Month: July 2021

_{Note: these three pieces were written over a week ago and things move very fast with the Covid-19 pandemic! The pieces are ‘published’¹ here as a record of my views at a particular moment in time, notwithstanding the crowded space which is commentary on the pandemic and the updating that might be necessary. Among the revisions that could be noted is a reappraisal of the politics of National Cabinet, which have festered somewhat. [¹ The word implies a move to expose the piece to global gaze. In fact the blogg doesn’t even have global immediate family readership. The world is too congested.]}

If enough of us get vaccinated to move beyond the immediate emergency, it will be useful to reflect on the medium-term implications of the global pandemic for the governance of Australia and the world. As well as the gloom and uncertainty, there have already been just a few welcome developments and there will be more to unearth.

PART 3: Some better news

National Cabinet

One of the most positive developments in governance to have emerged during the pandemic was a National Cabinet. This worked well for some time and showed the value of close collaboration between all governments on issues of urgency and national significance. It was so successful that, for a while, it no doubt increased the public’s respect for government and politics – albeit from a very low base.

Questions have already been asked about whether the partial success of this National Cabinet suggests ways in which inter-governmental work (including meetings about Federal fiscal relations) can be undertaken in a manner that improves on the Council of Australian Governments (COAG) model.

That is not to say that the National Cabinet for Covid was devoid of politics. During the period when it was cohesive and decisive, the Federal Government was not averse to taking advantage of the (politically desirable) position of backing the options that were most popular, knowing that, in fact, decisions on these matters were not within their compass. This was the case with lockdowns in general, and with parts of lockdowns such as school closure, masks and inter-State travel.

With schools, for example, for some time the Prime Minister was able to argue the critical value of schooling, the difficulties with home schooling, and to express the general belief that, for these reasons, schools should remain open. All the while, decisions on the matter lay with the States and Territories.

The National Cabinet was faced with the challenge of balancing health (as  measured by cases, hospitalisations and deaths) against the economic and social effects of lockdowns. To date it has been unwise or unpopular to be too explicit about this balance. All governments, at least as far as public commitments have been concerned, have leaned towards suppressing the virus as a prerequisite for economic recovery.

Of the decisions made by the National Cabinet, none was more important than the one relating to quarantine. International quarantine is a Federal responsibility but decisions on internal borders lie with the States and Territories. Tasmania locked its borders on 19 March 2020. Australia’s national borders were closed the following day and on 24 March Australians were prohibited from leaving the country.

Thus it was that a complex, layered Commonwealth-State system emerged in relation to quarantine. The Federal Government took the decision to require all overseas arrivals to quarantine for 14 days. And through National Cabinet the States and Territories agreed to run hotel quarantine as part of their responsibility for public health. They also agreed to fund most of it.

This turned out to be a massive false economy for the Commonwealth. The fact that there has been no national system or standardised procedures for hotel quarantine has been one of the causes of the leakages from the hotels involved. These have resulted in huge financial commitments from the Commonwealth to support the economies affected by lockdowns determined and managed by the States and Territories.

For any kind of National Cabinet arrangement to persist will require leadership from the Commonwealth. And the situation in which one level of government makes lockdown decisions with another picking up the bulk of the economic costs that result looks like an unlikely bargain.

Decisions are ‘evidence based’

One of the phrases we have heard most often during the pandemic is when governments, federal and state, have attributed a decision to “the best possible advice from the health experts”.

It is surely a positive development for policy decisions to be made on the basis of scientific and other real evidence. Some parts of the world have had their fill of ‘alternative facts’.

The thought that occurs is what other issues have the same characteristics as a viral pandemic and, also, are accompanied by the same volume of applicable science. Climate change is one obvious case. And perhaps the challenge of improving the health and well-being of Australia’s Aboriginal and Torres Strait Islander people is another.

