In one of the more hopeful developments of late for public health, the Social Determinants of Health Alliance was formally launched in Canberra last week.
The Alliance is “a collaboration of like-minded organisations from the areas of health, social services and public policy established to work with governments to reduce health inequities”.
Its launch is timely, given that a Senate inquiry is due to report on March 27 on Australia’s response to the World Health Organization’s Commission on Social Determinants of Health report Closing the gap within a generation. (And not before time given that it’s now more than four years since that report’s launch.)
Thanks to Gavin Abraham of Catholic Health Australia for providing the transcript below of the launch presentations, including:
• How can we make all our policies as health equitable as possible?
Professor Fran Baum, director of Southgate Institute at Flinders University, former commissioner of WHO Commission on the Social Determinants of Health, global steering council of People’s Health Movement
• We need to mobilise political and popular support for a radical break from the status quo
Professor Sharon Friel, professor of health equity, Australian National University, head of scientific secretariat for WHO Commission on the Social Determinants of Health
• Time to ditch the old paradigm of risk factors and behaviour (take note diabetes strategy)
Professor Stephen Duckett, health program director, Grattan Institute; former chair of Brotherhood of St Laurence
• A call to tackle the multiple, interrelated factors that result in some people and communities being unwell, unemployed and trapped in cycles of disadvantage
Lin Hatfield Dodds, Australian Social Inclusion Board, CEO of UnitingCare Australia
• The general public and policy makers need to develop a better understanding of the social determinants of health
Social Inclusion Minister Mark Butler
(And below the transcript is a short summary of the Alliance’s recommendations to the Senate inquiry.)
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How can we make all our policies as health equitable as possible?
Professor Fran Baum, director of Southgate Institute at Flinders University, former commissioner of WHO Commission on the Social Determinants of Health, global steering council of People’s Health Movement
This is a great day for me. I’ve long hoped that we would have such a strong alliance in Australia.
WHO director general Margaret Chan, when launching the [WHO Commission on Social Determinants of Health] report said “health inequity really is a matter of life and death”. Professor Sir Michael Marmot “Social injustice is killing people on a grand scale”.
We have to note that men in the lowest socioeconomic group in Australia are twice as likely to die prematurely as those in the highest socioeconomic group. These health inequities permeate our society.
Action on the social determinants of health is best led by the head of a government, where the mandate lies to promote a health equity in all policies approach.
I’m pleased to say that my home state, South Australia, has instituted such an approach, which is led by Premier and Cabinet, that is linked to our state’s strategic plan and is driven by a catalyst unit at SA Health which is working systematically with other sectors to look at their health impact, including in urban planning, transport, education, regional settlement and really asking the question: How can we make all our policies as health equitable as possible?
The WHO Commission made recommendations to national bodies like the NHMRC so that they fund not just medical research but also fund research about how to keep people healthy. We recognise most of these bodies, NHMRC included, spend most of their money on how to cope with people when they get sick, not on how to keep them healthy in the first place.
This Alliance realises the Commission’s recommendations for a global movement in Australia.
The report laid out a blueprint for creating a healthy and fair society in which all citizens are able to flourish.
The report has been widely quoted in Australia and is having a direct impact on policy in some instances, for instance the Health in All Policies approach in South Australia. I must admit I am disappointed that the report hasn’t received more attention in Australia since its launch.
It’s true much of what the report argues for we already do in Australia. The report was global, and some countries just do not have the level of social protections and health services that we do, but there is still much that Australian can do to flatten the gradient in health so that more Australians can live longer lives.
A real challenge is that the social determinants of health approach is a long-term developmental one that works because it prevents problems in the future. Politically, I think that’s a hard message because politics is often more about what can be achieved in the short term before the next election. A social determinants approach requires a strong and consistent commitment to a spirit of equity and a pursuit of social justice.
The focus of prevention in the social determinants of health agenda means success in ensuring adverse outcomes don’t happen, and unfortunately that isn’t the stuff of headlines. Can you see “We prevented hundreds of children developing diabetes in 30 years’ time”? It just doesn’t have the same ring.
So I’ve been very happy to work with Catholic Health as they’ve led this process towards forming this Social Determinants of Health Alliance and I look forward to the Alliance working with all political parties and policy makers – federally and in the states and territories – to persuade them that in the long term, investment in health and health equity makes sense socially, makes sense economically and makes sense politically and that making this investment will require a very concerted effort on the social determinants of health by all our policy makers at all levels of government.
