At a recent public health forum in Victoria, Mary-Anne Thomas, the Parliamentary Secretary for Health in the Labor Government, urged participants to ‘watch this space’ on action on prevention and promotion issues, as she worked to update the state’s public heath and wellbeing plan. “I think you’ll see we have made a profound leap in the quality of the plan and the information and strategy it provides,” she promised.
The Victorian public health and wellbeing plan 2015–2019 has now been released, but we might still have to ‘watch this space’ on the detail and the speed and breadth of implementation. See the posts below for the initial verdicts from Victorial public health experts Brian Vandenberg and Rebecca Zosel.
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Brian Vandenberg writes:
The Victorian Government has just released a new 5-year plan for improving public health and wellbeing that ticks a lot of boxes. It is evidence-based, ambitious, and far-reaching. It presents the Labor government’s high level strategic directions for change and improvement in health and claims to introduce a stronger focus on outcomes, targets and accountability than the previous plan, developed by the former Coalition government.
Very little detail, though, is actually included in the plan about outcomes and targets, which are still to be developed it seems. More fundamentally, there is no action plan included to detail how the plan will be rolled out. So while an initial, critical look finds much to be applauded, some big questions remain about the implementation and resourcing of the plan.
The 2015-2019 plan is the second of its kind handed down as one of the legislative requirements under the Victorian Public Health and Wellbeing Act 2008. In many ways, this new plan builds on its predecessor rather than offering a radical new direction, but it is still a substantial improvement on the 2011 version. The new plan is bolstered from taking into account the latest scientific evidence, recent international developments, best practice, and feedback from consultations with the public health sector. The new plan has a strong focus on health inequalities, health across the life course, and addressing local priorities. The plan focuses on 6 priorities areas, many of which share common risks, determinants and protective factors, and hence have shared opportunities for preventive strategies. The priorities include:
- healthier eating and active living
- tobacco free living
- reducing harmful alcohol and drug use
- improving mental health
- preventing violence and injury
- improving sexual and reproductive health.
What you will find in this plan is a very comprehensive and impressive explanation of the concept of health, the determinants of health, and the state of health in Victoria. This plan will have your head frequently nodding in agreement as you read through it, as it is loaded with compelling evidence about the health issues facing the State and sensible plans for strengthening public health and wellbeing in Victoria. But, what you won’t find is any concrete plan of action – other than what the government mostly promised pre-election.
Hence, this is a plan lacking a great sense of urgency. It’s true that improving public health is a more like a marathon than a sprint, but that shouldn’t mean we delay getting on with the job. An accompanying action plan is promised, and eagerly awaited by many, as that may prove to be a more fundamentally important blueprint for improving public health in Victoria than this broad framework plan.
6 priority areas
The choice of six priority areas in the plan is welcome, though no doubt good arguments could be made for dropping some of these and including others, given the competing demands on resources. It’s pleasing to see tobacco free living make it into the set of six priorities, given Victoria has long been among the national leaders in reducing smoking prevalence. However, in recent times Victoria’s performance in tobacco control has slipped back relative to other jurisdictions. Last year, for instance, Victoria was judged to be the worst performing jurisdiction nationally by the Australian Medical Association in terms of taking policy action to reduce smoking and the harms it causes. So, as a recent custodian of the “Dirty Ashtray” award, Victoria’s performance in tobacco control is now under close scrutiny across the nation. Yet, there are not clear indications of rapid improvement. For example, the banning of smoking in outdoor dining and drinking areas in Victoria, which other jurisdictions have already implemented, is a no-brainer, but the government continues to delay action in this area.
In relation to alcohol and drugs, which is another welcome inclusion among the six priority areas, the government has already made good on its promise to address the issue of methamphetamine (“ice”) use, through its $45 million investment in an Ice Action Plan. However, so far the government has travelled a rocky road in addressing the much bigger health burden caused by alcohol. While it has recently made some welcome, though modest, moves in this area such as extending a freeze on issuing any new late night liquor licenses in the inner city and banning powdered alcohol, it has promised little else to reduce the huge preventable toll that alcohol takes on the health and wellbeing of Victorians. The government recently came under fire for cutting funding for alcohol research, and it scored a clear ‘fail’ (41 out of 100 points) in the recent national alcohol policy scorecard. The inclusion of alcohol as a priority area in the new public health plan will hopefully now see more concerted effort and substantive action on this issue.
Despite good evidence that prevention is better than a cure when it comes to improving overall population health, worryingly, this plan does not offer much good news for increasing the investment in preventative health. The plan is almost resigned to this, when it states that there is a “need to ensure limited prevention resources are used to best effect”. Setting priorities in spending makes perfect sense, but for me, that statement raises the question: surely we have not given up demanding more investment in prevention? We know prevention is often far better for the long term health of individuals and communities, and research shows that investment in prevention is highly cost-effective and hence also better for the health of government budgets instead of tipping endless resources into treating people for avoidable diseases. This government has not been timid about tackling difficult social issues (for example, family violence), and hopefully it will also be brave in tackling the health budget so that prevention is given a greater share.