The considerations of the Chief Medical Officers have enabled governments to say, in effect, “Don’t blame or credit us governments; we are simply following independent, world’s best scientific advice.” In turn, the Chief Medical Officers have been guided by modelling of COVID-19 transmission and infection dynamics. It is perhaps surprising to note that the only three pieces I posted in the early days of the pandemic (April 2020) focused on modelling and a re-reading of them shows very little that needs to be revised or regretted. An extract from the post of 10 April 2020 is at the end of this piece.

It could be argued that governments’ constant deferral to scientific advice is a kind of delegation of responsibility and avoidance of accountability. It is politically attractive to have someone to blame for difficult decisions or to blame if decisions taken were the wrong ones. But one cannot argue against the idea that all policy decisions should be determined on the basis of evidence from science.

The fact that the distribution of money for sports grants and suburban car parks has not been based on evidence is one of the reasons why there is such a lack of respect for and trust in governments and politics.

Institutional flexibility

The good things to have come out of the pandemic include an extra  measure of flexibility in certain policy and regulatory matters.

Consider, for example, the supply of oxygen. The Australian New Zealand Industrial Gas Association is the peak body for suppliers of medical oxygen to hospitals and similar facilities. Because of the public benefits that would result, the Australian Competition and Consumer Commission (ACCC) has granted ANZIGA temporary authorisation to exchange information and work through arrangements which in other circumstances might be deemed to reduce competition in the sector.

Another positive spin-off from the pandemic has been the extension of publicly-funded telehealth services. When I was at the National Rural Health Alliance we battled persistently to achieve small steps forward on telehealth, one at a time, painfully and slowly! Over time there were extensions to the geographic areas in which funded telehealth was available; eligibility for additional health care settings, for additional  professionals (eg specialist to GP link-ups), and for additional interventions (eg for mental health).

Rural people and their advocates were no doubt delighted when, for the pandemic, there were major extensions made in one fell swoop to telehealth services under Medicare. Some 300 additional items became eligible. Over 30 million services were claimed in the first six months at a cost of over $1.5 billion.

There will need to be evaluations. When they are done, telehealth and other things such as e-prescriptions and home delivery of medications should be evaluated as initiatives that make access to service more equitable, not only for what they do to facilitate social distancing or contactless care.

In the face of the pandemic, governments in other countries have granted pharmacists greater authority. In Canada, for example,  pharmacists have been given opportunities to join actively in the fight against the virus. Aimed at assisting an overloaded health system, the extensions for pharmacy practice in that country have included performing COVID-19, influenza, and Group A Streptococcus screening tests, and vaccine administration.

In Australia, due almost certainly to the vexed political situation relating to medicine v. pharmacy, it is still unclear as to where and when pharmacists are involved in Covid vaccinations. In any case the vaccination ‘system’ is already mixed-mode and unclear enough.

It is to be hoped that the passing of the health emergency will not see the end of such sensible increased flexibility of these sorts.

Evaluations can start now

A main course of co-ordinated decision making on national emergencies, with better use of scientific evidence (when available) in making policy decisions, plus a larger serve of sensible flexibility may not seem to be much of a feast. But any trauma and disruption as great as the world is currently facing must yield some opportunities for positive change management as well as misery and uncertainty.

There is a huge range of matters that will need to be evaluated, at global and domestic levels and at every level in between. And it will include positive changes which may not yet be even contemplated.

Evaluation will be useful. And some of those qualified in the field should start soon.

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From the post to this blogg of 10 April 2020:

This is the second of three posts on aspects of Australia’s Covid-19 response that it will be useful to analyse. The pandemic has exposed some hitherto under-emphasised realities of Australia’s federal system. Some of them are positive but a greater number can be described as challenges of the Federation.

PART  2: The Australian Federation

The pandemic has thrown new light on both the benefits and the challenges of Australia’s federal system. The positive elements include a new understanding of the need for inter-governmental cooperation within the nation and ways in which it can be effected, and some major (and rapid) changes in the way services are provided to the public. One example of the latter is how the pandemic led to a major extension of the provision of subsidised health services through telehealth.

 However there is a longer list of issues relating to Australia’s governance that have emerged – in particular as it relates to service delivery –  that are negative or even dysfunctional. Given their importance and general acceptability, some of the required changes to Australia’s system of governance that have come to light can and should be implemented as soon as possible.

