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Public policy plays a central role in creating and distributing resources and conditions of daily life that matter for health equity. Policy agendas have tended to focus on health care delivery and individualised interventions. Asking why there is a lack of policy action on structural drivers of health inequities raises questions about power inequities in policy systems that maintain the status quo. In this paper we investigate the power dynamics shaping public policy and implications for health equity. Using a Health Equity Power Framework (HEPF), we examined data from 158 qualitative interviews with government, industry and civil society actors across seven policy case studies covering areas of macroeconomics, employment, social protection, welfare reform, health care, infrastructure and land use planning. The influence of structures of capitalism, neoliberalism, sexism, colonisation, racism and biomedicalism were widely evident, manifested through the ideologies, behaviours and discourses of state, market, and civil actors and the institutional spaces they occupied. Structurally less powerful public interest actors made creative use of existing or new institutional spaces, and used network, discursive and moral power to influence policy, with some success in moderating inequities in structural and institutional forms of power. Our hope is that the methodological advancement and empirical data presented here helps to illuminate how public interest actors can navigate structural power inequities in the policy system in order to disrupt the status quo and advance a comprehensive policy agenda on the social determinants of health equity. However, this analysis highlights the unrealistic expectation of turning health inequities around in a short time given the long-term embedded power dynamics and inequities within policy systems under late capitalism. Achieving health equity is a power-saturated long game.

This paper applies a critical analysis of the impact of neo-liberal driven management reform to examine changes in Australian primary health care (PHC) services over five years. The implementation of comprehensive approaches to primary health care (PHC) in seven services: five state-managed and two non-government organisations (NGOs) was tracked from 2009 to 2014. Two questions are addressed: 1) How did the ability of Australian PHC services to implement comprehensive PHC change over the period 2009–2014? 2) To what extent is the ability of the PHC services to implement comprehensive PHC shaped by neo-liberal health sector reform processes? The study reports on detailed tracking and observations of the changes and in-depth interviews with 63 health service managers and practitioners, and regional and central health executives. The documented changes were: in the state-managed services (although not the NGOs) less comprehensive service coverage and more focus on clinical services and integration with hospitals and much less development activity including community development, advocacy, intersectoral collaboration and attention to the social determinants. These changes were found to be associated with practices typical of neo-liberal health sector reform: considerable uncertainty, more directive managerial control, budget reductions and competitive tendering and an emphasis on outputs rather than health outcomes. We conclude that a focus on clinical service provision, while highly compatible with neo-liberal reforms, will not on its own produce the shifts in population disease patterns that would be required to reduce demand for health services and promote health. Comprehensive PHC is much better suited to that task.

Next generation telecommunications infrastructure is expanding and supporting rapid growth of broadband technologies and a digital economy. In this context, digital information and communications technologies (ICTs) are of increasing importance as a means for people to gain access to health or social services, employment opportunities, information and social networks. In this article we draw on our recent case study research to examine the policy (and politics) shaping implementation of Australia's National Broadband Network (NBN) and its likely effects on equity of access to high speed broadband (HSB) services. We monitored NBN policy and implementation from 2015 to 2018 through policy documents, reports, and media. To assess likely effects of NBN policy on implementation and subsequently on equity of access to HSB we: a) applied a framework defining four elements of equity of access; and b) analysed stakeholder views drawn from media articles and 22 interviews with experts on NBN policy including politicians, government staff, and industry representatives. We found that equity considerations competed with political and commercial imperatives during the rollout of the NBN. This resulted in positive and negative consequences for equity of access to HSB, with a change in policy and implementation in 2013 bringing greater risks to equity of access. The case study provides a framework for considering equity in the implementation of next generation telecommunications infrastructure and highlights the importance of considering equity in the evaluation of telecommunications infrastructure.

The 1978 World Health Organisation Alma Ata Declaration on Primary Health Care (PHC) emphasised a comprehensive view which stressed the importance of cure, prevention, promotion and rehabilitation delivered in a way that involved local communities and considered a social, economic and political perspective on health. Despite this, selective approaches have dominated. This paper asks why this has been the case in Australia through a multi-method study of regional PHC organisations. Interviews with senior policy players, focus groups with non-government organisations and document analysis inform an institutional and power analysis of PHC. The findings indicate that there are different interests competing for attention in PHC but that medical perspectives prove the most powerful and are reinforced by the actors, ideas and institutions that shape PHC. Community perspectives which stress lived experience and social perspectives on health are marginal concerns in the implementation of PHC. The other important interest is that of a neo-liberal perspective on health policy which stresses cost-containment, close measurement of activity and fragmented contracting out of services. This perspective is not compatible with a social determinants of health perspective and can also conflict with a medical view. The result of the interplay between competing interests and the distribution of power is a selective PHC system that is not likely to change without radical shifts in power and perspectives.

Background There have been increasing national and international calls for the introduction of drug testing as a policy measure to address harmful drug use. Such strategies have been applied in workplaces, sporting arenas, prisons and more latterly school settings. They are predicated on a belief in their efficacy in reducing drug-related harm, a need to ‘send the right' message to potential users and to reassure the community at large that ‘something is being done.' Rigorous examination is required of purported benefits of drug testing in schools. Methods A comprehensive examination was made of testing efficacy and accuracy. Australian legal and ethical issues, encompassing duty of care, rights of the child and privacy determinations, were juxtaposed with that of the United States of America. Results Evidence examined indicates no compelling case for the application of drug testing and that caution should be applied when considering drug testing as a drug detection and prevention strategy in the school setting. Conclusion While this review did not support school drug testing, there are alternative evidence-based strategies that schools can implement to prevent drug-related problems among student populations.

To conduct a systematic review of hospital alcohol screening studies to identify effective and efficient evidence-based strategies.Sixty-five studies (N=100,980) of alcohol problem prevalence amongst hospital patients were reviewed.Prevalence of positive alcohol screens varied according to hospital location, screening tool and patient characteristics. BAC measures (26%) were nearly twice as likely (OR=1.92, p.001) to reveal positive screens in the ED than self-reports (16%). No difference was found in prevalence of self-report positive screens between ED (16%) and ward settings (17%). Males were two to four times more likely than females to screen positive (BAC: OR=2.37, p.001, ED self-report: OR=3.07, p.001, ward self-report: OR=4.30, p.001). ED patients aged 20-40 years and ward patients aged 30-50 years had the highest prevalence of positive screens.Prevalence of risky or problematic drinking among hospital patients is high and warrants systematic screening and intervention. Many hospitals lack sufficient resources to undertake widespread screening programs. For optimum return on resources, it is recommended to screen males in the ED using BAC measures. Established protocols applying priority criteria and staff training can increase screening accuracy and effectiveness.