Introduction by Croakey: Australian governments recently made a profound shift in their approach to health policy making, driven by the immensity and the urgency of the pandemic threat.
All jurisdictions, working collaboratively through the National Cabinet, centred health imperatives in decision making across portfolios and took a whole-of-government approach to safeguarding the community’s health.
Whether or not the governments used the language of the Health in All Policies (HiAP) framework, the pandemic has shown the power of this approach to disrupt established ways of doing business and to create significant change to protect the community’s health.
It is not clear whether such an approach will continue past that critical first stage of the pandemic. The terms of reference for the COVID Commission, for example, are that it “anticipate and mitigate the economic and social impacts of the global COVID-19 pandemic”, and that it will:
advise the Prime Minister on all non-health aspects of the pandemic response, working in tandem with the Chief Medical Officer (CMO), Dr Brendan Murphy.
The CMO and the medical expert panel he leads – the Australian Health Protection Principal Committee (AHPPC) – will continue their role of advising the National Cabinet on Australia’s health management and response to the virus.”
Where are the opportunities for promoting HiAP within these structures?
Georgia Gardner, the Secretary with the Australia Alopecia Areata Foundation, makes the case below for embedding health-based decision making in all levels of government through HiAP.
Georgia Gardner writes:
It’s been noted many times that we don’t really have a health care system – we have an illness care system. Treating and responding to ill health seems to be much easier than preventing it.
In our current system, only a small percentage of health budgets are allocated to preventative health, often narrowly focused on alcohol, tobacco and obesity. This approach focuses significantly on individual choices around a limited set of health-related behaviours. However, the reality of preventative health is far more complicated and a much wider focus is needed to address key health determinants.
In the Social Determinants of Health (SDoH) model, we see how individual health is significantly driven by factors outside the health sector. Employment, housing, transport, financial security, community design, education and other sectors have a massive impact on the health of individuals and communities.
In the light of the current health crisis, it has never been clearer that our health is connected to how we live and work, and how our neighbours and communities live and work. Health and wellbeing are impacted by every part of our lives, and every part of governance and policy has an impact on health. When looking at health from a social determinants perspective, we clearly see the need for cross-departmental health promotion and intersectional action at all levels of governance.
The Health in All Policies (HiAP) Framework is defined by the World Health Organisation (WHO) as “an approach to policy-making that places ‘health’ as a key decision-making factor in all areas of policy, by systematically taking into account the health and health-system implications of policy decisions, by seeking synergies between policy portfolios, and by avoiding harmful health impacts, in order to improve population health and health equity.”
Benefits could be massive
The HiAP framework is already in use in some Australian states, most notably South Australia. At the conceptual and practical levels, the HiAP framework addresses health determinants via a cross-sector and whole-of-government approach to all policy. Literature for implementing the HiAP approach (from the WHO and other peak bodies) already exists with a solid research base.
The benefits of implementing the HiAP framework Australia-wide could be massive, but we would require several key shifts in thinking and culture to support a successful transition to this model.
The first necessary shift in thinking is wider understanding and acceptance of SDoH as the key drivers of the health and wellbeing of communities and individuals. The literature around the SDoH model goes back to the beginnings of the World Health Organisation and is strongly supported by peak bodies in the health sector.
To seriously change in how we approach health in policy, we must first promote understanding of the SDoH model through all levels of governance and the public in general. Instituting a new approach to policy making at all levels of government is a complex task. It will be difficult and have costs. Increasing public support for serious action on the SDoH is crucial to building meaningful change and supporting a successful implementation of the HiAP model.
A second, related change is wider understanding and acceptance that cross-governmental intersectional action is the primary tool for managing complex policy problems. Our current system of departmental budgets and programs segregated by state, department or ministerial interest is seriously insufficient to deal with the complexity of our current policy landscape.
However, changing to new, interconnected systems and developing a whole-of-government approach to health and wellbeing is no small task. There will be challenges and setbacks. The success of these changes lies on public support and understanding the benefits of systematic change.
Strong leadership required
The third, most important shift requires us to value health and community wellbeing as just as important to policy development as the economic cost. This may require the greatest shift in thinking, culture and practice. We currently report and measure economic growth and costs of policies. Reporting measures for human impact are far less standardized and far less understood by the general public.
The dominance of GDP as a primary measure of political and social success has shifted policy making and public thinking to focus on short term dollar value rather than long-term impact on people. Implementing reporting measures that value equitable, sustainable well-being can help refocus policy-makers – and the public – towards policy decisions that benefit the health and wellbeing of everyone. This must be the highest priority moving forward.
Ultimately, all of these shifts in thinking require strong leadership from policy makers and politicians at all levels. It requires collaboration and dedication to difficult-but-necessary systematic change. The HiAP model reflects a growing push from the public for a more holistic approach to governance and for a whole-of-person approach within health sectors. Australian government leaders must commit to addressing health inequity at every level and promote the need for strategic change through their communities.
These challenges may seem serious, but there are major benefits to successful implementation of a HiAP framework – and major risks if we don’t.
Improving the health and wellness of individuals, families, and communities through systematically addressing the SDoH will have massive benefits. A properly implemented HiAP framework can address preventable ill health and significantly improve life expectancy and quality of life outcomes. This will lower costs and burden on the healthcare system in the long term and improve outcomes as our population ages. In addition to lower costs, improved health and wellbeing also improves economic productivity, security and civic engagement, which provides further economic and social benefits.
A properly implemented HiAP model will be a strong foundation for addressing other complex policy concerns, including the climate crisis and financial insecurity. The benefits of the HiAP model are largely long-term and systematic, which may make them complicated to measure. Developing appropriate measurement and reporting is a key step in the HiAP framework.
Severe and compounding
When policy decisions are not grounded in a health and wellbeing framework, there are major risks. In light of the COVID-19 pandemic, we can see how clearly individual and community health is impacted by policy decisions outside of the health sector.
Policy decisions in our national telecommunications strategy affect our capacity to support workers and students to work remotely. Policy decisions around financial support and rental affordability place households at severe risk and can force workers to presenteeism and spread illness further. Cuts to social service staffing and insufficient online service provision become woefully apparent when numbers needing these services surge. These areas are all deeply interconnected, and all have a massive impact on both the health and economic security of individuals and communities.
We see it clearest in times of crisis, but make no mistake, the cost of not grounding policy decisions in health and wellbeing is severe and compounding. Worse, it’s most often paid by those who can least afford it.
We cannot go forward with business as usual. We must make long-term health and wellbeing the highest priority in all policy decision making. We must put in place structures and strategies to embed health-based decision making in all levels of government. The only way to truly prevent unnecessarily ill health is to place the focus on health in all policies.
Frankly, we can’t afford not to.
Georgia Gardner is the Secretary with the Australia Alopecia Areata Foundation. Her experiences growing up with an autoimmune disease in rural NSW have inspired passion for accessible healthcare, rare diseases and peer-based support. In her nine year as volunteer with AAAF she has seen the mental health benefits of peer- based support and lived-experience storytelling. Her professional background is in media and communications, and non-profit business management.