Rarely has the public health sector’s critical role in protecting community health been clearer than it has been in 2020.
“From the [Black Summer] bushfires through to COVID-19 and the inequalities it has exacerbated – increased rates of mental health issues, domestic violence, alcoholism – public health education, workforce and research is more important now than ever before,” said Professor Joel Negin, Head of the School of Public Health, University of Sydney.
Professor Andrew Wilson, Menzies Centre for Health Policy, University of Sydney, said the COVID response had demonstrated the strengths of public health in Australia.
“We have had multiple centres and multiple perspectives being bought to bear on this problem including beyond communicable diseases,” Wilson said. “It has demonstrated yet again the importance of maintaining public health infrastructure and of keeping flexibility in its composition.”
But Australia’s public health sector is now facing another momentous challenge. In late March, when international borders were closed to non-residents in response to the pandemic, the gate was also shut on international students and the crucial funding they brought to Australian universities.
Professor Lisa Jackson Pulver, the University of Sydney’s Deputy Vice-Chancellor, Indigenous Strategy and Services, said when COVID-19 hit the university sector, it hit hard.
“Australians expect our university and our sector to provide a world class education for Australians as well as punch above our weight internationally,” Jackson Pulver said.
But the public funding of universities had fallen from 70-80% in the late 1990s to just 30% in recent years, she said.
“Despite being a publicly owned asset of the nation, the university sector had to look at external funding opportunities [away from government] and that has included the attraction of international, fee paying students.”
Jackson Pulver said the significant and sudden reduction of this crucial income for universities would be felt across the health sector for years to come.
“The universities train the doctors and the nurses, the scientists and researchers of tomorrow. This type of awful economic event will have a bump on effect for at least three to four years.”
Universities Australia has forecast that the sector could lose $16 billion in revenue between now until 2023, and a report into individual universities’ capacity to withstand the loss of revenue from international students put seven institutions into the highest financial management risk category (Monash, RMIT, University of Technology Sydney, La Trobe, Central Queensland, Southern Cross and Canberra universities).
While the university sector initially looked to the JobKeeper program as a way of supporting crucial teaching and research staff, several rule changes have locked public universities out of this support measure. Four private universities, however, are able to access the program.
Professor Stephen Leeder, Emeritus Professor of Public Health and Community Medicine at the University of Sydney, said it seemed the university sector had fallen out of favour with the public, and the Federal Government.
He said: “Why is it that universities are not valued as much as rugby league? There seems to be more discussion about sport getting back on track then maintaining academic life in the country, so you would have to conclude that universities are, at the moment, a low priority. The reality is that universities are not a popular sector, especially in terms of especially government support, which must mean public support.”
Professor Sharon Friel, Professor of Health Equity, Director, Menzies Centre for Health Governance, Australian National University, said the federal government’s refusal to bridge the funding shortfall for universities shows its “hypocrisy”.
She said: “Universities are working very hard to educate leaders of the future, and to help inform policy and the governing of the country, as we have done through the COVID-19 pandemic. But this also shines a light on the hypocrisy of this government. They say, ‘yes, we need you, come and help us, but we are not going to give you any additional money for that’. It is essential that we invest properly in universities on a long-term basis to support the fantastic researchers and teachers, and people with expertise in knowledge translation, who are able to engage with policy and practice in a very immediate way.”
Dr Devin Bowles, Executive Director, Council of Academic Public Health Institutions Australasia, said Australians from all walks of life had been under increased pressure due to the pandemic.
“Public health academics have been proud to help keep Australians safe,” he said. “They have trained the huge number of contact tracers, advised governments with epidemiological modelling, and educated the community in cooperation with the media.”
In its higher education COVID relief plan, the federal government guaranteed $18 billion funding for the sector, regardless of domestic enrolments, and announced a series of short courses.
Announcing the relief package in April, federal Education Minister Dan Tehan said the plan would not only support Australians who were looking to retrain but would provide an income stream for universities.
“Like the rest of the Australian community, the higher education sector has taken a financial hit because of the coronavirus,” Tehan said.
“These reforms will help universities pivot towards a closer alignment of domestic industry and student demands through innovative micro-credentials delivered flexibly online.
“Universities have proven they are up to the challenge of shifting their approach. Universities have been agile in their response to COVID-19, moving swiftly to the online delivery of courses and providing additional support to international students.”
