As in other federations, health care is a central concern of intergovernmental relations in Australia, a very large item in government budgets, and a major service delivery responsibility of the states.
And as Greer (2018, p. 238) emphasizes, ‘understanding territorial politics means understanding the politics of managing large public sector organizations such as health systems’.
For a long time, health care was a major area of state autonomy in Australian federalism. However, that changed in the last decades of the 20th century as the Commonwealth government assumed a progressively greater role in funding and regulating the health system. As a consequence, we must look ‘beyond autonomy’ to seek other ways of understanding the logic of such developments in Australian federalism as in other federations. In this case, current practices involve the continuing existence of a vertical division of roles and responsibilities, acknowledging the several different dimensions of healthcare delivery, combined with an emerging structure of complex collaborative intergovernmentalism. As Duckett (2015) has written, neither complete centralization, nor restoration of the status quo ante, are likely or plausible; ‘[t]he real action in terms of reforming federalism in health care has been on improving coordination.’In this chapter, we outline the general characteristics of health care and federalism, before turning to look at Australia, which has undergone a significant remodelling in health governance over the past decade. In doing so, we also move from the macro to the meso or even micro, looking in particular at the concerted attempts by both levels of government to increase local responsiveness and improve patient outcomes, while also promoting greater system integration and cooperation between the states and the Commonwealth. While the process and substantive outcomes of these efforts are still being played out, the trend of growing joint governance, rather than preservation of state autonomy, appears unstoppable.
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