This post provides an overview of two new reports on the social determinants of health, and at the bottom is a link to a recent overview of global inequality by Nobel Laureate Joseph Stiglitz.
The Senate committee reports, but will it make any difference?
At last, we have the findings of a long-overdue inquiry into Australia’s response to the 2008 report by the World Health Organisation’s Commission on the Social Determinants of Health.
For those not familiar with the import of the social determinants of health, here is a short grab from the report:
“Good health involves improving access to education, reducing insecurity and unemployment, improving housing standards, and increasing the opportunities for social engagement available for all citizens. Addressing the discrepancies of health outcomes resulting from the prevailing social determinants means addressing the causes of those social determinants.”
The report’s recommendations are:
1. That the Government adopt the WHO Report and commit to addressing the social determinants of health relevant to the Australian context.
2. The committee recommends that the government adopt administrative practices that ensure consideration of the social determinants of health in all relevant policy development activities, particularly in relation to education, employment, housing, family and social security policy.
3.The committee recommends that the government place responsibility for addressing social determinants of health within one agency, with a mandate to address issues across portfolios.
4. The committee recommends that the NHMRC give greater emphasis in its grant allocation priorities to research on public health and social determinants research.
5. The committee recommends that annual progress reports to parliament be a key requirement of the body tasked with responsibility for addressing the social determinants of health.
An uphill battle ahead?
Despite an optimistic response to the report from the new Social Determinants of Health Alliance (available here), an in-between-the-lines reading of the report suggests it will be an uphill battle to get traction on the recommendations.
The Federal Department of Health and Ageing doesn’t seem at all convinced that a different approach is needed. We’re doing just fine as it is, thank you very much, (now butt out), seems to be the essence of its response to the inquiry.
The Senate Committee doesn’t seem to have been particularly impressed by this attitude.
“…in spite of the evidence presented to the committee arguing that the Commonwealth is taking numerous measures to address the social determinants of health, evidence for these claims appears to be minimal. Word searches of recent annual reports and appearances by the Department at Senate Estimates hearings reveal that:
• The 564–page 2011–12 Annual Report makes one mention of social determinants of health;
• The 634–page 2010–11 Annual Report makes one mention of the social determinants of health; and
• There have been no mentions of the social determinants of health during appearances at Senate Estimates in either 2011–12 or 2012–13.”
The report said that evidence provided in the Department’s supplementary submission also appears to emphasize that they currently maintain a traditional focus on addressing health concerns using the health system as the primary vehicle for attaining improved health outcomes, stating: “While many factors affect health, recognition must be given to the importance of health programs and policies on health. There is a risk that focusing on delivering programs more broadly, outside the health sector, may result in inadequate resourcing of health programs. If such diversity leads to dilution of health effort, or adversely impacts on access to health services, health outcomes may suffer.”
The committee noted that it was not alone in querying whether the Department was taking the kind of social determinants approach as indicated in their submission.
HealthWest Partnership, at the request of the committee, reviewed the submission of the Department and concluded:
“On review of the DOHA submission, it was not clear that social determinants were being considered as complex, interlinked and requiring comprehensive response, as would be expected if a Health in All Policies approach was adopted.”
The committee said these facts appear to support the observation made to the committee by Catholic Health Australia that Australia has so far addressed the social determinants of health ‘in an ad hoc and not necessarily coordinated way.’
While the establishment of the Australian National Preventive Health Agency (ANPHA) and the Australian Social Inclusion Board (ASIB) meant there was infrastructure with the capacity to address the social determinants of health, the report said there were concerns about the narrow focus of these agencies.
“Women’s Health Victoria noted for example that ANPHA currently has an issues-based focus rather than a social determinants approach and that social inclusion is only one of the social determinants of health. The committee also heard that the current focus on individual lifestyle factors did not represent a social determinants approach that call for complex intersectoral strategies that achieve long-term improvements.”
The report quotes HealthWest Partnership:
“We see responding to the social determinants of health to prevent the unfair difference in health outcomes between population groups and responding to disease epidemics as similarly needing a complex set of strategies. The current focus of programs on changing individual’s behaviours is equivalent to teaching people to swim to prevent Titanic-like disasters. It is a limited and inadequate response.”
The report said: “The narrow focus of ANPHA in particular, but also ASIB to a lesser extent, limits their ability to take a social determinants approach.”
The “pre-eminent idea” put to the committee to address the social determinants of health was for the Commonwealth government to adopt a similar mechanism as the South Australian ‘Health in All Policies’ (HiAP) approach.
However, the report notes resistance from DoHA and the Social Inclusion Board to this proposal.
