School of Public Health
Associate Professor David Legge
Director, La Trobe China Health Program
Contact Details
Email:D.Legge@latrobe.edu.au
Office phone: +61(0)3 9479 5849
Home phone: +61(0)3 9489 1934
Home voip: +61(0)3 9012 5882
Mobile: +61(0)408 991 417
Fax: +61 (0)3 9479 1783
Office: HS1-218
Qualifications
MD, BS, BMedSc Melb., FRACP
MB BS BMedSci (University of Melbourne) 1968; MD (University of Melbourne)
1974; FRACP (1976)
Interests
My research and policy interests span a range of issues and topics. My policy and research preoccupations currently include:
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Political economy (including globalisation)
The health chances of human populations are shaped by the constraints of our physical environments, by the practices through which we meet our material needs and by the ways we choose collectively to organise our affairs.
These social and environmental determinants of health are too complex to be adequately represented by any single overarching theory, or by the theories and models of any single social science discipline (economics, sociology, political science etc). At best these disciplines provide partial accounts of this complexity; accounts which are of varying use in different circumstances.
However, if public health practitioners are to engage effectively with these influences on population health they need to be able to draw upon theoretical resources which help to make sense of the particular problems they face and to project possible outcomes of different strategies of engagement.
With the growing immediacy of globalisation the disciplines of political economy are increasingly useful in making sense of the economic and political determinants of health and in thinking through the economic and political implications of different public health strategies. The political economy tradition has been marginalised by orthodox economics and there is wide scope for a continuing exploration of the insights which political economy perspectives offer on the economic and global dynamics which shape people's health chances. I have had a longstanding interest in exploring these insights, particularly at the international level. See Legge (2002a) and Legge (2002b).
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International health policy and health system policies
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Principles, strategies and styles of primary health care practice
Primary health care refers to a sector of service delivery, a set of principles which (it is suggested) should be expressed in the delivery of health care (in particular, concerning the work of the PHC sector) and an approach to health care policy-making.
One of the most important of the PHC ideas is the proposition that primary health care practitioners can work together and with consumers and communities to address the social determinants of population health. However, this idea has all too often led to a kind of compartmentalisation of clinical work on one hand and community development on the other.
My colleagues and I within the Centre for Development and Innovation in Health at La Trobe have been exploring the idea of 'styles of practice', focusing in particular on the 'micro macro dimension'. We are documenting styles of practice which address local and immediate problems in ways which contribute to redressing the social dynamics which reproduce those patterns of need. To access a range of publications from our group click here.
One of the most challenging aspects of this area of work is the need to develop new methods for describing and evaluating passages of practice and the styles with which they are carried out. This question is closely related to the idea of evidence based policy. What sort of evidence? More particularly, what is the interplay between universalising generalisation and unique contextual detail.
In medical research we seek universalising generalisations through the power of the RCT (controlling out contingency) and leave it to the clinicial to adapt the generalisations to the specificity of the individual patient. In the policy research which controls out the contextual detail also controls out most of the fact and logic of each case.
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Health outcomes and evidence for health development strategies
The medical profession has been the main target of the rising focus on measuring outcomes and requiring evidence to justify the norms of clinical practice. In earlier times medical autonomy was protected by its small business structure and political leverage. These conditions are passing. The increasing bureaucratisation of health care, associated principally with technological change, has contributed to the loss of medical autonomy. However, the rising sophistication of medical care measurement, clinical epidemiology and information technology have also contributed to the emergence of the new technologies of managerial control.
A central theme of the new public sector management is the use of markets and contracts to control the allocation of health care resources more effectively and more efficiently by controlling the parameters of the market and the terms of the contract. Markets and contracts rely on performance measures, the measurement of outcomes. For markets to work in health care requires that the core of the transaction can be measured, counted and priced. For contracts to work as a means of effecting particular functions in health care requires that (real) outcomes and performance standards be precisely (and properly) specified.
The policy interest in measurement of outcomes and evidence presents particular problems to primary health care practitioners and for public health more generally. The measurement of primary care practice and the counting of its 'outcomes' face technical problems which are yet to be clearly defined, far less overcome. The building of a body of evidence about the efficacy of the models, strategies, principles and styles of practice used in primary health care likewise faces significant methodological challenges.
