What will the next health reform agreement bring?

BY ASSOCIATE PROFESSOR SUSAN NEUHAUS, CHAIR, HEALTH FINANCING AND ECONOMICS COMMITTEE

The Health Financing and Economics Committee (HFE) has a very keen interest in the likely direction and detail of the next public hospital funding agreement that will take effect from 2020.

Negotiations between the commonwealth and State Health Ministers will begin in earnest in 2018 but early signs of the likely reform agenda are emerging, with some consistent themes coming to the fore. Unsurprisingly, most of these themes are a continuation of the changes to public hospital financing agreed by all Australian Governments in June 2017 as documented in the National Health Reform Addendum.[1] Whether States and Territories agree is hard to predict and will likely depend on how much new funding, and over what period, the Commonwealth Government is prepared to offer it.

The themes in the Addendum we would expect to see considered as part of a 2020 agreement are:

i. improve patient outcomes;

ii. decrease avoidable demand for public hospital services;

iii. improve the coordination of care for patients with chronic and complex conditions to reduce avoidable demand for hospital admissions for this group;

iv. incentives to reduce preventable, poor quality patient care; and

v. incorporate quality and safety into hospital pricing and funding to reduce poor quality patient care: sentinel events, hospital acquired complications and avoidable readmissions.

Recent media speculation[2] [3] suggests Minister Hunt will seek COAG agreement to reward jurisdictions that can demonstrate improved patient outcomes, with the goal of readmissions over the short term being avoided.

Such a move may also represent the first step towards ‘outcome based’ hospital funding. Media speculation[4] also suggests the government will frame the push as a reduction in ‘low value care’. It is likely not coincidental that the Productivity Commission released a report on 24 October 2017 that recommends low value care in public hospitals should not be funded[5]. Of course, what is finally argued by the Commonwealth in the lead-up to the negotiations with State Ministers is yet to be seen – but it is clear they are laying the groundwork.

On the topic of coordinated care, it is worth noting that jurisdictions already have the ability to enter bilateral agreements to trial coordinated care initiatives, for the 2017-2020 period. These are intended to inform the development of an evidence-based national approach in the 2020 funding agreement – but clearly we are also in early days of this work.

The National Health Reform Addendum reforms might be worthy in the abstract – it is hard to argue against improved patient outcomes, a reduction in preventable poor quality patient care, better care coordination across the boundary of admitted/non-admitted care – especially for patients with one or more chronic conditions.

But whether they are they worthy in practice depends entirely on how they are implemented. For example, shifting public hospital funding away from payments based on cost and quantity to a formula based on patient outcomes represents a massive organisational change for the public hospitals delivering the care. They will require substantial additional funding to build the necessary organisational capacity. And this will take time.

Outcome-based funding will also require substantial new government investment in data infrastructure to collect and measure robust clinical patient outcome data – not just patient reported outcomes, which may or may not be clinically relevant. It must include patient outcomes in the non-admitted setting. This capacity does not yet exist. We first need robust, consistent primary healthcare data definitions used and recorded by all primary healthcare providers. The primary and tertiary outcomes data must be linked. And if the Government is serious about linking outcomes to funding and ‘quality’ then it would need to develop an entire framework of quality-adjusted life year (QaLYs) per episode of care. Overcoming the constraints and barriers inherent in a health system that is structured within a federated system of government is no small feat, nor will it be cheap.

So far, the AMA has been bitterly disappointed in the Government’s opportunistic use of the ‘improved safety and quality’ agenda to do little more than reduce the Commonwealth’s share of public hospital funding. My Australian Medicine article published on the September 18, 2017 summarises this. The AMA will be carefully examining the detail of the 2020 health care agreement to ensure it is a genuine effort to empower public hospitals, including in providing them with the resources they will need to successfully transition to outcomes based funding with improved care-coordination. These are massive reforms that will require time, a clearly articulated evidence-based pathway and substantial new Commonwealth investment, not less.

[1] Schedule I – Addendum to the National health Reform Agreement: Revised Public Hospital Arrangements, p1, 2017.