Ben Harris-Roxas, a public health consultant and an authority on health impact assessment, says the lukewarm response on HIA is disappointing.
Writing at the Health Impact Assessment blog, he says the suggestion that HIA is expensive, time-consuming and unnecessary is often trotted out, but is not evidence-based.
“Any discussions about expense and time investment should be in comparison to other interventions, rather than continuing to do nothing. HIA practitioners in many Federalist countries (e.g. Canada, U.S.A, Austria, Switzerland) have faced similar rationales to not develop an HIA or HiAP agenda at a federal level.
“We need to be more assertive in calling out these kind of untested attitudes if we want to see further intersectoral action for health.”
Meanwhile, you don’t have to look too hard to find examples showing that the Government does not take a health in all policies approach (Newstart, anyone? More on that later).
One example that struck me recently (as discussed at this recent roundtable meeting on health and energy policy) is that the Government’s Energy White Paper 2012, which purports to represent a whole-of-government approach to policy, has virtually no focus on health beyond occupational health and safety concerns.
Yet energy policy is a major area of concern globally for public health.
Another reason for thinking that the SDOH lobby face an uphill battle is that nearly all of the submissions to the inquiry came from the health sector.
This suggests that the sectors which need to be engaged in this work – education, employment, planning etc – are not. It also suggests that the SDOH lobby needs to broaden its reach beyond the health sector.
Some other snippets from the report: income matters – especially if you’re trying to survive on Newstart
The committee heard that ‘income is probably in everybody’s top three’ social determinants of health.
It said that:
“The impacts of low income on health can be seen through statistics provided by the Australian Social Inclusion Board that indicate that 33 per cent of people in the lowest income quintile reported fair or poor health compared with just 6.5 per cent of those in the highest income quintile.
Research by the Australian Council of Social Services provides an insight into the number of low income families in Australia, finding that:
In 2010, after taking account of household costs, an estimated 2 265 000 people or 12.8% of all people, including 575 000 children (17.3% of all children), lived in households below the most austere poverty line used in international research. This is set at 50% of the median (middle) disposable income for all Australian households…A less austere but still low poverty line, that is used to define poverty in Britain, Ireland and the European Union, is 60% of the median income….When this higher poverty line is used, 3 705 000 people including 869 000 children, were found to be living in poverty. This represented 20.9% of all people and 26.1% of children.
The committee received evidence that addressing income and employment disadvantage results in better health outcomes in the Australian context. A recent study conducted in the Northern Territory found that lifting socio-economic index scores for family income and education/occupation by two quintile categories for low socio-economic indigenous groups was sufficient to overcome the excess hospital utilisation among the Aboriginal population compared with the non-Aboriginal population in the Northern Territory.”
The report says that:
“A major obstacle in improving society-wide health outcomes is intergenerational poverty. Children born to parents from lower socioeconomic backgrounds are more likely to do poorly at school, more likely to be unemployed, and more likely to have poor health. Adequate social protection systems can prevent intergenerational poverty and prevent temporary unemployment from becoming entrenched unemployment.
The committee heard that unemployment allowances in Australia had not been increased in real terms in Australians of working age for over two decades, and that now ‘over 50 per cent of people living on [Newstart] are living below the poverty line.”
Case studies underway
In preparation for the Helsinki 2013 8th Global Health Conference on Health Promotion, a number of jurisdictions, led by SA Health, have formed a working group to develop a publication of Australian case studies of action on social determinants and health equity. As explained by the Tasmanian Department of Health and Ageing:
The Australian social determinants case studies book will be used to promote and document examples of Australia’s work on the social determinants at the Global Conference, as well as providing a useful resource for jurisdictions. Its purpose is to support the current momentum for action on social determinants and health equity in Australia and overseas.
A report from the UK: What can health professionals do?
Professor Michael Marmot and colleagues at the Institute of Health Equity at University College London have released a new report, Working for Health Equity, looking at how health and medical professionals can tackle the social determinants of health, an area it says should be a “a core part” of their work.
Marmot says that “the medical and health professions are well placed to take action on the social determinants of health – they are trusted, expert, committed, and great powerful advocates”.
Interestingly, the report begins with a story from outside the health sector.
“The Merseyside Fire and Rescue Service made a lasting impression. When conducting the Marmot Review of Health Inequalities, published as Fair Society Healthy Lives, we partnered with the North West Region of England.
On one of our visits to Liverpool, we were hosted by the fire fighters. Their compelling story was of going outside their core professional practice of fighting fires to preventing them, which entailed engaging with the local community.
They then became involved in looking at quality of housing, and at smoking, which are fire risks, to more general issues that benefit the community, including activities for youngsters and older people.
