder the growing funding burdens of infectious and chronic diseases.

This submission has been summarised in The Australian.

Other recent reports, proposals and reviews

There’s a lot going on. Hopefully this (incomplete) list will help keep readers up-to-date.

Grattan Institute report: Putting the “reform” in the National Health Reform Agreement.
Members of the Health Services Union, in a submission to the NSW Special Commission of Inquiry, offer a possible mechanism to address growing Medicare out-of-pocket costs, making the case that that bulk-billing rights should be stripped from doctors who charge more than double the Medicare rebate.
The Australian Dental Association has proposed that the Australian Government establish a Seniors Dental Benefit Schedule for the 200,000 elderly Australians in residential aged care. This is estimated to cost $100 million per year. This has been ADA policy for some years. There is little detail available and, on the basis of the ADA media release, I would say (unkindly) that this looks like a boondoggle for private dentistry.
The Federal Health Minister has announced the Working Better for Medicare Review. It is to review to “urgently” investigate how to more equitably distribute doctors and other healthcare workers around the country.
The review is described as looking at “how current policies and programs can be strengthened to make it easier to see a doctor, nurse or other healthcare worker in the outer suburbs of our major cities and in regional, rural and remote Australia”. It is not clear how this review will link into the Unleashing the Potential of our Health Workforce Review, announced in August – but it is imperative that it does so.

Medicare reforms

On 1 November the new Medicare bulk billing incentives – described by the Albanese Government as the largest investment in Medicare in forty years – came into effect.

In a speech given to the Committee for Economic Development of Australia (CEDA) on 21 November, Health and Aged Care Minister Mark Butler highlighted this and the range of Medicare and other healthcare reform measures that are underway or under review.

In comparison to the laissez-faire approach of the previous Coalition Government, these are welcome initiatives.

But they do not constitute meaningful primary care reforms, they do not address the huge unmet mental health needs, they do little to address out-of-pocket costs for specialist care faced by many Australians, and it is still very difficult for patients with chronic and complex conditions to navigate the healthcare system.

Butler’s speech is all about medicine and illness and there is no recognition of or reference to prevention, the social determinants of health, and the need to tackle the health inequalities across the nation.

Maybe that’s not part of Medicare or part of the National Health Reform Agreements, but these issues must be addressed if Medicare and the NHRAs are to be reformed and made sustainable into the future.

Addendum: As I was writing this, the Australian Institute of Health and Welfare released the latest data on Medicare-funded services that show the proportion of the cost covered by the Medicare Benefits Schedule is steadily declining, leaving patients increasingly out-of-pocket.

The situation for specialist appointments is especially dire – in October 2023 the proportion of the cost covered by Medicare for specialists’ visits dropped to 57.96 percent.

The Australian quotes doctors now saying they “fear that ordinary healthcare is increasingly out of reach of battlers, who are treating doctors’ visits as a discretionary expense”.

Evaluation of Primary Health Networks

These days I see little focus on the work of the Primary Health Networks (PHNs) – arguably they have an important role developing and implementing practice changes at the local level, facilitating integrated care, and in supporting GPs and other healthcare workers in the primary care sector.

Back in 2019, Dr Paresh Dawda and I wrote a paper questioning whether PHNs are fit for purpose to drive and foster primary care reforms. I don’t think that question has been answered, and there is little evaluation to help understand what PHNs are currently doing well and what could be done better.

As just one example from the mental health area, where GPs are currently struggling to meet the demand for services, we have no idea how effectively the Five Year Horizon for PHNs prepared by the PHN Advisory Panel on Mental Health in 2018 has been implemented. And given that the five year horizon is up – what comes next?

The documents on the Department of Health and Aged Care website that are stated to provide guidance, clarity, expectations and best-practice examples to PHNs implementing primary mental health care reform activities have not been added to since 2019.

It feels like there are no ministerial/departmental eyes on the ball; indeed, maybe the ball has been dropped?

A recent paper from Professor Fran Baum and colleagues has evaluated the work of PHNs in addressing health inequities. Their analysis found that PHNs’ equity actions were limited.

The PHNs displayed clear intentions and goals for health equity and collected considerable evidence of health inequities in their area. However, planned activities (it’s not clear these ever proceeded beyond plans on paper) were largely restricted to individualistic clinical and behavioural approaches, with little effort to facilitate access to other health and social services, or act on the broader social determinants of health.

The authors argue that PHNs need autonomy and scope to act on the “upstream” factors that contribute to local health issues. Unstated but obvious is the heavy bias towards medicine and illness rather than prevention and wellness.

Turmoil for health in Aotearoa/New Zealand

In the immediate aftermath of the recent New Zealand elections, an article for Inside Story Magazine by Jennifer Curtin, Professor of Politics and Public Policy at the University of Auckland, described the result as a “return to pre-Ardern, pre-COVID politics”.

The article further described how the election featured a resurgence of anti-Māori sentiment to initiatives including co-governance of natural resources and infrastructure, the reorganisation of healthcare to better support the needs of Māori communities, and the widely accepted recognition of the Treaty of Waitangi’s significance in fostering strong partnerships between Māori and the Crown to ensure greater equity in policy outcomes.

With the conservative coalition led by Prime Minister Christopher Luxon now installed as the new government, we are seeing what is in store for New Zealanders.

Many of the actions in their 100-day plan involve repealing initiatives from the previous Labour government.

Croakey readers will be aware that a key action is backtracking on the world-first ban of tobacco sales for future generations, a move that academic research indicated could have saved some NZ$2 billion in health system costs over 20 years, and reduced mortality rates.

The explanation given for abandoning the SmokeFree Goal was that funds from cigarette taxes are needed to deliver promised income tax cuts.