[2] Parnell S GP Patient Incentives – Rewards to reduce crush in hospitals Weekend Australian 29/7/2017 p10-11

[3] Avoiding hospital admissions a priority, The Pharmacy Guild of Australia, 27 September 2017

[4] Martin P Education, health face shake-up, The Age, 23 October 2017 p 4

[5] Shifting the Dial:5 Year Productivity Review, Productivity Commission, 2017

Close the clean drinking water gap

BY AMA PRESIDENT DR MICHAEL GANNON

Safe drinking water is an indispensable human right. The leading national and international health bodies, such as the World Health Organization and the United Nations, all agree that safe drinking water is essential to sustain life, and a prequisite for the realisation of other human rights. The UN General Assembly explicitly recognises the human right to clean drinking water.

Having access to sufficient, safe, accessible and affordable drinking water is an important public health issue.

In developed nations such as Australia, it is often assumed that safe drinking water is accessible to all. However, this is not the case, particularly in many remote or very remote communities where artesian (bore) water is often the primary source of drinking and household water.

According to the Bureau of Statistics (2007), for discrete Indigenous communities the majority accessed bore water (58 per cent), while other sources of water included: town supply (19 per cent), river or reservoir (5 per cent), rain water tank (3 per cent), well or spring water (3 per cent), and other sources of water (2 per cent).

While the supply of potable water (defined as waterthat is safe to drink or to use for food preparation, without risk of health problems) impacts on all people living in remote areas of Australia, Aboriginal and Torres Strait Islander people are disproportionately affected.

Many Aboriginal and Torres Strait Islander people living remotely find it challenging to obtain water that is of sufficient quantity (and quality) to meet their needs.

In 2012, the Australian Bureau of Statistics estimated that there were more than 400 discrete Aboriginal communities across Australia, with the largest number in Western Australia. Data collected on over 270 remote WA communities indicated that the quality of drinking water did not meet the Australian standards, as outlined in the Australian Drinking Water Guidelines (ADWG), approximately 30 per cent of the time.

While the National Health and Medical Research Council (NHMRC) has responsibility for the ADWG, this is not a mandatory standard, with State and Territory Governments and local councils responsible for the implementation and monitoring of water quality and safety. Yet during the two year period 2012-2014, 80 per cent of remote Aboriginal communities in Western Australia failed to meet quality standard testing at least once.

There are obvious health consequences from drinking poor quality water. Some Aboriginal communities are known to have unsafe levels of chemical contaminants such as nitrates and uranium in the water. Nitrates and uranium occur naturally, and are common in the Goldfields and Pilbara regions.

‘Blue Baby Syndrome’ – where an infant’s skin shows a bluish colour and they can have trouble breathing – can be caused by excessive nitrates in the diet, which reduce the blood’s ability to carry oxygen. It can occur where prepared baby formula is made with well water. Water tested in over 270 remote communities in WA showed nitrate levels 10 times the recommended levels.

It is concerning that Aboriginal and Torres Strait Islander people living remotely often have no choice but to pay for safe drinking water. While the majority of us enjoy free, safe drinking water from the tap, those who can least afford it often have to pay just to ensure they are not drinking water sourced from rivers, streams, rivers, cisterns, poorly constructed wells, or water from an unsafe catchment.

The AMA is a member of the Close the Gap steering committee and the Public Health team has raised potable water as a Close the Gap target.

The solution may not just be in more bottled water. In communities without adequate recycling and waste disposal services, thousands of extra plastic water bottles create additional environmental problems.

Governments must invest in infrastructure, such as proper treatment facilities, water storage facilities and distribution systems to meet the changing demands of communities.

All Australians must have permanent and free access to safe water. It is a basic human right and it is difficult to understand how this hasn’t already been implemented and addressed.

Encouraging times for rural health

BY AMA VICE PRESIDENT DR TONY BARTONE

Readers of this column will know that improving access to health care for rural Australians is one of my chief motivating passions.

We know there are many indicators that show people living in the bush generally suffer worse health outcomes than those in major cities.

Regrettably, many of the initiatives put in place to increase training places in rural Australia and expand the local medical workforce have not improved these discrepancies, kept pace with the demand for rural medical services, nor resulted in a better distribution of suitably qualified doctors.