Bowles said at least seven universities are believed to have taken up the government-funded short courses initiative and are offering undergraduate and postgraduate certificates in public health and related areas.
“Universities and lecturers have done an amazing job of shielding students from the financial effects of decreased international students,” he said.
Trauma and anxiety
Public Health Association of Australia president David Templeman said the public health sector was not immune to the financial crisis engulfing the university sector.
“Universities are educating our future public health workforce, and this is the last thing we need,” said Templeman, adding that the lack of access to the JobKeeper program was a further blow to both the university and public health sectors.
The lack of job security was resulting in “enormous amounts of trauma and anxiety” in the public health academic workforce, many of whom were at an age where they had mortgages to pay and childcare to consider, he said.
“We have to make sure that [federal government] leadership listens to some of these issues, because the whole notion about public health and preventive health is to keep people out of hospitals,” he said.
Templeman added that COVID-19, coupled with the long term effects of the catastrophic bushfire season, would have an enormous impact on community health in the coming years.
“Leadership needs to appreciate that our professional public health workforce has been a driving force in Australia’s success in dealing with COVID-19.”
Templeman also pointed to potential impacts on rural and regional communities as universities in these areas came under financial pressure. “Universities are often the lifeblood of these communities,” he said.
Jackson Pulver is concerned that some Indigenous programs, such as those that she leads, may be some of the first programs to be impacted.
She said some Indigenous student support programs have been reduced and the university was having to “do more with less”.
Jackson Pulver said cultural competence programs were also at risk.
She said: “We were working to get all staff across the university aware of what it is to be on this land, a place that has always exchanged knowledge and learning for 60,000 years. We are having to revisit those programs and reduce the number of people in them. This is at a time when Closing the Gap is writ large in people’s minds.”
Professor Fran Baum, Matthew Flinders Distinguished Professor of Public Health and Director of the Southgate Institute of Health, Society and Equity at Flinders University, said the impact of the COVID-19 travel restrictions had been swift on some projects, such as a time-limited National Health and Medical Research Council (NHMRC)-funded program looking at the decolonisation of Aboriginal Health Services.
“We can’t do any of our field work at this time, but staff [costs] are ticking away,” Baum said. “We might be able to extend the time, but we won’t get more money.”
At a time when the world is searching for a vaccine for SARS-CoV-2 and a treatment for COVID-19, Baum said there were also concerns that clinical and biomedical research, while worthy, would dominate research funding in the coming years.
“It’s pretty tough being a social determinants researcher in the health research landscape at any time and we don’t anticipate that those pressures are going to go away,” she said.
“And yet the pandemic has shone a light on how inequities affect people’s responses in a health crisis; who is vulnerable and who isn’t. So, you would hope that that would lead to some grant programs to look at growing health inequities.”
Baum said changes to the NHMRC funding system last year – placing emphasis on patient impact – also put public health research projects at a disadvantage.
“It’s quite hard to show a public health impact, whereas if you invent a new patient treatment, it’s easier to show patient impact,” she said. “Our fear is that the new system is not as favourable to research that is looking at those broader determinants of health.”
Friel said the cancellation of some funding streams that supported “blue sky-type projects”, such as the 2020 NHMRC Synergy Grants, was also cause for concern.
“These are large grants for interdisciplinary, intersectoral teams to address issues that just can’t be answered by any one discipline or any one sector,” she said. “It seems to me that as we try to recover from COVID-19, these are the sorts of questions that we will be grappling with as a society, so this sort of funding is needed.”
Negin said that while some doors had closed, others had opened. He said: “There are a lot of Medical Research Future Fund and NSW Health opportunities that are COVID-related. The broader concern is whether the Australian Research Council and NHMRC feel any of the brunt of funding cuts and whether they are able to continue to fund the work that they were doing, that’s a risk down the road. Even the Synergy Grants were cancelled [but] they might be revived at some point in the future.”
Baum said a new national program was needed to shore up public health research. “We need a special scheme recognising that public health has been crucial in keeping Australia relatively unaffected by the COVID-19,” she said.
She called for the revival of the Public Health Education and Research Program (PHERP), which provided funding for public health training, predominantly Master of Public Health programs, for more than a decade until it was abandoned in mid-2010.
