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At long last, we have a National Preventive Health Strategy. What next?

The National Preventive Health Strategy (NPHS) is one pillar (with mental health) of the Government’s Long Term National Health Plan, released in 2019. The strategy was launched on 13 December by the Minister for Health, Greg Hunt, in one of his last major announcements as Health Minister – just a few days after he announced plans for the development of a National Health and Medical Research Strategy.

The NPHS has the potential to improve Australia’s current piecemeal and poorly coordinated approach to preventive health but its failure to adequately address some fundamental determinants of health (particularly those outside of the health portfolio) and uncertainty around its implementation challenges may mean that this potential is not fully realised.

Below, Croakey editor, Jennifer Doggett, highlights the main features of this ten-year strategy and summarises responses from the health sector.


Jennifer Doggett writes:

The launch of the National Preventive Health Strategy was the culmination of several years of work by the government and the expert steering committee, comprising around 25 representatives of health peak bodies and individuals with expertise in specific areas.

Of 1,200 people registered for the virtual event, more than 750 dialled in, highlighting the importance of this strategy to health experts and groups (although a disappointing lack of coverage in the mainstream media suggests that prevention is still not seen as a high priority outside of the health sector).

Many had provided input into its development via feedback on the initial discussion paper and the first draft of the strategy, as well as participating in the series of consultation workshops held by the Government.

Patchy record

Australia has a patchy record on preventive health with some standout successes (such as childhood immunisation and tobacco control – although a recent Croakey contributor noted there “has been little policy innovation since the implementation of tobacco plain packaging laws in 2012”), as well as notable failures (inadequate efforts on obesity, inequality and the health impacts of climate change).

One notable factor hampering our ability to comprehensively address the drivers of poor health has been the lack of a systematic approach across all areas of government in favour of isolated initiatives on specific issues.

Australia did not have any national approach to prevention until the development of the first National Preventative Health Strategy in 2009. While this strategy integrated a number of preventive health issues that had previously been addressed in isolation, it still had a narrow focus on addressing the health harms of alcohol, tobacco and overweight/obesity.

The establishment of the Australian National Preventive Health Agency (ANPHA) in 2011 provided an opportunity for the Federal Government to work with state and territory governments, community and health promotion organisations, industry, primary healthcare providers and others to broaden the approach to preventive health.

However, this agency was abolished by the Coalition Government in 2014 as part of its “commitment to reduce the size of government and to ensure that government services are as efficient and well-targeted as possible”.

Given this track record, a key ask for the new National Preventive Health Strategy from stakeholders, such as the Australian Healthcare and Hospitals Association, was for a broad and comprehensive approach that recognises the determinants of poor health from both inside and outside the health system.

Stakeholder responses to the strategy thus far indicate that while it might be a distinct improvement on Australia’s previous approaches to prevention, it is still too narrowly focssed within the health portfolio and ignores the opportunity to address major threats to our health, such as climate change.

The launch

The launch of the strategy, broadcast from Minister Hunt’s electorate office, was hosted by Adjunct Professor Terry Slevin, CEO of the Public Health Association of Australia, with speakers including the Minister, Professor Emily Banks, Professor Andrew Wilson and Dr Katie Allen.

In launching the strategy, Hunt mentioned his personal commitment to prevention and his Government’s success in areas such as vaping and childhood immunisation. He also highlighted the role of the Pharmaceutical Benefits Scheme (PBS) several times as a preventive health strategy.

He described the development of the strategy as an “intense period of consultation” and, in a swift pivot to pre-election mode, he mentioned Australia’s response to COVID, saying that it has been one of the world’s best.

Some specific aspects of the strategy highlighted by Hunt include the quantifiable series of targets for each area, the importance of a good start for kids, health equity (including telehealth and rural health) and the call for increased funding. (General practitioner and Croakey Contributing editor Dr Tim Senior argues, however, that the telehealth measures announced this week will worsen health inequities).

In response to a question on climate change and health, Hunt acknowledged that it is an important issue and mentioned recent progress on emissions targets and mentioned a Government program on dengue fever, currently under review.

He also flagged the imminent launch of a new SunSmart program over the Summer to target Australia’s high rate of skin cancer. The campaign, which will launch ahead of the election, has been urged for years by public health advocates.

Complexities

Professor Emily Banks, a member of the expert advisory committee, provided a presentation on the committee’s approach to the development of the strategy.

She highlighted the efficiency of preventive health compared to other areas of the health system and stressed the importance of epidemiology and rigorous data.

Banks also talked about the complexity of prevention, saying that it involves systems, policies, frameworks as well as individual and provider behaviours.  She highlighted the need to provide support for people to undertake health-promoting and preventive health activities and identified a number of challenges to the successful implementation of the strategy.

Professor Andrew Wilson, co-director of the NHMRC Australian Prevention Partnership Centre, said that one challenge is to get the complexity of prevention recognised in health policies and strategies.

He gave the example of COVID prevention strategies like masking to highlight the multi-layered nature of preventive health, adding that this demonstrated how important it was to capture the key upstream determinants of health in any prevention strategy.