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We need to mobilise political and popular support for a radical break from the status quo
Professor Sharon Friel, professor of health equity, Australian National University, head of scientific secretariat for WHO Commission on the Social Determinants of Health
In the Commission’s final report, we recommended the establishment of a global alliance to keep shining that spotlight on social and health inequities. A number of us have been working to do that at the global level.
It is absolutely fantastic that now in Australia we have the Social Determinants of Health Alliance as part of that global movement to bring things to account.
Why is it very important to establish such an alliance or a mechanism? It is very, very easy to remain with the status quo, and that’s clearly not working, witnessed by the level of social exclusion and disadvantage that we see in Australia, and I would also say the current levels of human-induced environmental degradation and of course those marked differentials in well-being and health outcomes.
Why is it important to establish such an alliance? It is really vital to have a concerted, strong voice. That was a key message that came out of the global work, all working together around common goals with a strong voice because we know that addressing the social determinants of health is very complex, and it’s not a very easy thing.
Action on these sorts of social issues really does challenge the status quo. A concerted voice is also needed to remind people it’s not about the medical treatment, or it’s not just about the treatment, and it’s not just about individual behaviours.
Another reason why it’s important to establish such an alliance is because there’s no one person that can improve the social determinants of health or health equity on their own. It clearly is a cross-disciplinary, cross-sectoral and cross-border collaboration that’s vital for this.
The evidence is crucial. We can of course learn from what’s been happening overseas … and how we might adapt it here. But through something like the alliance we can really share what we’ve been doing and what we’ve been doing well in this country.
We should be showcasing the cigarette plain packaging successes, we should also share the carbon pricing and all those social protection policies that were introduced at the same time. We should be sharing the strong voice around gun control and the policies that have been implemented in Australia in relation to that, and of course, the third determination and Aboriginal control to services. The Alliance provides a vehicle to do that.
Bringing the health equity and also the environmental agenda together is really about coherent policy at the national, local and also global level. And we need that to mobilise the necessary political and popular support to bring for a radical break from what is often a complacent attitude in terms of remaining with the status quo.
Some of the policies – cigarette plain packaging, for example – show that if we want to do it, it can happen, so it is absolutely fantastic that Minister Butler thinks this social determinants agenda is something that is important and worth pursuing. It is really exciting that Australia is now making a response to the commission’s recommendations.
Of all the things I’ve spoken about, we absolutely need a policy framework that is oriented around the social determinants and societal level factors. We need an evidence base that is not treatment focussed and which is not behaviour focussed.
And we need a social movement that highlights what needs to be done, that brings the evidence to bear on how to do it, and of course also keeping government and the corporate sector to account.
The Social Determinants of Health Alliance has an extremely important role to play, constantly reminding us that addressing the social determinants of health doesn’t only improve health, but it also reduce social exclusion, it will help reduce poverty, it will help us pursue sustainable economic development and it will also help us build societies that live within environmental limits. So I look forward very much to working with colleagues in the Alliance.
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Time to ditch the old paradigm of risk factors and behaviour (take note diabetes strategy)
Professor Stephen Duckett, health program director, Grattan Institute; former chair of Brotherhood of St Laurence
I’d like to start by talking about the significant impact that social determinants have on health status.
And if you just use diabetes as an example, people who live in the poorest areas of Australia, the lowest 20 per cent of areas of Australia, have more than two-and-a-half times the risk of getting diabetes relative to people who live in the top 20 per cent of areas.
That difference in risk between a 2 per cent chance of getting diabetes if you live in the best areas versus a 5 per cent chance in the worst areas is a much more significant difference than, say, so-called behavioural factors such as exercise, which is 6 per cent if you are high to moderate exercise person versus 8 per cent if you are sedentary risk of getting diabetes. It’s much more important than alcohol, and even more important than obesity.
To understand diabetes, for example, you cannot understand the risk of getting diabetes if you don’t start by thinking about the broader social factors. And so it shouldn’t be possible to develop, for example, a diabetes strategy in Australia without first starting with a social determinants approach, without starting with those broader factors.
But if you look at the Department of Health and Ageing website today, it refers to lifestyle-related chronic disease as the determining factor or one of the critical factors, and so that suggests to me that we in our health policy are applying the wrong frame as a starting point.
