Introduction

Health policy debates reflect ‘a strife of interests’ (Sax, 1984). They are usually fraught, dealing as they do with matters of life and death, our hopes for long healthy life and our fears of pain, grief and loss of capacity. The Australian health system delivers essential care and enacts public health policy and programmes designed to keep us healthy. It is also a major industry with ever expanding capacity to diagnose and treat. It is one of Australia's largest employers (ABS, 2013), consistently delivering better than average wage growth for its professional workforce, and supporting strong growth in the pharmaceutical and medical technology sectors. Health policy can also act against powerful commercial interests and through concerted and sustained attention can effectively change the daily habits of the population (Scollo and Winstanley, 2012).

National health systems have many common features, but each is differentiated by what Tuohy describes as the ‘accidental logics’ of history and culture, structural and institutional parameters, and the interactions of the many actors in health policy and the health system. Structurally, power and influence are distributed between the state, capital and the health professions. The institutional dimension is the mix of instruments of control – hierarchy, market and professional collegiality – and the interacting patterns and pathways of their use over time (Tuohy, 1999, pp 6–7). Thus health policy and health systems develop with at least a degree of internal consistency as the various elements, shaped by circumstance, interests and compromise, influence each other to produce something that works in practice. In this chapter we argue that contemporary health policy in Australia is shaped by its response to three fundamental challenges: how to maximise health outcomes; how to ensure equity in access to health care; and how to operate an effective health care delivery system within constrained resources.

Maximising health outcomes: health is ‘produced’ in everyday life

The noise and heat in health policy debates is often driven by the question of who gets what health care at what price and standard. But if the underlying goal is healthy life, a focus on prevention offers a more direct route to health gain.

Introduction

The health status and life opportunities of those in poorer communities are less than those elsewhere (Australian Institute of Health and Welfare 1998). Responding to this situation is internationally recognised as requiring a multifaceted national as well as community approach that includes both social and economic initiatives (World Health Organization 1986a). This chapter explores the potential for social capital to provide a framework for developing communities in such a way that the health and life opportunities of poorer communities are improved.

We address the relationship between social capital and the health and life opportunities of people in communities. This includes not only the individual health of those in communities, as often measured by mortality, morbidity, and quality of life instruments, but also the idea that there are ‘healthy communities’ in and of themselves - communities in which there is a good stock of social capital and other forms of resource. ‘Life opportunities’ refers to the equality of opportunity that comes about through the local availability of many types of resources - for example, access to local childcare to encourage early child development that is so important to later achievements at school and beyond. Indeed, where access to and availability of social, economic and cultural resources are limited, so the life opportunities are also limited and this eventually becomes reflected in health statistics.

The breadth of views about social capital necessitates a brief investigation of its historical origins and the way different disciplines have conceptualised the links to health and life opportunities. We begin with the theoretical underpinnings, address some of the key empirical findings and them describe the Adelaide study of health development and social capital. This is a study that pays attention to levels and types of local participation in community life, the role of organisations and groups in the generation of social capital in communities, and the predictive value of social capital on health status.

Historical and theoretical underpinnings

The 1960s saw the adoption of ideas about social capital as the source for social action in a range of community studies.