The final speaker was Dr Katie Allen MP, who described how the COVID-19 pandemic has raised awareness of the importance of prevention across the world.

She described the strategy as “a very important step in the right direction”, citing the Intergenerational Report’s finding that Australia will need to double our health funding (as a percentage of GDP) over the next 40 years in order to meet the needs of our ageing population.

Allen mentioned the problems associated with siloed health funding and stressed the need to move health dollars “upstream” and to get the community to take control of their own health.

“There is so much more for us to do to pivot the political class to understand the importance of prevention in promoting healthier communities for the future,” she said.

Allen also acknowledged the difficulties involved in prioritising funding for prevention when there are already so many service delivery challenges in the health system.

What’s in

The strategy identifies a series of aims, principles, enablers and focus areas which range from the very broad (all Australians have the best start in life) to the specific (increasing cancer screening and prevention).

Under each aim is specific measurable goals against which the implementation of the strategy can be measured.

Key areas of action

The strategy identifies five immediate priorities for action to support the overall implementation of the strategy as well as recommendations for specific activities in key areas.

The five immediate priorities are:

•      developing the Blueprint for Action to guide implementation of the Strategy

•      creating an evidence-based Prioritisation Framework

•      analysing the current public health workforce profile to determine the growth

·      levels, training opportunities, development pathways and areas of unmet demand

•      developing a national consumer engagement strategy, and

•      developing a national health literacy strategy.

Some examples of specific aims and recommended actions in focus areas are below.

Tobacco control

In relation to tobacco, Associate Professor Coral Gartner from the Centre of Research Excellence on Achieving the Tobacco Endgame, said that the Strategy confirmed the goal of a national daily smoking prevalence of less than 5% for adults (≥18 years) overall and announced a goal of 27% or less daily smoking among Aboriginal and Torres Strait Islander people aged ≥15 years) by 2030.

“A renewed mass media campaign was flagged, but few details were provided on any other new specific strategies that would be used to achieve these targets.

“At the launch, the Health Minister, The Hon Greg Hunt, advised that the much anticipated National Tobacco Strategy 2020-2030 would be finalised and released in late Q1 2022. The minister was unable to advise whether Australia would also consider adopting similar bold tobacco control strategies, such as a very low nicotine content standard for cigarettes, as was announced in New Zealand last week, due to needing more time to understand and consider these policies.

“In reflecting on his achievements in tobacco control policy, he noted the re-scheduling of nicotine vaping products as prescription medicines in 2021 to protect Australian youth, which is a unique policy in the world, but also acknowledged the controversy around that measure when it was introduced,” Gartner said.

Obesity

A range of aims are included in the strategy to address rising obesity levels including “halting the rise and reverse the trend in the prevalence of obesity in adults by 2030; reducing overweight and obesity in children and adolescents aged 2-17 years by at least 5% by 2030; and increasing fruit consumption among adults and children over 9 years to an average 2 serves per day by 2030.”

It also recognises that “multiple strategies aimed at the individual, communities, the food system and the food environment will be needed to achieve the targets in this focus area.”

Cancer screening

Cancer screening was mentioned a number of times by the Minister in his speech at the launch as a priority area for the strategy.  The targets contained in the strategy for screening programs are to:

•      Increase participation rates for bowel screening to at least 53% by 2025

•      Increase participation rates for breast screening to at least 65% by 2025

•      Increase participation rates for cervical screening to at least 64% by 2025

The strategy also aims to eliminate cervical cancer as a public health issue in Australia by 2035.

The document does not suggest specific mechanisms to achieve these targets but states that “strong community engagement and more innovative, data driven approaches are integral to ensuring all eligible Australians are accessing the available screening programs.”

It also mentions a range of possible strategies to make screening more accessible including “expanded opening hours, co-locating services, customising materials and supporting culturally or gender appropriate approaches”, noting that CALD groups and men have low rates of screening.

Stakeholder responses

The Consumers Health Forum welcomed the strategy, saying that it “sets out a positive agenda for a future healthier Australia” and was “backed by the aim to earmark 5 per cent of the health budget for preventive action by 2030.”

“We have waited some years for the Federal Government to provide a comprehensive national agenda on preventive health and this new strategy provides a strong case for bold, cohesive measures,” the CEO of the Consumers Health Forum, Leanne Wells, said.

In its media statement, CHF mentioned the “strong consumer and community-focused thrust of the strategy”, along with its “recognition of the importance of health literacy and consumers as partners in pursuing better health for all Australians.”

The Australian Healthcare and Hospitals Association (AHHA) the Strategy “points the way towards better health for all Australians” and recognised the importance of cross sectoral partnerships, strong leadership and governance, dedicated funding and better evaluation.

AHHA CEO John Gregg called for an accelerated approach to increasing funding for prevention in order to meet the additional challenges being posed by the COVID-19 pandemic.