Forcing the primary health care field into the new regime of markets and contracts regardless of the weaknesses of the available methods carries certain risks. These risks are more pressing in those jurisdictions and bureaux where policy is driven by ideology and bonuses rather than a concern for population health outcomes.
Proponents of primary health care need to respond to these challenges on several levels: first, challenging policy narratives which appear to be solely based on ideology, unsupported by the necessary evidence and technologies; second, documenting and analysing the problems associated with applying the methods and norms of clinical epidemiology in primary health care and population health; and third, taking up the challenge to develop measurement tools and evaluation strategies that correspond to the purposes and circumstances of primary health care and public health practice.
My colleagues in the CDIH group and I have been working on all three fronts for several years. See Legge (1999).
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Historical perspectives on how population health improves
One of the major challenges to public health is the burden of ill-health carried by socially and economically disadvantaged populations. There is presently a resurgence of interest in documenting and explaining socio-economic inequalities in health and in defining policy and health care strategies that might redress the conditions which reproduce such health disadvantage.
This links to an earlier debate about the role of the health system in health development across historical time, in relation to the other non-health influences on changing population health. The promise of this kind of research is that if we could learn more about the dynamics through which deliberate health care initiatives have interacted with other 'non-health' influences in shaping population health this might assist us in framing our response to socio-economic gradients in health.
Historical perspectives have been quite powerful in teasing out the role of health care in shaping health development in whole populations (in industrialised and developing countries) and in relation to indigenous health.
These precedents suggest the possibility of useful historical studies of the role of health care, in relation to other influences, on the changing health status of different socio-economic strata.
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Aboriginal health
What are the pathways of Aboriginal health improvement? What are the roles that health care organisations can play in following those pathways? Ian Anderson says that the two key principles for Aboriginal health development are self-determination and shared responsibility. How can non-Aboriginal health organisations and practitioners fulfill their responsibility?
One of the key challenges facing public health practitioners in relation to Aboriginal health is the recognition of the role that our own professional forebears played in the colonisation of Aboriginal people in Australia. We now recognise that many of the theories and practices of the health and welfare systems contributed to the dispossession and alienation of Aboriginal people (eg the theories of eugenics and the practices of removing so-called "half-caste" children). But we ourselves are the products of these traditions; how shall we learn to see the continuities between our institutional histories and the ways we think and practise now? How can we know that our own ways of thinking and practising are not reflections of these continuities?
See Bartlett and Legge (1995) for a bit of background to the transfer of Aboriginal health administration federally from ATSIC to Commonwealth Health in 1995. See
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Clinical governance, performance including quality in health care and the management of change
Clinical governance is a slogan which invites us to rethink the doctrine of separate responsibilities (the clinicians will look after quality of care (of individual patients) and the managers will look after volume and budget). In the UK clinical governance refers to a framework of accountability; a system in which quality assurance is no longer voluntary; an environment in which a wide range of mechanisms for measuring, encouraging and reporting all have their place.
Clinical governance formalises and systematises a large number of mechanisms which had been somewhat ad hoc and perhaps a matter of choice previously. But is clinical governance more than this?
My colleagues and I are a bit dissatisfied with the way in which the term 'clinical governance' is being used. We think there are several key issues being missed by the current focus on structures of accountability. One such issue is how the uncertain and contested boundaries between clinical autonomy and managerial prerogative are being managed. Another aspect of clinical governance concerns the management of the trade-offs between budget and volume on one hand and quality of (individual) patient care on the other. We think that the logic of clinical risk assessment has a major contribution to make to negotiating these choices.
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Current trends in public sector management
Since around 1970 the global economy has slowed from the relatively high growth rates of the 'long boom' (5-6% pa) to much slower growth including prolonged periods of contraction in many countries. The most persuasive explanation for the 'long slow down' is that accelerating productivity globally is facing sluggish demand (mainly associated with lack of buying power) and that the responses of capitalist corporations and capitalist states are making things worse. The corporation responds by shedding labour, cutting wages and increasing market share and the state responds by reducing taxes and public expenditure and deregulating labour standards and environmental protection. These responses make the basic imbalance worse. So they are applied with redoubled vigour.
This is the background to the 'new public sector management': marketisation, contracturalism, casualisation, managerialism and various forms of neo-Tayorism.