The challenge remains – we need to get doctors to rural communities, and give them the opportunity to experience rural and remote medicine and make it an attractive and valuable career option.

Some may feel achieving real change is a truly Sisyphean task.

But with the recent appointment of Professor Paul Worley as the nation’s new Rural Health Commissioner, there is perhaps some cause for optimism. Professor Worley has made a substantial contribution to rural health over many years; all of his experience will be needed for this welcome opportunity to build a strong health care workforce in regional, rural and remote Australia.

One of Professor Worley’s important tasks is to help the Government design and roll out a national rural generalist pathway. The pathway will try to address the lack of access to training for rural generalists with the ultimate aim of improving the supply of doctors to rural and regional communities.

Many people have been waiting for the announcement on the Rural Health Commissioner for a long time; we are not alone in believing that Australia’s medical workforce needs more generalists to meet the healthcare needs of rural (and metropolitan) communities as the demographics of the population shift and the numbers of patients with long-term chronic conditions and co-morbidities rises.

The AMA has been championing for a long time an improved and expanded advanced training pathway for rural generalists, with the proper resources to attract and train the appropriate number of doctors with the right skills mix necessary for rural practice.

The Queensland Rural Generalist Pathway is often put forward as the model for vocational training that could increase the numbers of doctors training and staying in rural locations, and able to deliver a broad range of hospital and community-based medical services, as well as the much-needed specialised services.

The Queensland model is a good starting point, and there is the potential to apply its principles to a national pathway that can be adapted to suit the geography and demographics of different regions.

Nonetheless, there are some contentious and vexing issues that will need to be addressed as the national rural generalist pathway is conceived and put into effect. For example, should there be quarantined procedural training places for rural generalist trainees? Should some thought be given to extending the training pathway beyond general practice as a strategy for ensuring a balanced rural workforce with the right skills mix?

Concerns around accreditation, training and recognition will need serious collaboration between the Colleges and health services.

Several AMA committees are considering the design principles for the national rural generalist pathway.

We look forward with great purpose to meeting with Professor Worley soon to discuss our ideas. Overall, the signs are positive for rural health.

Progress and barriers to a digital health upgrade

In collaboration with Harvard Business Review Analytic Services, Microsoft has published a briefing paper that highlights the progress being made in digital-enabled health care, the barriers to progress, and how a digitally augmented system can improve the lives of all Australians.

Microsoft sought input from Australian experts on the current and future state of our health care system and has released Embracing the Change Mandate: The 2020 Digital Transformation Agenda for Australia’s Health Care Sector.

Establishing a new digital health care system is complex.

“We need to deliver care; reduce errors, waste, and duplication of services; and create a sustainable system amid growing expectations and financial constraints,” says Professor Johanna Westbrook, Director of the Centre for Health Systems and Safety Research (CHSSR) at Macquarie University in Sydney.

The report states there are key steps for leveraging digital technologies: working towards full digital transformation; localising international technology options; collaborating with technology providers and IT staff; sharing lessons learned within the sector; promoting digital success; and developing digital health skills.

With Australian healthcare organisations clearly moving down the track to digital health initiatives, many have seen positive results.

Richard Royle at PricewaterhouseCoopers Australia believes the evidence supports electronic records leading to improved length of stay and clinical outcomes.

“The ability to document, in an electronic record, the clinical pathways to follow for diagnoses produces greater consistencies of clinical outcomes and reduces readmissions,” he says.

However, there are still digital challenges needed to be overcome.

Dr Andrew Hugman of South East Sydney Local Health District, part of NSW Health, also contributed to the report and believes there needs to be greater engagement across all stakeholders.

“Many clinicians believe health IT projects create barriers to patient care as opposed to being the crucial tools for delivering the potential for massive gains,” he says.

“Once there is a better awareness from both the public and clinicians of how we can use the huge amount of health data we are collecting, there will be more drive for greater transparency to interrogate and analyse the data.”

The AMA provided a submission earlier this year to the Joint Standing Committee’s inquiry into the rollout of the National Broadband Network (NBN). The submission focused on broadband access for regional, rural and remote health services, while centred around the principle that all Australians, regardless of where they live or work, should have equitable access to high-speed and reliable internet services.