The old paradigm of this was behavioural risk factors led to disease and the intervention was to change the behaviours. But we’ve got to recognise those behaviours in many case are shaped by the social determinants – the areas in which you live, the income you have and so on. And so we need, in our policies, to be focussing more upstream in that regard.
Unfortunately we’re also beginning to see in the research that there’s another link that’s important; that the social determinants lead to biological changes that in turn lead to health changes.
One of the more depressing studies I read recently was about brain development in kids. Kids in the lowest income families start with the same sort of brains as kids born in other families, but in time – over the first four years of their life – their brain doesn’t develop as much, so obviously they are then set up for a lifetime of disadvantage. And so even greater this tragedy suggests we need to pay even more attention to these social determinants.
The issue, then, is what practically can be done. The WHO report outlined a raft of suggestions. What can be done now that have immediate payoffs, in some senses, but also move into the future? Some of those include focusing on the early years.
Seriously addressing the social determinants of health means we need to be serious about addressing poverty in Australia. Being serious about addressing poverty in Australia means we have to be serious about growing the Australian economy. And I’m not just talking here about some remote trickle-down theory where eventually the benefits of a bigger economy flow down to everyone in the country. I’m talking about policies which are not “instead of” focusing on social justice and social determinants, but “as well as” policies. So focussing on growing the economy is not instead of developing the issues of the social determinants report of the WHO.
And I just want to mention one suggestion. The Grattan Institute last year published what it calls a Game Changers report, which suggested a number of interventions, which could be expanding the gross domestic product of Australia, expanding the size of the Australian economy.
There were three things they suggested could change the size of the Australian economy. One was changing the tax mix. One was increasing the number of older people who participate in the workforce, and that’s an issue of increasing relevance to me, and one was about increasing the participation of women in the workforce.
For example, if you look at the participation rates of women, about 67 per cent of women are in the workforce versus 78 per cent of men. About 55 per cent of women work full time versus 85 per cent of men and so on.
If Australian women had the same participation rate as Canadian women, that’s 6 per cent greater, then Australia’s GDP would be $25 billion bigger, that is, our economy would be significantly greater. Now just think about what the benefits of that are – a $25 billion increase in the size of the economy by increasing the participation rates of women in the workforce. Among other things, it would mean there is more tax income to pay for things. But if you think about that, it means, how are you going to get there?
The Grattan Institute highlighted a number of barriers to increasing the participation rate of women. One was a high effective marginal tax rate. If you are home looking after the kids and you go into work, you lose a whole lot of your benefits. But also there were barriers like parental leave, and the importance of expanding access to parental leave, and there were also barriers in terms of childcare costs.
And if you think about women going into the workforce – women have traditionally taken that family role of looking after the kids – we need to expand childcare.
Expanding childcare creates more jobs in the childcare industry and often they’re relatively low-paid jobs, so people in low-paid jobs are moving from being unemployed into employment and that then changes their social circumstances, that then changes the social determinants of health for them and their families, that then improves the health system, reduces some of these burdens and so on.
And so my argument here is this: When we think about the social determinants, we don’t think about just this terrible burden on society that is going to cause a whole lot of problems and cost the government a whole lot of money we can’t afford.
What we should be talking about is this – we can do both. We can in an economically rational way improve the economy, and in so doing, we can improve the life situation of people who are affected by this and in so doing we can start to address the social determinants.
I’m not saying this is instead of the other issues – the health in all policies approach and so on. This is as well as, it is an economically sensible way. Don’t say we can’t afford to do it, because we can.
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We need to tackle the multiple, interrelated factors that result in some people and communities being unwell, unemployed and trapped in cycles of disadvantage
Lin Hatfield Dodds, Australian Social Inclusion Board, CEO of UnitingCare Australia
It’s a delight for me to be here for the launch of the Social Determinants of Health Alliance. It’s a really important group coming together right now.
Appreciation and thanks to the four senators who are involved in the current Senate Inquiry: Senators Claire Moore, Dean Smith, Sue Boyce and Rachel Siewert. We would never get as much traction on these kinds of things that matter unless we have parliamentarians who take it seriously and track these issues through the parliamentary system.
I give credit to the Government, and in particular to Minister Mark Butler for driving a national social inclusion agenda. It’s something that many of us in the non-government sector and in academe asked for over a very long time, and that includes the establishment of the board I chair, the Social Inclusion Board.
Some of you here from a health background may wish to the think of the board and the social inclusion agenda as the social determinants agenda, and that’s OK. It’s really about nomenclature. Social inclusion and social determinants are two sets of language speaking about the same thing from different professional backgrounds.