“If the fire fighters can do it, why not the doctors?” was a question I posed to the British Medical Association, during my time as President.
Doctors are involved in treating illness but most accept they have an important role in prevention. If illness arises from the conditions in which people are born, grow, live, work, and age – the social determinants of health – should the doctors not get involved in the causes of illness and, indeed, the causes of the causes.”
While the BMA subsequently produced a report on what doctors could do about the social determinants of health, this new report engages much more widely.
It contains nineteen Statements for Action from a variety of professional groups, and commitments from such organisations to work in partnership to implement the report’s recommendations.
Key recommendations from the report that might be relevant for Australian health professionals, services and organisations include:
Workforce Education and Training
- A greater focus on information about the social determinants of health, and information on what works to tackle health inequities, should be included as a mandatory, assessed element of undergraduate and postgraduate education.
- Communication, partnership and advocacy skills are all general areas that will help professionals to tackle the social determinants of health. There are also specific practice-based skills, such as taking a social history and referring patients to non-medical services, which should be embedded in teaching in undergraduate and postgraduate courses.
- Student placements in a range of health and nonhealth organisations, particularly in deprived areas, should be a core part of every course. This will help to improve students’ knowledge and skills related to the social determinants of health.
- Both knowledge about the social determinants of health and skills to tackle these should be taught and reinforced as a compulsory element of CPD.
- Universities should take steps to ensure that students from all socio-economic backgrounds have fair access to health care careers.
Working with individuals and communities
- Health professionals should build relationships of trust and respect with their patients. They should promote collaboration and communication with local communities to strengthen these relationships.
- Health professionals should be taking a social history of their patients as well as medical information. This should then be used in two ways: to enable the practitioner to provide the best care for that patient, including referral where necessary; and at aggregate level to help organisations understand their local population and plan services and care.
- Health professionals should refer their patients to a range of services – medical, social services, other agencies and organisations, so that the root causes of ill health are tackled as well as the symptoms being medicated.
Working in Partnership
- Partnerships within the health sector should be consistent, broad and focussed on the social determinants of health.
- Partnerships between the health sector and other agencies are essential – they should be maintained, enhanced, and supported by joint commissioning, data-sharing and joint delivery. They must, however, be well designed and assessed for impact.
Workforce as advocates
- Individual health professionals and health care organisations should, where appropriate, act as advocates for individual patients and their families.
- Individual health professionals and health care organisations such as local NHS Trusts should act as advocates for their local community, seeking to improve the social and economic conditions and reduce inequalities in their local area.
- Individual health professionals, students, health care organisations such as NHS Trusts and professional bodies such as medical Royal Colleges and the BMA should advocate for a greater focus on the social determinants of health in practice and education.
- Individual health professionals, students and professional bodies such as medical Royal Colleges should advocate for policy changes that would improve the social and economic conditions in which people live, and particularly those that would reduce inequalities in these conditions. They should target this advocacy at central government, and bodies such as the NHS
What might we learn from Singapore?
The New York Times is running an online series on inequality, The Great Divide, moderated by the economist and Nobel Laureate Joseph Stiglitz, and author of a recent book, The Price of Inequality (which is unfortunately lacking in any comprehensive examination of health inequalities).
His most recent article looks at what Singapore and the Nordic countries can teach America about addressing inequalities, and many of his comments have relevance for Australia as well.
Singapore has had the distinction of having prioritized social and economic equity while achieving very high rates of growth over the past 30 years — an example par excellence that inequality is not just a matter of social justice but of economic performance. Societies with fewer economic disparities perform better — not just for those at the bottom or the middle, but over all.
It’s hard to believe how far this city-state has come in the half-century since it attained independence from Britain, in 1963. (A short-lived merger with Malaysia ended in 1965.) Around the time of independence, a quarter of Singapore’s work force was unemployed or underemployed. Its per-capita income (adjusted for inflation) was less than a tenth of what it is today.
There were many things that Singapore did to become one of Asia’s economic “tigers,” and curbing inequalities was one of them. The government made sure that wages at the bottom were not beaten down to the exploitative levels they could have been.
Government programs were universal but progressive: while everyone contributed, those who were well off contributed more to help those at the bottom, to make sure that everyone could live a decent life, as defined by what Singaporean society, at each stage of its development, could afford. Not only did those at the top pay their share of the public investments, they were asked to contribute even more to helping the neediest.
Singapore also realized that the key to future success was heavy investment in education — and more recently, scientific research — and that national advancement would mean that all citizens — not just the children of the rich — would need access to the best education for which they were qualified.