The submission highlights that the NBN is a necessary and worthy investment that is needed to enhance the important contribution made by regional areas to Australia’s economy. It notes that the economic and social benefits of advances in information and communications technology can only be fully realised through access to fast, reliable and affordable broadband services.

However, the submission notes there are many regional rural and remote areas that have very poor broadband connection. Internet services delivered via satellite only make available relatively small download allowances and these come at a much higher cost and slower speed than those services available via fibre or fixed wireless in metropolitan areas. The submission stresses that this ‘data drought’ must be addressed as a matter of priority.

Among other things, the AMA has urged the Government to find ways to extend the boundaries of the NBN’s fibre and fixed wireless footprints into the satellite footprint wherever possible to lessen the reliance on satellite for those living in rural and remote Australia and to address the increase in internet usage over time.

A copy of Microsoft’s report can be found here: https://sendto.stwgroup.com.au/message/JNd9m1h4J9MGnIf0yE9CDo/YBqDGbzcKslfYjQVos48fE/xHupsBS0HNo4x2VyBLPkhH/20624_HBR_Briefing%20Paper_Microsoft_Health.pdf

The AMA’s response to the Joint Standing Committee’s inquiry into the rollout of the National Broadband Network (NBN) can be found here: https://ama.com.au/system/tdf/documents/AMA%20submission%20to%20Joint%20Standing%20Committee%20on%20the%20NBN.pdf?file=1&type=node&id=46166

MEREDITH HORNE

Senate Committee hears AMA on private health insurance

AMA President Dr Michael Gannon appeared before the Standing Committee for Community Affairs Senate Inquiry into the Value of Private Health Insurance on 31 October, supplementing the AMA submission lodged with the Committee in July.

Dr Gannon told the Committee that the private system is an essential part of the health system and working with the public system to deliver the care Australians expect and deserve.

But he also began dispelling a few myths about the causes of consumer discontent with private health insurance.

Out-of-pocket medical costs are not the cause of discontent among consumers with their health insurance, he said.

“Most consumers understand that they may need to contribute to the cost of their care,” Dr Gannon said.

“The problem facing consumers is that they believe they are covered, but have inadvertently purchased a product that is, unfortunately, useless. If a policy does nothing more than avoid the tax penalty, it is a junk policy.

Out-of-pockets costs are not growing. The proportion of health expenditure funded by individuals, not Government or insurers, has remained relatively static at 17 per cent over the decade to 2015-16.

Importantly, of that 17 per cent of health expenditure funded by individuals, only 10 per cent is spent on medical services. The majority of individual expenditure is on dental services and pharmaceutical products. Out-of-pocket medical expenses are a small proportion of what patients pay for their healthcare.

“The second myth is that medical expenses are the cause of increased premiums,” Dr Gannon told the Committee.

“Medical expenses are a small proportion of total benefit outlays for private health insurers. Medical expenses, as a proportion of benefits, have remained static at around 16 per cent since 2007.

“In fact, administration expenditure by private health insurers is around 10 per cent. So it is costing insurers almost as much to run their business as it is to pay for the practitioners who treat their customers.”

With regard to individual out-of-pocket costs, the AMA has a clear position that it does not support exorbitant charges or egregious fee setting, i.e. fees that the majority of a practitioner’s peers would consider to be unacceptable.

Further AMA position statements maintain that providing informed financial consent is not only best practice, it is demanded by medical ethics.

The clear majority of practitioners charge a reasonable amount. The vast majority of health care provided in Australia is provided at no direct cost to the patient. 88.1 per cent of services are provided at no-gap and a further 6.9 per cent have a known-gap charge of less than $500.

A major source of gaps is the extended freeze on Medicare Benefits Schedule rebates, which has led to insurers also freezing payments to doctors or indexing well below inflation.

The MBS continues to fall behind. Health inflation has sat between 3.6 per cent and 6.6 per cent per annum over the past seven years. Over the same period of time, PHI premium increases have been between 4.8 per cent and 6.2 per cent. Even when it was not frozen, MBS rebates have increased at best by 2 per cent, meaning that the MBS rebate is far removed from the cost of providing a quality specialist service.

