Search

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. [ABSTRACT FROM AUTHOR]

The potential for regulatory measures to address escalating rates of obesity is widely acknowledged in public health circles. Many advocates support regulations for their potential to reduce health inequalities, in light of the well-documented social gradient in obesity. This paper examines how different social groups understand the role of regulations and other public health interventions in addressing obesity. Drawing upon focus group data from a metropolitan city in southern Australia, we argue that implementing obesity regulations without attention to the ways in which disadvantaged communities problematise obesity may lead to further stigmatisation of this key target population. Tuana's work on the politics of ignorance, and broader literature on classed asymmetries of power, provides a theoretical framework to demonstrate how middle class understandings of obesity align with dominant ‘obesity epidemic’ discourses. These position obese people as lacking knowledge; underpinning support for food labelling and mandatory nutrition education for welfare recipients as well as food taxes. In contrast, disadvantaged groups emphasised the potential for a different set of interventions to improve material circumstances that constrain their ability to act upon existing health promotion messages, while also describing priorities of everyday living that are not oriented to improving health status. Findings demonstrate how ignorance is produced as an explanation for obesity, widely replicated in political settings and mainstream public health agendas. This politics of ignorance and its logical reparation serve to reproduce power relations in which particular groups are constructed as lacking capacity to act on knowledge, whilst maintaining others in privileged positions of knowing. [ABSTRACT FROM AUTHOR]

This paper examines the spatio-temporal disjuncture between ‘the future’ in public health obesity initiatives and the embodied reality of eating. Drawing upon ethnographic fieldwork in a disadvantaged community in South Australia (August 2012–July 2014), we argue that the future oriented discourses of managing risk employed in obesity prevention programs have limited relevance to the immediacy of poverty, contingencies and survival that mark people's day to day lives. Extending Bourdieu's position that temporality is a central feature of practice, we develop the concept of short horizons to offer a theoretical framework to articulate the tensions between public health imperatives of healthy eating, and local ‘tastes of necessity’. Research undertaken at the time of Australia's largest obesity prevention program (OPAL) demonstrates that pre-emptive and risk-based approaches to health can fail to resonate when the future is not within easy reach. Considering the lack of evidence for success of obesity prevention programs, over-reliance on appeals to ‘the future’ may be a major challenge to the design, operationalisation and success of interventions. Attention to local rather than future horizons reveals a range of innovative strategies around everyday food and eating practices, and these capabilities need to be understood and supported in the delivery of obesity interventions. We argue, therefore, that public health initiatives should be located in the dynamics of a living present, tailored to the particular, localised spatio-temporal perspectives and material circumstances in which people live. [ABSTRACT FROM AUTHOR]