He highlighted the need for preventive health strategies to draw on the “inherent capabilities” of primary health care professionals and to support team-based models of care involving nurses, allied health and the broader social care system.  Gregg also emphasised the role of Primary Health Networks and local hospital networks or health districts in integrating local services and called for the current silos of health data to be combined to provide nationally consistent data standards and data collection for primary care

The Australian Chronic Disease Prevention Alliance (ACDPA), comprising Cancer Council Australia, Diabetes Australia, National Heart Foundation of Australia, Kidney Health Australia and the Stroke Foundation, welcomed the release of the Strategy and particularly its targets and aims to increase spending on prevention and reduce chronic disease risk factors by 2030.

Sharon McGowan, ACDPA Chair, was a member of the Expert Reference Group and noted the collaborative approach to develop the Strategy. She urged Federal, State and Territory governments to commit to the Strategy’s aim to increase investment in prevention to 5% of the health budget by 2030 and called on the Government to build on the momentum generated by the Strategy’s release and commit to developing the Blueprint for Action in the next year with funding for implementation.

The Royal Australasian College of Physicians (RACP) welcomed the strategy’s release and its recognition of a number of issues raised by RACP, including:

  • A five percent funding commitment of total health expenditure across all jurisdictions
  • Inclusion of the determinants of health, and especially the environmental determinants of health, including climate change
  • Improved nutrition through the reduction of sugar, saturated fat, and sodium content of packaged and processed foods, including through consideration of tax reform
  • An equity focus in the strategy, with the inclusion of specific equity targets for Indigenous Australians, Australians in regional and remote areas, and Australians impacted by social and economic disadvantage
  • A commitment to future proofing the public health workforce and the importance of a multi-disciplinary approach
  • Improved cultural safety across the Australian health system for appropriate and responsive health care for all Australians and the prioritisation of care through ACCHSs.

RACP President Professor John Wilson said, “The strategy sets a comprehensive preventive health agenda for Australia over the next decade. We strongly support these commitments and ask the Government to move towards this goal with the alacrity it deserves.

“We are calling on the Federal Government to demonstrate its commitment to this Strategy by providing a comprehensive funding plan commencing with next year’s March budget linked to the aims and targets in the strategy.”

Other stakeholders welcomed the focus on equity, determinants of health, cancer and stroke prevention.

Read the AHPA statement.


 

The Climate and Health Alliance emphasised the efforts that it had put into having climate change recognised in the strategy as a health threat.

What’s not in it

However, stakeholders also identified some limitations of the strategy to address some of the most fundamental and significant threats to the current and future health of Australians.

CHF noted that some important areas are absent, in particular dental/oral preventive health, which it said disproportionally affects disadvantaged communities and people.

CHF also stressed the need for a broader approach to some of the priority issues, such as obesity which it said needed attention from  “all policy makers, both within health and broader government portfolios” as well as “schools, workplaces, businesses, and community organisations.”

Other commentators highlighted areas which are not adequately addressed in the strategy, including the regulation of digital platforms and breastfeeding.

 

Other limitations of the strategy include a lack of focus on major structural determinants of health which lie outside the direct responsibility of the health portfolio, such as poverty, inequality and racism.

The lack of an Indigenous speaker at the launch was disappointing given the focus of the strategy on addressing the health inequities experienced by Aboriginal and Torres Strait Islanders. Without visible leadership from Indigenous communities and community ownership of its recommended approaches, this important goal is unlikely to be achieved.

There is also no detailed mention of approaches which have been used elsewhere to embed a health focus into all government policy and decision making, such as ‘health in all policies’.

This indicates the fundamental paradox at the heart of the strategy: it acknowledges the critical importance of sectors outside health in prevention and speaks of the importance of partnerships but also suggests that its scope is limited to the actions of the health sector.

“It is important to note that whilst many of the wider determinants sit outside of the direct control of the health system (i.e. climate change,racism, social media etc.) and consequently the scope of this Strategy, it is important to acknowledge the significant impact that they currently have on health and wellbeing outcomes and will continue to have in the future. It is also important to recognise the influential role that health leaders can have on other sectors in order to achieve better health for all Australians.”

Nor does this framing acknowledge the direct role that the health sector has in addressing racism (within its ranks and through population-wide interventions) and climate change adaptation and mitigation.

Implementation challenges

The retirement of current Minister for Health, Greg Hunt, who has overseen the development of the strategy, together with a Federal election and possible change of government next year, means that the future of the strategy is not assured.

While the document provides a detailed blueprint for action for a future health minister and government, it also contains recommendations which will be challenging for any government to implement.

These include actions which would be opposed by powerful corporate interests (such as tax reform to reduce the consumption of packaged and processed foods and greater restrictions on the supply of tobacco products) or which require a high degree of cooperation across different levels and sectors of government (using urban design, land use and infrastructure to support physical activity by providing Australians with access to natural environments, public open spaces and green areas, and active transport networks).

At the conclusion of the launch, Terry Slevin made clear the PHAA will be pressing for bipartisan support and urged attendees to advocate for the full implementation of the strategy.

Given the current uncertain political environment and Australia’s poor track record on mounting successful inter-sectoral and cross-jurisdictional responses to health challenges, it is clear that ongoing support and advocacy from all health stakeholders will be required to translate the recommendations of the strategy into effective action.


See Croakey’s previous articles on the National Preventive Health Strategy.

 

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