Dr Gannon then turned to the next challenge for this inquiry. It is an issue of social policy – what is the role of the private health insurer?

From the AMA’s perspective, he said, it is a payer for medical services, not a manager of clinical care.

“Private health insurers are moving private health care in Australia towards a system similar to that of the United States – a ‘managed care’ system,” Dr Gannon said.

“Health insurers in Australia are focused on minimising their expenditure and are creating barriers for patients accessing care. These are the same patients that have paid substantial premiums for top cover.

“Who is running the health system? The shift to a for-profit industry has created the need to ensure that there are sufficient profits to allow a return to shareholders. APRA data show an industry surplus (before tax) of $1.56 billion for the 2015-16 financial year, up from $1.45 billion for the previous year.”

This inquiry has come at a crucial time. Insurers are understandably concerned about the viability of the sector.

Insurers need to improve their offerings. Insurance products should be easy to understand, payments should be made on clinical need, and the ‘de facto’ risk rating system created through products with incomprehensible exclusions and ‘carve-outs’ needs to cease.

The AMA supports a system of Bronze, Silver and Gold product standards. All policies should cover maternity services and mental health services.

The policies must be based upon an agreed set of standard understandable clinical definitions, Dr Gannon stressed, saying the categories must be more than labels. “The review into private health and the Government needs to deliver on removing the policy confusion from the 20,000-plus policies,” he said.

CHRIS JOHNSON

Government’s Brain Cancer Mission

The Federal Government has announced a $100 million funding plan to rapidly increase brain cancer survival by bolstering patients’ access to clinical trials and accelerating the discovery of new therapies.

This will be done by expanding research platforms and technologies, and equipping researchers with the best tools and infrastructure.

The Australian Brain Cancer Mission is a partnership between the Federal Government, philanthropists, medical experts, patients and their families.

As a first step, the Government is providing $50 million through the Medical Research Future Fund (MRFF), combined with $10 million from the Minderoo Foundation’s Eliminate Cancer Initiative and a commitment of $20 million from Cure Brain Cancer Foundation.

The Government is expected to announce the remaining $20 million in the coming months.

Health Minister Greg Hunt said the commitment was made with the aim of halving deaths from brain cancer over the next decade and to “imagine the potential in our lives to eliminate brain cancer as a fatal disease”.

The Mission is underpinned by a research roadmap developed by Australian and international experts in brain cancer treatment and research, and those affected by brain cancer, their advocates and philanthropic interests.

Cure Brain Cancer Foundation chief executive officer Michelle Stewart said the announcement: “makes a massive difference in the new activities that can be started up, but also in terms of providing a spotlight for brain cancer.

“We’ve never had an overall strategic framework or a plan for tackling brain cancer and now we have a national plan.”

Ms Stewart said brain cancer killed more than 30 children in Australia each year, more than any other disease. It also kills more people aged over 40 than any other type of cancer.

A key objective of the Australian Brain Cancer Mission is to ensure every patient, adult and child in Australia has the opportunity to participate in clinical trials.

“We want to get every Australian who has brain cancer the opportunity to be part of a clinical trial to address their particular type of brain cancer, there are more than 100 subtypes, and at the end of the day our goal is to halve mortality rates over the course of the next decade, but ultimately to defeat it as part of a global initiative,” Minister Hunt said.

Prioritised first investments include the establishment of an Australian arm of the GBM AGILE, an international adaptive trial platform for adults with glioblastoma, which will be co-funded by the Turnbull Government, the Minderoo Foundation’s Eliminate Cancer Initiative and Cure Brain Cancer Foundation.

Other priorities include new funding for Australian and New Zealand Children’s Haematology Oncology Group (ANZCHOG) clinical trial centres, and support for the consolidation of the national ZERO Children’s Cancer initiative.

There will be opportunities for new research grant projects, scholarships, fellowships and biopharmaceutical industry partnerships to collaborate on drug discovery.

Cancer Australia will administer the Mission, supported by a Strategic Advisory Group.

