Centre for Public Service Research, UNSW Canberra, Canberra, Australia.
School of Population Health, University of Melbourne, Melbourne, Australia.
Int J Equity Health. 2017 Nov 6;16(1):192. doi: 10.1186/s12939-017-0682-z.
Increasing attention is being given to political agenda setting for the social determinants of health. While designing policies that can improve the social determinants of health is critical, so too is ensuring these policies are appropriately administered and implemented. Many policies have the potential to entrench or even expand inequities during implementation. At present little attention has been given to this in the social determinants of health literature. There is an international trend in the personalisation of funding for care services, from the National Health Service in the England to the Brukerstyrt Personlig Assistanse in Norway. Part of this trend is the Australian National Disability Insurance Scheme (NDIS). The NDIS has the potential to secure gains in health for hundreds of thousands of Australians living with a disability. However, policies are only as good as their implementation.
As part of a longitudinal study on the implementation of the Australian NDIS, we conducted a systematic document search of policy documents pertaining to the Scheme on the websites of government departments with auspice over the design and implementation of the scheme with the aim of examining issues of equity.
Scheme architects have argued that the NDIS has the potential to replace a piecemeal and fragmented set of state-determined services with an empowering model of user choice and control. However, without careful attention to both existing inequities and, diversity and difference across populations (e.g. different disability types and different localities), market based approaches such as the NDIS have the serious potential to entrench or even widen inequities.
The research concluded that 'personalisation' approaches can widen inequities and inequalities unless careful consideration is given at both policy design and implementation stages.
人们越来越关注社会决定因素健康的政治议程设置。虽然设计能够改善社会决定因素健康的政策至关重要，但确保这些政策得到适当的管理和实施同样重要。许多政策在实施过程中都有可能加剧甚至扩大不平等现象。目前，社会决定因素健康文献中对此关注甚少。从英国的国民保健制度到挪威的布鲁克斯特赖特个人援助，个人化的护理服务资金在国际上呈趋势。这一趋势的一部分是澳大利亚国家残疾保险计划（NDIS）。NDIS 有可能为数以十万计的残疾澳大利亚人保障健康方面的收益。然而，政策的实施情况与其本身一样重要。
作为对澳大利亚 NDIS 实施情况进行的一项纵向研究的一部分，我们对政府部门网站上与该计划的设计和实施有关的政策文件进行了系统的文件搜索，目的是审查公平问题。
计划设计者认为，NDIS 有可能用一种以用户选择和控制为特点的赋权模式来取代零碎和分散的由国家决定的服务。然而，如果不仔细考虑现有的不平等现象以及人口（例如不同类型的残疾和不同的地区）之间的多样性和差异，那么像 NDIS 这样的基于市场的方法就有可能严重加剧或扩大不平等现象。
研究得出结论，“个性化”方法可能会扩大不平等和不公平现象，除非在政策设计和实施阶段都给予慎重考虑。
