Implementing Universal and Targeted Policies for Health Equity: Lessons From Australia

Document Type : Original Article


1 Southgate Institute for Health, Society and Equity, Flinders University, Adelaide, SA, Australia

2 Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW, Australia

3 College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia

4 The George Institute for Global Health, Sydney, NSW, Australia

5 School of Allied Health Science and Practice, University of Adelaide, Adelaide, SA, Australia

6 RegNet School of Regulation and Global Governance, Australian National University, Canberra, ACT, Australia


Debate continues in public health on the roles of universal or targeted policies in providing equity of access to health- related goods or services, and thereby contributing to health equity. Research examining policy implementation can provide fresh insights on these issues.

We synthesised findings across case studies of policy implementation in four policy areas of primary healthcare (PHC), telecommunications, Indigenous health and land use policy, which incorporated a variety of universal and targeted policy structures. We analysed findings according to three criteria of equity in access – availability, affordability and acceptability – and definitions of universal, proportionate-universal, targeted and residual policies, and devolved governance structures.

Our analysis showed that existing universal, proportionate-universal and targeted policies in an Australian context displayed strengths and weaknesses in addressing availability, affordability and acceptability dimensions of equity in access.

While residualist policies are unfavourable to equity of access, other forms of targeting as well as universal and proportionate-universal structure have the potential to be combined in context-specific ways favourable to equity of access to health-related goods and services. To optimise benefits, policies should address equity of access in the three dimensions of availability, affordability and acceptability. Devolved governance structures have the potential to augment equity benefits of either universal or targeted policies.



Commentaries Published on this Paper

  • Resisting the Effects of Neoliberalism on Public Policy; Comment on “Implementing Universal and Targeted Policies for Health Equity: Lessons From Australia”

        Abstract | PDF


  • Policies for Social and Health Equity: The Case for Equity Sensitive Universalism; Comment on “Implementing Universal and Targeted Policies for Health Equity: Lessons From Australia”