Probably none is more serious (or more familiar) than the need to rationalise, re-order and clarify governmental responsibilities for health-, aged- and disability-care.

Australia’s care systems

 Major reforms to the health, aged care and disability care systems have been called for by many people for very many years. But never before has there been such a naked, loud and transparent series of events that attest to the need for Big Reform to these care systems as have occurred during the Covid-19 pandemic.

Coupled with the Report of the Royal Commission into Aged Care Quality and Safety – an important piece of work, but just the latest in a long series of inquiries into aged care – the pandemic has surely demonstrated to everyone’s satisfaction that Australia’s aged care system needs massive, urgent change. It is under-funded, under-staffed and inadequately regulated.

To date the residential aged care sector in Victoria has been the location of the largest group of Covid deaths in Australia. Down the track it will be useful and important to unpick the evidence about rates of mortality, management and ownership structures, staffing, and emergency procedures in that sector.

The results of such analyses will be valuable in the consideration of changes that, at last, seem inevitable.

There are fundamental questions about whether the Commonwealth has the capacity and skills to manage aged care, including the regulation of staffing. The pandemic has also laid bare basic questions about the legal rights and responsibilities of residential aged care facilities, for instance in relation to the mandating of staff vaccination.

There will be studies and comparisons made of the performance of various Health Departments – Federal, State and Territory. In particular, their public health operations and staff will come under close scrutiny. Also under the microscope will be Australia’s body of public health and related health professionals, and the research, teaching and practice settings in which they work.

The universities will be able to claim the Australian response to the pandemic as evidence of the need for extra investment in public health and other health-related research and teaching, as well as in clinical practice.

It is certain that the capacity of our health system and the agencies within it to do effective public relations and communications (‘messaging’), and for the management of data, will come under particular scrutiny. Eighteen months ago we were promised an open approach to the decisions made in the pandemic and the modelling behind them, and the numbers of patients involved. In fact the data systems relating to the pandemic, and relating to vaccination in particular, have been appalling.

Efficiency of the public service

 The pandemic has drawn attention to a number of matters related to the confidence and flexibility of institutions in the health sector. Given the daily widespread publicity associated with the pandemic, the public has had the opportunity to peek inside Health Departments and health research agencies. We have become familiar with some of the country’s epidemiologists and we now have some idea of what they do.

Overall Australia seems to be well-placed where public health management and research are concerned. As someone who has been glued to current affairs television, I can attest to the fact that the nation’s public health professionals have proved themselves to be a hard-working and charming lot, whether from research institutes, universities or state health agencies.

When it is time, there will inevitably be comparisons drawn between the various agencies that have been ‘out front’ during the pandemic. Underlying the criticism of the Federal response on vaccination is the question of the efficiency or competence of the Federal Department of Health. There will be comparisons of the efficiency with which various jurisdictions have undertaken the tracking and tracing work which have been so central to suppression of the virus.

At one stage in 2020 the differences in the apparent success of suppression activities as between the two largest States were attributed to the different structure of public health activity in the respective jurisdictions. This is the kind of assertion it will be useful to analyse.

One of the most surprising things has been a general inability of governments and the public service to inject a real sense of urgency into responses to the pandemic. This is particularly the case for the vaccination regime. The Commonwealth knowingly grabbed responsibility for vaccination at the beginning, presumably because it seemed to be an obvious way in which to win political points and public support. However it turns out that, on vaccines and vaccination, the Commonwealth is now being slowly hoist by its own petard.

The lack of urgency related to vaccination has been compounded by mixed messaging and uncertainty as to what arrangements relate to which parts of the population and to which vaccine at any given time. There has been  no decent information campaign, no use of appropriate celebrities.

