In a multicultural society the consideration of culture in health policy development cannot be overlooked because care-giving and receiving is profoundly affected by cultural issues (Buse et al., 2012; Napier et al., 2014). Different values about what constitutes good health, customs addressing for example the delivery of health services to women,
language difficulties, and power hierarchies in different cultural communities all affect the development and delivery of health policy (Buse et al., 2012). In the health policy context, critical multiculturalism offers a pathway to greater understanding about how the accepted policies and procedures of health authorities operate to marginalise CALD citizens. This understanding is achieved by raising awareness of how the dominant norms and values of a society became dominant and how the policies arising from these norms and values, along with their associated “standards and structures”, contribute to “institutional or structural discrimination” making it unlikely that health policy will meet the health needs of minority groups (Fuller, 1997, p154-156). This process moves the policy maker’s thinking away from a focus on the cultural practices of the minority and towards the effects of marginalisation on the individual (Daniel, 2008). Jeff Fuller suggests that health policy makers’ awareness can be greatly assisted if minority groups participate in the “political processes of the health system”, so as to communicate directly their needs and contribute to potential solutions (Fuller, 1997, p157). Equally, health policy makers and their leadership must be willing and open to hearing the views of minority groups. Fuller’s position is supportive of deliberative citizen engagement in health policy development.
Public policies are only useful if they are both sensitive to, and meet the needs of, the audience they purport to serve (Davis et al., 1993; Hess and Billingsley, 2007), therefore it is crucial to identify the policy development process most appropriate for the issue under consideration. As John Coveney says, the best method of health policy development is the one that will work best for the topic under consideration (Coveney, 2010). From a critical multicultural perspective, an appropriate policy development process must enable structural discrimination to be identified, named, and addressed. This requires attention be given to how a problem is represented, in the process exposing the assumptions and values of society (Coveney, 2010).
Isabel Awad argues that equitable access to health policies and programs can be addressed best when intended policy beneficiaries are identified in relation to other similarly situated groups rather than along cultural lines (Awad, 2011). Her approach is to ensure that all people with low income or all people with low levels of education are identified without the need to fall back on ethnicity as a discriminator.
The challenge that Coveney’s and Awad’s approaches present lies in the expectation that the policy maker is neutral, thoughtful, and enabled to undertake a critical multicultural process of enquiry. In my view these characteristics are difficult to demonstrate, not necessarily because of ill will but because of the influence that institutional values and structures have on the way in which policy makers are enabled to carry out their responsibilities. This puts the onus on policy makers as individuals to search for information to broaden their understanding of the policy audience, and especially to be aware of their own assumptions about the policy audience (Alkadry, 2005; Young, 2010) in the pursuit of “open and inclusive” health policy that is “transparent, accessible and responsive to as wide a range of citizens as possible” (Organisation for Economic Cooperation and Development, 2009, p24).
It is hard to say that one set of interests in health policy development is more influential or challenging than another. Nevertheless, drawing on my own experience as well as discussions with health policy makers, I would suggest that the most difficult factor to manage is that of cultural diversity because it cannot be bound and labelled and therefore it is questionable whether culture can ever be ‘known’. Knowing your policy audience is sound advice but when that policy audience is so diverse I wonder how the policy officer can be expected to achieve this knowledge.
On the face of it, policy officers have some work to do to harness not only the strengths that immigrants bring to a country but the strength that can be gained through collaboration with the community. But let us not be hasty in pointing the finger of blame at the health policy officer. Developing health policy is usually about aggregate populations even though the resulting policy will impact on individuals or groups differently. Pressures of time and priorities, limited financial and personnel resources, and electoral cycles all impinge on the policy officer’s work making it hard to take into account the specific needs of CALD background individuals. Empirical data from both Australia and Canada confirmed that, whilst developing health policy should be straightforward because it entails a step-wise process from defining the problem, to identifying solutions, to implementation and evaluation, the ‘difference lens’ is not often applied in health policy development. Indeed, attempting to balance the different lenses – of budgets, gender, age or culture – can be overwhelming. My own experience of nearly
three decades as a policy officer in the health sector tells me that policy officers are not making excuses.
2.5 Conduct and analysis of empirical research