Different stories can be told about the rise of new public sector management. On the one hand privatisation can be represented as the opening up of the public sector to private investment; cutting taxes and deregulating labour and environmental protection can be seen as part of a global auction in which different jurisdictions compete to attract footloose global capital. The new technologies of public sector management, according to this view, represent devices to protect big capital from the threats of global slow down.
But this account is too simple. There is merit in some of the criticisms of the 'old public sector management'. There are some positives in the new focus on efficiency, outcomes and evidence. The horrors of the new should not lead to a romanticisation of the old.
This situation points towards the need for 'evidence based policy making'. We need finer ways of evaluating the criticisms of older ways of doing things and finer ways of evaluating the nostrums of the new public sector management.
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Epistemology and public health
Many of the uncertainties and debates in public health turn on different ways of understanding the world and different ways of thinking about how we understand the world.
The tension between realism and constructivism is one important axis around which many of these debates turn. The paradigms, theories and methods of the physical and biological sciences tend to sit comfortably with realist assumptions; that there is a singular reality 'out there' beyond our senses and through the disciplines of 'objective' science we shall progressively extend our knowledge of this reality.
There are alternative ways of understanding our knowledge practices. Quantum theory and recent developments in information theory suggest that the observer is inevitably embedded in the knowledge generated by his or her observations. Language theory challenges taken-for-granted assumptions about the representational functions of language.
Postmodernism, one school of postmodernism in particular, suggests that the realist paradigm, whilst associated with many great achievements, may also be associated with certain counter-productivities. Humanity's (cultural and political) failures to harness its technical prowess in equitable and sustainable ways may be due in some ways to the dominant status of the realist paradigm.
One of the areas where a commitment to discovering truth through objectivist research might be counter-productive is in relation to communication and the building of solidarity across difference. Realism can promote deafness, reification and coercion. Commitment to a singular source of correct truth is a barrier to collaborating with people who have a different world view; listening open-mindedly to a different world view is difficult if you know that the methods on which your knowledges are based are the best so far developed. Knowledge as truth encourages reification (treating people as knowable things; categorising people and then treating the categories as properties) and reification prevents us from acknowledging other people's agency. All regimes of singular truth are potentially coercive; because of our commitment to our own truths we are blind to the power relations out of which our methods arise; the coercion embedded in our communications is hidden from us by our assumption that 'it is for your own good'.
Objectivity is an integral part of modern science and a source of some of its most celebrated successes. (Objectivity: constructing the people or relationships or processes which we are studying as 'out there', separate from us; removing bias, removing ourselves from the field we are studying.) However, the corollary of this pursuit of objectivity is our lack of reflexivity; we are left with no tools for speaking about own presence in the field of study or the field of practice; the embodied (as opposed to algorithmic) nature of our practice. Our failures are sometimes due to our inability to speak about our own presence in the fields of research and practice. We redouble our efforts at achieving objectivity (and achieving the erasure of our own presence) and we fail again.
These ideas may have some applications within public health. Public health is a field where the Enlightenment tradition has scored impressive triumphs. And yet it is a field which is sadly impotent in the face of widening inequalities, flaring violence and environmental degradation. The possibility of counter-productivities within the public health tradition, counter-productivities which are rooted in epistemology, deserve to be taken seriously.
I have been exploring for some years the implications of post-structuralism, postmodernism and complexity theory for public health research, policy and practice. See Legge (1996).
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Management education in health care
I am fascinated by practice. What are the links between the knowledges of the disciplines and the practices of the doers?
In creating knowledge we are (rightly) concerned with consistency, logical development, evidence. In practice (take management for example but it could be teaching or medicine or airline pilotting) we often do first and rationalise later. The doing is informed by a myriad of subterranean influences (including but going well beyond cognitive knowledge). But when we come to rationalise what we have done we are so often constrained by conventions such as the myth of the primacy of disciplinary knowledge.
Who cares? Well it matters for teachers. If we are trying to teach people how to manage we need a theory about the personal resources which they deploy in managing. And these resources go well beyond the knowledges of the disciplines. See Legge and Stanton (2002) for a deeper exploration of these ideas.
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Health management and health policy issues in China
My colleagues and I in the La Trobe China Health Program have been increasingly involved in documenting and analysing some of the management and policy challenges involved in moving from a 'planned socialist economy' to a 'socialist market economy'. See Pei, Legge and Stanton (2000).