Clear messaging is important but is a second order issue if the target for the messaging is uncertain. A good campaign will be one that achieves some specific action or attitude. But it has not been clear whether ‘a good campaign’ would be one that moves people to be supportive of vaccination, or inspires them to get an appointment with ‘their GP’ (if they have one), or drive to a pop-up clinic, or attend a health clinic, ask at the local pharmacy, run the gauntlet of an on-line system or phone the dreaded telephone number to learn what number they are in the queue.

At the risk of seeming parochial, it may be that the ACT has been  an exception to the charge of failing to take urgent action. Just down the road from my home, a cricket ground was transformed eighteen months ago into a temporary field hospital for Covid-19. It cost $23 million and was built in just 37 days. In May 2020 it was thought that it would never be used. It is now a vaccination hub for the administration of the Pfizer vaccine.

Care of vulnerable groups

One of the worst characteristics of the vaccination regime has been its failure to identify and treat population groups in order of their vulnerability to illness and hospitalisation as a result of Covid-19.

 When comes the time for evaluation of what went wrong there will be important lessons to learn about who is vulnerable, in what settings, and how their needs can be swiftly met. It will be clear that there then needs to be clear communication of these priorities, built in to the schedule or road map made public.

So far, when it comes to protection from risks, elderly people in residential care and at home, and people with a disability, have been badly let down.

It was during the 2020 lockdown in Victoria that the majority of Australia’s pandemic deaths occurred. The greatest number of those deaths was among elderly patients in aged care accommodation. And in this group a disproportionate number were in private aged care institutions rather than the State’s public facilities. This raises the question as to whether there are some structural, attitudinal or operational characteristics of facilities in the various sectors which may help to explain the different rates of illness and mortality.

In contrast to care of the elderly and those with a disability, one of the standout successes of Australia’s suppression of the Covid-19 virus to date has been with Aboriginal and Torres Strait Islander people. Aboriginal and Torres Strait Islander communities have barely been affected. It will be important and useful to understand how and why this has been the case – and critical to prioritise Aboriginal and Torres Strait Islander people in the vaccination queue, especially communities in more remote areas where there are limited numbers of health clinicians.

[See Part 3 of this post: Some better news]

If enough of us ever get vaccinated to overcome the immediate emergency, it will be useful to take time to reflect on the medium-term implications of the global pandemic for the governance of Australia and the world. There is much to be done and much we can learn. The first of three parts, this piece reflects on some of the global issues it will be useful to evaluate.

PART 1: Globalisation

The pandemic has thrown new light on the benefits and costs of globalisation.

The economic status of Australia and the well-being of its citizens are closely tied to aspects of globalisation. Australia is a relatively small economy with limited domestic demand. The nation has prospered through having natural resources in abundance which, given a worldwide free trade regime, can be sold to countries less well endowed.

However the pandemic has woken Australia to the risks of too great a dependence on globalisation. It is now clear that the single most serious issue for the nation is supply of vaccine. In preparing for vaccination, the Federal Government made errors in commissioning and negotiating supply from other nations. This was compounded by decisions made by some of those other nations which were in their own interests and over which Australia had no control.

The problems posed by the absence of sovereign capacity to manufacture goods and services that become essential when the world faces a widespread emergency were apparent even before vaccination started. There were shortages of items of personal protective equipment and hand washing gel (in the days before we understood that soap and water was best). These were mitigated to some extent by the flexibility of some manufacturers who re-tooled rapidly; and by home-grown household activity, such as mask-making.

Incidentally, perhaps it would be wise to include toilet paper as a bottom-line commodity in forthcoming trade agreements that Australia signs.

On the other side of the globalism ledger, the pandemic led very rapidly to the effective closure of two of Australia’s major export sectors and employers: international tourism and international education. This was caused by interruption of another key element of globalism: the free and untrammelled movement of people around the world.

Fortunately the export of natural resources, particularly iron ore and coal, as well as agricultural produce, seems to have proceeded unabated. The astonishing increase in the international price for iron ore, not related to the pandemic, has done much to shelter Australia from the worst economic effects of Covid-19.

Building manufacturing capacity and finding ways to make existing industries more resilient will have beneficial economic effects. Just as the shift to renewable energy sources is making new industries economic, so will national re-tooling for greater emergency self-sufficiency help to build Australia’s economy and provide employment opportunities.

