Health equity implementation expectations and challenges in a multi-level system reform initiative

Abstract

Abstract Background Within Australia, a system reforming place-based initiative across an area the size of Spain is being implemented. The aim is to expand community-based care models and reduce hospital demand. As COVID-19 demonstrated, sustainability of healthy societies requires a health equity focus across all stages of health reform. Despite central equity principles, pressures risk diminishing this goal as policy is translated into practice across system levels. This initiative is a perfect case study opportunity to inform policy implementation through understanding operationalisation challenges and protections across a multi-level system. Methods 18 semi-structured interviews were conducted in 2022 and 2023 with a purposive sample of senior policy executives, program managers and clinicians across partner organisations and the NSW Ministry of Health. An iterative interview process captured perspectives across system levels as the program was progressively implemented. Interviews were analysed using an inductive constant comparative approach. Results Preliminary findings indicate tensions that impact on realising equity goals. Key tension points exist between levels of operationalisation. These can manifest as perceived trade-offs between health equity and efficiency; place-based reforms that put downward pressure on resource challenged local services to manage equity; and funding models that discourage access. Tension mitigation is partially achieved through leadership commitment, community building, and ring-fenced equity funds. The shared equity understanding in rural areas is also a protective factor. Conclusions While local mitigation factors can protect equity goal preservation, we recommend consideration towards building alignments across system levels. This can include aligning leadership goals and designated funding streams across levels. Further opportunities not often captured in the interviews exist, including aligning accountability and monitoring processes. Key messages • Mitigation strategies exist to overcome inherent system tensions that impact on reforms achieving equity goals. While these can be partially achieved at one level, multi-level alignment is critical. • Shared leadership goals and designated funding streams can support overcome health equity tensions during implementation of reform initiatives, and would be supported by multi-level system alignment.