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I am a keen member of the Public Health Association of Australia, in particular the Political Economy Special Interest Group of PHA, although less active than I would wish. I was for some years the Policy Coordinator for PHA.
I am also a member of the editorial boards of the Australian and New Zealand Journal of Public Health, the Australian Journal of Primary Health - Interchange, Critical Public Health, Health and Social Care. I am an occasional reviewer for these journals plus Health Promotion International and Australian Health Review.
I am also a member of the International People's Health Council, an international network of primary health care practitioners and academics. IPHC is committed to building a global movement which can contribute to changing unfair and unhealthy social structures at local, national and international levels. The IPHC was one of the sponsors of the first People's Health Assembly in Dakha in 2000.
I am also involved in the People's Health Movement which emerged out of the first PHA in Dakha, both at the global level and in Australia.
One particular activity in which I am involved is the International Peoples Health University which is a contribution of IPHC to the PHM. IPHU provides short courses for health activists, in particularly, activists from developing countries.
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A brief work history
I commenced my paid working life as a medical doctor (MB, BS, BMedSci). After completing physician training (MD, FRACP), I was for several years a rat doctor (exploring the influence of calcium on cell regeneration under Professor Jack Martin). During this time I was also active in the community health movement and in consumer health activism. In 1974 I left laboratory research to become a health planner with the Syme Townsend Committee of Inquiry into Health Services in Victoria.
From 1975 to 1984 I was a part time physician, medical administrator, health services researcher and medical academic at the Austin Hospital. My main research interests at this time were in the measurement and maintenance of quality in medical care, community participation in health care and health policy making.
In 1984 I left hospital work to become the coordinator of the Victorian District Health Councils Program and Manager of Community Health Programs in the Victorian Health Department. The District Health Councils Program was an attempt to provide systematic support to consumer and community participation in health care and public health in Victoria.
The political climate changed during in the late 1980s and in early 1990 I left Victoria for a five year exile in Canberra at the National Centre for Epidemiology and Population Health. This was a great opportunity for reading and thinking and in 1995 I returned to Victoria and La Trobe University, rehabilitated and refreshed, and have been here ever since.
Since joining La Trobe my main involvements have included:
- teaching policy related subjects in the Melbourne MPH (but gradually letting go now) ;
- coordinating the academic component of the Victorian Public Health Training Scheme (now handed over to Dr Cathy Mead);
- leading the La Trobe China Health Program and
- undertaking my PHM and IPHU work noted above.
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A life beyond work
I live in East Brunswick with Jill Sanguinetti. Our lives are enriched by the company of our extended families and friends and by music, reading, camping and cycling. And Socrates.
Some publications (which may be of interest)
Bartlett B and DG Legge, Beyond the maze: proposals for more effective administration of Aboriginal health care funding, 1995 Canberra: NCEPH and CAAC
Boleyn T and DG Legge (1997). 'Abandoned to their fate: social policy and practice towards severely retarded people in America,1820-1920 (book review).' Social Science and Medicine 44(4): 549-550.
Houston S and D Legge, Aboriginal health research and the National Aboriginal Health Strategy (editorial), Aust J Public Health, 16(2) 114-115, 1992.
Legge DG (1995), Research to improve partnerships for public health, Health Transition Review, 5, 223-227
Legge DG (1997), 'Implications of post-structuralism for policy work in public health' in Hunt L (ed), Proceedings of Third Asia and Pacific Conference on the Social Sciences in Medicine, 1996, Section 3, 'Health Policy', Volume 1, Published by Faculty of Health Sciences, Edith Cowan University, Western Australia.
Legge DG (1999), 'The evaluation of health development: the next methodological frontier?' (editorial), Australian and New Zealand Journal of Public Health 23(2), 3-4
Legge, DG Wilson, P Butler, M Wright, T McBride, et al. (1996). Best practice in primary health care. Melbourne: Centre for Development and Innovation in Health and Commonwealth Department of Health and Family Services
Legge, David, Gai Wilson, Paul Butler, Maria Wright, Tony McBride, et al. (1996). 'Best practice in primary health care.' Australian Journal of Primary Health Care-Interchange 2(1): 12-26;
Legge, David, Paul Butler and John Scott (1995). Policies for a healthier Australia: achievements and challenges. Melbourne: La Trobe University, CDIH & HIC.