You can read more in this Croakey Health Media article, New Government in Aotearoa / New Zealand launches attack on public health. Māori health experts have warned that the most vulnerable will pay the price for these tax cuts cushioning the wealthiest.

The new government seems to be in the thrall of the tobacco industry.

See the Twitter thread by Professor Richard Edwards

Some of the other proposed policy changes seem even worse: a roll back of the use of the Māori language (the Deputy Government Leader slammed the use of Māori names for agencies as “marginal, culture-driven distractions”), the abolition of Te Aka Whai Ora – Māori Health Authority, and a push back on major healthcare reforms designed to close the gap on health inequalities instituted less than two years ago (I wrote about these in The Health Wrap 29 August 2022).

The future of the New Zealand Health Strategy, published only a few months ago, is uncertain.

In what has been described by a baffled Kiwi public health expert as an “incoherent” move, the new Government has urgently lodged a reservation – a letter saying the country would not sign up yet – for amendments to WHO health regulations.

This was part of Luxon’s National Party agreement with Winston Peter’s New Zealand First Party, which requires the government to ensure a “National Interest Test” before New Zealand accepts any United Nations agreements, or those from its agencies “that limit national decision-making, and reconfirm that New Zealand’s domestic law holds primacy over any international agreements”.

What happened to NPS MedicineWise and Choosing Wisely?

Last September there was considerable concern over the decision of Health Minister Mark Butler to proceed with the forced closure of NPS MedicineWise proposed by the Morrison Government and to hand over (at least some of) the responsibilities to the Australian Commission on Safety and Quality in Health Care (ACSQHC).

Several Croakey Health Media articles covered this issue and the concerns of clinicians, consumer health groups, researchers and public health experts.

Early last month the ACSQHC held the National Medicines Symposium – previously hosted by NPS MedicineWise. This conference was covered by Croakey; see relevant article here.

I was interested to discover what work was being done to cover off that previously undertaken by NPS MedicineWise and Choosing Wisely Australia but could find no mentions of this in the conference coverage.

The NPS MedicineWise website has not been updated since December 2022. A note on the ACSQHC website says that the Commission has commenced a review of the site content.

The Choosing Wisely website has also not been updated. A note on the ACSQHC website says “The Choosing Wisely website and associated resources have transitioned to the Commission’s custodianship and continue to be available for public access. The content was last updated in December 2022 and will remain static while the Commission undertakes a review process.”

At the time the changes were announced the Department of Health stated that $3.9 million of funding would be provided to support the transition to the ACSQHC, and that the changes would “help improve access to vital information for clinicians and patients regarding medicines, diagnostic tests, and possible harmful medication interactions”.

The Department also said that there would be grant processes for “projects to deliver health professional education and consumer education and health literacy around quality use of medicines and tests”.

So it appears nothing much is happening – a lost year of work in this important area for the Quality Use of Medicines.

In case you missed it

Dental services

The parliamentary Select Committee into the Provision of and Access to Dental Services in Australia has just released its final report: A system in decay: a review into dental services in Australia.

My colleague Charles Maskell-Knight will report more on this at Croakey in coming days.

Misinformation

A review article in the November issue of Health Affairs – A Systematic Review Of COVID-19 Misinformation Interventions: Lessons Learned – has some salient lessons for Australia.

There is no silver bullet for mitigating health misinformation.
Health misinformation, similar to any public health issue, requires a multifaceted approach.
To ensure the most resilient response to ongoing public health and information crises, officials and policy makers should support and test community-driven interventions and systems-based strategies, such as investing in local trusted sources of information, including journalists and community-based organisations, as vigorously as individual-level interventions.
The field urgently needs to include more public health experts in intervention design and to develop a health misinformation typology and agreed-upon outcome measures.

Budgetary

From the Australian Parliamentary Library: Australian Government Indigenous-specific bodies and budgets – a quick guide. Essential information!

Health spending

A new report from the Australian Institute of Health and Welfare looks at health system spending on the response to the pandemic, over the time period 2019-20 to 2021-22.

The report has been succinctly summarised for Croakey Health Media by Charles Maskell-Knight; you can access his article here.

Media matters

Australians for a Murdoch Royal Commission has a new report – Under the Façade of Journalism: How News Corp used fear, manipulation and division to campaign against an Indigenous Voice to Parliament – that analyses over 1,600 pieces of News Corp’s Voice coverage.

The conclusion is unequivocal – that during the historic referendum, the Murdoch Press ran an aggressive political campaign that weaponised misinformation and disinformation.

Audit

The Australian National Audit Office has announced it is undertaking a performance audit of the administration of the Pharmaceutical Benefits Scheme by the Department of Health and Aged Care and Services Australia.

The audit is due by October 2024.

The best of Croakey

As COP28 is underway and Australia confronts a long, hot summer and bushfire threats, a series of recent articles outline the issues:

To stay in touch with health and First Nations news from COP, follow

This Twitter list
The hashtag, #HealthyCOP28.

The Indigenous good news story

I loved this recent story in The Sydney Morning Herald about a group of deaf Indigenous dancers preparing for their Sydney Opera House debut.

Deaf, Indigenous and proud: The performers taking the dance world by storm.

There’s an inspiring interview with one of the dancers here.

The good news story

Long-time Canberra residents and others living around the Australian Alps will remember (maybe not fondly) the days spring/early summer that were plagued with bogong moths.

Then around 2017, the moth population just crashed (perhaps because of drought) and there was no recovery in the years since.

So a post from Zoos Victoria about a growing number of early bogong moth sightings is good news.

You can log bogong moth sightings at mothtracker.swifft.net.au

Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.

Previous editions of The Health Wrap can be read here.