        Abstract | PDF


Authors' Response to the Commentaries

  •   Universal and Targeted Policy for Health Equity in the Neoliberal Era

         Abstract | PDF



  1. Ellison N. Beyond universalism and particularism: rethinking contemporary welfare theory. Crit Soc Policy. 1999;19(1):57-85. doi:1177/026101839901900104
  2. Bergh A. The universal welfare state: theory and the case of Sweden. Polit Stud. 2004;52(4):745-766. doi:1111/j.1467-9248.2004.00506.x
  3. Mkandawire T. Targeting and Universalism in Poverty Reduction. Geneva: United Nations Research Institute for Social Development; 2005.
  4. Sanders D, Nandi S, Labonté R, Vance C, Van Damme W. From primary health care to universal health coverage-one step forward and two steps back. Lancet. 2019;394(10199):619-621. doi:1016/s0140-6736(19)31831-8
  5. Carey G, Crammond B, De Leeuw E. Towards health equity: a framework for the application of proportionate universalism. Int J Equity Health. 2015;14:81. doi:1186/s12939-015-0207-6
  6. Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Geneva: World Health Organization; 2008.
  7. Baum F, Friel S. Politics, policies and processes: a multidisciplinary and multimethods research programme on policies on the social determinants of health inequity in Australia. BMJ Open. 2017;7:e017772. doi:1136/bmjopen-2017-017772
  8. Public Health Information Development Unit. Monitoring Inequality in Australia. 2020; Accessed December 15, 2020.
  9. Chetty R, Stepner M, Abraham S, et al. The association between income and life expectancy in the United States, 2001-2014. JAMA. 2016;315(16):1750-1766. doi:1001/jama.2016.4226
  10. Bremberg S. Rural-urban mortality inequalities in four Nordic welfare states. Scand J Public Health. 2020;48(8):791-793. doi:1177/1403494820921684
  11. Woolf SH, Schoomaker H, Hill L, Orndahl CM. The social determinants of health and the decline in U.S. life expectancy: implications for Appalachia. J Appalach Health. 2019;1(1):6-14.
  12. Beveridge W. Social Insurance and Allied Services. London: The Stationery Office; 1942.
  13. Carey G, Crammond B. A glossary of policy frameworks: the many forms of 'universalism' and policy 'targeting.’ J Epidemiol Community Health. 2017;71(3):303-307. doi:1136/jech-2014-204311
  14. Harvey D. A Brief History of Neoliberalism. Oxford: Oxford University Press; 2005.
  15. Raphael D. The political economy of health promotion: part 1, national commitments to provision of the prerequisites of health. Health Promot Int. 2013;28(1):95-111. doi:1093/heapro/dar084
  16. Baum F. Governing for Health: Advancing Health and Equity Through Policy and Advocacy. Oxford: Oxford University Press; 2019.
  17. Rose G. Sick individuals and sick populations. Int J Epidemiol. 1985;14(1):32-38. doi:1093/ije/14.1.32
  18. Lorenc T, Petticrew M, Welch V, Tugwell P. What types of interventions generate inequalities? evidence from systematic reviews. J Epidemiol Community Health. 2013;67(2):190-193. doi:1136/jech-2012-201257
  19. Williams F. Somewhere over the rainbow: universality and diversity in social policy. In: Manning N, Page R, eds. Social Policy Review. Canterbury: Social Policy Association; 1992. p. 200-219.
  20. Reynolds AJ, Temple JA, White BA, Ou SR, Robertson DL. Age 26 cost-benefit analysis of the child-parent center early education program. Child Dev. 2011;82(1):379-404. doi:1111/j.1467-8624.2010.01563.x
  21. Davy C, Harfield S, McArthur A, Munn Z, Brown A. Access to primary health care services for Indigenous peoples: a framework synthesis. Int J Equity Health. 2016;15(1):163. doi:1186/s12939-016-0450-5
  22. Marmot M, Allen J, Goldblatt P, et al. Fair Society, Health Lives: Strategic Review of Health Inequalities in England Post-2010. London: U.K. Department of Health; 2010.
  23. NHS Scotland. Proportionate Universalism and Health Inequalities. Edinburgh, Scotland: NHS Scotland; 2014.
  24. de Leeuw E. Engagement of sectors other than health in integrated health governance, policy, and action. Annu Rev Public Health. 2017;38:329-349. doi:1146/annurev-publhealth-031816-044309
  25. Fisher M, Freeeman T, Mackean T, Friel S, Baum F. Universal Health Coverage for non-communicable diseases and health equity: Lessons from Australian Primary Health Care. Int J Health Policy Manag. 2020; doi:34172/ijhpm.2020.232
  26. Fisher M, Freeman T, Schram A, Baum F, Friel S. Implementing policy on next-generation broadband networks and implications for equity of access to high speed broadband: A case study of Australia’s NBN. Telecomms Policy. 2020;44(7):101911. doi:1016/j.telpol.2020.101911
  27. Fisher M, Mackean T, George E, Friel S, Baum F. Stakeholder perceptions of policy implementation for Indigenous health and cultural safety: A study of Australia’s ‘Closing the Gap’ policies. Aust J Public Admin. 2021;80(2):239-260. doi:1111/1467-8500.12482
  28. Harris P, Kent J, Sainsbury P, Riley E, Sharma N, Harris E. Healthy urban planning: an institutional policy analysis of strategic planning in Sydney, Health Promot Int. 2019:35(4):649-660. doi:10.1093/heapro/daz056
  29. Gardiner FW, Bishop L, de Graaff B, Campbell JA, Gale L, Quinlan F. Equitable Patient Access to Primary Healthcare in Australia. Canberra: Royal Flying Doctor Service; 2020.