MEREDITH HORNE

Diabetes data linked to double death rates

The Australian Institute of Health and Welfare (AIHW) has examined data from National Diabetes Services Scheme and the National Death Index to provide a more complete understanding of deaths among people with diagnosed diabetes.

With 280 Australians developing diabetes every day, the bearing of the disease and its complications have a major personal cost to the individual and their family as well the health system.

The AIHW believes their comprehensive picture of diabetes-related deaths is important for population-based prevention strategies and could help to improve care for all people with diabetes.

The report found that overall death rates among people with diabetes were almost twice as high as the general population. And, with around 1.7 million Australians having diabetes, the numbers are significant.

“Overall in Australia, there is a trend toward lower death rates, but for people with type 2 diabetes, these improvements have not been seen,” AIHW spokeswoman Dr Lynelle Moon said.

“In fact, death rates among people with type 2 diabetes increased by 10 per cent between 2009 and 2014, mainly driven by the increase among the very old (85 and over).”

The disparity in death rates between people with diabetes and the general population was highest at younger ages – death rates were 4.5 times as high for people aged under 45 with type 1 diabetes and almost 6 times as high for those with type 2 diabetes, compared with the Australian population of the same age.

“Overall, diabetes, coronary heart disease and stroke were the most common underlying causes of death among people with type 1 or type 2 diabetes,” Dr Moon said.

“Kidney failure was also a leading cause of death for people with type 1 diabetes, while dementia was a common cause of death in those with type 2 diabetes.”

The report also shows that death rates among people with diabetes increased with socioeconomic disadvantage and remoteness.

People with diabetes living in the lowest socioeconomic areas experienced higher death rates than those in the highest socioeconomic areas. Among people with type 2 diabetes, the highest death rates were in remote and very remote areas.

Diabetes is the fastest growing chronic condition in Australia; increasing at a faster rate than other chronic diseases such as heart disease and cancer, according to figures from Diabetes Australia.

The total annual cost impact of diabetes in Australia is estimated to be at $14.6 billion. This includes a cost to the Australian health system of around $875 million per year in amputations. Diabetes Australia estimates that 4,400 amputations are performed in Australian hospitals every year, with up to 85 per cent of these preventable.

Diabetes Australia believes that awareness and early detection is incredibly important to address this growing concern and has called on the Australian Government to implement a Diabetes Amputation Prevention Initiative to ensure systematic early detection of foot problems, and early treatment to prevent amputations.

“Most people in the community have no idea that diabetes causes so many amputations. We need to raise awareness within the community and with key political leaders about the scale of the problem, its impact and what we need to do to fix it,” Diabetes Australia CEO Professor Greg Johnson said.

“Every year thousands of Australians are not so lucky and have to undergo traumatic and debilitating amputations. The sad truth is that health outcomes for people undergoing major amputations are poor. Many people will die in the first five years after a major amputation.”

MEREDITH HORNE

WHO discusses health strategies for our region

Low breastfeeding rates and “aggressive” baby formula marketing have been raised as an urgent issue by delegates at the World Health Organisation’s Western Pacific Regional Committee in Brisbane last month.

The annual meeting brings together ministers of health and senior officials from 37 countries and areas to decide on issues that affect the health and well-being of the Region’s nearly 1.9 billion people.

A new WHO regional action plan has been developed to strengthen protections for children from the harmful impact of food marketing.

WHO remains concerned that the baby food industry manipulates policies and practices by creating a positive public image as well as denying wrong-doing. WHO also believes evidence suggests that infant formula industry advertisements, gifts and sponsorships promote misconceptions and myths and ultimately have a negative impact on feeding practices.

Marketing of breast-milk substitutes, including infant formula, follow-up formula and growing-up milk, to caregivers continues to undermine breastfeeding in the first six months and continued breastfeeding beyond that age.

“The baby formula business is booming,” WHO’s regional director Dr Shin Young-soo said.

“And that is undermining breastfeeding.”

WHO believes that globally, 13 per cent of child deaths can be prevented with exclusive and continued breastfeeding.

Protecting children from the harmful impact of food marketing is critical in a region where more than 6.3 million children are overweight or obese. Countries were at the forum to develop a regional action plan to provide greater protection for children and support better health and nutrition, from birth onwards.