National Centre for Epidemiology and Population Health, Improving Australia's Health, Final Report of the Review of the Role of Primary Health Care in Health Promotion in Australia by DG Legge, DN McDonald and CF Benger, National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT, 1992
Public Health Association of Australia (1995). System-wide learning for public health: report to the Commonwealth Department of Human Services and Health. Canberra: PHAA.
Stagoll O, DG Legge, S Everill, "Community development in health", pp 20-34, in M Miller and R Walker (eds), Health promotion: the community health approach, papers from the Second Conference of the Australian Community Health Association (1988), ACHA, Sydney.
Sylvan L and DG Legge, "Community participation in health", pp 58-78, in M Miller and R Walker (eds), Health promotion: the community health approach, papers from the Second Conference of the Australian Community Health Association (1988), ACHA, Sydney.
Butler, P., D. Legge, et al. (1995). Towards best practice in primary health care: a working paper of the Best Practice in Primary Health Care project. Melbourne, Centre for Development and Innovation in Health.
Legge, D. (1997). “Questioning the solution: the politics of primary health care and child survival with an in-depth critique of oral rehydration therapy (book review).” Australian Journal of Primary Health - Interchange 3(2&3): 114-117.
Legge, D. (1998). “Globalisation: what does 'intersectoral collaboration' mean?” Aust N Z J Public Health 22(1): 158-63.
Legge, D. (1999). Public policy perspective. Perspectives on health inequity. E. Harris, P. Sainsbury and D. Nutbeam. Sydney, Australian Centre for Health Promotion, Department of Public Health and Community Medicine, University of Sydney: 96-110.
Legge, D. (1999). Rethinking public health practice. Developing health: proceedings of NCEPH 10th Anniversary Conference. D. Broom. Canberra, NCEPH, ANU.
Legge, D. (2002). Health inequalities in the new world order. The social origins of health and well being. R. Eckersley, J. Dixon and R. M. Douglass. Melbourne, Cambridge University Press. (in the press)
Jennings, R. and D. Legge (2003). The Victorian Primary Health Care Reforms: A Case Study of Evidence-based Policy Making (Chapter 14) in. Evidence-based Health Policy: Problems and Possibilities. V. Lin and B. Gibson. Melbourne, Oxford University Press.
Legge, D., L. Pei, et al. (2000). Priorities for health service management education in China. Challenges for public health at the dawn of the 21st Century: selected proceedings from the 9th International Congress, World Federation of Public Health Associations, Beijing, World Federation of Public Health Associations.
Legge, D. (1999). “The evaluation of health development: the next methodological frontier?” Australian and New Zealand Journal of Public Health 23(2): 117-118.
Legge, D. (2004). "Book Review: Global Public Goods for Health edited by Richard Smith, Robert Beaglehole, David Woodward and Nick Drager. Published by Oxford University Press,." ANZJPH 28(4).
Legge, D., P. Stanton, et al. (2005). Learning management (and managing your learning). Managing health services: concepts and practice. Mary Harris and associates, Society for Health Administration Programs in Education and Australian College of Health Service Executives. Sydney, Elsevier Mosby: 1-17.
Legge, D. (2002). "Challenges of globalisation deserve better than simplistic polemics (letter)." BMJ 324: 44.
Legge, D. G., D. H. Gleeson, et al. (2007). "Micro macro integration: reframing primary health care practice and community development in health " Critical Public Health accepted for publication.
Legge, D., D. Gleeson, et al. (2007). "Conceptual practices in primary health care." BMC Health Services Resarch (under consideration).
Legge, D. (2007). "Global trade and health promotion." Health Promotion Journal of Australia accepted for publication.
McCoy, D., D. Sanders, et al. (2004). "Pushing the international health research agenda towards equity and effectiveness." The Lancet 364(9445): 1630.
Pei, L., D. Legge, P. Stanton. (2000). “The need for hospital management training in China.” Asia Pacific Journal of Human Resources 38(3): 12-28.
Gong, Z., S. J. Duckett, et al. (2004). "Describing Chinese hospital activity with diagnosis related groups (DRGs): a case study of Chengdu." Health Policy 69: 93-100.
Pei, L., D. Legge, P Stanton. (2000). “Policy contradictions limiting hospital performance in China.” Policy Studies 21(2): 99-113.
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