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Some suggestions for how to achieve a fairer distribution of health

Continuing a Croakey series on the social determinants of health, this article calls for the establishment of mechanisms to drive the agenda forward in Australia and to overcome the current state of inertia.

Below is an edited extract from a new book from Catholic Health Australia, Determining the Future: A Fair Go and Health for All, which outlines how the recommendations of a 2008 report of the WHO Commission on Social Determinants of Health should be adopted in Australia.

***

Australia needs a 2040 Commission to push for a fairer distribution of health

Fran Baum and Matt Fisher from Flinders University write:

The Commission on the Social Determinants of Health (CSDH) reported in 2008[2] following three years of work. The final report made a series of recommendations that went to the heart of the ways in which the world internationally and within countries could organise social, economic and everyday life in order to maximise population health and health equity.

The CSDH report was aimed at a global audience and so inevitably the recommendations are broad in scope and have to be re-interpreted within each country context.

To date there has been no systematic response to the CSDH report from Australia which has been disappointing. In this context of lack of response the initiative of Catholic Health Australia in commissioning from The National Centre for Social and Economic Modelling (NATSEM) the ‘Health lies in wealth: Health inequalities in Australians of working age’ report[3] is a very welcome addition to the debate about social determinants in health.

NATSEM report

The report documents the ways in which health status is affected by social factors in Australia. In summary it shows significant social gradients, and marked differences in health outcomes for Australians of working age between the most and least disadvantaged groups—according to most of the health outcome measures used, and with most of the indicators employed to measure socio-economic status (SES).

Remoteness was an exception with no significant differences found between regional/remote and city dwellers in self-assessed health status, or long-term health conditions. The picture drawn of health inequities and their links with social factors reflect patterns repeated around the world.

Australian policies relevant to health equity

We have conducted a brief survey of the Australian landscape in terms of policy initiatives relevant to the social determinants[4]. The main policy initiative that does recognise the social determinants of health is the COAG Closing the Gap initiative[5]. It includes among its objectives the need for access to early childhood education, increasing reading, writing and numeracy achievements for Indigenous children, and improved year 12 completions, and sets out to halve the gap in employment outcomes between Indigenous and non-Indigenous Australians within a decade. Thus two of the most powerful determinants of health—education and employment—are central to the policy.

The national social inclusion agenda[6],[7] also addresses social determinants from the perspective of improving the lives of the 5 per cent of Australians who are most disadvantaged, and considers geographical areas of extreme disadvantage and the need to involve disadvantaged people in education and employment.

However, one can see that while the Closing the Gap and the social inclusion initiatives tackle social determinants, they do this from the point of view of the most disadvantaged and don’t tackle the issue of the health gradient. The CSDH report was clear that addressing health equity required consideration of the evidence showing that health status most often operates as a gradient across society.

For the broad Australian population the main policy response has been the national preventive health strategy[8] which is primarily a disease prevention agenda. There is, of course, much to applaud about this: it often takes a public health perspective; it does seek to prevent disease; and it does keep a focus on the need to shift the focus of the health system to what causes illness. Yet it is also frustrating, because it could be so much more exciting and cutting edge if our national agenda had also devised strategies to address the social determinants of health in a more systematic way.

A social determinants agenda for Australia

The current preventive health agenda appears to be motivated by a fear of a threatening tidal wave of health care expenditure in the wake of a growing epidemic of chronic disease[9]. This explains the focus on risk factors (something very tangible that can be tackled and so is immediately politically attractive) and also explains the relative silence on social determinants of health, especially those that address the more fundamental causes of inequity and ill health.

In the context of this article there is insufficient space to expand fully on the responses we suggest to the CSDH Report. The changes required are elaborated on in more depth in Baum’s The New Public Health[10] (Part 6: Healthy Societies and Environments).