“PHERP provided funding to departments of public health, partly in the recognition that it is a very applied subject and that support is needed to have a flourishing public health sector that works closely with local health system.”
Bowles said international student numbers were expected to be lower through the medium term. “With the importance of public health more widely appreciated due to the pandemic, we are optimistic that domestic enrolments in public health courses will increase,” he said.
He agreed that designated federal government funding for capacity-building in the public health workforce – similar to PHERP – should be reinstated.
“While PHERP funding focused on postgraduate training, future funding should focus on other areas,” he said.
These included: gaining a better insight into the public health workforce, consistent with the information routinely gathered the National Health Workforce Dataset; expanding delivery of public health content in medicine, nursing and allied health programs; developing the infrastructure to support large and smaller scale outbreak investigation and management; creating a structure for accredited training for pandemic/epidemic response, health promotion/communication, chronic disease reduction, and other specialty areas; and enhancing the training of the public health workforce of other countries in our region.
“A world-class public health education is available in Australia,” Bowles said. “Our public health workforce includes many people with different educational backgrounds who would benefit from accessing that education. The federal and state governments should provide incentives to public health agencies (including within government) to link with universities.”
Early career researchers
The path to a career in research and academia was never easy, Wilson said, but post-COVID, it has potentially become harder.
“One of the strengths of public health in Australia is a strong research base that is innovative and commonly linked to practice,” he said.
“There is no indication that mainstream research funding programs through the NHMRC or Australian Research Council are going to be expanded and history shows they tend to be frozen.”
Wilson added that that the Medical Research Future Fund (MRFF) had largely been focussed on specific topics and was not structured in ways that were “very open to early- and mid-career researchers”.
Dr Tess Ryan, a Biripi woman, a writer and president of the Australian Critical Race and Whiteness Studies Association, said the impact on early-career researchers, particularly Indigenous researchers, could impede growth in public health research.
She said: “Universities will be looking across their space to cut costs. While they won’t want to necessarily take away from health research, we may see less Indigenous health researchers because those projects often get relegated to the bottom of the pile – or are run by the same people in higher positions. So early career researchers may not get a look-in, which means there could be an issue with growing the health research space.”
Negin said the federal government’s recent announcement of funding for mental health research was a positive sign that broader public health research projects would be supported.
“There have been some positive signs that people are seeing COVID as not just about a respiratory issue, but as a society wide-issue.”
Negin said some belt tightening was inevitable across all university faculties and schools – “it will mean some fixed-term contracts across the university sector won’t be renewed and there are some hiring freezes”. However, schools of public health did have some cost advantages.
“We don’t need labs and cadavers, complex laboratories and simulation centres,” he said.
“We are not an expensive program; we are about ideas, scenarios, and we have been doing online teaching for more than a decade.”
Rebuilding after COVID
Wilson said he hoped that one of the responses to COVID would be a greater recognition that our health and biosecurity is interdependent on our broader environment.
“In a connected world with other populations, a response to this should be increasing our public health engagement at least regionally if not beyond,” he said.
“This is an opportunity that government could create to support and influence better public health in the region and at the same time promote our capacity in public health education, research and practice.”
Leeder said there was likely to be a “recalibration of public health interest” that would encompass a fresh look at infectious diseases.
“My hope would be that alongside that, we don’t lose track of the great causes of morbidity and mortality – heart disease, stroke, cancer and dementia and mental illness – that afflict us year-in and year-out and don’t elicit anything like the response we have given to COVID.”
More broadly, Leeder said it was time for a major rethink about the way in which Australian universities are funded.
He said: “We need a new business proposition for universities, both for their research and their teaching. And that requires clever minds, it requires managers, accountants, academics themselves who might have clear and strong views about how it could prosper. There needs to be almost a Royal Commission into funding of tertiary institutions in Australia.”
Universities also have to take a critical look at themselves, Leeder said.
“These organisations fulfil very valuable public roles, but inevitably I think, some degree of self-satisfaction or laziness creeps in. Their systems of governance may no longer be fit for purpose – there are a lot of questions that need to be asked beyond saying, ‘yoo-hoo, government, we need more money’.”
Nicole MacKee is a freelance health journalist, and an editor at Croakey
This article was first published by Croakey Health Media and is cross-posted with permission.