The Social Inclusion Board is aware and agrees with the Alliance that a person’s social experience impacts the quality of their health and well being.
The evidence is clear and compelling. We know we have to move beyond only the presenting symptoms of ill health, be they physical or social, and tackle the multiple and interrelated factors that combine to result in some people and communities being unwell, unemployed and trapped in cycles of disadvantage.
Across Australia now we are seeing areas of locational disadvantage where unemployment is hitting the fourth generation. It’s the first time we’ve ever encountered that as a nation.
The board’s role is to provide advice to Government in exactly this space. Our advice is always shaped by three key approaches: An approach that talks about joined-up solutions – solutions that are cross-disciplinary, multi-sectoral and cross-portfolio; an approach that calls for whole-of-government reform; and an approach that most importantly prioritises the needs of the most disadvantaged and vulnerable in our communities.
It’s in no one’s interests to see large numbers of Australians left out and missing out. A social determinants approach makes economic, as well as common, sense.
I’ve been speaking till now as chair of the Social Inclusion Board. Let me now take that hat off, leaving me wearing my hat as national director of UnitingCare Australia.
I’m sure it hasn’t escaped anybody’s notice in this space that we’re in an election year. It’s a good time, therefore, to launch an alliance focussed on the social determinants of health because elections create spaces to talk about things that matter.
And I can think of few things that matter more than focussing our combined intelligence and activity on ensuring every Australian has the means and opportunity for a decent and healthy life by seriously addressing the social and structural barriers that too many face.
The Government has signed up to this agenda. The Greens strongly support it. And as we move into this election year I don’t doubt that given Tony Abbott’s proven commitment to Indigenous communities that we will see the Liberals, too, committing to a social determinants approach.
Rising to meet the complex and entrenched challenges we face in building a healthy and fair society will require thinking across disciplines, action across political boundaries and support from all political parties.
It’ll be essential to have the Alliance active and calling on us all to throw our professional and personal support behind this evidence-based approach to healthy people and communities.
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The general public and policy makers need to develop a better understanding of the social determinants of health
Social Inclusion Minister Mark Butler
I’m really excited to launch the Alliance. I want to congratulate members of the Alliance for the work they’ve done over the last 12 months in convincing people like Senators Rachel Siewert and Claire Moore to co-chair this Inquiry. And I think it will add greatly to the understanding Australians have of what it means to address the social determinants of health.
I thought I would start by talking more broadly about how I see this fitting into a health system in Australia that has a very proud history but in many ways is under the pressure of a number of significant demographic and other changes.
We spend a little less than 10 per cent of our GDP on health. Our health system has a very proud history and essentially rests on three pillars – the pillars of a universal public hospital system, a great pharmaceutical benefits system, probably the best in the world, and Medicare. The first two of those pillars are universal in concept and universal in delivery. There are public hospitals in every Australian community, by and large, and the PBS operates in an entirely universal way. Medicare is a universal entitlement, but its actual application on the ground does vary across the country.
I thought I’d talk about an example that’s been close to my heart over the last couple of years as the Minister of Mental Health, and that was as we evaluated the Better Access program, a program that Tony Abbott as Health Minister added to the MBS.
The evaluation showed, not different really from most other MBS services, a program whose delivery to Australians varied greatly depending on where you lived and depending on your socioeconomic status. Basically, the further away you got from a GPO, the less likely you were to be receiving a service under this program. We found particularly the further you got from a GPO, the less likely you were to be receiving a service from a clinical psychologist, compared to other types of allied health providers.
Most disturbingly I think, and I sound like I’m picking on Better Access but it is true of many other MBS programs, most disturbingly we found three times the number of Medicare dollars went to services provided to the highest quintile of the country, in terms of income, compared to the lowest or poorest quintiles for reasons I just outlined (that poorer Australians tend to live in outer suburbs of our cities or in rural or regional Australia).
So to deal with that, respond to that very significant maldistribution of an important resource and a successful program, we have another program called ATAPS – the Access to Allied Psychology Services program – that allows Government, using taxpayer dollars, to direct money to regions that aren’t accessing their fair share of services through the market-driven system of MBS.
Although we have a wonderful health system, we have a system I think that requires two quite fundamental debates that are under way – one of which is this, which I’ll come to, and the other, which is the debate about preventative health or health promotion.