Crucially, there are no simple answers and responses must be framed within an understanding of complexity[11], and the need to develop salutogenic environments which promote positive health[12]. Baum[13] has suggested the establishment of an Australia 2040 Commission with the following brief:

  • Develop a broad strategic vision and plan for Australia’s future.
  • Be mandated to encourage cross-government action towards implementing this plan. Encourage and facilitate a widespread citizens’ debate about the future, posing the question of, What society do we want for us and our future generations to live in by 2040?
  • Determine mechanisms to implement this vision and plan across government through processes such as the Health in All Policies approach.
  • Determine measures of our progress as a society that go beyond a focus on economic development and encompass a consideration of human health and well-being.

A 2040 Commission would be able to provide vision and integration across government, and stimulate a broad citizen dialogue about our future in order to produce a strategic planning framework for ensuring a healthy Australia.

Finally, we need to develop a few agreed measures or an index to determine how well we are doing as a society. Economic growth remains a central measure of how we measure our success and progress but increasingly the wisdom of this is questioned. Calls are mounting for measures of progress that count factors that matter to people’s everyday lives. An example is the Happy Planet Index[14] which is based on the criteria of average life expectancy, life satisfaction and ecological footprint.

Conclusion

We commend Catholic Health Australia’s initiative in striving to put and keep social determinants of health on the Australian policy agenda. We have made a series of recommendation of how Australia might respond to the CSDH report and proposed an Australian 2040 Commission to develop a vision supported by a strategic framework for shaping our collective futures in a way that is inclusive, equitable and supportive of health and well-being.

This is an edited extract from the Catholic Health Australia book, Determining the future—a fair go and health for all (chapter 1). Copies of the book can be ordered at http://www.connorcourt.com/catalog1/index.php?main_page=product_info&cPath=7&products_id=169

References

Antonovsky A. (1996) ‘The salutogenic model as a theory to guide health promotion.’ Health Promotion International,11: 11-18.

Australian Government (2010) A Stronger, fairer Australia: National statement on Social Inclusion. Canberra: Department of Prime Minister and Cabinet, Australian Government.

Baum F. (2008) The new public health. 3rd edition. Melbourne: Oxford University Press, 2008.

Baum, F. (2009) ‘Prevention: The Commission on the Social Determinants of Health and recasting the debate to focus on health and well-being.’ Public Health Bulletin of South Australia 6: 16-20.

Brown, L. & Nepal, B. (2010) Health lies in wealth: Health inequalities in Australians of working age. Canberra: National Centre for Social and Economic Modelling, Catholic Health Australia.

Commission on the Social Determinants of Health (2008) Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva: World Health Organization. Available at: www.who.int/social_determinants/en/

Commonwealth of Australia (2010) Taking preventative action—A response to Australia: The Healthiest Country by 2020—The Report of the National Preventative Health Taskforce. Canberra: Commonwealth of Australia, Department of Health and Ageing.

Council of Australian Governments (2007) National Indigenous reform agreement (closing the gap). Canberra: Council of Australian Governments.

Jayasinghe, S. (2011) ‘Conceptualising population health: From mechanistic thinking to complexity science’. Emerging Themes in Epidemiology, 8: 1-7.

Marks, N., Abdallah, S., Simms, A. & Thompson, S. (2006) The happy planet index: An index of human well-being and environmental impact. London: New Economics Foundation.

National Preventative Health Taskforce (2009) Australia: The healthiest country by 2020—National Preventative Health Strategy—the roadmap for action. Canberra: Commonwealth of Australia.

Newman, L., Baum, F. & Harris, E. (2006) ‘Federal, state and territory government responses to health inequities and the social determinants of health in Australia’. Australian Journal of Health Promotion, 17: 217-25.

The Treasury (2010) Australia to 2050: Future challenges. Barton ACT: Commonwealth of Australia.

***

For previous articles in this series:

• Bringing urban design into the health debate

• The health issues that really matter

• How children are bearing the cost of increasing prisoner numbers

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