  30. Anderson I, Baum F, Bentley M. Beyond Bandaids: Exploring the Underlying Social Determinants of Aboriginal Health. Darwin: Cooperative Research Centre for Aboriginal Health; 2007.
  31. Yin RK. Case Study Research: Design and Methods. 4th ed. London: SAGE Publications; 2009.
  32. Deleted for review.
  33. Solar O, Irwin A. A Conceptual Framework for Action on the Social Determinants of Health. Geneva: World Health Organization; 2010.
  34. Howlett M, Ramesh M, Perl A. Studying Public Policy: Policy Cycles & Policy Subsystems. Toronto: Oxford University Press; 2009.
  35. Alcantara C, Morden M. Indigenous multilevel governance and power relations. Territ Politic Gov. 2019;7(2):250-264. doi:1080/21622671.2017.1360197
  36. Hooghe L, Marks G. Unraveling the central state, but how? types of multi-level governance. Am Polit Sci Rev. 2003;97(2):233-243. doi:1017/s0003055403000649
  37. Hill M, Hupe P. Implementing Public Policy: An Introduction to the Study of Operational Governance. 3rd ed. London: SAGE Publications; 2014.
  38. Bradford N. Place-Based Public Policy: Towards a New Urban and Community Agenda for Canada. Ottawa: Canadian Policy Research Networks; 2005.
  39. Dankwa-Mullan I, Pérez-Stable EJ. Addressing health disparities is a place-based issue. Am J Public Health. 2016;106(4):637-639. doi:2105/ajph.2016.303077
  40. Goldstein G. Healthy cities: overview of a WHO international program. Rev Environ Health. 2000;15(1-2):207-214. doi:1515/reveh.2000.15.1-2.207
  41. Mackean T, Fisher M, Friel S, Baum F. A framework to assess cultural safety in Australian public policy. Health Promot Int. 2019;35(2):340-351.
  42. Crotty M. The Foundations of Social Research: Meaning and Perspective in the Research Process. Sydney: Allen & Unwin; 1998.
  43. Harris MF, Harris E, Roland M. Access to primary health care: three challenges to equity. Aust J Prim Health. 2004;10(3):21-29. doi:1071/py04043
  44. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health. 2003;57(4):254-258. doi:1136/jech.57.4.254
  45. Levesque JF, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12:18. doi:1186/1475-9276-12-18
  46. Thiede M, Akweongo P, McIntyre D. Exploring the dimensions of access. In: McIntyre D, Mooney G, eds. The Economics of Health Equity. Cambridge: Cambridge University Press; 2007. p. 103-123.
  47. Leseman PPM, Slot PL. Universal versus targeted approaches to prevent early education gaps. The Netherlands as case in point. Z Erziehwiss. 2020;23(3):485-507. doi:1007/s11618-020-00948-8
  48. Menadue J. Propping up Private Health Insurance is Like Putting Lipstick on a Pig. Surry Hills, NSW: The Guardian Australia; 2017.
  49. Schram A, Friel S, Freeman T, Fisher M, Baum F, Harris P. Digital infrastructure as a determinant of health equity: an australian case study of the implementation of the National Broadband Network. Aust J Public Adm. 2018;77(4):829-842. doi:1111/1467-8500.12323
  50. Hajizadeh M, Connelly LB, Butler JR. Health policy and horizontal inequities of health-care utilization in Australia: 1983-2005. Appl Econ Lett. 2012;19(18):1765-1775. doi:1080/13504851.2012.659337
  51. Korda RJ, Banks E, Clements MS, Young AF. Is inequity undermining Australia's 'universal' health care system? socio-economic inequalities in the use of specialist medical and non-medical ambulatory health care. Aust N Z J Public Health. 2009;33(5):458-465. doi:1111/j.1753-6405.2009.00430.x
  52. Alsharif AT, Kruger E, Tennant M. Disparities in dental insurance coverage among hospitalised Western Australian children. Int Dent J. 2014;64(5):252-259. doi:1111/idj.12116
  53. Chrisopoulos S, Luzzi L, Brennan DS. Trends in dental visiting avoidance due to cost in Australia, 1994 to 2010: an age-period-cohort analysis. BMC Health Serv Res. 2013;13:381. doi:1186/1472-6963-13-381
  54. Duckett S, Swerissen H, Moran G. Building Better Foundations for Primary Care. Melbourne: Grattan Institute; 2017.
  55. Australian Institute of Health and Welfare (AIHW). Australian Health Expenditure by Remoteness: A Comparison of Remote, Regional and City Health Expenditure. Canberra: AIHW; 2011.
  56. Empowered Communities. Empowered Communities: Empowered Peoples Design Report. Canberra: Wunan Foundation Inc; 2015.
  57. Australian Government, NSW Government, Blue Mountains City Council, et al. Smart Cities Plan - Implementation: Western Sydney City Deal. Sydney; 2018.
  58. Brennenstuhl S, Quesnel-Vallée A, McDonough P. Welfare regimes, population health and health inequalities: a research synthesis. J Epidemiol Community Health. 2012;66(5):397-409. doi:1136/jech-2011-200277
  59. Windle A, Fisher M, Freeman T, et al. Increased private health fund involvement in Australia's primary health care: Implications for health equity. Aust J Soc Issues. 2018;53(4):338-354. doi:1002/ajs4.45
  60. Tsey K. The control factor: a neglected social determinant of health. Lancet. 2008;372(9650):1629. doi:1016/s0140-6736(08)61678-5
  61. Dockery AM. Culture and wellbeing: the case of Indigenous Australians. Soc Indic Res. 2010;99(2):315-332. doi:1007/s11205-010-9582-y
Volume 11, Issue 10
October 2022
Pages 2308-2318
  • Receive Date: 28 May 2021
  • Revise Date: 05 November 2021
  • Accept Date: 08 November 2021
  • First Publish Date: 09 November 2021