Moves to mitigate against inadequate supply of goods and services needed in an emergency, and in response to the decline of major industries, provide incentives for Australia to rebuild its manufacturing sector. In the 1960s manufacturing provided one quarter of GDP. By 2010 this had fallen to 6%, providing 8.6% of employment. In 2020 it was 4.2% of GDP and 7% of employment –  or 853,000 people.

The Federal Government has indicated that it has plans for what it calls A Sovereign Manufacturing Capability Plan. It will apparently cover business opportunities both small and large, from manufacturing for niche markets right through to the production of guided weapons.

International agencies

As a middle-sized nation which benefits from both international trade and the rule of law, Australia has traditionally been a strong supporter of the bastions of globalism: multilateralism and international agencies. Once the health emergency is over it will be useful to scrutinise the performance of these agencies and to act on lessons learned about their structure, operation and value.

The agency most closely involved in the pandemic has obviously been the World Health Organisation (WHO). The majority view seems to be that the WHO had a poor start due to being slow in declaring the novel coronavirus outbreak ‘A public health emergency of international concern’, its highest level of alarm. Some commentators have attributed this to sensitivity about China’s potential reaction to such a declaration.

Since then, the WHO has been a critical and positive contributor to management of the pandemic. The challenge for the WHO was all the greater given that it was confronted by active opposition from the United States under Donald Trump. He cut funding for the WHO in May 2020.

Some of the WHO’s most important work is concerned with global vaccine equity and thegap between richer and poorer nations – the so-called ‘two-track pandemic’. The scale of this challenge is illustrated by the fact that several affluent countries are already discussing the rollout of booster shots to their populations, while the majority of people in developing countries—even front-line health workers— have still not received their first shot.

This is a matter that needs urgent international agreement and action, in which Australia, as an affluent country, should take an active part. There is much to be done in the medium term to make the world a fairer place before the next pandemic or similar crisis emerges.

The most critical immediate task in world health is to ensure that developing nations are given all necessary support for obtaining and using vaccines. Supply in sufficient quantities is the core challenge and spreading it fairly between richer and poorer nations. One way to achieve this would be to assist medium-sized countries to establish the capacity for producing vaccines. Cost is a key factor and it is to be hoped that ways can be found for the sort of generosity shown by governments and the private sector over the last 18 months to continue to be demonstrated.

Given the massive impact on world trade and damage  to the budgets of all countries, including those that are affluent that have been donors of international aid, the impact of the Covid-19 emergency on the people and governments of poorer countries may yet become unmanageable.   

Much will depend on the role played by international aid and trade in the new order.

One particular example of successful collaborative international action is COVAX. Its aim is to accelerate the development and manufacture of Covid-19 vaccines, and to guarantee fair and equitable access for every country in the world. Among other things it is working to ensure that donations of vaccine to developing countries are synchronized with national vaccine deployment plans.

Apart from the WHO, international agencies concerned with the pandemic include the International Monetary Fund (IMF), the World Trade Organisation (WTO), the World Bank and the OECD.

The IMF is preparing a Special Drawing Rights (SDR) allocation to boost the financial reserves and liquidity of its members.

The WTO is involved because cooperation on trade is needed to ensure free cross-border flows and increasing supplies of raw materials and finished vaccines. It is working on negotiations towards a solution around intellectual property, which remains the main sticking point in relation to making medications available at low prices. The WTO is also working on freeing up supply chains for vaccines and other medicines. 

The World Bank has provided a $12 million financial facility for vaccination and has vaccine projects in some 50 countries.

In anticipation of an end to the immediate Covid crisis, preparations can begin for evaluation of the way international agencies have performed since the beginning of 2020.

Note: a version of this piece was published in Pearls and Irritations, 19 July 2021 as ‘Covid 19 has revealed the weaknesses but also the importance of globalisation.’

[See Part 2 in Aggravations.org: The Covid pandemic and the Australian Federation]