Of the $130 or $140 billion we spend on health, we currently spend about 98 per cent on treatment. We spend about 2 per cent on trying to stop people getting sick in the first place, and two-thirds of that 2 per cent is spent on vaccination and immunisation programs, very worthy programs, but it tells you less than 1 per cent is spent on health promotion that is not immunisation programs or screening programs – quit smoking programs and so on.
And we’ve had a great debate over recent years – led by the Preventative Health Taskforce – about how we move more of that health spend upstream. We do great treatment in Australia, but we know equally that about a third of our health spend is attached to risky behaviour – drinking too much, smoking, poor diet, not sufficient levels of physical activity.
So this big debate about how we shift our resources and effort upstream try to stop people getting sick in the first place, to try to relieve pressure on our health system, our primary care systems and acute care systems in particular, is a debate that’s still got a very long way to go.
And the second debate that goes to the fundamentals of our systems – our delivery and our policies – is the social determinants debate. And that’s why this Alliance and the Senate Inquiry are so important and so timely because I have to say I think this debate is not well understood in Australia.
People understand that poorer Australians, living in lower socioeconomic conditions, tend to have poorer health.
We’ve known that anecdotally, from broad longitudinal evidence, for a long while. The work that the Social Inclusion Board does, through the How is Australia Faring? report, brings to particular light the vicious circle that too many Australians are locked into – that poor health is the surest path to living in complex social disadvantage.
The 600,000 Australians now who live with complex, multi-layered disadvantage – they’re poor, they’ve got a disability, they might have substance abuse issues – more often than not have ended up there through poor health, and we know that the surest path out of that is fixing those health problems and giving them decent education and training to find employment.
We know this instinctively, we’ve got programs that are doing really important things, but this debate does have a long way to go in terms of permeating the Australian population, permeating the public policy makers.
[We’ve decided] that Closing the Gap is a really important thing to do for Indigenous Australians, and that the family-centred employment programs that operate in 10 Australian communities are a joined-up approach to good health, good training opportunities, good childcare arrangements, good housing, for some of the most disadvantaged families that is a really good way to get them out of disadvantage.
But this very siloed approach to some of the pilots we’re running need to be overlain by a much more sophisticated understanding of social determinants.
I don’t pretend to have it; I don’t think many Australians do. This is not the language of health policy or of policies tackling disadvantage, and we would be much better off if it became the language of this. That’s why I supported the Inquiry so heavily and that’s why I’m pleased to launch this Alliance, because I think this is a really important discussion for Australia to have. Thanks for inviting me and I look forward to the Alliance’s work.
• And here are more photos from the launch.
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More reading: Key points from the Alliance’s submission to the Senate Inquiry (available here).
The submission says that there is “some way to go” to advance understanding of social determinants of health within government, and notes that national health reform and the National Health and Hospital Reform Commission did not fully address equity issues.
It calls for:
- Adoption of the WHO framework from the Commission on Social Determinants of Health report Closing the Gap in a Generation.
- Leadership from the Department of Prime Minister and Cabinet to implement a coordinated whole-of-government approach to social determinants of health and health inequities.
- Federal Government encouragement for COAG to adopt the WHO framework, and a COAG-led discussion with states and territories to examine the impact of the social determinants of health through their administration of state-based policies and programs, for example within the justice system, housing, utilities and community-based services.
- Delivery of an annual report to Parliament by the Prime Minister on the social determinants of health that aims to monitor the distribution of health inequities in order to feed back into policy development.
- Implementation of mechanisms to routinely assess the impacts of policies on health and equity across all sectors of government.
- An equity audit of existing health and social programs – conducted as a starting point to support the development of a national strategy. The audit should include information on accessibility and use of programs, as well as duplication.
- Development of a national strategy to address health inequity by actions to reduce social inequities in income distribution, educational achievements, labour market, working environments, health behaviours and health services.
- Continued action in partnership with Indigenous communities and leaders to advance the social, economic and cultural development of Aboriginal and Torres Strait Islander peoples through action on social determinants of health – including in the justice system and policing.
- Building on the social inclusion agenda to address social determinants of health affecting disadvantaged groups and areas of concentrated disadvantage.
- A Productivity Commission assessment of the cost of health inequity and the benefits of adopting a Social Determinants of Health approach.
- A specific focus on understanding and evaluating effective interventions to address social determinants of health and health inequities within ANPHA, ARC and NHMRC research agendas.