Growing out of ‘nanny state’ concerns?
In better news, the plan is refreshingly clear and confident about the key role of government in promoting health, which is very welcome in an era where politicians often fear being branded with the ‘nanny state’ label. It ‘recognises the role of the state in providing safe, healthy and sustainable environments to protect and secure the health and wellbeing of Victorians, as well as the role individuals and families play in looking after their own health and wellbeing’. Now that wasn’t too hard to say, was it? Perhaps in Victoria we have now moved to a post-anti-nanny era in public policy.
The authors of this plan should be commended for producing a very accessible and relatively jargon free document. The plan is well organised into three main parts:
- a discussion of health determinants, risk factors, trends and challenges
- strategic directions and priorities
- governance accountability and outcomes
There is a brief section on the achievements under the previous plan (2011-2015), which have laid a sound foundation for this new plan. A disappointing part of this section, however, is the feeble explanation for why the government’s funding for the Healthy Together initiative has stopped. The plan states that ‘this initiative was delivered as part of the implementation of the National Partnership Agreement on Preventive Health, which the Commonwealth Government ended in 2014’. It will be a great pity if the Victorian Government’s ongoing commitment to this initiative is totally contingent on federal dollars. That would mean all which has been learnt, built and achieved in improving the health of several Victorian communities in recent years through the investment in Healthy Together is discarded because of a quarrel with Canberra about funding, which ultimately represents only a tiny fraction of the overall State budget.
This plan certainly raises expectations, and we should stay optimistic and believe that the government will soon deliver to us an action plan, accompanied with adequate funding, to see the plan properly implemented over the next five years. The government has already been impressive in demonstrating its follow-through on promises, with the establishment of the Royal Commission into Family Violence being a prime example. If this same resolve can be applied to the numerous public health priority areas identified in this plan, we can look forward to period of progress and change. Those of use working in public health should get behind this plan and do what we can to help it succeed. Holding government accountable will be critical to this end.
Brian Vandenberg is president of the Public Health Association of Australia (Victorian Branch). He is currently a PhD candidate in the Centre for Health Economics, Monash University. He tweets at @thevandenbergs.
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Rebecca Zosel writes:
Too early to call: waiting for the action plan and outcomes framework
Victoria’s new Public Health and Wellbeing Plan 2015-2019 has an admirable vision and presents a detailed picture of public health in Victoria. Yet the plan is so high level that it is hard to be confident about achieving its vision: “A Victoria free of the avoidable burden of disease and injury, so that all Victorians can enjoy the highest attainable standards of health, wellbeing and participation at every age” (pg. v).
The ‘plan’ appears more like a scoping exercise, a current snapshot of health or summary of current evidence. It presents a plethora of public health approaches and theory, and some useful statistics on health and wellbeing in Victoria– but most of this is re-hashing old ground and it is disappointing that the plan does not move beyond this. The plan has no concrete actions. No indication of resources, roles and responsibilities. It contains six key areas for action accompanied by strategic directions which are so high-level and ‘business as usual’ that they are almost meaningless, and a handful of “possible outcome measures”. The forthcoming action plan and outcomes framework will surely deliver more details, but it is a shame these details weren’t included in the plan itself.
The six key areas for action in the plan are broadly aligned with the National Health Priority Areas and VicHealth’s strategic imperatives, with the exception of ‘sexual and reproductive health’. With the four common modifiable risk factors for chronic diseases within scope (physical inactivity, tobacco and alcohol use and unhealthy diet), the plan reinforces that “Chronic diseases are the most significant health challenge for the population overall” (pg. 15). We will have to wait and see how the state-based plan aligns with the work currently underway to develop a National Strategic Framework for Chronic Conditions.
There is a useful one-page summary of the plan (see pic) although it doesn’t capture the breadth or depth of information that is presented in the plan (detail that may be tricky for our non-health partners to digest).
What’s missing?
Some points around what is missing. Notably, the ‘platforms for change’ (which in my head reflect the ‘domains’ in the ecological model of health) don’t appear to consider technology, or the changing nature of ‘community’ away from being defined by ‘geography’ to ‘identity’.
Health literacy gets a handful of mentions however has a surprisingly low profile. There are no overarching principles, or priority population groups – despite the plan’s recognition that Aboriginal people experience persistent inequalities in health and wellbeing. I get a sense that the plan has been informed by the work of Healthy Together Victoria; however a more explicit recognition would have been good, together with some reassurance that the effort and resources invested in this world-leading initiative continues to be put to good use, despite its dismal end. It is heartening to see climate change recognised, but until the action plan and outcomes framework is finalised it is too early to say whether the commitment is commensurate with the scale of the problem.
I hope the forthcoming action plan and outcomes framework further distil what is a very lengthy but non-specific plan, and provide us with clear and measurable actions over the coming four years. It is time for public health to stop moving backwards and to start moving forwards, preferably in leaps and bounds.
Rebecca Zosel is a public health practitioner, advocate and consultant. Her current clients include VicHealth, CEIPS, VARTA and National Asthma Council Australia. Rebecca tweets at @rzosel.