“When children are exposed to food marketing, their diets change,” Dr Shin said.

WHO and the Australian Government have also launched their first ever country cooperation strategy, on the sidelines of the 68th session of the WHO Regional Committee for the Western Pacific.

Issues discussed at the forum included: eliminating major communicable diseases, including measles and rubella, as well as mother-to-child transmission of HIV, hepatitis B and syphilis; financing of priority public health services; strengthening regulation of medicines and the health workforce; improving food safety; and health promotion for sustainable development.

Dr Shin Young-soo said the forum was important to the region because: “Our strength in solidarity is our best defence against whatever the future holds.”

It also provided a vision for WHO’s joint work with Australia over the next five years to improve the health of Australians and contribute to better health outcomes in the broader region.

Dr Shin said the strategy with Australia is the first of its kind, but it builds on a history of strong cooperation while also looking towards the future. Traditionally, country cooperation strategies are established between WHO and developing countries, where the Organisation has offices and provides direct support.

“I sincerely thank Minister Hunt and the Department of Health for their commitment to this strategy – and for paving the way for other high-income countries in this Region, with a new form of engagement that goes beyond the traditional donor country relationship,” he said.

Health Minister Greg Hunt, who attended the meeting, said the strategy: “Strengthens our systems to guard against emerging diseases at home and abroad, boosts our public health capacities and improves our already robust regulations to ensure we have safe and effective medicines and treatments.”

Australia’s breastfeeding guidelines are in line with WHO recommendations that infants up to six months should be exclusively breastfed. However, the Department of Health Australian National Breastfeeding Strategy expired in 2015.

The AMA believes that breastfeeding should be promoted as the optimal infant feeding method. AMA has also called for doctors and other health professionals to be appropriately trained on the benefits of breastfeeding, including how to support mothers who experience difficulties with breastfeeding.

AMA’s position statement can be read here: position-statement/infant-feeding-and-parental-health-2017 .

MEREDITH HORNE

Rec leave rewards for non-smokers in Japan

Japan currently comes in last on the World Health Organisation’s ranking of nations’ anti-smoking regulations, rated according to the type of public places entirely smoke-free.

So, it is quite remarkable that Japanese marketing company Piala Inchas announced it is granting its non-smoking staff an additional six days of holiday a year to make up for the time off smokers take for cigarette breaks.

“I hope to encourage employees to quit smoking through incentives rather than penalties or coercion,” Chief Executive Officer Takao Asuka said in regards to his company’s decision.

Hirotaka Matsushima, a spokesman for the company, said the idea came about following a message in the company suggestion box earlier in the year saying that smoking breaks were causing problems.

Other companies are also pushing for change. Convenience store chain Lawson Inchas introduced an all-day ban on smoking at its head office and all regional offices in June with an eye toward lowering the ratio of smokers in its entire workforce by around 10 percentage points in fiscal 2018.

“The company is willing to take an even tougher anti-smoking measure in the future,” a public relations officer for Lawson Incsaid.

A recent government survey in Japan showed that the number of smokers nationwide has fallen below 20 percent of the population for the first time on record, estimating about 18 per cent of Japanese are believed to smoke. Both genders recorded a decrease. The rate of male smokers fell 2.6 points to 31.1 per cent, while smoking among women declined 1.2 points to 9.5 per cent.

The Japanese health ministry is seeking new restrictions on smoking in public places before the 2020 Tokyo Summer Olympics. But the proposal is likely to encounter strong opposition from Japan Tobacco, which is one-third government owned.

MEREDITH HORNE

[Editorial] Support for a publicly funded health system in the USA

On Nov 8, a high-level panel—Health for All: #Walktogether—was held in New York City, NY, USA. It brought together two Elders—former Secretary General of the UN Ban Ki-moon and former Director General of WHO Gro Harlem Brundtland—and local health activists and politicians to discuss the need for publicly funded health systems in order for governments to deliver universal health coverage (UHC) by 2030. This event was held as part of a global tour that marks the tenth anniversary of the founding of The Elders, an independent group that provides leadership on the most pressing issues facing humanity.